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Narrative Matters

Using And Misusing Anecdote In Policy Making

PREFACE: During the 2000 presidential campaign, Al Gore’s questionably accurate tale of his dog paying less than his mother-in-law for the same drug, and years ago, President Ronald Reagan’s similarly creative story about a nonexistent "welfare queen," share common thread. They underscore the power of stories to dramatize political positions, despite the moral and informational hazards of personal narratives as policy currency. The policy anecdote is an omnipresent form of policy discourse that Health Affairs attempts to capture in a responsible and literary way in the Narrative Matters column. With support from the Kellogg Foundation, in March 2000 Health Affairs convened a group of writers, health policymakers, editors, and journalists to explore the role of the personal essay in the making of health policy. The following commentaries from that conference by John McDonough and Barbara Sharf address the power and the pitfalls of the personal story in the health policy process. McDonough, former politician, and Sharf, a professor of communication and humanities, derive strikingly similar conclusions from quite different vantage points.

My opponents were unimpressed by my pile and, in the context of the times, were right. They knew what they saw on the ground—a bewildering regulatory behemoth, calcified by years of political deals between hospitals and the state, that prevented them from negotiating contracts that would give them more value and accountability. My studies were based on pre-1985 data; the research community pretty much gave up studying rate setting after that, satisfied with results showing that it worked. But the fast-changing health system bore little resemblance to that earlier period, and the research community had yet to grasp what was happening in the field. My adversaries spoke from the real world, telling anecdotes describing their actual experiences in controlling costs by becoming active, aggressive purchasers of health care. In the end, their perspective mattered more than the reams of scientific evidence I brought to the debate.

The lesson that personal observation can easily trump hard data revealed itself again to me the following year. I lacked firsthand knowledge of the 1993 bill mandating Massachusetts insurers to pay for bone marrow transplants for breast cancer patients, because I didn’t sit on the relevant committees. But I had read accounts of the hearings and discerned a familiar dynamic. Breast cancer victims and their advocates argued that greedy insurance companies and HMOs refused to pay for these transplants because they were too costly, regardless of the benefits. Women who had undergone this treatment testified to its life-saving value. Insurers argued that the treatment’s efficacy had not been scientifically demonstrated and that suffering from the treatment was as inordinate as its cost. They were then portrayed as callous, white, male-dominated parties who were insensitive to women’s health needs.

When A Story Is Off Base

 
I considered taking is sue with the bill but had learned, as most legislators do, to pick my fights. Initiating opposition that would be futile and would be viewed as blind to women’s health needs didn’t make sense. The measure passed both houses easily and was signed into law by then Gov. William Weld, an otherwise vigorous critic of health insurance mandates. A similar pattern played out in many other states and the federal government, which approved their own mandates in the 1990s.

But the rush by providers, patients, and states to provide, obtain, and finance these services had an unfortunate effect. Researchers could find few volunteers for controlled studies to evaluate the treatment’s effectiveness. Indeed, not until 1999 were studies completed demonstrating that bone marrow transplant, much more costly and painful than conventional treatments, was no more effective in extending the lives of breast cancer victims.

These two encounters illustrate both the value and harm of relying on storytelling in making public policy. Stories can enable lawmakers to understand a legitimate need for policy change but just as readily can lead them to make bad policy decisions. Stories can bring to life drab data analyses, helping us to visualize problems and opportunities for change. But stories also can lead us down wasteful and dangerous paths and blind us to uncomfortable uncomfortable truths we would prefer to ignore, like the fact that there yet is no easy cure for breast cancer.

It comes as no surprise, then, that almost as common as using narrative and anecdote in policy making is criticizing them. Former Minnesota state legislator Lee Greenfield often remarks that one compelling anecdote (true or false) at a crucial moment in a floor debate can vaporize a mountain of data and careful policy analysis.

Anecdote’s Inescapable Humanity

Top When A Story Is... Anecdote's Inescapable Humanity Values Versus Data Using Stories Wisely How Do You Know...

 
Why is narrative so central to policy making? Because it is central to life. We live our lives crafting, telling, and receiving stories. We tell our loved ones stories from our day. We catch up with old friends by sharing tales from our lives. We receive from all forms of the media stories to help make sense of our world. In constructing our stories, we are necessarily selective in choosing and editing details to drive home a lesson, to engage our audience, or to meet time, space, and other constraints.

This is true for the hardest of sciences. "So much of science proceeds by telling stories," writes Harvard naturalist Stephen Jay Gould, in Bully for Brontosaurus: Reflections in Natural History. He sees us as "vulnerable to the constraints of this medium" because we are unaware of our tale telling in observing the natural world. "We think that we are reading nature by applying rules of logic and laws of matter to our observations," he says, "but we are often telling stories."

Policymakers, like scientists, are as human as the rest of us. Part of our uniquely human heritage involves telling stories to find meaning from the events, data, and stimuli in our lives. Most policymakers, and especially legislators, have not had training in research methods and share the layperson’s suspicion of statistical analysis. The adage "Lies, damn lies, and statistics" makes more sense to most of them than does the value of the r-square.

Values Versus Data

Top When A Story Is... Anecdote's Inescapable Humanity Values Versus Data Using Stories Wisely How Do You Know...

 
Perhaps the real power of stories lies in their reflection of ideas and values. As Deborah Stone argues in her book Policy Paradox, much of the policy process involves debates about values masquerading as debates about facts and data. "The essence of policymaking in political communities [is] the struggle over ideas," she writes, even though in legislatures and other deliberative bodies, participants engage in fierce debate about data and statistics as though the process were a straightforward search for truth. Her view, which I share, challenges the concept of policy making as simply a scientific exercise in data analysis.

I recall numerous debates in the Massachusetts legislature on whether to mandate use of seat belts and motorcycle helmets, provide clean needles to addicts, require insurance coverage for infertility treatments, dictate gun ownership restrictions, and obligate employers to provide health insurance to their workers. In each case, both sides argued about data as if identifying the right statistic would compel the other side to surrender. But data were only rhetorical weapons used to bolster competing values.

When policy differences are grounded in divergent value structures, empirical research rarely helps much until participants allow for those value differences. Recognizing differing value frameworks marbled through a policy dispute can enable participants to reach a resolution that acknowledges those differing concerns, or can make it clearer why agreement is not possible.

In 1995, while chairman of the legislature’s insurance committee, I remember how community housing activists fought with insurance company executives over home insurance "redlining"—an unwillingness to write coverage of homes in marginal urban neighborhoods. A series of trust-building exercises brought both sides to a greater appreciation of each other’s differences and led to passage of consensus anti-redlining legislation the following year.

That said, stories’ power also can have an adverse effect. When false or out-of-context stories provide the basis for public policies that impose requirements on unwilling citizens, those suffering the imposition may, with reason, feel indignant. An untrue or misused story in everyday life holds little impact beyond a few individuals, but in public policy it may result in adverse consequences for millions. Ronald Reagan’s reference to a mythical Chicago welfare queen—happily collecting her monthly check while sitting pretty at home—tarnished the way Americans viewed recipients of government assistance in ways that set the tone for a public and congressional backlash against helping needy populations in the early 1980s.

Using Stories Wisely

Top When A Story Is... Anecdote's Inescapable Humanity Values Versus Data Using Stories Wisely How Do You Know...

 
The question to ask is , How do we craft a more appropriate role for narrative and anecdote in the policy process? Narrative should be to policy making what suitable case study is to empirical research. Case study alone can never establish scientifically based claims but does play a key role in the research enterprise. One valid, well-documented case study can effectively demolish a theory, demand rethinking of an approach, or set the stage for further empirically based investigations.

In a similar way, contextually appropriate stories used in the policy environment can identify important, neglected policy problems. For example, no policy analysis can illustrate the need for culturally competent health care as compellingly as Anne Fadiman’s account of a Hmong child’s experience with epilepsy in The Spirit Catches You and You Fall Down. Anecdotes help to signal problems with existing programs or policies that have been unrecognized or insufficiently understood. They can even provide evidence that a program or law is working as intended. Stories assist policymakers in thinking about the consequences of rival policy choices. Also, most policy decisions cannot wait for the gold-standard randomized clinical trial, while many others do not even lend themselves to scientific investigation. Valid stories and anecdotes are better than nothing to guide decision makers. Stories also help policymakers to think about the potential political impact of their policy decisions.

Stories even benefit lawmakers when the going gets tough. In my years in the Massachusetts legislature, I developed great affection and respect for the long-serving representatives who would regale newer members with tales from other eras. During the difficult fiscal crisis of 1989–1991, hearing their stories of what worked to control the impact of the previous fiscal meltdown (in the mid-1970s)—and understanding that "this, too, shall pass"—was enormously helpful when the pressures seemed unending.

But using narrative to make policy requires the same standards of validity as those applied to case study. Lack of accountability is the bane of storytelling in the policy environment. A story needs to be true and presented in a context that does not distort its relevance to the policy choice at hand. Red herrings are unacceptable. For instance, I remember that to prove their harmlessness, an angry landlord once ate lead paint chips before a Massachusetts legislative health committee hearing. Policymakers must develop the necessary discipline to be intelligent consumers of anecdotes.

How Do You Know That?

Top When A Story Is... Anecdote's Inescapable Humanity Values Versus Data Using Stories Wisely How Do You Know...

 
Given the pace and frenzy of their world, policy veterans may find it unrealistic to consistently pay scrupulous attention to sources and truth. The most valuable approach may therefore be a defensive one. A research methods instructor taught me that one of the most powerful questions one can ask is, "How do you know that?" After receiving his advice, I began asking this question carefully and respectfully in public hearings and in corridor conversations. I was amazed by the results. The most brazen and self-confident witness could melt when pressed for the validity and appropriateness of a source. A few choice responses: "I read it somewhere, but I can’t remember where." "My brother told me." "Everyone knows that!" (my personal favorite).

Asking "How do you know that?" may not come naturally to policymakers. Many public officials develop (or possess a priori) a tendency to accept the individual stories of their constituents. Perhaps they do this in response to routine accusations of losing contact with the "folks back home." Real folks don’t discuss the latest issue of the New England Journal of Medicine; they tell stories about their lives. And when they meet a politician, they continue their storytelling to communicate what’s important to them.

Some constituents’ stories are off the wall, while others are pertinent and valuable. The challenge is not to get narrative and storytelling out of policymaking. They are oxygen to the process and cannot be eliminated. We might as well try to ban conversation. The challenge is to raise everyone’s skill level—officials and citizens alike—to be more intelligent consumers of stories.

Editor's Notes

 
John McDonough <jmcdonough{at}brandeis.edu> is an associate professor at the Heller School at Brandeis University and former health committee chairman in the Massachusetts House of Representatives. He is the author of Experiencing Politics: A Legislator’s Stories of Government and Health Care (University of California Press and Milbank Memorial Fund, 2000).

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