Social Equipoise

Another consideration around applying biomedical research principles to public health is that of equipoise.
Clinical equipoise is typically understood within the context of randomised controlled trials. In public health,
clinical trials are not carried out and, in fact, randomised controlled trials are less used. Public health research is
often directed by governments and may concern itself with policy analysis and development. As such, there may
be a gap in evidence around effectiveness of policy due to variations in practice and outcomes. Where
differences in public health policy have been identified, it’s often associated with necessary variations due to
context. Public health also often involves complex social interventions, where there may be multiple outcomes.
The importance of these may vary depending on which stakeholder is consulted. So for example someone from
the Ministry of Health might think that one outcome is really important, a recipient of an intervention in a
community might think that another outcome is much more important. Consensus around uncertainty linked to
each outcome when compared to alternatives is difficult to achieve. So remembering, this right there is the
principle of equipoise, that justifies carrying out research, you have to have the uncertainty about 1 treatment or
intervention compared to another.

Public health also often exists within the realm of politics and is hugely influenced by political priorities.
Governments may be hesitant to acknowledge uncertainty in the policies or practices that they have endorsed.
Equipoise in social and public health interventions is further complicated by the fact that indirect health effects
may be unknown, but economic, social, or other health benefits are well-established—for example, improving
housing conditions obviously has a clear economic benefit and a social benefit, but its outcomes in terms of
respiratory illness might be less known. So that presents some grey area in terms of equipoise because
obviously this intervention is multi-faceted, so it’s aiming to improve some of the known as well as unknown
outcomes.

Given these limitations in the application of clinical equipoise to public health, establishing a concept of “social
equipoise”, which can be facilitated through an acknowledgement of uncertainty, an honest evaluation of
outcomes, and a movement away from the advocacy of certain reforms as though they are destined to be
successful may be increasingly beneficial (Petticrew et al, 2013).