Policy Memo for Masters in Public Health

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HowtoWriteaPolicyMemo_MPHCore_20181.pdf

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How to Write a Policy Memo MPH Core |Fall 2018 There’s a famous essay on Tolstoy’s view of history by Sir Isaiah Berlin called The Hedgehog and the Fox. It’s inspired by a line of Greek poetry that reads, “The fox knows many things, but the hedgehog knows one big thing.” You get your hedgehog knowledge in your concentrations and certificates. The MPH core is your opportunity to think like a fox, to be stretched to ask questions that you might otherwise feel are not in your domain. So, then, one of the ideas that animates the core is that being able to ask a good question about a text, a presentation, an issue—is perhaps more important than being able to answer one. It shows that you can identify critical issues, discern important themes, draw connections between ideas or events, and analytically organize the materials at hand. It is, in the end, not your topical or disciplinary focus but your ability to ask questions as you begin any inquiry that will make your own professional work relevant. The core, of course, requires a particular kind of questioning involving a case that is challenging you to make decisions and justify them in the face of tension (between conflicting values or goals) and uncertainty (created by contested or contradictory evidence or perhaps a dearth of evidence). If you come away from the case as experts in meningitis, obesity, or autonomous vehicles rather than understanding the kinds of questions that our cases raise then we haven’t accomplished our goal. Our task as instructors it is to teach you not just to be able to say, “I think this,” but rather, “I think this because….” We want you to move beyond opinions and hone the ability to come to a reasoned position. In order to achieve this, you need to learn not to rush to premature closure on an issue, but to wrestle with and weigh multiple viewpoints and perspectives. One argument theorist has described it as learning to “dwell with” and “dwell in” the ideas of others, to feel some sympathy for alternatives in order before making a judgment.

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As an exercise, writing a memo captures the full range of what we are doing in the core, but it has the danger of emphasizing the ultimate end of a memo, which is to find a solution and persuade. We want to make certain that you first engage in inquiry, weigh the evidence, assumptions, context, and different perspectives carefully before you move to judgment. You have to first give yourself the opportunity to change your own mind before you start to work on changing someone else’s. And, of course, as we move into writing policy memos we are going to start by focusing first on just the key questions rather than rushing to closure. But why policy memos at all? Why not a research paper or, staying mindful of the increasingly competitive funding environment, a grant proposal? I. Purpose Memos are perhaps the most common form of professional communication. We will all write a memo (or something that requires the same kind of analytic and presentation skills) at some point in our careers. A policy memo is a short document. It is intended to help decision- makers make a choice, considering data, values, costs, and social and political context. We call them policy memos, but a decision-maker can be anybody and policy can mean a grand decision (like the Affordable Care Act) or a determination on smaller scale, so don’t be thrown by the word policy. But don’t discount it either. And don’t get programs confused with policies: a policy might call for implementation of a program, but a program without a policy mandate is just a program. The point isn’t to write a memo complaining that you can’t get WIFI reception unless you hang out a window (we’ve tried that one), but rather to grapple with and look at all sides of a compelling public or social problem or issue.

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A policy memo is always directed to an individual or at least an identifiable group (perhaps a committee) within an organization, and you are always seeking to help your reader make a decision. A policy memo is not a journal article, though certainly it shares much in common with the kind of perspective pieces that we might find in journals such as Science, JAMA, NEJM, AJPH or even the Op-Ed section of a major newspaper. That means, of course, that a memo has to be able to stand alone or, at least, be understandable without further reading given the knowledge that you believe your audience to have. Think carefully about the kind of knowledge or technical background that your audience has. For example, are readers going to know what an odds ratio is? Are there cultural or political constraints that your audience is working within? Is a libertarian-leaning organization going to open to a welfare-state proposal? Is it an issue that the person or organization has likely been exposed to before? If so, what is the current state of discussion? What do people know and not know? What is prevailing opinion? How controversial is your argument? Do you have reason to think that your audience is open to it or liable to be resistant? For example, on New Year’s Day, 2012, the Times reported that individuals at the lowest obesity levels have lower mortality than those with Body Mass Indexes defined as normal. You might want to take a look at the study they cite and ask yourselves how different organizations with diverse agendas are likely to interpret the data, given its strengths and limitations, and respond. Keeping this example in mind, the final thing you want to ask yourself is what general approach and specific information is going to resonate with and hook your reader? In this case, say you wanted to consider the issue of recalibrating the Body Mass Index—redefining what represents obesity. What’s going to make different organizations think, Hey, that’s a good point; Yeah, yeah, I’ve heard this before; or Gimme a break…? II. Organization There is no gospel on how to organize a memo, but it should have some clear structure. In general, there are some standard elements that you

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must include and label. A thoughtful consideration of each of these elements will help you to write a tight and internally consistent document (and then you’ll find that you can use the same strategy for writing something longer). As you think about what job or position you want to give yourself, bear in mind that a memo is typically an internal form of communication. Further, because one of the goals for our purposes is to show that you’ve thought through all sides of an issue, this might limit your To/From choices. Of course, this isn’t a major issue for this particular assignment: you know the organization you working for; you know that your boss is asking for the memo. But it is worth thinking about the To/From logic nonetheless because it can help you understand the freedom you have in an internal policy memo. Is Barbara Loe Fischer, a leading figure in the national movement against immunization, likely to write a memo to anyone outside her own organization that seriously considers the potential benefits, say, of routine HPV vaccination for children? Of course, this is a somewhat extreme example where there would probably also be no internal consideration of another position either, here is the key point: a policy memo represents an opportunity to think through an issue and take an informed position, yet it isn’t a narrow piece of advocacy. After you make the To/From/Date decision, think about the next two elements in parallel: an Aim or Background section and a statement of the Issue or Problem. It might be useful to think first about writing a clear, crisp statement of the Issue or Problem. Your reader is likely to start here. But if you start here, you are going to give yourself a very clear target to hit as you prepare your background statement: the one (maybe two) sentence issue or problem statement is where you need to lead your reader. The issue or problem can be almost anything within the case that resonates with you; it can be theoretical, methodological, evidentiary, political, ethical. But whatever the problem or issue you choose to take on, you need to be able to convey it to the reader clearly, succinctly, yet in a way that captures interest and attention.

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The opening section, then, represents the information that the reader needs in order to understand why they should care. What information do they need in order to have a good grasp of the issue before you suggest your reasoning and strategy for moving forward? And notice that we wrote what information not what data. To be sure, you may want to give the reader some numbers about the scope of a problem, but history, politics, ethics, values, etc. may be just as important as data or evidence. Regardless of how you choose to hook and then educate the reader, remember that the goal of the memo is to help someone (maybe your boss, maybe another agency, perhaps an elected official) decide. Therefore, a memo is going to lay out a series of Options and Recommendations grounded in Evidence. How you lay these three elements out is a matter of preference and style. You may well want three sections with bulleted lists. You may want a single recommendations section that covers these elements more narratively. Different issues lend themselves to slightly different arrangements, but at least identify for yourself where in the memo you provide your reader with these essential pieces and ask whether you think he or she will be able to identify them as readily as you can. As you think about the options and recommendations, in particular, take care to make specific, concrete suggestions rather than provide your reader with mere abstractions. Your studio instructor will review some examples with you in class so that you can begin to think critically about what constitutes a meaningful option. I’ll give you one quick example now, though. Suppose that I’ve identified myself as Modena Wilson, Senior Vice President and Chief Health and Science Officer at the AMA and I want this leading professional organization to ask whether we need to rethink the BMI (Body Mass Index). The memo might list the following options: 1. Make no changes until further study 2. Adjust the BMI

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Both of these options are too vague to be helpful. It wouldn’t help me much to change that second option to “Adjust the definition of ‘normal’ BMI.” The real question is how? Perhaps, then, for option 2, the memo should offer something more specific, like “Redefine a BMI of 30 to 34.9 as normal provided there are no other conditions present such as high cholesterol or diabetes.” Once you begin to think like this, you might want to consider other options, for example simply redefining a BMI of 30 to 34.9 as normal without any qualifiers. Finally, remember, as you entertain different options or make recommendations, to make sure that the strategies you consider are consistent with the identity you’ve adopted for purposes of memo writing. If you are writing from within the AMA, you are unlikely to recommend that, given these data, Americans can exercise less and eat more. Above all, a memo should have an argument. Because an argument requires that we bring together some of these different threads in a way that amounts to a decision about how to take action, the argument might not be a specifically-labeled section. But it is vital nonetheless. An argument is an authoritative synthesis (of data, of normative frameworks, of history, of politics, of risks) informed by a wide reading (in this instance, distilled for you by the case but, of course, with the core to back you up) and critical, probing thought. It represents your best judgment within a given organization at a given moment in time. And it is important to be aware of the moment in time you choose to work within because things do change over time. The economist Adam Smith theorized in a context in which there was not really a concept of unemployment. The situation was very different for John Keynes, who came to prominence in the 1930s. In some respects, the structure of your memo captures the different elements of a persuasive argument. Your recommendation represents a kind of claim about what we should do.

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The evidence you rely on provides the grounds for making that particular claim. But a sound argument is more than just a claim, which may amount to no more than mere opinion—usually shaped narrowly by experience (which might hit the target but not for a good enough reason) or bias (an unchallenged and often even unrecognized assumption that often strays wide from the mark). How you link your evidence to your recommendation, then, is critical to crafting an overarching argument. In addition to having limits, data don’t speak for themselves, so you must provide a convincing Rationale showing us why the evidence you’ve rested your case on is relevant. Why should we agree with your recommendation? Culture, values, politics, economics, practicalities, ethics, history, methodology—all of these may figure as you provide a warrant for your position, a reason for prioritizing any given theory or method or privileging some ways of knowing above others. In other words, the warrant is more than just the rationale, but the value, or belief, of principle that the audience has to accept and hold if the argument is going to hold (be warranted) for them. Above all, a good argument is not one-sided. Whether it is justice or cost- benefit or equity or neo-liberalism, making a good argument demands that you not cleave religiously to a single concept, principle, or theory but rather recognize and take seriously the notion that there are always competing values and contradictory evidence. Thus, we must always ask what are the Pros and Cons? Think Michael Walzer here. You should make key dissenting voices heard: you don’t want your boss to be broadsided because you personally don’t hew to libertarianism or paternalism or health care for all or name your value. You have to take those values seriously and not make credible opposing positions look ridiculous (you want others to take your cherished values seriously, don’t you?). Making a defensible decision requires us to be challenged by the opposition. Have we really considered the alternatives, done our best to weigh different perspectives, or have we simply created straw men, that is, positions easily knocked down and trampled? So, as you think about the counterarguments, remember George Bernard Shaw, who famously said, “A man never tells you anything unless you contradict him.” Have you truly tried to contradict

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yourself as you thought about what position you will ultimately take in your memo? If you have, it doesn’t necessarily mean you right, but you’ve likely made a good argument and that’s what’s being assessed. As you write your policy memos, give some thought to the difference between evidence, claims, rationales (reasons), and warrants (the justification for claims). Perhaps the most common error in constructing an argument is mistaking reasons (that is, rationales) for evidence. If we continue on with our obesity example, imagine the following argument: We need to rethink our approach to the obesity problem. Being overweight is not cleanly linked to poor health. While a 2012 JAMA study found an 18 percent higher mortality (all causes) for all grades of obesity, it found a 6 percent lower risk for those classified as overweight (statistically significant). The current public health concern with weight is overwrought and contributes to stigmatization.

Stop for a moment and ask yourself, if I took this argument piece by piece, how would I label the different pieces? Write down your assignments. When you’re ready, continue on to see whether we agree. Here it is ready to be dissected. Claim: We need to rethink our approach to the obesity

problem. Rationale: Being overweight is not cleanly linked to poor

health. Evidence: While a 2012 JAMA study found an 18 percent

higher mortality (all causes) for all grades of obesity it found a 6 percent lower risk for overweight (statistically significant).

Warrant: The current public health concern with weight is overwrought and contributes to the stigmatization

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of overweight. (The warrant is the justification for your claim.)

Hum. Wait a second. But if the warrant is the

justification for your claim, this goes too far. This warrant really requires the memo to make a claim about stigma and to find evidence to back it up.

So then a better warrant would be: There’s a

mismatch between the national policy emphasis and the evidence. This is an appropriate warrant for the claim that we need to shift our approach.

The point is that while it might all seem self-evident, as you begin to construct your memo—your argument—you’ll find that you’ll be tempted to use more than what might strictly be described as “evidence” to provide the grounds and backing for your claims. Remember, too, that values are different than evidence, though a finding that 80 percent of the population ascribes to a certain set of values is evidence. But, above all, be consistent. Make sure that the evidence fits with the argument as a whole. III. Writing Whatever position you take, you should always take care with your writing. And be aware that a short document has a particular, insidious way of throwing grammatical errors, inchoate writing, and disorganized thought into bold relief. So as you construct the memo pay special attention to writing and organization. Keep the language accessible as opposed to inscrutable, impenetrable, exhausting. A reader should never have to stop and puzzle over a sentence. This doesn’t mean it must be dull and simplistic. The last thing that anyone wants when reading a memo is to be bored. The writing in your memo can certainly lift a reader up with its crispness and clarity, even poetry. So avoid jargon, buzz words, and catch phrases (particularly those that we in public health may not recognize as such, like, one of my favorites, normative frameworks, which might be appropriate for some but not all contexts), not a rich vocabulary.

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IV. Length Tom Frieden, former head of the CDC and former Commissioner of Health in New York City, insisted that any MPH student should be able to write a solid policy memo in two hours or less. That assumes, of course, that you have a command of the issue in advance. But the point is, we need to cultivate a mindset in which we’re always thinking in terms of options, evidence, and arguments (and framing, but we’ll get to that in SOPH 604). And we need to be prepared to convey our arguments quickly and concisely (some say within a minute). A policy memo is not a dissertation. It’s not even a research paper. Think of it this way: when Sanchez hands this memo to Walker, the senator is perhaps going to spend a minute deciding whether or not to take your option seriously. So, then, assume that all memos will get the one-minute treatment. The effective ones will end up being considered more thoughtfully. The rest will find their way to the recycle bin (particularly if you live in that community with the tiny trash cans and the huge recycle containers). This particular memo should be at least three single spaced pages. Try to keep it within five. The most important thing is to give your best effort to what will be a very different way of writing for many of you, knowing that you will also have the opportunity to appreciate that the key to achieving splendid writing regardless of the format is rewriting! FAQs In general, use your professional judgment if you have questions that are not spelled out in the assignment. That’s the common theme running through almost all of our answers below. Can I use charts and graphs? Sure, but think about whether you need them. Can you convey what you need to narratively? Will your reader be able to decipher? (Ultimately Sanchez may give this memo to Walker.)

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Do I need citations? In practice, not necessarily, but absolutely for our purposes. We are requiring APA style. I can’t do due diligence to my subject less than 20 pages: have I bitten off more than I can chew? Without question. Narrow your focus. But can’t I just give you 20 pages? No. Can I just be myself when I’m writing my memo? Yes, but a memo from Amy Fairchild, MPH Candidate, Texas A&M School of Public Health is a sure sign that I either didn’t want to or was afraid to invest in this assignment. Take a chance. Be someone else or, at the very least, give yourself a title that interests you. Please, keep in mind that when we read your memos we aren’t going to assume that this is necessarily what you believe even though you should be making a credible argument. If you believe in paternalism, why not argue from the libertarian perspective? Or vice versa. This is your time to play with ideas (and note that once you are in a job, the expectation is that you argue the organization’s position even if you disagree). Can I identify more than one problem or issue? Yes, but unless they are highly interrelated you are unlikely to be able to tackle them thoroughly and convincingly. There’s not a strict page limit, but more than five pages starts to raise eyebrows. Do I have to include and label all of the things you mentioned? Background, Issue, Options, Evidence, Pros, Cons, Recommendations, Rationale? In general, yes, all of these elements should be in the memo. Yes, you should find a way to label and format so that the reader can follow you easily. But, no, depending on the issue at hand and how you choose to construct your argument, you have some freedom (i.e., maybe labeling a section Pros and Cons prevents you from discussing the pros and cons in the way you find most effective). Further, you might want to name things differently. Again, the idea of pros and cons may seem artificial to you, but perhaps risks and benefits or potential and limits or barriers and obstacles may feel far more salient. You can give the reader a strong rationale without actually having a section so labeled. Perhaps the word justification is more meaningful to you. The structure of the

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memo isn’t meant to prevent you from doing things differently, but rather to prevent you from engaging in sloppy thinking and writing. There are lots of other things listed as elements in the rubric (e.g., cultural values, equity, measures of performance and impact) that aren’t mentioned above. Do we still need to include them? Yes. Use your professional judgment about where and how to integrate them into the fabric of your policy memo. They might be woven through the background, issue, evidence, or rationale sections, for example, as appropriate given your particular framing. If creating a separate section for some of the elements works in your particular memo, it is also fine to take that approach.