Epidemiology and the Liberal Arts-Toward a New Paradigm? - NCBI

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fabric, II-the London Bridge-it never fell. IntJEpidemiol. 1980;9:299-304. 72. Stolley PD. Faith, evidence, and the epide- miologist.JPublic Health Policy. 1985 ...

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Ad Hoc Advisory Panel. In: Reiser SJ, Dyck AJ, Curran WJ, eds. Ethics in Medicine: Historical Perspectives and Contemporary Concems. Cambridge, Mass: MIT Press; 1977:316-321. Weales G. Review of "Miss Evers' Boys." Commonweal. 1991;118:750-751. Weed DL. Lament for an epidemiologist. Pharos. 1986;49:43. Weed DL. Epidemiology's triple crown. J Chron Dis. 1987;40:905-906. Martinez-Maldonado M. John Snow takes the waters. Pharos. 1994;57: 10. Pellegrino ED. Educating the humanist physician: an ancient ideal reconsidered. JAAL4. 1974;227:1288-1294. Engelhardt HT. rhe birth of the medical humanities and the rebirth of the philosophy of medicine: the vision of Edmund D. Pellegrino. J Med Philos. 1990;15:237-241. Pellegrino ED. Medical practice and the new curricula.JAMA4. 1970;213:748-752. Moore AR. Medical humanities-a new medical adventure. NEnglJMed. 1976;295: 1479-1480. Bickel J. Integrating Human Values Teach-

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ing Programs into Medical Students' Clinical Education. Washington, DC: Association of American Medical Colleges; 1986. Pabst D. Medicine and the humanities. Humanities. 1992;13:33-35. Arnold RM, Povar GJ, Howell JD. The humanities, humanistic behavior, and the humane physician: a cautionary note. Ann Intem Med. 1987;106:313-318. Pellegrino ED. Teaching medical ethics: some persistent questions and some responses. AcadMed 1989;64:701-703. Pellegrino ED, Hart RJ, Henderson S, Loeb S, Edwards G. Relevance and utility of courses in medical ethics: a survey of physicians' perceptions. JAMA. 1985;253: 72-86. Self DJ, Wolinsky FD, Baldwin DC. The effect of teaching medical ethics on medical students' moral reasoning. Acad Med. 1989;64:755-759. Brieger GH. Do the humanities make for humane physicians? Pharos. 1994;57:42. Anderson AD. A collection of poetry by a physician with progressive neurological disease. J Chron Dis. 1984;37:863-868.

68. Warren RP.AII The King's Men. San Diego, Calif: Harcourt Brace Jovanovich; 1990. (Originally published 1946). 69. Graham S. Enhancing creativity in epidemiology.AmJEpidemiol. 1988;128:249-253. 70. Lilienfeld AM, Lilienfeld DE. The 1979 Heath Clark lectures: the epidemiologic fabric, I-weaving the threads. Int J Epidemiol. 1980;9:199-206. 71. Lilienfeld AM, Lilienfeld DE. The 1979 Heath Clark lectures: the epidemiologic fabric, II-the London Bridge-it never fell. IntJEpidemiol. 1980;9:299-304. 72. Stolley PD. Faith, evidence, and the epidemiologist.JPublic Health Policy. 1985;6:3742. 73. Susser M. Causal Thinking in the Health Sciences. New York, NY: Oxford University Press; 1974. 74. Kunitz SJ. Explanation and ideologies of mortality patterns. Popul Dev Rev. 1987;13: 379408. 75. Stolley PD, Lasky T. Johannes Fibiger and his Nobel Prize for the hypothesis that a worm causes stomach cancer. Ann Intem Med. 1992;116:765-769.

Comment: Epidemiology and the Liberal Arts-Toward a New Paradigm? Gerald M. Oppenheimer In this Public Health Policy Forum, Douglas Weed raises the specter of epidemiology, caught in the gap "between past and future."12 The author finds that contemporary epidemiologists have drifted from their traditional base in public health. Instead of committing themselves to or intervening in the communities they study, practitioners put greater value on pursuing epidemiology as a biomedical science in which methodology and technical virtuosity are prized. As a consequence, epidemiology, like medicine 2 decades ago, has become technologybound, depersonalized, and out of touch with the people it serves. This deracination of epidemiology, writes Weed, "goes to the heart of what it means to be an epidemiologist."' Without its tradition-or the memory of that tradition-what, asks Weed, is epidemiology's future? What inheritance can it hand on? Epidemiology has developed into an academic discipline, institutionalized, in the decades following World War II, in schools of public health and other departments within schools of medicine. Like other academic disciplines, epidemiology

has constructed a body of theory and research, a corpus of literature and methodology. Since the early 1970s, academic programs in epidemiology have offered doctoral studies to students without an advanced degree beyond the baccalaureate.3'4 The emergence of epidemiology as a significant academic field followed an "epidemic transition,"35 in which chronic, noninfectious disorders displaced infectious diseases as the major force of mortality in the United States and elsewhere. As Susser has argued, epidemiologists "entrained a line of research which was to establish a different paradigm for chronic disease."3 That paradigm, and the methodology associated with it, comprehends chronic disorders as preventable medical problems having multiple environmental determinants whose character and path are best studied in human populations. During the postwar years, the rich development of epidemioThe author is a Contributing Editor of the

Journal. Editor's Note. See related editorial by Bloom (p 907) in this issue. July 1995, Vol. 85, No. 7

Public Health Policy Fomm logic methodology and its successful application to the elucidation of heart disease and lung cancer established the new paradigm as an intellectual force.3 The acceptance of that paradigm by medicine and public health made epidemiology a crucial biomedical science with a place in the most important loci of power and prestige: academic medical centers, the National Institutes of Health, and other areas of the Public Health Service. The new paradigm overlay an older model of response to disease with origins in the "new" public health and epidemiology of the turn of the century. That model centered on the microbial laboratory, the germ theory, and the scientifically trained professional.6 In that model, state and local departments of health were crucial institutions. Although they made contributions to chronic disease epidemiology,7 their traditional responsibility was (and is) to understand, prevent, and control infectious disorders. Moreover, leadership and important positions in these departments, and in public health generally, were reserved for physicians; public health was essentially a medical specialty.4 Postwar academic epidemiology illfitted this model. Apart from its focus on chronic, noninfectious disease and its primary location in academic centers, it recruited nonclinicians with few skills to offer directly to the communities they studied. Drawn from the sciences, mathematics, and the social sciences, and educated on the graduate level in epidemiologic theory and methodology, they would logically use and exploit that background and training. As Weed and others before him have made clear, an academic epidemiology suffers from certain problems, among them a fascination with theory or methodology for its own sake and "an orientation geared more to the goal of 'publish or perish' than to the goal of preventing disease and death."7 Nonetheless, we should not overstate the estrangement of academic epidemiologists from the problems of health and disease in their communities. Epidemiologists who perceive themselves primarily as scientists work in institutions with ties to the community, and many believe they are affecting the public health, albeit indirectly. A well-designed study, for example, that supports an association between a drug and a decreased rate of perinatal human immunodeficiency virus infection would constitute, for many epidemiologists, an important contribution to public health. July 1995, Vol. 85, No. 7

Weed holds that modern epidemiology leaves its practitioners doubly circumscribed. Not only disenfranchised from professional participation in the communities they serve, they are bereft of knowledge that might intellectually link them to those communities. Like physicians, epidemiologists are well trained but not "educated." They are not "humanists," in the sense both of caring about the welfare of others and of being students of the liberal arts or classics. Weed proposes steeping epidemiologists in the humanities, thereby serving a twofold purpose: educating them while "refocusing attention upon ... the nature of humanity, and upon the social and cultural forces binding this mix together."1 Epidemiologists, he argues, must study history, philosophy, literature, and art-the keys to epidemiology's past, present, and future. Through humanistic studies, epidemiologists stand to gain qualities we all wish to have: creativity, nondogmatism, values, and the ability to think clearly. This is a tall order for the humanities and one they will, in all probability, be unable to fulfill. It has been a long time since history and literature, for example, have been seriously treated as illustrative stories or as inspirational or moral and intellectual behavioral models for the reader. The humanistic disciplines and the corpus of texts each contains are socially determined intellectual constructs that are periodically revised or completely changed. As texts and objects, the humanities are not transparent, that is, open, easily read, and understood: they are subject to profound, sometimes ruthless, reinterpretation within and over periods of time. Certainly, the humanities were never created to serve epidemiologists as Weed describes, that is, to bring them to "the core of humanity itself,"1 to move epidemiologists to attend more to the welfare of the community. To meet Weed's concerns, what can the liberal arts do? That is a very large question, to which I can only provide a partial answer. The liberal arts-and I would add the social sciences and lawcan assist epidemiologists in being what they should be: creatively skeptical about their discipline. Weed rightly holds that historical, philosophical, and other research cannot replace etiologic or intervention studies. I believe, however, that the former might actually invigorate the latter. For example, epidemiologists incorporate sex, race, and social class into investigations and explanatory models. All too often, sex and race are treated as

essentially biological variables,8 although both are also complex social constructs and socially lived realities that history, literary criticism, sociology, and anthropology, among other disciplines, are carefully studying. By steeping themselves in such disciplines, students and practitioners of epidemiology can explore and grapple with the multiple dimensions of biological sex and culturally determined gender, race and ethnicity, and social class. By analyzing how these variables are used and understood in other disciplines, epidemiologists may become more self-conscious and critical of how they construct, validate, and apply them to their own work. Nancy Krieger, for example, has employed historical case studies to bolster her critique of the use (or lack thereof) of social class, race, and gender, singly or jointly, in epidemiology.8 Through crossdisciplinary studies, epidemiologists could test the strength and limitations of a number of measures and data sources and take the opportunity to formulate new constructs, measurements, hypotheses, and research designs. Such a course conceivably could achieve the synthesis Weed advocates, combining the current stress on technical virtuosity with an increased appreciation for the social (and political) grounding of health, disease, and research questions. To begin this intellectual process, a number of questions must be answered. Should there be changes in student recruitment policy, for example? As epidemiologists drew upon nonmedical scientists and social scientists to meet the demands of an academic chronic disease epidemiology, should a community-conscious epidemiology now draft individuals with significant training in the humanities, anthropology, etc.? Currently, students are loaded down with courses. Without unduly burdening them, how can we integrate new areas of knowledge? Who will be the teachers? Using the model of the medical humanities, faculty may be epidemiologists, but more often they will be drawn from persons with training in the alternative disciplines with a particular facility in epidemiology. How to encourage the process? Epidemiologic journals might set aside pages or create special sections to publish appropriate articles. An examination of the American Joumal of Epidemiology, a major publication in the field, for the years 1993 and 1994 revealed almost no articles bridging epidemiology and the humanities. Professional meetings offer further opportunities to explore and test

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the usefulness of the proposed expansion of epidemiology. In 1993, the Society for Epidemiologic Research included a symposium on ethics in epidemiology; perhaps this could serve as a precedent. Douglas Weed has raised an important problem; the issue is whether epidemiologists will accept his challenge and, if they do, how they will proceed. I believe a rapprochement of epidemiology, the liberal arts, and the social sciences can broaden and deepen the concerns and questions that epidemiologists bring to their work. It should allow them to step back and reevaluate their assumptions and values and to reinvigorate the social dimensions of a field that can sometimes

be overwhelmed by biomedical factors. Perhaps, most importantly, a dialectical process of learning and critical reassessment-whether in training programs, journals, or professional meetings-can lead a significant number of epidemiologists into an extended dialogue concerning the future of epidemiology. ]

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References 1. Weed DL. Epidemiology, the humanities, and public health. Am J Public Health.

1995;85:914-918. 2. Arendt H. Between Past and Future, Sir Exercises in Political Thought. Cleveland, Ohio: Meridian Books; 1963. 3. Susser M. Epidemiology in the United

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States after World War II: the evolution of a technique. Epidemiol Rev. 1985;7:147-177. Fee E. Disease and Discovery:A History ofthe Johns Hopkins School of Hygiene and Public Health, 1916-1939. Baltimore, Md: The Johns Hopkins University Press; 1987. Omran AR. The epidemiologic transition: a theory of the epidemiology of population change. Milbank Mem Fund Q. 1971;49:509538. Rosner D. Introduction: "Hives of sickness and vice." In: Rosner D, ed. Hives of Sickness: Public Health and Epidemics in New York City. New Brunswick, NJ: Rutgers University Press; 1995. Terris M. The Society of Epidemiologic Research (SER) and the future of epidemiology.Am JEpidemiol. 1992;136:909-915. Krieger N. The making of public health data: paradigms, politics, and policy.JPublic Health Policy. 1992;13:412-427.

APIIA Publications Board Invites Proposals for Book Projects APHA's Publications Board invites APHA members to submit proposals for publication as books. The Board is looking for manuscripts that speak to public health topics, especially to those not previously or not adequately addressed. We need your most innovative work, your dedication, and your enthusiasm to create the best possible public health book program that APHA can offer. If you are interested in making a submission or ifyou have a topic in mind, feel free to discuss it with the Chair of the Publications Board, Dr Berttina Wentworth, or with the APHA Director of Publications Services, Sabine J. Beisler. To reach either or to receive guidelines on making a formal submission, call the Association Office at (202) 789-5693; fax (202) 789-5661. Please send preliminary inquiries or formal proposals to Sabine J. Beisler, Director of Publications Services, American Public Health Association, 1015 15th St, NW, Washington, DC 20005. Please note that all inquiries about publication in theAmenican Joumal of Publc Health must be sent to the Editor of the Journal, Dr Mervyn Susser, at the APHA Washington, DC, address given above.

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