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Epi Wit & Wisdom Articles
Susser Discusses “Ecologism” as
New Paradigm
Dawning of a New Era in
Epidemiology is Described
Brazilians Said to Be Most
Likely to Lead New Thinking
“The ‘Black Box’ is faltering as
the dominant paradigm in epidemiology,” according to Columbia
University epidemiologist Mervyn Susser, “and we are on the verge of a
new era.” Speaking as the keynoter in the packed closing session of
the recent Brazilian Congress on epidemiology, Susser would not
predict which new paradigm will emerge to guide epidemiologists.
However, he did express his preference for thinking about disease in a
broader context than is customary for North American epidemiologists.
Invited initially to speak on
the future of epidemiology, Susser was not willing to predict the
future. Instead he redefined his task—if we could choose, what future
would we choose, he asked. To present the options, he reviewed the
status of epidemiology today and how we got to where we are.
According to Susser,
epidemiology has passed through three eras, each one with its
accompanying paradigm. In the first era of “undifferentiated sanitary
statistics” which coincided with the sanitary movement at the
beginning of the 19th century, the miasma theory of disease dominated
thinking. Though incomplete as a theory, there were public health
successes with sanitary reform.
In the second microbiological
era, a germ theory emerged to displace the miasma theory. During this
period, epidemiology was lab-driven, and the public health drive
declined.
“Black Box” Dominates Third Era
In the more recent third era
following World War II, chronic diseases have garnered the attention,
and there have been major public health drives to control or reduce
illnesses. The “Black Box” paradigm—connecting exposure with outcome
based on the probability of the relationship without the necessity of
explaining the connecting links—has governed more and more of the
thinking in epidemiology. In this era, epidemiologists are very
invested in analytic techniques. There have been notable early
successes with smoking and lung cancer, CHD and peptic ulcer, for
example, but epidemiologists have strayed from their earlier more
intense commitment to public health concerns evident in the immediate
post World War II period.
The new era before us is driven
by two major forces, he continued. The first is molecular biology
which is giving our understanding of disease a new depth and
precision, and the second is the network of information systems which
are changing the breadth and sophistication of large scale analyses
which could be done in epidemiology with proper data collection. In
short, we are on the verge of a “global epidemiology” according to
Susser, and the paradigm should be “ecologism,” that is, bringing our
techniques and concepts together to study disease in the full context
of all the macro and micro-level factors that contribute to disease
occurrence. “Ecologism” recognizes that there is a hierarchy of
organizational levels from molecule to cell, tissue, organ system,
individual organism, couple, family, nation, continent and globe.
Ecologism does not allow us to ignore that each level brings a new set
of variables, and that each level influences and interacts with the
others. This broad view is very compatible with the larger social
orientation taken by much of Latin American epidemiology, which seeks
to understand the more macro-level causes of disease attributable to
social factors and public policies.
According to University of
Michigan epidemiologist Jim Koopman, “the Brazilians are searching for
a new paradigm in epidemiology that goes beyond the search for risk
factors acting on individuals and encompasses causal issues relating
to the conformation of society and how individuals interact with each
other. Susser has outlined a new epoch of “ecologism” into which
epidemiology is moving.
Brazilians Will Lead Movement
“I think there are several
reasons why the Brazilians and not the Americans will lead this
movement,” Koopman continues. First is that Brazilian public health
has emerged so rapidly that it has fewer established interests to
constrain it. Second is that some of the best work in integrating
dynamic systems analysis into epidemiology is being done in Brazil. To
emerge into this new era, epidemiology needs to forge new
collaborations with systems analysts in the same way that we forged
relationships with biostatisticians in the past.”
Susser refused to predict
whether the driving force of molecular biology with its micro-level
orientation will become the dominant paradigm driving epidemiology
back into the laboratory where it resided during the microbiological
era, or whether the more macro-level concerns would prevail to
encourage epidemiology to take an even broader orientation. If we go
towards “ecologism,” it will have to be an active choice, according to
Susser, because the attraction of the countervailing molecular
paradigm will be enough to drive us into the lab. Our choice will
depend on the values we deploy. If improving the public’s health is
really our ultimate purpose, then we may actively choose to work with
a more contextual analysis. If given a choice, Susser stated he would
choose the option of studying disease in broader context.
Published June 1995 v
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