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Epi Wit & Wisdom Articles
American College of Epidemiology
Will Host Debate on the Future of Risk Factor Epidemiology
Philosophers use the term “epi
phenomena” to describe the discussion of peripheral aspects of a
thing, for example, the exhaust of a car rather than the car itself,
or a person’s shadow rather than the person. Some in the epidemiology
community contend that the field regularly engages in this practice
when studying specific risk factors of disease rather than broader
societal and environmental issues.
This “Black Box”
paradigm—connecting exposure with outcome based on the probability of
the relationship without the necessity of explaining the connecting
links—has come under fire before; it will do so again at a debate
focusing on the future directions of epidemiology scheduled during the
annual meeting of the American College of Epidemiology, to be held
September 21 - 23 in Cambridge, MA. It is titled, “Motion: That Risk
Factor Epidemiology is Placing Epidemiology at Risk.”
John McKinlay, the moderator of
the upcoming debate, explains that proponents of the “new public
health” would argue that the shadow never moves the body—the body
moves the shadow—so why should epidemiologists just focus on risk
factors when they could instead focus on what drives those risk
factors? He says those in favor of a new paradigm believe
epidemiologists should look beyond risk factors and at the actual
underlying causes of disease, such as the places people live and their
position in society. Those against the new paradigm don’t believe it’s
within an epidemiologist’s realm to delve deeply into the whys and
hows of people’s lives, he says.
“Some people think epidemiology
is at a crossroads,” McKinlay says. “They think we are teaching more
technique rather than underlying philosophy, that we’re training
tradesmen with power tools—such as statistical techniques and study
designs—versus training students to be able to read architectural
plans.”
Debate Has Long History
Last year, a group of
epidemiology graduate students at Harvard’s School of Public Health
organized a panel discussion at the annual meeting of the Society for
Epidemiologic Research. The limitations of epidemiology and the “Black
Box” paradigm were central issues. But McKinlay says the debate has
been going on for a much longer time. He went back as far as John
Snow, who didn’t just report his findings that a single water source
was causing a cholera outbreak, but additionally “crept out of his
flat late at night and stole the pump handle. If he were living today,
some folks would say John Snow should have stayed in bed that night.”
McKinlay is looking forward to a
“very lively and interesting debate,” he says. “The speakers are all
tops in their field.” Those in favor of a new paradigm are Mervyn
Susser at the American Journal of Public Health and Lisa Berkman at
Harvard; those against the proposition that the study of causal
mechanisms is counterproductive are Kenneth Rothman at Epidemiology
and David Savitz at the University of North Carolina.
Black Box vs. Chinese Boxes
Susser has been outspoken in his
belief, that a new era in epidemiology is dawning, an era he calls “ecologism.”
He believes the concept of “black boxes” should be replaced with the
concept of Chinese boxes, which are boxes within boxes, representing
the levels of causality. For example, when speaking of heart disease
in women, one could discuss the cellular level; the level of endocrine
function and hormones; relationships and marriage; work environments;
access to the health care system; and overall position in society.
On the other hand, following the
route of such boxes could present misleading information. “Those who
suggest that we should study and manipulate the root causes of disease
first have to establish the entire causal chain, from root cause all
the way to disease,” Rothman tells the Epi Monitor. “Consequently, and
contrary to what has been implied, any public health action depends on
knowing the intricacies of causal mechanisms. That is, we all need
‘risk factor epidemiology’. Furthermore, manipulation of root causes
may be less effective and less reliable than intervening at the causal
brink of disease onset.”
Black box, Chinese box...or
Pandora’s box? The Epi Monitor will keep you posted as this debate
continues.
Published August/September 1997
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