EPID 600; Class 14

The future

University of Michigan School of Public Health

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 What is epidemiology?

The study of the determinants of disease and the

distribution of disease

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 How do we think about the next steps for
epidemiology?
1.  Where are we with respect to changing epidemiologic
paradigms?
2.  What is the central motivation behind our work?
3.  What are the challenges and potential problems as we
try to move forward?

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 1. Shifting paradigms

Paradigms change by “attrition”

Conceptual shifts are derived by external forces
Failure of a science to reinvent itself brings about
stagnation and inertia

Susser M. Does risk factor epidemiology put epidemiology at risk? Peering into the future. Journal of Epidemiol Community Health. 1998 608-611. 4
 The epidemiologic approach

1.  Identify a disease of interest

2.  Identify exposures of interest based on what is known about the
disease (prior epidemiologic research, biology, laboratory studies)
3.  Examine statistical associations between exposures and disease
4.  Hold constant factors that may be “mixed up” in this measure of
association
5.  Infer a causal association between exposure and disease on the
individual level
6.  Recommend behavior change

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 The epidemiologic approach

Identify a disease of interest

Identify exposures of interest based on what is known about the
disease (prior epidemiologic research, biology, laboratory studies)
Examine statistical associations between exposures and disease
Hold constant factors that may be “mixed up” in this measure of
association
Infer a causal association between exposure and disease on the
individual level
Recommend behavior change

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 Conclusions from the epidemiologic
approach
“…strategies should focus on reducing obesity, in particular through
physical activity, elimination of cigarette smoking, and moderation of
alcohol intake”

“…programs that effectively prolong virginity among adolescents

make sense as part of a comprehensive strategy for reducing STIs
among adolescents, who carry a substantial part of the STI burden.”

Costanza MK, Cayanis E, Ross BM, Flaherty MS, Alvin GB, Das K, Morabia A. Relative contributions of genes, environments, and interactions to blood lipid
concentrations in adult populations. American Journal of Epidemiology 2005;161(8):714-724.
Kaestle CE, Halpern CT, Miller WC, Ford CA. Young Age at First Sexual Intercourse and Sexually Transmitted Infections in Adolescents and Young Adults American
Journal of Epidemiology 2005;161(8):771-780. 7
 Reduction vs. reductionism

Reduction: taking something apart to see what it is made of

vs

Reductionism: the illusion that once that has been done, the rest is an
exercise for the reader

Levins R. Whose scientific methods? Scientific methods for a complex world. New solutions: A journal of environmental and occupational health policy. 2003;13(3):
261-274. 8
 Two kinds of etiologic questions

Why do some individuals have disease?

Why do some populations have more disease than others?

The key insight: the determinants of incidence are not

necessarily the same as the causes of causes

Rose G. Sick individuals and sick populations. International Journal of Epidemiology. 1985;14:32-38 9
 Operationally

“What puts one at risk of being murdered in New York City” is

a different question than “what are the factors that determine
community homicide rates?”

Poverty may be associated with the rate of homicide but

individual poverty may not be a risk factor for being murdered

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 The challenge of ubiquity

Rose G. Sick individuals and sick populations. International Journal of Epidemiology. 1985;14:32-38 11
 Understanding individual vs.
population health

Rose G. Sick individuals and sick populations. International Journal of Epidemiology. 1985;14:32-38 12
 Applying the paradigm to prevention

“High-risk” strategy vs. “population” strategy

High-risk strategy aims to achieve the “truncation” of risk distribution

Population strategy aims to control the determinants of incidence and
to shift the whole distribution of exposure in a “favorable direction”

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 Applying the paradigm to prevention

Prevalence of disease

Disease risk

Risk factor
Rose G. The strategy of preventive medicine. Oxford: Oxford University Press; 1992. 14
 The “high risk” strategy

Prevalence of disease

Disease risk

Risk factor
Rose G. The strategy of preventive medicine. Oxford: Oxford University Press; 1992. 15
 Advantages of “high-risk” approach

Intervention appropriate to individual

Motivates person to change behavior
Motivates caregiver to look after patient
Cost-effective use of resources (?)
Benefit-risk ratio favorable

Rose G. Sick individuals and sick populations. International Journal of Epidemiology. 1985;14:32-38 16
 Disadvantages of “high-risk” approach

Difficulties and cost of screening

Temporary and does not address “borderliners”
Limited effectiveness for whole population
Fundamentally flawed when considering population likelihood
of disease

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Persons at “high” vs. “low” risk

High risk Low risk

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 Cases of disease

High risk Low risk Disease

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 Worth remembering

The most common cause of death in those with the lowest

risk of cardiovascular disease is cardiovascular disease

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 The “population” strategy

Prevalence of disease

Disease risk

Risk factor
Rose G. The strategy of preventive medicine. Oxford: Oxford University Press; 1992. Rose 1991 21
 Shifting the curve?

Rose G. Sick individuals and sick populations. International Journal of Epidemiology. 1985;14:32-38 22
 A premise

“The health of populations is a function of the immediate

physical and social context that is in turn shaped by
national and global trends…” and it is the responsibility of
health care researchers and practitioners to understand,
and intervene on, determinants of health at all levels

Modified from Galea S, Freudenberg N, Vlahov D. Cities and population health. Social Science & Medicine. 2005;60(5):1017-33. 23
 Advantages of “population” approach

Potential for achieving meaningful population change

Appropriately considers contribution of different diseases to
population health

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 Disadvantages of “population” approach

Small benefit to individual

Prevention paradox: Preventive measure which brings much
benefit to population offers little advantage to each individual
Little motivation for each individual
Little motivation for physician
Benefit-risk ratio

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 Herd immunity

Resistance of a group to attack by a disease because a large portion

of that population’s members are immune to that disease

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 Herd immunity

Resistance of a group to attack by a disease because a large portion

of that population’s members are immune to that disease

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 Implications of the high-risk vs.
population perspective
“…Rose’s conceptualization requires a shift in thinking,
particularly in contexts where individual autonomy and
choice is given real priority. Social facts imply that individual
autonomy and choice is constrained by social position and
physical environment. One cannot, as an individual, simply
choose to be healthy or to behave in a way that increases
one’s health.”

Schwartz S, Diez-Roux R. Commentary: Causes of incidence and causes of cases: a Durkheimian perspective on Rose. 201;30:435-439. 28
Individual risk factor era

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A broader paradigm?

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 Or, in other words…

Kaplan GA. What's wrong with social epidemiology, and how can we make it better? Epidemiologic Reviews 2004;26:124-135. 31
 2. What motivates epidemiology?

Is it the search for causes of health and disease?

Or is it the search for causes of health and disease so that we may
improve the health of populations?

…put another way…

Is the motivation of epidemiology any different than the motivation of

astrophysics?

Rothman KJ, Adams HO, Trichopoulos D. Should the mission of epidemiology include the eradication of poverty? Lancet. 1998;352(9130):810-3 32
 Succinctly

“Epidemiology can demystify disease sources and explain

determinants in a manner that impacts on public policy and
action. Under current conditions of globalization this implies
addressing methodological challenges and enhancing
uptake of evidence in policy processes”.

Loewenson R. Epidemiology in the era of globalization: skills transfer or new skills? International Journal of Epidemiology. 2004;33:1144-1150. 33
 The divide

“We understand that adding voices to the chorus in favor of

social betterment and human rights will help attract
attention to fundamental social problems…”1

“A powerful and under-recognized value of our work is the

generation of explanations about health….that help people
understand the other side of the “us”/”them” divide…”2

1Rothman KJ, Adams HO, Trichopoulos D. Should the mission of epidemiology include the eradication of poverty? Lancet. 1998;352(9130):810-3.
2Link BG. The production of understanding. Journal of Health and Social Behavior. 2003(44): 457-469. 34
 3. Key pitfalls in epidemiology today

Most epidemiology remains based on individuals

Although in some ways theory is limited, in other ways
methodologic limitations hamper our ability to explicate
pathways guided by theory
Epidemiology extends very little beyond the western world,
limiting its application where it might truly matter and
comparative insights
General hesitation to embrace methods/areas of inquiry
typically reserved for sociologists or economists (note, the
converse is not the case)

Kaplan GA. What's wrong with social epidemiology, and how can we make it better? Epidemiologic Reviews 2004;26:124-135.
Galea S, Ahern J. Considerations about specificity of association, causal pathways, and heterogeneity of association in multilevel thinking. American Journal of
Epidemiology. In Press. 35
 Epidemiologic approach: problems

Tools of epidemiology are based on populations

Estimates of population rates
Estimates of population risks
Rate or risk of disease in a population does not tell you who
will get sick

Rockhill B. Theorizing about causes at the individual level while estimating effects at the population level. Epidemiology 2005;16(1) 124-129.
Kleinbaum DG, Kupper LL, Morgenstern H. Epidemiologic research, principles and quantitative methods.1982 John Wiley & Sons Inc. Hew York, NY. 36
 For example, usefulness of risk factors for
individual disease detection
Odds ratios (relative odds) are related to detection rate for particular
false positive rates independently of incidence or prevalence of
disorder
Therefore, odds ratios essentially compare risk in the tails of the
distribution of the risk factor therefore giving an “overoptimistic
impression of the value of the risk factor used as a screening test”
For example, odds ratio of 5 is associated with a 14% detection rate
and a 5% false positive rate for an individual with a risk factor,
assuming the standard deviations of the risk factor distributions in
people with and without disorder are the same

Wald N, Hackshaw A, Frost C. When can a risk factor be used as a worthwhile screening test? BMJ. 1999;319:152-1565. 37
 Individual risk and population discrimination

Pepe M, Janes H, Longton G et al. Limitations of the odds ratio in gauging the performance of a diagnostic, prognostic, or screening marker. American Journal
of Epidemiology. 2004;159:882-890. 38
 Therefore

Individual-level relative risks, rates, or odds are not terribly

meaningful in terms of identifying who is at risk of disease
And, even if individuals were equipped with such information
about individual risk, what then will individuals do with that
information?

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 The root of this problem

Biologic mechanisms take place in individuals, not in

populations and any one statistical association is consistent
with many mechanisms in individuals
Epidemiology focuses on smaller pieces of disease processes
to isolate different causal mechanisms but makes use of
population averages
Results from estimates using such averages may not be
fruitfully applicable to individuals

Rockhill B. Theorizing about causes at the individual level while estimating effects at the population level. Epidemiology 2005;16(1) 124-129.
Koopman JS, Lynch JW. Individual causal models and population system models in epidemiology. Am J Public Health 1999;89:1170-1174. 40
So.....?

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 A premise: Imagination is central to the
future of social epidemiologic research
We seldom think of “imagination” in conjunction with
research
Failure of imagination could be the primary reason why our
methods, and our theory, may stagnate
We need to apply imagination to our thinking about
1.  The questions we should be asking
2.  The methods we should be employing
3.  Potential solutions that may apply to macrosocial and
economic problems

Emihovich C. Compromised positions: The ethics and politics of designing research in the postmodern age. Educational Policy. 1999;3(1):37-46. 42
 In conclusion

The study of the determinants of disease and the distribution

of disease
Epidemiology is a growing and evolving field, with tremendous
potential and also many challenges
Epidemiologic insight has much to gain from careful
understanding of the questions we are asking, measures of
inference we are applying to answer these questions, and the
conclusions we (judiciously) draw from epidemiologic studies

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