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smallpox could not have been eradicated without a clever,

global strategy to contain it, and malnutrition rooted in


poverty cannot be prevented without societal interventions
that ease the burden of poverty or that address
malnutrition directly.
The distinction between individual and societal
applications of epidemiological knowledge are at the core
of the new wave of criticism. The central complaint is that
epidemiologists have focused on individual risk factors to
the exclusion of broader societal causes of disease. Thus,
wrote Shy, epidemiologists
tell us that a lower fat content of the diet, a lower
population-average body weight, or a lower prevalence of
smoking will reduce the population risk of coronary disease.
But they do not explore societal policies, incentives, or other
interventions at the organised community level that would
bring about a shift in the population distribution of fat
consumption, body weight, or smoking habits.
3
Pearce, one of the harshest critics of epidemiologists,
portrays this slant as a personal and political choice.
4
In
his view, it is not so much the lure of science as an end in
itself that has swivelled epidemiologists to a biomedical
orientation; rather it is a tide of political conservatism and
a personal indifference to the health problems of others
that account for the new direction in epidemiology.
According to Pearce, epidemiologists are so self-indulgent
that they prefer to study decontextualised individual risk
factors instead of upstream causes of health problems,
such as poverty, because
epidemiologists tend to be most interested in risk factors
that they can relate to, or may even be exposed to.
Epidemiologists are frequently at risk from tobacco smoke,
alcohol, diet, viruses, and even some occupational chemical
exposures, but they are rarely at risk of being poor.
4
Pearce has gone so far as to criticise the dogged reliance
of the biomedical establishment on randomised,
controlled trials. Whereas many scientists believe that a
randomised trial is a crucial tool in helping distinguish
causes from confounding factors, Pearce claims, without
any illustration, that randomised trials can be dangerous
instruments of decontextualisation that are
inappropriate in studies that require a consideration of the
historical and social context. The danger is that attempting
to eliminate the influence of other causes of diseasesin an
attempt to control confoundingstrips away the essential
historical and social context . . ..
4
Accusat i on 2: epi demi ol ogi st s need more moral
and pol i t i cal f i bre
Critics contend that epidemiologists have a greater
responsibility than merely to study the causal role in
human health of factors such as poverty or tobacco
consumption. In their view, epidemiologists must also
strive to eradicate the upstream causes of health problems.
For example, if epidemiological research indicates that
poverty causes malnutrition, which in turn causes infant
Physicists seem to have escaped the old criticism that their
work is impractical. Perhaps the criticism was blunted by
technological innovations that rest on physical theory.
Nevertheless, even astrophysicists, whose work seldom
induces engineering breakthroughs, can now pursue
knowledge for its own sake without fear of being badgered
about the practical relevance of their work. What
physicists have gained, however, epidemiologists seem to
have lost. Accusations have been mounting that
epidemiologists have abandoned their public-health
mission of being physician-scientist to society
1
in favour
of studying the scientific arcana of disease causation.
Editors at TheLancet suggested last year that the woolly
breadth of this criticism should be replaced by a detailed
proposal for what should be done to put public health
back into epidemiology.
2
We believe that, contrary to
what the critics suggest, epidemiology has been evolving in
line with its public-health mission, and that the criticism
itselfhowever noble in its motivationis not coherent.
The critics allege that epidemiologists have lost their
traditional social perspective; instead, they argue,
epidemiologists have become mired in statistical
procedures and molecular mechanisms in the study of
individual risk factors of lesser and lesser importance.
According to Shy, who deigned to put academic
epidemiology on trial, the focus of [epidemiology] still
remains on understanding the proximate and individual
rather than the underlying and societal determinants of
disease.
3
Accusat i on 1: epi demi ol ogy i s t oo
i ndi vi dual i st i c
As with other biomedical sciences, epidemiology yields
practical knowledge. Many applications can be carried out
directly by individuals. For example, information about
the risks of having unprotected sex can persuade people to
change their sexual behaviour, and information about the
risks of smoking can motivate smokers to give up their
habit. These actions are, to some extent at least, personal
choices, which public-health programmes can influence
through educational materials, as they have done through
campaigns on smoking and health.
Other epidemiological knowledge, however, cannot be
easily applied without actions at societal level. Thus,
Should t he mission of epidemiology include t he eradicat ion of
pover t y?
Kenneth J Rothman, Hans-Olov Adami, Dimitrios Trichopoulos
VIEWPOINT
810 THE LANCET Vol 352 September 5, 1998
Lancet 1998; 352: 81013
Depart ment of Medi ci ne and Epi demi ol ogy, Bost on Uni versi t y
Medi cal Cent er, Bost on, MA, USA (Prof K J Rothman DrPH),
Depart ment of Epi demi ol ogy, Harvard School of Publ i c Heal t h,
Bost on, MA, USA (K J Rothman, Prof H-O Adami MD,
Prof DTrichopoulos MD); and Depart ment of Medi cal Epi demi ol ogy,
Karol i nskay, Inst i t ut e, St ockhol m Sweden (H-O Adami)
Correspondence t o: Prof Kenneth J Rothman, Boston University,
School of Medicine, Evans Department of Medicine, Section of
Preventive Medicine and Epidemiology, Boston, MA, 02118-2526,
USA
Viewpoint
death, the epidemiologists responsibility is to work
towards the elimination of poverty. This activity requires
the lumbering apparatus of social and political forces to be
set in motionsomething that most epidemiologists have
been loath to attempt. Critics claim that todays
epidemiologists lack the moral resolve and political fire to
complete their professional mission. In a 1997 book,
Public Health at the Crossroads, Beaglehole and Bonita
write
5
Unfortunately, for many epidemiologists the study of social
factors is considered too political . . . it is necessary for
epidemiology to affirm its connection with policy and to
reject scientific isolation.
Susser and Susser
6
suggest that the perceived drifting of
epidemiologists away from social commitment stems from
a deficiency in their training. They argue
a practical programme must be devised to ensure that, in
the course of their education, epidemiologists are socialised
in a manner that keeps alive the idea of improving the public
health as a primary value.
6
In short, some critics believe that epidemiologists of
today lack a firm commitment to public health. Instead,
claim the critics, they fritter away their professional time
by studying scientific minutiae at the expense of urgent
public-health problems.
Knowl edge bef ore act i on, or Ready, Fi re,
Ai m ?
There is no denying that epidemiologists have
progressively concentrated on the details of causal
mechanisms. The only surprise to us is that anyone would
regard this preoccupation with causal mechanisms as a
problem. In past decades, epidemiologists could be
criticised for studying mostly superficial relations between
exposure and disease occurrence. Now the field is
maturing, along with other biological sciences, and such
superficiality is gradually being replaced with clearer
insights into causal pathways. Whereas epidemiologists
once studied factors such as dietary-fat consumption and
total serum cholesterol, they have now progressed to
classifying dietary fat by chemical structureby
comparison of low to high lipoprotein ratiosand are
moving on to assessing the protective effect of antioxidants
on fat-induced endothelial impairment.
7
Is the preoccupation with causal mechanisms as
detrimental as critics allege?Not if reasonable
knowledge of causation is deemed a sensible antecedent to
intervention. If the moral purpose of epidemiology is to
alleviate the human burden of disease, the primary task of
epidemiologists should be to acquire insight into the
causal chain, starting from root causes and continuing up
through the beginnings of the disease itself. True, we do
not necessarily need to know every detail about the
pathway between intervention point and outcome; we can
infer the effects of interventions even with gaps in
understanding, just as John Snow showed how to curtail
cholera before Vibrio cholera was identified. Knowledge is
never perfect, and action is often indicated in the face of
substantial uncertainty. Public-health professionals,
however, do not have a license to tinker promiscuously
with society. Public-health programmes may be conceived
and implemented with great hope and yet turn out to be
useless,
8
or even damaging. One and a half centuries after
Snows work on cholera, the public-health threat from
the disease lingers, as research continues into how
pathogenicity of the Vibrio organism depends on the El
Nio Southern Oscillation, and how cholera may spread
between continents through ocean currents.
9,10
For
cholera, as for other diseases, the more knowledge we
acquire of causal pathways at all pointsfrom the most
fundamental or ultimate social, political, and
economic determinants to the molecular and biochemical
determinants most proximal to disease occurrencethe
better the foundation we lay for any effective public-health
action.
To observe, for example, that in regions where poverty
is rife, a given disease occurs at a greater rate than in areas
not affected by poverty, is surely not enough.
Epidemiologists have been preoccupied with methodology
mainly because they understand that such comparisons
are often affected by innumerable biases that can lead to
false inferences. Their preoccupation with methods is the
inevitable evolutionary consequence of their drive to
understand the causes of disease in the natural human
environmentrather than in the laboratory cage or the
petri dish. The same kind of concern that makes
epidemiologists wary of ecological comparisons impels
them to carry out randomised trials when experiments are
ethical and feasible.
When i s i nt ervent i on most ef f ect i ve?
Generally, the further upstream we move from the
occurence of disease towards root causes, the less secure
our inferences about the causal path to disease become.
Even if our inference is correct, moreover, intervention
with respect to upstream causes may be less efficient and
therefore less effective than intervention closer to disease
occurrence. Consider the causal path: poverty to
malnutrition to infection to death. Control of infection at
the level of the human individual may be the most
efficient way to prevent death in this causal chain. True, if
control of infection does not address the malnutrition
underlying the infection, the infection is likely to recur;
one might therefore reasonably look upstream to address
the malnutrition problem. Nevertheless, if we attempt to
combat malnutrition without also dealing with the
concomitant infections, many people will die needlessly.
Furthermore, there may be little that an epidemiologist
can do in the short term to overcome malnutrition as a
population problem. To awaken the public or political
authorities to the problem of malnutrition and to redirect
societal resources may eventually do the trick, but public-
health accomplishments mediated through social changes
are won slowly. In the meantime, through their study of
risk factors at the individual level and by the use of
randomised trials, epidemiologists have discovered that
vitamin-A supplements can prevent serious morbidity and
many deaths in malnourished children.
1112
This
knowledge will save lives, despite the fact that it does not
alleviate gross malnutrition, does not require manipulation
of any upstream cause, and is obtained from the type of
epidemiological work that critics of epidemiology
disparage.
What i s t he publ i c-heal t h sol ut i on t o t he
povert y probl em?
The ultimate step in the preceding intervention scenario is
to eliminate the poverty that causes the malnutrition. The
critics urge that we take this step. It requires deep societal
involvement in a laudable public-health endone that any
VIEWPOINT
THE LANCET Vol 352 September 5, 1998 811
VIEWPOINT
humane person would embrace. Yet, it is only fair to ask
whether epidemiologists have the means to eradicate
poverty. Is poverty eradication a public-health
programme? How exactly should it be accomplished?
Economists would seem the most likely candidates to
supply the answer, which might go something likeLet
markets be free to expand without guiding them too
firmly. But other economists might give a different
answer. Do the critics of epidemiology suggest that
epidemiologists should lobby against international trade
barriers, or in favour of them, in the pursuit of their
public-health objectives? Perhaps the critics believe that
epidemiologists should second-guess economists and
attempt to eradicate poverty using their own
epidemiological model. Given the scope of the task,
sympathy might go to the epidemiologists who prefer to
focus on a comparatively simple problem, such as the
causes of cancer.
Di d epi demi ol ogi st s cause t he gl obal t obacco
probl em?
Beaglehole and Bonita,
5
and Pearce,
4
cite the global
tobacco problem as another example of epidemiological
malfeasance. Their theme is that epidemiologists fiddle
while the epidemic burns: epidemiologists have, ostrich-
like, studied the effects of tobacco smoking well beyond
the need to characterise this health menace. [I]t can be
argued that the fundamental problem of tobacco, says
Pearce, lies in its production, rather than in its
consumption.
4
Beaglehole and Bonita go further,
blaming the worldwide tobacco problem in part on
epidemiologists themselves, whose studies focussed on
consumption and not on production, have only added to
the inequalities in health between the poor and rich within
wealthy countries, and between poor and wealthy
countries.
5
Apparently, they believe that epidemiologists
would have done better to lobby against the planting and
manufacturing of tobacco than to carry out research on its
health effects, and that their failure to take concerted
action makes them responsible for the fact that tobacco
remains heavily promoted and a legal product in every
nation on earth. Although it is true that tobacco
production will ultimately have to be curtailed to eliminate
this health menace, to attack those who brought the
tobacco problem to light is bizarre. The need to deal with
tobacco production in no way diminishes the importance
of the many epidemiological studies that have illuminated
the full detail of the problem. Skeptics might also question
whether control of production is feasible without
diminishment of consumption first; as the illicit drug trade
illustrates, to believe that production can be turned off in
the face of strong demand is simplistic.
Al l povert y i s unaccept abl e
We agree wholeheartedly that the study of the social
causes of disease is an important epidemiological goal, and
that societal causes can explain much of the variation in
disease occurrence. We abhor tobacco promotion and
production. We would like to see the eradication of
poverty, and agree with Susser and Susser that
epidemiologists should be well educated with regard to
their public-health role.
Nevertheless, the importance of societal causes of
disease does not mean that biological pathways to disease
should be ignored, or that epidemiologists who choose to
study causal mechanisms have been neglecting their
mission. Furthermore, as with any public-health
professionals who share humanist values, epidemiologists
do not need to establish the health effects of poverty to
know that society should aim to eliminate it. Two decades
ago, a prominent college dean in public-health spoke out
against nuclear war. His innovative argument was that
nuclear war should be banned because it would disrupt
the delivery of health services. In the same vein, todays
critics of epidemiology use health as an argument for
social endssuch as the eradication of povertythe
desirability of which is obvious and quite independent of
their public-health consequences.
14
Perhaps the most valuable message in this new criticism
of epidemiology is simply that those who wish to ease the
burden of disease should not forget that the people of the
world often bear larger burdens than those we sometimes
choose to study. Nevertheless, epidemiologists cannot be
expected to solve every problem, especially not those
beyond our expertise. However well motivated,
epidemiologists cannot rid the world of poverty. Even if
we claimed that poverty is the root cause of all disease,
which it surely is not, we would hardly be closer to solving
the problemjust as we were no closer to eliminating the
threat of nuclear war after pointing out that Armageddon
would interfere with physicians treatment of their patients.
We understand that adding voices to the chorus in
favour of social betterment and human rights will help
attract attention to fundamental social problems. There is
no reason to believe that epidemiologists have become
more reluctant to combat poverty, injustice, and
oppression. Yet, epidemiologists are not social engineers;
they are public-health scientists who have a right to
specialise as they see fit. They should be free to choose the
subject of their inquiries, whether it be social causes or
molecular causes of disease. They should not be
discouraged from answering questions such as whether
vitamin-A supplements in poverty-stricken children will
reduce morbidity and save young lives. The answers to
such questions will prevent deaths with an immediacy that
social reforms, however desirable, cannot match. To get
such answers, we must study decontextualised disease
mechanisms in individuals.
It is remarkable that epidemiologists are now chastised
for their scientific accomplishments, which include such
victories as the elaboration of the effects of tobacco
smoking on many diseases, and the effect of folic acid on
neural-tube defects. Countless other fragments of useful
epidemiological knowledge, such as the benefits of breast
milk over infant formula, have enabled many people to
improve their health even if they could not avoid poverty
and repression. If an astrophysicist can study the origin of
the universe without apology, should an epidemiologist
have to apologise for work that is so practical?
For helpful comments, we thank Katarina Augustsson, Cristina Cann,
Nancy Dreyer, Sander Greenland, Stephan Lanes, Charles Poole,
David Savitz, Ezra Susser, Mervyn Susser, Aleaxander Walker, and
Allen Wilcox.
Supported by grants from the Swedish Cancer Society.
References
1 Susser M. Epidemiology today: A thought-tormented world. Int J
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2 Editorial. Putting public health back into epidemiology. Lancet 1997;
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3 Shy CM. The failure of academic epidemiology: witness for the
prosecution. AmJ Epidemiol 1997; 145: 47984.
812 THE LANCET Vol 352 September 5, 1998
I n actual fact, Crohn called the disorder eelietis
(because of his New York accent) and that I found
appropriate because Sir Kennedy Dalziel, the
Glaswegian surgeon who had described the disease, in
immaculate clinical detail, 20 years before Crohn and
colleagues,
3
had suggested that the appearance of the
terminal ileum resembles that of an eel in rigor mortis.
I t was because I believed that Dalziel had not been
given the credit due to him that I attempted to do so in
1987. My plea was turned down flat by the editors of
both The Lancet and the BMJ , who argued that
Crohns disease had come to stay and that was that.
The Bristol editor took a more lenient view and
published my suggestion
4
that the name should be
changed. Unfortunately Dalziel is pronounced Dayell,
or something akin to that, and nobody could be
expected to postulate such an eponym. So I suggested,
as a compromise, Crohn-Dalziel disease; and to my
surprise and gratification, I found it being used at a
recent surgical conference. I once asked Ginzburg if I
should attempt to change the name, Not only you
should (he replied); you must. That is my justification.
Second, the pathology. Crohn described regional ileitis
as a clinical entity, and so it is.
2
Contemporary
pathologists have turned the disease into an academic
beanfeast. Squinting down their microscopes they
identify Crohns disease throughout the entire digestive
tract, from the gingiva to the muscle of Ellis, better
known as the Corrugator cutis ani. This is about as far
from what Dalziel had in mind as calling Scotch, Coca-
Cola.
Next, history. Any searcher-after-truth knows that the
further one looks back, the more references come to
light. So although Dalziel anticipated Crohn and
colleagues, he himself was certainly not the first.
Moynihan, in 1907, and Mayo Robson, in 1908, had
written papers on I nflammatory tumours of the
bowel. I myself once suggested that, mouldering in the
British Museum or the Bodleian, someone will find a
I n July, 1986, The Lancet published a personal paper
entitled Crohns disease: two fortunate young men,
1
which I had written with A G S (Joe) Bailey to celebrate
our 50th and 43rd anniversaries since elective surgery
for the treatment of so-called Crohns disease by
excision of our affected small intestines. My operation
was performed in 1936, when I was about to qualify
from St Bartholomews Hospital, and Joes was done in
1943, when I assisted Mr Harold Wilson (as his then
Chief Assistant) and who performed both our
operations. We related these events in our article; and
we promised ourselves that 10 years later we would
write a follow-up paper. I an Munro, TheLancets editor
at the time, was generous enough to respond that he
would look forward to us so doing. Fate decided
otherwise. By 1996, I had been forced to submit to a
couple of trivial complaintsan aortic valve
replacement (from a small piglet) and a rather
troublesome colostomy, which today behaves, possibly
due to the absence of my ilea-caecal valve, more like an
ileostomy. I n 1997, Joe, alas, died. Hence my title. My
purpose in writing yet again about this strange disorder,
now universally known as Crohns disease, is to attempt
to clear up, if possible, some misconceptions about its
origin and nomenclature.
First, the name. The landmark (sic) article published
in the J ournal of The American Medical Association in
1932,
2
was written by three pathologists, since the
surgeon who was also involved in the investigation, A A
Berg, declined to put his name to a joint report. Crohn
himself accepted that Ginzberg had done most of the
work and never sought the eponym for himself. The
practice of according authorship alphabetically led to
the disorders present name. This I know because I
spoke to and corresponded with Crohn and Ginzberg
for several years before their deaths. Berg I never met.
One for t unat e ol d man
Michael Harmer
ESSAY
THE LANCET Vol 352 September 5, 1998 813
Lancet 1998; 352: 81314
Perrot Wood, Graffham, Pet wort h, Sussex GU28 0NZ (M Harmer)
Essay
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