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The future
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What is epidemiology?
2
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?
3
1. Shifting paradigms
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
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The epidemiologic approach
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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”
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
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
Rose G. Sick individuals and sick populations. International Journal of Epidemiology. 1985;14:32-38 9
Operationally
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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
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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
Rose G. Sick individuals and sick populations. International Journal of Epidemiology. 1985;14:32-38 16
Disadvantages of “high-risk” approach
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Persons at “high” vs. “low” risk
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Cases of disease
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Worth remembering
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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
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
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Disadvantages of “population” approach
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Herd immunity
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Herd immunity
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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?
Rothman KJ, Adams HO, Trichopoulos D. Should the mission of epidemiology include the eradication of poverty? Lancet. 1998;352(9130):810-3 32
Succinctly
Loewenson R. Epidemiology in the era of globalization: skills transfer or new skills? International Journal of Epidemiology. 2004;33:1144-1150. 33
The divide
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
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
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
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The root of this problem
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
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