Milton Terris1

October 15,1992 Sponsored by the Society for Epidemiologic Research

SPECIAL SOCIETY FOR EPIDEMIOLOGIC RESEARCH (SER) ISSUE: Downloaded from PAPERS PRESENTED AT THE 25TH ANNUAL MEETING OF THE SER, MINNEAPOLIS, MINNESOTA, JUNE 9-12, 1992

INVITED ADDRESSES http://aje.oxfordjournals.org/

The Society for Epidemiologic Research (SER) and the Future of Epidemiology at Oxford University Press for SER Members on April 15, 2014 Milton Terris1

I appreciate very much this opportunity SOCIAL MEDICINE IN GREAT BRITAIN to help celebrate the 25th Anniversary of the In that same year, 1943, John A. Ryle, Society for Epidemiologic Research (SER). the Regius Professor of Medicine at Cam- I think it will be useful to present the histor- bridge, resigned his position to become the ical background to the Society's formation first Professor of Social Medicine in Great as a necessary prelude for discussing SER Britain, accepting the Chair which had just and the future of epidemiology. been established at Oxford University. This I was a student in 1943 at the Johns dramatic event signalized the leap from in- Hopkins School of Hygiene and Public fectious disease to noninfectious disease ep- Health, where Wade Hampton Frost had idemiology. As Ryle stated, "Public health served as the first Professor of Epidemiology. ... has been largely preoccupied with the Frost had defined epidemiology as "the sci- communicable diseases, their causes, distri- ence of the mass-phenomena of infectious bution, and prevention. Social medicine is diseases" (1), and the epidemiology courses concerned with all diseases of prevalence, at Hopkins were limited entirely to infec- including rheumatic heart disease, peptic ul- tious diseases. We studied Panum on Mea- cer, the chronic rheumatic diseases, cardio- sles (2) and Snow on Cholera (3), but the vascular disease, cancer, the psychoneu- great American classic of epidemiology, roses, and accidental injuries—which also Goldberger on Pellagra (4), was not men- have their epidemiologies and their correla- tioned. tions with social and occupational condi- tions and must eventually be considered to Received for publication June 19, 1992. be in greater or less degree preventable" (5). 1 Editor, Journal of Public Health Policy, 208 Mead- The British movement toward social medi- owood Drive, South Burlington, VT 05403. cine which Ryle symbolized was essentially This paper was presented as an Invited Address at the 25th Annual Meeting of the Society for Epidemiologic a movement toward noninfectious disease Research, Minneapolis, MN, June 9-12, 1992. epidemiology. 909 910 Terris

The connecting link between infectious eminent epidemiologists, including Milton and noninfectious disease epidemiology in J. Rosenau, author of the first comprehen- Great Britain was Major Greenwood, Pro- sive American textbook on public health fessor of Epidemiology and Vital Statistics (14), who was Director of the Hygienic Lab- at the London School of Hygiene; President oratory from 1899 to 1909, then Professor of the Royal Statistical Society; primary au- of Preventive Medicine at Harvard Medical thor, with Bradford Hill, Topley, and Wil- School, Professor of Epidemiology at the son, of the pioneering work on the Experi- Harvard School of Public Health, and fi- mental Epidemiology (6) of infectious dis- nally Dean of the University of North eases; and author of Epidemiology and Carolina School of Public Health; and Wade Downloaded from Crowd Diseases, An Introduction to the Hampton Frost, who was assigned by the Study of Epidemiology, the first textbook to US Public Health Service to the Johns Hop- include cancer in its scope (7). kins School of Hygiene and Public Health Major Greenwood combined the two dis- in 1919 to develop the first university de- http://aje.oxfordjournals.org/ ciplines, epidemiology and biostatistics, in partment of epidemiology (15). his own person. The tradition of interdisci- The Hygienic Laboratory did not limit plinary collaboration at the London School itself to infectious diseases. One of its offi- of Hygiene was carried forward by Green- cers, Dr. Joseph Goldberger, solved the wood's colleagues, the epidemiologist Rich- problem of pellagra through investigations ard Doll and the statistician A. Bradford conducted from 1914 to 1930; these stand Hill. In 1950, Doll and Hill shared honors with John Snow's work on cholera as a

with two American groups, Wynder and classic of epidemiologic research (4). In at Oxford University Press for SER Members on April 15, 2014 Graham, and Levin, Goldstein, and Ger- 1931, a year after the Hygienic Laboratory hardt, in publishing the results of the first was renamed the National Institute of major retrospective studies linking cigarette Health, Dr. H. Trendley Dean began his smoking and lung cancer (8-10). And it was important epidemiologic studies of fluorine Doll and Hill who carried out the first pro- and dental caries; these culminated in the spective study confirming this relation (II- Grand Rapids-Muskegon fluoridation ex- 13). They and their colleagues at the London periment conducted by the US Public School of Hygiene—including Donald Reid, Health Service. And, beginning in 1910, the Peter Armitage, and Jerry Morris—provided Service carried out numerous studies in oc- the most important center for the develop- cupational epidemiology, including investi- ment of noninfectious disease epidemiology gations of silicosis, lead poisoning, industrial in Great Britain. dermatoses, radiation, pneumoconiosis, and mercury poisoning (15). PUBLIC HEALTH IN THE UNITED After World War II, there was further STATES expansion of federal leadership in epidemiologic research. The Communicable Disease Research in noninfectious disease epide- Center was founded in 1946 by conversion miology in Great Britain developed primar- of the wartime agency for Malaria Control ily as an academic discipline. This was quite in War Areas; it is now the Centers for different from the situation in the United Disease Control, which is concerned with a States, where epidemiologic research had de- wide variety of infectious and noninfectious veloped primarily as a function of federal, diseases. Perhaps one of the most important state, and local health departments. In 1891, federal actions was the establishment of a the Hygienic Laboratory was organized by statistical unit in the National Cancer Insti- the US Public Health Service (then the tute under the leadership of a sociologist, Marine Hospital Service), and rapidly be- Harold Dorn. This unit, which included came the focal point for epidemiologic re- such outstanding statisticians as Jerome search in the United States. It was the train- Cornfield and Nathan Mantel, made major ing ground for many of the country's most contributions to the methodology of nonin- SER and the Future of Epidemiology 911 fectious disease epidemiology; it became, in Departments in cancer epidemiology; and a sense, the statistical nerve-center of the the Ohio State Health Department in the entire movement. During this period, also, epidemiology of occupational diseases. And the Framingham studies were begun by the local health departments in New York National Heart Institute. These turned out City, Chicago, and Los Angeles produced to be perhaps the most important investiga- important findings in the epidemiology of tions ever carried out in the field of cardio- cardiovascular disease. vascular epidemiology; they opened up an

entirely new area of public health, pointing Downloaded from the way toward the conquest of the pan- ORIGINS OF THE SOCIETY FOR demic of coronary heart disease. EPIDEMIOLOGIC RESEARCH A number of the more advanced state The role of epidemiology in achieving ma- health departments also played important jor scientific breakthroughs received na-

roles in the development of noninfectious tional and international attention in the dec- http://aje.oxfordjournals.org/ disease epidemiology. The people of Mas- ades following World War II. Funds were sachusetts, for example, alarmed by the made available for epidemiologic training growing problem of cancer and other and research. In the schools of public health, chronic diseases, "had demanded with in- the replacement of the infectious disease- creasing insistence that action be taken, and oriented chairs of epidemiology with repre- through a legislative resolve passed in 1926 sentatives of the new approach—a process the Massachusetts Department of Public which took several decades to complete—

Health was committed to a program of can- was begun at Harvard in 1958 with the at Oxford University Press for SER Members on April 15, 2014 cer control" (16). George H. Bigelow and appointment of Brian MacMahon, an im- Herbert L. Lombard of that Department port from England who had been a fellow in carried out intensive investigations, both de- social medicine with Thomas McKeown in scriptive and analytic, of cancer epidemiol- Birmingham. The first textbooks of epide- ogy. Their pioneering work, Cancer and miology based primarily on noninfectious Other Chronic Diseases in Massachusetts, disease appeared: Morris's Uses of Epide- published in 1933, includes one of the first miology (18) in Great Britain in 1957, and case-control studies to demonstrate the re- MacMahon, Pugh, and Ipsen's Epidemio- lation of tobacco use to cancer of the buccal logic Methods (19) in the United States in cavity (16). This study was later extended to 1960. include lung cancer, for which the same Young people flocked to the field, re- relation was reported in 1945 (17). It was sponding to the increased opportunities for these findings that prompted Morton Levin training and research and to the excitement and his colleagues in the Division of Cancer of the rapidly growing list of accomplish- Control of the New York State Department ments of this new area of epidemiology. The of Health to undertake their landmark study professional epidemiologists were joined by of the relation of tobacco to lung and other pathologists, physiologists, chemists, intern- cancers, which, published in 1950 in the ists, and other specialists. The verve and Journal of the American Medical Association spirit of these epidemiologists, whatever (9) with a similar paper by Wynder and their background, was reminiscent of Wil- Graham (8), signaled the beginning of the liam Henry Welch's description of the sci- first great scientific breakthrough resulting entific explosion that ushered in the first from the new epidemiology. epidemiologic revolution: "At the end of Several other states made outstanding that wonderful decade, 1880-1890, perhaps contributions to the development of nonin- the most wonderful decade in the history of fectious disease epidemiology: the New York medicine, there had been a revolution in State Department of Health, particularly in medical thought through the discovery of cancer, heart disease, and dental caries; the the agents causing infectious disease—such California and Connecticut State Health discoveries as the bacillus of tuberculosis, of 912 Terris

Asiatic cholera, of diphtheria, of typhoid on consideration of its fundamental tasks. I fever, and other infectious diseases. Those define the field broadly, as follows: living today can hardly realize the enthusi- Epidemiology is the study of the health of asm and youthful spirit which was stirred human populations. Its functions are: not only among medical men, but in the general public by these discoveries" (20). 1. To discover the agent, host, and environ- During the 1950s, associations devoted mental factors which affect health, in order to provide the scientific basis for the pre- primarily to noninfectious disease epidemi- vention of disease and injury and the pro- ology were organized: the Society for Social motion of health. Medicine in Great Britain, and the Interna- Downloaded from tional Epidemiological Association. In the 2. To determine the relative importance of causes of illness, disability, and death, in United States, the American Epidemiologi- order to establish priorities for research and cal Society, concerned primarily with infec- action. tious diseases, was unable to include the large number of new recruits to epidemiol- 3. To identify those sections of the popu- http://aje.oxfordjournals.org/ ogy because it had limited capacity for ex- lation which have the greatest risk from specific causes of ill health, in order that pansion: only those nominated by existing the indicated action may be directed appro- members could be considered, and their priately. qualifications and scientific contributions had to be evaluated and approved by a mem- 4. To evaluate the effectiveness of health programs and services in improving the bership committee. health of the population.

This is why, in 1967, we wrote the letter at Oxford University Press for SER Members on April 15, 2014 to epidemiologists which was republished It should be noted that all four of these in the Fall 1991 SER Newsletter with the research functions are described in terms of announcement of this 25th Anniversary their specific relations to public health, their meeting. It stated that "We have been con- contributions to the social goal of improving cerned for some time with the need for an the health of the population. That goal is organization of epidemiologists which now being achieved by the public health would include all those who are active in movement, which, despite many obstacles, this field. Such an organization would pro- is applying the results of epidemiologic re- vide a common meeting ground for stimu- search with increasing success. This is al- lation and encouragement of the different ready evident in US mortality data. From generations of epidemiologists and the var- 1970 to 1987, the age-adjusted death rate ious categories of specialists in infectious, declined by 33 percent for heart disease, 55 chronic and mental disease epidemiology" percent for cerebrovascular disease, 35 per- (21). We had hoped to have an eminent cent for accidents, and 40 percent for infectious disease epidemiologist join us in chronic liver disease and cirrhosis. As a re- signing the letter, but he declined. Undoubt- sult, the overall death rate fell by 25 percent, edly, this was because of his many years of a remarkable achievement (22). membership in the American Epidemiolog- ical Society and the possible embarrassment TRENDS IN ORIENTATION resulting from sponsorship of what appeared to be a rival organization. The future of epidemiologic research depends on many factors, including the state of the US economy, the willingness of legislators to provide the necessary funds, and THE FUNCTIONS OF EPIDEMIOLOGY the degree of understanding and support by This, then, is the background for the for- the public at large. But it also depends on mation of SER. Let me now turn to a dis- factors related to the background and ori- cussion of the future of epidemiology, based entation of epidemiologists themselves. SER and the Future of Epidemiology 913

One such factor is the shift of epidemio- observations made originally in his practice, logic research from health departments to developed and tested the hypothesis that the schools of public health as a major locus. rubella early in pregnancy causes congenital As a result, some of the intrinsic tendencies malformations (23). It would be valuable, of academic life have become increasingly also, for epidemiologists to work closely with evident: a greater concern with the meth- laboratory scientists who could help deepen odology of data manipulation than with the their understanding of disease processes. solution of disease problems; a withdrawal There are still many areas of epidemio- from the community, from field studies in logic research in which we have come to Downloaded from which the investigator knows the data and dead ends because of the lack of suitable their limitations, and the increased use of hypotheses. Perhaps we should change the someone else's data regardless of their value; current situation in our teaching programs, an orientation geared more to the goal of in which the formulation of hypotheses re- "publish or perish" than to the goal of pre- ceives little or no attention, while most of http://aje.oxfordjournals.org/ venting disease and death; and, finally, an the time and effort is spent on teaching how arrogant and elitist attitude toward the to test hypotheses. All of us need to learn, health officer that is similar to the academic not only how to formulate hypotheses, but clinician's attitude toward the medical prac- how to formulate productive hypotheses that titioner. will break through the dead ends and move Another factor is the widespread overem- the field forward. phasis on statistical approaches, with the Unlike doing tests of hypotheses, the for- at Oxford University Press for SER Members on April 15, 2014 concomitant tendency to neglect the fact mulae for which can be learned by most that epidemiology is a biologic science con- people, the ability to develop a good hypoth- cerned with disease in human beings. This esis is a creative act, one that requires the lack of a biologic orientation has led a num- ability to synthesize available information in ber of eminent statisticians into serious er- an unusual and original manner. Such crea- ror. Joseph Berkson, J. Yerushalmy, R. A. tivity is relatively rare, and whether we can Fisher, and others took a negative position teach it in our courses is problematical. in the lung cancer controversy because they Nevertheless, we need to try. A part of the had a purely statistical view of the problem; time we now give in our courses to painstak- they failed to recognize the important fact ing analyses of the methods by which given that the smoking hypothesis was physiolog- hypotheses are tested by case-control, co- ically reasonable and sound. hort, experimental, and other studies, could The clinical disciplines are a major com- easily be devoted to similarly painstaking ponent of the biologic side of epidemiology. analyses of the laboratory, clinical, epide- They not only help determine whether hy- miologic and other bases of hypothesis for- potheses are biologically reasonable, but mulation. they also identify the specific cases that re- There are many instructive examples quire epidemiologic investigation. Most im- which provide documentation on both suc- portant, the clinical disciplines provide a cessful and unsuccessful hypotheses for the major source of epidemiologic hypotheses. same disease: pellagra, cholera, retrolental For example, it was chest surgeons such as fibroplasia, syphilis, coronary heart disease, Evarts Graham (8) who first noted the as- yellow fever, etc. The history of the contro- sociation of cigarette smoking and lung can- versy between contagionists and anticonta- cer in their patients. The epidemiologists gionists is full of significant lessons on hy- came later, carrying out the numerous in- pothesis formulation. The study of these and vestigations which tested and eventually other lessons will sharpen our wits, show us proved the truth of the surgeons' hypothesis. the pitfalls, and perhaps even teach us to And it was an Australian ophthalmologist, formulate new and more productive hy- N. McAlister Gregg, who, on the basis of potheses. Thereby the past may be used to 914 Terris help us solve our current problems and undertake field experiments designed to sub- strengthen the forward surge of epidemiol- ject different methods of organizing medical ogy. care personnel and facilities to epidemiologic evaluation, by determining the effect on outcomes, on the health of the people THE FRONTIERS OF EPIDEMIOLOGY receiving care. And, most important of all, The concerns of epidemiologic research epidemiologists must greatly expand their have broadened considerably in recent years. role in improving preventive programs The resurgence of cholera (now pandemic through experimental studies of alternative Downloaded from in the Americas), the increase in sexually strategies and tactics in both infectious and transmitted diseases, and the re-emergence noninfectious diseases. This will require of tuberculosis, are regressive phenomena closer working relationships with federal, which require further study and explanation state, and local health departments. as a guide to appropriate action. New dis- Your success in addressing this agenda for http://aje.oxfordjournals.org/ eases have arisen, such as legionellosis, gen- research will help determine the future of ital herpes, and the most frightening of all epidemiology and its role in improving the modern pandemics, HIV infection and health of the public. However, the future of AIDS; these have presented major problems epidemiology does not depend on the epi- for epidemiologic research. demiologists alone. As I stated earlier in this The recent epidemics of noninfectious dis- paper, it is influenced by many factors, including the state of the economy, the will- eases, such as the Bhopal and Chernobyl at Oxford University Press for SER Members on April 15, 2014 disasters, emphasize the need for much ingness of legislators to provide the necessary greater attention to research on the occupa- funds, and the degree of understanding and tional and environmental hazards that pro- support by the public at large. duce disease and injury. The etiology of Epidemiology is a key component of pub- many noninfectious diseases is still to be lic health, and epidemiologists constitute an determined; diabetes, arthritis, mental dis- important sector of public health workers. ease, duodenal ulcer, Alzheimer's disease, They are employed in federal, state, and and various sites of cancer are among the local health departments, schools of public major examples. health, departments of community and pre- In addition, there is greater recognition ventive medicine, and voluntary health now of the need to study the epidemiology agencies. The funding for their research of health, not only in the sense of well-being, comes from these public health agencies, but also in terms of ability to function. Re- and foremost among them is the federal cent investigations of the effect of maternal government through the US Public Health and child nutrition on physical growth and Service. mental performance provide a case in point. The support of all public health services, Finally, epidemiologists need to give including epidemiology, is being placed in much greater attention to research on the jeopardy by the current pandemic of budget- effectiveness of health services. These serv- cutting, which has already affected health ices for prevention, treatment, and rehabili- departments, universities, and voluntary tation are important determinants of health health agencies. The chronically inadequate status. It is essential, therefore, for all aspects funding of epidemiology and other compo- of current medical therapy to be systemati- nents of public health is being threatened cally subjected to the critical tools of epide- further as expenditures for medical care— miology in order to determine their effect for treating the failures of epidemiology and on disease outcomes. The US Public Health public health—continue to escalate. Service has already undertaken such re- Epidemiologists, and other public health search through nationwide trials of alterna- workers, cannot stand idly by while their tive treatments for breast cancer and other ability to carry on and improve their work diseases. We now have the capacity, also, to is being undermined. The American College SER and the Future of Epidemiology 915 of Epidemiology has responded by making al. Experimental epidemiology. Medical Research Council, special report series, no. 209. London: arrangements for information services on HMSO, 1936. legislative developments in the nation's cap- 7. Greenwood M. Epidemics and crowd diseases: an ital. Epidemiologists and other public health introduction to the study of epidemiology. New York: The Macmillan Co, 1935. workers in the American Public Health As- 8. Wynder EL, Graham EA. Tobacco smoking as a sociation are urging their association to place possible etiologic factor in bronchogenic carci- greater emphasis on legislative support for noma, a study of six hundred and eighty-four preventive services. And SER needs to proved cases. JAMA 1950; 143:329-36. 9. Levin ML, Goldstein H, Gerhardt PR. Cancer and explore more thoroughly the implications tobacco smoking. A preliminary report. JAMA Downloaded from of its statement that "The objective of the 1950,143:336-8. Society shall be to foster epidemiologic 10. Doll R, Hill AB. Smoking and carcinoma of the lung: preliminary report. BMJ 1950:2:739-48. research" (24). 11. Doll R, Hill AB. The mortality of doctors in rela- We cannot remain indefinitely in our tion to their smoking habits: preliminary report.

BMJ 1954:2:1451-5. http://aje.oxfordjournals.org/ ivory towers; they may crumble around us. 12. Doll R, Hill AB. Lung cancer and other causes of We need to foster epidemiologic research, death in relation to smoking. A second report on not only by improving our methodology and the mortality of British Doctors. BM J 1956;2:1071 - 81. sharing our scientific experience, but by 13. Doll R, Hill AB. Mortality in relation to smoking: helping to convince the American public ten years' observation of British doctors. BMJ and its legislators that prevention is far more 1964.2:1399-1410. 14. Rosenau MJ. Preventive medicine and hygiene. important than treatment, that our ex- New York: D Appleton and Co, 1913. panded agenda for research needs full legis- 15. Williams RC. The United States Public Health at Oxford University Press for SER Members on April 15, 2014 lative and financial support, and that the Service, 1798-1950. Washington, DC: Commis- sioned Officers Association of the United States application of our findings to improve the Public Health Service, 1951, Chapters 4. 5. health of the public must become the highest 16. Bigelow GH, Lombard HL. Cancer and other priority for health policy in the United chronic diseases in Massachusetts. Boston: Hough- ton Mifflin. 1933:118.293. States. 17. Potter EA. Tully MR. The statistical approach to the cancer problem in Massachusetts. Am J Public Health 1945:35:485-90. 18. Morris JN. Uses of epidemiology. Baltimore: Wil- liams & Wilkins, 1957. REFERENCES 19. MacMahon B. Pugh TF. Ipsen J. Epidemiologic methods. Boston: Little, Brown, 1960. 1. Frost WH. Papers of Wade Hampton Frost, MD. 20. Winslow C-EA. The life of Hermann M. Biggs. A contribution to epidemiologic method. Maxcy Philadelphia: Lea & Febiger, 1929:78. KF, ed. New York: The Commonwealth Fund, 21. Letter signed by Milton Terris, Abraham Lilienfeld, 1941:494. and Brian MacMahon, 1967, undated. Reprinted 2. Panum on measles. New York: Delta Omega So- in SER Newsletter, Fall 1991. ciety, 1940. 22. Health United States 1989. Bethesda. MD: US 3. Snow on cholera. New York: The Commonwealth Department of Health and Human Services, Public Fund, 1936. Health Service, 1990. 4. Terris M, ed. Goldbergeron pellagra. Baton Rouge. 23. Gregg NMc. Congenital Cataract Following Ger- LA: Louisiana State University Press. 1964. man Measles in the Mother. Trans Ophthal Soc 5. Ryle JA. Changing disciplines. London: Oxford Austr 1941:3:35-46. University Press, 1948:11-12. 24. Society for Epidemiologic Research. Masthead. 6. Greenwood M. Bradford Hill A, Topley WWC, et SER Newsletter. Fall 1991.