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tion. The trainees materially help the Ministry of Health health and the prevention of is, in truth, a dis- attain the goal of health for all by the year 2000. The cussion of the measurement of national and interna- graduates provide a steady increase in the numiber of tional civilization. The practice of at trained field epidemiologists available to take on pos- CDC, or any other place, is the practice of social jus- itions of responsibility in preventive in the tice. It is the effort to make health a matter of choice country. As the graduates assume these positions, they for all-not chance for some. e can provide day-to-day supervision of new trainees It has been said: "We cannot remain consistent with and make it possible to gradually increase the number the world save by growing inconsistent with our own of trainees accepted into the program each year. past selves." There are many things to learn from one another. In the last decades of the 20th century, the measurement of national stature will be the way coun- Conclusion tries treat their own people and one another. Epidemiol- ogy, its practice and persuasion, is a key to universal Any discussion of the role of in public social justice.

The International Clinical Epidemiology Network

Background over time and place requires that data on hospitalized patients be linked to the population from which they Achievements in biomedical and behavioral come. Further requirements include identification of have raised society's expectations, yet many segments high-risk groups and critical evaluation of the diagnostic, e of society risk being disenfranchised from access to therapeutic, and preventive interventions (, vac- the fruits of those successes. A disproportionate cines, surgery) that will have the greatest effect on the amount of the world's health resources is spent on priority health problems of the entire population. treating of the urban affluent, while masses All this is the province of epidemiology, and in- of periurban and rural poor suffer and die from common volves the application of scientific methods and statis- preventable or treatable maladies. This imbalance1 tical reasoning to the problems of disease and health raises fundamental questions regarding resource alloca- care in populations as small as the communities served tion, efficacy of.interventions, and community priori- by a health center, , or , or as ties-questions which impinge upon the quality and large as the global community. The use of epidemiolog- quantity of care for individuals and the health status( ical concepts and methods is essential for estimating of populations. the burden of illness experienced in a community; for --- These problems cannot be addressed by basic bio- identifying environmental, behavioral, and occupa- . Nor can investigations conducted on tional health hazards; for establishing the efficacy of small samples of hospitalized patients alone provide preventive, diagnostic, and therapeutic measures; and sound bases for either clinical or policy decisions. In- for assessing the relative impact and cost-effectiveness deed, the hospital perspective tends to distort the physi- of different combinations of resources and services cian's impression of the real burden of illness in terms used to improve the health status of populations. of numbers, distribution, and extent of physical impair- Epidemiology as a discipline was originally con- ment. In all countries, uncontrollable costs, ceived by clinicians, but in the past 60 years it has to say nothing of inequities in "north-south" and developed outside the mainstream of clinical medicine, "urban-rural" distribution of services, reinforce the largely within schools of public health. Over time, need for more rational approaches to difficult choices. clinicians became increasingly involved in laboratory An adequate picture of the distribution of diseases research and drew further away from their colleagues e

10 in schools of public health who were developing the and epidemiologists. INCLEN uses as its model the field of epidemiology. The net effect is that clinicians strategies for introducing the natural into today have lost touch with epidemiological perspec- medicine pioneered by Abraham Flexner. The Network tives and skills, and epidemiologists have lost touch seeks to add the population-based sciences, epitomized with clinical medicine. What is needed is a bridge in medicine by epidemiology, to the mainstream of between the two approaches. scientific medicine, and to train and support bright There have been two major efforts over recent de- young and established clinical faculty members in this cades to bridge the gap-that is, to provide field. with population-based perspectives and skills. The first INCLEN's emphasis on clinical epidemiology is effort was to train clinicians in Schools of Public consistent with the widespread belief that physicians, Health, providing them with a Master of Public Health especially clinicians, are being trained more and more (M.P.H) degree. Useful as this exposure may have narrowly. While focusing on molecular events and in- been, it really only provided an introduction to the dividual patients, they have lost contact with other diversity of health problems in the community. For factors that influence the health of populations. Knowl- the most part, it failed to give physicians the substantive edge of disease and use of resources allow physicians critical and analytical skills required for independent to play a crucial role with respect to individual health, judgment, and offered few clinical teaching examples. to the health of populations, and to the economic well- Success was modest at best. During a recent 10-year being of the countries themselves. Epidemiology is the period, the Johns Hopkins University School of Public basic discipline for studying disease and health, and Health produced only one graduate who was also a for organizing cost-effective means of achieving health graduate of its School of Medicine. A recent poll of goals. Although these matters are of great concern to that University's M.P.H. class of about 140 students, the developed world, they are of overwhelming con- found only nine American physicians under the age of cern to the developing world. 30. Finally, the 23 Schools of Public Health in the The expansion of epidemiological thinking and skills United States currently have only 26 assistant profes- is crucial for the evaluation and application of the fruits sors who are physicians, out of a total assistant professor- of biomedical and behavioral research. Without the ship cohort of perhaps 400 to 500. The situation in the information about the disease priorities of underserved developing world is much worse. populations and the relative efficacy of intervention The second effort involved establishing separate de- measures, it is unlikely that research efforts, policies, partments concerned with population-based medicine or resources will be directed effectively to meet those within the medical schools themselves. These have priorities. variously been called departments of public health, As Dr. John Evans has noted: "A population per- preventive medicine, social medicine, community med- spective of medicine is something which all clinicians icine, community health, and environmental medicine. need, because of the effects which their decisions have Their activities have been coupled with emergency on distribution of resources. This is especially so in medicine, nutrition, occupational medicine, family developing countries where massive demand competes medicine, and a range of nontraditional activities that with puny supply."' focused on underserved groups such as mothers, in- fants, the aged, the handicapped, and the poor. Their Goals and Objectives combined impact on medicine appears to have been minimal. Indeed, they have been described as depart- There is a worldwide dearth of epidemiologists ments of "miscellaneous medicine" which tend to be working in clinical departments. Clinicians, particu- perceived as academically weak, lacking in prestige, larly senior professors, have a critical influence on the out of the medical mainstream, and often as irrelevant. attitudes of colleagues, student politicians, cabinet ministers, and other decision-makers who determine national and community priorities and allocate re- sources for health and other enterprises that impinge The International Clinical Epidemiology Network on health. INCLEN links Clinical Epidemiology Re- source and Training Centers (CERTC) to groups of The International Clinical Epidemiology Network (INCLEN), founded in Honolulu, Hawaii, in February 1983, differs conceptually 'Evans, J. R. et al. Shattuck Lecture-Health Care in the Developing and organizationally from World: Problems of Scarcity and Choice. NEnglJMed305(19): 1117-1127, both prior attempts to bridge the gap between clinicians 1981.

11 clinical epidemiologists in medical schools throughout cies affiliated with INCLEN. At least one meeting will the developing world. be held annually, usually at a location with one or Clinical epidemiologists placed in major clinical de- more Clinical Epidemiology Units. partments receive the benefit of being associated with The Network does not aim to develop another clin- a prestigious institution, and enjoy daily contact with ical specialty within medicine; rather it seeks to pro- both undergraduates and postgraduates (house officers) mote the dissemination of epidemiological and biosta- o over a minimum four-year span. The impact of the tistical thinking throughout clinical medicine and health program lies not only in developing Clinical Epidemi- policy-making by fostering a focus on epidemiology ology Units (CEU) and training clinical epidemiolo- within the mainstream of scientific medicine in the gists, but in exposing all students to concepts and universities. Appreciation by physicians of epidemiology methods of epidemiology and to perspectives broader as both a powerful analytic tool and an essential med- than the confines of a single patient and four hospital ical perspective should contribute to the intellectual walls. and scientific underpinnings of preventive and clinical INCLEN seeks to promote CEUs in medical schools medicine and of public health measures. The incorpo- as focal points for research and training activities. Clin- ration of these perspectives and methods within clinical ical epidemiology is visualized as a discipline in which medicine should result in institutional and public physicians are educated to use efficacious, effective, policies and health priorities that conform more closely and cost-efficient interventions, and to allocate re- to the real medical needs of the entire population sources more rationally to improve the health status served. of populations. This may be accomplished by applying epidemiological principles to health research and by Clinical Epidemiology Resource and using critical and systematic approaches to research Training Centers design, measurement, and evaluation. INCLEN has five operational goals: Currently there are three CERTCs at the Universities 1. The establishment of strategic plans that provide of Pennsylvania (United States), McMaster (Canada), reasonable assurances that both external and local re- and Newcastle (Australia), each offering a Master of sources allocated to this effort are put to the most degree following full-time intensive study last- effective use; ing 12 to 16 months. Courses are for junior faculty 2. The establishment of at least three regional Clin- members from clinical departments of medical schools ical Epidemiology Resource and Training Centers, in developing countries, and cover the concepts, prin- e using existing institutions in the developed world to ciples, methods, and practical applications of epide- serve as catalysts for resource mobilization in less de- miology. Participants learn to apply the basic concepts veloped countries, to give prestige to the application of causation, bias, clinical measurement, natural his- of epidemiological concepts and methods within major tory, and disease frequency. The concepts are used to clinical specialties, and to provide educational con- acquire more advanced skills in the areas of research tinuity to the field; questions and design, sampling procedures, measure- 3. The continuing support of graduate training pro- ments of events and attributes, and analyses, as well grams leading to a Master of Science degree based in as the critical appraisal of the clinical literature. Super- these Centers. When trainees return to their own uni- vised by a designated preceptor, candidates apply these versities, they are expected to staff the Clinical skills in designing a research project to be conducted Epidemiology Units being established in their home in their own country upon return. Participants are given universities. The Clinical Epidemiology Resource and the opportunity to take part in faculty research pro- Training Centers would then provide support through grams designed to provide experience in practical re- exchange of faculty, site visits, and regional and global search methods. Consultancy experience and oppor- meetings; tunities for participating in the related activities of a 4. The establishment and continuing support of designated preceptor are also offered. Clinical Epidemiology Units in one or more clinical Financial support is available to cover the recipient's departments of selected medical schools in the develop- tuition, travel, and maintenance expenses. About one ing world, with the participation of trained clinical year following successful completion of the course, a epidemiologists, biostatisticians, and health econ- visit by a preceptor to the candidate's institution to omists; and consult on the research project also may be provided. 5. The conduct of periodic regional and global sci- Applications, usually initiated by a dean, department entific meetings of the individual institutions and agen- head, or senior faculty member, should be made in o

12 writing to the Director of a specific program. The letter Training Centers, write to: the institution's plan for developing a should outline Professor Stephen R. Leeder, Director, Epidemiology Unit or similar entity and the Clinical Asian and Pacific Centre for Clinical Epidemiology, candidate's past experiences, current interests and re- Faculty of Medicine, The University of Newcastle, sponsibilities, and future professional plans; it should New South Wales, 2308, Australia also be accompanied by a curriculum vitae and endors- ing letters, which would include reasons the department Professor Paul D. Stolley, Director, head and dean have for sponsoring the applicant. Pref- Clinical Epidemiology Unit erence will be given to candidates with assured full- Department of Medicine time faculty appointments in departments of internal University of Pennsylvania, NEB/S2 medicine, pediatrics, and family medicine, as well as Philadelphia, Pennsylvania 19104, USA those from other clinical departments. Evidence of pro- in English is required. ficiency Professor Peter Tugwell, Chairman, INCLEN is currently being funded by the Rockefeller Department of Clinical Epidemiology and Foundation, and other financial resources are being Faculty of Health Sciences organized by the Australian Development Assistance McMaster University Board, the Brazilian National Research Council, the 1200 Main Street West International Development Research Center, the Hamilton, Ontario L8S 4J9, Canada Swedish Agency for Research Cooperation with De- veloping Countries, the World Bank, and the World (Source: Epidemiology Unit, Health Organization. Health Programs Development, PAHO.) To contact the Clinical Epidemiology Resource and

Smallpox: Post-eradication Surveillance

In 1980 the Thirty-third World Health Assembly, involves risk both to the vaccinees and to their following its declaration of the achievement of global contacts. In fact, a number of patients with eradication of smallpox, recommended that smallpox complications are regularly being re- vaccination should be discontinued in every country, ported among contacts of recently vaccinated except in the case of investigators at special risk. Cur- military personnel. Because of this, the Com- rently all 165 Member States and Associate Members mittee recommends that military personnel of WHO have discontinued routine smallpox vaccina- who have been vaccinated be confined to their tion, except for Albania. bases and prevented from contacting unvacci- The Committee on Orthopoxvirus Infections, which nated persons for a period of two weeks follow- met in Geneva for the third time from 28 to 30 March ing vaccination. " 2 1984, has reviewed the situation, and has made the The eight countries mentioned above are Belgium, following comment on the vaccination of military per- Denmark, Finland, the Netherlands, Norway, Switzer- sonnel: land, the United Kingdom, and Zimbabwe. WHO "Eight countries have informed WHO that smallpox vaccination of military personnel has ISeveral reports on vaccination complications in military personnel and been discontinued. The Committee expresses their contacts were published in the Weekly Epidemiological Record 57(41):319, 1982; 58(5):32-33, 1983; and 59(11):83, 1984. the hope that other countries may elect to do 2For the report of the Third Meeting of the Committee on Orthopoxvirus likewise since vaccination of such personnel Infections, see document WHO/SE/84.162.

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