Epidemiologic Reviews
Copyright © 2000 by The Johns Hopkins University School of Hygiene and Public Health
All rights reserved
Vol. 22, No. 1
Printed in U.S.A.
Interface of Epidemiology and History: A Commentary on Past, Present, and
Future
Warren Winkelstein, Jr.
INTRODUCTION
THE ORIGINS OF EPIDEMIOLOGY
From time immemorial, epidemics have ravaged the
human species. In his book Rats, Lice, and History,
Hans Zinsser reviewed the mechanisms by which
infectious diseases arise and become epidemic and
chronicled their impact on the populations affected (1).
By implication, Zinsser also indicated the analogous
impact of noninfectious diseases. His analyses
revealed a broad range of outcomes, from the interruption of military conquests to the disorganization of
nation-states. Furthermore, Zinsser correctly predicted
the emergence of "new" epidemic diseases with consequent impact. Thus, as we enter the new millennium,
we find ourselves experiencing a great pandemic of a
new disease, acquired immunodeficiency syndrome,
which is decimating the populations of sub-Saharan
Africa and disrupting the health and disease care
resources of many other locales. Indeed, it is a truism
that epidemics have been major contributors to the
course of history and that in the future we will experience further visitations. The epidemiologic literature is
replete with reports of particular investigations which
led to the identification of etiologic mechanisms and
subsequent effects on disease incidence and prevalence in the populations affected.
Although there may be some disagreement as to
whether epidemiology is truly a science or simply a
method (2), most modern epidemiologists consider
themselves biomedical scientists investigating a particular paradigm—i.e., the interaction of host, environment, and agent—to explain the occurrence of health
and disease in human populations. This commentary
examines the historical origins of this science and considers several examples of how it has interfaced with
some historical trends.
The origins of epidemiology as a science have been
examined by Lilienfeld (3). Lilienfeld emphasized the
role that early 19th century developments in statistics
and their application to medicine played in the establishment of the Statistical Society of London in 1834
and, subsequently, the Epidemiological Society of
London (ESL) in 1850. He pointed to the previously
uncoordinated efforts to control cholera and other
infectious disease epidemics that were interfering with
the efficiency of mid-19th century British industrialism as being an additional stimulus to the establishment of the ESL. The statistical influence and its societal impact was emphasized by the first president of
the ESL, Benjamin Guy Babington, in his inaugural
address: "Statistics too have supplied us with new and
powerful means of testing medical truth, and... how
appropriately they may be brought to bear on the subject of epidemic disease" (4, p. 641). According to
Lilienfeld, the ESL was primarily oriented towards the
development of a theory of disease which would guide
the analysis of epidemiologic data and have the salutary effect of epidemic control envisioned by
Babington.
During the 19th century, the industrial revolution
reached its zenith in Europe and North America. From
an epidemiologic viewpoint, two aspects of the industrial revolution impacted most prominently on the
health of populations: urbanization and rapid longdistance transportation (also noted in Babington's
inaugural address). The crowded, unsanitary conditions in industrial slums resulted in the repeated introduction of cholera, typhoid fever, and smallpox in epidemic form into these milieus. The objectives of the
ESL were consequently broad and, it may be asserted,
reflected the social and political context as well as the
scientific context of mid-19th century England. Thus,
they extended beyond the comprehensive study of
contagious diseases and the investigation of epidemics in humans to the study of animal and plant diseases and the measures employed to deal with them.
The committee structure of the ESL reflected an inten-
Received for publication June 9, 1999, and accepted for publication January 21, 2000.
Abbreviation: ESL, Epidemiological Society of London.
From the Department of Epidemiology, School of Public Health,
140 Warren Hall, University of California, Berkeley, CA 94720-7360.
(Reprint requests to Dr. Warren Winkelstein, Jr., at this address).
Epidemiology and History
tion to pursue an activist policy. In addition to committees on smallpox and vaccination, cholera, and
continued fevers, committees were established to deal
with epizootic and plant diseases and hospitals and to
"consider supplying the labouring classes with nurses
in epidemic and other diseases" (5). In the commemorative volume of the transactions of the ESL (6), the
roles of epidemiology in the social reform movement
of the mid-19th century (through its application in the
reports of the Poor Law Commissioners and the
Health of Towns Commission) and in the Public
Health Act of 1848 were cited. The decline in epidemic diseases in the United Kingdom during the last
half of the 19th century has generally been credited to
developments stemming from these actions (7).
Parenthetically, in industrialized countries, the last
half of the 19th century saw two major historical
trends in health: the declines in total and tuberculosis
mortality (beginning in the 18th century) and the
beginning of the decline in infant mortality. Many
hypotheses have been advanced to explain these
trends, and they have generated intense interest and
controversy (8, 9). Imbedded in most explanations of
these phenomena is a role for epidemiology, but with
the major factor(s) ostensibly lying in broad social and
environmental forces.
The emergence of epidemiology as a recognized science in the United States lagged behind its origins in
England by approximately 40 years, and its debut was
not signaled by a particular event like the 1850 founding of the ESL. Whereas epidemiology in England had
its scientific antecedents in the field of statistics and its
"raison d'etre" in the social reform movement, epidemiology in America grew out of several currents: the
new bacteriology pioneered in Europe by Pasteur and
Koch; the imperatives generated by waves of
European immigrants; the Spanish-American War; the
construction of the Panama Canal; and the Progressive
Era in domestic politics, in which activists tried to
address issues like food and drug purity and occupational safety (10).
According to Lilienfeld, with the advent of the "bacteriologic era," epidemiology in England went into
hibernation, to await the realization in the mid-20th
century that "bacteria were not responsible for all disease" (3, p. 528). However, in the United States, the
new bacteriologic knowledge and its methodologies
were soon adapted to the study of disease agents in the
environment, to the screening of immigrants, and to
the establishment of a science-based hygiene. In 1887,
the Marine Hospital Service established a one-room
bacteriology laboratory in the attic of its Staten Island,
New York, facility. The laboratory's first investigations were directed toward analyses of New York Bay
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3
water for its ability to support the growth and multiplication of cholera bacilli and examination of the stools
of immigrants to detect cases and carriers of this agent.
The laboratory, soon named the Hygienic Laboratory
(and eventually the National Institutes of Health), went
on to study air pollution in the "halls of Congress" and
to provide laboratory support for the US military during the Spanish-American War (10). Meanwhile, in
Cuba, responding to the exigencies of the war, Finlay,
Reed, and Gorgas used epidemiologic approaches to
solve the multiple problems associated with transmission and control of typhoid fever, yellow fever, and
malaria. Subsequently, Gorgas applied the new epidemiologic knowledge in Panama, facilitating the
completion of the Panama Canal—a task which had
frustrated the French for 20 years as they vainly tried
to cope with engineering challenges while suffering
the debilitating effects of these diseases (11). Finally,
in response to public pressure (particularly to the
"muckraking" journalism of the early 20th century
(12, 13)), the US Congress passed the Biologies
Control Act in 1906. Congress placed responsibility
for the enforcement of the act on the Hygienic
Laboratory, which proceeded to use epidemiologic
methods to discharge its mandate (10). Thus, it may be
asserted that in the United States, as in England, the
development of epidemiology owed as much to the
social and political milieu of the time as it did to the
scientific developments of the era.
THE MATURATION OF EPIDEMIOLOGY AND ITS
HISTORICAL CONTEXT, 1910-1945
The first half of the 20th century was a period of cataclysmic events: two world wars, the 1918-1919
influenza pandemic (which probably precipitated the
end of World War I), the clash of two major political/
economic philosophies (capitalism and communism),
the dissolution of the European colonial empires of
Great Britain and France, the worldwide economic
depression of the 1930s, and the acceleration of the
world's population growth. While a detailed consideration of the role of epidemiology in any or all of these
events is beyond the scope of this paper, during this
period there were very significant developments in the
field. These included the advancement of epidemiologic theory by British epidemiologists Hamer, Ross,
and Brownlee (14); the refinement of epidemic investigation and the inferential process by Frost and other
investigators at the Hygienic Laboratory (15); the
introduction of case-control methodology for the study
of noninfectious diseases by Lane-Claypon (16); and
the refinement of the methodology of randomized clinical trials by Hill (17). However, two series of studies
from this period—namely, the studies of pellagra car-
4
Winkelstein
ried out by Goldberger and Sydenstricker at the
Hygienic Laboratory (18) and the longitudinal investigations of disease and medical care carried out by
Falk and colleagues for the Committee on the Costs
of Medical Care (19)—epitomize the interactions
between epidemiology and history during this time.
At the turn of the century (1900), pellagra was
essentially unknown in the United States. However,
during the first decade of the 20th century, it
"emerged," first in mental hospitals and subsequently
in the general population of the southeastern states. By
1912, the annual incidence of pellagra was estimated
to be approximately 25,000, with a case fatality of 40
percent (20). The controversy over its etiology was
intense; the major theories were that the disease was
caused by an unknown infectious agent and that it was
caused by the ingestion of spoiled corn. Most epidemiologists are familiar with the brilliant observations of Joseph Goldberger, which led him, in a brief
period of time, to the conclusion that the cause was a
dietary deficiency of some necessary nutrient that was
present in fresh fruits and vegetables (21). These
observations, combined with additional experimental
evidence, provided the necessary information for the
essential eradication of pellagra from the United
States. Nevertheless, it was the subsequent innovative
survey research (primarily designed by Edgar
Sydenstricker) carried out in seven South Carolina mill
towns which revealed the complex underlying economic, social, and structural factors at play in the postCivil War South that had created the conditions in
which pellagra could become epidemic (22).
Among the most important events in US medical
history was the reform of medical education resulting
from the so-called Flexner Report, published in 1910
(23). Briefly, the report, which was commissioned by
the Carnegie Foundation for the Advancement of
Teaching, called for the elimination of proprietary
medical schools, the establishment of academic standards, the association of medical schools with accredited universities, the designation of teaching hospitals,
stricter admission requirements, and assurance of the
availability of laboratory resources for teaching purposes. Among the mostly positive consequences of
these reforms were the proliferation of medical specialities, the fragmentation of services, and increases
in the cost of medical care. Thus, by the mid-1920s,
questions were being raised in the United States
regarding the status of medical care, its availability
and cost, and how it should be paid for. At the 1927
annual meeting of the American Medical Association,
a broadly representative committee of 50 men and
women was organized as the Committee on the Costs
of Medical Care to investigate these and other issues
related to health and medical care (19). With support
from eight major philanthropic foundations, a staff of
51 conducted 26 studies, many of which were epidemiologic, during a 5-year period (1927-1932) to
support its far-reaching recommendations. The committee's major recommendations were as follows.
1. Medical services, both preventive and therapeutic, should be provided by interdisciplinary
groups of medical care professionals.
2. Basic public health services should be available
to all without cost.
3. The costs of medical care should be placed on a
group basis (through insurance, taxation, or a
combination thereof)4. The study, evaluation, and coordination of medical and public health services should be considered important functions of local and state governments.
5. Professional education for a wide variety of medical and public health personnel should be greatly expanded, with emphases on prevention,
social considerations, and the need for limited
cadres of specialists.
Not unexpectedly, the final report and recommendations of the Committee on the Costs of Medical Care,
published in 1932 (19), raised a storm of protest from
organized medicine. Nevertheless, over the 60 years
since its publication, this report, which was based primarily on epidemiologic data, has provided a focus for
the development of medical and public health policy
and practice in the United States.
THE LAST HALF OF THE 20TH CENTURY
After World War II, the field of epidemiology
expanded greatly. The numbers of epidemiologists
grew rapidly as training programs multiplied. Funding
for epidemiologic studies increased, particularly in the
United States, where each of the National Institutes of
Health established epidemiologic units with extramural research-granting authority. Health science
training programs began to recognize epidemiology as
a core subject, and academic accrediting bodies began
requiring the subject to be included in their curricula.
Space limitations preclude a comprehensive review of
the impact of epidemiology on contemporary history,
but a few important events must be noted.
By midcentury, the application of sanitary engineering, the control of infectious diseases of childhood,
and improved nutrition in the industrialized nations
had resulted in substantial increases in life expectancy
at birth and a consequent increase in the proportions of
the aged in these populations. Thus, epidemiologists
turned their attention to the study of the major diseases
Epidemiol Rev Vol. 22, No. 1, 2000
Epidemiology and History
of the aged: heart disease, cancer, and stroke. In the
Framingham studies, a series of studies of a cohort of
middle-class Whites in Framingham, Massachusetts,
major risk factors for coronary heart disease—high
blood pressure, elevated serum cholesterol levels, and
cigarette smoking—were identified (24). In a classic
cohort study of British physicians, Doll and Hill definitively established the etiologic association between
cigarette smoking and lung cancer (25). These studies
and numerous corroborative investigations worldwide
had substantial impacts on agricultural policies and on
smoking and dietary habits, particularly in Europe and
North America.
In the United States, the Korean War stimulated anxiety concerning the possible importation of exotic diseases from Asia. The result was the establishment of a
far-reaching surveillance program in the Communicable
Disease Center (later named the Centers for Disease
Control and Prevention) (26). This program created a
cadre of trained epidemiologists, the Epidemic
Intelligence Service, to implement surveillance programs in the United States and certain other areas and to
provide epidemic aid to states. Eventually this aid
would be provided worldwide. The concept of surveillance (discussed elsewhere in this issue of Epidemiologic Reviews (27)) and the expertise of the Epidemic
Intelligence Service were major factors in the establishment and implementation of the World Health
Organization's program for the global eradication of
smallpox (28). The eradication of smallpox has aptly
been considered one of humankind's major achievements. Furthermore, the epidemiologic strategy that led
to this result promises to pave the way for future eradication efforts.
Despite substantial declines in death rates, particularly in the industrialized nations, large differences
between socioeconomic, ethnic, gender, and occupational groups have been demonstrated wherever these
factors have been investigated. In a recent study carried out in the United Kingdom and based on epidemiologic data, these differences were again demonstrated; furthermore, it was shown that inequalities in
health have been increasing in recent years (29). The
published report on the study contains extensive recommendations pertaining mostly to sociopolitical
issues such as poverty, income, taxation, education,
employment, housing, environment, transportation,
and nutrition/agricultural policy; these issues, the
investigators assert, underlie the health status of the
population. Because it was commissioned by the
Minister of Health and chaired by a prominent former
medical officer of health (Sir Donald Acheson), the
likelihood that this report will receive serious consideration by the British government is good. If even a
Epidemiol Rev Vol. 22, No. 1, 2000
5
few of these recommendations are implemented, substantial social consequences are likely.
THE FUTURE OF EPIDEMIOLOGY
In a provocative 1995 article, science writer Gary
Taubes presented the views of a number of prominent
epidemiologists that observational epidemiology may
have reached the limit of its ability to make causal
inferences from weak associations (30). Some people
have interpreted the views expressed in the article as
signaling the beginning of the demise of epidemiology,
or at least its marginalization. Others have suggested
that a new paradigm will extend the ability of epidemiologists to reveal causal relations. They term this
model "eco-epidemiology," by which they mean the
study of "causal pathways at the societal level and with
pathogenesis and causality at the molecular level" (31,
p. 668; 32, p. 674).
Whether or not "eco-epidemiology" represents a
new paradigm, it seems inevitable that the new
insights into biologic mechanisms and the tools that
have been invented to reveal them will substantially
extend the ability of epidemiologists to identify etiologic relations at the population level (33). However, it
has been argued that this view of epidemiology
overemphasizes methodology and a reductionist
approach to the understanding of the dynamics of disease distribution in populations (34). What seems to be
needed for the future is a more expansionist approach
that will address disease problems arising out of the
manifold socioenvironmental conditions likely to
affect the global population in the 21st century. A partial list of these conditions includes air, water, and soil
pollution; global warming; population growth; poverty
and social inequality; and civil unrest and violence.
The challenges these issues will present to epidemiologists are indeed daunting.
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