Credit for coining the concept of “consequential epidemiology” is given to Bill Foege, former CDC Director who presented the concept publicly for the first time as part of his Wade Hampton Frost Lecture at the American Public Health Association meeting in 1983, according to Jim Marks, Senior Vice President at the Robert Wood Johnson Foundation and former Director of the Chronic Disease Center at CDC. In an article published in Preventing Chronic Disease (1), Marks has described the context for Foege’s remarks as a time when a debate was taking place in epidemiology about whether epidemiologists should engage in the political process.

Harsh Judgment

Foege’s view was that public health work occurs in a political context. Divorced from that context, our science is stillborn, a missed opportunity, said Marks. Furthermore, to pretend otherwise is self delusion and a failure of vision and responsibility.

Guilty Profession?

Are epidemiologists as a professional group guilty of these failures? Sandro Galea in his recent SER Presidential Address (see related story in this issue) comes close to this conclusion by seeing a gross failure to make a difference on key indicators of population health in the US. Unlike Galea, Foege at the time did not appear to be addressing any lack of impact on population health, but he made clear, as does Galea, that epidemiologists have the responsibility for population health, and US health has been markedly worse than health in many other countries for many years.

Ward Cates

Another former CDC epidemiologist to pick up on the concept of consequential epidemiology is Ward Cates who used the concept in his SER Presidential Address covered in The Epidemiology Monitor in July 1994. At that time, Cates was optimistic about the future of epidemiology because the health care reform movement was calling for more outcomes research and Cates believed that epidemiology was ideally suited for this work. To actualize the enormous potential of epidemiology in the era of heath reform, Cates said the key will be the ability to market our epidemiologic skills in a way that is seen by society as making a difference. Epidemiologists need to ask themselves---1) do our inferences work to change people’s lives, and 2) what do interventions cost for the benefits they provide? He called on epidemiologists, much as Galea did in his SER address,  to reframe our science to emphasize consequential outcomes.

Cates Revisited

In a postscript to his 1994 SER talk written in 2000 and published in Epidemiology Wit and Wisdom, Cates told the Monitor “the use of scientific data to answer key questions is a necessary, but not a sufficient step along the pathway to promote public health action. He called for epidemiology to include other disciplines, other prevention sciences within its scope to become truly consequential.

Jim Marks

Jim Marks, in his Langmuir Lecture at CDC in 2009, presented his views about what makes epidemiology consequential. As reported in the Epidemiology Monitor in April 2009, he stated that the central purpose of epidemiology is to “find, assess, and confirm truth” and that role differs from the activist role. He stated that scientific discovery and widespread application of findings must never be separated, “as each bears little fruit without the other.” He called this a defining tension for epidemiologists and for all of public health.

Galea’s remarks at SER on the need for recalibration of epidemiology is another way of saying that epidemiologists have been addressing this tension in a way which defines them as too unconcerned with making a difference in population health.

Marshfield Clinic Mission

Other speakers over the years have discussed the concept of consequential epidemiology and at least one research group, the Marshfield Clinic Research Foundation has adopted consequential epidemiology as a guiding principle.  In its mission statement, the Clinic focuses on consequential epidemiology defined as applied research questions that make a difference in the lives of people. The Clinic states that its mission is to improve population health and patient care outcomes by leading and promoting consequential epidemiology research.

Epi SubSpecialty

A recent paper in Epidemiology by David Dowdy and Madhukar Pai shared Galea’s concern about the need to make a greater impact on population health. The authors proposed the creation of Accountable Health Advocates as a subspecialty in epidemiology that could be more focused on translation. However, commentators on the proposal were generally not receptive because of fear the new subspecialty would diminish the responsibility all epidemiologists have for translating knowledge into action.

Dowdy and Pai told the Monitor in October last year“there is a surplus of relevant public health evidence, and a deficit in the utilization of these findings to improve population health. They argued that a greater balance needs to come about and will come about between the creation of knowledge and the use of this knowledge. Otherwise public support will become unsustainable and unjustifiable. The balance they called for is reminiscent of the recalibration Galea described in his SER talk.

(1) Prev Chronic Dis 2009; 6(4): A134

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