Most epidemiologists would agree that the purpose of epidemiology is to investigate the causes of disease to improve public health. In a surprisingly candid observation made during his opening Presidential Address at the recent SER meeting in Boston, Columbia University’s Sandro Galea, Chairman of the Department of Epidemiology, told epidemiologists in attendance  “we are seeing a gross failure in our improving the health of populations…”

Contributing to this failure, according to Galea, is the excessive focus on etiologic questions and a dearth of research centered on approaches to disease control and prevention.

As a result of this imbalance, he added, epidemiologists are not only failing to make an impact on population health, but epidemiology is falling out of favor with the National Institutes of Health, the primary funder of epidemiologic research.

Galea called for a consequentialist epidemiology which gives more weight to questions that have a greater chance of making a difference in population health.

Echoes

In reminding the audience that the discipline is not only about investigating the causes of disease but also doing something about them, he echoed the concept of “consequential epidemiology” first coined by Bill Foege in a Wade Hampton Frost Lecture in 1983 and repeated in a 1994 SER Presidential Address by Ward Cates. Foege described epidemiology as a tool to change the world-- not only to study the world. Cates said epidemiologists make their work consequential by asking “so what?” about the impact of epidemiologic findings and “how much?” about the cost of health interventions.

Evidence

Finding that epidemiologists have failed to improve population health is a serious conclusion and Galea backed up his assertions with several

observations.  First, to establish the excessive focus on etiologic research, Galea investigated all papers published in 2012 in the four leading epidemiology journals. “We found that 85% of papers in these journals can be reasonably considered papers concerned with etiology or with efforts to help deal with causes,” he said.

To back up his assertion that epidemiologists are not able to impact the problems of population health, he cited a recent Institute of Medicine study that showed the US lags behind nearly all high income countries on 9 important indicators of population health despite spending more on health care than any of these other countries. “This is exactly what is in our remit to tackle, to help do something about, and, well, someone, maybe it’s us, maybe it’s not, is failing.”

Solution

The solution, Galea said, is “a recalibration of what we do.” In calling for more research focused on questions that lead directly to doing something to improve population health, he used the example of firearm deaths to make his point. He called these deaths “outrageous calamities” and saying “there is no way to countenance this from within a discipline that is concerned with the promotion of health.” He added, “we should run, not walk, to a research agenda that addresses these issues.”

Intended Consequences

Galea concluded by saying that embracing a more consequentialist epidemiology would have epidemiologists doing a few things differently, including:

1. It would have epidemiologists looking for “big wins” such as that which occurred with the reduction in motor vehicle deaths. Can we show the same curve for firearm deaths in 20 years? In 50 years? he asked.

2. It would have epidemiologists spending a lot less time arguing about what scope and methods constitute epidemiology. Instead, epidemiologists would be focused simply on methods that improve population health while rejecting those that do not.

3. It would have epidemiologists more focused on the health of populations

wherever there is a need to do so. This would mean “Think Globally and Work Globally” because that is where the problems are greatest and where associated challenges around equity and efficiency are found.

4. It would have epidemiologists embrace translation and implementation science. These topics are an effort by the federal government to make a difference, said Galea, and epidemiologists should participate in it.

5. It would have epidemiologists getting away from teaching students the canon of methods and how we apply them, to teaching students from first principles with encouragement to take on epidemiology as the science of population health with an explicit and express intent to improve population health.

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