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Historical Keynote
Addresses
SER Keynoter Challenges
Epidemiologists to Seek a Fuller Understanding of Disease Causation
The ideas and concepts of
“social” epidemiology were much in evidence at this year’s SER
meeting. In direct response to issues raised at the SER meeting in
Boston two years ago, organizers sought to include more discussion
about the influence of social and environmental factors and their
influence on disease. In addition to symposia and a roundtable on the
topic, the keynote address by London’s Tony McMichael
focused on the need for taking a more ecological view of population
health. Entitled “Prisoners of the Proximate: A Sympathetic Critique
of the Scope of Modern Epidemiology.” McMichael detailed four
important constraints on the mindset and methods of modern
epidemiology. These were the same factors McMichael highlighted in his
interview with the Epi Monitor last May, 1) the focus on proximate
“downstream” risk factors; 2) preoccupation with individual-level
influences on health; 3) a static view of how we acquire changes in
risk status; and 4) our confinement, by the tenets of empiricism, to
working in the past and present tenses.
Framework
In contrast to the earlier Epi
Monitor article, the keynote address gave a fuller understanding of
why McMichael believes these four constraints are operating in modern
epidemiology. According to McMichael, “...the theoretic framework
within which we formulate our research questions determines the
ultimate quality and the social relevance of our answers. We need good
breadth and length of vision if we are to understand the determinants
of population health in terms beyond the immediate, the tangible, the
proximate. Yet much of modern epidemiology has ignored issues of
context. It has sought to estimate presumed universal risk
relationships—the one true value that we pursue with our
meta-analyses. It has often treated populations as mere aggregates of
free-range individuals. That type of context-free positivist
epidemiology yields only limited understanding of the causes and
distribution of disease within populations.”
Constraints Linked
Another key point that did not
emerge in the earlier article but was made clear during the talk is
the inter-relatedness of the four constraints. According to McMichael,
“these are four inter-related aspects of our limited ability to
conceptualize people, groups, populations, and their health within a
dynamic, interactive, and essentially ecological framework... That, in
turn, reflects a general limitation in western scientific thought.
This century we have increasingly embraced the liberal-democratic idea
of the primacy of free individuals, exercising independent choices in
the marketplace of life. For several centuries we have embraced the
idea of Man as Technological Master, uniquely entitled and able to
live apart from the natural world. These pervasive assumptions
influence how we frame questions about disease causation. Hence, we
look for immediate, individual-level risk factors, and we think of the
environment as a source of specific avoidable toxic hazards rather
than as a holistic and life-sustaining habitat.”
Prescriptions
McMichael concluded by giving
his prescriptions for addressing the constraints he has identified. In
his view, epidemiologists should 1) “look upstream more often, to
understand the social, political, and ecological determinants of the
differential distribution of risks to health within and between
populations; 2) explore the levels of influence on health because
the assumption that real, measurable, risk variation occurs at the
level of the individual is misleading; 3) view human biology and the
evolution of disease risk as a dynamic, interactive, and often,
whole-of-life process; and 4) help society, especially in a world
undergoing rapid demographic and environmental change, to foresee the
future and its range of plausible health consequences.”
Published July 1998
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