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Point-Counterpoint
Article Highlights Enduring Tension About The Proper Role Of
Epidemiologists In Public Health
Fact Finders Only
Or Fact Purveyors Also?
Should
epidemiologists be devoted primarily to producing findings and
publishing them objectively or should they also encourage the use of
their findings in formulating evidence-informed control measures?
This question was posed almost 40 years ago in the early days of The
Epidemiology Monitor (October 1982) by a Florida-based epidemiologist
who encountered resistance to implementing sanitary control measures.
(See reprint this issue).
He had
recommended these measures based on his investigation of a foodborne
outbreak at a health care facility. As reported in letters to the
editor at the time, the epidemiologist wondered to what extent he had
a responsibility to be simply “an attack rate calculator” or also “a
hell raiser” so that his data-based recommendations to protect the
at-risk population would be adopted.
Agreement on Purpose
The question of the
proper role for academic or applied epidemiologists as public health
scientists has been debated for decades with apparently no consensus
emerging on how epidemiologists can best navigate the gap between data
and action. On one question the consensus has not been in doubt, and
that is that epidemiology exists not as a basic science but for the
sake of improving public health. How best to do that is the perennial
question on the table.
AJE
Articles
Recently, two senior
epidemiologists, David Savitz at Brown University and
Rodolfo Saracci, formerly at the International Agency for Research
on Cancer have taken on the dilemma and tried again to explain the
differing viewpoints on the proper role for epidemiologists in
Point-Counterpoint articles in June 2021 in the American Journal of
Epidemiology. Also, in this issue of the Epi Monitor we publish
answers to follow-up questions we asked the authors such as one about
the impact of the pandemic on their thinking. (see related article in
this issue).
Rigor and Objectivity As Paramount
Savitz is keen to
protect the scientific rigor and integrity of epidemiologic work and
is quick to caution that epidemiologists should not overpromise or
over-interpret their findings. He believes that epidemiologists are
particularly vulnerable in this regard because of pressures or
incentives to overpromise about the significance of research to
obtain
funding, and similar pressures after the research is completed to
exaggerate the significance of the findings.
He would
prefer to leave careful balanced assessments of findings to
independent assessors charged with connecting evidence to action. He
does not assign any responsibility to epidemiologists who have
actually conducted the research to make that connection. Particularly
in what Savitz calls the “heat of battle” in referring to public
health policy controversies, he cautions that researchers tend to be
defensive about studies that support their desired policies rather
than carefully examining criticisms. This is especially the case when
the stakes are high and the battles are intense. Depending on the
positions of stakeholders in different controversies, there are both
welcome and unwelcome results and these are scrutinized differently,
according to Savitz.
Being
Doggedly Dispassionate
In
concluding his article, Savitz states that “the fundamental nature and
challenge of epidemiology is to balance the goal of generating
knowledge that advances public health and maintaining absolute
allegiance to scientific rigor and objectivity. In fact,
epidemiologists make their greatest contributions to advancing public
health when they design and conduct studies to interpret their
findings with a neutral, doggedly dispassionate perspective.” Savitz
even considers it an “obligation” not to connect evidence to action
but to actually keep separate the role of scientist from the other
interests epidemiologists might have as advocates, ambitious scholars,
or people with preconceptions and desires for certain outcomes.
Counterpoint
In his
counterpoint article, Saracci challenges Savitz’s singular focus on
the epidemiologist’s role as scientist and posits that epidemiology
underwrites a contract either formally or informally with society to
deliver on its goal to improve public health and thus has a dual
commitment to science and to people’s health.
Saracci
questions whether epidemiologists can maintain the “absolute
allegiance to scientific rigor and objectivity” called for by Savitz.
According to Saracci, objectivity can be sought but is beyond the
reach of an individual epidemiologist. He goes further to suggest that
non-neutrality is actually helpful because it favors research
questions that are relevant and applicable to population health and
because it can influence the interpretation of uncertain findings in
the direction of protecting public health. Finally, non-neutrality can
help build public trust in epidemiologic findings when trust in those
findings is essential to be being able to implement recommended public
health actions.
According to Saracci, epidemiologic findings need to be entered into
decision making processes to produce actual benefits for health and
this transfer from field to policy “…implies proactively driving the
results into the decision process and supporting them from a
science-for-health viewpoint in the same way as other
participants…will argue from their viewpoints.” According to Saracci,
epidemiologic findings with any implications for public health become
like the germ of an idea “the germ of a decision” and a
co-responsibility. He says, “If it has practical importance, it must
entail also practical responsibility, or else it does not possess
either.
To read
the article by Savitz, visit:
https://bit.ly/2Twa6xT
To read the
article by Saracci, vist:
https://bit.ly/3gAGzuU
Post-Publication Question and Answer Series with David Savitz and
Rodolfo Saracci On the Proper Role for Epidemiologists
Following the publication of their point-counterpoint articles in the
American Journal of Epidemiology in June, Drs. Savitz and Saracci
kindly agreed to field these additional questions from the editor of
The Epidemiology Monitor.
1.
Epi Monitor:
As you know, the question or dilemma you each addressed in your AJE
article has been around for many years and no definite consensus has
emerged in the profession as far as I know. Is there something very
specific about the current period of time which prompted you to write
now about the proper role for epidemiologists?
Saracci:
Actually there was not a specific circumstance related
to the pandemic that prompted my intervention. We can safely say that
the issue "always" existed, as shown - just an example - in a paper of
1978 [Epidemiological strategies and environmental factors. Int J
Epidemiol 1978; 7: 101-110 ] in which discussing the problematic
aspects of epidemiologists' responsibilities I wrote: "More likely to
be affected is the newer generation of epidemiologists who, however,
are less likely than the classic communicable disease epidemiologists
to have had the benefit of direct experience of decision making (for
example in the control of an epidemic)". What it meant is that older
time 'classic' epidemiologists had very often at least some experience
as public health officials, obliged to take (with others) decisions :
there is nothing better than this to grasp all terms of the
'scientific evidence - practical decision' problem. I never had that
experience but my clinical practice years presented problems that, at
the individual rather than at the population level, are not
dissimilar.
Savitz:
Epidemiologists are affected by the social and political climate of
the times, which is notably antagonistic. In calmer, more civil
times, we can be confident that evidence will speak for itself,
limitations can and should be acknowledged with trust that the
research won’t be inappropriately dismissed, and that reasoned debate
is beneficial and can change interpretations. When engaged in
ideological warfare, such reasoned examination and debate tends to be
replaced with hyperbole and defensiveness, which we need to
consciously avoid to maintain the integrity of the discipline.
2.
Epi
Monitor:
Epidemiologists have had a great deal of work to do during the
pandemic and have never been as much in the spotlight as they have
been during the pandemic. Has anything you have observed during the
pandemic altered your thinking about the proper role of
epidemiologists as public health scientists? Should they be doing more
or less of something?
Savitz:
I believe the pandemic and our our heightened visibility has
accelerated an ongoing shift in our focus from the esoteric to the
practical, which I personally believe is beneficial to the discipline
and society. While there may be long-term scientific payoffs from
delving into arcane biological, social, and theoretical avenues of
research, epidemiology is at its best in addressing practical,
real-world topics that only epidemiology can tackle – When is wearing
masks beneficial? What settings and activities increase risk of
infection and which ones are safe? Why is the magnitude of social
disparity so profound and how can we mitigate it?
Saracci:
In this respect I can elaborate a little more on what I wrote in the
Counterpoint. I am well aware of the danger of becoming an advocate
and I know more than one scientist-cum-advocate whose science has
become thinner and thinner, in the end spoiling the very purpose of
soundly based advocacy. I think that epidemiologists while keeping
constant attention to the danger should not evade from making their
case, even forcefully, rather than simply letting the results at the
door of "decision makers". The rationale for this is that in the real
(as opposed to an ideal, conflict-free) world the other parties
(technologists, economists, sociologists, citizen's groups,
corporations etc.) which provide inputs to the "decision makers"
rarely if ever depose their inputs at the door, most often they cross
the door and enter at least a few steps into the decision room. Hence
I feel almost obliged to exercise my part of results support and
advocacy. A closely related argument was made, in his usual sharp
style, by Geoffrey Rose when he wrote (The strategy of
preventive medicine, 2nd ed,
page 151) "...the difficulty is the massive amount of
persuasion that comes from the other side ("Drink more vodka!" "Drive
bigger and faster cars!").Maybe freedom [of choice] suffers
less if it is attacked from both sides, not from only one. On that
ground alone I grudgingly allow that persuasion [as opposed to
information that he had discussed before] has some place in health
education".
3.
Epi Monitor:
Presumably, agreeing on the proper role for epidemiologists would
improve what epidemiologists are able to accomplish. Since no
consensus has emerged about the proper role of epidemiologists in
regard to the transfer of findings from the world of science to the
world of public health, what do you believe it will take beyond your
articles for such a consensus to develop?
Savitz:
I continue to believe epidemiologists have much to contribute to many
realms of society but what we need is a seat at the table where those
decisions are made and not to be prescriptive regarding what should be
done. We should not take it on ourselves to remove the pump handle
but to provide research findings in a clear and balanced way to those
who manage the water distribution system who need to take other
considerations into account to make the best decisions. This goes
well beyond the conventional public health arena and should include
generating and providing evidence to decision-makers in the realms of
urban design, transportation systems, criminal justice, agriculture,
immigration, etc.
Saracci:
As usual we can organize, also in the light of the
pandemic experience, some kind of conference or workshop with ample
discussion time on the topic: it can be highly enjoyable coming after
months and months of confinement. Its main value would be to ensure
that, more than a consensus, an open and healthy spectrum of views and
attitudes is alive. Given the dual commitment of epidemiology it would
be dangerous if only one attitude would uniformly prevail, it would
end by obscuring the awareness that more than one commitment is at
stake and that the two cannot be automatically reconciled by any fixed
formula to be memorized by all epidemiologists. ■
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