A 19^th century cartoon used as the image for the book cover of Risk, Chance, and Causation by Yale University’s Michael Bracken piqued our curiosity more than usual when we learn about new books. It shows the picture of a man, presumably Benjamin Perkins,  the American who discovered a new treatment, applying electrophysical force with metal rods to a male patient’s face. The cartoon ridicules the claim graphically but also with these words:

The Epidemiology Monitor questioned Mike Bracken about his new book, and here is what he had to say. Readers interested in reviewing the book for The Epidemiology Monitor should contact us at epimon@aol.com We will select a qualified reviewer who will get a free copy of the book in exchange for the review.

Epi Monitor:  The book has a humorous image on the cover for an epidemiology book. What is that image and why was it selected?

Bracken: James Gilray is a famous satirical cartoonist working at the turn of the 18^th century and in this

image he comments on an episode that relates to two themes in the book. A Yale (sorry to say) doctor Benjamin Perkins went to London to promote his metallic tractors that appeared to cure everything from gout to syphilis by using “electro-physical forces”.

This is not unlike many of the numerous quack “treatments and cures” to which the public today falls victim. Our villain, Ben, is exposed by a Dr. John Haygarth who paints wooden tractors to look like metal and achieves the same successful cures. Thus, providing the first known example of masking in a clinical trial, demonstrating the placebo effect, and alluding to another theme in the book - how sources of bias are recognized and avoided.

Epi Monitor:  How did the idea for the book come about?

Bracken: I hoped to write a book that explored for the public the work of epidemiologists. The public faces a tsunami of misinformation about the value of therapies and the risks of environmental and life-style exposures. At the same time, they are ill prepared to properly evaluate this information.

Because epidemiology is not taught in schools (I think it should be but that’s a topic for another day) the public is never formally educated in how to evaluate claims of therapeutic effectiveness and safety.

Risk Chance and Causation is an effort to make some of these concepts available to the general public and to hopefully help them navigate through this wave of hyperbole that constantly washes over them.

Epi Monitor:  How would you describe the book in just a few sentences?

Bracken: We all take risks every day without giving much thought to the pros and cons, or weighing alternatives. We are exposed to events that may occur by chance although we attribute some cause to them. And we are exposed to other events that are not random although we think they are because we do not know a cause.

Indeed how we conceive of causation is poorly understood. Nowhere are these complexities more salient than in the context of health and disease and these are the issues the book is intended to explore

Epi Monitor:  What were your main aim(s) in writing the book?

Bracken: We epidemiologists talk about risk and chance and causation continuously in our daily work, often without spending too much time analyzing them in depth. When we do give them serious thought, we realize what difficult concepts they are. How much more difficult it must be for the public to come to grips with these ideas.

My main goal for the book was to introduce these ideas to the public in what I hope is an understandable way, and particularly in the context of how scientists investigate the origins and treatment of disease, which is the book’s subtitle.

If the public understands how epidemiologists consider evidence, people will have a better chance of arming themselves against the onslaught of information they face. They can filter out information that is still hypothetical, not replicated or based on biased and unreliable studies from that which they should know about to be able to better protect their health.

Epi Monitor:  What is the main audience you are trying to communicate with?

Bracken: The hardest part of writing the book was pitching the material to a non-specialist audience. Not being too technical while not dumbing it down and over-simplifying. After a lifetime writing papers for scientific journals it took some time to find the style I was hoping for and I’m not sure I was completely successful.

Epi Monitor:  How would you contrast your book with existing epidemiology textbooks?

Bracken: Risk Chance and Causation is not a textbook. Epidemiology is well endowed with many superb texts and it was certainly not my goal to add another. You likely wouldn’t find a chapter entitled “Celebrity Trumps Science” in a standard text, but in my book it shows examples of  the misinformation the public is exposed to and then discusses the underlying evidence supporting (or, most likely, not supporting) the claim.

It was one of the most enjoyable chapters to research and write because even being an aging skeptic didn’t prepare me for some of the modern “snake oil” sales personalities lurking on the internet and, surprisingly, even in the alumni magazines of some of our most prestigious universities.

Other chapters less likely seen in epidemiology texts include an introduction to genetic causation and reflections on the poor predictability to the human condition of much animal research.

Epi Monitor:  Are there unique aspects to this book other than the cover?

Bracken: Because of my own interests and from teaching evidence based medicine and health care the book melds these newer paradigms with more traditional themes in observational and classic epidemiology. I have never accepted that epidemiology should not, for example, include RCTs or that clinical epidemiology was somehow a distinct discipline.

Epidemiologists have always been concerned about biased papers but evidence-based medicine (EBM) has highlighted the particular problems of bias in first published results (the winner’s curse) and even bias in entire bodies of literature. 

Other examples of methodology concepts arising from the EBM paradigm include protocol registration, outcome reporting bias, citation bias and the science of systematic reviewing and meta-analysis, which have all been to differing degrees adopted by epidemiologists.

These themes are all discussed in the book with reference to why the public should be cautious of many of the health claims and risks they read about.

Finally, without taking anything away from the remarkable work of everybody’s hero, John Snow, I have tried to rehabilitate the enormous achievement of Joseph Goldberger’s work on pellagra. Unlike Snow, he includes experimental as well as observational methods. Goldberger is truly (with apologies to Gilbert and Sullivan) the very model of a modern major epidemiologist.

Epi Monitor:  How long did it take you to write the book?

Bracken: I was writing daily for about 12 weeks to draft 80% of it while on sabbatical at my home outside Oxford, which may explain the large number of references to British epidemiology. But in other respects Risk Chance and Causation gestated over 45 years.

I have drawn on many examples from my own career which, as for most epidemiologists, has been rewarded by a rich variety of personal experiences and acquaintance with fascinating characters, many of whom have become dear friends. I hope this more personal approach makes the subject matter more accessible for the intended non-specialist reader.

Reviews To Date

Here is what reviewers have said about the book so far as seen from the book jacket.

“Risk, Chance, and Causation is remarkable for a text covering such technical and scientific subject matter…Bracken provides his audience with an engaging, entertaining and educational read.”—Audrey F. Saftlas, University of Iowa

“The book is very enjoyable to read, and the author has successfully diversified the cold scientific topics with anecdotal material and popular quotes.”—John P. A. Ioannidis, Stanford University

"This book is a great read for almost anyone, from the interested lay reader to the experienced epidemiologist. We are quickly drawn into to the foundation of epidemiologic science and thinking by way of stories, cautionary tales and numerous examples, from both history and current events. Whether you are a practitioner, teacher, student, or you just happen to pick up the book, you will be certain to find Bracken’s stories compelling and even eye-opening."—Kay Dickersin, Johns Hopkins Bloomberg School of Public Health

"Using a great range of examples, Michael Bracken provides a masterful guide to identifying the many false claims about what makes humans healthy or sick.  This book should be required reading for all in the media who try to explain health studies to the public."—Nigel Paneth, University Distinguished Professor, Michigan State University

"This book is a credit to epidemiology and an exciting and joyful read for lay and learned readers alike.”—Geir W. Jacobsen, Norwegian University of Science and Technology 

The book is available on Amazon at:  http://tinyurl.com/m37uzw4 ■

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