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In the epidemiological imagination, the Framingham Heart Study has attained iconic status, both as the prototype of the cohort study and as a result of its scientific success. When the Public Health Service launched the study in 1947, epidemiological knowledge of coronary heart disease was poor, and epidemiology primarily involved the study of infectious disease. In constructing their investigation, Framingham's initiators had to invent new approaches to epidemiological research. These scientific goals were heavily influenced by the contending institutional and personal interests buffeting the study. The study passed through vicissitudes and stages during its earliest years as its organizers grappled to define its relationship to medicine, epidemiology, and the local community. (Am J Public Health. 2005;95:602-610.doi10.2105/AJPH.2003.026419). [ABSTRACT FROM AUTHOR]

Part I of this paper traced the evolution of modern epidemiology in terms of three eras, each with its dominant paradigm, culminating in the present era of chronic disease epidemiology with its paradigm, the black box. This paper sees the close of the present era and foresees a new era of eco-epidemioiogy in which the deployment of a different paradigm will be crucial. Here a paradigm is advocated for the emergent era. Encompassing many levels of organization-molecular and societal as well as individual-this paradigm, termed Chinese boxes, aims to integrate more than a single level in design, analysis, and interpretation. Such a paradigm could sustain and refine a public health-oriented epidemiology. But preventing a decline of creative epidemiology in this new era will require more than a cogent scientific paradigm. Attention will have to be paid to the social processes that foster a cohesive and humane discipline. [ABSTRACT FROM AUTHOR]

This article attempts to contribute to the debate on the future of epidemiology by combining Thomas Kuhn's ideas on scientific paradigms with the author's observations on some epidemiology textbooks. The author's interpretations were based on his readings of Kuhn's The Structure of Scientific Revolutions, epidemiology textbooks, and papers on the future of epidemiology. Thomas Kuhn's view is that sciences mostly work with a single paradigm driven by exemplars of successful work, and that proposals for paradigm change are resisted. Sciences that are maturing or changing do not have a dominant paradigm. Epidemiology textbooks showed diversity in their concepts, content, and approach. Most exemplars related to etiologic research rather than public health practice. One key focus of the recent controversy regarding the role of epidemiology has been the increasing inability of epidemiology to solve socially based public health problems. Kuhn's views help explain the polarization of views expressed. Kuhn's philosophy of science offers insights into controversies such as whether a paradigm shift is needed or imminent and the gap between epidemiology and public health practice. Interaction between science philosophers, epidemiologists, and public health practitioners may be valuable. [ABSTRACT FROM AUTHOR]

Ecological studies have been evaluated in epidemiological contexts in terms of the "ecological fallacy." Although the empirical evidence for a lack of comparability between correlations derived from ecological- and individual-level analyses is compelling, the conceptual meaning of the ecological fallacy remains problematic. This paper argues that issues in cross-level inference can be usefully conceptualized as validity problems, problems not peculiar to ecological-level analyses. Such an approach increases the recognition of both potential inference problems in individual-level studies and the unique contributions of ecological variables. This, in turn, expands the terrain for the location of causes for disease and interventions to improve the public's health. [ABSTRACT FROM AUTHOR]

Today, our understanding of approach to the exogenous causes of cancer are dominated by epidemiological practices that came into widespread use after World War II. This paper examines the forces, considerations, and controversies that shaped postwar risk factor epidemiology in the United States. It is argued that, for all of the new capabilities it brought, this risk factor epidemiology has left us with less of a clinical eye for unrecognized cancer hazards, especially from limited and localized exposures in the workplace. The focus here is on Wilhelm Hueper, author of the first textbook on occupational cancer (1942). Hueper became the foremost spokesman for earlier identification practices centering on occupational exposures. The new epidemiological methods and associated institutions that arose in the 1940s and 1950s bore an unsettled relation to earlier claims and methods that some, Hueper among them, interpreted as a challenge. Hueper's critique of the new epidemiology identified some of its limitations and potentially debilitating consequences that remain with us today. [ABSTRACT FROM AUTHOR]

Objectives. This paper reviews Russia's health crisis, financing, and organization and public health reform needs. Methods. The structure, policy, supply of services, and health status indicators of Russia's health system are examined. Results. Longevity is declining; mortality rates from cardiovascular diseases and trauma are high and rising; maternal and infant mortality are high. Vaccine-preventable diseases have reappeared in epidemic form. Nutrition status is problematic. conclusions. The crisis relates to Russia's economic transition, but it also goes deep into the former Soviet health system. The epidemiologic transition from a predominance of infectious to non infectious diseases was addressed by increasing the quantity of services. The health system lacked mechanisms for epidemiologic or economic analysis and accountability to the public. Policy and funding favored hospitals over ambulatory care and individual routine checkups over community-oriented preventive approaches. Reform since 1991 has centered on national health insurance and decentralized management of services. A national health strategy to address fundamental public health problems is recommended. [ABSTRACT FROM AUTHOR]

Abstract: This paper provides an overview of problems in multivariate modeling of epidemiologic data, and examines some proposed solutions. Special attention is given to the task of model selection, which involves selection of the model form, selection of the variables to enter the model, and selection of the form of these variables in the model. Several conclusions are drawn, among them: a) model and variable forms should be selected based on regression diagnostic procedures, in addition to goodness-of-fit tests; b) variable-selection algorithms in current packaged programs, such as conventional stepwise regression, can easily lead to invalid estimates and tests of effect; and c) variable selection is better approached by direct estimation of the ° of confounding produced by each variable than by significance-testing algorithms. As a general rule. before using a model to estimate effects, one should evaluate the assumptions implied by the model against both the data and prior information. [ABSTRACT FROM AUTHOR]

Abstract: Despite the widespread use of ecologic analysis in epidemiologic research and health planning, little attention has been given by health scientists and practitioners to the methodological aspects of this approach. This paper reviews the major types of ecologic study designs, the analytic methods appropriate for each, the limitations of ecologic data for making causal inferences and what can be done to minimize these problems, and the relative advantages of ecologic analysis. Numerous examples are provided to illustrate the important principles and methods. A careful distinction is made between ecologic studies that generate or test etiologic hypotheses and those that evaluate the impact of intervention programs or policies (given adequate knowledge of disease etiology). Failure to recognize this difference in the conduct of ecologic studies can lead to results that are not very informative or that are misinterpreted by others. (Am J Public Health 1982: 72:1336-1344.) [ABSTRACT FROM AUTHOR]

The article presents various research papers on epidemiology and discusses public health of the aged in the United States. The history of epidemiology and public health is replete with examples of ingenious and brilliant use of available data that were used to answer important questions and that yielded major public health advances. The Davis report on living arrangements is a sophisticated analysis that reveals the limitations of secondary data, albeit more subtle ones, when one are asking complex questions. If the data reflects a national sample, having national data becomes strength of the study. It is important to note that "secondary data" is an imprecise label that covers a great diversity of types and sources of data. The data set has information on some additional variables not previously examined. It becomes important to look at these variables as possible controls or as risk factors.

Objectives. The purpose of this study was to determine the frequency and character of policy statements in epidemiologic reports. Methods. The first author followed a standardized protocol and reviewed a random sample of articles selected from the American Journal of Epidemiology, Annals of Epidemiology, and Epidemiology. The second author reviewed all articles with policy statements and a 10% sample without such statements. Results. Overall, 23.8% of the articles contained policy statements. Annals of Epidemiology and the American Journal of Epidemiology had similar frequencies of articles with policy statements (30% and 26.7%, respectively), while Epidemiology evidenced the lowest frequency (8.3%). The majority of policy statements (55%) pertained to public health practice; 27.5% involved clinical practice, and the remainder (17.5%) focused on corporate policies, regulatory actions, or undefined arenas. The frequency of policy statements differed according to first author's affiliation, type of publication, area of research, research design, and study population. Conclusions. Although a minority of publications included policy statements, the inclusion of a statement seemed to be influenced by specific study characteristics. [ABSTRACT FROM AUTHOR]

We used Medicare data bases and U.S. Census data to address two questions critical to the use of Medicare files for epidemiologic research. First, we examined the degree to which the population enrolled in the Medicare program is similar to the elderly resident population of the United States, as estimated by the US Census. We found small differences in the total population estimates hut substantial differences by age and race. Second, we found that among Medicare enrollees, physician claims identify a small proportion of hip fracture cases which are not documented in the hospital discharge files. This proportion varies by age region, and state within the United States. Calculation of rates based on Medicare hospital discharge data, and probably other hospital discharge data sets as well, must take these limitations into account. Use of all available Medicare data files can overcome these limitations. [ABSTRACT FROM AUTHOR]

Abstract: Over the fast decade there has been a marked increase in information on the epidemiology of psychiatric disorders, particularly major depression, in adults living in the community and in families. The ability to conduct large epidemiologic studies of psychiatric disorders is due to improvements in diagnostic precision and reliability in psychiatry and to the development of systematic methods for collecting information on signs and symptoms to make diagnoses. Results from a recently completed epidemiologic survey of psychiatric disorders in five urban communities in the United States and from several large-scale family genetic studies suggest that major depression is a highly prevalent disorder. It occurs in adults and children, and there in evidence for an increased rate in younger people. The average age of first onset is in young adulthood. Most depressions are untreated. The firm risk factors for major depression include being female: young (born after World War lib separated/divorced or in an unhappy marriage: and having a family history of major depression. There is a two-to-threefold increased risk for major depression if there is a family history of the disorder. The relevance of these findings to clinical practice and public health is discussed. (Am J Public Health 1987:77:445-451.) [ABSTRACT FROM AUTHOR]

Abstract: Records of 642 outbreaks of acute gastroenteritis were reviewed to determine the proportion of outbreaks that were clinically and epidemiologically consistent with Norwalk-like virus infection. Using as our criteria stool cultures negative for bacterial pathogens. mean (or median) duration of illness 12-60 hours, vomiting in is ≥ 50 per ¢ of cases, and, if known, mean (or median) incubation period of 24-48 hours, we found that 23 per ¢ of waterborne outbreaks. 4 per ¢ of foodborne outbreaks, and 67 per ¢, 60 per ¢, and 28 per ¢ of outbreaks in nursing homes, in summer camps, and on cruise ships. respectively, satisfied the criteria for Norwalk-like pattern. Of 54 outbreaks that satisfied the criteria for Norwalk-like pattern, 14 were investigated for virus etiology. Ten of these (71 per ¢) yielded serologic evidence of Norwalk-like virus infection. Norwalk-like viruses are probably an important cause of outbreaks of acute gastroenteritis, investigation for Norwalk virus antibody in outbreaks that are clinically and epidemiologically consistent with Norwalk-like virus infection ix likely to yield diagnostically useful results. (Am J Public Health 1982; 72: 1329-1332.) [ABSTRACT FROM AUTHOR]

Comparative studies of health conditions and medical problems involving various nations and cultures may cast light on a frequently complex and difficult scientific problem and at the same time, have highly practical significance for the populations involved. Examples include large scale multinational research projects on nutrition and heart diseases and international comparisons of cancer epidemiological. These projects have made important theoretical and applied contributions and promise still more exciting results in the future. The political dispute over whether the government in Peking or that in Taipei was entitled to represent the huge population of China kept the People's Republic out of the World health Organization until 1912.

Ensuring the conditions for all people to be healthy, though always the core mission of public health, has evolved in approaches in response to the changing epidemiology and challenges. In the Public Health 3.0 era, multisectorial efforts are essential in addressing not only infectious or noncommunicable diseases but also upstream social determinants of health. In this article, we argue that actionable, geographically granular, and timely intelligence is an essential infrastructure for the protection of our health today. Even though local and state efforts are key, there are substantial federal roles in accelerating data access, connecting existing data systems, providing guidance, incentivizing nonproprietary analytic tools, and coordinating measures that mattermost. [ABSTRACT FROM AUTHOR]

Epidemiology instruction has expanded at the undergraduate level in part because it increases student critical thinking and scientific literacy, promotes students' perception of public health as both practical and relevant, and empowers students as independent, lifelong learners. Why then are more high schools not adopting epidemiology as a course requirement for students? Although prior iterations of high school epidemiology courses are noteworthy for incorporating active and participatory learning, embedding them into existing and continually shifting curricula is challenging and time-consuming, especially for teachers not trained in the field. It also may be argued that currently available epidemiology teaching resources emphasize content rather than thinking skills and therefore do not optimally promote students' personal engagement with, and in-depth understanding of, the mission and goals of public health. I propose a new framework for high school epidemiology that draws from progressive education ideology, including three critical elements: empowerment, authenticity, and transfer. I provide multiple examples to show how this framework has been used across a wide array of settings to hone epidemiology thinking skills in high school students. [ABSTRACT FROM AUTHOR]

Several studies have implicated the sexual networks of Black men who have sex with men (MSM) as facilitating disproportionally high rates of new HIV infections within this community. Although structural disparities place these networks at heightened risk for infection, HIV prevention science continues to describe networks as the cause for HIV disparities, rather than an effect of structures that pattern infection. We explore the historical relationship between public health and Black MSM, arguing that the current articulation of Black MSM networks is too often incomplete and counterproductive. Public health can offer a counternarrative that reconciles epidemiology with the social justice that informs our discipline, and that is required for an effective response to the epidemic among Black MSM. [ABSTRACT FROM AUTHOR]

The article discusses the benefits of training in epidemiology and public health to the improvement of global public health leadership. The Field Epidemiology Training Programs and Public Health Schools Without Walls established the Training Programs in epidemiology and Public Health Interventions Network (TEPHINET). The programs are increasingly popular as catalysts for strengthening the scientific basis of policymaking through the continuous examination of data available from surveillance systems. The TEPHINET programs will improve surveillance, disease prevention and health promotion programs.

Graduate students and postdoctoral fellows—including those at the Harvard School of Public Health (HSPH)— have somewhat limited opportunities outside of traditional coursework to learn holistically about public health. Because this lack of familiarity could be a barrier to fruitful collaboration across disciplines, HSPH postdocs sought to address this challenge. In response, the Public Health 101 Nanocourse was developed to provide an overview of five core areas of public health (biostatistics, environmental health sciences, epidemiology, health policy and management, and social and behavioral sciences) in a two half-day course format. We present our experiences with developing and launching this novel approach to acquainting wider multidisciplinary audiences with the field of public health. [ABSTRACT FROM AUTHOR]

The author offers observation on epidemiology and its role in public health and society. He describes the first textbook of epidemiology, "Epidemics and Crowd-Diseases: An Introduction to the Study of Epidemiology," by Major Greenwood. He analyzes the article "Choosing a Future for Epidemiology: I. Eras and Paradigms," by M. Susser and E. Susser. He also examines the article "Traditional Epidemiology, Modern Epidemiology, and Public Health," by N. Pearce.

Objectives. We examined a syndemic of psychosocial health issues among young men who have sex with men (MSM), with men and women (MSMW), and with women (MSW). We examined hypothesized drivers of syndemic production and effects on suicide attempts. Methods. Using a pooled data set of 2005 and 2007 Youth Risk Behavior Surveys from 11 jurisdictions, we used structural equation modeling to model a latent syndemic factor of depression symptoms, substance use, risky sex, and intimate partner violence. Multigroup models examined relations between victimization and bullying experiences, syndemic health issues, and serious suicide attempts. Results. We found experiences of victimization to increase syndemic burden among all male youths, especially MSMW and MSM compared with MSW (variance explained = 44%, 38%, and 10%, respectively). The syndemic factor was shown to increase the odds of reporting a serious suicide attempt, particularly for MSM (odds ratio [OR] = 5.75; 95% confidence interval [CI] = 1.36, 24.39; P < .001) and MSMW (OR = 5.08; 95% CI = 2.14, 12.28; P < .001) compared with MSW (OR = 3.47; 95% CI = 2.50, 4.83; P < .001). Conclusions. Interventions addressing multiple psychosocial health outcomes should be developed and tested to better meet the needs of young MSM and MSMW. [ABSTRACT FROM AUTHOR]

The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease (1909-1914) fielded a philanthropic public health project that had three goals: to estimate hookworm prevalence in the American South, provide treatment, and eradicate the disease. Activities covered 11 Southern states, and Rockefeller teams found that about 40% of the population surveyed was infected. However, the commission met strong resistance and lacked the time and resources to achieve universal county coverage and meet project goals. We explore how these constraints triggered project changes that systematically reshaped project operations and the characteristics of the counties surveyed and treated. We show that county selectivity reduced the project's initial potential to affect hookworm prevalence estimates, treatment, and eradication in the American South. [ABSTRACT FROM AUTHOR]

Objectives. To better understand the trajectory that propels people from poverty to poor health, we investigated health resilience longitudinally among African American families with incomes below 250% of the federal poverty level. Methods. Health resilience is the capacity to maintain good health in the face of significant adversity. With higher levels of tooth retention as a marker of health resilience, we used a social-epidemiological framework to define capacity for health resilience through a chain of determinants starting in the built environment (housing quality) and community context (social support) to familial influences (religiosity) and individual mental health and health behavior. Results. Odds of retaining 20 or more teeth were 3 times as likely among adults with resilience versus more-vulnerable adults (odds ratio = 3.1; 95% confidence interval [CI] = 1.3,7.4). Children of caregivers with resilience had a lower incident rate of noncavitated tooth decay at 18- to 24-month follow-up (incidence risk ratio = 0.8; 95% CI = 0.7, 0.9) compared with other children. Conclusions. Health resilience to poverty was supported by protective factors in the built and social environments. When poverty itself cannot be eliminated, improving the quality of the built and social environments will foster resilience to its harmful health effects. (Am J Public Health. 2008; 98:1101-1106. doi:10.2105/AJPH.2007.119495) [ABSTRACT FROM AUTHOR]

We describe the emergence of lesbian, gay, bisexual, and transgender (LGBT) health as a key area of study and practice for clinicians and public health professionals. We discuss the specific needs of LGBT populations on the basis of the most recent epidemiological and clinical investigations, methods for defining and measuring LGBT populations, and the barriers they face in obtaining appropriate care and service's. We then discuss how clinicians and public health professionalscan improve research methods, clinical outcomes, and service delivery for lesbian, gay, bisexual, and transgender people. (Am J Public Health. 2008;98:989-995. doi:10.2105/AJPH.2007.127811) [ABSTRACT FROM AUTHOR]

Concepts of cause and causal inference are largely self-taught from early learning experiences. A model of causation that describes causes in terms of sufficient causes and their component causes illuminates important principles such as multicausality, the dependence of the strength of component causes on the prevalence of complementary component causes, and interaction between component causes. Philosophers agree that causal propositions cannot be proved, and find flaws or practical limitations in all philosophies of causal inference. Hence, the role of logic, belief, and observation in evaluating causal propositions is not settled. Causal inference in epidemiology is better viewed as an exercise in measurement of an effect rather than as a criterion-guided process for deciding whether an effect is present or not. [ABSTRACT FROM AUTHOR]

Today, many of the 10 million childhood deaths each year are caused by diseases of poverty--diarrhea and pneumonia, for example, which were previously major causes of childhood death in many European countries. Specific analyses of the historical decline of child mortality may shed light on the potential equity impact of interventions to reduce child mortality. In our study of the impact of improved water and sanitation in Stockholm from 1878 to 1925, we examined the decline in overall and diarrhea mortality among children, both in general and by socioeconomic group. We report a decline in overall mortality and of diarrhea mortality and a leveling out of socioeconomic differences in child mortality due to diarrheal diseases, but not of overall mortality. The contribution of general and targeted policies is discussed. (Am J Public Health 2005;95:208-216.). [ABSTRACT FROM AUTHOR]

In 1876, Robert Koch established anthrax as the first disease linked to a microbial agent. But Koch's efforts had followed more than 150 years of scientific progress in characterizing anthrax as a specific human and veterinary disease. Focusing on France and the period between 1769 and 1780, this brief review examines noteworthy early events in the characterization of anthrax. It suggests that some "new" diseases like anthrax might be "discovered" not only by luck, brilliance, or new technologies, but by clinical/epidemiological "puzzle-fitting," which can assemble a cohesive picture of a seemingly specific disease entity. If such processes have operated over 2 or more centuries, studying them may yield clues about desirable interactions between epidemiology/public health and experimental science in the characterization of new diseases. [ABSTRACT FROM AUTHOR]

The resistance of disadvantaged groups to antismoking advice is remarkable. In relation to the study of differing cultures, there is a long-standing academic tradition assuming that behavior that may otherwise be difficult to understand is indeed rational within particular cultural contexts. Persistent smoking among the most deprived members of society may represent a rational response to their life chances informed by a lay epidemiology. Health promotion initiatives designed to reduce smoking among members of these groups may continue to fail unless the general health and life chances of such individuals are first improved. (Am J Public Health. 2003;93: 266-270) [ABSTRACT FROM AUTHOR]

Objectives. This study estimated the burden of disease due to 48 major causes in the Netherlands in 1994 in disability-adjusted life-years (DALYs), using national epidemiologic data and disability weights, and explored associated problems and uncertainties. Methods. We combined data from Dutch vital statistics, registrations, and surveys with Dutch disability weights to calculate disease-specific health loss in DALYs, which are the sum of years of life lost (YLLs) and years lived with disability (YLDs) weighted for severity. Results. YLLs were primarily lost by cardiovascular diseases and cancers, while YLDs were mostly lost by mental disorders and a range of chronic somatic disorders (such as chronic nonspecific lung disease and diabetes). These 4 diagnostic groups caused approximately equal numbers of DALYs. Sensitivity analysis calls for improving the accuracy of the epidemiologic data in connection with disability weights, especially for mild and frequent diseases. Conclusions. The DALY approach appeared to be feasible at a national Western European level and produced interpretable results, comparable to results from the Global Burden of Disease Study for the Established Market Economies. Suggestions for improving the methodology and its applicability are presented. (Am J Public Health. 2000;90:1241-1247) [ABSTRACT FROM AUTHOR]

Epidemiologic research has shown that prone sleeping is a major risk factor for sudden infant death syndrome (SIDS). In a public health review from Sweden, we explored the historical background of the SIDS epidemic, starting with the view of the Catholic Church that sudden infant deaths were infanticides and ending with the slowly disseminated recommendation of a prone sleeping position during the 1960s, 1970s, and 1980s. The story of the SIDS epidemic illustrates a pitfall of preventive medicine--the translation of health care routines for patients to general health advice that targets the whole population. False advice, as well as correct advice, may have a profound effect on public health because of the many individuals concerned. Preventive measures must be based on scientific evidence, and systematic supervision and evaluations are necessary to identify the benefits or the harm of the measures. The discovery of the link between prone sleeping and SIDS has been called a success story for epidemiology, but the slow acceptance of the causal relationship between prone sleeping and SIDS illustrates the weak position of epidemiology and public health within the health care system. (Am d Public Health. 2000;90:527-531) [ABSTRACT FROM AUTHOR]

A group of individuals behaves as a population system when patterns of connections among individuals influence population health outcomes. Epidemiology usually treats populations as collections of independent individuals rather than as systems of interacting individuals. An appropriate theoretical structure, which includes the determinants of connections among individuals, is needed to develop a "population system epidemiology." Infection transmission models and sufficient-component cause models provide contrasting templates for the needed theoretical structure. Sufficient- component cause models focus on joint effects of multiple exposures in individuals. They handle time and interactions between individuals in the definition of variables and assume that populations are the sum of their individuals. Transmission models, in contrast, model interactions among individuals over time. Their nonlinear structure means that population risks are not simply the sum of individual risks. The theoretical base for "population system epidemiology" should integrate both approaches. It should model joint effects of multiple exposures in individuals as time related processes while incorporating the determinants and effects of interactions among individuals. Recent advances in G-estimation and discrete individual transmission model formulation provide opportunities for such integration. [ABSTRACT FROM AUTHOR]

Epidemiologists, biostatisticians, and health physicists frequently serve as expert consultants to lawyers, courts, and administrators. One of the most common errors committed by experts is to equate, without qualification, the attributable fraction estimated from epidemiologic data to the probability of causation requested by courts and administrators. This error has become so pervasive that it has been incorporated into judicial precedents and legislation. This commentary provides a brief overview of the error and the context in which it arises. [ABSTRACT FROM AUTHOR]

This commentary examines the scope of epidemiology and delineates the role of epidemiology in relation to public health. Epidemiology is a science; public health is a mission that is implemented through societal action. The implications of this difference are considered, and the sufficiency of epidemiology for guiding public health is evaluated in relation to other scientific disciplines and nonscientific considerations. The authors conclude that epidemiology is not the basic science of public health but one of many contributors to guiding action. The need for public health decisions despite scientific uncertainty and the potential for epidemiologic certainty's failing to provide clear guidance to public health action emphasize the distinctiveness of these endeavors. Criticisms that epidemiology fails to solve major public health problems, such as tobacco use; that it overemphasizes methods; that it fails to meet the needs of public health practitioners; and that it isolates itself from public health ethics are unwarranted. However, epidemiology should focus on addressing issues that directly affect public health decisions and should clearly communicate information about such issues to public health workers. Public health is far more complex than merely applying epidemiology. [ABSTRACT FROM AUTHOR]

The article comments on how the new political economy of medical care is creating an unprecedented demand for epidemiological knowledge in the United States. The article author first summarizes the conventional opinion of historians about the use of epidemiology in clinical medicine. Then he explains why the contemporary revision of the social contract between medicine and American society is creating an intense demand for knowledge based on the study of defined populations. Next, he explores implications of this new social contract for physicians, patients, and purchasers. Finally, he address a paradox that throughout the 20th century, academic physicians and most practitioners of medicine have taken pride in being at the forefront of scientific progress. Yet, medical care may be one of the last sectors of society in industrial countries to embrace fully probabilistic thinking. It explores contemporary history relevant to the controversy about silicone breast implants. This controversy offers practical examples of the conflict between the certitudes of a decaying social contract and the implications of another that is emerging.

Objectives. This study examined trends and risk factors for infant mortality associated with necrotizing enterocolitis in the United States. Methods. Necrotizing enterocolitis-associated deaths and infant mortality rates from 1979 through 1992 were determined by means of US multiple cause-of-death and linked birth/infant death data. Results. Annual necrotizing enterocolitis infant mortality rates decreased from 1979 through 1986 but increased thereafter and were lower during the 3-year period before (1983 through 1985; 11.5 per 100 000 live births) the introduction of surfactants than after (1990 through 1992; 12.3 per 100 000). Low-birthweight singleton infants who were Black, male, or born to mothers younger than 17 had increased risk for necrotizing enterocolitis-associated death. Conclusions. As mortality among low-birthweight infants continues to decline and smaller newborns survive early causes of death, necrotizing enterocolitis-associated infant mortality may increase. [ABSTRACT FROM AUTHOR]

Objectives. This study describes the mental health status, disability, physical health, and mental health service utilization of informal caregivers under the age of 65 in the province of Ontario. Methods. The study analyzed data collected in the 1991 province-wide, population-based mental health supplement to the Ontario Health Survey. Diagnoses from the Diagnostic and Statistical Manual of Mental Disorders, 3rd edition, revised, were generated on the basis of a structured diagnostic interview. Caregivers and noncaregivers are compared here on past-year prevalence of psychiatric disorder, physical illness, disability, and utilization of mental health services. The possible confounding effects of age, sex, employment status, and economic disadvantage are explored. Results. Informal caregivers (n = 1219) constituted 15.0% of the sample. Caregivers had higher rates of affective (6.3% vs 4.2%) and anxiety (17.5% vs 10.9%) disorders than noncaregivers and used health services for mental health problems at nearly twice the rate. Conclusions. Documentation of the prevalence of caregiving and the increased prevalence of psychiatric disorders, disability, and service utilization among caregivers is of critical importance as governments continue to move toward community-based care. To accomplish this goal, the needs of caregivers must be acknowledged and met by the establishment of appropriate and readily accessible support services. [ABSTRACT FROM AUTHOR]

Objectives. This study tested the hypothesis, first proposed by Chaussinand, that individual-level immunity acquired from exposure to tuberculosis may have contributed to the disappearance of leprosy from western Europe. Methods. The epidemiological consequences of cross-immunity were assessed by the formulation of a mathematical model of the transmission dynamics of tuberculosis and leprosy. Results. The conditions under which Mycobacterium tuberculosis could have eradicated Mycobacterium leprae were derived in terms of the basic reproductive rates of the two infections and the degree of cross-immunity. Conclusions. If the degree of cross-immunity between two diseases within an individual is known, then the epidemiological consequences of this cross-immunity can be assessed with transmission modeling. The results of this analysis, in combination with previous estimates of the basic reproductive rate of tuberculosis and degree of cross-immunity, imply that tuberculosis could have contributed to the decline of leprosy if the basic reproductive rate of leprosy was low. [ABSTRACT FROM AUTHOR]

There have been significant developments in epidemiologic methodology during the past century, including changes in basic concepts, methods of data analysis, and methods of exposure measurement. How- ever, the rise of modem epidemiology has been a mixed blessing, and the new paradigm has major short-comings, both in public health and in scientific terms. The changes in the paradigm have not been neutral but have rather helped change-and have reflected changes in-the way in which epidemiologists think about health and disease. The key issue has been the shift in the level of analysis from the population to the individual. Epidemiology has largely ceased to function as part of a multidisciplinary approach to understanding the causation of disease in populations and has become a set of generic methods for measuring associations of exposure and disease in individuals. This reductionist approach focuses on the individual, blames the victim, and produces interventions that can be harmful. We seem to be using more and more advanced technology to study more and more trivial issues, while the major causes of disease are ignored. Epidemiology must reintegrate itself into public health and must rediscover the population perspective. [ABSTRACT FROM AUTHOR]

To inform choices about the future of epidemiology, the present condition of epidemiology is examined, in terms of its evolution through three eras, each demarcated by its own paradigm: (1) the era of sanitaty statistics with its paradigm, miasma; (2) the era of infectious disease epidemiology with its paradigm, the germ theory; and (3) the era of chronic disease epidemiology with its paradigm, the black hot The historical context in which these eras arose is briefly described. In each era, the public health was at the center of the concerns of the founders and early protagonists of the prevailing paradigm. Around this intellectual development we weave a further theme. We argue that in the present era, the public health has become less central a concern. At the same time, in epidemiology today the dominant black box paradigm is of declining utility and is likely soon to be superseded. [ABSTRACT FROM AUTHOR]

Objectives. This study sought to estimate the size and direction of the human immunodeficiency virus (HIV) epidemic in US metropolitan statistical areas (MSAs) with populations greater than 500 000. Methods. A "components model" from review of more than 350 documents, several large datasets, and information from 220 public health personnel was, used. Data review focused on injection drug users, men who have sex with men, and high-risk heterosexual men and women. Results. In the 96 MSAS, there are, broadly, an estimated 1.5 million injection drug users, 1.7 million gay and bisexual men, and 2.1 million at-risk heterosexuals, and, among them, an estimated 565 000 prevalent and 38 000 incident HIV infections. This implies about 700 000 prevalent and 41 000 new HIV infections yearly in the United States. Roughly, half of all estimated new infections are occurring among injection drug users, most of them in northeastern cities, Miami, and San Juan. Gay and bisexual men still represent most prevalent HIV infections, although incidence-except in young and minority gay men-is much lower now than it was a decade ago. Relatively high prevalences of HIV in at-risk heterosexual persons in several cities indicate the potential for an increase in transmission among them. Conclusions. This review and synthesis outline the comparative epidemiology of HIV in major US cities and identify populations for interventions. [ABSTRACT FROM AUTHOR]

Objectives. Our objectives were (1) to describe an analysis of the spatial pattern of cancer incidence in Ontario and (2) to discuss the quality of data in the Ontario Cancer Registry with respect to the accuracy of local cancer rates. Methods. Cancer incidence rates were calculated for 22 cancer sites in 49 counties of Ontario during 1976 to 1986. Capture-recapture methods were used to estimate completeness of case registration, and completeness of residence information was also assessed. Spatial autocorrelation was used in measuring the geographic pattern of incidence rates. Comparisons were also made between sexes and with earlier data from 1966 to 1975. Results. The quality of the geographic data in the registry appeared good, and corrections for incomplete or inaccurate registration had little impact. About one third of the sex-site combinations showed some evidence of spatial patterning in the cancer rate. Particularly strong regional variation was noted for cancers of the stomach, lung, uterus, and prostate. Conclusions. The analysis revealed a number of cancers with significant spatial patterning of risk. Further work is needed to relate the cancer data to other information on potential life-style and environmental factors. [ABSTRACT FROM AUTHOR]

Objectives. If Helicobacter pylori plays an important role in the occurrence of three distinct diseases - gastric cancer, gastric ulcer, and duodenal ulcer - their individual epidemiologic behaviors should show a resemblance to one common pattern. Methods. To test this hypothesis, birth cohort and linear regression analyses were used to study the US temporal and geographic variations, respectively, of mortality from the three diseases. Results. US mortality form gastric ulcer in males and duodenal ulcer in both sexes showed a clear-cut peak of occurrence in subjects born around 1885, whereas gastric cancer declined continuously in all Americans born since 1855. The geographic distributions showed a strong correlation between gastric and duodenal ulcer, as opposed to weak correlations between either ulcer type and gastric cancer. Conclusions. The similarities in the behavior of the three diseases support the idea that identical risk factors play a crucial role in their occurrence. However, the time lag between the decline in mortality from peptic ulcer and their weak geographic correlations indicate that factors beside H pylori must have influenced their epidemiology. [ABSTRACT FROM AUTHOR]

Objectives. Statistics on prevalence of pneumoconiosis among working underground coal miners from data collected as part of a large national radiographic surveillance program between 1970 and 1986 are presented. The main intent was to examine the time-related trend in prevalence over this period, which coincides with historically low dust levels mandated by federal act. Methods. Tenure-specific prevalence rates and summary statistics derived from them for four consecutive time intervals within the 16-year period were calculated and compared. Results. The results indicate a reduction in pneumoconiosis over the life of the program. This trend is similar to that seen in epidemiological studies undertaken concurrently. Conclusions. Although low participation in the surveillance program and other problems complicate the findings, it appears that reductions in dust exposure mandated by federal act in 1969 have led to lower prevalence of pneumoconiosis among underground coal miners. [ABSTRACT FROM AUTHOR]

Objectives. Statistics on prevalence of pneumoconiosis among working underground coal miners based on epidemiological data collected between 1960 and 1988 are presented. The main intent was to examine the time-related trend in prevalence, particularly after 1969, when substantially lower dust levels were mandated by federal act. Methods. Data from studies undertaken between 1960 and 1968 were collected and compared. Information for the period 1969 to 1988 was extracted from a large ongoing national epidemiological study. Tenure-specific prevalence rates and summary statistics derived from the latter data for four consecutive time intervals within the 19-year period were calculated and compared. Results. The results indicate a reduction in pneumoconiosis over time. The trend is similar to that seen in a large radiological surveillance program of underground miners operated concurrently. Conclusions. Although such factors as X-ray reader variation, changes in x-ray standards, and worker self-selection for examination may have influenced the findings to some extent, adjusted summary rates reveal a reduction in prevalence concurrent with reductions in coal mine dust levels mandated by federal act in 1969. [ABSTRACT FROM AUTHOR]

This presentation reviews occupational epidemiology as a foundation for workplace disease prevention activities. By examining descriptive, etiologic and intervention occupational epidemiology studies, a range of opportunities are illustrated where epidemiology has played, or could play a principal role in guiding preventive efforts. Descriptive studies presented include ones based on vital records, on epidemic investigations, cross-sectional surveys, and surveillance. Etiologic studies review the largely successful development of knowledge for lung cancer and asbestos exposure for pulmonary effects of isocyanate exposures. However, attention is also directed to the need for etiologic studies of work environment risks for both cardiovascular and musculoskeletal disease. Finally importance is placed on the too infrequent epidemiologic studies of intervention. Historical examples of control of large risks from nickel cancers and silicosis are balanced with more recent examples of successes at reducing smaller risks of cardiovascular disease and oil acne. Throughout, emphasis is placed on the importance of reintegrating the academic discipline of epidemiology into the application of study findings to prevention of workplace risks. [ABSTRACT FROM AUTHOR]

Beginning with the swine flu litigation of the early 1980s, epidemiological evidence has played an increasingly prominent role in helping the nation's courts deal with alleged causal connections between plaintiffs' diseases or other harm and exposure to specific noxious agents (such as asbestos, toxic waste, radiation, and Pharmaceuticals), Judicial reliance on epidemiology has highlighted the contrast between the nature of scientific proof and of legal proof. Epidemiologists need to recognize and understand the growing involvement of their profession in complex tort litigation. [ABSTRACT FROM AUTHOR]

Background: Cuba's response to the human immunodeficiency virus (HIV) epidemic has been to conduct mass testing of the population to ascertain seroprevalence, to enforce mandatory relative quarantine of persons testing positive, and to implement educational interventions using media and school-based programs. Methods: Interview with the Vice-Minister of Health and review of available data. Results: Reports to date show a very low seroprevalence rate without evidence of a widespread epidemic. Sexual contact with foreign-bom persons is the primary risk factor. Possible advantages of Cuba's polity include rapid reduction in the risk of HIV transmission by infected blood products, an opportunity for focused education and secondary prevention, and limitation of new infections. Possible disadvantages include the restriction of individual freedom in those who are not guilty of any illegal act, quarantine of persons with false positive HIV tests, and ongoing transmission because of the incomplete nature of the quarantine. The policy is expensive and may displace other public health priorities. The content of the media-based educational interventions has emphasized rational medical information in unimaginative formats with a limited focus on prevention. Conclusions: The issue of personal responsibility for behavioral change versus government imposed regulations is at the core of Cuba's HIV policy. The quarantine polity may paradoxically permit most Cubans to feel that they are personally invulnerable to the HIV epidemic. [ABSTRACT FROM AUTHOR]

Background: Epidemiologic description of long-term adverse health effects of childhood sexual abuse is lacking, despite estimates that perhaps 30 percent of adults have experienced sexual assault in childhood. Methods: In an adult cohort enrolled to investigate causes of transmission of human immunodeficiency virus, we identified current behaviors affecting risk of infection that were associated with a history of early sexual abuse. One hundred and eighty-six individuals provided information on the occurrence of abuse and subsequent sexual and drug using activities. Results: Approximately half of the women and one-fifth of the men reported a history of rape during childhood or adulthood. Twenty-eight percent of the women and 15 percent of the men recalled that they had been sexually assaulted during childhood. People who reported childhood rape compared with people who did not were four times more likely to be working as prostitutes (90 percent confidence interval = 2.0, 8.0). Women were nearly three times more likely to become pregnant before the age of 18(90% CI = 1.6, 4.1). Men who reported a history of sexual abuse had a twofold increase in prevalence of HIV infection relative to unabused men (90% CI = 1.0, 3.9). Conclusions: The disturbing prevalence of early sexual abuse and its possible health-related consequences call for prompt and routine investigation of sexual abuse histories. Identification of sexual victimization may be an important component for management of risk factors for human immunodeficiency virus. [ABSTRACT FROM AUTHOR]

This report demonstrates the role of epidemiologic surveillance and investigation in the control of infectious diseases in a long-term refugee camp. The applications of simple epidemiologic methods in a refugee camp on the Thai-Cambodian border are described for a one-year period. The development of a Health Information Office facilitated the collection of demographic and vital statistics data, administration of a disease surveillance system, regular monitoring of hospital and outpatient discharge diagnoses, and investigation of disease outbreaks. This office also, organized community health education campaigns and disease control efforts. Examples of specific disease investigations are provided to demonstrate the utility of epidemiologic surveillance in the control of infectious diseases. We conclude that simple epidemiologic methods play an important role in health planning in long-term refugee camps. [ABSTRACT FROM AUTHOR]

To evaluate behavioral and immunologic factors related to transmission of human immunodeficiency virus (HIV) by homosexual intercourse, we studied a population of 329 homosexual/bisexual men (155 partner-pairs) seen in a community health center and medical outpatient clinic. Logistic regression analysis showed that behavioral risk factors for infection in the 130 HIV-infected men included: receptive anal intercourse (OR 4.6, 95% CI-1.8, 12.1): receptive fisting (OR 2.5, CI-1.1, 7.0); nitrite use (OR 2.3, CI-1.2, 4.6); history of gonorrhea or syphilis (OR 2.3, CI-1.4, 3.9); and history of sexual contact with men from areas with many AIDS cases (OR 1.9, CI-1.0, 3.5). Comparing seven men who were probable transmitters of HIV and 11 men who had not transmitted HIV to their uninfected partners despite unprotected insertive anal intercourse, we found no differences in HIV isolation from peripheral blood mononuclear cells, circulating HIV antigen detection, or presence of neutralizing antibody to HIV. Helper T-cell numbers were not significantly different between the two groups, but transmitters bad more suppressor T-cells than did nontransmitters. [ABSTRACT FROM AUTHOR]