Choosing a future for epidemiology: I. Eras and paradigms.

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 sanitary 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 box. 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the same time, in epidemiology today the dominant black box paradigm is of declining utility and is likely soon to be superseded.     

Does risk factor epidemiology put epidemiology at risk? Peering into the future

The multiple cause black box paradigm of the current risk factor era in epidemiology is growing less serviceable. This single level paradigm is likely to be displaced. The signs are that the growing strength of molecular epidemiology on the one side, and of a global epidemiology based on information systems on the other, will come to dominate epidemiology and segregate it into separate disciplines. At the same time, the links with public health interests grow weaker. A multilevel ecoepidemiology has the potential to bind these strands together.     

The changing role and legitimate boundaries of epidemiology: community-based prevention programmes

Epidemiology is the basic science of public health. It combines medical and social sciences, both of which are developing with new inventions. Therefore, the role of epidemiology and its boundaries are also changing over time. An important role of epidemiology is to develop and implement community-based control programmes for major diseases in the community. Such programmes are essential for large scale public health policy. It is necessary that epidemiological research can as freely as possible test new methods of disease prevention and health promotion. The first community-based control programme for cardiovascular diseases, the North Karelia Project is reviewed against this background. At present, it is still possible to define the boundaries of epidemiology geographically and culturally, but in the future, however, it will become more difficult. There is no doubt that epidemiology will remain as the basic science of public health but the scope of public health problems are growing much wider. These include the prevention of the final epidemic--the destruction of our planet by nuclear bombs. In the control of the existing epidemics and in the prevention of new ones the boundaries of epidemiology cannot stay rigid but they must be changing as new facts about the emerging public health problems are identified.     

HIV, international travel and tourism: global issues and Pacific perspectives.

AIDS, like plagues throughout human history, has been blamed repeatedly on foreigners. This has heightened ramifications, from the personal to the geopolitical, in an era of escalating population movement and rapid international travel. By the end of 1990, the World Health Organization had estimated that the total number of AIDS cases worldwide was close to 1.3 million. Recent estimates suggest that by the year 2000, 38-100 million adults and over 10 million children will have been infected with HIV. Seventy-five to eighty-five percent of that number will be from the developing world. AIDS has rapidly become pandemic, with wide-ranging consequences for humankind. Human population movement is an important component in the natural history of AIDS. With respect to this, a central consideration is the relationship between AIDS and international travel, especially tourism. In this paper, after reviewing HIV in the Asia-Pacific region, we present the epidemiology of HIV in the Pacific Islands, discuss its impact with particular reference to population movement, and explore some of the specific challenges that the Pacific Island region faces.     

The molecular epidemiology of mumps virus.

The molecular epidemiology of MuV is characterized by the co-existence of 10 (or more) distinct genotypes named A-J based on the nucleotide sequence of the SH gene. MuV show distinct geographic clustering. More than one genotype may circulate simultaneously in a geographic region. Limited data suggest redistribution of genotypes to occur over time. The selective forces remain speculative. Currently used vaccine strains belong to different genotypes. Some MuV genotypes (C, D, H, J) and vaccine strains (Urabe Am9) have been associated with enhanced neurovirulence. Also, reduced cross-neutralization capacity has been observed between genotype A and genotypes C and D. At present vaccine failure cannot be attributed to this phenomenon. Strain redistribution may lead to the emergence of new MuV strains with enhanced neurovirulence or reduced cross-neutralization capacity with current vaccine strains. Close monitoring of the genotype distribution of MuV and genotype-specific population immunity is needed in the vaccine era.     

Paradigms in epidemiology textbooks: in the footsteps of Thomas Kuhn.

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.     

Recognition of historic influenza epidemics from parish burial records: a test of prediction from a new hypothesis of influenzal epidemiology.

On the current conception of the epidemiology of epidemic influenza, as caused by a mechanism of direct spread of the virus from the sick, epidemics must have travelled much more slowly in former times than at present. In contrast, a new hypothesis involving virus latency with seasonal reactivation predicts that in previous centuries influenza epidemics would have spread across the country at much the same speed as in the twentieth century. The study of burial registers in Gloucestershire parishes reported in this paper shows that lethal influenza epidemics at least as early as the sixteenth century can be recognized and dated as at present by the characteristic brief but large excess mortality that they cause. Examples are given showing that the character of the excess mortality caused by lethal influenza has not changed significantly over the centuries, a finding that supports the prediction of the new hypothesis but would not be expected on the current conception of influenzal epidemiology. In each century, influenzal excess mortalities in Gloucestershire parishes coincided with the date of the relevant influenza epidemic as recorded from widely different parts of Britain, thus further supporting the prediction of the new hypothesis as against current conceptions.     

Personal crisis: growth or pathology?

PURPOSE. The aim of this article is to present an emerging theoretical framework for viewing certain types of personal crises as developmentally healthy rather than as psychopathological. These types of crises are referred to as "spiritual emergence" and "spiritual emergency." SEARCH METHODS USED. Selected literature from psychology, psychiatry, and philosophy is used to describe the new paradigm, which views the development of human consciousness across the life span as going beyond the well-adjusted and productive adult ego. The intent is to introduce this paradigm and some of its implications for further critical consideration by health promotion professionals. It is not the authors' purpose to critically evaluate the relevant theoretical literature in this article. SUMMARY OF IMPORTANT FINDINGS. The new paradigm represents an expanded theory of human development that explicitly recognizes a spiritual dimension in personal growth and health. Within this paradigm, spiritual emergence and spiritual emergency are viewed as signs of transitional, personal growth rather than as symptoms of psychopathology. Accordingly, signs of growth need to be differentiated from symptoms of pathology. The first step in doing this is to contextualize human experience in a larger developmental framework. MAJOR CONCLUSIONS. Health promotion professionals may benefit personally and professionally by being aware of the new developmental paradigm which differentiates spiritual growth from pathological symptoms. Further theoretical clarification and research will be needed before detailed recommendations for practice can be made.     

Critical epidemiology: for a theoretical praxis of knowing how and when to act

Some of the most significant questions related to the concept of health present in contemporary discursive practices, such as its relation with the normative capacity of the individuals when faced with the institution of new social and/or biological norms, are initially reexamined in this paper. Subsequently, the dialectical model of the social determination process of health-disease is examined in the context of the contradictory processes of the social reproduction system as in the scope of the bio-psychological nexuses on outcome and its historically specific ways of life. The contradictory dimensions of the capitalist social reproduction process and their techno-economic logic of production and consumption are then analyzed, considering their respective impacts on the living and health conditions of citizens and communities. Lastly, the importance of the emancipative praxis for epidemiology in the achievement of well-being and quality of life are considered and the need for commitment in the construction of a new paradigm for the public health field in its praxis of knowing how and when to act are emphasized.     

Feminist theory: the challenge of turning into a paradigm

From crisis of traditional paradigm and having feminist criticism as an epicentre, this work attempts to present the challenge feminist theory faces for becoming a new paradigm and for that, a bibliographical research is accomplished, sustained by literature regarding to this theme. It is evidentiated that the challenge of being a paradigm in ascension makes this theory to face theoretical, conceptual and methodological problems which need a joined effort to be deepened and solved. However, this theory development depend not only on the academic world but is also linked to changes in social structure for it will more easily emerge, from a more equalitary society, knowledge with no domination of gender.