Choosing a future for epidemiology: II. From black box to Chinese boxes and eco-epidemiology.

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-epidemiology 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.     

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.     

What's new about the "new public health"?

From its origins, when public health was integral to societies' social structures, through the sanitary movement and contagion eras, when it evolved as a separate discipline, to the "new public health" era, when health promotion projects like Healthy Cities appear to be steering the discipline back to society's social structure, public health seems to have come full circle. It is this observation that has led some to ask, "What's new about the 'new public health'?" This article addresses the question by highlighting what is new about the health promotion era-including adapted components of previous eras that have been incorporated into its core activities-and its suitability in addressing established and emerging public health threats.     

A review of UK housing policy: ideology and public health

OBJECTIVES: The aim of this paper is to review UK public health policy, with a specific reference to housing as a key health determinant, since its inception in the Victorian era to contemporary times. REVIEW: This paper reviews the role of social and private housing policy in the development of the UK public health movement, tracing its initial medical routes through to the current socio-economic model of public health. The paper establishes five distinct ideologically and philosophically driven eras, placing public health and housing within liberal (Victorian era), state interventionist (post World War 1; post World War 2), neoliberal (post 1979) and "Third Way" (post 1997) models, showing the political perspective of policy interventions and overviewing their impact on public health. The paper particularly focuses on the contemporary model of public health since the Acheson Report, and how its recommendations have found their way into policy, also the impact on housing practice. CONCLUSIONS: Public health is closely related to political ideology, whether driven by the State, individual or partnership arrangements. The current political system, the Third Way, seeks to promote a sustainable "social contract" between citizens and the State, public, private and voluntary organizations in delivering community-based change in areas where health inequalities can be most progressively and successfully addressed.     

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.     

Health promotion in Canada: 1986 to 2006

The evolution of health promotion in Canada between 1986 and 2006 is characterized by three major eras: Health Promotion in the Limelight, 1986-1992, Health Promotion Behind the Scenes, 1993-2003, and Health Promotion Restaged, 2003-2006. These eras are illustrated using the Canadian Heart Health Initiative as an example. The first era, backed by strong federal government leadership and support, was a progressive time of developing concepts, collaborations and infrastructure for health promotion across the country. Despite significant progress, by the end of this era, health promotion was neither sufficiently developed nor funded to make it a cornerstone of the health system. In addition, the emphasis was heavily biased towards changing individual behaviour. In the second era, health promotion continued to develop in pockets across the country and debates within the field intensified. However, these events went largely unnoticed and massive overall cuts at federal and provincial levels of government made acute care a much higher priority than health promotion. The third era, mostly shaped by fears linked to public health threats, saw a restaging of health promotion through efforts to strengthen public health infrastructure. Nevertheless, at the end of this era, the necessary intersectoral partnerships (such as in health, housing, education, food, income) remained scarce, and little progress was made to decrease health inequalities. The Canadian Heart Health Initiative was implemented over the same time period as the three eras. Its legacy includes collegial relationships across various levels of government and with non-government organizations, a culture that values pan-Canadian initiatives, and support for integration of research, evaluation, surveillance, policy and practice. It remains to be seen how quickly it will be possible to advance the vision of health promotion conceived during the Limelight Era in Canada.     

The role of epidemiology in chronic disease prevention and health promotion programs.

Although the role for epidemiology is widely accepted in public health programs in general, its role in chronic disease programs is not as widely recognized. One possible barrier to improving epidemiologic capacity in chronic disease prevention and health promotion programs is that chronic disease program managers and public health decision makers may have a limited understanding of basic chronic disease epidemiology functions. We describe the assessment process of data collection, analysis, interpretation, and dissemination, and, using examples from two states, illustrate how this approach can be used to support program and policy development in three areas: by defining the problem, finding programs that work, and evaluating the effects of the program over time. Given the significant burden of chronic diseases in the United States, the scientific guidance provided by epidemiology is essential to help public health leaders identify priorities and intervene with evidence-based and effective prevention and control programs.     

Does federal health care policy influence switching between the public and private sectors in individuals?

OBJECTIVE: The aim of this study was to determine if changes in Australian Federal health policy have influenced individual behaviour regarding utilisation of private health insurance in Western Australia. METHOD: The WA Data Linkage System was used to extract all hospital morbidity records in Western Australia from 1980 to 2001. For each individual, episodes were grouped into hospital couplets classified according to the mix of public and privately insured events. Logistic regression was used to estimate the likelihood of switching towards or away from the private sector, according to the time between episodes in each of five health care policy eras. RESULTS: The odds of a switch away from the private sector increased by 29% with each additional year between episodes, while the odds of a switch towards the private sector increased by 15% per intra-couplet year. In those with a private first episode the odds of switching decreased approximately exponentially across the five eras whereas the odds of switching in those with a public first episode stabilised after 1985. In the last era (1999-2001) the odds of switching away from the private sector reduced substantially. CONCLUSION: Our analysis suggests that the recent policies supporting PHI (30% rebate and Lifetime Health Cover) appear to have been effective at modifying individual behaviour to reduce the drift away from the private sector. However, the reported increases in utilisation of PHI were only partially explained by switching of existing demand in patients who had been previously hospitalised as public patients, suggesting that the policy reforms had generated, rather than merely shifted, demand for health care. This finding has significant policy implications for Australia.     

Social epidemiology: Definition,history, and research examples

Social epidemiology is a branch of epidemiology that focuses particularly on the effects of social-structural factors on states of health. Social epidemiology assumes that the distribution of advantages and disadvantages in a society reflects the distribution of health and disease. It proposes to identify societal characteristics that affect the pattern of disease and health distribution in a society and to understand its mechanisms. The central and initial question of social epidemiology to be answered is what effect do social factors have on individual and population health. However, the new focus on this theme using current epidemiological methods is a relatively recent phenomenon. There are several significant concepts in the field of social epidemiology: 1) the bio-psychosocial paradigm, 2) the population perspective, 3) use of new statistical approaches such as multilevel analysis, and 4) significance of theory. The relationship between social class and health has been a major research field since the beginning of public health history. Many studies have identified the disparities in health among social classes and developed several theories, such as social selection theory and socio-biological translation theory. However, despite the long history of this research field, the effect of social class on health is not yet fully understood. Income distribution and health is a relatively new field within social epidemiology. Three possible mechanisms for the consequences of income distribution on health are 1) disinvestment of human capital, 2) disinvestment of social capital, and 3) psychological process. Refining theories of income distribution is a major challenge in research on income distribution.