VoL 6. No. 2
International Journal of Epidemiology © Oxford Unfvararty Pratt 1977
Printad In Great Britain
Editorial Epidemiology and Health Policy
99
Downloaded from http://ije.oxfordjournals.org/ at University of California, San Fransisco on April 12, 2015
In this context epidemiologists have had to learn to cooperate with administrators, politicians and the public. The third type of epidemiologist is primarily concerned with health policy, but it is the usefulness of this type of work that is still questioned. His work may vary from how to change behaviour patterns to reduce the incidence of, say, cancer of the lung or coronary heart disease, to decisions on delivery of health services and on setting priorities. The work of Doll and Hill (4) on cancer of the lung and by Doll (5) on health service monitoring has shown the importance of our techniques to decision-making and the occasions when policies have been influenced by such work are becoming more frequent One particular message which the discipline of epidemiology has been trying to get across for some time is the importance of developing effective preventive services rather than curative services. There is already some concentration on prevention in a number of developed countries. A further message from epidemiologists is the need for development of systems of surveillance, not only for infectious disease but for chronic conditions as well (as discussed in a previous issue of this journal (6)). In the United Kingdom these would enable monitoring of decisions on, for example, provision of welfare foods and general food policy. Until 1976 in the UK health service resources were allocated on the basis of 'the same amount as last year plus a little extra' but for some years we have been aware that this means perpetuation of inequalities. This situation led to creation of a Working Party (1) whose members included administrators, those delivering services and academics concerned with the 'distribution of disease and the need for health services, including an epidemiologist. As a result of lengthy deliberations the Working Party has developed a formula which is thought to be roughly responsive to the varying needs of the Regions. The formula contains variables about the population including age and
While reviewing our past editorials we have become aware that few of the challenges thrown down 'for discussion' have been taken up by readers. We have also become aware that a constant theme appears to recur in many of our editorials—that is the importance of sound measurement in epidemiology. A number of recent publications (1-3), particularly in the United Kingdom, have discussed the relevance of epidemiological techniques and measurements to health policy and the Eighth International Meeting of the Association in Puerto Rico will also devote some time to this subject. Our recent involvement in discussion of allocation of health service resources has revealed the applications and need for appropriate measurements to enable policy-makers and administrators to take suitable decisions. There are three distinct types of epidemiologist and each has a different contribution to make from his particular environment. In an office or laboratory the epidemiologist is primarily involved with design of studies and analysis of information to illuminate hypotheses on aetiology, prevention or health service use. Such studies will be accepted or respected by fellow epidemiologists but rarely will they be of interest to policy-makers until perhaps several years later. What could be called the 'shoe-leather' epidemiologist is the second type—he is on the spot at an outbreak of disease and it is he who could perhaps develop and introduce preventive measures. The WHO smallpox eradication campaign, led by D A Henderson and contributed to by a number of members of the Association, is a good example of the success of 'shoe-leather' epidemiology. The need for such work in eradicating the communicable diseases in developing countries is apparent in the work of the Epidemic Intelligence Service in the United States, but such investigations are often subject to political pressure. Examples here are the outbreak of a strange respiratory disease among American legionnaires in Philadelphia and the outbreak of food poisoning from cockles in the United Kingdom.
100
INTERNATIONAL JOURNAL OF EPIDEMIOLOGY
to exchange information must be developed. Far too often the data that is available is irrelevant and there is no data related to the question being raised. Only by deliberate involvement of epidemiologists and other research workers in discussion of health policy can we begin to learn which are the important questions for health policy-makers and only by governmental involvement in research discussions can officials in government understand the limitations of research. Demands on research workers are increasing, not only in terms of expected results but also in terms of what they are being asked to do—some aspects of which they may be reluctant to undertake. The expectations on both sides must be brought more closely together by means of more appropriate exchange of ideas. If government can become more open and research more flexible then epidemiologists may be able to play a better role in the future than they have in the past. REFERENCES
(1) Sharing Resources for Health in England. Report of the Resource Allocation Working Party. Department of Health and Social Security, London, HMSO, 1976. (2) Holland, W W and Gilderdale, S: Epidemiology and Health, London, Henry Kimpton, 1977. (3) White, K L and Henderson, M M: Epidemiology as a Fundamental Science. Its Uses in Health Services Planning, Administration and Evaluation. New York, Oxford University Press, 1976. (4) DolL R and HUT, B A: A study of the aetiology of carcinoma of the lung. British Medical Journal 2, 1271, 1952. (5) Doll, R: Monitoring the National Health Service, Nuffield Lecture. Proceedings of the Royal Society of Medicine 66, 729, 1973. (6) International Journal of Epidemiology 5, No. 1, 1976.
Downloaded from http://ije.oxfordjournals.org/ at University of California, San Fransisco on April 12, 2015
sex, mortality for particular disease categories standardized for age, and the cost of care for each individual age/cause of death specific group. One of the most important lessons we can learn from this exercise is the application of epidemiological methods to decision-making, but we must also recognize its limitations, for example the lack of adequate data to decide exactly the amount of health care which should be available in different parts of the country. The limitations of epidemiology have also recently become apparent in attempts to set criteria for individual environmental pollutants. It is difficult for both the epidemiologist, who is asked to determine criteria, and for the policymaker and legislator to appreciate that the epidemiologist can only give some idea of relative risks for populations exposed to particular levels of pollutants. In the past few studies have been sophisticated enough to establish a precise dose/ response relationship between a given hazard and the development of a particular condition—this is true for some studies on cancer of the lung but most epidemiological studies have been designed to simply determine if a substance is harmful or not. The epidemiologist can say what the risk of disease is at level x of a particularly pollutant and that it is less at level x-n. However in establishing appropriate environmental levels of chemicals or pollutants, other factors such as the consequences and costs of setting particular standards must be considered and in this respect the epidemiologist is no better qualified than anyone else. In all these situations where the epidemiologist is called upon to help in policy-making an ability
International Journal of Epidemiology © Oxford Unfvararty Pratt 1977
Printad In Great Britain
Editorial Epidemiology and Health Policy
99
Downloaded from http://ije.oxfordjournals.org/ at University of California, San Fransisco on April 12, 2015
In this context epidemiologists have had to learn to cooperate with administrators, politicians and the public. The third type of epidemiologist is primarily concerned with health policy, but it is the usefulness of this type of work that is still questioned. His work may vary from how to change behaviour patterns to reduce the incidence of, say, cancer of the lung or coronary heart disease, to decisions on delivery of health services and on setting priorities. The work of Doll and Hill (4) on cancer of the lung and by Doll (5) on health service monitoring has shown the importance of our techniques to decision-making and the occasions when policies have been influenced by such work are becoming more frequent One particular message which the discipline of epidemiology has been trying to get across for some time is the importance of developing effective preventive services rather than curative services. There is already some concentration on prevention in a number of developed countries. A further message from epidemiologists is the need for development of systems of surveillance, not only for infectious disease but for chronic conditions as well (as discussed in a previous issue of this journal (6)). In the United Kingdom these would enable monitoring of decisions on, for example, provision of welfare foods and general food policy. Until 1976 in the UK health service resources were allocated on the basis of 'the same amount as last year plus a little extra' but for some years we have been aware that this means perpetuation of inequalities. This situation led to creation of a Working Party (1) whose members included administrators, those delivering services and academics concerned with the 'distribution of disease and the need for health services, including an epidemiologist. As a result of lengthy deliberations the Working Party has developed a formula which is thought to be roughly responsive to the varying needs of the Regions. The formula contains variables about the population including age and
While reviewing our past editorials we have become aware that few of the challenges thrown down 'for discussion' have been taken up by readers. We have also become aware that a constant theme appears to recur in many of our editorials—that is the importance of sound measurement in epidemiology. A number of recent publications (1-3), particularly in the United Kingdom, have discussed the relevance of epidemiological techniques and measurements to health policy and the Eighth International Meeting of the Association in Puerto Rico will also devote some time to this subject. Our recent involvement in discussion of allocation of health service resources has revealed the applications and need for appropriate measurements to enable policy-makers and administrators to take suitable decisions. There are three distinct types of epidemiologist and each has a different contribution to make from his particular environment. In an office or laboratory the epidemiologist is primarily involved with design of studies and analysis of information to illuminate hypotheses on aetiology, prevention or health service use. Such studies will be accepted or respected by fellow epidemiologists but rarely will they be of interest to policy-makers until perhaps several years later. What could be called the 'shoe-leather' epidemiologist is the second type—he is on the spot at an outbreak of disease and it is he who could perhaps develop and introduce preventive measures. The WHO smallpox eradication campaign, led by D A Henderson and contributed to by a number of members of the Association, is a good example of the success of 'shoe-leather' epidemiology. The need for such work in eradicating the communicable diseases in developing countries is apparent in the work of the Epidemic Intelligence Service in the United States, but such investigations are often subject to political pressure. Examples here are the outbreak of a strange respiratory disease among American legionnaires in Philadelphia and the outbreak of food poisoning from cockles in the United Kingdom.
100
INTERNATIONAL JOURNAL OF EPIDEMIOLOGY
to exchange information must be developed. Far too often the data that is available is irrelevant and there is no data related to the question being raised. Only by deliberate involvement of epidemiologists and other research workers in discussion of health policy can we begin to learn which are the important questions for health policy-makers and only by governmental involvement in research discussions can officials in government understand the limitations of research. Demands on research workers are increasing, not only in terms of expected results but also in terms of what they are being asked to do—some aspects of which they may be reluctant to undertake. The expectations on both sides must be brought more closely together by means of more appropriate exchange of ideas. If government can become more open and research more flexible then epidemiologists may be able to play a better role in the future than they have in the past. REFERENCES
(1) Sharing Resources for Health in England. Report of the Resource Allocation Working Party. Department of Health and Social Security, London, HMSO, 1976. (2) Holland, W W and Gilderdale, S: Epidemiology and Health, London, Henry Kimpton, 1977. (3) White, K L and Henderson, M M: Epidemiology as a Fundamental Science. Its Uses in Health Services Planning, Administration and Evaluation. New York, Oxford University Press, 1976. (4) DolL R and HUT, B A: A study of the aetiology of carcinoma of the lung. British Medical Journal 2, 1271, 1952. (5) Doll, R: Monitoring the National Health Service, Nuffield Lecture. Proceedings of the Royal Society of Medicine 66, 729, 1973. (6) International Journal of Epidemiology 5, No. 1, 1976.
Downloaded from http://ije.oxfordjournals.org/ at University of California, San Fransisco on April 12, 2015
sex, mortality for particular disease categories standardized for age, and the cost of care for each individual age/cause of death specific group. One of the most important lessons we can learn from this exercise is the application of epidemiological methods to decision-making, but we must also recognize its limitations, for example the lack of adequate data to decide exactly the amount of health care which should be available in different parts of the country. The limitations of epidemiology have also recently become apparent in attempts to set criteria for individual environmental pollutants. It is difficult for both the epidemiologist, who is asked to determine criteria, and for the policymaker and legislator to appreciate that the epidemiologist can only give some idea of relative risks for populations exposed to particular levels of pollutants. In the past few studies have been sophisticated enough to establish a precise dose/ response relationship between a given hazard and the development of a particular condition—this is true for some studies on cancer of the lung but most epidemiological studies have been designed to simply determine if a substance is harmful or not. The epidemiologist can say what the risk of disease is at level x of a particularly pollutant and that it is less at level x-n. However in establishing appropriate environmental levels of chemicals or pollutants, other factors such as the consequences and costs of setting particular standards must be considered and in this respect the epidemiologist is no better qualified than anyone else. In all these situations where the epidemiologist is called upon to help in policy-making an ability
