VoL 6, No. 4
International Journal of Epidemiology O Oxford Univwsity Prat* 1977
Prfntad in Great Britain
Perspectives of Epidemiology in Europe MICHEL F LECHAT1
were organized, whose subjects range from nationwide population surveys to the use of medical records. Cooperative research, was initiated, and among the first projects was a multiregional study of the epidemiology of congenital malformations. Perhaps the most significant achievement is the coming publication of a textbook entitled Health Care and Epidemiology sponsored by the EEC and written by epidemiologists from the nine countries. These exercises in European cooperation provide ample opportunity for comparing and exchanging experience. Their greatest impact however is in acting as a catalyst for change in the countries concerned. Other institutions such as the Council of Europe and NATO have also played a role in this recent evolution, mostly by organizing seminars on epidemiology—related topics, establishing inventories of relevant research, and providing fellowships. However, this is no reason for complacency: the achievements of the past few years almost exclusively consist of changes in attitude. These changes are at many levels—in government, in the community, even in the medical profession—and in many directions. This includes realization of the need to spend money in the most relevant way, that is the need for planning and evaluation of health services, and adoption of a more balanced and quantified approach towards measuring the hazards and risks related to environmental deterioration and/or technological development. There is now a much better perception of the contribution of epidemiology to these and relatedfields.While these changes in attitude are the preliminary condition for achieving progress, beyond that most of the difficulties still remain, with a few more added. This at times makes epidemiology a frustrating activity. First among the difficulties is that in many countries there is a most noticeable discrepancy between the amount of statistical data collected and its validity for epidemiological use. It seems that data are collected everywhere on everything with the seemingly overall common purpose of being
1 Profeisor, Ecole de Santi Publique, University of Louvain Ooa Chapelle aux Champs 30 1200 Bnnelles, Belgium
327
Downloaded from http://ije.oxfordjournals.org/ at University of Illinois at Urbana-Champaign on March 9, 2015
Phenomena] amounts of money are spent in Europe on medical care often without proper evaluation of the effect of this expenditure on health: all types of preventive services are flourishing with no apparent strategy and purpose, and today's deep concern towards the environment is surprisingly devoid of any epidemiological approach. Epidemiology at times looks like a world of missed opportunities. One should, however, recognize that the situation has considerably changed in Europe over the last decade. Not so long ago, the word epidemiology was unknown to many or at best it was considered as the study of epidemics. Doctors were expected to cater exclusively for sick individuals: concern with priorities and choices and the community were considered to be incompatible with the dignified image of medicine or even resented as a threat to the quality of care. Little epidemiological research was carried out Credit must be given to international agencies and multinational institutions who have largely been responsible for the development of new attitudes. The World Health Organization has played a major role in supporting efforts to achieve a place for epidemiology in the training of doctors and other health professionals. It has also promoted cooperative epidemiological studies involving many universities. The use of epidemiological methods for evaluating health services has been stressed. But these are only some examples of what could be termed the education role carried out by WHO in relation to epidemiology. More recently, the European Community (EEC) has also taken initiatives which have a direct bearing on the promotion of epidemiology in the nine countries. Working groups were constituted which have covered subjects from the standardization of screening techniques to the teaching of epidemiology to general practitioners. Workshops
328
INTERNATIONAL JOURNAL OF EPIDEMIOLOGY
taken over by those concerned in a kind of do-ityourself fashion. The methods of epidemiology are unique for the measurement and prediction of the impact of ecological changes on the health of human populations. New technologies, dietary changes, inindustrial hazards, urbanization, pollution—the effects of all these and other upheavals in our way of life are amenable to the epidemiological approach. The nineteenth-century tradition of John Snow, Mareska and others has erupted into the twenty-first century, and spread from cholera in London and cotton mills in Ghent to food additives, drugs, nuclear plants, pesticides, plastics, asbestos and a galaxy of new products, new habits and new hazards. There is in many circles an increasing realization of the importance of epidemiology for decision making in the field of the environment In the midst of raging interests, which may be both unscrupulous and irrational, and among politicians, consumers, labour, and industry, all with the future of human health at stake, epidemiology is now a highly politicized discipline, perhaps the most politicized in the field of medicine. The danger of such a situation is not of course that results of investigations be tendentious or manipulated in any way. It is much more subtle than that There is no argument about whether epidemiology should help solve current issues of interest to the community. This is what largely justifies our very existence, and also keeps our budgets afloat The problem is who is to define the issues. If defining the issues—what is worth considering and what is not, what is to be studied and what is to be left out, the pollutants incriminated, the population exposed, the system, the process, is entirely left to political powers or vested interests, there is a great chance that epidemiology will end up as an alibi. This is not a claim for technocratism. It is a plea for us to be aware of the political importance of our trade in tomorrow's world. Our responsibility is not only to execute a good technical job, it is also to be involved in the process of defining which problems should be analysed and to independently raise sensitive issues. Epidemiologists should in some way serve as ombudsmen for health in its relationship with the environment. It is hoped that exchanges and cooperation between epidemiologists of various European countries will help develop and strengthen the independence required to assume this role.
Downloaded from http://ije.oxfordjournals.org/ at University of Illinois at Urbana-Champaign on March 9, 2015
of no possible use to epidemiologists. This applies to vital statistics, death certificates, medical records of births, hospital files, medical records, files of preventive medicine or occupational health services, payrolls of workers exposed to environmental hazards, insurance records, notification of communicable diseases, maintenance of registers, and so on. Although it has been said that epidemiology is the art of drawing valid conclusions from messy data, there are limits to this. And the difficulties do not only reside in problems of linkage or of central processing. Nor do issues of confidentiality automatically appear. Above all it is a matter of collecting clean data, with appropriate coverage, well-defined criteria, and standardized methods. In many countries there is a laissez-aller attitude to the collection of health data and a crucial gap in communication between statistical and health services. This has to be corrected, otherwise epidemiology may to a great extent remain a futile exercise. A second problem is the lack of dialogue between epidemiology and other health disciplines. This does not exist everywhere but dialogue could probably be improved in most places. Epidemiologists are often complaining of having too few contacts with clinicians. While it is true that a number of our colleagues have no idea at all of what epidemiology is about, and still less idea of what is the importance of standardized definitions or appropriate denominators or matched controls or whatever, we should also question ourselves about whether we ever try to find out more about other disciplines. There is a danger of epidemiology becoming a technique without content, which is another form of academism. This remark I believe applies equally to our relationship with basic scientists, be it geneticists, immunologists, or neurochemists, and also when dealing with people engaged in everyday work in the community, such as general practitioners. Since epidemiology is the study of health in populations and GPs are active within these populations, there is no doubt of the need for GPs to be trained in the basic tools of epidemiology. Conversely there is also the need for us when discussing how to organize such a training, to have personal experience of what the daily work of a general practitioner is. We must be aware of possible deficiencies in our knowledge of what others do, and need, and can offer, otherwise with epidemiology gradually becoming a recognized discipline the practical teaching of it could be
International Journal of Epidemiology O Oxford Univwsity Prat* 1977
Prfntad in Great Britain
Perspectives of Epidemiology in Europe MICHEL F LECHAT1
were organized, whose subjects range from nationwide population surveys to the use of medical records. Cooperative research, was initiated, and among the first projects was a multiregional study of the epidemiology of congenital malformations. Perhaps the most significant achievement is the coming publication of a textbook entitled Health Care and Epidemiology sponsored by the EEC and written by epidemiologists from the nine countries. These exercises in European cooperation provide ample opportunity for comparing and exchanging experience. Their greatest impact however is in acting as a catalyst for change in the countries concerned. Other institutions such as the Council of Europe and NATO have also played a role in this recent evolution, mostly by organizing seminars on epidemiology—related topics, establishing inventories of relevant research, and providing fellowships. However, this is no reason for complacency: the achievements of the past few years almost exclusively consist of changes in attitude. These changes are at many levels—in government, in the community, even in the medical profession—and in many directions. This includes realization of the need to spend money in the most relevant way, that is the need for planning and evaluation of health services, and adoption of a more balanced and quantified approach towards measuring the hazards and risks related to environmental deterioration and/or technological development. There is now a much better perception of the contribution of epidemiology to these and relatedfields.While these changes in attitude are the preliminary condition for achieving progress, beyond that most of the difficulties still remain, with a few more added. This at times makes epidemiology a frustrating activity. First among the difficulties is that in many countries there is a most noticeable discrepancy between the amount of statistical data collected and its validity for epidemiological use. It seems that data are collected everywhere on everything with the seemingly overall common purpose of being
1 Profeisor, Ecole de Santi Publique, University of Louvain Ooa Chapelle aux Champs 30 1200 Bnnelles, Belgium
327
Downloaded from http://ije.oxfordjournals.org/ at University of Illinois at Urbana-Champaign on March 9, 2015
Phenomena] amounts of money are spent in Europe on medical care often without proper evaluation of the effect of this expenditure on health: all types of preventive services are flourishing with no apparent strategy and purpose, and today's deep concern towards the environment is surprisingly devoid of any epidemiological approach. Epidemiology at times looks like a world of missed opportunities. One should, however, recognize that the situation has considerably changed in Europe over the last decade. Not so long ago, the word epidemiology was unknown to many or at best it was considered as the study of epidemics. Doctors were expected to cater exclusively for sick individuals: concern with priorities and choices and the community were considered to be incompatible with the dignified image of medicine or even resented as a threat to the quality of care. Little epidemiological research was carried out Credit must be given to international agencies and multinational institutions who have largely been responsible for the development of new attitudes. The World Health Organization has played a major role in supporting efforts to achieve a place for epidemiology in the training of doctors and other health professionals. It has also promoted cooperative epidemiological studies involving many universities. The use of epidemiological methods for evaluating health services has been stressed. But these are only some examples of what could be termed the education role carried out by WHO in relation to epidemiology. More recently, the European Community (EEC) has also taken initiatives which have a direct bearing on the promotion of epidemiology in the nine countries. Working groups were constituted which have covered subjects from the standardization of screening techniques to the teaching of epidemiology to general practitioners. Workshops
328
INTERNATIONAL JOURNAL OF EPIDEMIOLOGY
taken over by those concerned in a kind of do-ityourself fashion. The methods of epidemiology are unique for the measurement and prediction of the impact of ecological changes on the health of human populations. New technologies, dietary changes, inindustrial hazards, urbanization, pollution—the effects of all these and other upheavals in our way of life are amenable to the epidemiological approach. The nineteenth-century tradition of John Snow, Mareska and others has erupted into the twenty-first century, and spread from cholera in London and cotton mills in Ghent to food additives, drugs, nuclear plants, pesticides, plastics, asbestos and a galaxy of new products, new habits and new hazards. There is in many circles an increasing realization of the importance of epidemiology for decision making in the field of the environment In the midst of raging interests, which may be both unscrupulous and irrational, and among politicians, consumers, labour, and industry, all with the future of human health at stake, epidemiology is now a highly politicized discipline, perhaps the most politicized in the field of medicine. The danger of such a situation is not of course that results of investigations be tendentious or manipulated in any way. It is much more subtle than that There is no argument about whether epidemiology should help solve current issues of interest to the community. This is what largely justifies our very existence, and also keeps our budgets afloat The problem is who is to define the issues. If defining the issues—what is worth considering and what is not, what is to be studied and what is to be left out, the pollutants incriminated, the population exposed, the system, the process, is entirely left to political powers or vested interests, there is a great chance that epidemiology will end up as an alibi. This is not a claim for technocratism. It is a plea for us to be aware of the political importance of our trade in tomorrow's world. Our responsibility is not only to execute a good technical job, it is also to be involved in the process of defining which problems should be analysed and to independently raise sensitive issues. Epidemiologists should in some way serve as ombudsmen for health in its relationship with the environment. It is hoped that exchanges and cooperation between epidemiologists of various European countries will help develop and strengthen the independence required to assume this role.
Downloaded from http://ije.oxfordjournals.org/ at University of Illinois at Urbana-Champaign on March 9, 2015
of no possible use to epidemiologists. This applies to vital statistics, death certificates, medical records of births, hospital files, medical records, files of preventive medicine or occupational health services, payrolls of workers exposed to environmental hazards, insurance records, notification of communicable diseases, maintenance of registers, and so on. Although it has been said that epidemiology is the art of drawing valid conclusions from messy data, there are limits to this. And the difficulties do not only reside in problems of linkage or of central processing. Nor do issues of confidentiality automatically appear. Above all it is a matter of collecting clean data, with appropriate coverage, well-defined criteria, and standardized methods. In many countries there is a laissez-aller attitude to the collection of health data and a crucial gap in communication between statistical and health services. This has to be corrected, otherwise epidemiology may to a great extent remain a futile exercise. A second problem is the lack of dialogue between epidemiology and other health disciplines. This does not exist everywhere but dialogue could probably be improved in most places. Epidemiologists are often complaining of having too few contacts with clinicians. While it is true that a number of our colleagues have no idea at all of what epidemiology is about, and still less idea of what is the importance of standardized definitions or appropriate denominators or matched controls or whatever, we should also question ourselves about whether we ever try to find out more about other disciplines. There is a danger of epidemiology becoming a technique without content, which is another form of academism. This remark I believe applies equally to our relationship with basic scientists, be it geneticists, immunologists, or neurochemists, and also when dealing with people engaged in everyday work in the community, such as general practitioners. Since epidemiology is the study of health in populations and GPs are active within these populations, there is no doubt of the need for GPs to be trained in the basic tools of epidemiology. Conversely there is also the need for us when discussing how to organize such a training, to have personal experience of what the daily work of a general practitioner is. We must be aware of possible deficiencies in our knowledge of what others do, and need, and can offer, otherwise with epidemiology gradually becoming a recognized discipline the practical teaching of it could be
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