The future of epidemiology: World class science, real world impact

By: Charles Branas

This past July, I was honored to be invited by the Mailman School of Public Health to speak on the future of epidemiology and its place in science more broadly.

Needless to say, it was a tall order—the field of epidemiology is a centuries-old science and my contributions only a few decades. Reflecting on the experiences that I have had, as well as those of my colleagues in the many cities, towns, and countries within which we have worked, I thought carefully on where the field of epidemiology has been and perhaps where it should go.

In responding to a request for some sort of vision for the field, I settled on a few core concepts that ultimately made me think epidemiology should build on its storied past and monumental accomplishments, but at the same time, stop under-selling itself as a science and downplaying its massive potential as an engine for change in the real world. Epidemiology is, and should be seen as, a world-class science that impacts the lives of real people, in ways we can all appreciate.

This short statement encompasses a lot so let me unpack its three core components:

  1. World class science
  2. Impacting the lives of real people
  3. Ways we can all appreciate

I recently read The Great American University, a book by former Columbia University Provost Jonathan Cole. In it, he argues that our U.S. research universities are creative machines unlike any other in history. They are central to our place in the world, intellectually as well as technologically. I couldn’t agree more. I always tell people that America has two great exports: storytellers and scientists.

The U.S. does storytelling and science better than any other country. Hollywood manages to export our stories to the world like no other country. And our research universities export our science like nowhere else. Scientists, including epidemiologists, enjoy a privileged position in U.S. society. We earn decent salaries and we get to make our own waythere are no time cards to punch; we study questions that interest us, educate the next generation of scientists, and, for the most part, choose how we will spend our days.

Along with the many advantages we have in our working lives, we as epidemiologists also have certain responsibilities, perhaps the most important of which is to conduct research that is new and cool. We have a duty to be curious, imaginative, and skeptical. We also have a duty to do work that ultimately impacts real people in positive ways. To paraphrase John F. Kennedy: To those whom much is given, much is expected in return.

Has epidemiology lived up to this challenge?

The field has made some truly impressive contributions to humanity, including the eradication of smallpox, fluoridation of drinking water, improved motor vehicle safety, and recognition of tobacco as a health hazard. According to the CDC, the greatest public health achievements of the 20th century are built on epidemiology. Still, it was a list released by the National Academy of Sciences that dominated headlines in 2003. Based on media coverage alone, it would seem that the greatest achievements of the 20th century are largely not built on epidemiology and that innovations like electrification, automobiles, and airplanes are more deserving of recognition than inventions and programs emerging from the public health sciences and epidemiology.

Perhaps this is one reason why epidemiology does not receive the same level of attention as many other sciences. The public impression of the field was summarized years ago by a Washington Post reporter who wrote, “epidemiology is, by its very nature, much more inexact than the kind of science that puts people on the moon.” An unfortunate statement, but one that I would argue is perhaps a useful ground-truthing for the field.

Epidemiology is a world-class science, but there are a few reasons why it is not always viewed as such.

I’ve often heard my colleagues complain about a scientific hierarchy, lamenting the existence of a continuum where the “harder sciences” (physical sciences) outrank the “softer sciences” (social sciences).

I think we as epidemiologists are viewed by the public as perhaps “medium-soft,” somewhere between biologists and sociologists. And this view may be echoed among our scientific colleagues. At one of the large research universities where I had the pleasure of working, a mantra that I often heard was that, in the search for answers, there was a biologist who spoke to a chemist, who spoke to a physicist, who spoke to God, and scientific truth somehow emerged. The implication of this, of course, was that epidemiologists somehow had no place in the chain of scientific evidence.

This is how the public and other scientists see epidemiology. I believe the field has to contend with its image, which is improving, but still needs work.

The other major issue that stands in the way of epidemiology being viewed as a world-class science is that prevention, while saving millions of lives, is not a tangible product like electricity and, by design, not easily noticed and often overlooked. Epidemiologists have saved millions and millions of lives, and we’re not getting credit.

To be considered a world class science, epidemiology must do a better job of touting accomplishments that would otherwise go unnoticed.

We could, of course, continue to march on without concern for our place in the pantheon of science. Doing so, however, would be a disservice to humanity.

Epidemiologists save lives. To insist that epidemiology receive greater recognition is to insist that the world take advantage of the field’s unique and highly effective approaches for solving problems that touch large groups of people.

Competing for financial resources to fund our work is made easier if the public has even a basic idea what we do and, more so, if policymakers see epidemiology as an important force for change. There is great value to what we do and we must do a better job of broadcasting this fact.

In addition to promoting specific epidemiological success stories and breakthroughs, let’s remind the world that epidemiology is a fundamental science with a centuries-old history, much the same as the ‘hard sciences.’

Money tends to flow towards more recognizable sciences. Perform a quick search on USAspending.gov and you’ll see that biology, chemistry, and physics, for example, receive four times more grants and contracts than epidemiology.

Even the term ‘hard’ science is misleading. Given the higher-order complexities and challenges inherent in studying large groups of people, epidemiology and the social sciences should more aptly be called the ‘really hard sciences.’

So what else should we do as a field besides reminding others about epidemiology’s centuries-old history and touting the real world implications of our work? We should also consider other actions like introducing epidemiology as an obligatory part of any general science curriculum at our universities. Teaching fundamental epidemiology to undergraduate students has been the joy of my teaching career, and ensuring the next generation of scientists has foundational knowledge about our field is critical to epidemiology’s reputation in the decades to come.

Additionally, we must embrace team science. Fifteen years ago, ‘multidisciplinary’ meant getting a cardiologist and a cardiothoracic surgeon to work together. Since then, much has changed. As someone who develops programs targeting multidimensional public health problems like gun violence, I’ve collaborated with researchers from law and business schools, as well as city planners and engineers. Embracing mixed methods, including approaches that are not traditionally associated with epidemiology, enriches our field. Sharing our expertise with other disciplines showcases our many strengths and highlights for scientists outside epidemiology how we uniquely contribute to the world.

And contribute we must. Epidemiology should be an applied science and a force for change. We cannot simply study the distribution and determinants of health-related states or events; we must use our knowledge to actually intervene on diseases and other health problems for the betterment of humankind.

To paraphrase Dr. Inder M. Verma, Editor-in-Chief for the Proceedings of the National Academy of Sciences of the United States of America, we need to focus more on impact and less on impact factor.

Most academics, especially those working at research universities, aspire to publish frequently in top tier journals—but this is not the only (or even the most important) measure of success.

Whenever possible, epidemiologists should pursue ‘win-win’ science that produces knowledge while simultaneously helping communities in need.

Public health advocates, and I, of course, count us among them, seek to alter one or more components in the epidemiologic triad—acting on pathogens, people, or places. To curtail malaria’s spread, for example, we can target the parasite itself, the behaviors of the people who are at risk for infection, or the swamp from which the mosquitos that transmit malaria emerge in the first place.

Addressing “place” can often have the largest effects and the most lasting impacts on health. As the CDC Director has noted, not all ideas to improve health will have the same levels of success and when it comes to choosing those that will have the highest impact we should be looking more to basic approaches that “make the healthy choice the easy choice” and that affect more people for longer periods of time. A 2012 letter in the American Journal of Public Health points this out and I often like to quote it in support of the importance of place: “if a brackish tidal pool is breeding mosquitoes that serve as a vector for malaria, the intervention of filling it in . . . may be far more likely to continue reducing the incidence of malaria five years after funding has run out than . . . expecting local community members to continue regular applications of larvicide.”

Place-based interventions often cost less than programs aimed at changing people’s behaviors and the benefits of these interventions often appear to be more sustainable over the long term. They can also address a wide range of public health issues. Gun violence is one example of a public health problem that is especially amenable to place-based interventions, which I have focused on in my own epidemiologic research.

There are substantial political hurdles to focusing on the users of firearms or the firearms themselves in working to reduce firearm violence. My research has shown there’s another way to reduce gun-related injuries and deaths—changing places. Making improvements to urban neighborhoods, such as fixing abandoned building and greening vacant land, is inexpensive, scalable, and highly effective in the fight against gun violence. Experimental and quasi-experimental studies we’ve completed have shown a significant drop of almost 40% in gun violence lasting for years after blighted urban places, like abandoned buildings and vacant lots, were remediated.

These sorts of place-based interventions are also key examples of ‘win-win’ science, something on which epidemiology can more overtly begin to focus. That is, our research to reduce gun violence not only raised funds from the NIH and CDC to conduct field trials of urban blight remediation and produce new scientific knowledge, it also concurrently managed to repair, clean, and green thousands of vacant and abandoned urban spaces in heavily under-resourced neighborhoods across multiple cities.

Our contributions to knowledge are thus only useful to the extent that they impact the lives of real people. But, again, what if the people (and policymakers) who would most benefit from these great epidemiologic actions remained unaware that they had ever been undertaken on their behalf? This brings me to the last component in my aspirational statement about the future of epidemiology, the notion that the impacts we have should be packaged in “ways we can all appreciate.”

In saying this, I do mean ‘all.’ This includes fellow epidemiologists, other scientists, policymakers, and the public. The more the world knows about our work, the more grants we’ll receive to pursue our research goals, the greater the likelihood that health-enhancing policies will emerge, and the better the chances that we’ll improve the public’s health.

We need to be scientists first but to reach those outside academia, we also need to be storytellers with clear, and compelling narratives that explain what we do. If you can convince the person sitting next to you on the subway that your research has merit, chances are you’re on to something. And framing our science this way, so that a reasonably educated non-scientist would say, “Wow, that’s really important!,” gives our scholarship the focus it needs and really helps to refine and clarify for ourselves mechanisms and applications that we may not have seen in just presenting to our scientific colleagues.

As Atul Gawande has recently argued, it is unnatural to think like a scientist. We follow a purposefully dispassionate scientific method to minimize bias in our research. We ‘fail to disprove’ our hypotheses, and never ‘prove’ them since we must remain open to new evidence. It’s easy to forget that this is quite a departure from normal thinking. We must remind ourselves that nonscientists, including policymakers and members of the general public, will often be baffled by our refusal as scientists to ‘take a side’ and that the very cornerstone of scientific discourse is dissent and constantly evolving findings.

Yes, it’s challenging to describe our findings in a way that nonscientists can understand, but communicating with a broader audience is critically important. It’s enormously beneficial to get the media and the public at-large behind our work.

Talking with reporters about your research, providing compelling statements that convey its real-world implications, and always exuding the enthusiasm that motivated you to start your decades-long research project in the first place, will ensure that your scholarship does what it is intended to do: improve public health.

Take the time to really think about how to frame and deliver your message. Whenever possible, use analogies to explain conceptsmitochondria are like factoriesand describe magnitude with comparisons to familiar objects – enough hazardous waste to fill a hundred Olympic-sized swimming pools. A little imagery and social math go a long way.

Preparing a “three-minute thesis” to summarize your latest study results isn’t dumbing-down your scholarship; it’s making it accessible to those who can benefit from it. After all, isn’t that why we became epidemiologists?

As epidemiologists we owe it to the world to create the highest caliber science and disseminate this science in ways that will ensure it is understood and applied to significantly improve the public’s health. World-class science that impacts the lives of real people, in ways we can all appreciateit’s a vision for the future of epidemiology that is hopefully intuitive to many of you, and one that we should doggedly embrace as a field and teach to our students.

References:

Branas CC, Kondo MC, Murphy SM, South EC, Polsky D, MacDonald JM. Urban Blight Remediation as a Cost-Beneficial Solution to Firearm Violence. Am J Public Health. 2016 Oct 13:e1-e7.

Branas CC, MacDonald JM. A simple strategy to transform health, all over the place. J Public Health Manag Pract. 2014;20:157–159.

Card AJ. Sustainability of public health programs. Am J Public Health. 2012;102(5):776–777.

Cole JR. The great American university: Its rise to preeminence, its indispensable national role, and why it must be protected. New York: PublicAffairs, U.S.; September 1, 2007.

Frieden TR. A framework for public health action: the health impact pyramid. Am J Public Health. 2010 Apr;100(4):590-5.

Gawande A. The mistrust of science. New Yorker, June 10, 2016.

Greatest Engineering Achievements of the 20th Century. National Academy of Engineering. http://www.greatachievements.org/. Published 2003. Accessed November 09, 2016.

Ness RB, Bondy ML, Branas C, et al. Editorial. Annals of Epidemiology. 2003;13(9):597–598. doi:10.1016/j.annepidem.2003.09.001.

Thompson B. WashingtonPost.com: The Science of Violence. Available at: http://www.washingtonpost.com/wp-srv/national/longterm/trigger/trigger6.htm. Accessed October 28, 2016.

Verma I. Impact, not impact factor: Proceedings of the National Academy of Sciences. 2015;112(26):7875-7876. doi:10.1073/pnas.1509912112.