International Journal of Epidemiology 2001;30:440-441
© International Epidemiological Association 2001
Reiterations
Commentary: A radical future for public health
Douglas L Weed
Chief, Office of Preventive Oncology, National Cancer Institute, EPS T-41, 6130
Executive Blvd, Bethesda, MD 20892?7105, USA. E-mail: [log in to unmask]
Keywords causation, epidemiology, ethics, prevention, public health, screening
radical1 adj 1. of or relating to the root or origin: FUNDAMENTAL 2. marked by a
considerable departure from the usual or traditional: EXTREME: DRASTIC
With this reprinting of 'Sick individuals and sick populations,'2 Rose's ideas
deservedly attain the status of 'not to be forgotten' in the annals of
epidemiology and
public health. But let us not wax too historic; we remember his contributions
for their staying power, having achieved the rare status of being current and
remarkably
prescient. Hundreds of references over the past 15 years confirm that his ideas
continue to strike a deep resonant chord. Three central themes are most often
cited:
there are two types of causal explanations, those of individual susceptibility
and those of population incidence rates;3?23 there are two corresponding
strategies for
prevention: 'high risk' and 'population';8,14?21 and lastly, applying the
'population' strategy of prevention incurs the paradoxical effect of small
benefit to each
individual and a much greater benefit to the population.17,22?28 These ideas
have served us well and will continue to do so long into the future.
Rose had a knack for carefully reasoned arguments, rich in theoretical detail
and practical significance. His is a radical future, consistent with our deepest
convictions
about the fundamental nature of public health29 but also a serious challenge to
traditional views. Flowing through Rose's writings are the roots of public
health:
prevention and community, science and its methods, and society in all its
complexity. His pronouncements about public health's future, however, are as
startling as
they are refreshing. The best example is Rose's assertion that our priority
should always (his word, my emphasis) be the discovery of causes of incidence
and the
population strategy of prevention. Rose even labels this strategy 'radical'
because it requires wide-ranging changes in social norms of behaviour. But this
rhetorical
hook pales in comparison to what he articulates about the future of the other,
individually based, prevention strategy. Screening and other high-risk
prevention
strategies are something we may eventually abandon; Rose asserts that individual
susceptibility will 'cease to matter' if the underlying causes of incidence are
removed. This is radical stuff, considering our current and intense interest in
genetics and the molecular nature of disease.
So as we rush into the 21st Century, mapping genes, seeking biomarkers, and
wringing our collective hands over the dangers and promises of genetic
screening,
remember that preventing disease and injury in populations crowns our list of
priorities. Seat belts, immunizations, folic acid fortification, fluoridation,
and
anti-smoking efforts are a few obvious examples. And although there is a choice
between controlling 'these' sorts of causes or 'those' sorts of causes?incidence
and susceptibility respectively?preventing disease in populations by controlling
the causes of incidence is the bottom line. That normative claim is precisely
where
Rose ends this now-classic contribution to our literature.
Looking back over this paper from its radical perch on the moral high ground, we
find a careful examination of the pros and cons of the two approaches to
prevention, given a conceptual scientific framework, a theory of disease
causation if you will, comprised of two major categories of causes. There are
causes that
determine susceptibility?genes and the like?and those that we are exposed to:
toxins, infectious agents, diet and other lifestyle choices, and a host of
environmental
factors, some natural, some man-made. The latter category of causes drives
population-based incidence events and rates; the former how individuals respond
to
these same exposures. Rose recognizes the interconnectedness of these conceptual
causal pathways to disease and, from what I can gather, would never have
recommended that science stop its solipsistic crusade to uncover the origins of
disease wherever they are found. Put another way, in epidemiology's recent
'black
box' debate about biology versus society in epidemiology,30 I cannot see Rose
taking one side or another. He is neither for biology alone nor for society
alone. He
is truly an eco-epidemiologist, able and willing to explain the aetiology of
disease across the full spectrum of scientific knowledge.
But prevention?how it is to be done and who will do it?is a very different
story. When applying scientific knowledge, Rose is clear not only about the
priority of
the population-based approach but also about who will use it. As one commentator
put it, citing Rose, prevention is everyone's business and everyone's
responsibility.15 Rose fingers physicians as messengers of prevention2 and
society31 and each individual 'subject'.2 Quoting Dostoyevsky, Rose boldly
proposes that
everyone bears the responsibility of prevention.31 It follows that every member
of the public health professions?each and every epidemiologist ?has an important
role to play in participatory decision making, not as just another member of
society, but one with special knowledge and training and expertise and, above
all, a
commitment to public health practice. Once again, Rose fires up a radical
future, this time pointing his guns directly at those epidemiologists who,
anxious to stay as
far away as possible from direct participation in beneficent decisions, avoid
with great solemnity the practice of public health as they worship at the altar
of scientific
objectivity.32?35
All this talk of who bears the responsibility for prevention is just another way
of saying that there is a prominent ethic at the heart of Rose's philosophy of
public
health. It is an ethic congruent with the emerging scholarship from bioethicists
and practitioners alike on the philosophical and ethical foundations of public
health.29,36?39 It is an ethic of shared, community responsibility; it is an
ethic with beneficence and respect for populations (and people) at its core; it
is an ethic of
human rights and social justice, of commitment to the ideal inquiry of objective
science and to the careful application of technological knowledge. Rose's
ethic, in
other words, is radically fundamental, radiating out from the deep root of
humanity from which public health derives its sustenance.
Acknowledgments
Many thanks to Drs David Berrigan, Lori Beth Dixon, and Rachael
Stolzenberg-Solomon for helpful comments on an earlier draft.
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