Reflexiones históricas acerca del libro Epidemiologia & Saúde: Fundamentos, Métodos, Aplicações
Alfredo MorabiaI, II
IQueens College, City University of New York, New York, U.S.A.
IIMailman School of Public Health, Columbia University, New York, U.S.A.
Do we need a new epidemiology textbook in Portuguese? Would it not be easier to translate a book that epidemiology students have used for years in the United States?
Almeida Filho & Barreto have shown that the answer to the first question is "yes". Their recently published Epidemiologia & Saúde: Fundamentos, Métodos e Aplicações 1, consisting of seven parts, 63 sections, and comprising 98 collaborators, is different from all the epidemiology textbooks available in any of the languages I can read.
Briefly, the seven parts of the book cover:
(1) History (of the world and of Brazil) and philosophy (epistemology, concept of risk);
(2) Methodology (measurements of occurrence of health events and principal study designs);
(3) Epidemiological data analysis (regression models, multilevel, structural, and complex approaches, and meta-analyses);
(4) Applications of epidemiology by levels of organization (molecular, genetic, clinical, environmental, social, and "ethno-epidemiological");
(5) Applications of epidemiology across the live course (childhood, adolescence, adulthood, aging);
(6) Specific health problems (infectious, respiratory, and cardiovascular diseases, cancer, violence, addiction, mental, oral, occupational, nutritional, reproductive and sexual);
(7) Application of epidemiology to public health, health policy and economics, and concluding with a section entitled Panorama, Challenges, and Perspectives for a Brazilian Epidemiology.
In this comentary, I wish to highlight the original nature of Almeida Filho & Barreto's book by comparing their definition of epidemiology with several historical definitions. The oldest definition I know dates from 1866 (Table 1, item 1a). It's by the Epidemiological Society of London, which grouped researchers from various fields in the fight against cholera. The Society's definition emphasizes the population approach that characterizes epidemiology as opposed to physiology, pathology, and therapeutic medicine. In epidemiology, diseases are examined in the aggregate, in groups of cases. This definition also highlights the role of epidemiology in studying causal relations. It also mentions the application of new knowledge to the improvement of people's health (Table 1, item 1b).
Such was the "pre-formal" definition of epidemiology in the 19th century. Paradoxically, Wade Hampton Frost, the first North American Professor of Epidemiology, did not adopt this definition. Elizabeth Fee retraced the evolution of Frost's ideas concerning what constitutes epidemiology 2. Frost initially included only acute infectious diseases (Table 1, item 2a). In 1919, shortly before beginning his work at the Johns Hopkins School of Hygiene and Public Health in Baltimore, Maryland, he wrote that epidemiology deals with "the natural history of the infectious diseases, with special reference to the circumstances and conditions which determine their occurrence in nature" 2 (p. 134). His research soon included tuberculosis, a more chronic type of infectious disease. Five years after he began his work as head of epidemiology at Johns Hopkins, Frost expanded his definition to include other diseases, but not cardiovascular diseases or cancer (Table 1, item 2b). Finally, in 1937, a year before his death, Frost 2 (p. 134) described "epidemiology as comprising the whole of the unremitting effort being made to clarify the relation between the disease and disabilities which men suffer and their way of life" (Table 1, item 2c).
Nevertheless, it was Major Greenwood, Frost's British counterpart, who provided a universal definition, albeit less rich than that of the Epidemiological Society of London. According to Greenwood, epidemiology is "the study of disease, any disease, as a mass phenomenon" 3 (p. 15).
After World War II, a new generation consisting mainly of physicians embraced epidemiology as a way of promoting public health. Abraham Lilienfeld, head of Frost's department in the 1970s, stated that "without public health, there is no epidemiology". These epidemiologists had primarily social and sometimes political motivations. It is thus not odd that the "classical" definition of epidemiology in the first edition of Last's Dictionary of Epidemiology 4 had two components: to study the causes of diseases and to use such knowledge to improve people's health (Table 1, item 4).
The second part of Last's definition, which includes the relationship between epidemiology and public health, disappeared in the "modern" definition proposed by some authors, such as Rothman & Greenland 5 (Table 1, item 5). What about the definition proposed in Epidemiologia e Saúde: Fundamentos, Métodos e Aplicações? The quote in Table 1 (item 6) shows clearly that the book takes a position more in line with the classical definition, linking etiological investigation to improvements in public health.
It would be interesting to know why Almeida Filho & Barreto did not embrace the "modern" definition. Perhaps because epidemiology and the foundations of public health developed simultaneously in Brazil and the connection between the two is thus obvious to everyone? Meanwhile, in Europe and the United States, "modern" epidemiology germinated in a context in which the foundations of public health could be considered political and social conquests, that is, as a structural component of society; in this context, epidemiology could be confined to a more specific role of etiological exploration. We shall see in the future whether the "Brazilian" definition becomes more "modern" or whether the "modern" definition approaches the "Brazilian" definition. I have a preference for the second option.
I think the most impressive aspect of Epidemiologia e Saúde: Fundamentos, Métodos e Aplicações is the authors' encyclopedic ambition. The book covers more areas than the Handbook of Epidemiology 6, which has a thousand pages and costs US$ 450. Can a project of such magnitude be conducted in a single country? Would Brazil alone, or for example the United States alone, have the necessary expertise to carry out such a project?
I understand that, Epidemiologia e Saúde: Fundamentos, Métodos e Aplicações is a handbook for teaching epidemiology in Brazil. Some chapters are only of local interest. But others are of universal interest. It may be possible to conceive an international, multilingual, modular handbook to which experts from each area in the entire world can contribute. It would be a huge endeavor to harmonize the concepts and nomenclature, but I believe it is worth the effort.
With its smooth balance between the epidemiology of causal investigation and the epidemiology of public health, the book edited by Almeida Filho & Barreto is more than an adaptation, in Portuguese, of the contents of existing handbooks. It offers the best concept for teaching epidemiology that I have seen in many years.
I wish to thank Maria Amelia Veras, Catarina Cordeiro, and Moyses Szklo for their comments and stylistic improvements of the Portuguese version, and the National Library of Medicine, USA, for its grant n. 1G13LM010884-01A1.
1. Almeida Filho N, Baretto ML. Epidemiologia & saúde: fundamentos, métodos e aplicações. Rio de Janeiro: Guanabara Koogan; 2011.
2. Fee E. Disease & discovery. A history of the Johns Hopkins School of Hygiene and Public Health 1916-1939. Baltimore: Johns Hopkins University Press; 1987.
3. Greenwood M. Epidemics and crowd diseases: introduction to the study of epidemiology. North Stratford: Ayer Company Publishers; 1935.
4. Last JM. A dictionary of epidemiology. New York: Oxford University Press; 1983.
5. Rothman KJ, Greenland S. Modern epidemiology. 2nd Ed. Philadelphia: Lipincott Williams Wilkins; 1998.
6. Ahrens W, Pigeot I, editors. Handbook of epidemiology. Berlin: Springer; 2004.
7. Objects of the Epidemiological Society of London. Transaction of the Epidemiological Society of London. v. III. Sessions 1866-1876. London: Hardwicke and Bogue; 1876. Correspondence Submittd on 07/Mar/2013 A versão em inglês deste texto está disponível online no Portal SciELO (http://www.scielo.br/csp).
Center for the Biology of Natural Systems, Queens College, Columbia University
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Final version resubmitted on 21/Mar/2013
Approved on 26/Mar/2013
The English version of this text is available online in the SciELO (http://www.scielo.br/csp).
La versión en Inglés de este texto está disponible en línea en el SciELO (http://www.scielo.br/csp).
Submittd on 07/Mar/2013
A versão em inglês deste texto está disponível online no Portal SciELO (http://www.scielo.br/csp).