1. Choosing A Future For Epidemiology I.Pdf 1. Choosing A Future For Epidemiology

Choosing a Future for Epidemiology: I. Eras and Paradigms

Menvyn Susser, MB, Bch, FRCP(E), DPH, and Ezra Susser, MD, DrPH

Introduction
The present era of epidemiology is coming to a close. The focus on risk factors at the individual level-the hallmark of this era-will no longer serve. We need to be concerned equally with causal pathways at the societal level and with pathogenesis andcausality at the molecular level.' This paper prepares the groundwork for the argument that choices have to be made about the future of epidemiology. To look forward, we do well to look backward for guidance. Part I of this article sketches in brief outline the evolution of modern epidemiology in three successive eras. Following Kuhn,2 we set the bounds of these eras in terms of dominant paradigms.3 InPart II of this article, we advocate a paradigm for a fourth emergent era of "eco-epidemiology."

twin forces of capitalism and the Protestant ethic, science was sanctioned (in Robert Merton's words)6 by "economic utility" and "the glorification of God." This ideology fostered discoveries with immediate technical application in astronomy, navigation, firearms, optics, and many other fields.With the accelerating flow of discovery over the centuries, science as an institution abandoned its utilitarian roots to become an end in itself. For some time, however, that was not true for epidemiology. That field retained a central concern with the public health and its social distribution. Thus, in the face of the miseries of 19th-century England-the advance guard of industrialization and rapidurbanization-modern epidemiology gradually took shape and then burst into activity with the Sanitary Movement.7-9 Thereafter, one can discern at least three eras in epidemiology, each with its own dominant paradigm: (1) the era of sanitary statistics with its paradigm, miasma; (2) the era of infectious disease epidemiology with its paradigm, the germ theory; and (3) the era of chronic diseaseepidemiology with its
Mervyn Susser is the Editor of the Journal. Ezra Susser is with the School of Public Health, Columbia University, and the New York State Psychiatric Institute, New York, NY. Requests for reprints should be sent to

The Evohltion of Modern Epidemiology
The underlying idea that marked the beginnings of quantitative epidemiology
in the 17th century was concern for the

publichealth and disparities in mortality across society. John Graunt the haberdasher, in his book Natural and Political Observations Made upon the Bills ofMortality (1662),4 reported on the social distribution of death in London and especially on the mortal consequences of plague. In his book Political Arithmetick (1667),5 the physician William Petty, Graunt's friend and sponsor in the Royal Society,was the first to provide a method to quantify the costs of mortality. The utilitarian approach that Graunt, Petty, and others adopted was entirely in
accord with the justifications prevailing
over the beginnings of modern science in the 15th and 16th centuries. Driven by the

Mervyn Susser, MB, Bch, FRCP(E), DPH, Columbia University, Gertrude H. Sergievsky Center, 630 W 168th St, 19th Floor,New York, NY 10032. This paper was accepted January 17,
1996.

Editor's Note. Dr George Silver was the editor responsible for this paper. As is our practice, Dr Mervyn Susser had no part in the review and decision process. See related editorial by Winkelstein (p 621) and comment by Koopman (p 630) in this issue.
May 1996, Vol. 86, No. 5

Epidemiology's Future, L.

TABLE 1-Three Eras in theEvolution of Modem Epidemiology Era

Paradigm
Miasma: poisoning by foul emanations from soil, air, and water Germ theory: single agents relate one to one to specific diseases Black box: exposure related to outcome without necessity for intervening factors or pathogenesis

Analytic Approach

Preventive Approach
Drainage, sewage, sanitation

Sanitary statistics (first half of
19th...