Editor'S Choice |
Uses of epidemiology, ways of living and dying
E-mail: shah.ebrahim{at}lshtm.ac.uk
Accepted 29 October 2007
If you only read one thing in this issue, make it Jerry Morris's 1955 British Medical Journal paper ‘Uses of Epidemiology’ reprinted in this issue 1. But before you start, try writing down as many uses of epidemiology as you can think of. I certainly could not come up with the seven uses that Morris describes, and I would expect you all to put ‘discovering causes of disease’ at the top, or at least near the top, of your lists. Morris puts it last under an appropriately modest heading ‘Clues to Causes’. For me, the remarkable thing about Morris's ‘Uses’ is the direct engagement with public health and clinical medicine with examples that, although 50 years old, feel remarkably fresh in the insight they give and the questions they provoke. Epidemiology for Morris is a method ‘for finding things out, of asking questions, and of getting answers that raise further questions’. The increasing retreat of epidemiology from a contextualized view of itself to a decontextualized science of causation–as characterized by Nancy Krieger2 in her thoughtful reflection on epidemiology as history, as population science, and as pragmatic and contextual—loses several of the ‘Uses’, and with them opportunities for improving population health.
Ann Oakley, the daughter of Richard Titmuss—a long-standing collaborator with Morris—highlights the other post-Second World War flowerings of the social medicine project 3. In contrast, Dorothy Porter, traces the theoretical basis of his view of epidemiology from the Enlightenment rationalism to the ‘institutionalization of probabilistic thought’ into a post-Second World War political positivism, and defines his work as ‘late-modernist epidemiology’ because of its application of statistical modernism to health in an era of late-industrial capitalism4.
I am looking forward to discussing these commentaries with Jerry when I next see him for a much too infrequent gossip. Now in his mid-90's Jerry still comes into the London School of Hygiene and Tropical Medicine, walking more slowly, but still as passionate about the issues on which he is working. In this issue, we publish his latest work on the minimum income for health living in older age in England5. Reflecting his 50-year interest in ‘ways of living’, here the costs of a healthy diet, activity, housing, social engagement, getting about, medical care and hygiene are measured and compared with the state pension, which is inadequate to meet these needs. The simplicity of the idea, its execution with readily available data and the direct relevance of the findings to policy on ageing are breath-taking.
Our theme this issue is self-rated health—a widely used and abused measure of health outcome that has found considerable favour because of its strong association with survival, which has been taken to be a validation of its standing as a health outcome. The underlying mechanisms for ticking the box on the survey form that says ‘my health is poor’ are very variable and the articles in this issue explore the predictive ability of self-rated health by educational attainment6 and by socio-economic status,7,8, coming to somewhat different conclusions.
Feeling wretched and then successfully committing suicide is pretty direct evidence of a causal link between self-rated health and mortality. Gunnell's article on the impact of pesticide regulations on suicide in Sri Lanka builds on Morris's tradition of using epidemiology for practical purposes9. The most telling natural experiment of an intervention to prevent suicide was when UK domestic gas supplies were detoxified, removing a lethal source of poison from the home where most misery arises and resides. In Asia, pesticides are the most commonly available lethal poison. The article tells the story of how Sri Lanka restricted the import and sales of the most toxic pesticides in 1995 by which time it had witnessed a massive increase in the rate of suicide to one of the highest levels in the world. By 2005, rates had halved. Application of this evidence to all of Asia could substantially reduce the 300 000 annual deaths of young people. A compelling story that will become a classic.
In another causes of suicide investigation, the short-term impact of a media frenzy of coverage of a celebrity television actor's own suicide by hanging produced a 4-week increase in suicides, particularly by hanging10. Although it would never be possible to get information about exposure to the relevant media from those who have committed suicide, the authors did have information from a companion study in which people who had attempted suicide unsuccessfully were interviewed after the event and almost 90% reported exposure to media about the actor's suicide, and a quarter said that it had influenced their own suicide attempt.
Finally, migration is a powerful social exposure in terms of accommodation to different ways of living and is in itself determined by complex factors that vary over time and between places making untangling the effects of migration on health a difficult business. In a paper focused on Albania, that has seen massive emigration into the rest of Europe following the breakdown of its Stalinist regime in 1990, a novel twist is to look at the effect of emigration on the risk of acute coronary syndromes in those left behind11. Using a case–control design, Burazeri and colleagues12 found that emigration of a spouse who did not send financial support back home was associated with increased risk of coronary heart disease, particularly in women. Razum's commentary uses Homer's story of Odysseus (the wanderer) and Penelope (the left-behind spouse) to critically appraise their interpretation of the findings to good effect12.
References
1 Morris JN. Uses of epidemiology. Br Med J (1955) 2:395–401. Reprinted Int J Epidemiol 2007;36:1165–72.
2 Kreiger N. Commentary: Ways of asking and ways of living: reflections on the 50th anniversary of Morris’ ever-useful Uses of Epidemiology. Int J Epidemiol (2007) 36:1173–80.
3 Oakley A. Commentary: Fifty years of JN Morris's Uses of Epidemiology. Int J Epidemiol. (2007) 36:1184–85.
4 Porter D. Commentary: Calculating health and social change: an essay on Jerry Morris and late-modernist epidemiology. Int J Epidemiol. 2007(36):1180–84.
5 Morris JN, Wilkinson P, Dangour A, Deeming C, Fletcher A. Defining a minimum income for healthy living (MIHL): older age, England. Int J Epidemiol (2007) 36:1300–07.
6 Huisman M, van Lenthe F, Mackenbach J. The predictive ability of self-assessed health for mortality in different educational groups. Int J Epidemiol (2007) 36:1207–13.
7 Beam Dowd J, Zajacova A. Does the predictive power of self-rated health for subsequent mortality risk vary by socioeconomic status in the US? Int J Epidemiol (2007) 36:1214–21.
8 Singh-Manoux A, Dugravot A, Shipley MJ, et al. The association between self-rated health and mortality in different socio-economic groups in the Gazel cohort study. Int J Epidemiol (2007) 36:1222–28.
9 Gunnell D, Fernando R, Hewagama M, Priyangika WDD, Konradsen F, Eddleston M. The impact of pesticide regulations on suicide in Sri Lanka. Int J Epidemiol (2007) 36:1235–42.
10 Cheng ATA, Hawton K, Lee CTC, Chen THH. The influence of media reporting of the suicide of a celebrity on suicide rates: a population-based study. Int J Epidemiol (2007) 36:1229–34.
11 Burazeri G, Goda A, Tavanxhi N, Sulo G, Stefa J, Kark JD. The health effects of emigration on those who remain at home. Int J Epidemiol (2007) 36:1265–72.
12 Razum O. Commentary: Kisses or money for Penelope. Int J Epidemiol (2007) 36:1273–74.
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