Commentary: Ways of asking and ways of living: reflections on the 50th anniversary of Morris’ ever-useful Uses of Epidemiology
Department of Society, Human Development and Health, Harvard School of Public Health, Kresge 717, 677 Huntington Avenue, Boston, MA 02115, USA. E-mail: nkrieger{at}hsph.harvard.edu
Keywords Epidemiologic theory, social epidemiology, population health
Accepted 7 September 2007
‘Epidemiology is the only way of asking some questions in medicine, one way of asking others (and no way at all to ask many).’To be of use. To Jeremy Morris (b. 1910), writing a half-century ago in his now classic text, Uses of Epidemiology,1 the promise—and responsibility—of epidemiology was clear: to generate scientific knowledge about the ‘presence, nature and distribution of health and disease among the population’ (p. 96),1 ultimately in order to ‘abolish the clinical picture’(p. 98).1 Committed to improving the ‘health of the community’ (p. 96),1Morris argued that ‘one of the most urgent social needs of the day’ that epidemiology could address was ‘identifying harmful ways of living’ and ‘rules of healthy living’ (p. 98).1 Uniquely equipping epidemiology to carry out this task was, in his view, its population and historical perspective and its dual engagement with studying ‘human biology’ and ‘the social aspects of health and disease’ (p. 97).1 Viewing epidemiology as a necessary complement to what he deemed equally vital clinical and laboratory research (p. 99),1 Morris affirmed that the discipline's distinct uses ‘all stem from the fact that in epidemiology the group is studied and not merely particular individuals or cases in the group’ (p. 97).1Jeremy M. Morris
Uses of Epidemiology (1957, p. 96)1
How might epidemiologists enhance their capacity to do useful research? Morris’ answer: by use of better methods. Only the sort of methods Morris had in mind were not the kinds of technical methods emphasized by the ‘modern epidemiology’ of recent years,2 as necessary as he knew them to be. Rather, Morris’ objective was to articulate a methodical approach for epidemiological thinking:
In this book I am concerned mainly with epidemiology as a way of learning, of asking questions, and getting answers that raise further questions: that is, as a method (p. 3).1Using his technique, Morris systematically delineated seven ‘uses’ of epidemiology (Table 1), concerned with describing current and changing distributions of community health and the natural history of disease, identifying syndromes, evaluating health services, predicting risk and elucidating aetiology (p. 96).1 He first presented this list in his 1955 paper on ‘Uses of Epidemiology’,3 reprinted in this issue of the International Journal of Epidemiology. As this initial article and the subsequent book Uses of Epidemiology amply made clear, the first step was to get the questions right—after which of course it would be necessary to confront the ‘practical matters’ and ‘kinds of difficulties that arise’ when conducting epidemiological studies(p. 14).1
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In this commentary, I reflect on three key principles that underlie Morris’ approach to asking questions, as timely today as they were 50 years ago. These are: (i) epidemiology is an historical science, (ii) epidemiology is a population science and (iii) epidemiology is a causally pragmatic and contextual science. A corollary is that epidemiology necessarily must engage with the jointly social and biological aspects of health and disease, given its commitment to what Morris termed the ‘health of the community’(p. 96).1
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Epidemiology is an historical science |
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The pre-eminence of historical thinking in Morris’ approach is attested to by the book's opening pages. Its introduction commences with a review of the past century's trends, from 1850 to 1950, in mortality rates for women and men, 55- to 64-years-old, in England and Wales. Morris observed that rates for both groups began to fall in 1900, reflecting the impact of ‘sanitary reform’, and fell until 1920, after which ‘rather abruptly there was a change’(p. 1):1
Female mortality kept its downward course, but the reduction of male mortality has slowed and almost stopped. As one result of this, the death rate among men aged 55 to 64 which was about 10 per cent higher than for women a hundred years ago, and about 33 percent higher after the first world war, is now approach about 90 percent higher ... What has been happening? ... The most important is the emergence of three diseases from obscurity to become exceedingly common, disease which particularly affect men and are very frequent in middle-age: duodenal ulcer, cancer of the bronchus and ‘coronary thrombosis’ (pp. 1–2).1A graph comparing women and men for 1930–50 for all-cause mortality vs ‘all causes less coronary heart disease and cancer of the respiratory system’ showed a widening gap over time for the former, but parallel declines, with no widening gap, for the latter (p. 2).1
What points stand out from this example? First, disease rates change over time, sometimes very quickly, and epidemiologists need to track and account for these temporal changes. This requires attention to causes of disease distribution, as related to—but not simply reducible to—causes of disease mechanisms. Second, the change in disease rates over time can vary by type of disease; specificity matters. Whereas some disease rates may uniformly fall, others may rise, and this differential patterning over time provides important aetiological clues. Third, women and men do not exhibit a fixed all-cause mortality ratio; instead, the ratio is historically contingent. For some types of mortality, women and men exhibit similar temporal trends; for others, they do not. Commonalities and divergences both matter, with this principle relevant to comparisons of disease distribution across any groups (i.e. not just women vs men). The implication is that societal levels and distributions of disease are malleable, not an essential property of either the populations afflicted or their ailments, and so can potentially be altered. Indeed, to Morris, the central question posed by his presentation of the data was: ‘What are the social changes that underlie the biological changes expressed’ (p. 19)1 in the observed patterns?
Morris brought his historical orientation to not only the past but also the present and future. History provided the foundation for his view that epidemiology was a ‘mode of understanding of the changing picture of disease: study of changing people and their changing ways of living in changing environments; and the causes of disease that may be identified in these’ (p. 120).1 Writing about ‘Changing people in a changing society’ (p. 19),1 Morris emphasized that:
Diagnosis of the state of community health must be dynamic and the remarkable changes now occurring in the character of health problems ... will be a recurrent theme of the present exposition. In a society that is changing as rapidly and radically as our own (and these changes may well be small compared with what is in store for us and slight compared with the demographic—cultural—technological revolutions in some countries of S.E Asia or Africa) epidemiology has a special duty to observe contemporary social movements for their impact ‘upon the people,’ to diagnose what new problems are arising, where we are making progress and where falling back (p. 19).1Questions he posed sparked by this orientation included (pp. 19,22):1
What are the implications to Public Health of more married women going out to work? And less of the older men? Of still increasing urban—and surburbanisation? The rapid growth of new towns? Smokeless zones (still with sulphur)? The building of new power stations? Of less physical activity in work and more bodily sloth generally? Of the quickening transformations in industry? Of the prospect of an age of leisure? Or the growth of mass media and the use being made of these? Of the eleven-plus examination? Of the more than 1000 extra motor vehicles per day? Of the rising consumption of sugar; our astonishing taste for sweet – we eat more per head than any other population? Of the cheapening of fats? The multiplying interferences with food? The many physical and chemical exposures, known and potentially hazardous? More smoking in women? The prodigious increase of X-rays and antibiotics?Such questions (of contemporary history, it might be said) could readily be multiplied.
And indeed they have: a half a century later, epidemiologists are still actively engaged in pursuing Morris’ research agenda, whether or not aware just how long these questions have been on the table.
The essential point is that Morris’ appreciation of history as alive, relevant and embodied is what allowed him to propose a rich research and action agenda for epidemiology and public health that is relevant to this day. Encouragingly, recent work4,5 is reviving the view, held by eminent epidemiologists in prior generations, including William Guy (1810–1885),6 August Hirsch (1817–1894),7 Wade Hampton Frost (1880–1938)8 and Edgar Sydenstricker (1880–1936),9 that epidemiology is an historical science.10–12 Equally compelling, Morris, by his example, offers useful refutation of the narrow-minded view that asking where scientific questions come from is an unscientific question, as claimed by Popper's philosophy of science13,14—one adopted by key proponents of ‘modern epidemiology’,2,15 and which is premised on divorcing the creative questions scientists ask from the societies in which they live. Being grounded in the history of one's times and one's field is instead a very good place to start.2,4,10–12,16
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A second key principle is contained in Morris’ definition of epidemiology as: ‘the study of health and disease of populations and of groups in relation to their environment and ways of living’ (p. 16).1 Repeatedly, Morris emphasized that epidemiology was concerned with ‘populations’, not just cases or individuals (pp. 2–3,16,61,97,120):1
By contrast with clinical medicine, the unit of study in epidemiology is the population or group, not the individual. Death, or any other event, are studied only if information can be obtained, or inferred, about the population in which the events occurred (p. 3).1Put bluntly, if the topic of study was not population rates and risks, it was not epidemiology.
To Morris, one obvious reason for the population approach was that erroneous inferences could be made about disease occurrence or progression if only a skewed set of clinical cases were studied (p. 41):1
There may be hundreds or thousands of patients on the books of a diabetic clinic, but numbers alone will not ensure that the frequency in the clinic of vascular or nervous complications truly reflects the frequency of these in diabetes, and not merely among this particular (and may be indefinable) group of diabetics. For example, diabetics with such complications may be particularly referred to a university clinic. That is to say, having stated a question (about the frequency of complications), the next step is to decide how to ask it and the appropriate method for getting a correct answer. Merely multiplying the number of clinical cases will not necessarily help and indeed may multiply error. It would be better to try and assure that all the clinical cases occurring in a sufficiently large population are included, or a representative sample of such; that is to say this is an epidemiological question, and the appropriate method of asking it is epidemiological (p. 41).1Another was that knowledge of group levels and distributions is essential for investigating aetiology and preventing disease. Using the example of socioeconomic inequalities in reproductive outcomes, Morris wrote (p. 16):1
Such demonstration of inequalities between groups is the standard function of epidemiology. Obviously there will be great and small individual differences within these social classes. But resolution of these differences, and summarising the group experiences as such, is also obviously useful. In general, description of group differences is the essential part of method. Thus it may often provide the first indication that there is a problem for consideration. It is the beginning for the search for causes of disease. (p. 16).1As Morris reminded his readers, ‘The main use of epidemiology is to discover populations or groups with high rates of disease, and with low, in the hope that causes of disease and of freedom from disease can be postulated’ (p. 61).1
Morris further recognized that epidemiology's population vantage was critical not only for elucidating aetiology but for even identifying the outcomes of concern. Noting that population comparisons could give insight into what constituted both ‘disease’ and what was ‘healthy, or "normal" (not just the common, or average)’ (p. 51),1 Morris observed:
Thus, extending the customary picture obtained in any one country, population studies are beginning to make it clear that blood cholesterol levels may vary considerably from one country to another. Western populations may have higher levels than those in ‘under-developed’ countries, and may have different trends with age. The question at once arises: what are the normal ranges of blood cholesterol? May it be that most people in the West have pathologically high levels? ... That is to say, it must now be considered what is the appropriate population or ‘universe’ for the study of physiological norms ... My own first introduction to it was ... when I was told of the laboratory technician in China who believed that what we call megloblastic degeneration of the bone marrow was ‘normal’. (p. 51).1The implication is that it can be erroneous to categorize a study population's outcomes or exposures by percentiles (e.g. quartiles, deciles), or to focus on mean differences between groups, as typically is done, without first considering where the average lies within the full range of documented levels.
But how was an epidemiologist to determine who and what constituted meaningful populations or groups? And where did individuals fit in? Here, Morris offered brief but suggestive answers. To Morris, the ‘ "population" may be of a whole country, or any particular and defined section of it’ (p. 3),1 categorized in relation to people's ‘environment, their living conditions and special ways of life’ (p. 61),1 e.g. their social class, occupation and economic resources (p. 16),1 and also their ‘age’, ‘race’ and ‘sex’ (p. 65).1 These populations, in turn, set the context of the individuals within them, including the constraints on and options for their individual agency. To Morris, greater ‘understanding of properties of individuals which they have in virtue of their group membership’ (p. 120),1 was essential, given ‘the changing character of health problems’ (p. 39),1 precisely because the
... prevention of disease in the future is likely to be increasingly a matter of individual action and personal responsibility. Compare the Victorian programme for laying drains and today's campaign on washing the hands. In brief, we must look forward to building a new kind of partnership between community and individual in place of the old where so often in Public Health the community did things for the individual (p. 39).1The implication is that only by grappling with links between individuals and their communities would epidemiology and public health be able to understand and alter individual and population ‘ways of living’ so as to create a healthier world.
Behind Morris’ approach to ‘populations’ and ‘individuals’ lay a host of assumptions that have long been debated in the ‘population sciences’, whether social, ecological or biological (Table 2).17–24 Making explicit some of the contentious issues involved in understanding these complex terms is Raymond Williams’ reminder (Table 1) that: (i) the origin of ‘individual’ lies in it being ‘indivisible’ from the group of which it is a part and (ii) recognition of ‘individuality’ does not imply embracing the philosophical stance of ‘individualism’ (pp. 161–65).18 At an abstract level, the ongoing arguments centre on whether the designations of ‘population’ and ‘individual’ are:
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- externally imposed constructs vs categories reflective of intrinsic properties;
- meaningful as categories unto themselves vs acquire meaning only in context and in relationship to those excluded;
- necessarily distributional (variation is inherent and informative) vs fixed (variation is error or ‘noise’ that deviates from the true population value) and
- mutually constitutive (each shapes the properties of the other) vs aggregative (individual characteristics precede and produce, but are not shaped by, population characteristics).
In the case of people and hence epidemiology, both social and biological considerations are at play, with the questions more pointedly becoming: are the categories defining ‘populations’ societally created or biologically innate?—and do individuals belong to these groups by fiat, choice or necessity?
Suggesting epidemiologists’ understanding of ‘population’ and ‘individual’ could benefit from Morris’ ‘both/and’, instead of ‘either/or’, approach to conceptualizing individuals-in-populations-in-society and individuality-in-context are two current examples of problematic usage of these terms. In the United States, notions of ‘population groups’ and ‘special populations’ figure prominently in epidemiological studies and official definitions of ‘health disparities’,25–28 without any explicit explanation of why certain ‘population sub-groups’ are singled out and considered ‘special’.10,29 One hint, however, is that these ‘special populations’—women, children, people of colour, the disabled, the elderly, lesbian and gays, the poor and people in rural areas29—include just about everyone other than white, relatively affluent, urban, able-bodied, heterosexual, middle-aged white men.10,29 Moreover, within the growing discourse on ‘population health’, much of the literature surprisingly offers only scant5,30–33 or no34–36 definition—let alone nuanced discussion—of what ‘population’ means and the assumptions involved; instead, most rely on a head-count or administrative stance (Table 1).
The danger of epidemiology being vague about—or, worse, deliberately decontextualizing and depoliticizing—the criteria for defining ‘populations’ and their ‘individuals’ is it can lead to getting the causal arrows backwards. Consider only the case of racial/ethnic health inequities and the contrast between construing these disparities as an embodied biological expression of racism vs a consequence of ‘race’ as an ‘innate’ characteristic of ‘individuals’.37–40 If epidemiology is to live up to its claim—and Morris’ mandate—that we are a ‘population’ science, then epidemiologists have to be explicit about the societal divisions and/or biological criteria that inform when and how we demarcate ‘populations’ for study and view the individuals within them.
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The third principle informing Morris’ book is that epidemiology, as a science, is fundamentally pragmatic41,42 and contextual in its orientation to causality (pp. 10,61–68,104).1 To Morris, the objective is (p. 68):1
... to learn enough of the probable pattern of causes for a programme of action to be stated that will disrupt the pattern, reduce the frequency of diseases and at not too great a cost in consequent other troubles. The attack may be on a single cause or on a group of causes among the many that have been identified (p. 68).1Influenced by mounting evidence that disease was best conceptualized as a consequence of interactions between people and their ‘environment’ (p. 104),1 Morris accepted (pp. 66–68,71,122)1 the then growing view, replacing the mono-causal ‘germ theory’, that diseases can be due to ‘multiple causes’ that can interact in complex ways (Table 3).9,11,24,43–45 To Morris, these different causes afforded more opportunities for prevention, albeit with the caveat that interventions, including medical treatments, based on any one or several of these causes, could have unintended and potentially harmful consequences (pp. 22,23,71,122).1
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Morris, however, did not view the idea of ‘multiple causation’ as a panacea. Although he considered it to be ‘a liberating and clarifying concept’ (p. 104),1 compared with more narrow views that posited ‘the’ germ as ‘the’ cause of infectious disease without considering aspects of the ‘host’ and ‘environment’ involved in producing an actual case of disease (p. 65),1 Morris also recognized that it had its drawbacks, especially insofar as prevention was concerned. In his view, ‘multiple causality’ (italics in the original) (p. 104):1
is an especially tricky notion because of the ease under its influence of losing the sense of proportion and so regarding everything as ‘important’; it becomes so easily a stimulus to looser thinking. The whole history of preventive medicine shows that interference with one or a few of a complex of causes may be sufficient considerably to modify the occurrence of disease. As well as identifying the pattern of causes it is essential therefore to try to estimate their relative weight (p. 104).1In other words, however complex the causal processes may be, epidemiologists needed especially to identify those ‘causes’ substantially driving population levels and distribution of disease.
For Morris, this challenge translated, pragmatically, to addressing causes in context, located in what he termed the ‘environment’, ‘living conditions’ and ‘ways of life’ (p. 61).1 Both specific and general ‘factors’ merited intervention. The former referred to particular exposures, e.g. various occupational hazards, such as cutting oils, linked to skin cancer (p. 61).1 The latter included societal conditions such as ‘income level’ and ‘poverty’, linked ‘with nutrition, and with child growth, development and health’ (p. 62).1 To Morris, these latter ‘general factors’ were important preventable ‘causes of disease or of diseases, rather than of any specific disease’ (p. 61),1 e.g. the ‘purity (and abundance) of water-supply’ causally mattered for ‘bowel infections of many kinds – and not merely the cholera’ (p. 62).1 If the point was to change overall patterns of health, including its social distribution, it was a false choice to focus on only one or the other; knowledge of both was needed, including how the ‘general factors’ structured exposures to specific hazards caused by societally produced ways of living.
To Morris and his like-minded colleagues,9,11,24,43–45 the challenge was to think big and small at the same time: to see the details of disease mechanisms while not losing sight of the social production of disease distribution overall. It was a stance, however, that became increasingly out of step with the post-World War II rise of biomedical individualism and modern epidemiology,10–12,46–48 whose decontextualized approach to ‘risk factors’ and ‘multiple causation’ found form in the still influential spiderless10 ‘web of causation’ that MacMahon et al.49 proposed in 1960 in their classic textbook Epidemiologic Methods, the first such textbook in the field (Table 3). Recent efforts to theorize anew about multiple causation and the social determinants of health would do well to appreciate the nuances of Morris’ perspective. The choice is not ‘fundamental causes’ vs ‘specific risk factors’, as some now argue.50–52 An historical and population perspective, geared to effective prevention and sustainable reduction of health inequities, instead entails attention to both.4,5,53,54
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Conclusion: the importance of ways of asking for knowledge for healthy ways of living |
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In summary, Morris’ Uses of Epidemiology1 remains useful precisely because it offers a lucid way of thinking that translates into a powerful way of asking questions. The work of science is descriptive and analytic, both generating and testing hypotheses. Each aspect must be rigorous. Epidemiology as much needs well-articulated theories of disease distribution as it does well-defined methods. Such theories can help us better frame and answer the kinds of questions epidemiology is uniquely equipped to answer, as one contribution joining with those of the many social, ecological, biological and physical disciplines and the diversity of methods, both quantitative and qualitative, that are needed to understand, protect and improve societal health and the well-being of life on this planet.
In the 50 years since Uses of Epidemiology was published, much epidemiologic effort has been put into investigating the types of questions Morris posed and improving the methods to do so. Only recently, however, within the past two decades, has a renewed interest in epidemiological theory become apparent, prompted by the revitalization of social epidemiology and its focus on developing frameworks, concepts and models to explain and alter current and changing societal patterning of health, disease and health inequities.10–12,55–61 By building on the principles expressed in Morris’ Uses of Epidemiology1 and its deep appreciation for epidemiology as an historical, population-based and a causally pragmatic and contextual science, we stand a better of chance of producing epidemiological knowledge truly useful for preventing disease, promoting health equity and advancing the public's health. Doing this work, as Morris forcefully points out in his latest contribution—a 2007 study (!) on ‘Defining a minimum income for healthy living’62—is ‘directly in the tradition since World War II and the establishment of WHO for official acceptance of attainable levels of health as a human right and a prime goal of society’ (p. 5).62 What better use of epidemiology is there?
Conflict of interest: None declared.
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