IJE Advance Access originally published online on August 24, 2008
International Journal of Epidemiology 2008 37(5):936-937; doi:10.1093/ije/dyn105
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Commentary: Kristian Andvord—an under recognized star in the epidemiological firmament
International Union against Tuberculosis and Lung Disease, 68 boulevard Saint-Michel, Paris 75006, France.
E-mail: denarson{at}iuatld.org
Accepted 29 April 2008
The article ‘Continued Studies of Tuberculosis considered as a generation illness’ by Andvord1 published in this Journal in translation by Otto Jervell, makes available to a wide modern audience one of the milestones of research methods in medicine. This article is the text of a presentation in 1932 describing the concept of ‘birth cohort’, which is now a fundamental concept in medical research.
Andvord, a clinical practitioner in Kristiansand in Southern Norway, reported his observations on tuberculosis2 (translated into English with commentary3), a condition of immense consequence in the Norway of his time. By the beginning of the 20th century, one in 20 young adults died of tuberculosis each year (every village in the country would have suffered the death of a young person each year), rising in the last decades of the 19th century and then beginning a steady decline until the present. This extent in the burden of disease has been documented only rarely and usually under severe social distress and, more recently, as a consequence of the epidemic of HIV/AIDS.
The presentation of epidemiological analysis in terms of the ‘cohort’ was first introduced by the observations of Andvord. Last4 defines the ‘cohort’ as ‘(from Latin cohors, warriers, the tenth part of a legion). The component of the population born during a particular period and identified by period of birth so that its characteristics (e.g. causes of death and numbers still living) can be ascertained as it enters successive time and age periods’. This is exactly the concept that Andvord pioneered (subsequently broadened to include other types of ‘cohorts’). The idea was popularized by others (such as Wade Hampton Frost5) who are more widely associated with the concept.
It is interesting to note the apocryphal story that it was, indeed, a nurse working with Andvord who actually made the crucial observation upon which he expanded in his later work, although it is typical of the gender and class habits of the age that this is not officially acknowledged.
Andvord's concept, further developed by Frost and others, is essential to any understanding of the epidemiology and transmission of tuberculosis. It is a sad fact that this core concept is still not grasped by many modern investigators who continue to propagate the false notion that advancing age is a risk factor for tuberculosis (purportedly due to diminishing immunological competence). This erroneous thinking can only be attributed to a lack of discipline in understanding the critical heritage upon which the science of medicine is based. It was Andvord himself who pointed out that the ‘cohort effect’ made simple, cross sectional analysis untrustworthy when the dynamics of the disease were changing.
Andvord's work established the bridge between the epidemiology of communicable and non-communicable diseases. This is because of those peculiar characteristics of tuberculosis that make it appear somehow as both a ‘communicable’ and a ‘chronic’ disease and mark it as a model upon which not only epidemiological understanding can be based but also a framework for health service delivery.6
We, in science and medicine, owe a debt of gratitude to Andvord for his creative insights. Progress in research is measured not simply in terms of technology but particularly in the ability to think critically and creatively.
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1 Lecture at the Norwegian Society for Medicine, published Norwegian. J Med Sci (1932) 93.
2 Andvord KF. Der Verlauf der Tuberculose durch Generationen. Beitr Klin Tuberk (1930) 75:552–63.[CrossRef]
3 Blomberg B, Rieder HL, Enarson DA. Kristian Andvord's impact on the understanding of tuberculosis epidemiology. Int J Tuberc Lung Dis (2002) 6:557–59.[Web of Science][Medline]
4 Last JM. A Dictionary of Epidemiology. (1995) 3rd. Oxford: Oxford Univerity Press. 31.
5 Frost WH. The age selection of mortality from tuberculosis in successive decades. Am J Hyg (1939) 30:91–96.[Web of Science]
6 Harries AD, Jahn A, Zachariah R, Enarson D. Adapting the DOTS framework for tuberculosis control to the management of non-communicable diseases in sub Saharan Africa. PLoS Med (2008) (in press).
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