Enigmas of Health and Disease

Enigmas of Health and Disease: How Epidemiology Helps Unravel Scientific Mysteries

ALFREDO MORABIA
Copyright Date: 2014
Pages: 296
https://www.jstor.org/stable/10.7312/mora16884
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  • Book Info
    Enigmas of Health and Disease
    Book Description:

    This book is the principal account of epidemiology's role in the development of effective measures to identify, prevent, and treat diseases. Throughout history, epidemiologists have challenged conventional knowledge, elucidating mysteries of causality and paving the way for remedies. From the outbreak of the bubonic plague, cholera, and cancer to the search for an effective treatment of AIDS and the origins of Alzheimer's disease, epidemiological thought has been crucial in shaping our understanding of population health issues.

    Alfredo Morabia's lucid retelling sheds new light on the historical triumphs of epidemiological research and allows for contemporary readers, patients, and nontechnical audiences to make sense of the immense amount of health information disseminated by the media. By drawing from both historical and contemporary sources, Morabia provides the reader with the tools to differentiate health beliefs from health knowledge. The book covers important topics, including the H1N1 swine flu epidemic, breast cancer, the effects of aspirin, and the link between cigarettes and lung cancer.

    eISBN: 978-0-231-53767-4
    Subjects: Health Sciences, Public Health

Table of Contents

  1. Front Matter
    (pp. I-VI)
  2. Table of Contents
    (pp. VII-VIII)
  3. PREFACE TO THE ENGLISH EDITION
    (pp. IX-XII)
  4. PROLOGUE: A Science Named Epidemiology
    (pp. XIII-XXIV)

    Whether you are consumer of health services, practicing clinician, health professional in training, health journalist, epidemiologist, or epidemiology student, this book explains how and why epidemiology has evolved in 350 years from being a science of epidemics to being indispensable for the discovery of effective ways of preventing health harms, prolonging life, and treating diseases.

    To solve enigmas of health and diseases, epidemiology has become a science that compares groups of people. Group comparisons are a tool to study the health effects of many aspects of human life, including lifestyle factors such as tobacco smoking, lack of exercise, excess caloric...

  5. 1 COMPARING GROUPS AND THE FIFTH DIMENSION
    (pp. 1-12)

    Consider this health claim fromGlamourmagazine: “Great health news for every woman. Quick! Take this poll: If there were a pill that could … ‘Slash your chances of getting breast cancer / Help get rid of headaches / Cut symptoms of depression almost in half / Lower your risk of type 2 diabetes by 50 percent / Make it easier to get pregnant when you want to / Boost sexual arousal by 100 percent / Improve your body image / Make you fall asleep 40 percent faster / And help you lose up to a pound a week’ …...

  6. 2 PEOPLE, BUGS, AND EPIDEMICS
    (pp. 13-30)

    When I ask a class full of students, “How long have human societies been plagued by recurrent infectious diseases that have periodically decimated populations?” the answer I usually get is “always.” But what makes them believe that? And how can we know if human societies have always been plagued by epidemics or whether they experienced epidemics only for a limited and recent period of their existence?

    I first need to clarify what I mean by epidemics of infectious diseases. Consider the flu or what we commonly call the flu—that is, a combination of rhinitis, fever, and weakness, which can...

  7. 3 PLAGUE’S SHARK TEETH AND SEAMEN’S ENIGMATIC EXHAUSTION
    (pp. 31-40)

    During the first half of the seventeenth century, in the midst of a terrible period of war, famine, plague, and revolutions, Europe became the cradle of fresh scientific and philosophical ideas from people such as the philosophers Francis Bacon and René Descartes as well as the iatrochemist Jan Baptist van Helmont. These enlightened spirits were ready to dump ancient holistic complexity in history’s wastebasket and start from scratch, using drastically simplified models. In their attempts to study the world objectively, they were overwhelmed by a mode of thinking that integrated everything, from the smallest to the largest, from invisible particles...

  8. 4 THE MYSTERY OF THE BLUE DEATH
    (pp. 41-62)

    Imagine Adolphe Quetelet, a Belgian scholar of the nineteenth century, animated by a passion for population data, which he avidly collects. Quetelet gathers data from any source that he can. He obtains lists of heights and thorax circumferences of conscripts from military uniform contractors in Belgium, Scotland, Italy, and the United States. From registrar offices, he picks up statistics on marriage. And in some populations he even lays his hands on annual reports of crime and theft. He analyzes these data and is struck by the order hidden within these masses of apparently chaotic numbers.

    For example, Quetelet plots each...

  9. 5 THE NUMERICAL METHOD
    (pp. 63-74)

    In the preceding chapters, we saw the powerful impact of group comparisons in separating knowledge from beliefs regarding the cause and prevention of cholera. John Snow actively showed that cholera killed more clients of the water company that pumped polluted water than clients of the company that pumped clean water. Max von Pettenkofer failed to rely on a comparative experiment, but during the epidemic of 1892 the citizens of Hamburg, whose water came unfiltered from the river, were badly affected by cholera, whereas the citizens of Altona, who drank filtered water, were totally spared.

    Thus, comparing groups of people to...

  10. 6 EUGENICS, OYSTERS, SOUR SKIN, AND BREAST CANCER
    (pp. 75-96)

    We are now reaching the end of the nineteenth century. The discovery of the microscopic agents of cholera, tuberculosis, puerperal fever, and pneumonia put an end to the debate about whether these feverish diseases were caused by miasms or germs. Medicine and public health were largely converted to the so-called germ theory of diseases advocated by the new scientific stars, Louis Pasteur and Robert Koch.

    The availability of bacteriologic labs progressively tapered the need for group comparisons. Had Snow had access to bacteriological analyses of the water reaching the faucets of the two water companies’ clients, he would not have...

  11. 7 TOBACCO AND HEALTH: The Great Controversy
    (pp. 97-124)

    Twentieth-century populations demonstrated a formidable attraction to tobacco and its smoke—an aggressively marketed, addictive product.¹ In just a few decades, a substantial fraction of the working population began to smoke tobacco in the form of a cigarette.

    How could cigarette smoking, a rare habit in 1900, become ubiquitous by 1950? Psychologists emphasize the strong addictive properties of nicotine. Economists point to cigarettes’ affordability made possible by industrial production. Toxicologists note that cigarettes are an ideal way to titrate the blood concentration of nicotine. Sociologists mention the effects on cigarette sales of an aggressive marketing policy oriented toward all sectors...

  12. 8 DAILY LIFE MYSTERIES AND EPIDEMIOLOGY
    (pp. 125-134)

    Since 1965, the contribution of epidemiology has soared. The proliferation of group comparisons in medicine and public health precludes tracking the historical evolution of epidemiology from a few milestone studies as in earlier days. However, most of the group comparisons appear to have been used to answer five types of scientific questions: Is this treatment dangerous? Is this treatment effective? What is the optimal medical decision? Is there a health risk or a health benefit? Is this screening effective? These questions are very much part of our daily life. They lack the historical luster of the enigmas about the plague,...

  13. 9 IS THIS TREATMENT DANGEROUS FOR HEALTH?
    (pp. 135-140)

    “British Thalidomide Charity Rebuffs Gruenenthal Group’s Apology” ran the headline.

    A British charity has rebuffed the first apology for half a century from the German company which invented birth defect pregnancy drug Thalidomide. The Gruenenthal Group said in a statement on its website that it “regrets” the consequences of the drug. Thalidomide was used to combat morning sickness but led to the birth of children without limbs during the 1950s and 1960s. Friday’s apology was rejected as insufficient by the charity Thalidomide Agency UK, which represents people who were affected by the drug in Britain. Freddie Astbury, the charity’s head...

  14. 10 DOES THE TREATMENT WORK?
    (pp. 141-150)

    It has taken about half a century to work out the practice of RCTs. Two main potential mistakes in their conduct were picked up from the early experiences.

    In 1898 in Denmark, Johannes Fibiger, a twenty-eight-year-old physician, tested the efficacy of a serum containing antidiphtheria antibodies in treating patients suffering from diphtheria, a life-threatening form of sore throat. According to the day of hospital admission, patients suspected of having diphtheria were allocated to either the serum or no serum group. Only 8 patients out of 239 (3.3 percent) in the serum-treated group versus 30 out of 245 (12.2 percent) in...

  15. 11 WHAT IS THE OPTIMAL MEDICAL DECISION?
    (pp. 151-156)

    Consider a hypothetical clinician in the 1960s who suspects a young patient of having a “pulmonary embolism,” an acute disease of the lung. Excruciating pain occurs when a bullet made of a fibrous protein and blood cells, called an “embolus,” clogs a vessel that normally provides blood to a region of the lungs. Lacking oxygen, the lung tissue does not function properly, and the patient cannot breathe anymore. Depending on where in the lung an embolism occurs, the patient may feel pain, shortness of breath, or die from sudden suffocation due to lack of oxygen. Pulmonary embolism is a difficult...

  16. 12 HEALTH RISK OR HEALTH BENEFIT?
    (pp. 157-166)

    An 2011New York Timesarticle titled “Researchers Link Deaths to Social Ills” stated the following:

    Poverty is often cited as contributing to poor health. Now, in an unusual approach, researchers have calculated how many people poverty kills and presented their findings, along with an argument that social factors can cause death the same way that behavior like smoking cigarettes does….

    The researchers used various criteria to define an adverse social condition. Low education, for example, was defined as not having graduated from high school. Poverty was defined as a household income of less than $10,000. A population in which...

  17. 13 IS THIS SCREENING USEFUL?
    (pp. 167-170)

    An RCT was launched in 1963 among women covered by the Health Insurance Plan of Greater New York (HIP).¹ HIP was—and still is—a prepaid insurance plan covering the care provided by doctors belonging to the plan. In 1963, there were 62,200 women, ages forty to sixty-three, who had belonged to HIP for at least one year. After randomization into two groups,² the 31,000 women of the experimental group were invited to get a regular mammographic screening plus breast examination, but nothing was changed in the usual care of the other 31,000 women who composed the comparison group. When...

  18. 14 GROUP COMPARISONS ALSO FAIL
    (pp. 171-182)

    The previous chapters have provided examples of dramatic situations in which epidemiology contributed to replacing beliefs with knowledge. Digressing throughout the book about the errors that can plague group comparisons would have obscured the message about the positive function of epidemiology. I have sketched, however, an overly confident profile of the discipline and of what it can deliver.

    If I confess now that group comparisons can fail, would you be surprised? I did mention, for example, that cohort studies had long been interpreted as evidence of vitamin A’s protective effect on some cancers. All sciences can fail, but this is...

  19. 15 EPIDEMIOLOGIC LITERACY AND “EARTHLY SELF-REALIZATION”
    (pp. 183-192)

    The year 2013 marked the two hundredth anniversary of the birth of John Snow, the London anesthesiologist who had the brilliant idea to compare the clients of two water companies in order to prove his hunch that the polluted water of the Thames, as was popularly believed, was responsible for the humongous cholera outbreaks of 1854 (see chapter 4).

    Many reasons motivate epidemiologists to celebrate this achievement. Snow did not form his beliefs solely by chance: all sorts of evidence had already convinced him that cholera was a contagious disease. He was therefore prepared to seize the exceptional opportunity to...

  20. 16 BEYOND EPIDEMIOLOGY
    (pp. 193-204)

    I plead guilty for two oversimplifications I made in the previous chapters. The first is that, for the sake of clarity, I equated epidemiology with the practice of group comparisons. Epidemiology is of course much more than that. History attests that epidemiologists are scientists motivated primarily by the solution of major health problems in public health and in clinical medicine. We have seen in this book that since the appearance in 1662 of the first solid root of what would become the science of epidemiology, epidemiologists were involved in discovering effective means to prevent or treat the plague, smallpox, scurvy,...

  21. EPILOGUE: The End of Epidemiology?
    (pp. 205-212)

    In 350 years, epidemiology migrated from the periphery of medicine and public health’s focus to their center. Does it mean that it has reached its final destination? After all, for most of recorded history, doctors have aspired to understand and treat individual patients on the basis of individualized knowledge. However, aggregating information from individual patients, as epidemiologists do, inevitably means the loss of some distinguishing information because no two persons get sick in exactly the same way for exactly the same reasons.

    We can therefore legitimately wonder whether epidemiology will no longer be needed the day doctors won’t have to...

  22. APPENDIX 1: INTERACTION OF CAUSES
    (pp. 213-214)
  23. APPENDIX 2: ODDS RATIO AND RISK RATIO
    (pp. 215-216)
  24. APPENDIX 3: WHY COHORT AND CASE–CONTROL STUDIES CONCUR
    (pp. 217-220)
  25. APPENDIX 4: WHERE DO THE CASES OF LUNG CANCER COME FROM?
    (pp. 221-222)
  26. NOTES
    (pp. 223-242)
  27. BIBLIOGRAPHY
    (pp. 243-258)
  28. INDEX
    (pp. 259-272)