Richard Smith: Epidemiology—big problems and an identity crisis

richard_smith_2014The Germans probably have a more precise word for it, but it’s close to schadenfreude as an outsider to watch a professional group agonise over who they are, whether they matter, whether their methods are adequate, and whether they are missing something important. I had this experience in Bristol last week as a gaggle of epidemiologists simultaneously celebrated the achievement of Shah Ebrahim and George Davey Smith in editing the International Journal of Epidemiology and are now retiring.

BMJ readers will, unlike many members of the public, know the word epidemiology and that it’s something to do with studying disease in populations.  Indeed, in some fashionable quarters it’s being called “population health sciences.” As such, you’d think that epidemiologists have nothing to worry about because gigantic problems are arriving now with bigger ones on the horizon.

A major pandemic is eight years away

Tom Koch, no relation of “the Koch” (“Koch in Germany is like Smith in Britain”) a free booting epidemiologist from the University of British Columbia, confidently predicted the arrival within eight years of a major pandemic of a new and untreatable infection that would affect 60% of the population and have a mortality of 30-35% within eight years. “I used to say ten years but now I say eight,” he said when challenged.

Koch pointed out that “his friends,” the microbes he studies, are “home loving creatures,” but the factors that are driving them to move out into the world and evolve into lethal pathogens are currently common in the world: these are war, deforestation, income inequality, poverty, urbanisation, and global trade. Koch has tracked AIDS, SARS, MERS, Ebola, and Zika, any of which could have been the great pandemic. The new infections, he observed, are coming along faster, which is why he has reduced his prediction of the arrival of the great pandemic from ten to eight years.

The public, who may not know the word epidemiology, do know about these new infections, and so, Koch and others pointed out, scientists whom BMJ readers would call epidemiologists, are now starring in Hollywood blockbusters fighting terrible pandemics. Davey Smith, whom I always describe as the James Dean of epidemiology, has the star quality (and the mathematical ability) necessary to play the leading role, and Ebrahim could be Robin to his Batman.

Deaths in England have increased by 9%

While epidemiologists wait for the pandemic that will thrust them to stardom, big problems have already arrived. Danny Dorling, a geographer from the University of Oxford, pointed out that almost unnoticed deaths in England increased by around 9% last year and in Scotland by even more. Life expectancy has been stable in Scotland for three years, something that hasn’t happened in 150 years and may well, Dorling thought, presage a drop in life expectancy. The increase in England is the seventh biggest in England since 1840, and the other increases were the result of the flu pandemic, war, cholera outbreaks, and extreme weather. What might be causing the current increase?

The increase in deaths is among the very elderly, with the biggest increase among those over 90. It isn’t, insisted Dorling, the result of there simply being more elderly people. He thought that it might be something to do with cuts in social care and the fraying of the welfare state. He pointed out to his professional, middle class audience that these increases were among people like them—because you have to be middle class to live into your eighties and nineties. People in the audience said that the same increase has been seen in Italy and France. Epidemiologists in Italy thought that the increase in Italy was probably explained by the absence of a heatwave one summer leaving more people than usual alive to be killed by the extreme heatwave of the subsequent summer. Another person in the audience speculated that it might be assisted suicide, most of it illegal.

But is it actually a problem, Dorling asked. Perhaps it doesn’t matter that very elderly people are dying more. I thought of the decision whether to give my 86 year old demented mother a flu jab? Might it be kindest not to? Death from flu is not the worst death.

Are epidemiologists concerned with the trivial and missing the important?

What most people would agree is a major problem is an increase in maternal mortality in Texas. This, said Dorling, has happened among poor, mostly black, women, and authorities in Texas say they are “baffled” by why it’s happening. It’s almost certainly happening, argued Dorling, because of extensive cuts in clinics for the poor in the state. We should start, he suggested, from the assumption that that is the cause unless somebody can produce a compelling case for another cause. The cuts should be assumed guilty until proved innocent.

But, suggested Dorling, epidemiologists are also failing to notice good news. Child mortality has fallen so fast in China that within a year or two it will be the same as the US (probably, I thought but he didn’t say, with China continuing down and the US perhaps going up).

Dorling was challenging the epidemiologists : why was it him, a geographer, who was raising these issues? What are epidemiologists doing? The answer for at least some in the room was that epidemiologists had lost their way in ever cleverer mathematics, complex software programmes they barely understand, arcane debates over methods, and increasingly sophisticated studies of questions that hardly matter.

Is a revolution needed? A rebellion is underway among students of economics who feel that their teachers are complacently teaching complex mathematical techniques that completely failed to predict or even explain the financial collapse that has had such dire global consequences. There is no such rebellion among the students of epidemiology, and some thought that there was no need for such a revolution. Other’s thought that even if there was the academic straitjacket of increasing fees for students and pursuit of grants by their teachers would stop any rebellion. Epidemiologists seem content to continue their identity crisis in relative comfort.

Richard Smith was the editor of The BMJ until 2004. 

Competing interest. RS spoke at the meeting, will have his expenses paid (he hopes), and has served as a very part time mentor to Davey Smith and Ebrahim, the retiring editors.