The COVID-19 pandemic and the ongoing multi-country monkeypox outbreak have shown that competent field epidemiologists are needed worldwide, now more than ever. As we commemorate World Field Epidemiology Day, we are presented with another chance to reflect on the emergence and development of field epidemiology training programmes (FETPs) across the world. Many more people now recognise this profession and the value of epidemiologists in keeping the world safe. Field epidemiologists have a responsibility to seize opportunities to develop the profession even further, so that we can play a greater role in a strengthened health emergency architecture for the future.
I recognise my own extremely privileged position. Over the course of my career, I have gone from being a field epidemiology trainee to supervising a training site and finally leading a field epidemiology training programme at the national level. In 2003 I was a trainee field epidemiologist as part of the European Programme for Intervention Epidemiology Training (EPIET), in the South West of England. A few years later, in 2008, I became a site supervisor at the South East of England Regional Epidemiology Unit, supporting the training of many field epidemiologists. After a short stint in South Africa, where I also contributed to the training and mentorship of fellows, I moved to Nigeria, where I led the integration of the Nigeria FETP into the Nigeria Centre for Disease Control (NCDC). I also led the further development of the programme, as part of my role as NCDC’s Director General. This breadth of experience has been a great enabler in my new role at the World Health Organization (WHO). Since November 2022, I have been honoured to lead a new WHO Division for Surveillance and Health Emergency Intelligence, within which we have established a new unit to contribute to the development of field epidemiology. This is the first time WHO is contributing significant resources to FETPs in a strategic and intentional way, which puts field epidemiology training at the centre of workforce development for a strengthened global health emergency preparedness and response architecture.
Since becoming a trainee field epidemiologist, I have followed the evolution of FETP globally. What started as the Epidemic Intelligence Service (EIS) developed by the US Centers for Disease Control and Prevention (US CDC) for the United States, has now evolved to more than 80 countries across the world. Through FETP, a global community of field epidemiologists has been created with a camaraderie that can be found only in a handful of global communities. I feel incredibly privileged to be part of this community and am firmly committed to its ideals and aspirations. While FETPs have grown and been successful in many countries and across pandemics, local outbreaks and other health emergencies, there are increasing opportunities for us to step up. Here I outline three key opportunities to strengthen FETPs for our world today and in preparation for the future.
In the United States, the EIS was developed as an integral part of US CDC. EIS officers spend most of their training at CDC headquarters in Atlanta, Georgia, and are assigned to operational branches within the CDC or at state and local health departments around the country. Similarly, I spent my EPIET (field epidemiology) training year at a regional office of what was then the UK Health Protection Agency, where I applied my skills in field epidemiology across a wide range of public health challenges. This was done within the agency responsible for the delivery of these functions. When I started at NCDC, I found that the Nigeria FETP had been built separately from the national public health agency. Fellows spent most of their time in the classroom, with lectures delivered by university lecturers, with very limited time spent at NCDC or other health agencies. In Uganda, two separate programmes evolved, one of which confers a Master of Public Health degree. There are many other examples of this. This situation seemed to imply that we could improve surveillance and outbreak response capacity in countries only by training, without an institution to deliver this function. This is a challenge that we must work to correct as we continuously strengthen and expand FETPs to more countries. Many countries have learned that regardless of the attention given to epidemiology training, without an institutional framework, we are less likely to achieve the desired outcomes.
There is also the notion of the “field”. As FETP trainees and graduates, most of us have been socialised to do the frontline work ourselves. We travel to the place where an outbreak is occurring (the “field”), identify patients and contacts, collect the data, analyse them, and contribute to the response. We ask ourselves the obvious question, “How often have you been to the field?” Although the basic competencies of outbreak investigation and response and surveillance as taught in FETPs remain crucial for our world today, and our understanding of the context is extremely important, we must also prioritise the institutional framework for response at the heart of field epidemiology training and activities. Much more work can be done by field epidemiologists in developing and improving national surveillance systems outside of outbreak mode, reviewing or updating guidelines for response, and understanding better the drivers of disease emergence and transmission. The internet has enabled increased connectivity such that being in the field no longer needs to have such an elevated priority that we have included it in the term that defines our profession. Perhaps the terms used in the US, “Epidemic Intelligence Service”, or in Europe, “Intervention Epidemiology”, are more appropriate to describe our work than “Field Epidemiology”. The world has changed, and we now need more national capacity that can support colleagues at lower levels to respond. The romanticised notion of the field may have distracted us from the important work that we need to do in developing critical systems.
The world has changed greatly since the establishment of EIS in the 1950s. As we can glean from the spread of infectious diseases globally, the likelihood of pandemics has increased over the past century as a result of increased global travel and integration, urbanization, climate change, wars, and other disruptions. The curricula in FETPs also need to evolve, and I know this is already happening. While the basic competencies remain essential, good field epidemiologists in the 21st century need an expanded curriculum, including genomics, use of geographic information systems, data science, behavioural sciences, communications, and other areas where we have traditionally had gaps, gaps that are even more profound in low- and middle-income countries. Advanced FETPs, especially in countries with mature programmes, should not be spending scarce resources training fellows in the basics of epidemiology. These competences should become entry-level qualifications for the programme, while advanced FETPs should focus on building elite teams with the cutting-edge skills that will fulfil the human resource needs of the national public health institutes of the future.
Lessons from the Ebola outbreak led to changes in the global ecosystem for epidemic preparedness, response, and resilience. These include the establishment of WHO’s Health Emergencies programmes, the Africa CDC, and several national public health agencies across the world. Likewise, the COVID-19 pandemic has led to the establishment and expansion of pandemic and epidemic preparedness hubs and institutes, in public, philanthropic, and academic spheres. These institutions will need people, not with baseline generic skills, but with the latest advanced competencies that we need to solve some of the toughest challenges of our time. I look forward to seeing the next generation of FETPs providing these opportunities.
We must start now to focus more on building strong systems to host FETPs around the world, rather than a singular focus on merely building FETPs. In my experience, FETPs are best hosted within national public health agencies where the institutional framework for national preparedness and response is clearly defined. As fellows, graduates, and leaders of FETPs, we should spearhead these efforts. We should not be shy to take on the responsibility of leadership at the centre and move away from the nostalgia of the field. Our source of pride should come not from deploying international staff for every outbreak, but from having sufficient national trained staff to drive the local and national response. Finally, we must embrace new opportunities to understand the drivers of outbreaks and pandemics and incorporate these into how we teach and learn epidemiology. We need to create communities of practice that build expertise in the wide range of areas needed for preparedness, response, and resiliency. These communities must be globally connected to provide this capacity.
Finally, the learning, skills, and professional relationships established through our shared experience as field epidemiologists have been great enablers in my career and those of many other graduates. We need to be more radical in pushing FETPs to meet current needs and new realities, and to be stronger for the future – building on our success and moving from strength to strength to improve global health.
About the author: Dr. Chikwe Ihekweazu is Assistant Director General for the Division of Health Emergency Intelligence and Surveillance Systems in WHO’s Emergencies Programme. He is also co-chair of the FETP Enterprise Strategic Leadership Group (SLG), convened by TEPHINET and other key partners.
Competing interests: None
Handling Editors: Seye Abimbola and Neha Faruqui