Brief Report
Should the History of Epidemiology be Taught in Epidemiology Training Programs? Zoey Laskarisa and Alfredo Morabiaa,b Background: Currently, there is no evidence concerning the presence of historical content in the epidemiology curricula of the United States and abroad. Similarly, it is not known how epidemiologists view this topic in the context of master’s or doctoral level course work. Methods: We attempted to fill these knowledge gaps with data from 2 online surveys—Survey I administered to persons in charge of all epidemiology training programs in North America and Survey II to epidemiologists practicing around the world. Results: A substantial minority (39%) of graduate programs in epidemiology in the United States teach a course on the history of the field. In both surveys, the most common reasons selected for teaching such a course were “To build a sense of identity as an epidemiologist” and “As a tool for achieving a deeper understanding into specific methods and concepts.” Conclusion: The majority of respondents, from 63 countries, agreed that the history of epidemiology should be included in curricula for graduate students in epidemiology. (Epidemiology 2015;26: 133–135)
C
urrently, there is no evidence concerning either the presence of historical content in the epidemiology curricula of the United States and abroad. Similarly, it is not known how epidemiologists view this topic in the context of master’s or doctoral level course work. We attempted to fill these knowledge gaps with data from 2 online surveys—Survey I administered to person in charge of all epidemiology trainings programs in North America, and Survey II to epidemiologists practicing around the world.
Submitted 14 May 2014; accepted 9 August 2014; posted 11 November 2014. From the aBarry Commoner Center for Health and the Environment, Queens College, City University of New York, NY, and bDepartment of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY. Supported by a grant from the National Library of Medicine, 1G13LM010884. Supplemental digital content is available through direct URL citations in the HTML and PDF versions of this article (www.epidem.com). This content is not peer-reviewed or copy-edited; it is the sole responsibility of the authors. Correspondence: Alfredo Morabia, Barry Commoner Center for Health and the Environment, Queens College, CUNY, 65-30 Kissena Boulevard, Flushing, NY 11367. E-mail: [email protected]. Copyright © 2014 by Lippincott Williams & Wilkins ISSN: 1044-3983/15/2601-0133 DOI: 10.1097/EDE.0000000000000211
Epidemiology • Volume 26, Number 1, January 2015
METHODS Interviews with 4 senior epidemiologists and 1 historian familiar with epidemiology concerning their views on general history and the history of epidemiology informed the development of the survey questionnaire. We tested Survey I on an expanded group of epidemiologists and substantially revised thereafter. It was then sent by email to all persons holding a chair of epidemiology in a training program in North America (n = 80)—first between April and June 2013 and, to reach unresponsive subjects, again in February and March 2014. The survey contained questions on the importance, intended audience, and format for teaching the history of epidemiology in a university setting (online survey is available here: https:// www.surveymonkey.com/s/7CJ683S). The subsequent, shortened, Survey II was designed for the international membership of the International Epidemiological Association (IEA) and the Society for Epidemiologic Research (SER), comprising approximately 3000 practicing epidemiologists, educators, and students. We tested the survey anonymously among students enrolled in a class on the history of epidemiology at the Columbia University Mailman School of Public Health. The questionnaire was then made available through temporary links published in the IEA and SER newsletters and on their websites (https://www.surveymonkey.com/s/XKK9CTV) between March and May 2013. The Queens College Institutional Review Board approved both surveys.
RESULTS After multiple attempts to obtain a 100% participation rate (12 reminders, plus personal emails and phone calls), Survey I was completed by 72 out of 80 subjects (92%). The targeted department chairs either responded directly (78% of respondents) or delegated the survey to epidemiology professors in charge of the training (22%). Survey II had 303 participants representing 63 countries. Descriptive background information of the respondents is provided in eTables 1 and 2 (http://links.lww.com/EDE/A853). We learned that a substantial minority (39%) of graduate programs in the United States teach a course on the history of epidemiology, for which they reported using a variety of supporting material, including the series “Voices” from Epidemiology (eAppendix 1; http://links.lww.com/EDE/A853). www.epidem.com | 133
Epidemiology • Volume 26, Number 1, January 2015
Laskaris and Morabia
FIGURE. Percent of responses expressing favorable reception by students of a mandatory course on the history of epidemiology. Survey II: nonrandom, international sample of members of the Society for Epidemiologic Research or the International Epidemiological Association (n = 303).
In Survey I, there was an overwhelming consensus that the history of epidemiology should be taught to master’s level (76%) and doctoral students (90%). A slightly revised question in Survey II indicated that 61% were in favor of a mandatory class for master’s level students and 63% were in favor of a mandatory class for doctoral students. Results varied moderately across continents (eFigure 1; http://links.lww.com/EDE/ A853). This question may apply differently to programs operating under the United Kingdom’s PhD model, such as Australia, in which mandatory courses are not part of a doctoral program.
When asked directly how master’s or doctoral students would receive a mandatory course, there was no clear consensus from either sample (eTable 3; http://links.lww.com/EDE/ A853, Figure). Notably, epidemiologists in charge of training programs in North America who work in universities that offer a course on epidemiology history did not agree on how the students view the course, as there was an equal distribution among those that thought it would be favored if mandatory, favored if nonmandatory, and not favored at all. Meanwhile, those universities that do not teach history were twice as likely to think that a nonmandatory course would be favored among students. In Survey II, students themselves, responding to this same question, were also split on this issue. Approximately, 20% of the respondents from Survey I and 12% from Survey II shared the opinion that a mandatory course would be viewed unfavorably. Reasons given for such opposition include the following: the ideas are already or should be incorporated into other courses; graduate programs have little room for new courses; and a course that teaches only history is hard to conceive. When queried on the most effective teaching format for a graduate course on the history of epidemiology (Survey I only), there was a clear preference for a seminar setting (eTable 4; http://links.lww.com/EDE/A853). However, based on free text responses, approximately 10% of Survey I and 24% of Survey II respondents considered the best option to be an integrative approach that incorporates historical lessons and analysis into existent courses. We found strong consistency between the North American and international views on the reasons for teaching history (Table). The 2 most prominent reasons for teaching were: “To build a sense of identity as an epidemiologist” and “As a tool for achieving a deeper understanding into specific methods and concepts.” The second tier, consistent among 50% of the responses, includes “To translate past discoveries into
TABLE. Responses to the Question: “Why Should We Teach the History of Epidemiology?” (to Doctoral Students) Among Respondents to United States and International Surveys
Response As a necessary tool for becoming a good researcher To build a sense of identity as an epidemiologist To include a historical perspective in a dissertation As a tool for achieving a deeper understanding into specific methods and concepts To avoid repeating mistakes For general cultural knowledge To translate past discoveries into common knowledge and/or policy To encourage students to engage in historical research Other
Multiple Responses (Survey Ia) (n = 65)
Most Important (Survey Ia) (n = 65)
IEA and SER (Survey IIb) (n = 188)
% 37 88 32 68 42 48 51 11 12
% 11 40 0 34 2 3 6 0 5
% 53 69 30 80 42 45 50 15 10
a
Survey I: epidemiologists in charge of training programs in North America. Survey II: a nonrandom, international sample of members of the SER or the IEA. IEA, International Epidemiological Association; SER, Society for Epidemiologic Research.
b
134 | www.epidem.com
© 2014 Lippincott Williams & Wilkins
Epidemiology • Volume 26, Number 1, January 2015
common knowledge and/or policy,” “For general cultural knowledge,” and, in Survey II only, “As a necessary tool for becoming a good researcher.” After stratifying the results, it was evident that, within institutions teaching history of epidemiology, the chairs themselves were more likely to complete the survey and to consider building a sense of identity to be a greater concern, compared with respondents from institutions that do not currently teach epidemiology history. In the extensive free text responses, epidemiologists in charge of training programs in North America identified further examples of how historical context can add depth to a public health education. One response reads, “To understand the interplay between epidemiological findings and sociopolitical events and to understand the political and economic ramifications of epidemiological findings (e.g. tobacco-cancer link and reaction of tobacco industry, public).” And, in reference to the discoveries of John Snow, “to understand that through epidemiology we can begin to understand associations even when we do not fully understand the biology behind the associations.” Lastly, we asked Survey I respondents, “If you were writing a textbook on the history of epidemiology, where would you choose to end the timeline?” An overwhelming majority (83.3%) replied “Everything up until yesterday.” This question was not asked in Survey II.
DISCUSSION A limitation of both surveys was our decision not to define or seek an interpretation of “history of epidemiology,” even though definitions may vary. For example, Susser and Susser1 focus on the evolution of the framing of hypotheses, Krieger2 focuses on the evolution of theories of disease distribution and health inequities, and Morabia3 approaches it from the perspective of the evolution of the methods and concepts. Courses based on any of these 3 approaches (or others) would be different. Similarly, we were not able to capture the influence of geographical region on a respondent’s definition for the history of epidemiology. A second limitation lies in the distinct sampling approaches used in both surveys.
© 2014 Lippincott Williams & Wilkins
History in Epidemiology Training
Having quantified the interest and importance in the topic, new educators, accrediting agencies, and epidemiologic associations around the world should feel invited to define realistic and practical ways to familiarize epidemiologists in training with the history of their discipline. The evident challenges will be to fit a course on the history of epidemiology into the competitive curricula and to deal with the shortage of epidemiologists having the skills of historians and of historians having the skills of epidemiologists; the discipline needs to proactively ensure that it trains scientists by exposing them to both skill sets. In conclusion, an evident inclination from 63 different countries for the institution of the history of epidemiology into graduate curricula emerged with clarity. The importance of learning history as a means to building an identity as an epidemiologist withstood distinct geographical, professional, and personal differences. Epidemiologists often find themselves explaining to the general public what it is exactly that they do; an historical perspective on the evolution of epidemiology would inform that explanation. The history of epidemiology includes a rich cadre of doctors, nurses, city health workers, and public health professionals who were faced with solving tremendous health enigmas.4 In our current world, characterized by a complex web of global environmental and public health concerns, a strong community of international epidemiologists is needed to tackle these problems. The history of epidemiology can facilitate a common identity by serving as the unifying force.
ACKNOWLEDGMENTS Exploratory interviews and questionnaire development with David Celentano, Dan Fox, Sandro Galea, Albert Hofman, Miquel Porta, Zena Stein, and Michelle Williams. REFERENCES 1. Susser M, Stein Z. Eras in Epidemiology. New York: Oxford University Press; 2009. 2. Krieger N. Epidemiology and the People’s Health: Theory and Context. New York, NY: Oxford University Press; 2011. 3. Morabia A. A History of Epidemiological Methods and Concepts. Basel: Birkhauser; 2004. 4. Morabia A. Enigmas of Health and Disease: How Epidemiology Helps Unravel Scientific Mysteries. New York, NY: Columbia University Press; 2014.
www.epidem.com | 135
Should the History of Epidemiology be Taught in Epidemiology Training Programs? Zoey Laskarisa and Alfredo Morabiaa,b Background: Currently, there is no evidence concerning the presence of historical content in the epidemiology curricula of the United States and abroad. Similarly, it is not known how epidemiologists view this topic in the context of master’s or doctoral level course work. Methods: We attempted to fill these knowledge gaps with data from 2 online surveys—Survey I administered to persons in charge of all epidemiology training programs in North America and Survey II to epidemiologists practicing around the world. Results: A substantial minority (39%) of graduate programs in epidemiology in the United States teach a course on the history of the field. In both surveys, the most common reasons selected for teaching such a course were “To build a sense of identity as an epidemiologist” and “As a tool for achieving a deeper understanding into specific methods and concepts.” Conclusion: The majority of respondents, from 63 countries, agreed that the history of epidemiology should be included in curricula for graduate students in epidemiology. (Epidemiology 2015;26: 133–135)
C
urrently, there is no evidence concerning either the presence of historical content in the epidemiology curricula of the United States and abroad. Similarly, it is not known how epidemiologists view this topic in the context of master’s or doctoral level course work. We attempted to fill these knowledge gaps with data from 2 online surveys—Survey I administered to person in charge of all epidemiology trainings programs in North America, and Survey II to epidemiologists practicing around the world.
Submitted 14 May 2014; accepted 9 August 2014; posted 11 November 2014. From the aBarry Commoner Center for Health and the Environment, Queens College, City University of New York, NY, and bDepartment of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY. Supported by a grant from the National Library of Medicine, 1G13LM010884. Supplemental digital content is available through direct URL citations in the HTML and PDF versions of this article (www.epidem.com). This content is not peer-reviewed or copy-edited; it is the sole responsibility of the authors. Correspondence: Alfredo Morabia, Barry Commoner Center for Health and the Environment, Queens College, CUNY, 65-30 Kissena Boulevard, Flushing, NY 11367. E-mail: [email protected]. Copyright © 2014 by Lippincott Williams & Wilkins ISSN: 1044-3983/15/2601-0133 DOI: 10.1097/EDE.0000000000000211
Epidemiology • Volume 26, Number 1, January 2015
METHODS Interviews with 4 senior epidemiologists and 1 historian familiar with epidemiology concerning their views on general history and the history of epidemiology informed the development of the survey questionnaire. We tested Survey I on an expanded group of epidemiologists and substantially revised thereafter. It was then sent by email to all persons holding a chair of epidemiology in a training program in North America (n = 80)—first between April and June 2013 and, to reach unresponsive subjects, again in February and March 2014. The survey contained questions on the importance, intended audience, and format for teaching the history of epidemiology in a university setting (online survey is available here: https:// www.surveymonkey.com/s/7CJ683S). The subsequent, shortened, Survey II was designed for the international membership of the International Epidemiological Association (IEA) and the Society for Epidemiologic Research (SER), comprising approximately 3000 practicing epidemiologists, educators, and students. We tested the survey anonymously among students enrolled in a class on the history of epidemiology at the Columbia University Mailman School of Public Health. The questionnaire was then made available through temporary links published in the IEA and SER newsletters and on their websites (https://www.surveymonkey.com/s/XKK9CTV) between March and May 2013. The Queens College Institutional Review Board approved both surveys.
RESULTS After multiple attempts to obtain a 100% participation rate (12 reminders, plus personal emails and phone calls), Survey I was completed by 72 out of 80 subjects (92%). The targeted department chairs either responded directly (78% of respondents) or delegated the survey to epidemiology professors in charge of the training (22%). Survey II had 303 participants representing 63 countries. Descriptive background information of the respondents is provided in eTables 1 and 2 (http://links.lww.com/EDE/A853). We learned that a substantial minority (39%) of graduate programs in the United States teach a course on the history of epidemiology, for which they reported using a variety of supporting material, including the series “Voices” from Epidemiology (eAppendix 1; http://links.lww.com/EDE/A853). www.epidem.com | 133
Epidemiology • Volume 26, Number 1, January 2015
Laskaris and Morabia
FIGURE. Percent of responses expressing favorable reception by students of a mandatory course on the history of epidemiology. Survey II: nonrandom, international sample of members of the Society for Epidemiologic Research or the International Epidemiological Association (n = 303).
In Survey I, there was an overwhelming consensus that the history of epidemiology should be taught to master’s level (76%) and doctoral students (90%). A slightly revised question in Survey II indicated that 61% were in favor of a mandatory class for master’s level students and 63% were in favor of a mandatory class for doctoral students. Results varied moderately across continents (eFigure 1; http://links.lww.com/EDE/ A853). This question may apply differently to programs operating under the United Kingdom’s PhD model, such as Australia, in which mandatory courses are not part of a doctoral program.
When asked directly how master’s or doctoral students would receive a mandatory course, there was no clear consensus from either sample (eTable 3; http://links.lww.com/EDE/ A853, Figure). Notably, epidemiologists in charge of training programs in North America who work in universities that offer a course on epidemiology history did not agree on how the students view the course, as there was an equal distribution among those that thought it would be favored if mandatory, favored if nonmandatory, and not favored at all. Meanwhile, those universities that do not teach history were twice as likely to think that a nonmandatory course would be favored among students. In Survey II, students themselves, responding to this same question, were also split on this issue. Approximately, 20% of the respondents from Survey I and 12% from Survey II shared the opinion that a mandatory course would be viewed unfavorably. Reasons given for such opposition include the following: the ideas are already or should be incorporated into other courses; graduate programs have little room for new courses; and a course that teaches only history is hard to conceive. When queried on the most effective teaching format for a graduate course on the history of epidemiology (Survey I only), there was a clear preference for a seminar setting (eTable 4; http://links.lww.com/EDE/A853). However, based on free text responses, approximately 10% of Survey I and 24% of Survey II respondents considered the best option to be an integrative approach that incorporates historical lessons and analysis into existent courses. We found strong consistency between the North American and international views on the reasons for teaching history (Table). The 2 most prominent reasons for teaching were: “To build a sense of identity as an epidemiologist” and “As a tool for achieving a deeper understanding into specific methods and concepts.” The second tier, consistent among 50% of the responses, includes “To translate past discoveries into
TABLE. Responses to the Question: “Why Should We Teach the History of Epidemiology?” (to Doctoral Students) Among Respondents to United States and International Surveys
Response As a necessary tool for becoming a good researcher To build a sense of identity as an epidemiologist To include a historical perspective in a dissertation As a tool for achieving a deeper understanding into specific methods and concepts To avoid repeating mistakes For general cultural knowledge To translate past discoveries into common knowledge and/or policy To encourage students to engage in historical research Other
Multiple Responses (Survey Ia) (n = 65)
Most Important (Survey Ia) (n = 65)
IEA and SER (Survey IIb) (n = 188)
% 37 88 32 68 42 48 51 11 12
% 11 40 0 34 2 3 6 0 5
% 53 69 30 80 42 45 50 15 10
a
Survey I: epidemiologists in charge of training programs in North America. Survey II: a nonrandom, international sample of members of the SER or the IEA. IEA, International Epidemiological Association; SER, Society for Epidemiologic Research.
b
134 | www.epidem.com
© 2014 Lippincott Williams & Wilkins
Epidemiology • Volume 26, Number 1, January 2015
common knowledge and/or policy,” “For general cultural knowledge,” and, in Survey II only, “As a necessary tool for becoming a good researcher.” After stratifying the results, it was evident that, within institutions teaching history of epidemiology, the chairs themselves were more likely to complete the survey and to consider building a sense of identity to be a greater concern, compared with respondents from institutions that do not currently teach epidemiology history. In the extensive free text responses, epidemiologists in charge of training programs in North America identified further examples of how historical context can add depth to a public health education. One response reads, “To understand the interplay between epidemiological findings and sociopolitical events and to understand the political and economic ramifications of epidemiological findings (e.g. tobacco-cancer link and reaction of tobacco industry, public).” And, in reference to the discoveries of John Snow, “to understand that through epidemiology we can begin to understand associations even when we do not fully understand the biology behind the associations.” Lastly, we asked Survey I respondents, “If you were writing a textbook on the history of epidemiology, where would you choose to end the timeline?” An overwhelming majority (83.3%) replied “Everything up until yesterday.” This question was not asked in Survey II.
DISCUSSION A limitation of both surveys was our decision not to define or seek an interpretation of “history of epidemiology,” even though definitions may vary. For example, Susser and Susser1 focus on the evolution of the framing of hypotheses, Krieger2 focuses on the evolution of theories of disease distribution and health inequities, and Morabia3 approaches it from the perspective of the evolution of the methods and concepts. Courses based on any of these 3 approaches (or others) would be different. Similarly, we were not able to capture the influence of geographical region on a respondent’s definition for the history of epidemiology. A second limitation lies in the distinct sampling approaches used in both surveys.
© 2014 Lippincott Williams & Wilkins
History in Epidemiology Training
Having quantified the interest and importance in the topic, new educators, accrediting agencies, and epidemiologic associations around the world should feel invited to define realistic and practical ways to familiarize epidemiologists in training with the history of their discipline. The evident challenges will be to fit a course on the history of epidemiology into the competitive curricula and to deal with the shortage of epidemiologists having the skills of historians and of historians having the skills of epidemiologists; the discipline needs to proactively ensure that it trains scientists by exposing them to both skill sets. In conclusion, an evident inclination from 63 different countries for the institution of the history of epidemiology into graduate curricula emerged with clarity. The importance of learning history as a means to building an identity as an epidemiologist withstood distinct geographical, professional, and personal differences. Epidemiologists often find themselves explaining to the general public what it is exactly that they do; an historical perspective on the evolution of epidemiology would inform that explanation. The history of epidemiology includes a rich cadre of doctors, nurses, city health workers, and public health professionals who were faced with solving tremendous health enigmas.4 In our current world, characterized by a complex web of global environmental and public health concerns, a strong community of international epidemiologists is needed to tackle these problems. The history of epidemiology can facilitate a common identity by serving as the unifying force.
ACKNOWLEDGMENTS Exploratory interviews and questionnaire development with David Celentano, Dan Fox, Sandro Galea, Albert Hofman, Miquel Porta, Zena Stein, and Michelle Williams. REFERENCES 1. Susser M, Stein Z. Eras in Epidemiology. New York: Oxford University Press; 2009. 2. Krieger N. Epidemiology and the People’s Health: Theory and Context. New York, NY: Oxford University Press; 2011. 3. Morabia A. A History of Epidemiological Methods and Concepts. Basel: Birkhauser; 2004. 4. Morabia A. Enigmas of Health and Disease: How Epidemiology Helps Unravel Scientific Mysteries. New York, NY: Columbia University Press; 2014.
www.epidem.com | 135
