The Medicalization of Prevention: Whither epidemiology, prevention research and program?
Epidemiology is now firmly established in the administrative structure of major research institutions. Its methods, and the skills of its professionals, are sought-after in academic centers and hospital practice. Academic programs abound in the epidemiology of noncommunicable diseases and students flock to them, including women and minorities. Though lacking the dominant and elite status of bench and clinical research, epidemiology, nevertheless, needs no longer fight its old battles of legitimacy and recognition.
But in societies where today a “culture of the individual” predominates, where “personalized medicine” is the stated focus of its research policy, and where the competition for limited funds is fierce among research modes, discriminative rules and regulations have emerged in the review process, administration, and support of grants for population studies and programs.
In the early years of formal CVD epidemiology in the U.S., relations between CVD investigators and supporting institutions were healthy; resulting in good science and good program and policy. Since the mid-1970s the entities have come into increasing tension, conceptual and economic. Indeed, population studies and preventive trials last many years and are costly. A single, relatively low-cost cohort study at $1 million/year may represent 10 projects for jealous laboratory scientists.
As population studies and trials have grown in size, scope, and cost, the trend has been toward their greater institutional (NIH) initiation, with central management and control under the guise of fiscal responsibility and quality control, and with far less initiative and direction from the community of investigators. Meanwhile, institutions, particularly the NIH, have increasingly focused research priorities on individual medicine and on technical medical strategies, even those involved in the primary prevention of CVD.
University of Pittsburgh epidemiologist Lewis Kuller summed up the U.S. situation not so long ago, saying:
NIH gives lip service to prevention. They are heavily focused on end-stage disease and genomics. CDC has some excellent people, but is caught up in mindless process review with little funds for effective implementation. The state health departments are unfortunately undermanned, underfunded, weak, and ineffective. So the first thing that epidemiologists and prevention people have to do is find the leadership to develop a really first-rate prevention program. The second is to figure out where the resources should come from to implement an effective program (Kuller-Giddings 2008).
The evolution in CVD prevention toward highly technical medical strategies is in part generated by a large and powerful medical-industrial complex including NIH, with priority on “Personalized Medicine,” accompanied by an absence of policy relevant to the public health and fewer major researches in health promotion and population strategies of prevention. (The NIH credo, “From the bench to the bedside,” ignores “the population outside”). Popular mass screening, both academic and commercial, tends to serve as a funnel into the medical system with subsequent technical diagnostic procedures that lead into the gorge of costly and risky pharmaceutical, surgical, and machinated therapeutic procedures. Research follows policy and policy is dominated by a medical rather than a population strategy.
For example, the Polypill (various proposed combinations of lower doses of multiple risk factor-lowering medications) is today seriously considered as a mass preventive strategy, while research and promotion of healthy eating patterns and lifestyles is left to unnatural experiments of unregulated commerce or to untested alternative medicine.
The NIH focus on genomics and on personalized medicine promises eventual improvement in personal health for those with uncommon conditions. It ignores the social causes of the common diseases and rejects the healthy society attainable through research and programs in health promotion. A national policy promoting personalized medicine at its base eschews the mass phenomenon, public health, and, thus, the common good. With it, epidemiology, the basic science of prevention, becomes the handmaiden of personalized medicine rather than the engine of public health. (Henry Blackburn)
Kuller, L. 2008. Ending the cardiovascular disease epidemic: an interview by Samuel S. Gidding. Epidemiology 19(1):27-9.