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Epidemiology has been criticized for a perceived lack of scientific rigor, an obsession with
esoteric methodologic issues of limited practical relevance, a focus on individuals rather
than populations, an emphasis on biomedical rather than social or economic causes of
disease, and a failure to provide the knowledge needed for effective public health practice.
The public health problems that motivate all these criticisms are real, but the solutions are
not all to be found in epidemiology.
Epidemiology Is Not the Basic Science ofPublic Health
Although the proposition that epidemiology is the basic science of public health is rarely
stated in epidemiology texts, this is often the view of the public health community. The
Institute of Medicine committee's report states that public health "links many disciplines
and rests upon the scientific core of epidemiology." A commission reporting on higher
education in public health claimed that "epidemiology is the basic science of public health
work and of preventive medicine." The phrase "the basic science of public health work"
implies that the entire knowledge base underlying public health comes from epidemiology,
though we doubt that many would explicitly argue for that proposition. If the intended
analogy is the relationship between the basic biomedical sciences and clinical medicine, it
should be acknowledged that many other sciences serve public health as well. Among the
basic public health sciences are clinical medicine, sociology, toxicology, molecular biology,
anthropology, nutrition, sanitary engineering, policy analysis, risk assessment, industrial
hygiene, economics, and political science.
If epidemiology were the sole scientific basis for public health, one would expect
sufficiently strong epidemiologic evidence to result immediately in a predictable public
health response; clearly, this is not the case. The failure to respond rapidly, or in some
cases at all, to epidemiologic evidence may sometimes be a rational response to
extraepidemiologic considerations rather than a reason for disappointment. Only a
comprehensive evaluation of all the issues surrounding a policy choice, not merely the
epidemiologic evidence, can reveal when an unwise choice has been made.
Public health policy cannot be based solely on health considerations. Economics, culture,
politics, and ethics are critical components of public health policy decisions.
These factors may occasionally be in opposition to the epidemiologic evidence. Much of
public policy has relevance to health and the decisions reflect a balance between health
and other concems that fall outside the scope of epidemiology. Epidemiology cannot
absorb the broader array of scientific and societal concerns that must be considered in the
development and implementation ofpublic health policy.
Translation ofEpidemiologic Evidence Into Public Health Action
The nature of scientific hypotheses, which include epidemiologic hypotheses, renders all
knowledge tentative. The scientific process does not yield absolute truths, just evidence
pertaining to different theories that is based on the extent and quality ofchallenges to which
they have been subjected. Therefore, the guidance that epidemiology has to offer public
health cannot await certainty. Public health decision makers must be given a summary of
current epidemiologic knowledge when they need it, even if that evolving knowledge is
contradictory and confusing.
vista como peligrosamente ingenuo, ya que todas las decisiones acerca de la ciencia,
desde la eleccin de los temas a los mtodos y la interpretacin de la investigacin,
son vistos como las decisiones morales, polticos. la prctica de la salud pblica y el
deseo de mejorar la salud pblica se basan en valores, y hace un llamamiento a la
moralidad y la emocin son justificables en servir a ese fin. Sin embargo, mantenemos
que la epidemiologa mejor contribuye a los objetivos de salud pblica a travs de
rigor y mediante la consecucin de la meta cada vez ms difcil de objetividad. Mezcla
papeles cientficos y activistas no slo pone en peligro la validez de la ciencia
epidemiolgica, pero reduce su beneficio para la salud pblica. Tomadores de
decisiones de salud pblica obtienen una reducida parte de los estudiosos apasionados
que van ms all de avance y explicar la ciencia a la promocin de un programa
especfico para la salud pblica. En principio, los talentos que hacen que un cientfico
efectiva y los talentos que hacen que un defensor efectivo, los cuales son vitales para
la salud pblica, pueden coexistir en el mismo individuo. Sin embargo, la flexibilidad
para responder a la nueva informacin objetiva, un requisito de la ciencia, va en contra
de la ideologa coherente necesaria para el activismo de la salud pblica.
Conclusin
Hay quienes sostienen que la misma persona debe generar conocimiento, abogar por su
relevancia la salud pblica, e implementar acciones de salud pblica, pero no hay una
sola persona es probable que sea igualmente expertos en epidemiologa, promocin y
aplicacin. Necesitamos equipos de salud pblica, no individuos, que encarnan las
diversas necesidades de salud pblica. Wall argument, "Lo que el mdico es con el
paciente, el epidemilogo es para la sociedad", pero se sugiere el trmino "trabajador
de la salud pblica" debe ser sustituido por "epidemilogo," ya que es el trabajador de
la salud pblica que acumula informacin (algunos de que se genera por la
epidemiologa) sobre las enfermedades de la sociedad, se desarrolla un plan de
tratamiento, la terapia y los implementos necesarios (con la eficacia evaluada, en
parte, por la epidemiologa). La salud pblica es demasiado compleja para ser
considerado meramente epidemiologa aplicada.