A Conversation with Zena Stein

Wilcox, Allen J.

doi: 10.1097/01.ede.0000071471.35756.96
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Address correspondence to: Allen J. Wilcox, Editor-in-Chief, EPIDEMIOLOGY, 331 West Main St., Suite 606, Durham, NC 27701. E-mail: Wilcox@epijournal.org.

This interview was conducted 20 March 2002 at the Mailman School of Public Health, Columbia University, New York, NY. Zena Stein has approved this transcription for publication.

• Zena Stein’s curriculum vitae is available with the on-line version of the Journal at http://www.epidem.com.

Editor’s Note: VOICES is a project of the journal to provide personal, historical and scientific perspectives on the field of epidemiology, as seen through the eyes of the field’s most senior and accomplished practitioners. Subjects are selected by the Editors. Readers are welcome to nominate candidates for VOICES.

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Zena Athene Stein was born on the 7th of July 1922 in Durban, South Africa. After service in the armed forces during World War II, she entered medical school at the University of Witwatersrand, and trained in psychiatry in the United Kingdom. In 1968, she became Director of the Epidemiology Research Unit in the New York State Psychiatric Institute, a position she held for 30 years. She has been a professor of epidemiology at Columbia University School of Public Health since 1966 and at Columbia’s Gertrude Sergievsky Center since 1977. From 1986 to 1993 she was Columbia’s Associate Dean of Research. She is known for her work in mental retardation (especially through the establishment of the Dutch famine cohort study), for her role as a founder of the field of reproductive epidemiology, and most recently for her pioneering research on the role of women in the HIV epidemic. Dr. Stein received the Wade Hampton Frost Award from the American Public Health Association in 1992, and the Association’s John Snow Award in 1999. She is a Senior Member of the Institute of Medicine.

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AW: Most epidemiologists don’t start out planning to be epidemiologists. Could you discuss how you ended up in epidemiology – what you started out thinking you would do, and how you ended up where you did?

ZS: Before I did medicine, before I joined the military, I was a history student. I was drawn to history and enjoyed it. Sometimes I look back at my career and I think I might as well have done history as epidemiology. But after the War, both Mervyn [Susser, her husband] and I went into medicine, with quite a strong feeling that medicine was a way to make some impact on the inequalities and injustices of the society we knew.

Quite a few South African physicians of my generation ended up in epidemiology. The scene in which we grew up was two separate societies – poor blacks, and middle-class and wealthy whites. So, it was a good situation to learn and think, if you had a social conscience of any kind.

And then there was World War II. By the end of the war, I knew I had to work in some context that would make a difference to society. I took up medicine with the idea that medicine was the way to do something for the poorer populations.

We were lucky to meet others with similar motivations. The period in which we were students, in the late 1940s, was a period of stirring among South Africans. There were commissions to illustrate the poverty of the cities. The starvation and poor nutrition were obvious, although our formal training of medicine had nothing to do with that. For instance, our course in pediatrics was very small, I think two lectures, and they covered diseases that no black South Africans (the majority population) would ever have had. There was a mismatch between our formal lectures and what we knew was happening in our own country. We knew something was wrong, and we would have go beyond our formal training to address it.

By good fortune, we met Dr. Sidney Kark, who was already famous in the field of public health. He was the one who explained to us how work as a doctor could in fact do something to society. Something “promotive,” that was his word. We had preventive medicine and curative medicine; he had a new word for us, “promotive” medicine, which means you actually helped communities to make a difference to their health.

We had small study groups outside medical school that brought us into the field we later came to recognize as epidemiology. Epidemiology wasn’t on the syllabus. There was something called “public health”—very boring, as taught. This was unfortunate, because they are lovely words, public health. What we were taught was more about engineering, sanitation, than it was about people. If you read the smaller print, it had relevant facts that you needed for a community practice, but it had nothing of epidemiology. So, we learned a lot in the time off the strict medical school curriculum by going around it. I think that is how we came to understand what active public health could do. FIGURE

AW: You describe socially conscious physicians who are drawn to do something about health inequities. Where did the intellectual rigor of epidemiology come into play?

ZS: I don’t know the exact answer. In medical school, Joe and Teddy Gillman taught a very strong, thoughtful basic-science physiology group. Many of the best students in our year were drawn to work with them, including some of the really famous like Sidney Brenner (who won this year’s Nobel Prize for Medicine) and Philip Tobias (a paleontologist who has also been nominated for a Nobel). In a way they pushed us to think scientifically in our own field. Sidney Kark himself had quite a lot of that intellectual quality. We did have the idea that science was important in our work. Of course, Mervyn and I talked to each other, which was also important.

AW: In some ways, it sounds as if you created your own model.

ZS: I think that we did, although we were still focused on the particular issues of health in South Africa. We never thought we’d move. It seemed unpatriotic even to think of it.

AW: As events transpired, you ended up in the United Kingdom and then in the United States. At what point did you start to think of yourself as an epidemiologist?

ZS: For me, when we came to the States, in 1965. Even in the United Kingdom, I had clinical roles and I didn’t really see a distinction between my clinical work and my interest in public health. I did jobs every now and then at a general hospital, but that was not where my intellectual interests were. When I came to the United States, it was necessary to take the board examinations to become a physician, and I thought that wasn’t worth it. I wasn’t doing enough clinical work. My thinking was more in the field of epidemiology.

AW: What would you say is the biggest difference between epidemiology as it was practiced then, in the mid-1960s, and today?

ZS: Epidemiology was more closely concerned with public health and less with clinical problems. I can’t remember even thinking about what they now call evidence-based medicine, or clinical trials for treatment. We were much more interested in the problems of active prevention at the community level.

AW: Who would you say was the most influential in your development as an epidemiologist?

ZS: I’ve mentioned Sidney Kark in South Africa. In England, it was Jeremy Morris. Jerrie wrote a book, Uses of Epidemiology, which discussed epidemiology exactly where we were. One had to be knowledgeable about the health of the country. Issues of both treatment and prevention could be seen in epidemiological terms. It combined both the activist and the scientific approach that we were trying to understand.FIGURE

AW: One of the most important decisions an epidemiologist makes is what question to study. How have you picked your questions?

ZS: I’ve always been eclectic in my interests. Let me talk about one example. Because of my interest in mental retardation, I attended an international meeting on mental retardation in London in 1959 or 1960. Mental retardation was just coming into its own scientifically, and Lionel Penrose made a famous speech at that meeting. He said in the future, people will look to mental retardation for answers to biologic problems. Within a few months, the extra chromosome of Down syndrome was found. This was the first genetic chromosome anomaly to be identified.

So with that on my mind, I went to a lecture at a meeting of the American Public Health Association. An obstetrician described diagnosing a fetus with Down syndrome by finding the extra chromosome in amniotic fluid. I found that enormously interesting. There were scientific implications, and then the social implications. Diagnosis was a clinical service you could offer, and then, if appropriate, provide the option of termination. That started me off into the field of prenatal studies. 1

AW: It sounds as if, for you, a research question has to have biologic content and public health impact.

ZS: I think I prefer that. I also like it to have some intellectual bite, because that makes it more interesting, more fun.

AW: Our data don’t always support what we might believe is the best for public health. Has this ever happened to you?

ZS: Yes, with the Dutch Famine Study especially. The thinking in this country was that nutrition was very important to mental retardation. I remember a court case in which a woman had been advised by her doctor to eat mainly rice during pregnancy. The child was born mentally retarded. The family sued the doctor, and won. In the Dutch Famine Study, we found no evidence that 6 months of starvation in pregnancy, among a reasonably well-nourished population, had any effect on the intelligence of the offspring. 2,3 Many of our colleagues were furious with us because it would have been much more satisfactory (in terms of social justice) to have found that food did matter. But in fact, nothing has happened since to change that opinion. What we have learned is that certain nutrients, particularly folates, can make a difference depending on timing and outcome, but not general starvation in any direct way.

In another sense, this was comforting, because at that time there was civil war in Nigeria, mothers were starving, and people thought a whole Nigerian cohort would grow up retarded. We were happy to say we didn’t think that would happen.

AW: Who would you regard as the most important epidemiologist during your lifetime?

ZS: I would say Richard Doll. Richard Doll has a genius for putting his finger on where the problems might be. He doesn’t need high-powered, highly sophisticated statistics, even though he is fully capable in that regard. He employs hard thinking, an understanding of the possibilities of the biology. He chooses his colleagues well, and comes to a reasonable answer. I think he has hit a lot of targets. He is also very motivated to use his data and his position to emphasize a public message. He is a moral man and a very intelligent man. I think he is number one.

AW: What would you pick out as your most influential paper?

ZS: Not the famine study, because people didn’t want to believe it. Later, people have picked it up and used it. Our paper on early diagnosis of Down syndrome was picked up by a lot of people. 1 Nicholas Wald said recently that you should be able to diagnose a Down syndrome fetus by the first trimester, using radiology and biochemistry to narrow down whether the fetus has Down syndrome. I think we were early on in trying to think that through, although we didn’t have the sophistication or the techniques available now.

I think my work in the HIV field has helped to turn the focus on women. I wouldn’t say we have succeeded everywhere, but we have put that on the agenda. 4-7 Twice my fine colleague, Robin Flam, and I put in a proposal to study HIV in women, and the project was turned down because “women don’t get HIV.” When you look back at it now, it is absurd. Women are the centerpiece of the epidemic, and how to handle that—preventive care and treatment—depends on women in every way.

AW: You have been a woman in epidemiology during an era when men dominated the field. Do you think your perspective as a woman has contributed to your scientific work?

ZS: I feel that more now that I did earlier. In my perinatal work, I didn’t have the woman so much in mind as you might think. It was with my work in HIV that I came more and more to feel that women were important as a topic on their own. My 1990 paper on methods that women might use for protection against HIV and sexually transmitted disease has helped raise this awareness. 4 My current focus is on breast feeding in HIV infected women in Africa—a topic that needs much more attention.

AW: Would you single out a particular paper as one that you think has been more valuable than people have realized?

ZS: The work on the Dutch famine produced some useful and interesting papers that people haven’t taken up. 2,3,8-12 They covered in the main what you might call the epidemiology of intelligence—family size, birth order, rural and urban differences, the age of the mother when the child is born. I was on an Institute of Medicine Commission last year on IQ performance and the circumstances of young people in and out of the home. The distinguished chair of that group had never heard of our work on intelligence.

AW: What have been your own major interests outside of epidemiology itself?

ZS: I read a lot of novels—I seem to concentrate on the 19th Century. I don’t read as much of modern writing as I might. I love the theater. Travel—interesting, but not a hobby.

AW: What would be your assessment of the current health of the field of epidemiology?

ZS: It is strong, in general, but it has many problems. We do get wonderful applicants into the schools. In that sense, our field is in very good shape. My own reflection is that we don’t always know where the lines should be drawn between epidemiological methods and biostatistics. Many people will say “I need somebody to chew the data, to put the data onto a computer and give me the answers.” That’s not what epidemiologists do—they can do it, and many would take jobs like that. But that is not the particular quality an epidemiologist brings. Epidemiologists have to understand the problem, have to think it through. I think we should not overdo methods for the epidemiologist. The logic is more important than sophisticated statistics. I don’t want to put down methodology, but when you find very questionable fragmentary relative risks, it is probably not very important.

AW: What would you say are the biggest opportunities standing before the field right now?

ZS: The world and especially the developing world has been overtaken by 2 diseases, HIV and TB. That is an enormous challenge. It will take more than epidemiologists to make an impact—it needs clinicians and laboratory people. But the epidemiologists have an enormous contribution to make. I am not saying not to look to other problems, but for me that is what the world has to face at the moment.

AW: What would be the single most important piece of advice that you would give to a student entering epidemiology?

ZS: The main thing is that you have to spend time with the community, wherever that is. Epidemiologists need that community experience—not just experience with a computer. The community might be a hospital ward, or it might be a place they have volunteered as students. I’ve seen students come back from electives in the community transformed, with a whole different understanding of what they can do, and what they should do, and what they can’t do. I would like all scholars to have some experience outside. I would like them to collect data that will be meaningful, useful in the community. It is a prejudice of mine, not everybody believes that.

Students often ask me whether they should study medicine first before epidemiology. It is a difficult question. I enjoyed my medical training, but I don’t know what medicine exactly gives you, whether it’s the natural science, or the arrogance of the doctor, or the understanding of the patient-doctor situation. None of those is absolutely essential to the epidemiologist. There are many things you need outside of medicine. You need math strengths. You need molecular biology. Medicine is important, but it is not the only way. What epidemiologists need most is courage and persistence and energy, because answers are not obvious or easy.

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Allen Wilcox is a perinatal epidemiologist who has benefited from Dr. Stein’s scientific insights. While he has valued his opportunities to serve with her on advisory panels and committees, he continues to be dismayed that Dr. Stein routinely returns home on the red-eye flight, while he gets a good night’s sleep and goes home in the morning.

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The journal gratefully acknowledges the support and cooperation of the Division of Epidemiology at the Mailman School of Public Health, Columbia University, in making possible the video recording of this interview. Judy Eshelman carried out the initial transcription of the recording the interview.

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1. Stein ZA, Susser MW. The preventability of Down’s syndrome (mongolism). Pub Hlth Rep. 1971; 86: 650–658.
2. Stein ZA, Susser MW, Saenger G, Marolla F. Intelligence test results of individuals exposed during gestation to the World War II famine in the Netherlands. Tijschr Soc Geneeskd. 1972; 21: 766–774.
3. Stein ZA, Susser MW, Saenger G, Marolla F. Nutrition and mental performance. Science. 1972; 178: 708–713.
4. Stein Z. HIV Prevention: the need for methods women can use. Amer J Pub Hlth. 1990; 80: 460–462.
5. Ehrhardt A, Yingling S, Zawadzki R, Martinez-Ramirez M, Stein Z. Barriers to safer heterosexual sex for women from high HIV prevalence communities. (Abstract). Proceedings, Seventh International Conference on AIDS, Florence 1991;1:398.
6. Boylan L, Stein Z. The epidemiology of HIV infection in children and their mothers. Epidem Rev. 1991; 13: 143–177.
7. Stein Z. The double bind in science policy and the protection of women from HIV infection (editorial). Amer J Pub Hlth. 1992; 82: 1471–1472.
8. Stein ZA, Susser MW. Families of dull children. Part I. A classification for predicting careers. Br J Prev Soc Med. 1960; 14: 83–88.
9. Stein ZA, Susser MW. Families of dull children. Part II. Identifying family types and subcultures. J Ment Sci. 1960; 106: 1296–1303.
10. Stein ZA, Susser MW. Families of dull children. Part III. Social selection by family type. J Ment Sci. 1960; 106: 1304–1310.
11. Stein ZA, Susser MW. Families of dull children. Part IV. Increments in intelligence. J Ment Sci. 1960; 106: 1311–1318.
12. Stein ZA, Susser MW. The social distribution of mental retardation. Amer J Ment Defic.. 1963; 67: 811–821.

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