From new vaccines to better treatment for coronary heart disease, scientific knowledge has dramatically improved the public’s health in the past century.1 As a discipline with historic roots in public health but with modern emphasis on scientific discovery,2 epidemiology is at the center of translating scientific knowledge into better health.3–5 Although the “triumphs” of epidemiology—from understanding the importance of physical exercise6 to the elimination of folate-preventable spina bifida7—have been well documented, these are widely recognized not as triumphs of science alone, but also of evidence synthesis, engagement with stakeholders, and communication.8–10 The past decade has witnessed great strides in the translation of epidemiologic research into public health,11–14 including increased funding for translational research,15 implementation science,16 community-based participatory research,17 and most recently, comparative effectiveness research.18 At the same time, however, the discretionary budget of the Centers for Disease Control and Prevention—the major funder of public health research in the United States—is falling.19 Programs that could foster such translation (such as investigator-initiated extramural funding and Academic Centers for Public Health Preparedness20) are being eliminated.
Epidemiology in the United States (and to a lesser extent, other developed economies) is at a crossroads. On the one hand, the raw amount of scientific knowledge is exploding, and the translation21 of that knowledge into population-level public health benefit is increasingly difficult. For example, despite the sequencing of the human genome and the development of genetically targeted therapies, the first such therapy (trastuzumab) has saved fewer life-years in 12 years on the market22,23 than one day’s burden of fatal road accidents.24 After 30 years of developing experimental therapies to reverse myocardial ischemia, only one (early reperfusion) has affected clinical practice.25 On the other hand, academic epidemiology is evolving into a scientific discipline with increasing focus on objectivity26 and on education in methods to deduce causality.27 Although etiologic epidemiology is as necessary as ever, academic epidemiology in the United States could do more to develop scientists with integrative knowledge-translating skill sets, as well.
The process of knowledge translation in epidemiology may be understood diagrammatically (Fig.). As knowledge expands, a given increment of new knowledge generates incrementally less health impact than the translation of existing knowledge could produce. Knowledge generation and knowledge translation are 2 steps in the same value chain, but their relative importance to achieve the goal of improved health differs by the amount of knowledge available, with translation becoming more important as the amount of knowledge increases. By analogy, the explosion of information on the World Wide Web is useless without a corresponding search engine. The incremental value of generating additional information (eg, more Web sites) is dwarfed by that of improving knowledge translation (ie, better search engines and algorithms). Although supplying new knowledge will always be an essential task, the balance of scientific effort must, at some point, shift from knowledge generation to translation. Although this progression is common to all scientific disciplines, epidemiology is (unlike the basic sciences) historically an applied discipline, with public health and policymaking at its core.28,29 As our fund of incompletely translated knowledge grows, and translation of that knowledge into improved health becomes more difficult;30 epidemiology must resist an increasingly narrow focus on knowledge generation. Rather, epidemiology must expand and adapt its historical skill set to meet a new reality (Table).
A NEW BRAND OF EPIDEMIOLOGY: ACCOUNTABLE HEALTH ADVOCACY
In the United States, many of the structures and incentives of academic epidemiology reflect a scientific enterprise designed to generate knowledge.34 Knowledge-generating scientists (eg, climate change experts35) often fear professional fallout, if they engage with policymakers or advocates. Similarly, such researchers have little incentive to study or publish negative results36 (eg, lack of efficacy—or even harm—from new diagnostics37 and drugs38), as such findings are not “novel” and may generate professional controversy, despite their obvious health importance. Similarly, many of academic epidemiology’s existing structures (eg, funding sources, publication venues, and promotion practices) are designed to “fill the funnel” of knowledge, leaving others to “widen the spout” to health through translation. In an era of “knowledge surplus,” academic epidemiology should rediscover and adapt its historical emphasis on knowledge translation. As a heuristic, we suggest the term “accountable health advocate” (AHA), a model for the epidemiologist who specializes in knowledge synthesis, translation, implementation, and dissemination, in addition to knowledge generation. We focus on the epidemiologist as an individual, rather than epidemiology as a method, to emphasize the importance of training and equipping individuals to serve specific societal roles, rather than to use specific methods. Ultimately, the larger health science enterprise must address similar challenges, but epidemiology has a head start based on its history as a public health discipline.
The term “accountable health advocacy” emphasizes 3 key concepts. First, “accountability” states the importance of performing and communicating research in a way that makes sense to a broader nonexpert society. Second, “health” acknowledges that, unlike measurement of photons or cell signaling pathways, the work of epidemiology directly affects human lives. Third, “advocacy” implies that epidemiology should not limit itself to the traditional scientific domain, but rather that it should also act in the social, policy, and political domains to promote population health.
How might epidemiologists function as AHAs? In making themselves more accountable to society, epidemiologists might position themselves closer to the ideal of the “honest broker” of policy options,39 bringing scientific evidence to bear in policy decisions and speaking to the strengths and weaknesses of the data available. Epidemiologists would take sides on public health matters and defend their positions to society, acknowledging their intrinsic bias as scientists to seek positive results—and the corollary that most statistically significant findings will be clinically irrelevant or even false.40 Rather than make “vague and unattainable calls for objectivity,”41 epidemiologists would use methods and precise language that convey transparency and neutrality to both fellow scientists and the broader public.
In promoting health, epidemiologist should find innovative ways to pursue translational projects that might not generate new knowledge but would use existing knowledge to benefit the public’s health—benefits that would not accrue without epidemiologic expertise. Examples might include evidence-based, point-of-care clinical decision support tools,15 and market-based innovations to scale-up health technologies to marginalized populations through social entrepreneurs.42 When faced with professional conflict between promoting knowledge and promoting health (eg, whether to prioritize projects of etiologic interest or public health importance), epidemiologists should value both, but with a primary commitment to the improvement of human health.
As advocates, epidemiologists cannot operate within a strictly scientific domain but must actively engage with society. Faced with convincing data (eg, the benefit of antiretroviral therapy for HIV/AIDS), epidemiologists would join other health professionals in support of the requisite political or social change.43 By contrast, seeing data with multiple reasonable interpretations (eg, benefit of screening mammography before age 5044), they would speak out against narrow characterizations. Scientific opinion is molded by those who speak and those who remain silent45; epidemiologists need to provide their perspectives both where the data require action, and also when data require confirmation or exploration first.
MOVING TOWARD A NEW IDEAL: TARGETING FUNDING, PUBLICATION, AND PROMOTION
We present above an idealized portrait of the epidemiologist as AHA, acknowledging that many epidemiologists (eg, the Joint Policy Committee, Societies of Epidemiology46) already function in this mold, that certain programs (eg, Epidemic Intelligence Service47) provide relevant practical training, and that not all epidemiologists (eg, those engaged solely in etiologic research) need to master the “AHA skill set.” We argue not for a new paradigm in epidemiology, but rather for reallocation of academic resources—money, training, and professional support—to raise the knowledge translation enterprise to a level commensurate with knowledge generation efforts. The most efficient road to this goal would be to target the incentive structures that govern academic epidemiologists today: funding, publication, and professional advancement. We have suggestions for potential mechanisms to expand these incentive structures. We do not propose that existing structures be dismantled, but rather that alternative and parallel structures be established to train and develop epidemiologists (especially junior faculty), who wish to function as AHAs.
Current funding streams are dominated by industry, foundations, and public institutions in which public health practitioners, nonacademic physicians, and other guardians of the public’s health have little voice.48 Existing programs to translate knowledge into population health (eg, Centers for Disease Control and Prevention and Agency for Healthcare Research and Quality) are already underfunded relative to the total size of the health care industry.48 Given that these politically dependent agencies are unlikely to receive large budget increases, we should consider novel funding mechanisms for health research that serve the priorities of the public’s health, rather than the interests of individual politicians, industries, or philanthropists. Just as the American Recovery and Reinvestment Act has invigorated the field of comparative effectiveness research,18 a similarly bold initiative could energize the field of translational public health research. This initiative should include not only epidemiologists but also health educators, policymakers, and advocates for end users. In addition, funding initiatives should promote knowledge translation (eg, implementation science in cancer research49), expand the voice of clinical and public health practitioners on funding review committees, and provide more direct support (eg, National Institute of Health “New Innovator” Awards and institutional salary support). This would allow faculty members to pursue innovative knowledge-translation activities without having to rely solely on grants from traditional funding bodies.50
As with funding, existing publication practices often lack a voice that explicitly represents the public’s health. Although scientific journals may publish lay summaries, their editorial boards, peer reviewers, and readership are still largely composed of scientists, not public health practitioners, health advocates, or nonacademic clinicians. The ultimate goals of scientists and nonacademic health professionals are the same (to improve health), but their methods of interacting with society often differ. If epidemiologists were encouraged to write convincingly, not just to other scientists and health professionals, but to other members of society, their writing might take a different tone and, by achieving a wider audience, have more impact. Moving more journal content to open-access format, having practitioners contribute to the editorial and peer-review process, and encouraging communication in a wider variety of media (eg, newspapers, blogs, and social networking sites) would all enable epidemiologists to operate more closely to the AHA ideal, and make the output of epidemiology more accessible to the public. Journals that encourage diversity in their submissions are currently undervalued by a community that prizes metrics of impact on the scientific community (eg, number of scientific citations), rather than on the public’s health. Developing and promoting alternative metrics that evaluate publications’ impact in improving the health of populations could be a valuable step in providing incentives to journals and the epidemiologists who publish in them.
Finally, the criteria for professional advancement reward epidemiologists mostly for contributions to science not public health; hence, the importance of peer-reviewed publications and grants, and the weight of recommendation letters from other scientists in the tenure/promotions process. If we wish to recast epidemiologists as AHAs, leaders of the community of epidemiologists (eg, department chairs and deans of public health schools) must develop alternative frameworks for professional advancement that acknowledge the importance of knowledge translation. Such frameworks could better recognize accountability (eg, valuing an open and well-documented data set rather than personally authored publications), health promotion (eg, considering a scientist’s contributions to public health as well as science), and advocacy (eg, including public-sphere activities in curricula vitae). Changing advancement frameworks is a tremendously difficult task, and such changes could be implemented only on an institution-by-institution basis, with substantial political resolve. However, they need not replace the traditional promotions framework, rather specific faculty members could request—or be assigned—an evaluation by a given set of criteria (contributions to science vs. public health). The availability of such alternative frameworks would further encourage epidemiologists to adopt practices such as opening data sets, engaging with public health practitioners, and promoting health outside the scientific community (eg, through policy or lay publications). All of these practices are likely to have direct positive impact on public health, and they may ultimately lead to greater funding, as society comes to recognize which research institutions are most closely committed to improving health.
There is an urgent need to translate the growing fund of scientific knowledge into improved health, and to do so even while budgets are being slashed. Existing incentive structures (funding, publication, and promotion) are designed for knowledge generation rather than knowledge translation and are not appropriate for all aspects of epidemiology. We propose an alternative scheme in which some epidemiologists serve as “accountable health advocates”—scientific experts who also remain accountable to a larger society, prioritize population health over etiology, and actively engage with policymakers and opinion leaders. Creating additional funding streams for translational public health research, alternative journals, and impact metrics, as well as parallel frameworks for advancement and promotion, could all empower epidemiologists to operate more closely to the AHA ideal. In this way, epidemiology could maximize its impact on the public’s health and maintain the support of society at large.
1. Centers for Disease Control and Prevention. . Ten great public health achievements-united states, 1900–1999. MMWR Morb Mortal Wkly Rep. 1999;48:241–243
2. Pearce N. Traditional epidemiology, modern epidemiology, and public health. Am J Public Health. 1996;86:678–683
3. Gebbie KM Who Will Keep the Public Healthy? Educating Public Health Professionals for the 21st Century. 2003 Washington, DC National Academy Press
4. Institute of Medicine. The Future of the Public’s Health in the 21st Century. 2002 Washington, DC National Academies Press
5. Ness RB. Introduction. triumphs in epidemiology commentary. Ann Epidemiol. 2009;19:225
6. Blair SN, Morris JN. Healthy hearts–and the universal benefits of being physically active: physical activity and health. Ann Epidemiol. 2009;19:253–256
7. Oakley GP Jr. The scientific basis for eliminating folic acid-preventable spina bifida: a modern miracle from epidemiology. Ann Epidemiol. 2009;19:226–230
8. Brownson RC, Hartge P, Samet JM, Ness RB. From epidemiology to policy: toward more effective practice. Ann Epidemiol. 2010;20:409–411
9. Mercer SL, Sleet DA, Elder RW, et al. Translating evidence into policy: lessons learned from the case of lowering the legal blood alcohol limit for drivers. Ann Epidemiol. 2010;20:412–420
10. Widome R, Samet JM, Hiatt RA, et al. Science, prudence, and politics: the case of smoke-free indoor spaces. Ann Epidemiol. 2010;20:428–435
11. Clements-Nolle K, Ballard-Reisch DS, Todd RL, Jenkins T. Nevada’s academic-practice collaboration: public health preparedness possibilities outside an academic center. Public Health Rep. 2005;120(suppl 1):100–108
12. Covich JR, Parker CL, White VA. The practice community meets the ivory tower: a health department/academic partnership to improve public health preparedness. Public Health Rep. 2005;120(suppl 1):84–90
13. Morse SS. Building academic-practice partnerships: the center for public health preparedness at the Columbia university mailman school of public health, before and after 9/11. J Public Health Manag Pract. 2003;9:427–432
14. Orfaly RA, Biddinger PD, Burstein JL, Leaning J. Integration of academia and practice in preparedness training: the Harvard school of public health experience. Public Health Rep. 2005;120(suppl 1):48–51
15. Woolf SH. The meaning of translational research and why it matters commentary. JAMA. 2008;299:211–213
16. Zerhouni E. The NIH roadmap. Science. 2003;302:63–72
17. Minkler M, Blackwell AG, Thompson M, Tamir H. Community-based participatory research: implications for public health funding. Am J Public Health. 2003;93:1210–1213
18. Sox HC, Greenfield S. Comparative effectiveness research: a report from the institute of medicine. Ann Intern Med. 2009;151:203–205
19. U.S. Department of Health and Human Services. Advancing the Health, Safety, and Well-being of our People: FY 2012 President’s Budget for Health and Human Services. 2012 Washington, DC HHS
20. Thielen L, Mahan CS, Vickery AR, Biesiadecki LA. Academic centers for public health preparedness: a giant step for practice in schools of public health. Public Health Rep. 2005;120(suppl 1):4–8
21. Davis D, Evans M, Jadad A, et al. The case for knowledge translation: shortening the journey from evidence to effect. BMJ. 2003;327:33–35
22. Elkin EB, Weinstein MC, Winer EP, et al. HER-2 testing and trastuzumab therapy for metastatic breast cancer: a cost-effectiveness analysis. J Clin Oncol. 2004;22:854–863
23. Hoffmann-La Roche Ltd. Herceptin now approved in the EU for patients with HER2-positive advanced stomach cancer. http://www.roche.com/med-cor-2010–01–28
. Accessed March 3, 2012.
24. World Health Organization. Global Status Report on Road Safety. 2009 Geneva, Switzerland World Health Organization
25. Bolli R, Becker L, Gross G, et al. Myocardial protection at a crossroads: the need for translation into clinical therapy. Circ Res. 2004;95:125–134
26. Gori GB. Presentation: epidemiology and public health: is a new paradigm needed or a new ethic? J Clin Epidemiol. 1998;51:637–641
27. Gange SJ. Teaching epidemiologic methods. Epidemiology. 2008;19:353–356
28. Foxman B. Epidemiologists and public health policy. J Clin Epidemiol. 1989;42:1107–1109
29. Rothman KJ, Poole C. Science and policy making. Am J Public Health. 1985;75:340–341
30. Pearce N, McKinlay JB. Dissent: back to the future in epidemiology and public health: response to Dr. Gori commentary. J Clin Epidemiol. 1998;51:643–646
31. Sandman PM. Emerging communication responsibilities of epidemiologists. J Clin Epidemiol. 1991;44(suppl 1):41S–50S
32. Walter SD. The estimation and interpretation of attributable risk in health research. Biometrics. 1976;32:829–849
33. Rockhill B, Newman B, Weinberg C. Use and misuse of population attributable fractions. Am J Public Health. 1998;88:15–19
34. Hanna JF. The scope and limits of scientific objectivity. Philos Sci. 2004;71:339–361
35. Hart DM, Victor DG. Scientific elites and the making of US policy for climate change research, 1957–1974. Soc Stud Sci. 1993;23:643–680
36. Tatsioni A, Bonitsis NG, Ioannidis J. Persistence of contradicted claims in the literature. JAMA. 2007;298:2517–2526
37. Dowdy DW, Steingart KR, Pai M. Serological testing versus other strategies for diagnosis of active tuberculosis in India: a cost-effectiveness analysis. PLoS Med. 2011;8:e1001074
38. Young NS, Ioannidis JPA, Al-Ubaydli O. Why current publication practices may distort science. PLoS Med. 2008;5:e201
39. Pielke RA The Honest Broker: Making Sense of Science in Policy and Politics. 2007 Cambridge Cambridge University Press
40. Ioannidis JP. Why most published research findings are false. PLoS Med. 2005;2:e124
41. Greenland S. Transparency and disclosure, neutrality and balance: shared values or just shared words? J Epidemiol Community Health.
42. Bornstein D How to Change the World: Social Entrepreneurs and the Power of New Ideas. 2007 New York, NY Oxford University Press
43. Gruen RL, Pearson SD, Brennan TA. Physician-citizens—public roles and professional obligations. JAMA. 2004;291:94–98
44. Warner E. Clinical practice. Breast-cancer screening. N Engl J Med. 2011;365:1025–1032
45. Noelle-Neumann E The Spiral of Silence: Public Opinion, our Social Skin. 19932nd ed Chicago, IL University of Chicago Press
46. Ness RB, Andrews EB, Gaudino JA Jr, et al. The future of epidemiology. Acad Med. 2009;84:1631–1637
47. Thacker SB, Dannenberg AL, Hamilton DH. Epidemic intelligence service of the centers for disease control and prevention: 50 years of training and service in applied epidemiology. Am J Epidemiol. 2001;154:985–992
48. Moses H, Dorsey E, Matheson DH, Thier SO. Financial anatomy of biomedical research. JAMA. 2005;294:1333–1342
49. Wolin KY, Colditz GA, Proctor EK. Maximizing benefits for effective cancer survivorship programming: defining a dissemination and implementation plan. Oncologist. 2011;16:1189–1196
50. Stephan P How Economics Shapes Science. 2012 Boston, MA Harvard University Press