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Friday, 16 May 2008

From Miasma to Fractals: The Epidemiology Revolution and Public Health Nursing

Public Health Nursing
From Miasma to Fractals: The Epidemiology Revolution and Public Health Nursing
Author(s):

MacDonald, Marjorie A. Ph.D., R.N.

Issue:
Volume 21(4), July/August 2004, p 380–391
Publication Type:
[HISTORY]
Publisher:
Copyright © 2004 Blackwell Publishing Ltd.
Institution(s):
Marjorie A. MacDonald is Associate Professor, School of Nursing, University of Victoria, Victoria, British Columbia, Canada.
Address correspondence to Marjorie A. MacDonald, School of Nursing, P.O. Box 1700, University of Victoria, Victoria, British Columbia, Canada V8W 2Y2. E-mail: marjorie@uvic.ca
Keywords: ecology, ecosocial paradigm, epidemiology, history, nursing science, public health nursing
Abstract

If public health nursing is truly a synthesis of public health science and nursing science, then nurses must keep track of current developments in public health science. Unfortunately, the public health nursing literature has not kept pace with revolutionary developments in epidemiology, one of the sciences that informs population-focused nursing practice. Most epidemiology chapters in community health nursing texts do not reflect the intellectual development that has taken place in epidemiology over the past two decades. The purpose of this article therefore is to facilitate an updated synthesis by (a) reviewing the development of epidemiology and the focus of public health nursing practice through three historical eras, (b) discussing current controversies and tensions within epidemiology, (c) introducing an emerging paradigm in epidemiology based on an ecosocial perspective, and (d) discussing the congruence of this perspective with the evolving theory and practice of public health nursing.


Professional nursing bodies in both Canada and the United States have defined public health nursing as a synthesis of public health science and nursing science (American Nurses Association, 1984; American Public Health Association, 1996; Canadian Public Health Association, 1990). In other words, concepts, knowledge, theory, and skills from nursing and public health are synthesized to become a distinctive practice. Although this definition has not gone unchallenged (Duffy & Pender, 1987; Hanchett & Clarke, 1988), there is broad support for the definition in recent community health nursing texts (Allender & Spradley, 2001; Clark, 1999; Hitchcock, Schubert, & Thomas, 1999; Stanhope & Lancaster, 2000; Stewart, 1999) and in the nursing literature (Chalmers & Gregory, 1995; Kuss, Proulx-Girouard, Lovitt, Katz, & Kennelly, 1997).

THE PLACE OF EPIDEMIOLOGY IN PUBLIC HEALTH NURSING

If public health nursing is indeed a synthesis of nursing science and public health science, then it is important for us to be aware of developments in public health science that may have broad implications for our own disciplinary development and nursing practice. It appears, however, that developments in epidemiology, one of the sciences that contributes to population-focused nursing practice, have not been integrated explicitly into such a synthesis. For example, nursing authors have frequently referred to “the” public health model (Hanchett & Clark, 1988; Chalmers & Kristajanson, 1989; Kleffel, 1991; Shortridge & Valanis, 1992), meaning the classic epidemiologic triad of host–agent–environment (HAET), as though it was the only public health model or even the dominant model. There has been limited recognition of more recent models, such as the “web of causation” (McMahon, Pugh, & Ipsen, 1960).

Hanchett and Clarke (1988), more than a decade ago, argued that a synthesis of public health science and nursing science was not possible on the basis that concepts in the HAET model were not congruent with nursing's metaparadigm concepts (person, environment, health, and nursing). They pointed out that the HAET model implies a strict focus on disease prevention whereas health is the primary focus of nursing. Their argument was that, although the epidemiologic concepts of environment and host have parallels with nursing's concepts of person and environment, they are defined differently and are therefore incongruent.

Hanchett and Clarke's challenge to the relevance of epidemiology in nursing foreshadowed a decline in the importance of epidemiology in the curricula of many schools of nursing. Widespread nursing critiques of positivist science and the increasing alignment of epidemiology with clinical medicine (versus public health) have distanced the concerns of epidemiology from nursing. Hanchett and Clarke's specific concern about the congruence between epidemiology and public health nursing also paralleled concerns expressed by epidemiologists themselves about the science's relevance for public health in general (Pearce, 1996; Shy, 1997; Taubes, 1995).

Yet, Hanchett and Clarke's simplistic “either/or” analysis may explain their difficulty in seeing the possibilities for synthesis that might arise from a more dialectical analysis. Moreover, their argument reflected an outdated understanding of epidemiology. Not only did they ignore developments in social epidemiology, which challenged epidemiology's exclusive focus on disease rather than on the determinants of health (Tannahill, 1992; Scott-Samuel, 1989; Ashton & Seymour, 1988; Macdonald & Bunton, 1992), but they also ignored the dominant public health model of the day—the web of causation. Had they explored the congruence between nursing and the “web,” for example, rather than the HAET model, they might have found more basis for synthesis. As Kreiger (1994) pointed out, the web metaphor taps into an intuitive sense of interconnection that has long been a part of many philosophic traditions. The image of an elegantly linked network of delicate strands with multiple connected intersections certainly suggests some possibilities for congruence with nursing theories that emphasize the interconnectedness of persons and their environments (Falk Rafael, 2000; Kleffel, 1996; Rogers, 1970; Watson, 1999).

Although the dominant epidemiologic paradigm has begun to shift and controversies have raged within epidemiology over the past two decades, one would not be aware of this by reading the community health nursing literature. In fact, almost nothing has changed in the epidemiology chapters of community health nursing textbooks over the past 20 years to reflect the intellectual ferment going on in a discipline that we claim has relevance to our practice. For example, the epidemiology chapter in one recent community health nursing text (Hitchcock et al., 1999) did not even mention the web of causation despite its centrality in the current practice of chronic disease epidemiology. Although other nursing authors have more recently begun to give the web of causation its due (e.g., Brunt & Shields, 1999; Clark, 1999; Allender & Spradley, 2001), this recognition has occurred only at a time when the chronic disease paradigm in epidemiology is fading and we stand at the edge of a new epidemiologic era. Thus, it appears that public health nursing is only paying lip service to the notion of synthesis. The purpose of this article therefore is to facilitate an updated synthesis by exploring historical developments and current controversies in epidemiology and to consider the relevance of these to the evolving theory and practice of public health nursing.

DEFINITIONS OF EPIDEMIOLOGY

Epidemiology has been called the basic science of public health, although several authors have challenged its hegemony as “the” basic science (Kreiger, 1999; Tannahill, 1992; McQueen, 1994; Savitz, Poole, & Miller, 1999). The term epidemiology is derived from the Greek words epi (upon), demos (the people), and logos (knowledge), thus meaning the study of what happens to people (Mulhall, 1996; Spradley & Allender, 1996). Even though the origins of the term do not include anything about “disease,” epidemiology came to be associated with the infectious disease epidemics of the 19th century (Tannahill, 1992).

Since then, epidemiology's definition has changed several times (Lilienfeld, 1978; Wall, 1999) to reflect the health challenges of different historical eras. Epidemiology was defined originally as the study of the distribution of disease in populations. Later, the definition expanded to include the study of the determinants of disease. The scope of epidemiology broadened in the 20th century, from a focus on infectious diseases to encompass chronic diseases as well as health-related states and events such as injuries, violence, environmental health concerns, and social conditions (McKeown & Garrison, 1995). More recently, epidemiologists have called for new definitions of their science to include study of the determinants of health, not just illness (Scott-Samuel, 1989; Tannahill, 1992; Kemm, 1993). Last (1995) defined epidemiology as “the study of the distribution and determinants of health-related states or events in specified populations, and the application of this study to the control of health problems” (p. 42).

EPIDEMIOLOGIC ERAS AND PARADIGMS

In the recent epidemiologic literature, there seems to be general agreement that the modern history of epidemiology can be divided into three eras, each dominated by a particular paradigm: (a) the era of the sanitary movement and its miasma paradigm, (b) the era of communicable disease epidemiology with the germ theory paradigm, and (c) the current era of chronic disease epidemiology with its risk factor paradigm (Susser & Susser, 1996a; Susser & Susser, 1996b; Schwartz, Susser, & Susser, 1999). Each of these eras is or was associated with a particular public health model that guided and informed research and practice.

Although the risk factor paradigm may be the prevailing perspective in epidemiology and public health, it has been undergoing serious challenge for over a decade (Loomis & Wing, 1990; Skrabanek, 1994; Taubes, 1995; Pearce, 1996). Thus, epidemiology is in a state of turmoil and transition (Wall, 1999; Kreiger, 1994; Pearce, 1996; Winkelstein, 1996; Weed, 1998). The paradigm that will reign in a new fourth era has yet to be determined, but ecosocial or eco-epidemiology (Kreiger, 1994; Pearce, 1996; Schwartz et al., 1999) has been proposed as a possible contender and one that I will argue later comes closer to being congruent with emerging theoretical perspectives in nursing. I will return to a discussion of this paradigm and its associated metaphors, but first let us review each of the eras in turn.

The Era of the Sanitary Movement

The Sanitary movement gathered force in the early 1800s and reached its zenith in mid-century, although it had its roots in 17th century observations in Europe about disparities in morbidity and mortality across society in the wake of the plague and other epidemics (Susser & Susser, 1996a). The ancient miasma theory of disease causation, which goes back to early Greek and Roman times (Koplan, Thacker, & Lezin, 1999), underlay the sanitary interventions of the era. Miasma theorists suggested that harmful odors, mists, or substances (i.e., pollution), particularly resulting from organic matter in the environment, contributed to the development of disease. Thus, public health officials tried to control the rampant epidemics in the urban environments of a rapidly industrializing society by eliminating accumulated waste, cesspools, and contaminated water. They considered these to be the miasmic breeding grounds for epidemics. Public health measures accordingly focused on sewage management, drainage, clean water, ventilation, and other sanitary measures.

Nurses will recognize the focus of Florence Nightingale's practice in these strategies. The connection between poverty and poor sanitation was evident to the early sanitary reformers; hence, there was concurrent attention to nutrition, improved housing, and working conditions. Even though the theory underlying the interventions was inaccurate, the strategies were nonetheless effective in improving the health of the population. In the sanitary era, public health action was truly population focused and major public health achievements occurred. Epidemiology and public health practitioners of the time, including nurses, retained a central concern with the public's health and its social distribution (Susser & Susser, 1996a).

The Era of Infectious Disease Epidemiology

The next era was heralded by the discovery of germ theory, which led to the application of laboratory sciences to public health practice. This was a radical shift in focus, which was opposed by the sanitary reformers, including Chadwick (the father of public health) and Florence Nightingale who dismissed germ theory as being “on the same footing as witchcraft” (Schwartz et al., 1999: 23). One might wonder if such strong opposition was born out of fear that the new theory would turn attention away from the social distribution and causes of disease, which indeed it did.

Advocates of the new school criticized the sanitary reformers for carrying the danger of filth to an extreme (Scamman, 1934). Although laboratory science dominated epidemiologic research in the early 20th century, there were early critics who opposed the emphasis on infectious disease epidemiology because it could not explain all patterns of illness at a population level (Greenwood, 1935; Sydenstricker, 1933). These critics believed that the environment and social conditions surrounding illness needed to be considered.

In the latter part of the 19th century, as germ theory was gaining momentum, Lillian Wald founded public health nursing in the United States and coined the name (Buhler-Wilkerson, 1993). Despite the individualistic and biomedical focus that emerged with germ theory, Wald held a vision of “nursing practice that went beyond the care of individuals and families, to encompass an agenda of reform in health, industry, education, recreation, and housing” (Buhler-Wilkerson, 1993: 1780). Wald's experience working with the sick poor in crowded tenement homes led her to recognize that the illness she encountered in families could only be understood within the context of a larger set of social problems. In Wald's vision, the work of the public health nurse was built on an understanding of the social, environmental, and economic conditions experienced by those who were sick. Similar developments occurred in Canada by the Victorian order of nurses (Falk Rafael, 1999a), nurses in religious orders, and other public health nurse pioneers who shaped the practice of Canadian public health nursing (Duncan, Liepert, & Mill, 1999).

Although public health nursing began officially early in the era of infectious disease epidemiology, initially, nursing was not seduced by germ theory and retained the broad-based social and environmental concerns of the sanitary era well into the 20th century. Unfortunately, this view eventually became marginalized with the growth of the medical–industrial complex which cemented the biomedical emphasis on single-causative agents. The focus of the infectious disease era was on tracing specific agents, interrupting transmission through environmental control and enhancing host resistance through immunization (i.e., the HAET model). Germ theory dominated public health science and practice through to the mid-20th century.

Although the early public health leaders of this era, including public health nurses, continued to espouse a public health perspective on disease prevention, traditional population epidemiology and the social dynamics of disease seemed to be forgotten in the push to achieve ever greater precision in laboratory identification and isolation of infectious agents and in the development of vaccines (Pearce, 1996; Susser & Susser, 1996a). Not that these were not important, even dramatic, public health achievements, it is just that they tended to take the limelight away from a concern with social conditions. Near the end of the infectious disease era, public health was greatly weakened by the shift in power and resources to hospital-based services.

The Era of Chronic Disease Epidemiology

The next epidemiologic transition occurred at mid-20th century when infectious diseases were declining in the developed world and chronic diseases became the major causes of morbidity and mortality (Terris, 1976). Germ theory thus lost its force. Epidemiologists in the late 1940s challenged the germ theory paradigm for being too narrow, arguing that it limited the scope of epidemiology for addressing the important public health concerns of the day, which were increasingly about chronic diseases (Susser, 1985). These scientists viewed the classic epidemiologic triad of host, agent, and environment as too simplistic to explain the nature of causation in chronic illness, and a new model called “the web of causation” emerged (McMahon et al., 1960) thus leading to the “risk factor” paradigm (Susser & Susser, 1996a) in epidemiology and public health, sometimes referred to as the “black box” paradigm (Weed, 1998).

The basic premise of this paradigm is that patterns of health and disease can be explained by a complex web of interconnected risk and protective factors rather than by direct causative agents (Kreiger, 1994). Epidemiologists believed that improvement in the health of the population rested on their ability to identify the strands and points of connection in this web. Public health practice focused on breaking the strands of the web, at their most proximal locations, to interrupt the causal pathways. The implicit assumption in the web of causation is that there is no need to understand the underlying biological mechanisms of disease to effect prevention—thus, the “black box”—a metaphor for a self-contained unit whose inner processes are hidden from view (Susser & Susser, 1996a).

Health policy in most developed nations of the world was greatly influenced by the risk factor paradigm, as reflected in a number of important policy documents. These included the Lalonde Report in Canada (Lalonde, 1974), the report of the Task Force Report on Health Promotion and Consumer Health Education (1976) and Healthy People: The Surgeon General's Report on Health Promotion and Disease Prevention (U.S. Department of Health, Education and Welfare, 1970) in the United States, and Prevention and Health: Everybody's Business (Department of Health and Social Security, 1976) in UK. Not surprisingly, nursing practice also reflected the influence of the risk factor paradigm. Many nurses adopted a lifestyle modification approach to health promotion in which they utilized education and marketing strategies to persuade clients to change their individual health behaviors in the interest of preventing chronic illness (Kulbok, Baldwin, Cox, & Duffy, 1997; MacDonald, 2001; Pender, 1982; Pender, 1996).

THE CURRENT EPIDEMIOLOGIC TRANSITION

The transition between each of the first three eras was difficult and fraught with controversy, which ultimately had a tremendous impact on public health practice, radically altering its focus in each succeeding era. There is every indication to suggest that the new directions taken by epidemiology in the early years of the new millennium will affect public health practice in ways even more profound than germ theory did in the 19th century. But, as (Falk Rafael 1999b) has cautioned, it is essential that nursing stay focused on nursing rather than being driven solely by dominant paradigms in public health. When paradigm shifts in public health lead to changes in philosophy, structure, and organization, there can be a resulting shift in the focus of public health nurses away from nursing, often with adverse consequences (Falk Rafael, 1999b).

It is therefore important that public health nurses understand the issues in the latest epidemiologic transition; hence, we can, on the one hand, make thoughtful choices about what is relevant to integrate into our own synthesis and, on the other hand, influence the direction that public health practice will take in the next decade or more. The issues related to the current epidemiologic transition can be grouped under three broad themes: (a) criticisms of the risk factor paradigm in chronic disease epidemiology, (b) two emerging directions in epidemiology that threaten to split that discipline, and (c) changing global health patterns.

Criticisms of the Risk Factor Paradigm

Susser (1999) states that there are two major limitations of the risk factor paradigm. The first is “its steadfast commitment to a single level of organization, the study of individuals almost always disconnected from each other” (p. S1020).

Chronic disease epidemiology has succeeded in refocusing public health efforts away from populations onto individual risk factors with strategies targeting individual behavior change (Pearce, 1996). Implicit in the web of causation is a hierarchy of factors and those that have received most weight are the immediate biological and lifestyle causes of disease in individuals or other factors that can be addressed at the individual level through education or medical treatment (Kreiger, 1994). Macrolevel social and environmental concerns have received considerably less attention.

The web does not encourage us to make a distinction between the determinants of health and illness in individuals and populations even though we have long recognized that what affects health and illness production at the individual level is not the same as what produces population patterns (Rose, 1985). Instead, proponents of the web see populations as merely the sum of individuals. Yet, we know that populations have unique characteristics in their own right, just as individuals do. At each succeeding level of organization, collective properties are acquired, which do not belong necessarily to individual members of the group, and these are more than the sum of individual properties (Susser, 1999). A classic example of a population characteristic that has no corresponding representation at the individual level is herd immunity (McMichael, 1999).

Thus, the emergence of the web of causation model succeeded in shifting epidemiology away from its traditional questions about the origins of population patterns and why these exist or change. The exploration of social context and societal level influences on health status in both individuals and populations has been virtually ignored in much of the risk factor research. This has important implications for the adequacy of epidemiology as a knowledge base for public health action. A focus on individual level research means that knowledge will be limited for taking action on many important public health issues at the community and societal level, such as poverty and social inequities in health status.

The second major limitation of the risk factor paradigm, as noted previously, is that the underlying linkages between exposures and outcome are not viewed as important. Epidemiologic research has focused on the relationship between the inputs (risk factors and exposures) and the outputs (disease or health events), with little concern for the transformational processes in between (Susser, 1999). Thus, epidemiology has been characterized as “atheoretical” (Saracci, 1999), although one could argue that implicit theories of causation drive decisions about how a problem is framed and studied. Kreiger (1994) argues that biomedical individualism is the implicit theoretical framework of the web of causation.

In summary, the risk factor paradigm allows little room for research questions about either the influence of macrolevel social and physical environments on health, disease, and well-being or the microlevel biological processes by which disease occurs and health improves (Schwartz et al., 1999). In fact, the gold standard research design in epidemiology, the randomized controlled trial (RCT), exemplifies both the limitations of the risk factor paradigm. To establish a relationship between risk factors and disease, RCT researchers strip away contextual factors to control bias and limit confounding. At the same time, to economize and simplify, they ignore microlevel mediation (Susser, 1999). However, chaos and complexity theory (Gleick, 1987; Waldrop, 1992) suggest that it may be more important to understand the complex nature of relationships in an ecologic sense than to understand simple mechanisms stripped off their biological and social contexts. Risk factor epidemiology, however, has had notable successes, such as identifying the relationship between smoking and lung cancer, or between folic acid deficiency in pregnancy and neural tube defects. Thus, it is important not to “throw the baby out with the bathwater” (Pearce, 1999: S1016). As McMichael (1999) observes, the problem is not in doing risk factor research, it lies in doing only risk factor research.

Two Emerging Directions in Epidemiology

The limitations of the risk factor paradigm have spawned a schism in the discipline of epidemiology (Adami & Trichopoulos, 1999; Saracci, 1999; Susser, 1999). The challenges to this paradigm have led many epidemiologists to move in one of two directions—toward the microlevel of molecular epidemiology on the one hand or macrolevel of social epidemiology on the other, and there is a rising tension between them (Saracci, 1999).

Molecular epidemiology had its origins in infectious disease epidemiology, that is, in studies that used molecular techniques to subtype infectious pathogens (Hunter, 1999). More recently, these techniques have been used to improve assessments of risk factor exposures or to define inherited susceptibility in chronic diseases through DNA fingerprinting, particularly in cancer. At present, there are limitations to these techniques, but it is only a matter of time before these constraints will be overcome. Now that the Human Genome Project has nearly completed its mapping of the sequence of all human genes, it will be possible to determine individual susceptibility to a variety of diseases (Hunter, 1999; Munro, 2001). The advancement of molecular biology and epidemiology raises a number of critical issues, not the least of which are ethical concerns. These have been elaborated elsewhere (Hunter, 1999; Koenig & Stockdale, 2000; Strohman, 1993).

More germane to this discussion is the concern of public health professionals that the new molecular epidemiology may become the germ theory of the new millenium. Susser (1999) and others (Loomis & Wing, 1990) have argued that microlevel epidemiology is as forcefully attractive today as germ theory was in the 19th century. What makes it so attractive is its apparent definitiveness and specificity, and the public has always been enthralled with high technology (Koenig & Stockdale, 2000). The problem is that the “sexiness” of high technology and the power and influence of medicine makes it entirely possible that, once again, broad-based social and environmental conditions and their relationships to health and disease will be swept under the carpet by the “hype” of molecular medicine.

Molecular epidemiology involves very expensive technology, and the benefits may not ever be experienced by the majority of the world's poor. Health inequities will surely be perpetuated if great care is not taken to prevent this. Many have argued that the major issue for public health is how health improvements become distributed in the population (Saracci, 1999; Wall, 1999; Kreiger, 2001a). If so, then the potential for molecular epidemiology and biology to draw a disproportionate share of research resources, relative to their benefits for population health, does indeed raise legitimate concerns. The WHO Advisory Committee on Health Research argues that there is potential for improving health in developing countries through the genomics revolution [World Health Organization (WHO), 2002]. First, however, we must address a highly complex set of scientific, economic, social, and ethical issues if genomics research is to benefit the poor in developing countries.

On the other side of this divide is social epidemiology. (Kreiger 2001a) has traced its evolution from the first published use of the term in 1950 (Yankauer, 1950) through to the first published textbook in 2000 (Berkman & Kawachi, 2000). Before the emergence of social epidemiology, social factors in disease and health were treated as “mere background to biomedical phenomena” (Kreiger, 2001b: 693). The basic premise of social epidemiology is that health, disease, and well-being are the result of socioenvironmental, political, and economic factors and that population patterns of health and disease are rooted in the social organization of society (Kreiger, 2001a). Whereas molecular epidemiology integrates biomedical theories into epidemiologic inquiry, social epidemiology integrates sociological frameworks. Yen and Syme (1999) have argued that social environmental factors are particularly important in guiding public health practice because they play a crucial role in the design of prevention and health promotion strategies, particularly those interventions that go beyond a focus on individuals and are place-based or at the structural level.

Although there appears to be widespread recognition within epidemiology that a future challenge is to incorporate social contexts into the understanding of the health of populations (Beaglehole & Bonita, 1998; Frenk, 1993; Kemm, 1993; Kreiger, 2000; McMichael, 1999; Pearce, 1996; Wall, 1999; Yen & Syme, 1999), the reality is that social epidemiology is a small branch of the discipline with relatively fewer resources devoted to research than for other branches. (Kreiger 2001a) found that only 4% of the Medline references indexed as epidemiology between 1966 and 2000 were prefaced with the word “social.” It is evident that social epidemiology has, until recently at least, held a marginal position in the discipline.

The major question in social epidemiology is, “Who or what is responsible for population patterns of health, disease, and well-being, as manifested in present, past, and changing social inequalities in health” (Kreiger, 2001a: 677). Within social epidemiology, there is some tension between theories that find the cause of social and health inequalities within individuals (psychosocial theories) and those theories that name societal characteristics as the most important determinants of inequalities (social production of disease/political economy of health theories). But neither of these two types of theory find any place for biological “reality” in understanding population health patterns. As (Kreiger 2001b) argues, people are simultaneously social and biological beings and thus no biological process can be devoid of social context nor can any social process be unmediated by our biology. And hence, social epidemiology is somewhat lacking in its ability to explain population health just as molecular epidemiology is similarly lacking.

Shifting Global Health Patterns

Despite the emphasis in the developed world on chronic diseases since the end of World War II, infectious disease epidemiology has always been important in the developing world where the major causes of morbidity and mortality are still infectious diseases (WHO, 2000). In the developed world, however, recent changes in the patterns of communicable disease have reminded us of the continued relevance of infectious disease epidemiology. But, at the same time that communicable diseases remain the major threats to health in the developing world, those countries are poised on the verge of their own epidemiologic transition in which we can expect a major increase in chronic disease incidence, followed by dramatically increased morbidity and loss of life.

With respect to emerging patterns of communicable disease, there are three aspects that raise particular concerns (St. John, 1996). First, there are diseases caused by totally new pathogens, such as human immunodeficiency virus (HIV), which has emerged to become a global threat that we have been unable to bring under control using traditional strategies. It is unlikely that scientists or practitioners working at a single level (i.e., biological versus individual versus population versus societal) will be able to prevent and control the global spread of HIV. A more comprehensive model is needed that considers simultaneously such factors as the means and timing of transmission (biological level), the social behavior of individuals that fosters transmission (individual level), population patterns of sexual relationships, breastfeeding, nutritional status, and other relevant population characteristics, as well as the social conditions that support and sustain transmission (population level), and the interconnections among societies that will dictate the path of infection (societal/global level).

The second pattern is that known pathogens, with a previously well-defined ecologic niche, have emerged in new niches. The Hanta virus, which caused outbreaks in the North America during the 1990s, is an example of such a pathogen, which normally lives in deer mice but has jumped species to infect humans and may now be spread through human to human transmission (Damazo, 1999). Ebola is another new and mysterious communicable disease with a very high mortality rate for which there is no known reservoir in nature and for which the cause of outbreaks is not clearly understood. It seems likely, however, that disturbances to its ecologic niche have occurred as civilization has spread into previously uninhabited areas, thereby changing the natural landscape and environment creating conditions for its spread (Sy & Long-Marin, 2000). Complex factors at biological, individual, organizational, national, and global levels affect the emergence of new diseases. Without a multilevel perspective, we may be unable to deal with this emerging challenge.

Third, and of particular concern in the developed world, is the fact that “old” diseases, such as tuberculosis, have reemerged as major threats due to antibiotic-resistant bacteria and as a secondary infection to HIV. Tuberculosis (TB) is most prevalent among vulnerable and marginalized populations, including the homeless, the poor, drug users, aboriginal peoples (at least in Canada), and the elderly. TB is now the most common infectious cause of death worldwide (St. John, 1996; WHO, 2000). To address this issue, we need simultaneous attention to the biological issues of immunity, transmission, and antibiotic resistance; the social, political, and environmental conditions within which TB is spread in particular populations; individual practitioner actions related to treatment decisions and disease management; and personal decisions related to completing prescribed treatment.

In addition to the above threats, we now know that infectious agents are implicated in diseases we formerly thought were chronic of noninfectious origin, such as peptic ulcer (Marshall & Warren, 1984), cancer (Ewald, 2000), and now perhaps even cardiovascular disease (Ewald, 2000; Hooper, 1999). (Susser and Susser 1996b) argue that this blurring of the boundaries between infectious and chronic diseases is a hallmark of the new era. It is clear that this has important implications for preventing and managing the traditional chronic illnesses. Research to understand the evolving complexity of these conditions must take place at the biological, individual, social, and global levels.

ON THE VERGE OF A NEW EPIDEMIOLOGIC ERA

The turmoil related to the three sets of issues discussed above has set the stage for the potential emergence of a new and unifying era in public health. The emerging and reemerging communicable diseases are a major threat, especially in the face of what some have argued is the “global collapse of public health” (Garrett, 2000). We have a greater understanding of the biological process by which environmental, social, and structural conditions can influence health and disease. And, we now know that social and structural conditions in society are integrally related to local, national, and global inequalities in health status. It is clear that neither past nor present epidemiologic paradigms are capable of explaining, by themselves, the complex nature of current health and illness states among the world's populations. Nor are these paradigms capable of guiding public health action at the multiple levels necessary to affect positive health outcomes and improve quality of life. Yet, all of these perspectives have something to contribute to our understanding of population patterns of health and illness. A new paradigm that extends beyond each of the previous and emerging ones yet encompasses them all might be very useful. Such a paradigm is ecosocial epidemiology.

Congruent with developments in the new public health and/or health promotion, this ecosocial model seeks to embrace population-level thinking without discarding biology or rejecting the notion of human agency, while at the same time rejecting the underlying assumptions of biomedical individualism (Kreiger, 1994). It acknowledges the social production of illness at the same time that it acknowledges the role of human biology. This ecosocial view is consistent with the health promotion model of the Ottawa Charter (WHO, 1986; MacDonald, 2001) and the Alma Ata Declaration on Primary Health Care (WHO, 1977). The basic premise of ecosocial theory is that health, disease, and well-being are socially produced within constantly evolving biological and socially conditioned parameters that are integrally connected (Kreiger, 1994). This represents a shift away from traditional deterministic thinking in epidemiology—a radical shift for a science that speaks of the “determinants” of health and illness.

Different metaphors have been proposed to represent the multilevel ecosocial epidemiology, although it has been a struggle to identify one that can capture the complexity of this view (Kreiger, 1994). (Susser and Susser 1996b) have proposed the metaphor of “Chinese Boxes”; a nest of boxes each one holding within it another box representing successive levels of organization. Each box represents a localized structure, relatively bounded that can be described in its own terms, yet is intimately related to the other levels. Another metaphor was proposed by Kreiger (1994) that reflects a fractal pattern from chaos theory (Mandelbrot, 1977; Gleick, 1987). The graphic is a tree-like structure that merges two metaphors, one social and one biological: “the continually constructing ‘scaffolding’ of society that different social groups daily seek to reinforce or alter,” and the other an “ever-growing ‘bush’ of evolution, together defining the potential and constraints of human life” (Kreiger, 1994: 896). As in all fractal images, the same pattern exists at each level of organization from subcellular to societal, repeating indefinitely. Kreiger argues that this image reflects an understanding that societal patterns of health and illness are inextricably interconnected at all levels, so that the social and the biologic cannot be divorced. Through its fractal nature, the metaphor does not allow the individual to be viewed separately from society or the environment, nor does it take away from the “irreducible individuality” of people.

The ecologic perspective of the ecosocial model is evident in the holistic view that human agency (individual level), societal structures and the environment (macrolevel), and microbiologic processes (microlevel) are mutually influential in shaping population patterns of health, well-being, and disease. The knowledge gains of infectious disease, chronic disease, molecular, and social epidemiology are integrated within a view that situates the health status and actions of individuals (and the influences on these) within their social, historical, and biological context. Overall, ecosocial epidemiology recognizes population thinking in the study of individuals and individual variability (and similarity) in the study of populations (Kreiger, 1994).

The new ecologic approach also calls for new methodologies and forms of practice. Schwab and Syme (1996) have argued that the new paradigm in public health offers a way forward for epidemiology in the area of methodology. Defining features of the new public health include not only its ecologic perspective but the notions of collaboration and community participation. Participatory research methodologies that include qualitative analyses may be part of the future of epidemiologic research. For example, a graduate student in epidemiology was interested in studying the concept of youth empowerment at the community level as a determinant of health. The usual epidemiologic approach would require some way of measuring community empowerment in the youth population and determining its relationship to health outcomes. The problem was a lack of appropriate measures of individual and community level empowerment. Using the qualitative methodology of grounded theory and a participatory approach, she explored the process by which youth became empowered in an inner city community (Cargo, 1998). On the basis of this work, the development of a valid and reliable quantitative measure of youth empowerment is underway. A doctoral study of this nature would never have been approved in most epidemiology departments in the past, yet it is clear that such research can make an important contribution to knowledge development in the discipline.

Scott-Samuel (1989) has also called for a new “truly social, truly critical” development in epidemiology if it is to provide an adequate knowledge base for the new public health. But, he says, this new community epidemiology should be participative, collectivist, nonexpertist, and subjective. This will be an enormous challenge in the face of traditional methodological perspectives in epidemiology, but a movement forward is underway.

NURSING AND ECOSOCIAL EPIDEMIOLOGY

So how does ecosocial epidemiology relate to nursing? Many of you will recognize familiar themes in the foregoing discussion as reflecting some of the same developments, debates, and tensions within nursing that have occurred over the past one to two decades. Although the two disciplines have always had very different theoretical underpinnings, aims, strategies, and methodologies, their recent similar developments suggest that public health nursing and epidemiology may be moving closer to a common understanding on a number of issues.

Just as the risk factor paradigm has faced criticism within epidemiology, similar criticisms of the risk factor or “lifestyle” approach to health promotion have been raised by nurses (Brown & Piper, 1997; Dreher, 1982; Drevdahl, 1995; Williams, 1989). Although nursing authors were initially uncritical, more recent critiques have challenged this individualistic approach in nursing, public health, and health promotion that emerged during the chronic disease era of public health (Liashenko, 2001; MacDonald, 2001). The lifestyle approach in nursing, although still practiced, has been transcended by a radically revised vision of health promotion that emerged following release of the Ottawa Charter on Health Promotion (WHO, 1986; MacDonald, 2001). As I argued above, this revised vision is consistent with the emerging ecosocial paradigm in epidemiology. Many nursing authors have argued similarly that the ecologic view of health promotion put forward in the Ottawa Charter is relevant to nursing theory and practice (e.g., Canadian Public Health Association, 1990; Sheilds & Lindsey, 1998; Falk Rafael, 2000; Uosukainen, 2001; Young & Hayes, 2001).

The concept of “environment” is foundational in nursing theory. Over the past two decades, in the face of global environmental degradation and economic globalization, nursing authors have begun to challenge nursing's traditional conceptualization of environment. These nurses argue that most nursing theories have focused on the immediate psychosocial environments of individuals to the exclusion of social, political, and environmental contexts that affect the health of individuals, communities, and populations (Chopoorian, 1986; Starzomski & Rodney, 1997; Stevens, 1989; Kleffel, 1991). Similarly, epidemiologists have called for a reconceptualized understanding of the environment in epidemiology (Kreiger, 1994, Kreiger, 2000), recognizing the importance of the sociopolitical milieu in addition to the traditional focus on the physical environment.

Calls within epidemiology for new methods of research and new forms of practice (Scott-Samuel, 1989; Schwab & Syme, 1996; Kreiger, 2000) are consistent with nursing theoretical perspectives that acknowledge the centrality of relationship, the paramount importance of individual and community control over defining problems and determining the solutions, and the imperative for active participation of individuals and communities in making decisions that affect their lives, including decisions about research. The artificial distinction between individual and community/population that has been articulated by ecosocial epidemiologists (Kreiger, 1994, Kreiger, 2000; McMichael, 1999) echoes similar assertions by nurses (Bent, 1999; Diekemper, SmithBattle, & Drake, 1999; Falk Rafael, 2000; SmithBattle, Drake, & Diekemper, 1997).

Just as an ecosocial perspective redefines epidemiology in ecologic terms, some nursing theories are also moving toward an ecocentric paradigm (Kleffel, 1996), which similarly draws from ecologic concepts reconceptualized from a nursing perspective. Terms like “irreducible individuality,” and “mutual shaping” pepper the discourse in both disciplines. There are even striking parallels between the metaphors used by both disciplines to describe their ecologic perspectives; metaphors which incorporate the notion of “the whole in the part, and the part in the whole” (Kreiger, 1994; (Kleffel, 1996; Susser & Susser, 1996b).

A full discussion of consistencies and similarities (as well as differences) between public health nursing and an ecosocial perspective in epidemiology is beyond the scope of this already lengthy article. The point to be made is that both disciplines face in common many critical local and global health concerns, the dissolution of the public health infrastructure, and the need to develop knowledge for public health action at local, national, and international levels. Each discipline has recognized the limits of previous theories and paradigms and has drawn ecologic concepts into their models and theories to guide research and practice in addressing these almost overwhelming challenges. In nursing, we can no longer argue, as Hanchett and Clark did in 1989, that epidemiologic concepts are not congruent with nursing theory and practice. The fact that there is an emerging congruence between many of the concepts in public health nursing and epidemiology paves the way for an updated synthesis of public health science and nursing science.

ACKNOWLEDGMENTS

Parts of this article were originally conceptualized and written as a portion of a fourth year distance education course in Community Health Nursing developed by the author for the University of Victoria School of Nursing (Nursing 493A: Community Health Nursing), Victoria, British Columbia, Canada.

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Key words: ecology; ecosocial paradigm; epidemiology; history; nursing science; public health nursing

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