2001/10/01 by George Davey Smith · 2 citations
Social Sciences · Business, Management and Accounting · Health Professions · #Historical and modern epidemiology studies #Global Public Health Policies and Epidemiology #Obesity and Health Practices
paper · pdf · doi:10.1093/ije/30.5.1146
openalex publication_date 2001/10/01 · openalex created_date 2025/10/10 · openalex updated_date 2026/07/30
In 1944 the Association for Education in Citizenship published a pamphlet entitled ‘Health' by Major Jerry Morris1 (of the Royal Army Medical Corps), as one of a series of Handbooks for Discussion Groups. The preface to the pamphlets in this series said that they were intended to be used by discussion circles concerned with the social, economic and political problems that arose from the Second World War. The central problem the pamphlet dealt with was that of health as a social function: statistics on the current state of ill-health in Britain were presented (against the background of considerable improvement from the mid-19th century), the problem of socioeconomic differentials in health outlined and arguments in favour of a universal tax-funded health service presented. By way of a conclusion readers were exhorted to involve themselves in understanding—and through this improving—the health of the communities in which they lived (Box 1). TO THE READER Investigation The best way to make a further study of these subjects is to find out all you can about health conditions and health services in your own community. How many doctors and dentists? How are they distributed? How many clinics, how many hospitals? What is it like to be an out-patient? How many factories have medical officers? How many children are immunized against diphtheria or smallpox? How much of the milk is pasteurized or tuberculin tested? What does your council spend on health services? What has it done with its permissive powers? How much smoke in the air? How much overcrowding? How many parks, swimming pools, playing fields? How much does it cost and how long does it take to get into the country for a day's outing? How many factories and shops give holidays with pay? What are the local death-rates—infant mortality, tuberculosis in young persons, diphtheria, etc? In all these respects how does your community compare with neighbouring districts, with the whole country, with the best area? Why are there such differences? Taken from Morris JN, Health.1 In 1948—and now as a civilian—Jerry Morris became Director of the Medical Research Council Social Medicine Research Unit.2 This unit contributed importantly to the development of the methodology and practice of the epidemiology of chronic disease and in 1955 the Director published an article entitled ‘Uses of Epidemiology' in the British Medical Journal.3 This article was expanded into a book4 which, on publication in 1957, became one of the pioneering texts of 20th century epidemiology. Major Greenwood's 1935 Epidemics and Crowd Diseases5 had discussed occupational disease, psychological influences on morbidity, the importance of nutrition and the epidemiology of cancer, but it was largely concerned with infectious disease, as was the other pioneering text of 1957, Principles of Epidemiology by Taylor and Knowelden.6 What was new about Jerry Morris's book was illustrated in its characteristically modest preface, which pointed out that a more accurate title would be ‘Some uses of epidemiology in the study of non-communicable disease'. The book appeared at a time when epidemiology was undergoing a fundamental change. While exemplars of non-communicable disease epidemiology could, of course, be cited—the work of Goldberger and Sydenstricker on pellagra is the classic example—no systematic approach to the population aspects of non-communicable disease existed at the end of the Second World War.7Uses of Epidemiology, therefore, helped create the field that it documented. The area of concern of Uses of Epidemiology was similar to that of the Handbook for Discussion Groups, although the presentation was more attuned to an academic audience. There were seven uses of epidemiology in the 1955 British Medical Journal paper and there remained seven uses in the third edition of the book in 19758 (although the order of the fifth and sixth uses switched between the second9 and third8 editions). Box 2 reproduces the ‘recapitulation' from the first edition,4 and summarizes the way these uses were conceptualized. Epidemiology was seen as contributing to understanding the burden of disease in the community, changes in this over time (and perhaps projections of future burdens of disease), the characteristics of the health problems involved (their cause, their course, their nature and their response—or non-response—to health care) and the implications of this understanding for the health prospects of individuals. RECAPITULATION; GENERAL Epidemiology is the only way of asking some questions in medicine, one way of asking others (and no way at all to ask many). Seven ‘uses' of epidemiology have been described: In historical study of the health of the community and of the rise and fall of diseases in the population; useful ‘projections' into the future may also be possible. For community diagnosis of the presence, nature and distribution of health and disease among the population, and the dimensions of these in incidence, prevalence, and mortality; taking into account that society is changing and health problems are changing. To study the workings of health services. This begins with the determination of needs and resources, proceeds to analysis of services in action and, finally, attempts to appraise. Such studies can be comparative between various populations. To estimate, from the common experience, the individual's chances and risks of disease. To help complete the clinical picture by including all types of cases in proportion; by relating clinical disease to the subclinical; by observing secular changes in the character of disease, and its picture in other countries. In identifying syndromes from the distribution of clinical phenomena among sections of the population. In the search for causes of health and disease, starting with the discovery of groups with high and low rates, studying these differences in relation to differences in ways of living; and, where possible, testing these notions in the actual practice among populations. These various uses, it may be said, all stem from the fact that in epidemiology the group is studied and not merely particular individuals or cases in the group. The definition of groups involves accounting for all members; and this has immediate uses in the study of the natural history of disease. Describing group experience of health, disease and their circumstances is useful in itself, and it permits manifold comparisons in time, place and society. Epidemiology is today the cinderella of the medical sciences. Nevertheless, there have been advances during recent years in the study of lung and other cancers, dental caries, pneumoconiosis, of atherosclerosis, ischaemic heart disease, hypertension, of rheumatism, schizophrenia, the congenital malformations—to mention some examples. New ground is being broken in the investigation of health, in the determination of physiological norms, in studies of morbidity, in family studies, in application to genetics, in the study of psychological aspects. There have been improvements in techniques of sampling and surveys, diagnostic and screening devices, methods of prediction, in the estimation of observer validity and reliability, the treatment of qualitative data. The prospective study of cohorts, the combination of survey with case studies, international comparisons and field experiments are being increasingly used. The proposition might be advanced that Public Health needs more epidemiology; so does medicine in general; and, it may be said, society at large. Public Health needs more epidemiology—this cannot be doubted since epidemiology is the most likely basis for its further intellectual growth. Medicine as a whole needs more epidemiology because it is a social science as well as human biology and the epidemiological is the main method of studying the social aspects of health and disease. Moreover, epidemiology is rich with suggestions for clinical and laboratory research and it offers many possibilities for testing hypotheses emerging from these. The main relations of epidemiology with clinical medicine may be restated thus: Epidemiology is the study of populations and all cases that can be defined in them. These cases will often include, and in their due proportion, cases differing in type from those presenting to particular clinical attention (early disease, minor, the symptom-less cases, the somehow peculiar). The epidemiological method can also be used to identify subclinical manifestations and again in proper proportion to the clinical. Epidemiology thus helps to complete the clinical picture and natural history of disease. Epidemiology supplements the clinical picture by asking questions that cannot be asked in clinical medicine about the health of the community and of sections of it, present and past: it provides a different view of the world of medicine. Clinical problems are set in community perspective; health problems are revealed and indication may be given where among the population they might best be studied. Measurements can be made of the need for clinical services and how the needs are being met, thus providing an indicator of the quality of medical care. Finally, epidemiology by identifying harmful ways of living, and by pointing the road to healthier ways, helps to abolish the clinical picture. One of the most urgent social needs of the day is to identify rules of healthy living that might reduce the burden of the metabolic, malignant and ‘degenerative' diseases which are so characteristic a feature of our society. This is the main field today for the use of epidemiology. Taken from Morris JN, Uses of Epidemiology.4 Uses of Epidemiology contained a wealth of prescient ideas, which became a cornerstone for epidemiology as it developed over the second half of the 20th century. The book was certainly well received, as the quotes from the reviews in several journals (including Nature and the British Medical Journal) on the paper cover of the second edition9 attest. It was said that if read by clinicians the book would provide a new and fresh outlook on clinical problems, that it was one of the most significant contributions to the progress of preventive medicine in recent years, approached the stature of a minor classic, made exciting reading for the epidemiologist or any medical graduate and was a gold mine to the post-graduate research worker looking for a subject or a cause. Many ideas in Uses are simply included en passant, in a that the had considerable and in to make that were perhaps Discussion of many of these ideas has been expanded by others although perhaps the of the ideas has not in the While of in epidemiology may not have since the Uses first the nature of epidemiology has been The concern of most recent is health of populations has a to a of how to a from a study with and how to a view of to your study In had that recent work in epidemiology a concern for and the of that would to a and that at to all that is and in epidemiology an of and a view Jerry Morris In some ways the most of Uses was the on of health by was to of during the this medical as a for epidemiology. Research in this existed the in published a study relating health to in the and have that a in on research for health and medical at which Jerry Morris was the a in the of health services research in the the of and studies, and the for such the the clinical and the Morris certainly had with the view that health services only have a on population health to be in any concerned with some (and were healthy and some were In the of health in the first edition of Uses there were many of would now be to be services The of medical was illustrated with on the changing social distribution of at years, when most cases would be type 1). In the was in social and in social and the in all social but to a much for social and for social and to a in social of The is that the more social groups at an from the of and that had a on mortality, some much more in the quality of medical were through which were in for several health problems where treatment While differences in characteristics of the (and their account for much of it that differences in medical and also differences in health in medical practice was as a way of in at some was not being Morris that the in in some which be contributing to health service Morris that it was to the need for health in the population. needs for health and their for said to be the of research into has the of in which the is the of in a population can from medical the of with a particular Health services were not seen as being of the of and and could, in Morris's be said in the third edition of have an in the services with The current state of the of health services in the out in how this has to be largely through a of because it is in to the need for health services as an Uses are a of of about epidemiology which have been in the development of the there is for a examples. The of to disease to the of been given considerable in recent health The importance of the population approach was in are in population of or to the well on community health, and the burden on services out of all of the fact that clinical have to be to of medical which, not may have population has had considerable in recent Morris pointing out that the of health services to health be with other and a that the and often clinical for an Morris was involved in one of the first of these the World Health of in the of ischaemic heart disease, which over because this an in in the group to the its pioneering nature has been There has been considerable recent in the that groups over and the of the of and that these may disease of the which cannot be with is being and the of in infectious disease epidemiology has been to the need for in disease Morris discussed this with to in the first edition of a which has been that groups as groups which to infectious are not merely the of the of the individuals the to now in the present have been with are as or no systematic among the individuals in and often defined for the of the this a of the group as a in this psychological not the second In Morris that an if were to that the diseases are of the between and their place in the of causes in This view is in the recent which have been advanced for such as the of and and the by While the seven of epidemiology were in the in epidemiology was seen to be the of causes of disease. In the first the on about a third of the which had to about a half by the third much of the in the the other uses of epidemiology to how they can to understanding the causes of disease. For social differences in disease are in the on where it is pointed out that these differences can also provide useful to disease One concern of the Uses of Epidemiology that has to in more recent epidemiological is with the history and of disease. The book out with a of disease in It was concerned with the in rates, with indication of any improvement in from the through to the a during which The of ischaemic heart disease and lung to this was made These with causes of an proportion of from the and much attention in the book and its the causes of disease, the historical changes and differences between were of were a on be with such of in disease were also to the of disease the on and Morris are the social changes that the changes in the This of how the social be at the heart of the epidemiological although it Morris's own research on the of heart disease and of in in the increasingly population, While many of the problems epidemiology in the have been some One of the in Uses to the changing of during the when from ischaemic heart disease there was a in the of over this This to the that relating to were of a study of undergoing no in in the during the when looking at an of the in the ischaemic heart disease rates, it is to a in from of young in the (early and These have been as the high of in and the importance of It has often been that there was a in between the and The that the recent in ischaemic heart disease have been by changes in of the of the disease in This was discussed in several in For are that all the of hypertension, and heart disease as a that disease of may be in that in the experience of the and that there was of disease in The of in the years in the of in or how these have been how social circumstances in by social the of disease in These from Jerry Morris's These between and have a socioeconomic group in of over this of between and social circumstances is to account for the other causes of not the as disease, that and socioeconomic in other causes of in to not this study from has that different causes of different of with in and and are to social with from social circumstances over and heart disease and disease a of social circumstances the and lung and and a of social For some of these have a basis for the are as they For in this study was more with social circumstances and as is the of lung the disease would be to be by social is to an in and to family of or an and the to social circumstances would be to the of in as was The seen at an in prospective epidemiological studies can be with to the historical and in disease, as by Jerry It is that and diseases to in over the century in in with family and The of from these diseases as conditions in their It is not that the in and in several when an indicator of years is in relation to are seen for those causes of to be by and tuberculosis This that may and historical differentials in disease which, as Morris is an indication that they are likely to be of importance with to population The to chronic disease epidemiology the Second World was that of Morris of to the that as well as which are to the particular the clinical picture of disease'. It is how this from to these has developed over and is to for for social differences in These are to there is to disease in those in social the that one a of health among groups would to being of with the being the and of the This was the by by many to be the of social epidemiology in the in paper from of the social to from several that such a would the of socioeconomic differentials in particular causes of ill-health and are there is a considerable of in their with socioeconomic relating to from the study of among there was a in the between and For the and had a the and for the by The had a for seven of the the had a for The burden of and the is because the most to be those that of with socioeconomic such as lung with to the of with socioeconomic have from other In for a of causes of are presented from a of a third of a in the risks are given for with of the area of being used for this For some causes of disease, and heart are with risks The group had the for the group for these For other causes of such to as heart disease, lung and risks with were in the For these causes the had between and more those of the For a of causes of of minor to were or between and For in was more likely for because those more to The in the and of the between socioeconomic and attention to the need for which account for the and health of socioeconomic by how socioeconomic the distribution of for a of over time, and how this can by and is the for the most causes of to the most socioeconomic as particular causes of have more health problems over the of this the for to be among the most to on lung from to In when lung one of it no social by there was a the in social that of social similar picture is seen with to social differences in heart disease during the of in this as a of It the of social circumstances to some to The of these against the background of health and development in to the of disease. It be in this that lung disease for which a can be differentials over and those by While as a does not to health it is certainly to identify social which to being on those in social from to in different social of the social which they have The health and of the and of the individuals concerned and lung for which are in of future health These aspects of (and the of be as social as of health which, the social from The approach to health the and the social as being since aspects of can social in the way as social the ways in which the social the in of the social be a central of an at understanding of how health and how they can be The first edition of was much concerned with an in in and the international differences in the of were also Morris that this was a field that was not being and that may well be gold the By the to fall and by the second edition of Uses a was Morris discussed the work of and which in the rise (and of disease in analysis of from similar in all with some between in when the and In that the of contributions from and not the that a much of the research out in the and on to psychological it was the classic disease. In the third edition of Morris that there was no for hypotheses at the time, but was with these. pointed out that there was a in in the disease and that this to in with that the type of to the disease is not a that the is of a is In and Morris were that is a of The of is in a in with of the and and the of this health The of a in understanding and an disease. This was made by a and a with no from the of epidemiological research on this health epidemiology the century its uses of considerable importance in the The importance of the of by Jerry Morris is by the of epidemiology to more and more at the population individuals and their historical and social has much to to the of a new from at years of and of a new from at years of and in and and in and and disease in young disease in young risks of risks of of years in with at time of and at time of for of years in with at time of and at time of for of for of area of in in the study of for of area of in in the study social differences and to among of among of at time as social differences and to among of among of at time as of in relation to of of in The of heart diseases and lung and in the for low high of Health by published by the Association for Education in with of the to and Jerry Morris for on an of this