Epidemiology, Public Health, and Public Policy

I left the Centers for Disease Control and Prevention (CDC) more than 4 years ago to go to the Robert Wood Johnson Foundation (RWJF). RWJF had gone through a time of substantial rethinking about its role in society and come to the conclusion that the focus should not be grant-making; it should be creating social change for health. This could just as easily be said about public health — creating societal change to improve the health of the public. At its core, public policy is the way a society frames what it wishes to become. Does it want all children immunized? Does it want to limit the use of tobacco? Policy doesn't have to be federal legislation or regulation; it can be corporate or local or state. But an organization, a field, or groups that are about social change will find they are often about influencing public policy. How does this fit with epidemiology and its history, and the history of CDC? It is unlikely that John Snow would be revered in public health if he had merely studied cholera. His defining moment was when he removed the pump handle from the contaminated well that was the source of the epidemic. That intervention is honored with an award called the Pump Handle Award that is given by the Council of State and Territorial Epidemiologists. Our heroes have been tied to action. In 1983, giving the Wade Hampton Frost Lecture at the American Public Health Association meeting, Bill Foege, former CDC director, coined the term consequential epidemiology. Foege was taking sides in an active debate of the time by saying that epidemiology " is a tool to change the world, not merely to study the world " (unpublished material, 1983). The debate that Foege was speaking to was whether epidemiologists should engage in the political process. Should they advocate solutions about what should happen based on the science or merely do the science and let the advocates and policy makers use the science? Some people said that scientists would lose their objectivity if they took on this more activist role. This discussion has come back, quite strongly, in recent times in the context of the politicization of science. Politics and public policy can be tough business, especially recently. Bill Foege was of a very different opinion. It was his conviction that public health was inherently political, inescapably political. Foege argued that …