Introduction
In 2006, an epidemiologist named Larry Brilliant gave a TedTalk on the likelihood of a global pandemic in the coming years. With the onset of the COVID-19 pandemic in 2020, his prediction turned out to be true. Brilliant also brought up his work on the eradication of smallpox—a task that required international cooperation and resources. Both the public health efforts of the COVID-19 pandemic and the work to fight smallpox are products of a paradigm shift in how scientists learn about and deal with the disease.
Epidemiology, the study of determinants of health and health inequity, is engaged in a centuries-long arms race. As the world of public health adapts to novel infectious diseases, so too do those infectious diseases adapt to it. From my research, I determined that infectious disease (specifically communicable disease) is inextricably linked to human interaction. In a world of ever-expanding and entangling connections, the job of epidemiology is increasingly concerned with studying the effects of human interaction. The process of rationalization is changing both the way those effects are studied as well as the effects themselves. So how do we work to stop pandemics?
What is Rationalization?
Rationalization is a process of a field or organization toward maximizing a set of four principles: efficiency, calculability, predictability, and control. It is also a framework that I used to observe the occupation of epidemiology. Efficiency is the speed with which tasks are completed. Calculability is the transition of abstract qualities into usable quantities. Predictability is the consistency of a particular process/output. And control is the influence that the organization has over the consumers’ decisions.
History
Early infection control focused on causative agents The two most predominant examples of this were Humorism and Miasma Theory originating in the fourth and fifth centuries. Humorism stated that disease was caused by an imbalance of the body's four humors; Miasma Theory stated that it was caused by "bad air."
The problem with these theories wasn't just that they were wrong. It was that they emphasized the cause of disease rather than risk factors. Risk factors are behaviors/characteristics which make someone predisposed for a specific dysfunction. Focusing on causative agents simply gives an incomplete understanding of the behavior of that dysfunction. Epidemiology is a departure from the world of describing disease to the world of analyzing disease. The rationalization of epidemiology is driving this paradigm shift.
The work of John Snow in London represents modern epidemiological philosophy in microcosm. In 1854, John Snow observed a prevalence of gastrointestinal disease in London. Instead of prescribing bloodletting, John Snow looked at shared locations and behaviors of diseased individuals. He created an infographic comparing non-diseased from diseased with the location of drinking water. What he found was that the former tended to get water from the same community well. He prevented further infection and subsequently stopped the outbreak by blocking off that well.
In the context of John Snow’s work, the location of drinking water was a strong risk factor, but it didn’t cause the disease. The location simply facilitated the transmission of the pathogen. John Snow thus did not need to know the mechanisms of pathogenesis of cholera bacteria to stop the outbreak. He was therefore biasing toward greater calculability by collecting ample information to draw a conclusion.
CDC
The CDC was originally a malaria-fighting group during World War II. Then on July 1st, 1941, it expanded its sphere of influence to cover just about all communicable diseases (minus those of other organizations). I observed this shift through the lens of efficiency. It was economically inefficient to have an organization for specific diseases when the same work could be applied to a myriad of other ailments.
The CDC originally stood for the Centers for Disease Control, but that was changed to Centers for Disease Control and Prevention in 1992. I found this to be an essential addition with respect to epidemiology as it emphasized the shifting perspective on how public health operates. Dealing with outbreaks is far more cumbersome and expensive than preventing them in the first place. Prevention requires predictability.
As the CDC has broadened its areas of focus, it has also diverted more data collection responsibility to smaller, local health institutions. Instead of it taking on the responsibility of the whole, they created local public health. Locally-based public health organization recommendations yield precedence over state or federal because data collection is hyper-specific for each region. While state and federal public health are important for funding and broad disease recommendations, they are only there to facilitate greater information detail.
WHO
Similar to the CDC in the 1950s, the WHO focused on specific pestilences such as malaria and tuberculosis. This later expanded to meet the needs of other diseases as the WHO widened its role in global health. It made recommendations and brought together the members of the UN under the umbrella of coordinating public health efforts.
The CDC and WHO state themselves that the intention is not to be able to enforce their guidelines. Even countries that were "required" to submit health information would only experience the repercussions associated with violating their UN membership. This was a departure from the rationalization of other areas of public health. Instead of biasing toward greater control of the people in a given population, public health resists rationalization via minimized control.
One of the most significant triumphs of modern public health was on display in 1977 when the world was declared free of smallpox.
One of the most vital elements in eliminating smallpox was surveillance. October was the low point for smallpox transmission, so to stunt the spread of smallpox, the WHO established a strategy called eradication escalation. This involved heavily monitoring small groups of people during the virus’s off-season. When they identified a case, they had to work quickly to contain it. The important point here is the detail of the surveillance and the speed with which the WHO operated.
Prior to the eradication of smallpox, epidemiologists dealt with outbreaks as they flared up. This strategy marked a switch toward increased data collection of populations (calculability) and time sensitivity (efficiency).
Modern Epidemiology
Modern epidemiologists have few baseline credentials; however, the occupation has increased its monetary and opportunity incentives for specialization. After their undergraduate work, students must obtain at least a Master's of Public Health (MPH) or a Master of Science in Public Health (MSPH). That then fractals into several specializations such as infectious epidemiology, healthcare epidemiology, legal epidemiology (See COVID), and even quantum epidemiology. The highest-paid epidemiologists then go on to receive Doctoral degrees. In fact, every director of the CDC since 1953 has had an MD.
Two other optional opportunities are Epidemic Intelligence Service (EIS) training and the Certification in Infection Prevention and Control (CIC). The EIS is a two-year program that teaches post-undergraduate or graduate students applied epidemiology for future careers. 98% of people in this program go on to work in public health. The CIC is an exam that post-graduates can take to gain certification in infectious disease epidemiology. While neither are universally required, I found that the number of employers that require them has increased over the years.
Irrationalities
The same processes that influence the occupation of epidemiology toward greater rationalization led to the opposite outcomes as well. Irrationalities are consequences of biasing toward rationalization, often resulting in the opposite of the desired outcome. The work of modern epidemiologists is predominantly about dealing with the irrationalities from the transportation, agriculture, and communication industries.
Transportation
In modern cities, with people being able to travel from one side of the world to another in less than a day, so too can disease. From a historical standpoint, epidemics are a result of urbanization and domestication. If you have a dense enough population, the newly minted human pathogen has more opportunities to evolve and proliferate.
By increasing the efficiency with which people travel, we are decreasing the predictability of disease transfer and complicating the calculability of human movement and interaction.
Contact tracing is the response to this. Epidemiologists will look at one or two layers of contact between an infected individual and others. They separate the infected from the uninfected (known as isolation) and separate the exposed from the unexposed (known as quarantine). This is about risk assessment and preventing future infections. Through the lens of rationalization, I describe contact tracing as a tool for increased calculability and predictability of disease spread. Large-scale transportation and social events often make this impossible with super-spreader events where the web of exposures is too complex to track.
Agriculture
Antibiotics increased the efficiency of the healthcare system. Broad-spectrum antibiotics decrease both the morbidity and mortality of a given bacterial infection; thus, their use has expanded ever since. This led to antibiotics being used in agriculture when it was discovered that subtherapeutic doses of antimicrobials increase the size of livestock. Upwards of 80% of the current supply of antimicrobials is used for this purpose, and the consequence of this is a dramatic increase in the prevalence of antibiotic resistance.
New outbreaks of novel pathogens are even more likely now due to rationalized agricultural practices. As stated earlier, domestication (specifically of livestock) is a crucial factor in plague-causing pathogens. This is because livestock living in close proximity to humans provides greater opportunities for zoonosis (also referred to as “spillover”). Zoonosis is when pathogens in an organism mutate to be able to infect humans.
Most microbes in our bodies are harmless because they are adapted to our biology; they benefit from me living, the same way I benefit from my house not collapsing. The problem is that a zoonotic disease isn’t fully adapted to our biology and thus causes more damage to our tissues than it does in its origin species (known as the reservoir species). Zoonoses are the predominant source of epidemics because we have similar enough biology to spread but not similar enough to be harmless. As farmers increase the quantity of livestock, the density of their living arrangements, and their proximity to humans, so too increases the probability of emerging zoonotic infectious diseases.
Communication
Another example of irrationality comes from two sources: increased virtual connections and our natural cognitive biases. Organizations such as the CDC don’t have the regulatory powers as does the FDA. Whereas the FDA can ban certain products, the CDC predominantly provides recommendations. As such, the ability of public health organizations to perform their respective tasks is correlated with the trust they have sewn in a community and or government.
This is apparent in the adoption of mask or vaccine mandates for COVID-19. The rationalization of news media has certainly played heavily into this growing schism. With it, small and otherwise irrelevant news sources and influencers have developed larger, more densely supported platforms. In the age of algorithmically selected media, the more prominent sources are not the most reputable as much as the most eye-catching.
A less trusting population, mixed with a more interconnected world, mixed with an increased prominence of human-facilitated pathogens has occupied a greater proportion of the field of epidemiology. These issues are fueled by modern rationalized industries, leading to the exact opposite result of their intention.
What role has rationalization played in the COVID Pandemic?
Nowhere is the rationalization of epidemiology more apparent than in the current state of global health. Efforts to mitigate the effects of COVID-19 have revealed irrationalities in how countries structure international transportation and how larger corporations facilitate public discourse. Transcontinental flights catalyzed the spread of coronavirus, and unfettered news outlets catalyzed the spread of misinformation.
Before the FDA authorized the COVID vaccines and remdesivir, countries needed to use non-pharmaceutical interventions (NPIs) like lockdowns, testing requirements, and mask mandates to stunt the spread of COVID. At the same time, social media companies implemented fact-checkers on their platforms. Both of these are examples of an increased control of the public health processes in a given country.
We've also witnessed a significant increase in efficiency. In the timeframe that China responded to the novel coronavirus outbreaks, they were able to prevent approximately 67 times as many infections. If they had utilized NPIs,
...one week, two weeks, or three weeks earlier in China, cases could have been reduced by 66%, 86%, and 95%, respectively, together with significantly reducing the number of affected areas, (Nkengasong)
Because of the exponential spread of communicable diseases, the efficiency with which an epidemiologist responds to an outbreak is the subject of significant developments. That efficiency is supported by the increased calculability of predictive models of outbreaks.
Legal epidemiology
A legal epidemiologist studies the impact and development of public health-based legislation on a population. It is a growing field that has contributed to over 1000 health policy changes since the beginning of the COVID pandemic.
I identified two basic elements of modern epidemiology: recommendation and legal-based interventions. The former is the most prominent and is what sparked earlier governmental public health organizations. The latter used to be more common in the context of larger groups like schools and businesses. With the introduction of lockdowns, travel restrictions, and mask/vaccine requirements, legal epidemiology has moved the field into the realm of the individual and larger municipalities. This is a very recent and significant rationalization of epidemiology.
Another example of increased control and predictability is the introduction of COVID kiosk check-in stations in buildings. I compare this development to the introduction of food kiosks in McDonald’s and other fast-food restaurants. Instead of paying for the skilled labor of monitoring the movement of people in and out of a building, companies and schools are requiring people to act as prosumers by administering the screening questions and temperature checks before entering. The same shift exists in COVID testing. Originally, professionals administered the tests, but now we see more of the onus is on the patient to take their own sample.
Conclusion
Larry Brilliant’s warning of a global pandemic 16 years ago was significant not only in its accuracy but also in how it exemplified the philosophy of epidemiology. Pathogens adapt to the systems we have in place, and thus we must constantly be shifting our understanding of them. Epidemiology deals with this continuous shift through rationalization. Over the years, it has gradually increased the efficiency with which it deals with outbreaks, the calculability of disease spread and prominence, the predictability of human behavior and characteristics, and the control of human movement and political actions. On the flip side, I also concluded that epidemiology exists as a response to rationalization. Pandemics wouldn’t exist without agriculture to create the pathogens and transportation to spread them. The inherent interconnectedness of a rationalizing world tends toward more disease, and epidemiology deploys rationalization as a means of mitigating this trend.
Future Speculation
Epidemiology isn’t just about responding to public health threats as much as it is about prevention. And to be able to prevent, one much first be able to predict. All fields of modern epidemiology are biasing more toward predicting the future onset of disease (both communicable and not), so that efforts can be put into stopping fires before they even begin.
Epidemiologists have gone about developing better predictive models is by increasing the specificity of regional data. Global health is no longer about applying basic formulas and ideas to all areas around the world. Instead, global health will continue to fractal into specific areas with governments adopting stronger local public health operations.
Public health is moving in a more legislative direction. People within the public health sphere are pushing for a greater ability to control a given population through policy in high-risk areas like airports, farms, bus stations, and any high-density areas/gatherings. This has and will continue to make epidemiological studies more able to predict future public health issues.
Created by Lou Lindsley (Class of 2025)
Sources
“Brief History of Who.” Brief History of WHO | Credible Voice: WHO-Beijing and the SARS Crisis, https://ccnmtl.columbia.edu/projects/caseconsortium/casestudies/112/casestudy/www/layout/case_id_112_id_776.html.
Brilliant, Larry. “My Wish: Help Me Stop Pandemics.” Larry Brilliant: My Wish: Help Me Stop Pandemics | TED Talk, https://www.ted.com/talks/larry_brilliant_my_wish_help_me_stop_pandemics?language=en.
Burris, Scott, et al. “A Transdisciplinary Approach to Public Health Law: The Emerging Practice of Legal Epidemiology.” Annual Review of Public Health, vol. 37, no. 1, 2016, pp. 135–148., https://doi.org/10.1146/annurev-publhealth-032315-021841.
Burris, Scott, et al. “The ‘Legal Epidemiology’ of Pandemic Control.” New England Journal of Medicine, vol. 384, no. 21, 2021, pp. 1973–1975., https://doi.org/10.1056/nejmp2103380.
“CIC Certification.” APIC, https://apic.org/education-and-events/certification/.
“The Governmental Public Health Infrastructure - the Future ...” NCBI, National Academy of Sciences, https://www.ncbi.nlm.nih.gov/books/NBK221231/.
“Government's Responsibility for Public Health - CHS Administration Handbook - Minnesota Dept. of Health.” Government's Responsibility for Public Health - CHS Administration Handbook - Minnesota Dept. of Health, https://www.health.state.mn.us/communities/practice/resources/chsadmin/mnsystem-responsibility.html.
Grais, Rebecca F., et al. “Assessing the Impact of Airline Travel on the Geographic Spread of Pandemic Influenza.” European Journal of Epidemiology, vol. 18, no. 11, 2003, pp. 1065–1072., https://doi.org/10.1023/a:1026140019146.
Gray, Richard S. “Agriculture, Transportation, and the COVID‐19 Crisis.” Canadian Journal of Agricultural Economics/Revue Canadienne D'agroeconomie, vol. 68, no. 2, 2020, pp. 239–243., https://doi.org/10.1111/cjag.12235.
“Historical Perspectives History of CDC.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, https://www.cdc.gov/mmwr/preview/mmwrhtml/00042732.htm.
“How We Serve.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 4 Jan. 2022, https://www.cdc.gov/eis/what-eis-officers-do/how-we-serve.html.
“John Snow - The Father of Epidemiology.” MPH Modules, https://sphweb.bumc.bu.edu/otlt/mph-modules/ph/publichealthhistory/publichealthhistory6.html.
Jouanna, Jouanna. “Chapterseven - JSTOR.” JSTOR, Brill, https://www.jstor.org/stable/10.1163/j.ctt1w76vxr.12.
Kabat, Geoffrey C. “Taking Distrust of Science Seriously.” EMBO Reports, vol. 18, no. 7, 2017, pp. 1052–1055., https://doi.org/10.15252/embr.201744294.
Khachatourians, G G. “Agricultural Use of Antibiotics and the Evolution and Transfer of Antibiotic-Resistant Bacteria.” CMAJ : Canadian Medical Association Journal = Journal De L'Association Medicale Canadienne, U.S. National Library of Medicine, 3 Nov. 1998, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1229782/.
Martin, Sam, and Samantha Vanderslott. “‘Any Idea How Fast ‘It’s Just a Mask!’ Can Turn into ‘It’s Just a Vaccine!’’: From Mask Mandates to Vaccine Mandates during the COVID-19 Pandemic.” Vaccine, 2021, https://doi.org/10.1016/j.vaccine.2021.10.031.
Nkengasong, John. “China’s Response to a Novel Coronavirus Stands in Stark Contrast to the 2002 SARS Outbreak Response.” Nature Medicine, vol. 26, no. 3, 2020, pp. 310–311., https://doi.org/10.1038/s41591-020-0771-1.
“Principles of Epidemiology.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 18 May 2012, https://www.cdc.gov/csels/dsepd/ss1978/lesson1/section2.html.
Ritzer, George. The Mcdonaldization of Society. Sage, 2015.
Image References
Fig 5: "An 1855 map by John Snow showing..."
Fig 7: "World Health Organization"
Fig 9: "togolese, woman, child, vaccinated, smallpox"
(See Adobe References Below)
Credits:
Created with images by alfa27 - "professional disinfector male show stop gesture to coronavirus, epidemic COVID-19. worker in gas-mask and specialist protective suit conducts disinfection in contaminated area" • Casimiro - " epidemiology" • dusanpetkovic1 - "Experienced senior veterinarian in white uniform, hat and mask on face holding clipboard under armpit and closing up syringe while standing in cote surrounded by pigs." • Yury Zap - "really know Hippocrates" • MQ-Illustrations - "Centers for Disease Control and Prevention (CDC). Portrait of a man with face mask/breathing mask. Text on background (blue/green). Corona virus" • Gajus - "Pyramid build of blank wooden cubes" • Rawpixel.com - "Group of diverse graduating students" • Evgeny - "woman ecologist or epidemiologist takes water analysis in city river" • enanuchit - "Global business logistics import export background and container cargo freight ship transport concept" • putilov_denis - "Abstract futuristic - technology with polygonal shapes on dark blue background. Design digital technology concept." • dusanpetkovic1 - "Side view of calves on animal farm eating food. Meat industry concept." • Artinun - "Colorful capsule pills. Pharmaceutical industry. Healthcare and medicine background. Pharmaceutics concept. Antibiotic drug resistance. Pink, white, orange, red, green, blue, and gray capsule pills." • Blue Planet Studio - "Human Resources Recruitment and People Networking Concept. Modern graphic interface showing professional employee hiring and headhunter seeking interview candidate for future manpower." • IHX - "Chrome padlock and strained steel chains close up against blue clouded sky symbolizing lockdown" • uladzimirzuyeu - "Coronavirus pandemic. Flight ban and closed borders for tourists and travelers with coronavirus (covid-19) from Europe and Asia. Flight ticket refunds and route changes" • Tiko - "law book with a wooden judges gavel" • 88studio - "doctor physician practitioner measuring body temperature with infrared forehead thermometer gun"