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The history of epidemiology

No money in prevention

Kimberly Brouwer
Kimberly Brouwer

“It was surprising and very exciting,” says Professor Kimberly Brouwer, who teaches epidemiology at the UCSD School of Medicine. She’s talking about the brand-new graduate class she started last Tuesday, online. “I had 27 students sign in. Some from outside epidemiology. Some from outside the country. Interest is up.”

So how come epidemiology is suddenly hot, after being somewhat the “bean-counting branch” of medicine?

“I would say our experience with previous epidemics and pandemics has given us the [background] to accurately model things. All of those estimates of, for instance, how long we have to stay at home are based on the history of epidemiology, and of epidemics throughout the world. Advice such as ‘wash your hands’ has been informed by an evidence base of multiple [epidemics]. And it is important in the absence of cures and-or vaccines for this virus.”

“A lot of public health is quite basic,” says Brouwer. “In fact, I’d say that public health in recent years has moved from discovering new ways to prevent epidemics to finding ways to implement known solutions that we already have. Because we know how to prevent disease, but we are just not implementing. So implementation science is now hand-in-hand with epidemiology to make sure the basics we already know are put to work.”

But Professor Brouwer says epidemiology is also sprouting new wings. “We have genetic epidemiology, where we’re able to learn whether or not the virus is related between two people, or spreads by direct transmission. We’re also able to better predict where the virus will go, with what we call spatial epidemiology. We map it.”

Would it work here? “A place like South Korea, where they do widespread testing, mapping has been quite efficient. They’ve been linking mapping with cellphone alerts, authorities saying ‘You’re in an area, a shopping mall, whatever, where there was recently a diagnosed case.’ They’ll call you. ‘If you were there at a particular time, you may have been exposed...’ South Korea is the gold standard of spatial epidemiology.”

In the US, she says, we don’t have the data inputs to adequately inform infectious disease models.

“We’re using what we have, but right now the stay at home order is a kind of sledgehammer tool of control, because we’re missing a lot of the pieces of the puzzle with regards to where exactly the disease is. Is it everywhere? Or are there certain places that could have functioning economies, where people could still interact, and not have to be under a blanket stay-at-home order?”

The biggest thing we need, she says again and again, is testing. Two types: one that measures the virus itself, that can diagnose people who currently have the virus. But also testing that looks at antibodies, to determine who was previously infected, and maybe didn’t even know they’d already had it.

“If you could get blanket testing, then you could determine if we’ve built some type of herd immunity. Has it already passed through huge sections of our population? Or do we need to still have this stay at home policy?”

And after all this has hopefully passed by, are we going to have learned our lesson? Maybe, maybe not, says Professor Brouwer. “We’ll likely just go back to our old habits.”

Why?

“Because there’s no money in prevention.”

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Kimberly Brouwer
Kimberly Brouwer

“It was surprising and very exciting,” says Professor Kimberly Brouwer, who teaches epidemiology at the UCSD School of Medicine. She’s talking about the brand-new graduate class she started last Tuesday, online. “I had 27 students sign in. Some from outside epidemiology. Some from outside the country. Interest is up.”

So how come epidemiology is suddenly hot, after being somewhat the “bean-counting branch” of medicine?

“I would say our experience with previous epidemics and pandemics has given us the [background] to accurately model things. All of those estimates of, for instance, how long we have to stay at home are based on the history of epidemiology, and of epidemics throughout the world. Advice such as ‘wash your hands’ has been informed by an evidence base of multiple [epidemics]. And it is important in the absence of cures and-or vaccines for this virus.”

“A lot of public health is quite basic,” says Brouwer. “In fact, I’d say that public health in recent years has moved from discovering new ways to prevent epidemics to finding ways to implement known solutions that we already have. Because we know how to prevent disease, but we are just not implementing. So implementation science is now hand-in-hand with epidemiology to make sure the basics we already know are put to work.”

But Professor Brouwer says epidemiology is also sprouting new wings. “We have genetic epidemiology, where we’re able to learn whether or not the virus is related between two people, or spreads by direct transmission. We’re also able to better predict where the virus will go, with what we call spatial epidemiology. We map it.”

Would it work here? “A place like South Korea, where they do widespread testing, mapping has been quite efficient. They’ve been linking mapping with cellphone alerts, authorities saying ‘You’re in an area, a shopping mall, whatever, where there was recently a diagnosed case.’ They’ll call you. ‘If you were there at a particular time, you may have been exposed...’ South Korea is the gold standard of spatial epidemiology.”

In the US, she says, we don’t have the data inputs to adequately inform infectious disease models.

“We’re using what we have, but right now the stay at home order is a kind of sledgehammer tool of control, because we’re missing a lot of the pieces of the puzzle with regards to where exactly the disease is. Is it everywhere? Or are there certain places that could have functioning economies, where people could still interact, and not have to be under a blanket stay-at-home order?”

The biggest thing we need, she says again and again, is testing. Two types: one that measures the virus itself, that can diagnose people who currently have the virus. But also testing that looks at antibodies, to determine who was previously infected, and maybe didn’t even know they’d already had it.

“If you could get blanket testing, then you could determine if we’ve built some type of herd immunity. Has it already passed through huge sections of our population? Or do we need to still have this stay at home policy?”

And after all this has hopefully passed by, are we going to have learned our lesson? Maybe, maybe not, says Professor Brouwer. “We’ll likely just go back to our old habits.”

Why?

“Because there’s no money in prevention.”

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