ORIGIN, GROWTH &

DEVELOPMENT OF
EPIDEMIOLOGY
Dr. A. K. AVASARALA MBBS, M.D.
PROFESSOR & HEAD DEPT OF
COMMUNITY MEDICINE &
EPIDEMIOLOGY
PRATHIMA INSTITUTE OF MEDICAL
SCIENCES, KARIMNAGAR, A.P.
INDIA : +91505417
avasarala@yahoo.com

EPIDEMIOLOGY TREE
DEVELOPMENT 1915 till to date

GROWTH 1600-1905 AD
(GRAUNT TO FLETCHER)

ORIGIN
(HIPPOCRATIC TIMES ) 463 BC

EPIDEMIOLOGY TREE
Has taken roots in
Hippocratic times
Started growing in 17th century
Lull in next two centuries due
to microbial era domination
Developed and blossomed in
20th & 21st centuries.

ORIGIN
SLIDES 4 TO 8

ORIGIN 2400 YEARS AGO

HIPPOCRATES

planted the seed & the tree of

epidemiology has taken its roots in 463 BC, hence it is
very old.

His treatise on the role of environment in causing the

disease Airs,Waters and Places is the first vivid
epidemiological description
Hence paradoxically, Epidemiology , is both very old
and very young science as it has mostly developed
recently.

HIPPOCRATES , THE FIRST EPIDEMIOLOGIST

AIRS,WATERS & PLACES

OF HIPPOCRATES
He stated in his famous treatise On Airs, Waters,
Places, that...
Whoever wishes to investigate medicine properly
should proceed thus: in the first place to consider
the seasons of the year, and what effects each of
them produces. Then the winds, the hot and the
cold, especially such as are common to all
countries and then such as are peculiar to each
locality. In the same manner. When one comes
into a city to which he is a stranger, he should
consider its situation, how it lies as to the winds
and the rising of the sun; for its influence is not
the same whether it lies to the north or the south,
to the rising or to the setting sun.

HIS KEEN OBSERVATION &

APPLIED COMMONSENSE
HE ADVISED to search for factors causing
disease in
Air
(hot &cold winds)
Water (marshy, soft, hard, from rocky soil,
unfit for cooking)
places (naked without vegetation, deficient in
water, well watered, elevated and cold)
personal habits (drinking, excessive
eating, fond of exercise, and labor)

GROWTH
SLIDES 9 TO 24

GROWTH NOURISHED BY
GRAUNT, SNOW, LIND, FLETCER, DOLL,
HILL, GOLDBERGER, ARR, JENNER
WITH THEIR
PHILOSOPHICAL GENIUS
KEEN OBSERVATION
COUNTING OF CASES
EXPLOITING THE NATURAL DISTURBANCES
OF HEALTH & DISEASE
APPLIED COMMONSENSE, CREATIVE THINKING,
GENERALIZATION CONCEPT
SCIENTIFIC REASONING & VALIDITY
COMPARABILITY AND ACCOUNTABILITY

EVOLUTIONARY PROCESS
IT HAS GROWN FROM
PURE OBSERVATIONS &ADVICES FROM HIPPOCRATES TO
COUNTING OF CASES &ANALYSIS BY GRAUNT & WILLIAM
FARR

NATURAL EXPERIMENTS BY JOHN SNOW

TRUE EXPERIMENTS
BY LIND, JENNER, FLETCHER, DOLL & HILL & OTHER
EPIDEMIOLOGISTS IN THE LAST TWO CENTURIES

FIVE PHAGES OF GROWTH

First phage:
Investigation of specific diseases- efforts
were concentrated to investigate cholera,
pellagra, scurvy, beri beri, lung cancers ( e.g.
Snows cholera, Fletchers beri beri, Linds
scurvy experiments)

Second phage (turning point):

Introduction of randomization ,blinding
and controlling to eliminate bias and enhance

the quality of methods of investigation and make

them systematic without errors.

Credit of stimulus goes to DOLL & HILL

experiments at this stage.

GROWTH 17TH TO 19TH CENTURIES

1600AD
1747
1796
1880
1889
1849
1881
1900

JOHN GRAUNT
JAMES LIND
EDWARD JENNER

W.H .FROST
WILLIAM FARR

LONDON BILLS OF
MORTALITY ANALYSIS
CITRUS FRUITS TO CURE
SCURVY IN SAILORS

TRIAL WITH COWPOX

VACCINE
EXPLAINED INTERPLAY OF
FACTORS CAUSING EPIDEMICS

ANALYSIS OF VITAL STATISTICS

& EFFECTS OF IMPRISONMENT
IN PRISONERS

JOHN SNOW

NATURAL EXPERIMENT
ON LONDON CHOLERA

FINLAY

MOSQUITO BORNE NATURE

OF YELLOW FEVER

BRADFORD HILL. A

CONCEPT OF RANDOMIZATION
&SMOKING AND LUNG CANCER
EXPERIMENTS

JOHN GRAUNTS CONTRIBUTION (1600AD)

John

Graunt in 17th century counted the mortality

rates for 37 years in London from the Bills of
mortality and found
1) constancy in the ratio from male to female in
births and deaths.
2) age specific mortality is higher among males than
in females.
3) seasonal fluctuations in deaths from various
causes.
4) measured the ebb and flow of various diseases
and the host factors.
5) suggested quantitative methods to test the
hypothesis of this variations.

JAMES LINDS CONTRIBUTION (1747)

JAMES LIND (1747) of 18 th century made notable
contributions to the growth of epidemiology.
James Lind, a naval surgeon, conducted a true
experiment on his 12 soldiers suffering from
scurvy. He made them into six pairs and
supplemented each pairs diet with 1) vinegar,
2) mixture of nutmeg, garlic, mustard and
tamarind in barley water, 3) elixir vitriol, 4) sea
water, 5) cider, and 6) two oranges and one lemon
for six days. Limeys, the pair which has taken
oranges and lemons showed improvement from
Scurvy and it was a proved that fresh fruits
relieved scurvy. This is a true experiment he
carried out where in he deliberately modified the
diets to get the desired information.

EDWARD JENNERS CONTRIBUTION (1796)

EDWARD JENNER(1796), an English
Physician, was the first person to
immunize against smallpox with cowpox
vaccine. He accidentally found that
milkmaids infected with cowpox were
immune to smallpox. Then he inoculated
a boy of 10 years of age with mild live
cowpox vaccine to immunize against
smallpox and over the succeeding two
years he successfully inoculated 22
more persons thus paved the way for
preventive medicine and epidemiology.

WILLIAM FARRS CONTRIBUTION (1889)

William Farr, a physician of the 19th century,
working as the first in Registrar General office of
England & Wales, analyzed the vital statistics for
40 years and made valuable observations with
regard to the then health situation and
recommended their application for public health
improvement. He found high mortality in certain
occupations like miners. He studied the health of
prisoners and found, while 8 only died due to
executions, 52 died of imprisonment. He also
found that fluctuations in marriage rates depend
upon price of bread, cholera, population
movements and persons monetary value. His
findings paved the way for proper health planning
and policies and thus fostered epidemiology.

JOHN SNOWS CONTRIBUTION (1849)

John Snow (1849) is a physician for Queen

Victoria and great epidemiologist. He is a
philosophical genius because he could control
cholera in London even before the causative
organism was discovered and found out how
cholera spreads. His genius showed in his
meticulous and scientific way of conducting the
natural experiment to prove his hypothesis that
contaminated water is the vehicle for the cholera
spread. He thoughtfully considered all other
causes that may confound his hypothesis and
wisely neutralized them. He had seen that no
difference whatever existed, either in the houses
or the people receiving water supply of two water
companies, or in any physical conditions with
which they are surrendered.

SNOW S WORDS ABOUT HIS EXPERIMENT

The intermixing of the water supply of the
Southwark and Vauxhall Company with that of the
Lamberth Company, over an extensive part of
London, admitted of the subject being sifted in
such a way as to yield the most incontrovertible
proof on one side or the other. In the subdistricts enumerated in the above table [Table in
this chapter] as being supplied by both
Companies, the mixing of the supply is of the
most intimate kind. The pipes of each Company
go down all the streets, and into nearly all the
courts and alleys. A few houses are supplied by
one Company and a few by the other, according
to the decision of the owner or occupier at that
time when the Water Companies were in active
competition.

GREATNESS OF SNOWS EXPERIMENT

The experiment, too, was on the grandest
scale. No fewer than three hundred
thousand people of both sexes, of every
age and occupation, and of every rank and
station, from gentlefolks down to the very
poor were divided in to two groups without
their choice, and, in most cases, without
their knowledge; one group being supplied
with water containing the sewage of
London, and, amongst it, whatever might
have come from the cholera patients, the
other groups having water quite free from
such impurity.

AUSTIN BRADFORD HILLS CONTRIBUTION

(1900)

AUSTIN BRADFORD HILL, in mid 1900, gifted to the

concept of Randomization for the epidemiological
growth. It enhanced the value of all the
experiments that were carried in later years as it
eliminates the biases (systematic errors) and
neutralizes all the known and unknown confounders
in the studies. In the present century, any scientific
experiment, test, drug, method is accepted only
after it is subjected to randomized controlled trials.
All present clinical trials are randomized ones and
as the randomization made the procedure more
scientific, it is carried out first in any study. His
experiments in 1954, to prove causal relationship
between smoking and lung cancer really speeded
up the growth of epidemiology.

FLETCHERS CONTRIBUTION (1905)

FLETCHER(1905) studied Beriberi that
occurred in lunatics in mental asylum in Kuala
Lumpur (Malaysia) and proved that it is due to
nutritional deficiency and not a place disease
as suggested by Sir Patrick Manson. In this
true experiment, he allocated the lunatics into
two groups, one to receive parboiled rice and
other to get Siamese rice (polished one).
Siamese rice group had higher number of
deaths when compared to cured parboiled rice
group. He later changed the wards and found
the same results thereby disproving that it is a
place disease.

FLETCHER EXPERIMENT
By June 20th many cases of beri-beri had occurred
amongst the patients in the east ward who were
eating uncured rice, whereas no cases had
occurred in the west ward, the inmates of which
were dieted on cured (Indian) rice.
In view of the theory so strongly advocated by Sir
Patrick Manson that beri-beri is a place disease, it
was thought possible that the eastward was
infected. Therefore on June 20th the patients were
a, those on uncured rice being moved to the
westward and those on cured (Indian) rice
transferred to the east. From June 20th to Dec. 31st
no beri -beri developed among the patients on
cured rice although they were living in a ward
where beri-beri had been rife amongst the lunatics
who were fed on uncured (Siamese) rice.

GOLDBERGERS CONTRIBUTION (1915)

GOLDBERGER JOSEPH (1915) proved
that Pellagra is not an infectious disease
as it was thought earlier, but a
nutritional deficiency state. He induced
pellagra experimentally by providing a
diet deficient in Nicotinic acid and
conducted studies in several rural
communities and in institutions to
demonstrate conclusively that pellagra
was a dietary deficiency disease.

DEVELOPMENT
SLIDES 25 TO 32

ERNATIONAL CONTRIBUTION
FOR DEVELOPMENT

WORLD HEALTH ORGANIZATION

UNICEF
USAID
PRIVATE FUNDING AGENCIES
GLOBAL NETWORK OF NONGOVERNMENTAL ORGANIZATIONS
WORLD WIDE WEB
(INTERNET EPIDEMIOLOGY)

20 TH CENTURY DEVELOPMENT
1905

Fletcher

1915

Gold Berger & Wheeler

1942

Kinsley & Hemphill

1946
1948
1952
1954

1955
1969

1971

Medical Research Council (UK)

Framingham Heart Study
Doll
A.B. Hill

Brown & Hill

Doll

Boston Hospital Study

WHO CLOFIBRATE CLINICAL TRIAL,

20 OSLO STUDY, NORTH KARELIA PROJECT,
STANFORD THREE COMMUNITY
cen- MRFIT(USA),
STUDY, BETA BLOCKERS IN MYOCARDIAL
tury INFARCTION, ASPIRIN STUDY,
th

PARBOILED RICE FOR TREATING BERIBERI IN

LUNATICS

INDUCED PELLAGRA BY DIETARY

MODIFICATIONS
OXYGEN THERAPY & RETROLENTAL
FIBROPLASIA

WHOOPING COUGH VACCINE TRIA

CORONARY HEART DISEASE

SMOKING & LUNG CANCER

SMOKING & LUNG CANCER

LEUKEMIA DUE TO IRRADIATION TREATMEN

FOR ANKYLOSING SPONDYLITIS

ORAL CONTACEPTIVES & HEALTH

ADENOCARCINOMA OF VAGINA IN YOUNG
WOMEN

TO REDUCE
CARDIOVASCULAR
MORTALITY

FEW 21ST CENTURY

DEVELOPMENTAL STUDIES
ANTENATAL FOLATE
SUPPLEMENTATION

TO REDUCE NEURAL
TUBE DEFECTS

BETA CAROTENE IN
DIET

TO PREVENT CANCERS

ARSENIC STUDY

IN HUMAN CANCERS

IN URANIUM WORKERS

FOR LUNG CANCERS

POLYVINYL CHLORIDE

ANGIOSARCOMA OF
LIVER

21ST CENTURY DEVELOPMENT

RANDOMIZED
CONTROLLED
TRIALS ACCEPTED
BY WORLD AS
SCIENTIFIC
NECESSITY
MULTICENTRIC
TRIALS ARE
FOLLOWED BY THE
WORLD TO PROVE
THE CONSITENCY

COLLOBORATIVE
APPROACH IS
ACCEPTED BY
WORLD AS MOST
FEASIBLE WAY OF
DOING THINGS
WORLD WIDE WEB
(GLOBAL HEALTH
NETWORK) SUPERCOURSE
AIMED AT UNIVERSAL
DISTRIBUTION OF
EPIDEMIOLOGICAL
INFORMATION

SCOPE FOR FURTHER DEVELOPMENT

VERY VAST BECAUSE EPIDEMIOLOGY ENGAGES THE MOST HONEST

SERVINGMEN OF VON KIPPLING VERY WISELY.

ANY ASPECT OF LIVES OF THE POPUPATION CAN BE QUESTIONED
WITH WHY, WHAT, WHEN, WHERE, WHOM AND HOW. THERE IS NO
RESTRICTION FOR ITS TRANSGRESSION FROM PAEDIATRICS TO
GERIATRICS.
INTERNATIONAL ACCEPTANCE AND DEPENDENCE ON EPIDEMIOLOGY
TO MANAGE AND SOLVE HEALTH PROBLEMS MAKES ITS
DEVELOPMENT MANDATORY NOW AND IN NEAR FUTURE.
WORLD WIDE WEB (GLOBAL HEALTH NETWORK& SUPERCOURSE)
WITH ITS EXTENSIVE NETWORK ENRICHES THE QUALITY AND
QUANTITY OF EPIDEMIOLOGICAL INFORMATION TO THE PUBLIC WHO
WILL IN TURN APPRECIATE, ACCEPT, GET BENIFITTED AND NATURALLY
PROMOTE ITS GROWTH & DEVELOPMENT.

SUMMARY & CONCLUSIONS

NO ONE CAN CONCLUDE OR SUMMARISE AS
EPIDEMIOLOGICAL GROWTH &DEVELOPMENT AS IT IS
A PHILOSOPHICAL STUDY OF A HEALTH PROBLEM.
HENCE WE CANNOT PUT A FULLSTOP ANYWHERE FOR
EPIDEMIOLOGICAL GROWTH. IT WILL BE GROWING IN
ALL DIRECTIONS AS LONG AS APPLIED
COMMONSENSE IS PREVAILINGLE WITH
EPIDEMIOLOGISTS AND PUBLIC.

GREAT BEGINNING : HIPPOCRATES ADVISED,

GRAUNT AND FARR COUNTED AND ANLYSED THE

CASES, SNOW EXPLOITED & EXPERIMENTED THE
NATURAL EVENT TO TKNOW HOW ITS SPREADS.
LIND, FLETCHER AND OTHERS EXPERIMENTED AND
HENCE THEY BECAME THE FORERUNNERS OF
EPIDEMIOLOGY AND PAVED THE WAY FOR OTHERS AND
TAUGHT OTHERS WHAT IS EPIDEMIOLOGY AND HOW IT
SHOULD BE PRACTICED.

REFERENCES
Brian Mac Mahan -Epidemiologyprinciples & methods
Roger Detels, James Mc EvenOxford Text Book of Public Health
Maxcy-Rosenau-Last, Public
Health &Preventive medicine
Brett & Cassens - Public Health
Medicine, National Student Series.