Epidemiology As A Liberal Art
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Cited References
Solving Problems within Constraints
Engineering has not generally been considered one of the liberal arts, but at Swarthmore College, where it has been taught for more than 100 years, it fits in quite well. Recently, other colleges have begun to emphasize technologic thinking as a valid part of a liberal arts education (Ref. 14). The emphasis is not on the mastery of the technical details of machinery, systems, and materials, but rather on the principles under which they operate and their use to solve problems within a given set of constraints.
In the hands of the public health physician, epidemiology has traditionally been used as a tool to reduce the incidence of disease. The investigation of the outbreak of lymphocytic choriomeningitis described above illustrates one way in which epidemiology can help solve the problem of an epidemic within the constraints imposed by the institution in which it occurred and the limits of scientific knowledge about the agent and its hosts.
Increasingly, setters of public health policy use the methods of epidemiology (and economics) to determine how to minimize disease within the constraints of a budget. A new technique like the use of pneumococcal vaccine requires careful assessment, because not only are there limits on its effectiveness, but also, with its many components, it is fairly expensive.
The Office of Technology Assessment of the U.S. Congress has looked at pneumococcal vaccine to determine at what cost life of good quality could be prolonged by its use, and how that cost varies according to the age of the person to be vaccinated (Ref. 15). The total cost was taken to be the sum of the costs of vaccination, vaccine side effects, and future illnesses not prevented by vaccination among persons whose lives are prolonged by vaccination, minus the cost of treating episodes of pneumococcal pneumonia prevented by vaccination.
The total effects were measured in "healthy years of life," by a system according to which a year of full functioning counted as 1, one of disability but not confinement to bed counted as 0.6, and one of confinement to bed counted as 0.4. The total effect was taken to be the number of healthy years gained by vaccination, either through the prolongation of life or the prevention of morbidity, reduced by the morbidity and mortality resulting from vaccine side effects and the morbidity from future illness not prevented by vaccination among persons whose lives are prolonged by vaccination.
Assuming that vaccination costs $11.37, that it is 80 percent effective against the 14 vaccine types for eight years after it is given, and that 75 percent of the cases of pneumococcal disease are caused by those 14 types, the analysis suggested that an additional healthy year of life would cost on the average $4,800. That cost would vary greatly with age, from $77,200 for children 2 to 4 years old down to $5,700 for people 45 to 64 years old and $1,000 for those 65 and older.
In setting the recommendations of the U.S. Public Health Service for the use of pneumococcal vaccine, the Advisory Committee on Immunization Practices has suggested that it be used routinely for those over 65, as well as for younger people who have medical conditions that predispose them to pneumococcal infection (Ref. 16).
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