Editoriali minuti di lettura
The Italian Association of Epidemiology (AIE): how we started it and my hopes for its future
Associazione italiana di epidemiologia (AIE): come l’abbiamo costituita e le mie speranze per il futuro dell’associazione
This article is dedicated to the memory of Piero Morosini and Luigi Dardanoni, and is based on a keynote lecture at the “AIE-Youth section” meeting in Milan, November 22nd, 2022
The Italian Association of Epidemiology (Associazione Italiana di Epidemiologia, AIE)1 was established in the mid-1970s, a time when epidemiology in the Western world had undergone a substantial shift in research contents, emphasis having moved from communicable diseases to the raising waves of non-communicable diseases, largely of poorly known or unknown aetiology. In tune with this change, existing epidemiological approaches and methods had been adapted and new methods developed after World War II, as witnessed by the 1960 textbook Epidemiologic methods by MacMahon, Pugh and Ipsen2 and by the 1964 original Morris3 review of the Uses of Epidemiology.
1960 to 1975: all ways lead to epidemiology
My own involvement with epidemiology came in a roundabout way, as did for most colleagues at the origin of AIE. My path to epidemiology can give to the younger members of AIE, not yet born in 1960-1975, a glimpse to several scientific and cultural aspects of Italy during those years.
I spent the two final years of my undergraduate medical curriculum at the Institute of Genetics of the University of Pavia, directed by Adriano Buzzati-Traverso (1913-1983), a remarkable figure of scientist and research organizer.4 During the 1950s and 1960s, he promoted in Italy advanced genetics and molecular biology guided in his actions (including presence in the media) by an uncommonly clear vision, both positive and critical, of the role of science and technology in society. Working or associated with the institute, a reference at the national and international level, were young researchers bound to leave a mark in their fields: among many, Ferruccio Ritossa (1936- 2014) discovered in 1962 the Heat Shock Protein effect,5,6 Luigi Luca Cavalli Sforza (1922-2018) became, from Pavia to Stanford, a world leader in human population genetics,7 and Lucio Luzzatto is today continuing at the Muhimbili University in Dar es Salaam decades of study of haematological disorders genetics8 at top laboratories in Italy, Nigeria, UK ,USA. Preparing my MD thesis in the institute, challenging environment left a permanent imprint of interest in the quantitative dimensions of biology and medicine and on the population dimension of diseases.
The imprint was reinforced when I moved to the Clinical Medicine Department of the Pisa University, where metabolic research with radioactively labelled albumin and iron9 required mathematical analysis of metabolic multi-compartments systems: recently, at the beginning of the COVID-19 pandemic, I revisited my reference book of 196010 as the same differential equations approach applies when analysing an epidemic spread in terms of population multi-compartments (e.g., susceptible, immune, recovered, dead).
Quite obviously in the clinical environment, I also became interested in randomized controlled trials (RCT): when in 1964-65 I joined for training in RCT methods the MRC Statistical Research Unit in London directed by dr. (at the time) Richard Doll, I discovered that the unit research largely concerned a field that I knew little more than by name, epidemiology. The 1964-65 period is marked by several landmark publications: the ten-year follow-up of the British doctors study on tobacco related mortality by Doll and Hill,11 the US Surgeon’s General report on Smoking and Health12 that clearly established the carcinogenic role of tobacco smoking in respiratory cancers, the New York Academy of Sciences conference proceedings on biological effects of asbestos,13 and the paper by Hill on association or causation,14 even today a methodological reference in causal inference discussions.
Back to Italy, I spent three years on the newly established institute of biometry of the University of Milan, directed by Giulio Alfredo Maccacaro. I had known him for the first time in 1960 as a brilliant teacher of bacterial genetics, his field of research at the forefront of molecular genetics, before he decided to shift to biometry and medical statistics: always fascinated and involved with biometric methods, he devoted the institute activities to promote the quantitative approach in contemporary biomedical research in Italy, badly needed particularly within clinical medicine and public health. The latter soon became for him a central concern not only technical, but mostly political, a perspective within which he passionately defended issues of social justice.15 In addition, in the first years of activity the scientific production of the Milan institute spanned many topics, most in clinically relevant areas.16,17
In the late 1960s and early 1970s, epidemiology remained however a rare encounter in Italy, relevant contributions mostly arising from international collaborative works. A cardiologist, Alessandro Menotti, became a fulltime epidemiologist taking long-term responsibility of the Italian component of the ‘Seven countries’ study, now a classic in cardiovascular epidemiology.18 The investigation in 1973 of a cholera epidemic in the Campania, Puglia, and Sardinia Regions saw the collaboration of infectious diseases clinicians, researchers from the Italian National Health Insitute (Istituto superiore di sanità, ISS) and two epidemiologists from the USA CDC.19 Personally, I took part within an International Biometric Society committee in the review and reanalysis of a controversial major randomized controlled trial on oral hypoglycemic drugs conducted in the USA under the aegis of the NIH.20 Overall, the picture of epidemiology in the country was composed by a yet small volume of good quality research by few investigators from a variety of institutions: hospitals, university clinical, pathology, and occupational departments, cancer institutes, ISS, and the National Research Council (CNR) centre in Pisa, where I had moved. We were internationally connected, including within the European Community (EC, not yet EU) and with the International Epidemiological Association (IEA). Notable was at the time the absence in the academic departments of Hygiene, responsible of teaching public health related subjects, of educational programmes, formal or via research projects, on epidemiological methods developed after World War II mostly in the UK and the USA (in 1967, when in Milan, I had written a first elementary presentation of such methods for Italian readers).21
The foundation of AIE
Aware of this remarkable gap, Piero Morosini (1941-2008), my friend and colleague at the Milan institute, and I launched in 1974 in Pisa the first Italian course of epidemiological methods for medical research. Equally aware of the gap, Luigi Dardanoni (1928-2004), professor of Hygiene at Palermo University, organized in the same year in Erice a course centred on the epidemiological bases of preventive medicine. The Pisa course,22 intended for researchers in any field of medicine and public health, took place on June 24-29 and capitalized on our national and international connections being co-organized by the CNR, the ISS, the WHO Europe office and the IEA, which assisted in the teachers selection (P. Morosini being misspelled as A. Morisini in ref. 22!). During the course, some suggestions were aired for a follow-up in the form of an epidemiologists network club, but no concrete steps were taken. Events accelerated a year later when Walter Holland (1929-2018), professor of Clinical Epidemiology and Social Medicine at the St. Thomas’ Medical School in London, set up a ‘Panel of Epidemiology and Social Medicine in the European Community’ with the aim of promoting collaboration between the national societies of epidemiology. There was none in Italy nor any section of epidemiology within other societies: again with Piero Morosini, we decided to establish such an organization just in time for dispatching an Italian representative to the first gathering of the Panel. As reported in the ‘News’ of the IEA,23 the foundation meeting of the Associazione Epidemiologica Italiana (AEI) took place in Pisa on April 4-5 (Friday and Saturday) with the participation of colleagues who had attended the previous year course and the presence of representatives from the European Community and the IEA. The association had a light structure with an elected secretary (no president) to be succeeded after two years by the vice-secretary. The news of the AEI foundation was not well received by the academic establishment, being perceived as the initiative of a group of young outsiders – not even a single full professor among them – actually doing respectable epidemiological research, but ignoring academic codes and jealously guarded disciplinary boundaries. In response, the subsequent Monday, April 7, an alternative Società Italiana di Epidemiologia (SIE) was established in Milan reflecting in its structure the academic canon that senior professors, in particular of Hygiene, should occupy key positions. In less than 90 hours, Italy had moved from having no epidemiology associations to having two. In 1975 and 1976, annual separate meetings of the two societies were held in the same days in two twin halls at the ISS in Rome. After prolonged discussions at the end of 1977, the societies liaison group reached a merger agreement based on a modified statute of the AEI: the light secretariat structure was retained as was the requirement for membership of continuous involvement in good quality epidemiological research; the label AEI switched to the current one: AIE, i.e., Associazione Italiana di Epidemiologia. In the foundation annals of the AIE, three people should be recorded: Walter Holland, for having prompted via his new Panel the formation of an Italian association; Piero Morosini, remembered by colleagues as a sophisticated “gentleman of epidemiology”,24 for being my companion founder of the first association, parent of AIE; Luigi Dardanoni, an open-minded and forward-looking professor of Hygiene without whom the merger and the birth of AIE would have not occurred: he became the first secretary with myself as vice-secretary.
AIE in today’s world context
An appropriate subtext reflecting the foundation spirit of AIE, and very much its decade-long subsequent history, would read “Epidemiological research for health protection”. Importantly and deliberately, a name like “association for epidemiological research” was not chosen, the inspiring principle having always been that, if there is no public health without epidemiology, namely high-quality epidemiological research, there is also no epidemiology without public health, namely a firm anchoring to well defined health protection and promotion objectives.
Epidemiological research for health protection is today and the visible future unfolding in a variety of national and regional contexts, two of which are of special interest being typical, widespread, and impacting on health.
The first context, which I will call ‘destructive’, was brought vividly to me last February. On the evening of February 23, a long interview was shown at the French TV with the distinguished science philosopher Bruno Latour (1947-2022) commenting his last essay (he died in October), a “memorandum on a new ecological class”,25 where the word class is employed in the same way as in ‘bourgeois class’ or ‘proletarian class’. Latour’s Marxian thesis is that the ecological deregulation in all its dimensions cannot be tackled, other than very inadequately, without the formation of a social class of people for whom the ecological common interest is stronger than other, often divisive, personal interests; such a class would be able to act collectively, not just as individuals, in the public arena for specific ecological objectives. He puts forward seventy-six concise questions and suggestions to promote such a development. I went to sleep with his questions in mind and on waking-up on February 24, I was confronted with the news of the Ukraine invasion by the Russian army. Purely coincidental as it was, it sounded as a most ominous methodological response to Latour questions: “Here is the millennial and invariant method to solve human groups conflicts, including those inevitably arising from the ecological deregulation, and this method is war”. Wars mean direct and indirect military and civilian deaths, mass migration, ecological disruption, often (as in Ukraine) nuclear war alert, with health necessarily downgraded to a residual priority. It is however not only war that concurs to the ‘destructive context’ where health becomes disposable. Other powerful trends work in the same sense, as witnessed among many instances by the East African Crude Oil Pipeline (EACOP) project jointly carried by Total, a major French energy provider, and the national Chinese CNOOC company with full support of the Uganda government.26 For an investment of 10 billion US dollars, the project will start in 2025 to export by sea via Tanzania the oil extracted in the Uganda Lake Albert region. To reach the Tanzanian port of Tanga the world longest (1,443 km) electrically heated pipeline is under construction. Total has, at the same time, signed a memorandum of understanding with the Uganda government to explore the installation of 1 gigawatt of renewable power capacity, pursuing its policy of expanding in several countries both fossil fuels extraction and renewable energy facilities until the profit margins of the latter are such that the former is better phased out (the EAPOC revenues are projected until 2050 at 70 billion dollars).27 Whether this profitability time schedule fits or not the time schedule for an effective climate temperature containment seems to be of no concern.
A second context runs diametrically opposite to the destructive context and may be labelled as ‘consumerist’. A recent article in a major Italian newspaper titled Obesity is a public health problem and today there are drugs to cope with it.28 It sounds like a perfect formula for consuming whatever food you like or afford, provided you also consume some medication. In signalling the article, my friend Paolo Vineis remarked the media misunderstanding of public health most often seen only as an issue of technological fixes. The media reflect and reinforce the dominant attitude in economically advanced societies whose “native working language” is a non-stop consumption of everything techno-science produces through innovations, from life-saving drugs or diagnostically valuable n-generation MRI machines to intelligent toothpicks and thousands other gadgets. Anything hardly or not at all translatable in technological language ends by being poorly intelligible and implementable at social level. Just compare the fast development and large-scale production of novel, effective COVID-19 vaccines, a major scientific and technological success, with the mixed and, in some countries, poor success of the NPIs, non-pharmaceutical measures for COVID-19 control. Within the consumerist context, health maintenance becomes, at the opposite of the destructive context, a top societal priority as a main source for needed, and needless, consumption of public and private goods and services.
Every specific context, at the international, national, and local level reproduces to variable extent traits of the two extremes types, destructive and consumerist, and poses specific challenges to epidemiologists.
Four hopes for the future
Choices, plans, and responsibilities to respond to such challenges belong to the young who will shape the future with their visions and energies. I cannot do more than express some personal hopes for epidemiology and AIE within it.
First, the hope that the value of descriptive epidemiology is not downplayed. Trustable health and other data, collected by reliable observers with reliable procedures, are only a fraction, often minor, of today’s massive flows of big data and in destructive contexts, like a war, they may be especially difficult to acquire. They allow to derive descriptive epidemiology pictures that constitute forceful documents of the health damages occurring in brutal circumstances. With this in mind, I attracted the attention of epidemiologists29,30 on the fate of migrants attempting to cross the Mediterranean and I am comforted by the effort of several groups of health professionals to build a network devoted to the health of ‘in transit’ migrants in Italy.31 Most of the epidemiological research feasible in all such situations may be unsophisticated, but invaluable for public health.
My second hope is that epidemiology, in providing sound evidence on safety and effectiveness of interventions for health, does not involuntarily become an instrument for simply cutting health expenditure in consumerist contexts. Interventions of doubtful or minimal value for health (not rare) must be dropped and the corresponding resources used to improve a population-wide delivery of evidence supported interventions rather than cut out and ‘saved’. For this reason, I favorably see the participation of epidemiologists in policy decisions, beyond the primary role of scientific evidence providers.32
My third hope is ‘wise epidemiology’.33 In the last decades, large funds have been available in economically advanced countries to build infrastructures as biobanks of human blood and tissue specimens and to support epidemiological studies focused on genetic aetiology, biomarkers, and pathogenic mechanisms of diseases. While these investigations can and will ultimately contribute to health, epidemiology remains the most proximate knowledge base for public health actions: any ‘wise epidemiology’ research programme should give the highest priority to studies firmly oriented to specific public health objectives visible not far away in time and framed within the overarching goal of reducing the large health gaps within and between countries.
My fourth and final hope is that epidemiologists do not refrain from participating, as indeed any researcher should, in reflections of fundamental character on science and its relations to society. All societal contexts of health and epidemiology are fuelled in different ways by advancements of science and technology, defining features – with capitalism now unique and globalized in its varieties34 – of our contemporary civilization. In the aftermath of World War II, culminating with the nuclear bombing of Hiroshima and Nagasaki, scientists expressed grave concerns about science developments. Max Born (1882-1970), the Nobel theoretical physicist who formalized the probabilistic interpretation of quantum mechanics, went straight to the roots of the problem:35 “I am haunted by the idea that this break in human civilization, caused by the discovery of the scientific method, may be irreparable. Though I love science, I have the feeling that it is so greatly opposed to history and tradition that it cannot be absorbed by our civilization. The political and military horrors and the complete breakdown of ethics which I have witnessed during my lifetime may not a symptom of an ephemeral social weakness but a necessary consequence of the rise of science – which in itself is among the highest intellectual achievements of man”. The nuclear weapons menace was a key concern for physicists as Born and Lise Meitner (1878-1968), the first who had clearly seized the meaning of the early nuclear fission experiments,36 and for biologists as Buzzati-Traverso.37 The nuclear menace is still on us, notwithstanding intermittent successes at containing the weapons arsenal, and today forms a trio with two other developments of major concern, the ecological deregulation in its different dimensions and the impetuous advent of artificial intelligence, less of a concern for what it can learn to do than for what it may push humans to unlearn to do.38 Born text, pertinent to all such concerns, points to the nature of scientific research as a root cause of actual and potential adverse effects of techno-scientific advances, highlighting by the same token the inadequacy of the usual control approach cast in terms of good and bad uses by society of ethically neutral research products. Good and bad are, moreover, usually evaluated at the (too) late stage of actual use in society, often already on a substantial scale and almost always propelled by powerful profit-making drives. How can this status of affairs threatening to jeopardize the immense intellectual and material benefits accruing from science be corrected? I see a hint in a statement by Carlo Rovelli:39 “[…] science is a rebellious and critical mode of thinking capable of changing its own conceptual bases and capable of re-designing from zero the world”. Taken rigorously it implies reflectively re-thinking and in-depth re-designing science itself as it operates in its internal developments and limits and as a major societal institution and economic engine. Most likely nothing short of this could adequately prevent and control (i.e., without substantial damages) the actual and impending adverse effects of techno-science evolving within globalized capitalism. It is a tall order first of all for scientists, including epidemiologists: notwithstanding valuable initiatives as Citizen Science and a voluminous literature dating since several decades40 no one inside and outside science seems near to effective, practicable, and at least partially generalizable solutions to the challenge.
As a conclusion, I stress a message much more important than my personal hopes, the speech by Liliana Segre at the opening session of the Italian Senate on October 13, 2022:41 as a beacon of living moral and civic values, foundational of our commitment to ‘health for all’, the speech text is a ‘must’ reading for all epidemiologists and aspiring epidemiologists.
- Associazione Italiana di Epidemiologia. Available from: https://www.epidemiologia.it (last accessed: 25.01.2023).
- MacMahon B, Pugh TF, Ipsen J. Epidemiologic Methods. Boston: Little, Brown & Co.; 1960.
- Morris JN. Uses of epidemiology. 2nd edition. Edinburgh and London: Livingstone; 1964.
- Capocci M. Tra biologia e utopia: Adriano Buzzati Traverso nella scienza italiana. Medicina nei Secoli 2006;18(1):179-92.
- Ritossa F. A new puffing pattern induced by temperature shock and DNP in Drosophila. Experientia 1962;18:571-73.
- Ritossa F. Discovery of the heat shock response. Cell Stress & Chaperons 1966;1(2):97-98.
- Cavalli-Sforza LL, Bodmer WF. The genetics of human populations. San Francisco: WH Freeman & Co.; 1971.
- Makani J, Luzzatto L. Of mice and man: From hematopoiesis in mouse models to curative gene therapy in sickle cell disease. Cell 2022;185(8):1261-65.
- Giordani R, Giagnoni P, Saracci R, Navalesi R. On hepatic fixation of iron during intestinal absorption of the metal. Minerva Nucl 1965;9(5):317-20.
- Monasterio G, Donato L. I radioisotopi nell’indagine medica. Torino: Edizioni Minerva Medica; 1960.
- Doll R, Hill BA. Mortality in relation to smoking: ten years’ observations of British doctors. Br Med J 1964;1(5396):1460-67.
- US Department of Health, Education and Welfare. Smoking and Health-Report of the advisory committee to the Surgeon General of the Public Health Service. Washington DC: DHEW; 1964.
- New York Academy of Sciences. Biological effects of asbestos. Ann NY Acad Sci 1965; 132(1):5-705.
- Hill BA. The environment and disease: association or causation? Proc R Soc Med 1965;58(5):295-300.
- Maccacaro GA. Per una medicina da rinnovare. Scritti 1966-1976. Milano: Feltrinelli; 1979.
- Reale A, Maccacaro GA, Rocca E, et al. Computer diagnosis of congenital heart disease. Comput Biomed Res 1968;1:533-49.
- Saracci R. Factors affecting accuracy and precision in clinical chemistry: a survey of 404 Italian laboratories. Am J Clin Pathol 1969;52(2):161-66.
- Fidanza F, Puddu V, Imbimbo AB, Menotti M, Keys A. Coronary heart disease in seven countries.VII. Five-years experience in rural Italy. Circulation 1970;41(4) Suppl:163-75.
- Baine W, Mazzotti M, Greco D, et al. Epidemiology of cholera in Italy in 1973. Lancet 1974;2(7893):1370-74.
- Gilbert JP, Meyer P, Rumke CL, Saracci R, Zelen M, White C. Report of the Committee for the assessment of the biometric aspects of controlled trials of hypoglycemic agents. JAMA 1975;231(6):583-608.
- Saracci R. Metodi statistici elementary per l’epidemiologia clinica. Milano: Centro Gaetano Zambon; 1967.
- International Epidemiological Association. History of the IEA 1954-1977. Int J Epidemiol 1977;6:317.
- International Epidemiological Association. News. Int J Epidemiol 1975;4:153.
- Greco D. Piero Morosini il gentleman dell’epidemiologia. Available from: https://www.epicentro.iss.it/archivio/pdf/Morosini_Greco.pdf
- Latour B, Schultz N. Memorandum sur la nouvelle classe écologique. Paris: La découverte; 2022.
- Wilson T. Total gives green light to 10$ bn Uganda oil project. Financial Times, 01.02.2022. Available from: https://www.ft.com/content/324987e5-43c9-41fe-905a-7c4657a9ee59
- Neiman S. Fear and oil in Uganda. NYRB 2023;70:845-47.
- Li Volsi P. L’obesità è un problema di salute pubblica e oggi esistono dei farmaci per contrastarla: il punto. Corriere della Sera, 25.07.2022. Available from: https://www.corriere.it/salute/diabete/22_luglio_25/obesita-farmaci-diabete-383d893a-0bea-11ed-b3b8-bcecca2571b4.shtml
- Saracci R. The public health community need speak out on rising rates of migrants dying at sea. BMJ Opinion, 31.08.2018. Available from: https://blogs.bmj.com/bmj/2018/08/31/rodolfo-saracci-the-public-health-community-must-speak-out-on-rising-rates-of-migrants-dying-at-sea/
- Saracci R. Insidiosa barbarie. Rec Prog Med 2018;109(7):367-68.
- Bisanti L. Personal communication, December 2022.
- Saracci R. Epidemiology’s dual social commitment, science and health. Am J Epidemiol 2021;190(6):980-83.
- Saracci R. Epidemiology in wonderland: Big data and precision medicine. Eur J Epidem 2018;33(3):245-57.
- Milanovic B. Capitalism, alone. Cambridge Mass: Harvard University Press; 2019.
- Born M. My life and my views. New York: Charles Scribner’s Sons; 1968; p. 58.
- Sime RL. Lise Meitner, a life in physics. Berkeley: California University Press; 1996.
- Buzzati Traverso A. Morte nucleare in Italia. Bari: Laterza; 1982.
- Kissinger H, Schmidt E, Huttenlocher D. The age of AI. London: John Murray; 2022.
- Rovelli C. Helgoland. Milano: Adelphi; 2020; p.13.
- Ravetz JR. Scientific knowledge and its social problems. Oxford: Oxford University Press; 1971.
- Segre L. La stella polare della Costituzione. Torino: Einaudi; 2023.
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