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A Conversation With Jacob Brody

2008; Lippincott Williams & Wilkins; Volume: 19; Issue: 5 Linguagem: Inglês

10.1097/ede.0b013e3181778127

1531-5487

Leslie Stayner,

Historical and modern epidemiology studies

ArticlePlus Click on the links below to access all the ArticlePlus for this article. Please note that ArticlePlus files may launch a viewer application outside of your web browser. https://links.lww.com/EDE/A307 Jacob Brody is Professor Emeritus of Epidemiology at the School of Public Health at the University of Illinois at Chicago where he served as Dean from 1985 to1992. Under his guidance the School doubled in size and increased its research funding 700%, while developing a national model for teaching and implementing public health practice. His service at the Centers for Disease Control (Epidemic Intelligence Service) and at the National Institutes of Health from 1957 to 1985 included assignments in Costa Rica, Bangladesh, Panama, Russia, Alaska, and Hiroshima. He created the US government's epidemiology programs for neurology, alcoholism, and aging. In 1957, the American Medical Writers Association honored him for the “Best Book on a Medical Subject for Physicians.” He became President of the American Epidemiologic Society in 1980 and the following year was presented the Distinguished Service Medal of the U.S. Public Health Service and cited as the most decorated member of the Public Health Service. In 2000, he received the prestigious Lilienfeld Award from the American Public Health Association for outstanding contributions, leadership, and research in epidemiology. He has authored more than 250 scientific publications and in 2002 he was recognized as being among the top 0.5% of the most frequently cited authors in the field. INTERVIEW LS: How did you find your way to epidemiology? JB: In truth, I stumbled into it. I was an intern in 1957 and the Korean War had ended, but I was drafted by the Army. Someone told me about the Epidemic Intelligence Service (EIS) and I phoned them as quickly as possible. Although they were nearly booked up, they agreed to look at my application and offered me a position. I think the thing most in my favor was that, in my senior year in medical school, I had spent 6 months working at a health center in rural Mexico and was fluent in Spanish. I was pulled out of the EIS course to investigate an epidemic of St. Louis encephalitis in Harlingen, Texas. I stayed at CDC (Centers for Disease Control) for 2 years and paid my military debt. I did not really know what I wanted to do but knew I was going to go into internal medicine. I was interested in working at NIH, (National Institutes of Health) and Alex Langmiur, the creator of the EIS program, helped me apply to the National Institute for Allergy and Infectious Diseases (NIAID). I was hired by NIAID to work in their new laboratory in Panama from 1959 to 1961. I still had doubts about being an epidemiologist. I applied and was accepted into the US-USSR cultural exchange program, which was a new program created by Kennedy and Khrushchev, and was assigned to a virus laboratory in Moscow. I came back to Bethesda 6 months later and, since I'd been in a cold place, NIH asked if I would like to be head of an epidemiology program in Anchorage, Alaska. I worked in Alaska for 3 years. After experiencing the Great Alaskan Earthquake, I decided to come back to NIH and work in their neurology program. By that time I was called an epidemiologist by everyone, so I became an epidemiologist. LS: What do you see as the biggest difference between epidemiology when you started and epidemiology today? JB: The biggest difference is the size of the enterprise. We are just bigger. Also, in those earlier times most of our work was descriptive. The methods and theory have evolved enormously. These new methods in many ways far transcend the descriptive methods that we employed. That is probably the most marked difference, but there are others. It was really easier when I started. There weren't so many of us, and we were well funded. My third publication was in the New England Journal of Medicine.1 The field has also grown intellectually to incorporate information on genes, the environment, and social factors. However, in that process the field has become somewhat fractionated. For both good and bad, we now have subspecialties such as infectious disease, neuroepidemiology, pharmacoepidemiology, social epidemiology, genetic epidemiology, and so on. In a sense, it is wonderful that we are involved in all these fields, but the problem is that people in subareas don't run with epidemiologists working in other areas. It was easier for us to both have subspecialties and participate in the broader field of epidemiology, which was really fun and enlightening. Other obvious changes are that MDs no longer control the field, and that women, felicitously, have been added to our core in increasing numbers. The changes are certainly notable, but the bottom line is that epidemiology is epidemiology. LS: Who in your career would you say most strongly influenced you? JB: The one person who stands out is George Comstock. He first worked with me when I was in Alaska and then later in Hiroshima with the Atomic Bomb Casualty Commission. I was most influenced by George Comstock's purity of thinking, gentle manner, and engagement in all of his surroundings. LS: Collaboration is a critical part of good epidemiologic studies. What have you found to be the most important ingredients of a good collaboration and with whom have you had your best collaborations? JB: I would take some issue with the question; I don't think collaboration is essential. I think there are many good studies that have been done with a strong team. This was certainly the case when I was at EIS and NIH. Frequently, our only collaboration was with our own laboratory or clinical groups. Currently, the size and scope of much of epidemiology demands collaboration. I think, the greatest probability of successful collaborations comes when you get your collaborators together, and you spend about twice the time you thought you were going to on planning the protocol. During that period things happen—most important, you get to know each other and you get to fight a lot about specific issues. As a result of these intense interactions, things are likely to go more smoothly. But I've been involved in collaborative studies in which there was not a good deal of trust among the researchers, no friendships, and even times when there was publication theft. Yet these collaborations worked. My most successful collaboration was when I entered the field of aging in the late 1970s, and we founded the Established Populations for Studies of the Elderly (EPSE). Our collaborators were from Harvard, Yale, and Iowa. Later on Duke came in and, UT Galvaston is still doing it. These studies have been successful in many ways. There have been over 1000 publications. It was the first systematic evaluation over time of elderly populations. It created a whole generation of epidemiologists who were interested in aging. Discussions on the development of the protocols and questions for the EPSE study were long and difficult. The research group included Charlie Hennekens, Lisa Berkman, Dennis Evans, Adrian Osfeld, Bob Wallace, and a whole string of other people. None of them are shy. I think what made it work was the careful establishment of committees for everything, biostatistical analysis, and publications for each of the studies that we embarked upon. The publications committee was a powerful group. They had the authority to say who you would have to work with, and they could make comments on the final manuscripts. What also made it work with such major egos was to have one strong, respected, central leader who was given the right to resolve any dispute, which, fortunately, was me. The second thing was having a hands-on professional who interacted continuously with all the groups and was also a little grumpy and pushy.Figure: Jacob Brody.LS: Who would you regard as the 2 or 3 most important epidemiologists during your lifetime? You already mentioned George Comstock, but who else? JB: I would start with Alex Langmuir, who was my first mentor at EIS. What Alex did for the field of epidemiology and for the field of prevention in public health was staggering. Until Alex was on the scene, the word surveillance was almost exclusively used in military situations. He built the wonderful EIS program that has probably produced more epidemiologists than any other single entity. It's still invaluable and going strong. I also think Abe Lillienfeld did marvelous things. He brought focus into chronic disease epidemiology and the statistical methodologies necessary. He recognized the power of the group in approaching chronic diseases, and, above all, he created a lot of good epidemiologists. I had the highest regard for “Stony” (Ruell) Stallones. He was brilliant, controversial, honest, and combative. People really went head-on with Stony. I can remember several confrontations between Alex and Stony, but they would work it out because they both wanted to get the right answer. I remember a paper that Stony wrote in about 1970 on why deaths from acute myocardial infarction have been going down for the last ten years.2 He reviewed whatever soft logic there was, but the question has never been answered. It was prior to the advent of jogging and exercise, and for the most part, before effective smoking reduction. Stony also developed a School of Public Health at the University of Texas in Houston and put a lot of emphasis on epidemiology. Again, as with my other heroes, he turned out a lot of very good epidemiologists. One characteristic that these 3 and George Comstock had in common was that they could see the evolution and the logic of epidemiology as a thing of beauty. It's what can happen with ready and roving minds if they are given epidemiology to do. LS: What has been your most influential paper, and which paper of yours do you feel has been the least appreciated? JB: I think my most important paper was published in 1985 as the lead article in Nature on “Prospects for an Ageing Population.”3 I received numerous reprint requests, and there were many articles and laudatory comments both in Nature and in other journals. I stressed in it that we were adding years to life without adding health to life. We were running the risk of creating an old sick population. The other thing I pointed out was that most of the diseases associated with aging increase logarithmically. After a certain age, incidence increases exponentially. If you delay onset by one doubling, you cut the subsequent incidence in half. Cutting a disease incidence in half is enormously powerful prevention. The least appreciated was a paper I wrote on the absence of menopausal effect on hip fracture which has been studiously shunned.4,5 We showed that for white American women around the age 38 to 42 there is a 7-fold increase in hip fracture. After age 42, incidence goes on rising but just exponentially right through menopause (which is usually at age 50) and on into the 90s. Most papers on the epidemiology of hip fractures start at menopause, and so they have missed a critical time of the 7-fold increase. LS: How in your career have you gone about choosing what research questions to study? JB: The major factor is luck. Next is knowledge and reading a lot to be able to spot the right questions. My decisions about what to study have been influenced by my jobs. In 1964, I had worked in Alaska for 2 years and knew the State and its health care workers well. At that time almost all Alaska Native high school students attended one school in Mt. Edgecomb and were flown home for summer break. In the spring, rubella started to appear at the school. I spotted a Pannum-like opportunity to study a rubella epidemic on the Pribilof Islands where rubella had not occurred for more than 20 years. We arrived 2 days after the first case. We were able to show how the virus spread, the incubation period, and the duration of virus shedding. We demonstrated patterns of asymptomatic disease and found that virus would be present in the throat for up to seventeen days, making inapparent cases a potential source of infection.6,7 Another job-related way I chose my research is the studies I mentioned when I founded the epidemiology program at the newly established National Institute on Aging. We set up a series of large prospective population studies of people age 65 and over.8 LS: Of your many contributions to the field, which would you most like to be remembered for? JB: There are 2 types of contributions. You can either make the Crick-and-Watson contribution, an intellectual breakthrough that changes everything, or you can make an impact-on-your-discipline contribution. I had the good luck to be able to describe rubella in such a way that it's never going to have to be done again, and I'm proud of that. I think my idea of the log curve of aging-dependent diseases and prevention by postponement was a major contribution whose value will keep growing. But I really think I should be remembered for expanding various fields within epidemiology and the number of new epidemiologists. When I got to NINDB (National Institute of Neurologic Diseases and Blindness) in 1965, all I had was a secretary. These were the golden years, and because of the doctor's draft we built up a very large group of people doing good work in neurology, and I was able to give a major push to the careers of a large number of able people in the field of neurology. At the NIAAA (National Institute of Alcohol Abuse and Alcoholism), I founded epidemiology as an approach to studying alcoholism, and now there are a group of epidemiologists studying alcoholism and drug abuse. At the NIA (National Institute on Aging), we created a whole generation of epidemiologists studying problems of aging. During my 7 years as the Dean at the School of Public Health at the University of Illinois at Chicago, we increased the budget from about $3 million to about $18–19 million, mostly on grants. This enabled me to enlarge many of our departments and particularly Epidemiology and Biostatistics. Their agility in growing and securing funds has continued to the present time and is a true source of joy. So, I think that being remembered for having contributed to the development of the field of epidemiology and creating and enabling many epidemiologists is something I cherish. LS: What are your major interests outside of epidemiology? JB: I started a family late in life. I was almost 40 when I got married. I have a great wife, 2 great kids and now 4 grandchildren, and that's all pretty exciting. I've done a lot of photography. I was fortunate with epidemiology and other interests to travel and take a lot of pictures. In the late ’50s I became a scuba diver and am still doing it. Travel, theater, reading–these are all great interests but more and more I'm realizing now my major interest is finding opportunities to have intelligent adult conversation. LS: In your opinion, what is epidemiology's most important contribution to our society? JB: The epidemiologic method has permeated many other areas and is probably our towering achievement. The method can lead to recognition of causes, risk factors, and patterns. These in turn can lead to our culminating role in prevention and lately eradication. LS: What would your assessment be of the current state of the health of epidemiology? What are the biggest risks or hazards that we face? JB: The current state of epidemiology is very good. We are robust, growing, establishing, penetrating, and energizing new fields such as AIDS, aging, genetics, policy, health disparities, and healthcare delivery. At every juncture, since I can remember, we have felt under-funded. And while we always say that it was better before, we are still growing and still creating new journals and new areas of interest to study. LS: Do you have any predictions about what the future might hold for our field? JB: We cannot fail if we stay together as epidemiologists. Epidemiologists working alone are often clapping with one hand. To survive and enrich our future we must work together. We are, however, expensive and must expect some erosion of our turf. LS: What's the single most important piece of advice you could give to a new epidemiologist, or a middle-aged epidemiologist? JB: Be involved in epidemiology and not just the specialty areas, and get lucky. Keep amassing information, since knowledge will always benefit you. To quote Pasteur, “Chance favors a prepared mind.” Benjamin Franklin said, “I'm a strong believer in luck and I find the harder I work the more I have of it.” The most important thing for epidemiology is to have fun. ACKNOWLEDGMENTS I thank Elizabeth Budzik for her excellent assistance in arranging the interview and preparation of the transcript. ABOUT THE INTERVIEWER LESLIE STAYNER is currently a Professor of Epidemiology and Director of the Division of Epidemiology and Biostatistics at the University of Illinois at Chicago School of Public Health, where he has had the good fortune of working with and befriending Jacob Brody. He previously worked at the National Institute for Occupational Safety and Health for nearly 25 years. His primary research is on the epidemiology of occupational and environmental hazards.