Toxic Shock. Sharra L. Vostral

      Epidemiology is part science and part social detective work, and it is this component that is problematic to other fields of science, and under scrutiny in light of evidence-based medicine. Epidemiologists must gather pieces of evidence, which become factors, and judge whether or not correlation is significant to causation. Researchers readily rely on inklings, hunches, and past experiences, and they depend on both creative problem solving and stringent methods to identify known and unknown outbreaks. However effective this approach may be, its weakness lies in its inability to eliminate sufficient variables, or even provide significant proof. Lack of an occurrence can constitute evidence, which also becomes questionable methodologically in other scientific settings. Epidemiology is also reactive and thus does not have the luxury of long-term clinical studies to lean on for legitimacy.11

      This is important because at issue is whether or not the recommendations set forth by the CDC should be believed. Steven Epstein, a sociologist of health and medicine, discusses how trustworthiness is at stake with methods and procedures, and he suggests “knowledge emerges out of credibility struggles.”12 Scientists’ claims must be believable in order to elicit support, shape arguments, and garner recognition. Yet the very thing that propels some of these research aims is characterized by differences in fastidious science and pragmatic science, as pointed out by Epstein, and defined by Alvan Feinstein, an authority on clinical trials at the Yale University School of Medicine.13 Fastidious science relies on “clean” data and “elegant” research designs, and it is likely carried out by academically trained researchers, promoting an ideology of purity leading to truth. This method seeks ways to reduce ambiguity and bias, and produce clear findings. By contrast, the pragmatic approach accepts messiness, ordinary variables in field and clinical settings, as well as occasionally ambiguous results. These differences are linked to power struggles between science-based academic researchers and clinic-based physicians, but the tensions are inherent to epidemiology as well. Epidemiology embodies this conflict, with both its need for scientific rigor and also its requirement to act quickly on behalf of the public good, in the messy theater of human life, when there is no time to wait for “clean” results from a well-designed study. It is here where politics and health collide.

      New Diseases, New Difficulties