EPIDEMIOLOGY -EPIDEMIOLOGY - ITS PERSPECTIVES ITS PERSPECTIVES

& APPLICATIONS & APPLICATIONS

Dr. A.K.AVASARALA MBBS, M.D.Dr. A.K.AVASARALA MBBS, M.D. PROFESSOR & HEADPROFESSOR & HEAD DEPT OF COMMUNITY DEPT OF COMMUNITY

MEDICINE & EPIDEMIOLOGYMEDICINE & EPIDEMIOLOGY PRATHIMA INSTITUTE OF PRATHIMA INSTITUTE OF

MEDICAL SCIENCES, MEDICAL SCIENCES, KARIMNAGAR,A.P..KARIMNAGAR,A.P..

INDIA : +91505417INDIA : +91505417

avasarala@yahoo.comavasarala@yahoo.com

EPIDEMIOLOGY-EPIDEMIOLOGY-PRESENT PERSPECTIVESPRESENT PERSPECTIVES

• A PHILOSOPHICAL STUDY OF HEALTHA PHILOSOPHICAL STUDY OF HEALTH PROBLEM (SLIDES 3-11)PROBLEM (SLIDES 3-11)

• AN ART OF THE POSSIBLE (SLIDES 11 - 17)AN ART OF THE POSSIBLE (SLIDES 11 - 17)

• A SCIENCE WITH WIDER APPLICATIONSA SCIENCE WITH WIDER APPLICATIONS (SLIDES 18-37)(SLIDES 18-37)

(OXFORD TEXT BOOK OF PUBLIC HEALTH)(OXFORD TEXT BOOK OF PUBLIC HEALTH)

PHILOSOPHICAL STUDYPHILOSOPHICAL STUDY

SLIDES 3 TO 11

EPIDEMIOLOGYEPIDEMIOLOGY PHILOSOPHICAL PHILOSOPHICAL

STUDY STUDY

OF OF

HEALTH HEALTH

PROBLEMPROBLEM

(OXFORD TEXT BOOK OF (OXFORD TEXT BOOK OF PUBLIC HEALTH)PUBLIC HEALTH)

Philosophy is that ill health is non-randomly distributed in the nature in clusters making things easier to study its various presentations. It is not just the methodology of describing its distribution and determinants. It is more than a methodology.

VON KIPPLING ‘S SIX HONEST VON KIPPLING ‘S SIX HONEST SERVING MENSERVING MEN

• WHY ?WHY ?

• WHAT ?WHAT ?

• WHOM ?WHOM ?

• WHEN ?WHEN ?

• WHERE ?WHERE ?

• HOW ?HOW ?

• PHILOSOPHICAL APPROACHPHILOSOPHICAL APPROACH THERE IS NO SITUATION IN LIVES OF THE PEOPLE WHERE THERE IS NO SITUATION IN LIVES OF THE PEOPLE WHERE

ONE CANNOT OBTAIN INFORMATION EMPLOYING THESE ONE CANNOT OBTAIN INFORMATION EMPLOYING THESE SIX HONEST MEN WISELY. SIX HONEST MEN WISELY.

THIS IS GENERALIZED THIS IS GENERALIZED UNIVERSAL PHILOSOPHICAL LIFE UNIVERSAL PHILOSOPHICAL LIFE APPROACHAPPROACH UTILIZED IN EPIDEMIOLOGY. UTILIZED IN EPIDEMIOLOGY.

EPIDEMIOLOGICAL APPROACHEPIDEMIOLOGICAL APPROACH

IS ALSO TYPICALLY PHILOSOPHICALIS ALSO TYPICALLY PHILOSOPHICAL

THE ONLY WAY TO ASK SOME QUESTIONS THE ONLY WAY TO ASK SOME QUESTIONS

ONE WAY OF ASKING OTHERSONE WAY OF ASKING OTHERS

NO WAY AT ALL TO ASK MANYNO WAY AT ALL TO ASK MANY

(MORRIS)

WILLIAM FROSTWILLIAM FROST

• IT ISIT IS

SOMETHING SOMETHING BEYOND BEYOND THE USUAL THE USUAL FACTS OF FACTS OF OBSERVATIONOBSERVATION

MOST OF THE TIMES , WE MAY FIND DIFFICULTY IN KNOWING THE CAUSE OF ILLNESS INSPITE OF HAVING LOT OF KNOWN AND OBSERVED FACTS. THE SECRET MAY LIE SOMEWHERE IN THE NATURE (ENVIRONMENT). TACT AND SKILL ARE REQUIRED TO THINK PHILOSOPHICALLY TO DETECT THIS SECRET. IT IS LIKE MEDICAL DETECTION AND NEEDS CREATIVE THINKING AND GENIUS LIKE SHERLOCK HOLMES.

EPIDEMIOLOGY IS APPLIED COMMON EPIDEMIOLOGY IS APPLIED COMMON SENSE (BRETT & CASSENS )SENSE (BRETT & CASSENS )

COMMON SENSE MUST ALWAYS PREVAIL IN EPIDEMIOLOGICAL DEALINGS.IT IS AN INTELLIGENT WAY OF STUDYING HEALTH PROBLEM AND NEEDS COMMONSENSE.SINCE DISEASES USUALLY OCCUR IN CLUSTERS AND IN CERTAIN PLACES, WE APPLY COMMON SENSE IN SEARCHING FOR THEIR CAUSESIF CAUSE IS NOT SECURED, WE SEARCH FOR RISK FACTORS.

PERSONAL EXPERIENCEPERSONAL EXPERIENCEAN EXAMPLE FOR TIMELY COMMONSENSEAN EXAMPLE FOR TIMELY COMMONSENSE

SOMETIMES PLACE DISTRIBUTION ALSO GIVES CLUES ABOUT A DISEASE A PERSONAL EXPERIENCE OF MINE WHILE INVESTIGATING MALARIA EPIDEMIC OF 40 FEVER CASES AND 11 DEATHS IN A VILLAGE NEAR VISAKHAPATNAM STEEL PLANT SERVES AS AN EXAMPLE. SIX CHILDREN WITH ENLARGED SPLEENS AND FEVER FOUND THERE ARE EXPECTED TO BE SUFFERING FROM MALRIA. BUT AFTER SEEING THE ADDRESS OF ONE CHILD WHO CAME FROM WEST BENGAL, INDIA WHICH IS ENDEMIC FOR VISCERAL LEISHMANIASIS, A DOUBT CAME TO MY MIND THAT WHY IT COULD NOT BE KALA AZAR.

PAST PERSPECTIVESPAST PERSPECTIVES

• 1873 – PERKINS – TREATMENT OF EPIDEMICS.1873 – PERKINS – TREATMENT OF EPIDEMICS.

• 1927 – W.H. FROST – MASS PHENOMENON OF 1927 – W.H. FROST – MASS PHENOMENON OF INFECTIOUS DISEASE. INFECTIOUS DISEASE.

• 1934 – MASS PHENOMENON OF ANY DISEASE.1934 – MASS PHENOMENON OF ANY DISEASE.

EPIDEMIOLOGY DESCRIBES EPIDEMIOLOGY DESCRIBES FURNITURE OF EARTHFURNITURE OF EARTH

GOOD DEAL OF EPIDEMIOLOGY HAS A GOOD DEAL OF EPIDEMIOLOGY HAS A LITTLE TO DO WITH THE TESTING OR LITTLE TO DO WITH THE TESTING OR REFUTATION OF HYPOTHESIS BUT IS REFUTATION OF HYPOTHESIS BUT IS CONCERNED WITH THE DESCRIBING CONCERNED WITH THE DESCRIBING WHAT HAS BEEN CALLED THE WHAT HAS BEEN CALLED THE ““FURNITURE OF EARTH”FURNITURE OF EARTH”

STEBBING LS, PHILOSOPHY AND THE PHYSISTS, 2ND EDITION, NEWYORK DOVEV, 1958 CHAPTER III

IT IS AN ARTIT IS AN ART

SLIDES 12 TO 19

ART OF EPIDEMIOLOGYART OF EPIDEMIOLOGY

• SKILLS OF APPROPRIATENESS, SKILLS OF APPROPRIATENESS,

CREATIVITY & INNOVATIONCREATIVITY & INNOVATION

ARE ESSENTIAL. ARE ESSENTIAL.

• IT IS THESE ESSENTIAL SKILLS THAT IT IS THESE ESSENTIAL SKILLS THAT MAKES EPIDEMIOLOGY MORE MAKES EPIDEMIOLOGY MORE THAN A METHODLOGYTHAN A METHODLOGY

EPIDEMIOLOGICAL STUDY SHOULD BE EPIDEMIOLOGICAL STUDY SHOULD BE LIKE MOTHER’ S TASTY FOODLIKE MOTHER’ S TASTY FOOD

EVERYONE CAN PROCURE ALL THE NICE FOOD ITEMS AND CAN ALSO LEARN VARIOUS COOKING METHODS BUT CANNOT MAKE A TASTY FOOD LIKE MOTHER BECAUSE MOTHER SELECTS THE RIGHT FOOD ITEMS (APPROPRIATENESS)YOU LIKE AND COOK THEM IN THE CORRECT WAY YOU ENJOY AND SERVES YOU WITH AFFECTION.

CREATIVITY & INNOVATIONCREATIVITY & INNOVATION

•THAT TYPE OF ART IS ESSENTIAL IN MAKING A EPIDEMIOLOGICAL STUDY SUCCEESSFUL AND PLEASING(TASTY) TO THE NEEDY. •IT IS JUST NOT ENOUGHNOT ENOUGH TO KNOW TO KNOW VARIOUS EPIDEMIOLOGICAL METHODS. VARIOUS EPIDEMIOLOGICAL METHODS. •ONE MUST APPLY THEM CREATIVELY ONE MUST APPLY THEM CREATIVELY TO OBTAIN THE INFORMATION NEEDED TO OBTAIN THE INFORMATION NEEDED TO UNDERSTAND THE NATURAL TO UNDERSTAND THE NATURAL HISTORY OF DIEASEHISTORY OF DIEASE..

ART OF ART OF LINKING LINKING CAUSES, CAUSES,

CONDITIONS & CONDITIONS & FACTORS FACTORS

WITH HEALTH WITH HEALTH AND DISEASE AND DISEASE

OF OF POPULATIONPOPULATION

ART OF EPIDEMIOLOGY

CAUSES

CONDITIONS

FACTORS

HEALTH

&

DISEASE

OF

POPULATIONS

LINKING

• ART OF EXTRAPOLATING TWO TRIADSART OF EXTRAPOLATING TWO TRIADS

TO EXPLAIN VARIOUS INTERACTIONSTO EXPLAIN VARIOUS INTERACTIONS

AGENT

HOST ENVIRONMENT

TIME

PLACE PERSON

NOTHING CAN BE PROVED OR ESTABLISHED NOTHING CAN BE PROVED OR ESTABLISHED 100% AS IN LABORATORY EXPERTIMENT AS 100% AS IN LABORATORY EXPERTIMENT AS IT IS POPULATION BASED.IT IS POPULATION BASED.

ONLY MAXIMUM PROBABILITY CAN BE ONLY MAXIMUM PROBABILITY CAN BE TRIED.TRIED.

SO ONE SHOULD BE MODEST AND SO ONE SHOULD BE MODEST AND REALISTIC AND KNOW THE LIMITATIONS REALISTIC AND KNOW THE LIMITATIONS WHILE CARRYING OUT THE WHILE CARRYING OUT THE EPIDEMIOLOGICAL STUDIES.EPIDEMIOLOGICAL STUDIES.

ART OF THE POSSIBLE

ART OF POSSIBLEART OF POSSIBLE• ALL THE FRUITS OF SCIENTIFIC WORK, ALL THE FRUITS OF SCIENTIFIC WORK,

IN EPIDEMIOLOGICAL OR OTHER IN EPIDEMIOLOGICAL OR OTHER DISCIPLINES, ARE AT BEST ONLY THE DISCIPLINES, ARE AT BEST ONLY THE TENTATIVE FORMULATIONS OF A TENTATIVE FORMULATIONS OF A DISCRIPTION OF NATURE.DISCRIPTION OF NATURE.

• THIS TENTATIVENESS OF OUR THIS TENTATIVENESS OF OUR KNOWLEDGE DOES NOT PREVENT KNOWLEDGE DOES NOT PREVENT PRACTICAL APPLICATIONS BUT PRACTICAL APPLICATIONS BUT SHOULD KEEP US SCEPTICAL AND SHOULD KEEP US SCEPTICAL AND CRITICAL, NOT ONLY OF EVERYONE CRITICAL, NOT ONLY OF EVERYONE ELSE’S WORK, BUT OUR OWN AS WELLELSE’S WORK, BUT OUR OWN AS WELL

(OXFORD TEXT BOOK OF PUBLIC HEALTH)(OXFORD TEXT BOOK OF PUBLIC HEALTH)

A SCIENCEA SCIENCE

SLIDES 20-41

A SCIENCEA SCIENCE

• IT FOLLOWS ALL THE BASIC TENETS OF IT FOLLOWS ALL THE BASIC TENETS OF SCIENCESCIENCE

• IT HAS AN ORDER AND DEFINITE PURPOSEIT HAS AN ORDER AND DEFINITE PURPOSE

• IT HAS SEQUENCE, RELAVANCE, IT HAS SEQUENCE, RELAVANCE, INFERENCE AND IS SYSTEMATICINFERENCE AND IS SYSTEMATIC

• IT FOLLOWS ETHICSIT FOLLOWS ETHICS

• IT HAS WIDER & ACCEPTABLE IT HAS WIDER & ACCEPTABLE APPLICATIONSAPPLICATIONS

EPIDEMIOLOGY IS EPIDEMIOLOGY IS BOTHBOTH THE THE BASIC SCIENCE OF PUBLIC BASIC SCIENCE OF PUBLIC

HEALTH AND ITS MOST HEALTH AND ITS MOST FUNDAMENTAL PRACTICEFUNDAMENTAL PRACTICE

MAXCY

SURVILLANCE, EPIDEMIOLOGICAL INVESTIGATIONS

COUNT CASES & MEASURE THE POPULATION AFFECTED

DETECTS, INVESTIGATES & ANALYZES PROBLEMS

DISSEMINATION TO HELATH PLANNERS & PUBLIC

EVALUATION HEALTH POLICY

HEALTH PROGRAMS

RESULTING INFORMATION APPLIED FOR PREVENTION & CONTROL

LANGMUIR ON EPIDEMIOLOGICAL LANGMUIR ON EPIDEMIOLOGICAL PRACTICEPRACTICE

AIM

EPIDEMIOLOGYOF

HEALTH ACTION

DISEASE LOAD

EDUCATION AL & RESEARCH

CAUSE

OBJECTIVES OF EPIDEMIOLOGY

FOR

TAKING

RIGHT HAND OF COMMUNITY RIGHT HAND OF COMMUNITY MEDICINEMEDICINE

COMMUNITY MEDICINE

EPIDEMIOLOGY BIOSTATISTICS

EPIDEMILOGY PROVIDESEPIDEMILOGY PROVIDESINTELLIGENCEINTELLIGENCE

FOR HEALTH ACTIONFOR HEALTH ACTION

J. N. MORRIS

INTELLIGENCE MEANSINFORMATION REGARDINGTHE DETERMINANTS OF HEALTH & DISEASE AND THEIR OCCURRENCE & MAGNITUDE IN POPULATIONSFOR TAKING HEALTH ACTION

EPIDEMIOLOGICAL PURPOSE & EPIDEMIOLOGICAL PURPOSE & SEQUENCESEQUENCE

1.1. IDENTIFYING DISEASE/ HEALTH PROBLEMIDENTIFYING DISEASE/ HEALTH PROBLEM

2.2. LINKING WITH THE CAUSE / RISK LINKING WITH THE CAUSE / RISK FACTORSFACTORS

3.3. ESTABLISHING CAUSAL RELATION- SHIPESTABLISHING CAUSAL RELATION- SHIP

4.4. DESIGNING AN INTERVENTION FOR DESIGNING AN INTERVENTION FOR CONTROLLING PROBLEMCONTROLLING PROBLEM

5.5. TO EVALUATE THE EFFECTIVENESS OF TO EVALUATE THE EFFECTIVENESS OF INTERVENTIONINTERVENTION

(MAXCY)

MORRIS’ SEVEN USESMORRIS’ SEVEN USES

1.1. TREND STUDYTREND STUDY2.2. COMMUNITY DIAGNOSISCOMMUNITY DIAGNOSIS3.3. HEALTH SERVICES EVALUATIONHEALTH SERVICES EVALUATION4.4. TO KNOW THE INDIVIDUAL RISKS AND TO KNOW THE INDIVIDUAL RISKS AND

CHANCESCHANCES5.5. SYNDROME IDENTIFICATIONSYNDROME IDENTIFICATION6.6. COMPLETING THE CLINICAL PICTURECOMPLETING THE CLINICAL PICTURE7.7. SEARCHING FOR CAUSES / RISK FACTORS SEARCHING FOR CAUSES / RISK FACTORS

FOR ESTABLISHING CAUSAL FOR ESTABLISHING CAUSAL RELATIONSHIP RELATIONSHIP

TREND STUDYTREND STUDY

1.1. STUDYING THE PAST HISTORY FOR RISE STUDYING THE PAST HISTORY FOR RISE AND FALLAND FALL

2.2. STUDYING ITS CHANGING BEHAVIOURSTUDYING ITS CHANGING BEHAVIOUR

3.3. MAKING FUTURE PREDICTIONSMAKING FUTURE PREDICTIONS

4.4. GIVING EARLY WARNINGS OR FEED -BACKGIVING EARLY WARNINGS OR FEED -BACK

SOCIAL ANATOMY

COMMUNITY DIAGNOSIS

SOCIAL PATHOLOGY

SOCIAL PHYSIOLOGY

QUANTIFICATIONQUALITATIVE ESTIMATION

COMMUNITY DIAGNOSIS

COMMUNITY DIAGNOSISCOMMUNITY DIAGNOSIS1.1. SOCIAL ANATOMYSOCIAL ANATOMY: RACE, AGE AND : RACE, AGE AND

SEX COMPOSITION, SOCIO ECONOMIC SEX COMPOSITION, SOCIO ECONOMIC STATUS, POPULATION AT RISK, RESOURCES STATUS, POPULATION AT RISK, RESOURCES AVALAIBLE.AVALAIBLE.

2.2. SOCIAL PHYSIOLOGYSOCIAL PHYSIOLOGY: POSITIVE &NEGATIVE : POSITIVE &NEGATIVE LIFESTYLES, OCCUPATION, HEALTH LIFESTYLES, OCCUPATION, HEALTH SERVICES AWARENESS AND UILIZATION, SERVICES AWARENESS AND UILIZATION, NUTRITIONAL POLICES, LABOUR.NUTRITIONAL POLICES, LABOUR.

3.3. SOCIAL PATHOLOGYSOCIAL PATHOLOGY: MORBIDITY, : MORBIDITY, MORTALITY, DISABILITY, ALCHOLISM, MORTALITY, DISABILITY, ALCHOLISM, SMOKING, CRIME & VOILENCE, RISK PRONE SMOKING, CRIME & VOILENCE, RISK PRONE BEHAVIOUR.BEHAVIOUR.

COMMUNITY DIAGNOSISCOMMUNITY DIAGNOSIS

MUST BE DYANAMICMUST BE DYANAMIC IN A WORLD OF CHANGE, IN A WORLD OF CHANGE,

EPIDEMIOLOGIST HAVE A EPIDEMIOLOGIST HAVE A SPECIAL DUTYSPECIAL DUTY TO OBSERVE THE IMPACT “UPON THE TO OBSERVE THE IMPACT “UPON THE PEOPLE” AND THE WAY WE LIVE PEOPLE” AND THE WAY WE LIVE TO TO DIAGNOSEDIAGNOSE WHERE WELL -BEING IS WHERE WELL -BEING IS INCREASING AND WHERE LOSING OUT, INCREASING AND WHERE LOSING OUT, TO PROBE FOR UNINTENDED TO PROBE FOR UNINTENDED CONSEQUENCES ,CONSEQUENCES , TO IDENTIFY TRENDS TO IDENTIFY TRENDS AND TO THINK AHEAD.AND TO THINK AHEAD.

ONION PRINCIPLEONION PRINCIPLE

JUST LIKE THE LAYERS OF THE ONION, THE OLD DISEASES WANE AND GIVE PLACE TO NEWONES.INFECTIOUS ONES WILL BE REPLACED BY NON– INFECTIOUS ONES TO BE REPLACED LATERBY PERSONAL AND BEHAVIORAL PROBLEMS.ONE MUST BE AWARE OF THIS PHENOMENON BEFORE DIAGNOSING THE COMMUNITY HEALTH

OLD DISEASES

HEALTH SERVICES HEALTH SERVICES EVALUATIONEVALUATION

HEALTH PLANNING FOR HEALTH PLANNING FOR

• APPROPRIATEAPPROPRIATE

• COST EFFECTIVECOST EFFECTIVE

• COMMUNITY NEED BASEDCOMMUNITY NEED BASED

• JUDICIAL MIX OF PREVENTIVE, JUDICIAL MIX OF PREVENTIVE, PROMOTIVE, CURATIVE, PROMOTIVE, CURATIVE, REHABILITATIVE AND PUBLIC REHABILITATIVE AND PUBLIC HEALTH SERVICESHEALTH SERVICES

SYNDROME IDENTIFICATIONSYNDROME IDENTIFICATION

LUMPERSLUMPERS

&&

SPLITTERSSPLITTERS

GROUPING AND DIVIDING THE SYMPTOM- COMPLEXES AND NAMING THEM AS SYNDROMES IS THE STARTING POINT FOR THE STUDY OF NATURAL HISTORY OF ANY DISEASE

SEARCH FOR CAUSESSEARCH FOR CAUSES

SEVERAL CAUSESSEVERAL CAUSES SINGLE DISEASE SINGLE DISEASE

SINGLE CAUSE SINGLE CAUSE SEVERAL DISEASES SEVERAL DISEASES

SEARCH FOR CAUSE IN INTERRELATED SEARCH FOR CAUSE IN INTERRELATED DISEASES MAY YIELD CLUES FOR NEW DISEASES MAY YIELD CLUES FOR NEW CAUSES / RISK FACTORSCAUSES / RISK FACTORS

COMPLETING THE CLINICAL PICTURE COMPLETING THE CLINICAL PICTURE OF DISEASEOF DISEASE IN BREADTHIN BREADTH

• HOSPITAL STUDIES HAS TO BE BROADEND WITH HOSPITAL STUDIES HAS TO BE BROADEND WITH SIMULTANEOUS COMMUNITY STUDIES AS THEY POORLY SIMULTANEOUS COMMUNITY STUDIES AS THEY POORLY REPRESENT THE HELTH EVENT IN GENERAL POPULATION. REPRESENT THE HELTH EVENT IN GENERAL POPULATION. MERE DEPENDENCE ON STUDIES CONDUCTED IN HOSPITAL OR MERE DEPENDENCE ON STUDIES CONDUCTED IN HOSPITAL OR ANY HEALTH FACILITY SETTING IS BIASED BECAUSE THEY DO ANY HEALTH FACILITY SETTING IS BIASED BECAUSE THEY DO NOT INCLUDE THE PREPATHOGENIC AND FOLLOW-UP PHAGES NOT INCLUDE THE PREPATHOGENIC AND FOLLOW-UP PHAGES OF THE DISEASE STUDIED.OF THE DISEASE STUDIED.

IN DEPTHIN DEPTH • GOING TO THE BOTTOM, THE DEEEPER PART OF THE GOING TO THE BOTTOM, THE DEEEPER PART OF THE

ICEBERGH TO STUDY THE EARLIER PART OF DISEASE, WHICH IS ICEBERGH TO STUDY THE EARLIER PART OF DISEASE, WHICH IS EITHER STOPPABLE OR ATLEAST PREVBENTABLE BY EITHER STOPPABLE OR ATLEAST PREVBENTABLE BY SEARCHING FORSEARCHING FOR

• PRECURSORS OF THE DISEASEPRECURSORS OF THE DISEASE• DISPOITIONS DUE TO DISEASEDISPOITIONS DUE TO DISEASE• ASYMPTOMATIC DISEASEASYMPTOMATIC DISEASE• SUBCLINICAL CASESSUBCLINICAL CASES• LATENT CASESLATENT CASES• CARRIER STATECARRIER STATE

NATURAL HISTORY OF DISEASENATURAL HISTORY OF DISEASE

RISK ASSESMENTRISK ASSESMENT

INDIVIDUAL RISK INDIVIDUAL RISK

GENERAL POPUTLATION RISKGENERAL POPUTLATION RISK

PROGNOSIS FOR BY PHYSICIANPROGNOSIS FOR BY PHYSICIAN

CYCLE OF EXTENSIONCYCLE OF EXTENSION

TB

DISEASE IN MAN

MAN

INFLUENCING ENVIRONMENT

SCOPE AND JURISDICTIONSCOPE AND JURISDICTION STRICTLY SPEAKING, THERE IS NO LIFE STRICTLY SPEAKING, THERE IS NO LIFE

SCIENCE, WHERE EPIDEMIOLOGICAL SCIENCE, WHERE EPIDEMIOLOGICAL APPROACH AND PRINCIPLES CANNOT BE APPROACH AND PRINCIPLES CANNOT BE APPLIEDAPPLIED

FROM WOMB TO TOMB EPIDEMIOLOGY IS APPLICABLE FROM WOMB TO TOMB EPIDEMIOLOGY IS APPLICABLE

PREVENTIVE PAEDIATRICSPREVENTIVE PAEDIATRICSPREVENTIVE GERIATRICSPREVENTIVE GERIATRICS

PREVENTIVE CARDIOLOGYPREVENTIVE CARDIOLOGYCLINICAL EPIDEMIOLOGYCLINICAL EPIDEMIOLOGY