Scientific standards of criticism: a reaction to "Scientific standards in epidemiologic studies of the menace of daily life," by A.R. Feinstein

Exposing additional authors who suppress evidence about radiation-induced thyroid cancer in children: a Comment adding to Tsuda et al.'s response to Schüz et al. (2023)

BACKGROUND

The need to call out and expose authors for their persistence in improperly using epidemiology has been previously noted. Tsuda et al. have done well to expose Schüz et al.'s arguments/assertions in their recent publication in Environmental Heath. In this Comment, I point out that, also warranting being called out, are the arguments/assertions of Cléro et al. who, in their recent response to an article by Tsuda et al., reiterated the conclusions and recommendations derived from their European project, which were published in Environment International in 2021. Tsuda et al. had critiqued the Cléro et al. 2021 publication in their 2022 review article. However, in their response to it, Cléro et al. deflected by not addressing any of the key points that Tsuda et al. had made in their review regarding the aftermath of the Chernobyl and Fukushima nuclear accidents. In this Comment, I critique Cléro et al.'s inadequate response. Publication of this Comment will help in routing out the improper use of epidemiology in the formulation of public health policy and thereby reduce the influence of misinformation on both science and public policy. My critique of Cléro et al. is not dissimilar from Tsuda et al.'s critique of Schüz et al.: in as much as Schüz et al. should withdraw their work, so should Cléro et al.'s article be retracted.

MAIN BODY

The response by Cléro et al. consists of four paragraphs. First was their assertion that the purpose of the SHAMISEN project was to make recommendations based on scientific evidence and that it was not a systematic review of all related articles. I point out that the Cléro et al. recommendations were not based on objective scientific evidence, but on biased studies. In the second paragraph, Cléro et al. reaffirmed the SHAMISEN Consortium report, which claimed that the overdiagnosis observed in non-exposed adults was applicable to children because children are mirrors of adults. However, the authors of that report withheld statements about secondary examinations in Fukushima that provided evidence against overdiagnosis. In the third paragraph, Cléro et al. provided an explanation regarding their disclosure of conflicting interests, which was contrary to professional norms for transparency and thus was unacceptable. Finally, their insistence that the Tsuda et al. study was an ecological study susceptible to "the ecological fallacy" indicated their lack of epidemiological knowledge about ecological studies. Ironically, many of the papers cited by Cléro et al. regarding overdiagnosis were, in fact, ecological studies.

CONCLUSION

Cléro et al. and the SHAMISEN Consortium should withdraw their recommendation "not to launch a mass thyroid cancer screening after a nuclear accident, but rather to make it available (with appropriate information counselling) to those who request it." Their recommendation is based on biased evidence and would cause confusion regarding public health measures following a nuclear accident. Those authors should, in my assessment, acquaint themselves with modern epidemiology and evidence-based public health. Like Tsuda et al. recommended of Schüz et al., Cléro et al. ought also to retract their article.

A Future for Observational Epidemiology: Clarity, Credibility, Transparency

Observational studies are ambiguous, difficult, and necessary for epidemiology. Presently, there are concerns that the evidence produced by most observational studies in epidemiology is not credible and contributes to research waste. I argue that observational epidemiology could be improved by focusing greater attention on 1) defining questions that make clear whether the inferential goal is descriptive or causal; 2) greater utilization of quantitative bias analysis and alternative research designs that aim to decrease the strength of assumptions needed to estimate causal effects; and 3) promoting, experimenting with, and perhaps institutionalizing both reproducible research standards and replication studies to evaluate the fragility of study findings in epidemiology. Greater clarity, credibility, and transparency in observational epidemiology will help to provide reliable evidence that can serve as a basis for making decisions about clinical or population-health interventions.

Perspective: Randomized Controlled Trials Are Not a Panacea for Diet-Related Research

Research into the role of diet in health faces a number of methodologic challenges in the choice of study design, measurement methods, and analytic options. Heavier reliance on randomized controlled trial (RCT) designs is suggested as a way to solve these challenges. We present and discuss 7 inherent and practical considerations with special relevance to RCTs designed to study diet: 1) the need for narrow focus; 2) the choice of subjects and exposures; 3) blinding of the intervention; 4) perceived asymmetry of treatment in relation to need; 5) temporal relations between dietary exposures and putative outcomes; 6) strict adherence to the intervention protocol, despite potential clinical counter-indications; and 7) the need to maintain methodologic rigor, including measuring diet carefully and frequently. Alternatives, including observational studies and adaptive intervention designs, are presented and discussed. Given high noise-to-signal ratios interjected by using inaccurate assessment methods in studies with weak or inappropriate study designs (including RCTs), it is conceivable and indeed likely that effects of diet are underestimated. No matter which designs are used, studies will require continued improvement in the assessment of dietary intake. As technology continues to improve, there is potential for enhanced accuracy and reduced user burden of dietary assessments that are applicable to a wide variety of study designs, including RCTs.

Social desirability trait influences on self-reported dietary measures among diverse participants in a multicenter multiple risk factor trial

Data collected at 4 Behavioral Change Consortium sites were used to assess social desirability bias in self-reports derived from a dietary fat screener (PFat), a dietary fruit and vegetable screener (FVS), and a 1-item question on fruit and vegetable intake. Comparisons were made with mean intakes derived from up to 3 24-h recall interviews at baseline and follow-up (at 12 mo in 3 sites, 6 mo in the fourth). A social-desirability-related underestimate in fat intake on the PFat relative to the 24HR (percentage energy as fat) was evident in women [baseline b = -0.56 (P = 0.005); follow-up b = -0.62 (P < 0.001)]. There was an overestimate in FVS-derived fruit and vegetable consumption (servings/week) in men enrolled in any intervention at follow-up (b = 0.39, P = 0.05) vs. baseline (b = 0.04, P = 0.75). The 1-item fruit and vegetable question was associated with an overestimate at baseline in men according to SD score (b = 0.14, P = 0.02), especially men with less than college education (b = 0.23, P = 0.01). Women with less than college education expressed a similar bias at follow-up (b = 0.13, P = 0.02). Differences in the magnitude of bias according to gender, type of instrument used, and randomization condition are comparable to what has been seen for other instruments and have important implications for both measuring change in studies of diet and health outcomes and for developing methods to control for such biases.

Forging alliances to bridge the research-policy gap

It is critical that research findings be translated into policy if the research is to be beneficial. Researchers can play a role in bridging the research-policy gap by participating in the drafting of legislation and regulations, by testifying before lawmakers, and by building collaborations with key entities, including non-profit and governmental bodies outside of the health arena. Advocacy is inherent in the responsibilities of a researcher. A distinction must be made between researchers who serve as educators and advocates of change based on our current state of knowledge, and "scientific advocates" who rely on science only when it supports their political position. It is critical that researchers identify appropriate collaborators to bridge the research-policy gap and that the communities be involved in this process.

The controversial controversy of a passionate controversialist

Alvan Feinstein was among the pioneers who perceived the need to apply epidemiologic principles and methods to clinical medicine. In his attempt to convert his peers to his own views, he was very liberal in criticizing the work of others. Epidemiologists still recall his 1988 article in Science entitled "Scientific Standards in Epidemiologic Studies of the Menace of Daily Life," in which he criticized observational epidemiology for its lack of scientific rigor. In this context, Feinstein's work has also been the center of controversies. One in particular, related to the fact that he carried out research and consulted for industries, in particular the tobacco industry, has tainted the last years of Feinstein's career. My purpose in this article is to discuss Feinstein's relationship with the tobacco industry. It is not to judge the validity of his work. Against this background, a question of historic relevance, one that can be discussed on the basis of some evidence, is whether Feinstein, world-reknowned epidemiologist and editor of this journal from 1982 until his recent death, helped the tobacco industry to publish articles minimizing the deleterious effects of smoking in the Journal of Chronic Diseases and (since 1988) the Journal of Clinical Epidemiology. To address this question I have searched the articles related to the effects of tobacco that were published in the Journal since 1978. The tobacco industry has had the opportunity, via its consultants, to defend its own ideas in the "Variance and Dissent" section. Perhaps in hindsight Feinstein could be criticized for not having clearly indicated the sponsorship of the tobacco industry behind these publications, of which he was fully aware. However, this does not suffice to infer that he was the tobacco industry's "man." Feinstein's attitude in matters of publication appears balanced.

Reporting, appraising, and integrating data on genotype prevalence and gene-disease associations

The recent completion of the first draft of the human genome sequence and advances in technologies for genomic analysis are generating tremendous opportunities for epidemiologic studies to evaluate the role of genetic variants in human disease. Many methodological issues apply to the investigation of variation in the frequency of allelic variants of human genes, of the possibility that these influence disease risk, and of assessment of the magnitude of the associated risk. Based on a Human Genome Epidemiology workshop, a checklist for reporting and appraising studies of genotype prevalence and studies of gene-disease associations was developed. This focuses on selection of study subjects, analytic validity of genotyping, population stratification, and statistical issues. Use of the checklist should facilitate the integration of evidence from these studies. The relation between the checklist and grading schemes that have been proposed for the evaluation of observational studies is discussed. Although the limitations of grading schemes are recognized, a robust approach is proposed. Other issues in the synthesis of evidence that are particularly relevant to studies of genotype prevalence and gene-disease association are discussed, notably identification of studies, publication bias, criteria for causal inference, and the appropriateness of quantitative synthesis.

[Causal inference in medicine--decision making]

In the field of occupational medicine, either when we consider some preventive plans or when we make decisions to compensate for occupational diseases, it has been necessary to discuss causality between work and disease. Furthermore, epidemiologic causality has recently been used in risk assessment in occupational and environmental settings. We have shown that the law of causality in medicine is recognized as probability and continuous variables. Such a law of causality has been recognized in the same way as probability in physics, too, and has been regarded as a model of science. Physicists and mathematicians had claimed the importance of probability in causal inference as well as the principle of uncertainty before it was discovered. We, then, explained Etiologic Fraction (EF), Attributable Proportion for the Exposed Population (APE), Probability of Causation (PC), and so on. The PC has been used to ascertain the conditional probability in an individual case of a disease having been caused by a particular prior exposure, by using the experience of exposed populations to determine the appropriate relative risk, and this has been used for compensation for exposed cases. Next the applicability of information from a population to individuals was presented. Third, we provided a brief historical aspect of epidemiology. The evolutions in Epidemiology have been very rapid, so we pointed out that, in Japan, we could observe many incommensurable phenomena in epidemiologists and physicians depending on the era which was studied by them. Fourth, we discussed judgement and political application based on epidemiologic evidence, using Yanagimoto's classification is also taken or not should be estimated and compared. We presented several examples of reasoning in judgements. Lastly, we discussed several tasks and assignments for the future of epidemiology.

The risk environment for HIV transmission: results from the Atlanta and Flagstaff network studies

The purpose of this study was to investigate the hypothesis that human immunodeficiency virus (HIV) transmission may be facilitated or obstructed by network structure, incorporating a measure of risk that combines true risk and surrogates. Persons at presumed high risk for HIV were enrolled in long-term follow-up studies of urban and rural networks in Atlanta, Georgia, and Flagstaff, Arizona. We focused on respondents who were also contacts to evaluate information on both sides of the observed dyads and constructed a Risk Indicator, based on a four-digit binary number, that permitted assessment and visualization of the overall risk environment. We constructed graphs that provided visualization of the level of risk, the types of relationships, and the actual network. Although some of the findings conform to the hypotheses relating network structure to transmission, there were several anomalies. In Atlanta, HIV prevalence was most strongly related to men with a male sexual orientation, despite the widespread use of injectable drugs. In Flagstaff, an area of very low prevalence and no transmission, the risk environment appeared more intense, and the frequency of microstructures was as great or greater than representative areas in Atlanta. The network hypothesis is not yet sufficiently developed to account for empirical observations that demonstrate the presence of intense, interactive networks in the absence of transmission of HIV.

Science, ethics guidelines, and advocacy in epidemiology

This article examines current ethics guidelines for recommendations on advocacy as an acceptable activity for epidemiologists. Three sets of guidelines, those produced by the Industrial Epidemiology Forum (IEF), the International Epidemiological Association (IEA), and the Council of International Organizations of Medical Sciences (CIOMS), appear to endorse the role of advocate, although there are differences in their recommendations. The IEF guidelines hint that advocacy is appropriate, the IEA guidelines recommend separating the roles of scientist and advocate, and the CIOMS guidelines recommend advocacy dependent on the quality of epidemiologic research and on causal interpretations of the data. Advocacy in the form of public health recommendations can be justified in terms of the principle of beneficence found in the guidelines, but is a central obligation only if the aims of the profession are enlarged to include not only the study of disease but also a commitment to disease prevention. An important issue in women's health--alcohol and breast cancer--provides an illustrative example.

Social facts and the sociological imagination: the contributions of sociology to psychiatric epidemiology

This paper provides a conceptual framework for understanding the relationship of psychiatry, epidemiology, and sociology. After a section on definitions, seven empirical contributions by sociologists to the field of psychiatric epidemiology are briefly presented to illustrate the notion of the social fact (contributions by Durkheim, Dunham, Hollingshead, Srole and Langner, Kerckhoff and Back, Dohrenwend, and Brown). Four broad sociological theories are reviewed, as illustrations of the sociological imagination (stratification theory, the idea of Verstehen, symbolic interactionism, and the sociology of knowledge). It is concluded that two major contributions of sociology to psychiatric epidemiology are the concepts and data related to the social fact, and the possibilities offered by the sociological imagination.

Clinical medicine meets modern epidemiology--and both profit

The clinical epidemiology movement can be understood best through the work of people who have chosen to call themselves clinical epidemiologists. It has strong ties to both clinical medicine and epidemiology but is distinct from them; it bridges the two disciplines and helps each recognize and use the strengths of the other. Epidemiology has given clinicians strong methods for answering clinical questions, a population perspective on the care of individual patients, and the scientific basis for preventive health care. Clinicians have brought to epidemiology in-depth understanding of the biology of disease, direct experience with epidemiologic variables, and a strong interest in how the results of research will be used. The success of clinical epidemiology are apparent through research, courses, textbooks, and contributions to clinical and public policy. Clinical medicine and epidemiology began together, then drifted apart. Both have suffered from the schism and both can now profit from becoming reacquainted.