are required. There egtimate disagreement.

Although this is not an easy process, it must

be recognized that most ofWhat we know about human health and disease comes from
observation of human conditions

Types Of DecisionS The goal Of causal inference is to create a framework for takin action
in the face of varying levels Of Uncertainty. In adopting a pragmatic framework, it is helpful
to distinguish between two types Of epidemiologic decisions: those having to do with
scientific hypotheses and those having to do with public health actions. These processes
differ. Inferences about scientific hypotheses are intentionally skeptical with alternative
explanations and theories raised without restriction even after tentative conclusions are
reached. In contrast to the stringent level of skepticism required to test scientific hypotheses,
public health and regulatory decisions cannot always afford the luxury of unrestrained
scientific skep ticism. A framework for making choices with the best evidence currently at
hand is required, for to decide not to make a decision may itself represent a choice that may
prove costly.
Wynder (1994) notes that discoveries of many preventive measures predate discoveries
of the mechanisms responsible for disease, often by many years (Table 16.1). In the same
vein, there is evidence that the "war on cancer" initiated in the last quarter of the 20th
century had been misdirected toward understanding carcinogenic mechanisms and

TABLE 16.1. Discovery Dates of a Measure to Prevent a Disease Compared with the Date
of Identification of the Causative or Preventive Agent

Year of
Discoverer Discovery Year of
of of Discovery
Preventive Preventive of Causative or Discoverer of

Disease Measurea Measure Agent Preventing Agentb Agenta

Scurvy J. Lind 1753 1928 (Ascorbic acid) A. Szent-Gyorgi

Pellagra G. Casal 1755 1924 (Niacin) J. Goldberger et al.
 Scrolal p. pott 1755 1933 Benzo[a]pyrene J. W. Cook et al.
cancer
Smallpox E. Jenner 1798 1958 Orthopoxvirus F. Fenner
Puerperal J. Semmelweis 1847 1879 Streptococcus L. Pasteur
fever
Cholera J. Snow 1849 1893 Vibrio cholerae R. Koch
Bladder L. Rehn 1895 1938 2-Napththylamine W. C. Harper et al.
cancerc
Yellow W. Reed et al. 1901 1928 Flavivirus A. Stokes et al.
fever
Oral A. Abbe 1915 1974 N'-nitrosonornicotine D. Hoffmann et
al.
cancerd

Source: aWynder (1994, p. 548), used with permission.

b
References for each discovery are given in Wynder (1994).
Preventive agents are listed in parentheses.
Cd
Associated with aniline dye.
Associated with tobacco chewing.