Epidemiology For Dummies 1st Edition

Amal K. Mitra
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Epidemiology
Epidemiology

by Amal K. Mitra, MD, DrPH

Professor of Epidemiology and
Biostatistics
Epidemiology For Dummies®
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Library of Congress Control Number: 2023931886

ISBN: 978-1-394-17070-8 (pbk); ISBN: 978-1-394-17071-5 (ebk); ISBN: 978-1-394-17072-2 (ebk)

Contents at a Glance
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Part 1: Getting Started with Epidemiology. . . . . . . . . . . . . . . . . . . . . 5

CHAPTER 1: Entering the World of Epidemiology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
CHAPTER 2: Epidemiology 101 — Understanding the Basics. . . . . . . . . . . . . . . . . . . . . 17
CHAPTER 3: Exploring the Development of Epidemiological Thinking . . . . . . . . . . . . . 41
CHAPTER 4: Eyeing the Milestones in Public Health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
CHAPTER 5: Recognizing Diseases and Controlling Them. . . . . . . . . . . . . . . . . . . . . . . . 77

Part 2: Understanding Disease Causation. . . . . . . . . . . . . . . . . . . 103

CHAPTER 6: Tackling the Epidemiologic Triangle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
CHAPTER 7: Inspecting Descriptive Epidemiology: Person, Place, and Time. . . . . . 117
CHAPTER 8: Viewing Disease Patterns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
CHAPTER 9: Linking Demography and Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
CHAPTER 10: Digging into Math: Calculating Rates and Risks. . . . . . . . . . . . . . . . . . . . 163

Part 3: Prevention Is Better Than a Cure. . . . . . . . . . . . . . . . . . . . 187

CHAPTER 11: Focusing on the Levels of Prevention. . . . . . . . . . . . . . . . . . . . . . . . . . . . 189
CHAPTER 12: Preventing Disease with Vaccine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199
CHAPTER 13: Recognizing Methods of Disease Surveillance. . . . . . . . . . . . . . . . . . . . . 223
CHAPTER 14: Investigating an Outbreak. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231
CHAPTER 15: Identifying Disease by Screening. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247

Part 4: Examining a Study Finding. . . . . . . . . . . . . . . . . . . . . . . . . . . . 265

CHAPTER 16: Figuring Out Whether an Association Is Causal. . . . . . . . . . . . . . . . . . . . 267
CHAPTER 17: Investigating the Types of Epidemiologic Studies. . . . . . . . . . . . . . . . . . 287
CHAPTER 18: Encountering Bias and Confounding. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313
CHAPTER 19: Focusing On Ethics in Health Research. . . . . . . . . . . . . . . . . . . . . . . . . . . 329

Part 5: The Part of Tens. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 343

CHAPTER 20: Ten Careers with a Degree in Epidemiology . . . . . . . . . . . . . . . . . . . . . . 345
CHAPTER 21: Ten Tips for Acing Your Epidemiology Classes . . . . . . . . . . . . . . . . . . . . 351

Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 357

Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 363
Table of Contents
INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
About This Book. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Foolish Assumptions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Icons Used in This Book. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Beyond This Book . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Where to Go from Here . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

PART 1: GETTING STARTED WITH EPIDEMIOLOGY. . . . . . . . . . . 5

CHAPTER 1: Entering the World of Epidemiology . . . . . . . . . . . . . . . . . . . 7
Introducing Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Recognizing How Numbers Can Help Study Disease. . . . . . . . . . . . . . . . 8
Grappling with the epidemiologic triangle. . . . . . . . . . . . . . . . . . . . . . 8
Classifying epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Understanding epidemiologic transition. . . . . . . . . . . . . . . . . . . . . . . 9
Connecting demography and disease . . . . . . . . . . . . . . . . . . . . . . . . 10
Figuring out rates and risks. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Focusing on Prevention Rather Than a Cure. . . . . . . . . . . . . . . . . . . . . . 11
Identifying prevention levels. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Using vaccines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Surveilling disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Studying an outbreak . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Relying on screening. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Delving into Study Finding. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Figuring Out What You Know about Epidemiology: Some Q&As. . . . . 13

CHAPTER 2: Epidemiology 101 — Understanding the Basics. . . . . 17

Defining Epidemiology — What to Expect from Your Coursework
and Beyond . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Describing distribution. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Determining determinants. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19
Avoiding errors when conducting an epidemiological study . . . . . 19
Realizing Why Epidemiology Is Important. . . . . . . . . . . . . . . . . . . . . . . . 20
Identifying and measuring health status. . . . . . . . . . . . . . . . . . . . . . 20
Focusing on disease prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Searching for causes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Controlling epidemics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Understanding How Epidemiology Tools Are Applied. . . . . . . . . . . . . . 22
Using epidemiologic methods to identify risks. . . . . . . . . . . . . . . . . 23
Measuring morbidity and mortality . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Describing the impact of an intervention . . . . . . . . . . . . . . . . . . . . . 23

Table of Contents vii

 Preventing diseases before they hit. . . . . . . . . . . . . . . . . . . . . . . . . . 24
Investigating epidemics of unknown cause. . . . . . . . . . . . . . . . . . . . 25
Evaluating public health programs. . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Contrasting the Roles of a Physician and Epidemiologist. . . . . . . . . . . 27
Eyeing the differences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Helping people. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Describing diseases differently. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Grasping the difference between acute and chronic disease. . . . . 29
Seeking Medications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Eyeing over-the-counter (OTC) and prescription medication. . . . . 30
Examining the role of traditional healers. . . . . . . . . . . . . . . . . . . . . .32
Considering How a Disease Is Transmitted. . . . . . . . . . . . . . . . . . . . . . . 34
Defining key infection terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Spreading infection of an outbreak from person to person. . . . . . 35
Getting infection of an outbreak from a common source. . . . . . . . 36
Relating infections with cancers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Searching for Sources of Epidemiologic Data. . . . . . . . . . . . . . . . . . . . . 37
From the Centers for Disease Control and Prevention (CDC). . . . . 37
From the National Center for Health Statistics (NCHS) . . . . . . . . . . 38
From the World Health Organization (WHO). . . . . . . . . . . . . . . . . . . 38
From census data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
From the Vital Statistics System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

CHAPTER 3: Exploring the Development of Epidemiological

Thinking. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Meeting Hippocrates — the First Epidemiologist. . . . . . . . . . . . . . . . . . 42
Observing “airs, waters, and places”. . . . . . . . . . . . . . . . . . . . . . . . . . 42
Relating diseases to polluted water . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Tackling the Miasma Theory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Believing in bad air . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Getting benefits from a misconception. . . . . . . . . . . . . . . . . . . . . . . 43
Examining Contributions to Medicine and Public Health – Thomas
Sydenham. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Using Concepts of Environmental Epidemiology — Noah Webster. . . . 44
The Germ Theory — Washing Hands Is Essential. . . . . . . . . . . . . . . . . . 45
Hieronymous Fracastorius. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Edward Jenner. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Louis Pasteur. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Robert Koch. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Working on Workers’ Diseases — Bernardino Ramazzini. . . . . . . . . . . 48
The Birth of Vital Statistics: No Labor Pains Involved. . . . . . . . . . . . . . . 48
John Graunt . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
William Farr . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

viii Epidemiology For Dummies

 Examining the Start of Epidemiology and Public Health in
the United States. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Wade Hampton Frost . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Alice Hamilton . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
William Sedgwick. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Lemuel Shattuck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Stephen Smith. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Lillian Wald. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Benjamin Waterhouse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Developing public health institutes . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Reforming Public Health in England. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Deteriorating health after the Industrial Revolution . . . . . . . . . . . . 55
Moving toward sanitary reforms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Looking At Modern Epidemiology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Field epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Molecular and genetic epidemiology. . . . . . . . . . . . . . . . . . . . . . . . . 57

CHAPTER 4: Eyeing the Milestones in Public Health. . . . . . . . . . . . . . . 59

Finding the Treatment of Scurvy — James Lind . . . . . . . . . . . . . . . . . . . 59
Enquiring into the diet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Examining Lind’s experiment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Discovering Sources of Cholera in London’s Golden Square —
John Snow. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Questioning the miasma theory. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Suspecting a hand pump. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Mapping cases and deaths. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .63
Removing the handle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
Uncovering Causes of Pellagra — Joseph Goldberger. . . . . . . . . . . . . . 65
Suggesting pellagra not communicable. . . . . . . . . . . . . . . . . . . . . . . 66
Connecting pellagra with poverty and helping with diet. . . . . . . . . 67
Describing the 1918 Influenza Pandemic . . . . . . . . . . . . . . . . . . . . . . . . 68
Gathering mortality data of the pandemic . . . . . . . . . . . . . . . . . . . . 68
Controlling the pandemic. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Eradicating Smallpox. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .70
Finding Smoking as a Cause of Lung Cancer. . . . . . . . . . . . . . . . . . . . . . 71
Looking at early studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Recognizing what chemicals in cigarette cause cancers . . . . . . . . . 73
Feeling the Beat of the Framingham Heart Study . . . . . . . . . . . . . . . . . 74

CHAPTER 5: Recognizing Diseases and Controlling Them . . . . . . . . 77

Identifying the Modes of Transmission . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Eyeing the Chain of Infection: Can You Break It? . . . . . . . . . . . . . . . . . . 79
Classifying reservoirs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
Discovering what carriers are . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
Recognizing a susceptible host. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
Focusing on the portals of exit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82

Table of Contents ix
 Examining the Natural History of Disease. . . . . . . . . . . . . . . . . . . . . . . . 83
Describing the nature of infectious diseases . . . . . . . . . . . . . . . . . . 84
Passing through the stages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
Listing Common Notifiable Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
Controlling Waterborne Diseases. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
Naming common waterborne diseases. . . . . . . . . . . . . . . . . . . . . . . 88
Taking steps in controlling waterborne diseases. . . . . . . . . . . . . . . 90
Tackling Problems of Airborne Infections . . . . . . . . . . . . . . . . . . . . . . . . 91
Recognizing common airborne infections. . . . . . . . . . . . . . . . . . . . . 91
Controlling airborne infections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Curving Vector-Borne Diseases. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
Listing common vector-borne diseases. . . . . . . . . . . . . . . . . . . . . . . 92
Finding ways to combat vector-borne diseases . . . . . . . . . . . . . . . . 93
Limiting Parasitic Infections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Identifying common parasitic infections . . . . . . . . . . . . . . . . . . . . . . 94
Taking steps to control parasitic infections. . . . . . . . . . . . . . . . . . . . 94
Controlling Sexually Transmitted Infections. . . . . . . . . . . . . . . . . . . . . . 95
Listing common STIs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Carrying out control measures for STIs. . . . . . . . . . . . . . . . . . . . . . . 97
Dealing With Emerging Infectious Diseases . . . . . . . . . . . . . . . . . . . . . . 98
Finding common emerging infections . . . . . . . . . . . . . . . . . . . . . . . . 98
Controlling emerging infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
Identifying Diseases Caused by Heavy Metals . . . . . . . . . . . . . . . . . . . 101

PART 2: UNDERSTANDING DISEASE CAUSATION . . . . . . . . . 103

CHAPTER 6: Tackling the Epidemiologic Triangle . . . . . . . . . . . . . . . . 105

Scrutinizing an Acute Disease Model. . . . . . . . . . . . . . . . . . . . . . . . . . . 106
Examining agent factors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
Considering host factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
Looking at environment factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
Inspecting a Chronic Disease Model. . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
Understanding How Climate Change Can Affect Health. . . . . . . . . . . 110
Linking climate change with infectious diseases . . . . . . . . . . . . . . 110
Finding vector-borne diseases related to climate change. . . . . . . 111

CHAPTER 7: Inspecting Descriptive Epidemiology: Person,

Place, and Time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
Knowing Person Factors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
Age — More than just a number. . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
Gender — Battle of the sexes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
Race/ethnicity — Inequalities exist. . . . . . . . . . . . . . . . . . . . . . . . . . 122
Occupation — A person’s job matters . . . . . . . . . . . . . . . . . . . . . . . 123

x Epidemiology For Dummies

 Income — Money makes the world go ’round . . . . . . . . . . . . . . . . 124
Education — Knowledge is power. . . . . . . . . . . . . . . . . . . . . . . . . . . 125
Focusing on Place Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
Spot mapping. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
Using GIS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
Checking Time Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
Defining endemic diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
Finding sporadic diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
Discovering epidemics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
Considering pandemics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
Looking at epizootic diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132
Changing patterns by seasonality. . . . . . . . . . . . . . . . . . . . . . . . . . . 132
Differentiating between outbreak and cluster . . . . . . . . . . . . . . . . 133

CHAPTER 8: Viewing Disease Patterns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135

Defining the Epidemiologic Transition. . . . . . . . . . . . . . . . . . . . . . . . . . 135
Seeing how leading causes of death have changed. . . . . . . . . . . . 136
Considering causes of death in the world. . . . . . . . . . . . . . . . . . . . 137
Transitioning stages in some developing countries. . . . . . . . . . . . 138
Grasping Why Epidemiologic Transition Happens. . . . . . . . . . . . . . . . 139
Studying Some Chronic Health Conditions . . . . . . . . . . . . . . . . . . . . . . 141
Hypertension. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
Cholesterol and cardiovascular diseases. . . . . . . . . . . . . . . . . . . . . 143
Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
Understanding How Epidemiologic Transition Affects Healthcare. . . . 147
Increasing healthcare cost. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
Compromising quality of life. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148

CHAPTER 9: Linking Demography and Disease. . . . . . . . . . . . . . . . . . . 149

Defining Demography — Why It’s Important . . . . . . . . . . . . . . . . . . . . 149
Using Demographic Data to Identify Population at Risk. . . . . . . . . . . 151
Using census data. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
Focusing on population density . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
Finding demographic data. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
Tackling Population Pyramids: Not the Ones in Egypt. . . . . . . . . . . . . 155
Shaping population pyramids. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156
Calculating the dependency ratio. . . . . . . . . . . . . . . . . . . . . . . . . . . 156
Projecting Population – Simple Math. . . . . . . . . . . . . . . . . . . . . . . . . . . 158
Calculating population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
Working out some exercises . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
Projecting more populations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161

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 CHAPTER 10: Digging into Math: Calculating Rates and Risks. . . . 163
Addressing Some Basics When Calculating Descriptive
Epidemiology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
Recognizing the key elements of a formula. . . . . . . . . . . . . . . . . . .164
Focusing on rate, ratio, and proportion. . . . . . . . . . . . . . . . . . . . . . 164
Calculating Crude Morbidity and Crude Mortality Rates. . . . . . . . . . . 165
Focusing on the terms and formulas. . . . . . . . . . . . . . . . . . . . . . . . 166
Doing the math . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166
Figuring Out Commonly Used Rates. . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
Infant mortality rate (IMR) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
Maternal mortality rate (MMR) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
Neonatal mortality rate (NNMR). . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
Post-neonatal mortality rate (PNNMR). . . . . . . . . . . . . . . . . . . . . . . 172
Perinatal mortality rate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173
Cause-specific mortality rate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174
Gender-specific rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177
Age-specific rates. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
Proportionate mortality rate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
Case fatality rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
Measuring Incidence and Prevalence. . . . . . . . . . . . . . . . . . . . . . . . . . . 182
Standardizing Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
Using the direct method. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
Utilizing the indirect method. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186

PART 3: PREVENTION IS BETTER THAN A CURE . . . . . . . . . . . 187

CHAPTER 11: Focusing on the Levels of Prevention. . . . . . . . . . . . . . . 189

Identifying Primary Prevention. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189
Combating diseases by vaccines. . . . . . . . . . . . . . . . . . . . . . . . . . . . 189
Giving health education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191
Taking prenatal care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191
Assuring proper nutrition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193
Providing safe water, sanitation, and hygiene (WASH) . . . . . . . . . 195
Recognizing Secondary Prevention. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 196
Examining Tertiary Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197
Limiting any disability. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197
Providing rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198

CHAPTER 12: Preventing Disease with Vaccine. . . . . . . . . . . . . . . . . . . . 199

Getting the Lowdown on Immunity . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200
Understanding the body’s immune system. . . . . . . . . . . . . . . . . . . 200
Comparing natural and acquired immunity . . . . . . . . . . . . . . . . . . 202
Comparing active and passive immunity. . . . . . . . . . . . . . . . . . . . . 202
Planning Shots for Children, from Birth through Adolescence . . . . . 205

xii Epidemiology For Dummies

 Looking Closer at Cancer-Preventing Vaccines. . . . . . . . . . . . . . . . . . . 209
Identifying cancer-causing viruses . . . . . . . . . . . . . . . . . . . . . . . . . . 209
Cancer-causing bacteria. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213
Cancer-causing parasites. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214
Identifying Common Vaccine-Preventable Diseases . . . . . . . . . . . . . . 214
Measles. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214
Mumps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215
Rubella . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215
Diphtheria. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215
Whooping cough. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 216
Tetanus. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 216
Polio. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 216
Rotavirus. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217
Covid-19 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217
Chickenpox. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218
Shingles. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218
Hib. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218
Preventing Disease for World Travelers. . . . . . . . . . . . . . . . . . . . . . . . . 219
Vaccinating for cholera. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219
Protecting from malaria. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 220
Avoiding hepatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221
Knowing about the yellow fever vaccine . . . . . . . . . . . . . . . . . . . . . 222

CHAPTER 13: Recognizing Methods of Disease Surveillance. . . . . 223

Differentiating between Survey, Surveillance, and Monitoring . . . . . 224
Survey — Making a single observation. . . . . . . . . . . . . . . . . . . . . . .224
Surveillance — Tracking continuously . . . . . . . . . . . . . . . . . . . . . . . 225
Monitoring — Periodically checking. . . . . . . . . . . . . . . . . . . . . . . . . 226
Defining the Types of Surveillance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227
Active surveillance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227
Passive surveillance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228
Sentinel surveillance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228
Conducting Surveillance: The How-to. . . . . . . . . . . . . . . . . . . . . . . . . . .229

CHAPTER 14: Investigating an Outbreak. . . . . . . . . . . . . . . . . . . . . . . . . . . . 231

Conducting an Epidemic Investigation. . . . . . . . . . . . . . . . . . . . . . . . . . 232
Classifying epidemics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232
Understanding the threshold level of an outbreak . . . . . . . . . . . . 233
Planning for field investigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234
Digging Out Cases by Surveillance, Step-by-Step. . . . . . . . . . . . . . . . . 235
Establishing the existence of an outbreak. . . . . . . . . . . . . . . . . . . . 235
Verifying the diagnosis with data . . . . . . . . . . . . . . . . . . . . . . . . . . . 236
Identifying new and ongoing cases. . . . . . . . . . . . . . . . . . . . . . . . . . 237
Intensifying the existing surveillance system . . . . . . . . . . . . . . . . . 237

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 Performing descriptive epidemiology . . . . . . . . . . . . . . . . . . . . . . . 238
Using analytical statistics to calculate the attack rates . . . . . . . . . 238
Developing a hypothesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240
Evaluating the hypothesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241
Implementing control measures. . . . . . . . . . . . . . . . . . . . . . . . . . . . 241
Reporting the findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241
Using Makeshift Hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242
Walking through an Outbreak Investigation. . . . . . . . . . . . . . . . . . . . . 244

CHAPTER 15: Identifying Disease by Screening . . . . . . . . . . . . . . . . . . . . 247

Defining Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247
Identifying the detectable preclinical phase (DPCP). . . . . . . . . . . . 248
Understanding lead time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249
Naming Ingredients of a Good Screening Test. . . . . . . . . . . . . . . . . . . 249
Focusing on disease characteristics. . . . . . . . . . . . . . . . . . . . . . . . . 250
Noting effective test characteristics . . . . . . . . . . . . . . . . . . . . . . . . . 250
Explaining validity and reliability. . . . . . . . . . . . . . . . . . . . . . . . . . . . 251
Looking Closer at Some Common Screening Programs . . . . . . . . . . . 252
Mammogram. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252
Breast self-exam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253
Pap smear. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253
Colonoscopy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254
Prostate-specific antigen (PSA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254
Tuberculin test. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254
Fecal occult blood test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255
Screening newborn babies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255
Evaluating Screening Tests. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 256
Being familiar with key terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 256
Comprehending sensitivity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257
Looking at specificity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 258
Explaining multiphasic screening . . . . . . . . . . . . . . . . . . . . . . . . . . . 261
Differentiating between mass screening and selective
screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261
Selecting a cutoff point. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 262

PART 4: EXAMINING A STUDY FINDING . . . . . . . . . . . . . . . . . . . . 265

CHAPTER 16: Figuring Out Whether an Association Is Causal. . . 267

Establishing Causality. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 268
Examining an association that may not be causal. . . . . . . . . . . . . 268
Identifying confounders that affect a causal link . . . . . . . . . . . . . . 269
Seeing examples of a causal effect. . . . . . . . . . . . . . . . . . . . . . . . . . 270
Exploring a multifactorial model. . . . . . . . . . . . . . . . . . . . . . . . . . . . 272

xiv Epidemiology For Dummies

 Understanding Hill’s Criteria for Causality. . . . . . . . . . . . . . . . . . . . . . . 275
Examining strength of association . . . . . . . . . . . . . . . . . . . . . . . . . . 275
Considering dose-response. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 278
Grasping temporality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 280
Focusing on specificity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 280
Striving for consistency. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281
Explaining biological plausibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . 282
Contemplating coherence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 283
Conducting more experimentation . . . . . . . . . . . . . . . . . . . . . . . . . 283
Finding analogies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 284
Making Rothman’s Causal Pie . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 284
Knowing what a sufficient cause means . . . . . . . . . . . . . . . . . . . . . 285
Understanding a necessary cause . . . . . . . . . . . . . . . . . . . . . . . . . . 285
Defining component causes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285
Getting into contributory cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . 286

CHAPTER 17: Investigating the Types of Epidemiologic

Studies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287
Looking At the Anatomy of Epidemiologic Studies. . . . . . . . . . . . . . . . 288
Observing observational studies. . . . . . . . . . . . . . . . . . . . . . . . . . . . 289
Experimenting experimental studies. . . . . . . . . . . . . . . . . . . . . . . . 290
Using the hierarchy of study design. . . . . . . . . . . . . . . . . . . . . . . . . 290
Differentiating between retrospective and prospective
studies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291
Conducting a Cross-Sectional Study. . . . . . . . . . . . . . . . . . . . . . . . . . . . 292
Identifying the pros and cons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293
Formulating a cross-sectional study. . . . . . . . . . . . . . . . . . . . . . . . . 293
Plotting a Case-Control Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295
Selecting a suitable control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295
Counting the pros and cons. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299
Putting together a case-control study . . . . . . . . . . . . . . . . . . . . . . . 300
Measuring association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 302
Nesting a nested case-control study . . . . . . . . . . . . . . . . . . . . . . . . 302
Leading a Cohort Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305
Identifying the three types of cohorts . . . . . . . . . . . . . . . . . . . . . . . 305
Recognizing the pros and cons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306
Devising a prospective cohort study. . . . . . . . . . . . . . . . . . . . . . . . . 306
Figuring Out an Ecological Study. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 308
Knowing what ecological fallacy is . . . . . . . . . . . . . . . . . . . . . . . . . . 309
Focusing on the pros and cons. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309
Looking at examples of ecological studies . . . . . . . . . . . . . . . . . . . 309
Developing a Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 310
Creating an efficient questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . 311
Using closed and open-ended questions. . . . . . . . . . . . . . . . . . . . . 311
Knowing what else to include . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 312

Table of Contents xv
 CHAPTER 18: Encountering Bias and Confounding. . . . . . . . . . . . . . . . 313
Defining Bias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 314
Clarifying What Confounding Means . . . . . . . . . . . . . . . . . . . . . . . . . . . 314
Reviewing Bias-Affecting Research Findings. . . . . . . . . . . . . . . . . . . . . 315
Examining and avoiding selection bias . . . . . . . . . . . . . . . . . . . . . . 315
Eyeing and avoiding information bias . . . . . . . . . . . . . . . . . . . . . . . 318
Recognizing and avoiding instrument bias . . . . . . . . . . . . . . . . . . . 320
Understanding response bias. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 321
Noticing and avoiding lead time bias. . . . . . . . . . . . . . . . . . . . . . . . 323
Identifying and avoiding publication bias . . . . . . . . . . . . . . . . . . . . 323
Steering Clear of Bias in the Initial Stages of Research. . . . . . . . . . . . 324
Designing the study. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 324
Blinding. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325
Controlling for Confounders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 326
Addressing during the design phase . . . . . . . . . . . . . . . . . . . . . . . . 326
Focusing on confounders during analysis. . . . . . . . . . . . . . . . . . . . 327

CHAPTER 19: Focusing On Ethics in Health Research. . . . . . . . . . . . . 329

Comprehending the Evolution of Ethical Norms in Research. . . . . . . 329
Looking into cases of scientific misconduct. . . . . . . . . . . . . . . . . . .330
Examining some unethical practices in the past. . . . . . . . . . . . . . . 331
Responding to unethical studies. . . . . . . . . . . . . . . . . . . . . . . . . . . . 334
Grasping the Importance of a Code of Ethics. . . . . . . . . . . . . . . . . . . . 336
Respecting persons. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 336
Ensuring beneficence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 337
Providing justice. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 337
Using Informed Consent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 337
Including this essential information. . . . . . . . . . . . . . . . . . . . . . . . . 338
Using an expedited review. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 339
Waiving the informed consent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 339

PART 5: THE PART OF TENS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 343

CHAPTER 20: Ten Careers with a Degree in Epidemiology . . . . . . . 345

Epidemiologist. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 345
Environmental Epidemiologist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 347
Surveillance Data Analyst and Epidemiologist . . . . . . . . . . . . . . . . . . . 347
Infection Control Officer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 348
Research Scientist. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 348
Research Associate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 349
Data Analyst. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 349
Program Manager. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 349
Chief Medical/Quality Officer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 350
Data and Research Coordinator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 350

xvi Epidemiology For Dummies

CHAPTER 21: Ten Tips for Acing Your Epidemiology Classes. . . . . 351
Ask and Answer Questions in Class . . . . . . . . . . . . . . . . . . . . . . . . . . . . 352
Practice, Practice, and Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 352
Take Good Class Notes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 352
Get Information Online . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 353
Apply the Knowledge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 353
Make a Cheat Sheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 354
Use a Scientific Calculator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 354
Memorize Some Definitions and Steps . . . . . . . . . . . . . . . . . . . . . . . . . 354
Get Involved in Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 355
Participate in Group Work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 355

GLOSSARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 357

INDEX. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 363

Table of Contents xvii

Introduction
A
s a beginner in public health, you may be on a quest to know about diseases
that are affecting your community, other countries, and the world. If you
desire to build a career in a field of epidemiology, you want to know more
about what causes certain diseases and how they’re transmitted, or as a public
health professional, you want to advise people about disease prevention.

You’ve come to the right place. Epidemiology has been a hot topic in the past few
years with the Covid-19 pandemic, but there’s so much more to it. Getting a
degree in epidemiology is a good choice because the concepts and skills of epide-
miology will prepare you for plenty of jobs in public health. Even if you aren’t a
researcher or a data analyst, epidemiology can help you get a sense about numbers
when you hear that the Covid-19 rates are rising or coming down, or when you
hear that Forest County of Hattiesburg, Mississippi is the hot spot of lead
poisoning.

About This Book

Epidemiology For Dummies emerged from the needs of undergraduate and graduate
students in public health, especially in the field of epidemiology. During the
Covid-19 pandemic, almost all face-to-face classes were closed and classes were
only offered online. Some students faced challenges in fully understanding some
difficult topics during this online format.

This handy guide isn’t a textbook or workbook in epidemiology. Rather, I wrote

this book based on my decades of experience in practicing medicine, conducting
health research, and teaching public health for undergraduate as well as graduate
students to help explain the concepts of epidemiology in plain English with plenty
of real-life examples, calculations, and illustrations.

Here you can read about an array of concepts, starting from Epidemiology 101 to
more advanced research methods to ethics in conducting human research. I focus
on the following areas:

»» The history of the development of public health and epidemiology

»» The epidemiologic triangle
Introduction 1
Another random document with
no related content on Scribd:
hailstones. Instinctively dropping on my knees, I gripped an angle of
the rock, curled up like a young fern frond with my face pressed
against my breast, and in this attitude submitted as best I could to
my thundering bath. The heavier masses seemed to strike like
cobblestones, and there was a confused noise of many waters about
my ears—hissing, gurgling, clashing sounds that were not heard as
music. The situation was quickly realized. How fast one’s thoughts
burn in such times of stress! I was weighing chances of escape.
Would the column be swayed a few inches away from the wall, or
would it come yet closer? The fall was in flood and not so lightly
would its ponderous mass be swayed. My fate seemed to depend on
a breath of the “idle wind.” It was moved gently forward, the
pounding ceased, and I was once more visited by glimpses of the
moon. But fearing I might be caught at a disadvantage in making too
hasty a retreat, I moved only a few feet along the bench to where a
block of ice lay. I wedged myself between the ice and the wall, and
lay face downwards, until the steadiness of the light gave
encouragement to rise and get away. Somewhat nerve-shaken,
drenched, and benumbed, I made out to build a fire, warmed myself,
ran home, reached my cabin before daylight, got an hour or two of
sleep, and awoke sound and comfortable, better, not worse, for my
hard midnight bath.—From “The Yosemite.” Copyright by The
Century Co., New York, and used by their kind permission.

THE TORTURE OF THE STRAIT-JACKET

By Jack London
Have you ever seen canvas tarpaulins or rubber blankets with
brass eyelets set in along the edges? Then imagine a piece of stout
canvas, some four and one-half feet in length, with large and heavy
brass eyelets running down both edges. The width of this canvas is
never the full girth of the human body it is to surround. The width is
also irregular—broadest at the shoulders, next broadest at the hips,
and narrowest at the waist.
The jacket is spread on the floor. The man who is to be punished,
or who is to be tortured for confession, is told to lie face-downward
on the flat canvas. If he refuses, he is man-handled. After that he
lays himself down with a will, which is the will of the hang-dogs,
which is your will, dear citizen, who feeds and fees the hang-dogs for
doing this thing for you.
The man lies face-downward. The edges of the jacket are brought
as nearly together as possible along the center of the man’s back.
Then a rope, on the principle of a shoe-lace, is run through the
eyelets, and on the principle of shoe-lacing the man is laced in the
canvas. Only he is laced more severely than any person ever laces
his shoe. They call it “cinching” in prison lingo. On occasion, when
the guards are cruel and vindictive or when the command has come
down from above, in order to insure the severity of the lacing the
guards press with their feet into the man’s back as they draw the
lacing tight.
Have you ever laced your shoe too tightly, and, after half an hour
experienced that excruciating pain across the instep of the
obstructed circulation? And do you remember that after a few
minutes of such pain you simply could not walk another step and had
to untie the shoe-lace and ease the pressure? Very well. Then try to
imagine your whole body so laced, only much more tightly, and that
the squeeze, instead of being merely on the instep of one foot, is on
your entire trunk, compressing to the seeming of death your heart,
your lungs, and all the rest of your vital and essential organs.
I remember the first time they gave me the jacket down in the
dungeons. It was at the beginning of my incorrigibility, shortly after
my entrance to prison, when I was weaving my loom-task of a
hundred yards a day in the jute mill and finishing two hours ahead of
the average day. Yes, and my jute-sacking was far above the
average demanded. I was sent to the jacket that first time, according
to the prison books, because of “skips” and “breaks” in the cloth, in
short, because my work was defective. Of course this was ridiculous.
In truth, I was sent to the jacket because I, a new convict, a master
of efficiency, a trained expert in the elimination of waste motion, had
elected to tell the stupid head-weaver a few things he did not know
about his business. And the head-weaver, with Captain Jamie
present, had me called to the table where atrocious weaving, such
as could never have gone through my loom, was exhibited against
me. Three times was I thus called to the table. The third calling
meant punishment according to the loom-room rules. My punishment
was twenty-four hours in the jacket.
They took me down into the dungeon. I was ordered to lie face-
downward on the canvas spread flat upon the floor. I refused. One of
the guards, Morrison, gulleted me with his thumbs. Mobins, the
dungeon trusty, a convict himself, struck me repeatedly with his fists.
In the end I lay down as directed. And, because of the struggle I had
vexed them with, they laced me extra tight. Then they rolled me over
like a log upon my back.
It did not seem so bad at first. When they closed my door, with a
clang and clash of levered boltage, and left me in the utter dark, it
was eleven o’clock in the morning. For a few minutes I was aware
merely of an uncomfortable constriction which I fondly believed
would ease as I grew accustomed to it. On the contrary, my heart
began to thump and my lungs seemed unable to draw sufficient air
for my blood. This sense of suffocation was terrorizing, and every
thump of the heart threatened to burst my already bursting lungs.
After what seemed hours, and after what, out of my countless
succeeding experiences in that jacket I can now fairly conclude to
have been not more than half an hour, I began to cry out, to yell, to
scream, to howl, in a very madness of dying. The trouble was the
pain that had arisen in my heart. It was a sharp, definite pain, similar
to that of pleurisy, except that it stabbed hotly through the heart itself.
To die is not a difficult thing, but to die in such slow and horrible
fashion was maddening. Like a trapped beast of the wild, I
experienced ecstasies of fear, and yelled and howled until I realized
that such vocal exercise merely stabbed my heart more hotly and at
the same time consumed much of the little air in my lungs.
I gave over and lay quiet for a long time—an eternity it seemed
then though now I am confident that it could have been no longer
than a quarter of an hour. I grew dizzy with semi-asphyxiation, and
my heart thumped until it seemed surely it would burst the canvas
that bound me. Again I lost control of myself and set up a mad
howling for help.
In the midst of this I heard a voice from the next dungeon.
“Shut up,” it shouted, though only faintly it percolated to me. “Shut
up. You make me tired.”
“I’m dying,” I cried out.
“Pound your ear and forget it,” was the reply.
“But I am dying,” I insisted.
“Then why worry?” came the voice. “You’ll be dead pretty quick an’
out of it. Go ahead and croak, but don’t make so much noise about
it. You’re interruptin’ my beauty sleep.”
So angered was I by this callous indifference, that I recovered self-
control and was guilty of no more than smothered groans.—From
“The Star Rover.” Copyrighted by The Macmillan Co., New York, and
used with their kind permission.

A SON OF COPPER SIN

By Herman Whitaker
Within his bull’s-hide tepee, old Iz-le-roy lay and fed his little fire,
stick by stick. He was sick, very sick—sick with the sickness which is
made up of equal parts of hunger, old age, fever and despair. Just
one week before his tribe had headed up for Winnipegoos, where
the whitefish may be had for the taking and the moose winter in their
yards. But a sick man may not travel the long trail, so Iz-le-roy had
remained at White Man’s Lake. And Batiste, his son, stayed also.
Not that it was expected of him, for, according to forest law, the man
who cannot hunt had better die; but Batiste had talked with the
gentle priest of Ellice, and had chosen to depart from the custom of
his fathers.
And things had gone badly, very badly, since the tribe had
marched. North, south, east and west, the round of the plains, and
through the leafless woods, the boy had hunted without as much as
a jack-rabbit falling to his gun. For two days no food had passed their
lips, and now he was gone forth to do that which Iz-le-roy had almost
rather die than have him do—ask aid of the settlers.
“Yea, my son,” the old warrior had faltered, “these be they that
stole the prairies of our fathers. Yet it may be that Big Laugh, best of
an evil brood, will give us of his store of flour and bacon.”
So, after placing a plentiful stock of wood close to the old man’s
hand, Batiste had closed the tepee flap and laced it. At the end of an
hour’s fast walking, during which the northern sky grew dark with the
threat of still more cruel weather, he sighted through the drift a
spurting column of smoke.
The smoke marked the cabin of John Sterling, and also his
present occupation. Within, John sat and fired the stove, while Avis,
his daughter, set out the breakfast dishes, and his wife turned the
sizzling bacon in the pan.
“I declare,” exclaimed the woman, pausing, knife in hand, “if that
bread ain’t froze solid!”
“Cold last night,” commented Sterling. “Put it in the oven, Mary.”
As she stooped to obey, the door quietly opened and Batiste
slipped in. His moose moccasins made no noise, and he was
standing close beside her when she straightened. She jumped and
gasped:
“Lor’ ’a’ mercy! How you do scare one! Why don’t you knock?”
Batiste stared. It was the custom of his tribe thus to enter a house,
a custom established before jails were built or locks invented. His
eye therefore roamed questioningly from one to another until Sterling
asked:
“What d’ye want, young fellow?”
Batiste pointed to the frying pan. “Bakin!” he muttered. “The bakin
of Big Laugh, I want. Iz-le-roy sick, plenty sick. Him want flour, him
want ba-kin.”
 The thought of his father’s need flashed into his mind, and
realizing the impossibility of expressing himself in English, he broke
into a voluble stream of Cree, punctuating its rolling gutturals with
energetic signs. While he was speaking, Avis ceased rattling her
dishes.
“He looks awfully hungry, dad,” she whispered, as Batiste finished.
Now, though Sterling was a large-souled, generous man, and
jovial—as evidenced by his name of Big Laugh—it happened that,
during the past summer, a roving band of Sioux had camped hard by
and begged him out of patience. That morning, too, the threatening
weather had spoiled an intended trip to Russel and touched his
temper—of which he had a goodly share.
“Can’t help it, girl,” he snapped. “If we feed every hungry Injun that
comes along, we’ll soon be out of house and home. Can’t do
anything for you, boy.”
“Him want ba-kin,” Batiste said.
“Well, you can just want.”
“Iz-le-roy sick, him want ba-kin,” the boy pleaded.
His persistence irritated Sterling, and, crowding down the better
feeling which spoke for the lad, he sprang up, threw wide the door,
and shouted:
“Get, you son of copper sin! Get, now! Quick!”
“Father!” pleaded the girl.
But he took no heed, and held wide the door.
Into Batiste’s face flashed surprise, anger and resentment.
Surprise, because he had not believed all the things Iz-le-roy had
told him of the white men, but had preferred to think them all like
Father Francis. But now? His father was right. They were all cold
and merciless, their hearts hard as their steel ax-heads, their
tongues sharp as the cutting edge. With head held high he marched
through the door, away from the hot stove, the steaming coffee, and
the delicious smell of frying bacon, out into the cold storm.
 “Oh, father!” remonstrated his wife, as Sterling closed the door.
“Look here, Mary,” he answered testily, “we fed a whole tribe last
summer, didn’t we?”
“But this lad don’t belong to them,” she pleaded.
“All the worse,” he rejoined. “Do an Injun a good turn an’ he never
forgets. Give him his breakfast, an’ he totes his tribe along to dinner.”
“Well,” sighed the good woman, “I’m real sorry.”
For a few moments both were silent. And presently, as the man’s
kindly nature began to triumph over his irritation, he hitched uneasily
in his chair. Already he felt ashamed. Casting a sheepish glance at
his wife, he rose, walked to the door, and looked out. But a wall of
whirling white blocked his vision. Batiste was gone beyond recall.
“Where’s Avis?” he asked, returning to the stove.
“A-vis!” called her mother.
But there was no answer. For a moment man and wife stared each
other in the eye; then, moved by a common impulse, they walked
into the kitchen. There, on the table, lay the half of a fresh-cut side of
bacon; the bread-box was open and a crusty loaf missing; the girl’s
shawl was gone from its peg and her overshoes from their corner.
“Good God!” gasped the settler. “The child’s gone after him!”
They knew the risk. All the morning the storm had been brewing,
and now it thundered by, a veritable blizzard. The blizzard! King of
storms! It compels the settler to string a wire from house to stables, it
sets men to circling in the snow, it catches little children coming
home from school and buries them in its monstrous drifts.
Without another word Sterling wound a scarf about his neck,
grabbed his badger mitts, and rushed outside.
When Avis softly closed the kitchen door she could just see
Batiste rounding a bluff that lay a furlong west of her father’s stables.
She started after him; but by the time she had covered half the
distance a sea of white swept in between and blotted him from view.
 She struggled on, and on, and still on, until, in spite of the seventy
degrees of frost, the perspiration burst from every pore and the scud
melted on her glowing face. This was well enough—so long as she
kept moving; but when the time came that she must stop, she would
freeze all the quicker for her present warmth.
This, being born and bred of the prairie, Avis knew, and the
knowledge kept her toiling, toiling on, until her tired legs and leaden
feet compelled a pause in the shelter of a bluff. She was hungry, too.
All this time she carried the bread and meat, and now, unconscious
of a pair of slant eyes which glared from a willow thicket, she broke
the loaf and began to eat. While she ate, the green lights in the eyes
flared brighter, a long red tongue licked the drool from grinning jaws,
and forth from his covert stole a lank, gray wolf.
Avis uttered a startled cry. This was no coyote, to be chased with a
stick, but a wolf of timber stock, a great beast, heavy, prick-eared,
strong as a mastiff. His nose puckered in a wicked snarl as he slunk
in half-circles across her front. He was undecided. So, while he
circled, trying to make up his mind, drawing a little nearer at every
turn, Avis fell back—back towards the bluff, keeping her white face
always to the creeping beast.
It was a small bluff, lacking a tree large enough to climb, but
sufficient for her purpose. On its edge she paused, threw the bacon
to the wolf, and then ran desperately. Once clear of the scrub, she
ran on, plunging through drifts, stumbling, falling, to rise again and
push her flight. Of direction she took no heed; her only thought was
to place distance between herself and the red-mouthed brute. But
when, weary and breathless, she paused for rest, out of the drab drift
stole the lank, gray shadow.
The brute crouched a few yards away, licking his sinful lips,
winking his devil eyes. She still had the loaf. As she threw it, the wolf
sprang and snapped it in mid-air. Then she ran, and ran, and ran, as
the tired doe runs from the hounds. For what seemed to her an
interminable time, though it was less than five minutes, she held on;
then stopped, spent, unable to take another step. Looking back, she
saw nothing of the wolf; but just when she began to move slowly
forward, thinking he had given up the chase, a gray shape loomed
right ahead.
Uttering a bitter cry, she turned once more, tottered a few steps,
and fainted.
As, wildly calling his daughter’s name, Sterling rushed by his
stables, the wind smote him with tremendous power. Like a living
thing it buffeted him about the ears, tore at his breath, poured over
him an avalanche of snow. Still he pressed on and gained the bluff
which Avis missed.
As he paused to draw a free breath, his eye picked out a fresh-
made track. Full of a sudden hope, he shouted. A voice answered,
and as he rushed eagerly forward a dark figure came through the
drift to meet him. It was Batiste.
“What do you want?” he asked.
Sterling was cruelly disappointed, but he answered quickly: “You
see my girl? Yes, my girl,” he repeated, noting the lad’s look of
wonder. “Young white squaw, you see um?”
“Mooniah papoose?” queried Batiste.
“Yes, yes! She follow you. Want give you bread, want give you
bacon. All gone, all lost!” Sterling finished with a despairing gesture.
“Squaw marche to me? Ba-kin for me?” questioned Batiste.
“Yes, yes!” cried Sterling, in a flurry of impatience.
“I find um,” he said, softly.
Briefly Batiste laid down his plan, eking out his scanty English with
vivid signs. In snow, the white man rolls along like a clumsy buffalo,
planting his feet far out to the right and left. And because his right leg
steps a little further than the left, he always, when lost, travels in a
circle. Wherefore Batiste indicated that they should move along
parallel lines, just shouting distance apart, so as to cover the largest
possible ground.
“Young squaw marche slow. She there!” He pointed north and east
with a gesture. “Yes, there!”
 Batiste paused until Sterling got his distance; then, keeping the
wind slanting to his left cheek, he moved off north and east. Ever
and anon he stopped to give forth a piercing yell. If Sterling
answered, he moved on; if not—as happened twice—he traveled in
his direction until they were once more in touch. And so, shouting
and yelling, they bore off north and east for a long half-hour.
After that, Batiste began to throw his cries both east and west, for
he judged that they must be closing on the girl. And suddenly, from
the north, came a weird, tremulous answer. He started, and throwing
up his head, emitted the wolf’s long howl. Leaning forward, he waited
—his very soul in his ears—until, shrill yet deep-chested and
quivering with ferocity, came back the answering howl.
No coyote gave forth that cry, and Batiste knew it.
“Timber wolf!” he muttered.
Turning due north, he gave the settler a warning yell, then sped
like a hunted deer in the direction of the cry. He ran with the long,
lithe lope which tires down even the swift elk, and in five minutes
covered nearly a mile. Once more he gave forth the wolf howl. An
answer came close by, but as he sprang forward it ended with a
frightened yelp. Through a break in the drift he spied a moving
figure; then a swirl swept in and blotted it from view.
But he had seen the girl. A dozen leaps and he was close upon
her. Just as he opened his mouth to speak, she screamed and
plunged headlong.
When consciousness returned, Avis was lying on her own bed.
Her mother bent over her; Sterling stood near by. All around were
the familiar things of life, but her mind still retained a vivid picture of
her flight, and she sprang up screaming:
“The wolf; oh, the wolf!”
“Hush, dearie,” her mother soothed. “It wasn’t a wolf, but just the
Cree boy.”
Batiste had told how she screamed at the sight of his gray, snow-
covered blanket, and the cry had carried even to her father. But
when she recovered sufficiently to tell her story, the father shuddered
and the mother exclaimed:
“John, we owe that boy more than we can ever pay!”
“We do!” he fervently agreed.
Just then the latch of the other door clicked, and a cold blast
streamed into the bedroom. Jumping up, the mother cried:
“Run, John; he’s going!”
“Here, young fellow!” shouted the settler.
Batiste paused in the doorway, his hand on the latch, his slight
body silhouetted against the white of the storm.
“Where you going, boy?”
“To Iz-le-roy,” he answered. “Him sick. Bezhou!”
Sterling strode forward and caught him by the shoulder. “No, you
don’t,” he said, “not that way.” Then, turning, he called into the
bedroom: “Here, mother! Get out all your wraps while I hitch the
ponies. And fix up our best bed for a sick man.”—From “The
Probationer,” copyright and used by the kind permission of author
and publishers, Harper & Brothers, New York.

SOMBRE[7]
By William Wetmore Story
Long golden beams from the setting sun swept over the plains of
Andalusia, and fell upon the Geralda tower of the great cathedral of
Sevilla, many miles in the distance. In their path they illumined a
stretch of vast pastures enclosed by whitened stone walls, and
dotted with magnificent cattle. In a far corner of one of the
enclosures the figure of a young girl passed through an arched stone
gateway. As she paused to look upon the scattered groups of
grazing beasts, the level rays played in lights and shadows upon the
waving masses of dark chestnut hair, richly health-tinted young face,
creamy neck, and large, lustrous eyes now painfully dry, as if tears
were exhausted. She gazed from group to group, calling eagerly,
“Sombre! Sombre!”
A pair of long, gleaming horns rose abruptly amid the browsing
herd, and a magnificent bull came towards her at a brisk trot. The
sunbeams glinted upon his dark coat as it swelled and sank under
the play of powerful muscles. His neck and shoulders were leonine
in massive strength, the legs and hind-quarters as sleek and
symmetrical as those of a race-horse, but his ferociousness was
held in check by that devoted love dumb animals express for those
who love them.
In a moment the young girl’s white arms were thrown around the
animal’s dusky neck, and her cheek was lain against the silken skin.
“Oh, Sombre!” she murmured, “do you know what they are going to
do with you? Papa wants to send you to the Plaza de Toros! I have
begged him in vain to spare you. Does he think after Anita has
brought you from a tiny calf to be such a beautiful, dear toro that she
can give you to the cruel matador to be tortured, made crazy and
killed?”
She was sobbing bitterly, and the devoted beast was striving
vainly to turn his head far enough to lick the fair neck bending down
upon his. Presently the sobbing ceased, and she stroked the strong
shoulders with her small hand.
“Never fear, Sombre, if they take you to Sevilla Anita will find a
way to save you! Now, say good night.”
Sombre thrust out his huge tongue and licked the little hand and
arms. Then she bent forward and kissed him on the frowning, furry
forehead and departed.
Anita’s path homeward lay through another field where a herd of
cattle were being driven. A young herdsman, riding a strong horse at
a brisk canter, saw the young girl enter from the adjoining pasture.
With joyful exclamation in English he rode towards her calling,
“Anita, have you seen the posters?”
Waiting until he reached her side, with bated breath she asked, “Is
—is Sombre advertised?”
 “Yes, on the outer gateway. But here, I have a poster in my
pocket.”
Plaza de Toros de Sevilla
May 17.
Anniversary of the King’s Birthday,
Six Bulls to be killed,
The two magnificent brother bulls
Sol and Sombre,
and others very ferocious,
against
The intrepid Matadores,
Lariato, the American, and
Amador, of Sevilla.
“It is cruel of them, cruel! (Reading) ‘Lariato, the American.’ Why,
that is yourself! You will spare him! You will spare my Sombre!”
“They do not permit me to fight Don Alonzo’s bulls, for I raise them
and they would not fight me. Amador will fight Sombre.”
“No, no! You must fight Sombre. That wicked Amador will kill him!”
“But so would I, Anita, or be killed by him!”
Anita was silent for a time; suddenly she exclaimed: “Orlando, do
you love me well enough to put faith in a promise which will seem
impossible of fulfillment?”
“God knows I do!”
“Then listen; if Sombre goes to the Plaza de Toros, you must fight
him and spare him even though they hiss and jeer at you.”
“Death is easier. Perhaps the managers will let me fight him, for
you have raised him, and I can tell them that I have scarcely seen
him. I will fight him, Anita, and for your sake I will let him kill me!”
“No, no, Orlando, for this is my promise, even in the last extremity
Sombre shall not harm you!”
“And then, Anita!”
 “Then I will leave my father’s house and go with you. We will buy
Sombre and go to those plains in your country you love so to tell
about. You will become a ranch hero, and Sombre shall be the
patriarch of our herd!”
“I have tried that once and failed!”
“Ah, but you had neither Sombre nor Anita then!” And waving him
a kiss she ran off across the field.
On the 17th of May, in the Plaza de Toros, there was a murmur
from thousands of throats like the magnified hum of bees. Amador of
Sevilla had killed several bulls and now there was a short
intermission. In a stall of the lowest tier sat Anita alone. Presently a
band of music began a stately march, and under a high stone
archway a long procession advanced. First, gaudily caparisoned
picadors on blindfolded studs, two by two, separated and came to a
halt, facing the center, with long lances abreast. Then red-coated
toreadors carrying long barbs, with brilliant streamers of ribbon,
grouped themselves near the heavy closed doors of the bull-pen;
finally, the capeadors in yellow satin, carrying flaming red capes on
their arms, filed around like the mounted picadors and stood
between their studs.
The music ceased, the murmur of voices died away, and the gates
of the bull-pen were thrown open. At a quick trot, a great black bull
dashed in, receiving in his shoulders as he passed the toreador’s
two short barbs. Anita gripped her chair and gasped, “Sombre!”
Coming from a darkened pen, Sombre had trotted eagerly forward,
expecting to find himself once more in his loved pastures, but he
paused, bewildered in the glare of light. Hither and thither he turned
in nervous abruptness, his head raised high, his tail slowly lashing
his flanks. Then he lowered his grand head and sniffed the earth,
and then he smelled fresh, warm blood, the blood of his own kind.
With gathering rage he lowered his keen horns close to the ground
and gave a deep, hoarse bellow of defiance, flinging clod after clod
with his forefeet high above his back. Then there flaunted toward him
a red object at which he charged, but it swept aside, and a new sting
of pain was felt in his neck, and warm blood was trickling over his
glossy skin. Again and again he charged, but each time the red thing
vanished and there was more pain, more torturing barbs that
maddened him.
Presently a horseman advanced with lowered spear. Surely horse
and rider could not vanish. Ah, no! Sombre found that it was not
intended that they should. Rushing upon them he struck them with
such a blow that they were forced backwards twenty feet and both
gave a scream of pain. The picador was dragged away with a broken
leg, and the horse lay lifeless, for Sombre’s horn had pierced its
heart. Instantly a great cry went up from that crater of humanity,
“Bravo! Bravo, Toro! Bravo, Sombre!”
More than once he earned that grand applause, then his
tormentors disappeared and through one of the archways advanced
a young man tall and athletic. On his left arm hung a scarlet mantle,
and in his right hand he carried a long, keen sword. Passing under
the archway, the matador swept his sword in military salute, then
with lowered point he stepped into the arena and faced his
antagonist. Upon all fell an awful silence, for Lariato and Sombre
were met in a struggle to the death!
For a time the combatants stood motionless, eyeing each other
intently. Then came stealthy movements, hither and thither, then
thundering, desperate charges, and graceful, hair-breadth escapes.
At last in one great charge, Sombre’s horn tore the mantle from
Lariato’s arm and carrying it half around the ring, as a flaming
banner, the bull ground and trampled it in the dust. A slight hissing
was heard in the audience which turned to thundering applause
when Lariato contemptuously refused a new mantle! The audience
became breathless, the man alone was now the mad beast’s target!
Sombre, dripping with blood and perspiration, his flanks swelling
and falling in his great gasps for breath, his eyes half blinded by the
dust and glare of the arena, gave the matador one brief glance, then
with head low down, charged upon him. Lariato’s long keen blade
was lowered confidently to its death-dealing slant.
Just as the murderous sword-point seemed about to sink through
the bull’s shoulders, into his very heart, a despairing woman’s cry
reached the matador’s ears. Then a mighty hiss, interspersed with
hoots and jeers, went up from the exasperated spectators, for the
bull thundered on, with the sword scarcely penetrating the tough
muscles, standing upright between his shoulders, while Lariato stood
disarmed.
Coming to a standstill far beyond his antagonist, Sombre shook
his huge neck and the sword spun high into the air and fell toward
the center of the ring. Lariato took several steps toward it, but
tottered and fell upon the ground in a swoon, for he had been
severely bruised.
With an exultant roar, the bull rushed back to complete his victory;
the hissing and the hooting was hushed, and groans of horror filled
the air. Suddenly, just as the animal had gained full headway in his
murderous charge, a slight, white figure glided into the ring, and a
clear voice cried “Sombre!”
At the sound of that voice, the charging beast came strainingly to a
halt, threw up his head, and gazed eagerly about, then turned and
rushed toward the girl! Capeadors hurried forward flaunting their red
capes, but she waved them back.
“Go back! You shall torment him no more, my poor, tortured,
wounded Sombre!”
In a moment the great beast was beside her, licking her dress and
arms and hands. As she deftly extricated the barbs from his neck
and shoulders, the thousands of throats around them shrieked out a
vast pandemonium of bravos. Blood was covering her hands and
staining her dress, but Anita was blind to it. Meanwhile Lariato had
struggled to his feet and hurried towards her. “God bless you,” he
was saying, but she pushed past him with a glad smile, saying,
“Wait, I have something to say to them!”
Standing in the middle of the ring, Anita waited for silence.
Delaying until not a sound was heard, she said in a clear voice that
reached every ear:
“Jeer not at Lariato; he spared my pet, my Sombre, because he
loved me.”
 No matador ever gained such applause as followed. Bouquets,
sombreros, scarfs, and full purses showered into the ring, and as
that strange group stood facing the ovation, “Bravo, Lariato, Bravo,
la Señorita de Toros, Bravo, Sombre!” rang out and reëchoed over
the distant housetops.

A COMBAT IN THE ARENA

By George Croly
A portal of the arena opened, and the combatant, with a mantle
thrown over his face and figure, was led into the surroundery. The
lion roared and ramped against the bars of his den at the sight. The
guard put a sword and buckler into the hands of the Christian, and
he was left alone. He drew the mantle from his face, and bent a slow
and firm look around the amphitheater. His fine countenance and
lofty bearing raised a universal shout of admiration. He might have
stood for an Apollo encountering the Python. His eyes at last turned
on mine. Could I believe my senses? Constantius was before me.
All my rancour vanished. An hour past, I could have struck the
betrayer of the heart—I could have called on the severest
vengeance of man and heaven to smite the destroyer of my child.
But to see him hopelessly doomed, the man whom I had honored for
his noble qualities, whom I had even loved, whose crime was, at the
worst, but the crime of giving way to the strongest temptation that
can bewilder the heart of man; to see the noble creature flung to the
savage beast, dying in tortures, torn piecemeal before my eyes, and
his misery wrought by me, I would have supplicated earth and
heaven to save him. But my tongue cleaved to the roof of my mouth.
My limbs refused to stir. I would have thrown myself at the feet of
Nero; but I sat like a man of stone—pale—paralyzed—the beating of
my pulse stopped—my eyes alone alive.
The gate of the den was thrown back, and the lion rushed in with a
roar and a bound that bore him half across the arena. I saw the
sword glitter in the air; when it waved again, it was covered with
blood. A howl told that the blow had been driven home. The lion, one
of the largest of Numidia, and made furious by thirst and hunger, an
animal of prodigious power, crouched for an instant, as if to make
sure of his prey, crept a few paces onward, and sprang at the
victim’s throat. He was met by a second wound, but his impulse was
irresistible. A cry of natural horror rang round the amphitheater. The
struggle was now for an instant, life or death. They rolled over each
other; the lion, reared upon his hind feet with gnashing teeth and
distended talons, plunged on the man; again they rose together.
Anxiety was now at its wildest height. The sword now swung round
the Christian’s head in bloody circles. They fell again, covered with
blood and dust. The hand of Constantius had grasped the lion’s
mane, and the furious bounds of the monster could not lose his hold;
but his strength was evidently giving way—he still struck his terrible
blows, but each was weaker than the one before; till, collecting his
whole force for a last effort, he darted one mighty blow into the lion’s
throat and sank. The savage beast yelled, and spouting out blood,
fled howling around the arena. But the hand still grasped the mane,
and the conqueror was dragged whirling through the dust at his
heels. A universal outcry now arose to save him, if he were not
already dead. But the lion, though bleeding from every vein, was still
too terrible, and all shrank from the hazard. At last, the grasp gave
way, and the body lay motionless on the ground.
What happened for some moments after, I know not. There was a
struggle at the portal; a female forced her way through the guards,
rushed in alone, and flung herself upon the victim. The sight of a new
prey roused the lion; he tore the ground with his talons; he lashed his
streaming sides with his tail; he lifted up his mane and bared his
fangs. But his approaching was no longer with a bound; he dreaded
the sword, and came sniffing the blood on the sand, and stealing
round the body in circuits still diminishing.
The confusion in the vast assemblage was now extreme. Voices
innumerable called for aid. Women screamed and fainted, men burst
into indignant clamors at this prolonged cruelty. Even the hard hearts
of the populace, accustomed as they were to the sacrifice of life,
were roused to honest curses. The guards grasped their arms, and
waited but for a sign from the emperor. But Nero gave no sign.
 I looked upon the woman’s face; it was Salome! I sprang upon my
feet. I called on her name; called on her, by every feeling of nature,
to fly from that place of death, to come to my arms, to think of the
agonies of all that loved her.
She had raised the head of Constantius on her knee, and was
wiping the pale visage with her hair. At the sound of my voice, she
looked up, and, calmly casting back the locks from her forehead,
fixed her eyes upon me. She still knelt; one hand supported the head
—with the other she pointed to it as her only answer. I again adjured
her. There was the silence of death among the thousands around
me. A fire dashed into her eye—her cheek burned—she waved her
hand with an air of superb sorrow.
“I am come to die,” she uttered, in a lofty tone. “This bleeding body
was my husband—I have no father. The world contains to me but
this clay in my arms. Yet,” and she kissed the ashy lips before her,
“yet, my Constantius, it was to save that father that your generous
heart defied the peril of this hour. It was to redeem him from the
hand of evil that you abandoned your quiet home!—Yes, cruel father,
here lies the noble being that threw open your dungeon, that led you
safe through the conflagration, that, to the last moment of his liberty,
only sought how he might preserve and protect you.” Tears at length
fell in floods from her eyes. “But,” said she, in tones of wild power,
“he was betrayed, and may the Power whose thunders avenge the
cause of his people, pour down just retribution upon the head that
dared—”
I heard my own condemnation about to be pronounced by the lips
of my own child. Wound up to the last degree of suffering, I tore my
hair, leaped upon the bars before me, and plunged into the arena by
her side. The height stunned me; I tottered a few paces and fell. The
lion gave a roar and sprang upon me. I lay helpless under him, I
heard the gnashing of his white fangs above me.
An exulting shout arose. I saw him reel as if struck—gore filled his
jaws. Another mighty blow was driven to his heart. He sprang high in
the air with a howl. He dropped; he was dead. The amphitheater
thundered with acclamations.
 With Salome clinging to my bosom, Constantius raised me from
the ground—the roar of the lion had roused him from his swoon, and
two blows saved me. The falchion had broken in the heart of the
monster.
The whole multitude stood up, supplicating for our lives in the
name of filial piety and heroism. Nero, devil as he was, dared not
resist the strength of popular feeling. He waved a signal to the
guards; the portal was opened, and my children, sustaining my
feeble steps, showered with garlands and ornaments from
innumerable hands, slowly led me from the arena.

KAWEAH’S RUN
By Clarence King
As I walked over to see Kaweah at the corral, I glanced down the
river, and saw, perhaps a quarter of a mile below, two horsemen ride
down our bank, spur their horses into the stream, swim to the other
side, and struggle up a steep bank, disappearing among bunches of
cottonwood trees near the river.
They were Spaniards—the same who had swum King’s River the
afternoon before, and, as it flashed on me finally, the two whom I had
studied so attentively at Visalia. Then I at once saw their purpose
was to waylay me, and made up my mind to give them a lively run.
I decided to strike across, and jumping into the saddle threw
Kaweah into a sharp trot.
I glanced at my girth and then at the bright copper upon my pistol,
and settled myself firmly.
By this time I had regained the road, which lay before me traced
over the blank, objectless plain in vanishing perspective. Fifteen
miles lay between me and a station; Kaweah and pistol were my only
defense, yet at that moment I felt a thrill of pleasure, a wild moment
of inspiration, almost worth the danger to experience.
I glanced over my shoulder and found that the Spaniards were
crowding their horses to their fullest speed; their hoofs, rattling on