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Modern Epidemiology
FOURTH EDITION
Timothy L. Lash
O. Wayne Rollins Distinguished Professor of Epidemiology and Chair
Department of Epidemiology
Rollins School of Public Health, Emory University
Atlanta, Georgia
Tyler J. VanderWeele
John L. Loeb and Frances Lehman Loeb Professor of Epidemiology
Departments of Epidemiology and Biostatistics
Harvard T.H. Chan School of Public Health
Boston, Massachusetts
Sebastien Haneuse
Professor of Biostatistics
Department of Biostatistics
Harvard T. H. Chan School of Public Health
Kenneth J. Rothman
Distinguished Fellow, Research Triangle Institute
Research Triangle Park, North Carolina
and
Professor of Epidemiology
Boston University School of Public Health
Executive Editor: Sharon Zinner
Development Editor: Sean McGuire
Editorial Coordinator: Cody Adams, Julie Kostelnik
Production Project Manager: Catherine O
Design Coordinator: Steve Druding
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Copyright © 2021 Wolters Kluwer.
Copyright © 2008 Lippinco Williams & Wilkins. All rights reserved.

This book is protected by copyright. No part of this book may be
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Contents
Preface and Acknowledgments

Contributors
PART I
Foundations
1 The Scope of Epidemiology

Kenneth J. Rothman, Timothy L. Lash, Sebastien
Haneuse, and Tyler J. VanderWeele
2 Causal Inference and Scientific Reasoning

Tyler J. VanderWeele, Timothy L. Lash, and Kenneth J.
Rothman
3 Formal Causal Models

Tyler J. VanderWeele and Kenneth J. Rothman
4 Measures of Occurrence
Timothy L. Lash and Kenneth J. Rothman
5 Measures of Effect and Measures of Association

Kenneth J. Rothman, Tyler J. VanderWeele, and Timothy
L. Lash
6 Epidemiologic Study Design With Validity and
Efficiency Considerations
Kenneth J. Rothman and Timothy L. Lash
PART II
Study Design and Interpretation
7 Cohort Studies
Kenneth J. Rothman, Tyler J. VanderWeele, and Timothy
L. Lash
8 Case-Control Studies
9 Public Health Surveillance

Richard S. Hopkins and James W. Buehler
10 Field Methods
Lauren A. Wise and Patricia Hartge
11 Studies Relying on Secondary Data

Krista F. Huybrechts and Sebastian Schneeweiss
12 Confounding and Confounders

Tyler J. VanderWeele, Kenneth J. Rothman, and Timothy
L. Lash
13 Measurement and Measurement Error

Timothy L. Lash, Tyler J. VanderWeele, and Kenneth J.
Rothman
14 Selection Bias and Generalizability
15 Precision and Study Size

Kenneth J. Rothman and Timothy L. Lash
PART III
Data Analysis
16 Fundamentals of Epidemiologic Data Analysis

Sebastien Haneuse and Kenneth J. Rothman
17 Introduction to Categorical Statistics

Sebastien Haneuse
18 Stratification and Standardization

Sebastien Haneuse and Kenneth J. Rothman
19 Categorical Analysis of Polytomous Exposures and

Outcomes
Sebastien Haneuse
20 Regression Analysis Part I: Model Specification

Sebastien Haneuse
21 Regression Analysis Part II: Model Fitting and

Assessment
Sebastien Haneuse
22 Time-To-Event Analysis
Sebastien Haneuse
23 Introduction to Bayesian Statistics

Sander Greenland
24 Longitudinal and Cluster-Correlated Data Analysis

Sebastien Haneuse
25 Causal Inference With Time-Varying Exposures

26 Analysis of Interaction
Tyler J. VanderWeele, Timothy L. Lash, and Kenneth J.
Rothman
27 Mediation Analysis
28 Instrumental Variables and Quasi-Experimental

Approaches
M. Maria Glymour and Sonja A. Swanson
29 Bias Analysis
Timothy L. Lash
30 Ecologic Studies and Analysis

Hal Morgenstern and Jon Wakefield
31 Agent-Based Modeling
Brandon D.L. Marshall
PART IV
Special Topics
32 Infectious Disease Epidemiology

Matthew P. Fox and Emily W. Gower
33 Reproductive Epidemiology
Clarice R. Weinberg, Allen J. Wilcox, and Anne Marie
Jukic
34 Psychiatric Epidemiology
Katherine M. Keyes, Sharon B. Schwartz, and Ezra S.
Susser
35 Clinical Epidemiology
Jan P. Vandenbroucke and Henrik Toft Sørensen
36 Molecular Epidemiology
Claire H. Pernar, Konrad H. Stopsack, and Lorelei Mucci
37 Genetic Epidemiology
John S. Witte and Duncan C. Thomas
38 Injury and Violence Epidemiology

Stephen W. Marshall and Guohua Li
39 Social Epidemiology
Jay S. Kaufman
40 Environmental Epidemiology
Irva Hertz-Picciotto and Stephanie M. Engel
41 Occupational Epidemiology
David Richardson
42 Nutritional Epidemiology
Walter C. Willett and Frank B. Hu
43 Pharmacoepidemiology
Sebastian Schneeweiss and Krista F. Huybrechts
Index
Preface and Acknowledgments
The fourth edition of Modern Epidemiology arrives 35 years after the

first edition, which was a much smaller single-authored volume that
outlined the concepts and methods of a rapidly growing discipline.
The second edition, published 12 years later, was a major transition,
as the book grew along with the field. It saw the addition of a second
author and an expansion of topics contributed by invited experts in a
range of subdisciplines. The third edition, which was published in
2008, saw the addition of a third author and encompassed a
comprehensive revision of the content and the introduction of topics
that 21st century epidemiologists would find essential.
This fourth edition welcomes insights from two new authors,
whose work in the past decade has substantially influenced the
design, analysis, and interpretation of epidemiologic research. Like
the earlier editions, it encompasses a comprehensive revision of the
content, with coverage of methods that have emerged in the interim,
such as agent-based modeling, quasi-experimental designs,
mediation analysis, and causal modeling. It also updates coverage of
methods such as concepts of interaction, bias analysis, and time-
varying designs and analysis and continues to cover the full breadth
of epidemiologic methods and concepts.
This edition retains the basic organization of the earlier editions,
with the book divided into four parts. Part I (Foundations) now
comprises six chapters rather than five, with the topic of causation
now divided into a conceptual chapter on causal inference and
scientific reasoning and a second chapter on formal causal models.
We have also moved the introductory chapter on epidemiologic
study designs, with validity and efficiency considerations, into the
Foundations part of the text. The topic of interaction was Chapter 18
in the second edition, was Chapter 5 in the third edition, and is now
Chapter 26 (Part III, Data Analysis) of the fourth edition. We have
moved it again to reflect the recent and influential advances in
understanding interaction and mediation analyses (now Chapter 27),
which require a firm understanding of the fundamentals of
epidemiologic research and analysis before they can be fully
appreciated. The third edition saw the addition of a new chapter on
causal diagrams, which no longer appears as a standalone chapter in
the fourth edition. The use of causal graphs to encode assumptions is
now so widely incorporated into epidemiologic study design and
analysis that the content has been distributed and fully incorporated
into the other chapters of the text, including the chapters on causal
models. Part II of the text addresses fundamental and advanced
aspects of study design and interpretation. In this edition, each of
the three major threats to validity—confounding, selection bias and
generalizability, and information bias—receives separate treatment
in its own chapter. These chapters describe the structures that give
rise to the bias, design considerations to reduce the influence of the
bias, and simple methods of quantitative bias analysis to estimate
the direction, magnitude, and uncertainty a ributable to the bias.
Also new to this section is a chapter on the use of secondary data,
such as registry-based research, which now often serves as the
primary source of data, or an ancillary source of data, for many
epidemiologic investigations. As in earlier editions, Part II also
includes chapters that address cohort designs, case-control designs
(including case-crossover and other case-only designs), surveillance,
and field methods for data collection. This part concludes with an
initial treatment of precision and study size, particularly regarding
planning study size.
Part III of this edition addresses data analysis, with updated
treatments of conventional approaches to data analysis, such as
categorical statistics, stratification, standardization, regression
modeling, and dose-response analysis. New content expands on
analysis strategies for time-to-event analysis, longitudinal and
cluster-correlated analysis, and causal inference with time-varying
exposures. As noted above, methods for analyses to address
interaction and mediation now appear in Part III. The chapter on
bias analysis has been revised, with simple bias analysis methods
moved forward to chapters in Part II and with expanded coverage of
p p g
semi-Bayesian, Bayesian, and empirical bias analysis in its place. The
chapter on ecologic analyses has been updated, and we have added
a chapter on agent-based modeling and another chapter on
instrumental variables and quasi-experimental approaches. The
chapter on Bayesian Analysis has been reprinted without revision
from the third edition. The chapter’s author, Sander Greenland,
would have liked to update the chapter, but circumstances did not
permit it.
As in the second and third editions, Part IV comprises additional
topics that are more specialized than those considered in the first
three parts of the book. Prominent authors with substantial
experience in each of these topic areas have agreed to write these
chapters as an introduction to the topics. Each chapter keeps to a
common outline, including (1) a description of the major objectives
of the topic area, the history of how it came to be a topic unto itself,
and the seminal contributions to public health or medicine; (2) a
description of methodologies that are unique to the topic,
particularly well suited to the topic, ill advised for the topic area, or
otherwise especially relevant to the topic; (3) a description of
methodologic challenges that are particularly pertinent to the topic,
solutions that have been proposed or implemented, and evaluation
of whether these solutions have been adequate; (4) a description of
ethical, legal, policy, or social issues that are especially pertinent to
the topic; and (5) anticipated directions for the topic, with respect to
methodologic developments and content areas for research. For most
of the Part IV topics, there are excellent complete textbooks, so our
goal with this common outline was to assure that readers would
receive an overview of the topic’s history, unique challenges, and
anticipated directions. Many topics return for the fourth edition,
such as social epidemiology, infectious disease epidemiology,
genetic and molecular epidemiology, and others, and many new
topics have been added, such as psychiatric epidemiology, injury
and violence epidemiology, occupational epidemiology,
pharmacoepidemiology, and others.
In this text, we hope to acquaint those who wish to understand the
concepts and methods of epidemiology with the issues that are
p p gy
central to the discipline and to point the way to key references for
further study. The bibliography has been extensively revised and
updated, with each chapter now having its own reference list. To
make the text easier to read, we now use superscript numerals in
text to cite original papers, rather than inserting the paper’s authors
and publication years as in earlier editions. To facilitate access to all
relevant sections of the book that relate to a given topic, we have
indexed the text thoroughly. We thus recommend that the index be
consulted by those wishing to read our complete discussion of
specific topics.
We hope that this new edition provides a resource for teachers,
students, and practitioners of epidemiology. We have a empted to
be as accurate as possible, but we recognize that any work of this
scope will contain mistakes and omissions. We are grateful to
readers of earlier editions who have brought such items to our
a ention. We intend to continue our past practice of posting such
corrections on an internet page, as well as incorporating such
corrections into subsequent printings. Please consult
h ps://shop.lww.com/Modern-Epidemiology/p/9781451193282 to
find the latest information on errata.
We are especially grateful to our colleague Sander Greenland, who
was a coauthor of the second and third editions of Modern
Epidemiology. Although he decided not to join the author group for
the fourth edition, much of the text still reflects the id="eas and
writing that he contributed to the earlier editions. He has not
reviewed or approved the text of the fourth edition, but his earlier
contributions have been brought forward, revised, and edited by the
current authors throughout. As noted above, however, Chapter 23
on Bayesian Analysis appears without revision or updating from the
third edition.
We are also grateful to many colleagues who have reviewed
sections of the current text and provided useful feedback. Although
we cannot mention everyone who helped in that regard, we give
special thanks to Catherine Lesko and Penelope Howard for review
and comments on Chapter 14 “Selection Bias and Generalizability,”
to Dana Flanders for review and comments on material in Chapter 6
p
“Epidemiologic Study Design With Validity and Efficiency
Considerations,” to James Robins and Miguel Hernán with whom
discussions notably influenced the content of Chapter 12
“Confounding and Confounders,” to Sara Sauer, Harrison Reeder,
and Alexander Levis for review and comments on Chapter 24
“Longitudinal and Cluster-Correlated Data Analysis,” and to
Rebecca Nash who generated a revised and corrected Figure 29-1 in
Chapter 29 “Bias Analysis.” Brandon Marshall would like to
acknowledge Professors Melissa Tracy and David Savi for their
insightful comments and reviews of Chapter 31 “Agent-Based
Modeling.” Ma hew Fox and Emily Gower would like to
acknowledge Dr. Brooke Nichols and Samantha Tulenko for their
helpful reviews of Chapter 32 “Infectious Disease Epidemiology.”
An earlier version of Chapter 23 “Introduction to Bayesian Statistics”
appeared in the International Journal of Epidemiology (2006;35:765-778),
reproduced with permission of Oxford University Press.
Timothy L. Lash
Sebastien Haneuse
Kenneth J. Rothman
Contributors
Ma hew P. Abdel MD
Professor of Orthopedic Surgery
Mayo Clinic College of Medicine
Consultant
Department of Orthopedic Surgery
Mayo Clinic
Rochester, Minnesota
James W. Buehler, MD
Clinical Professor & Interim Chair
Department of Health Management & Policy
Dornsife School of Public Health
Drexel University
Philadelphia, Pennsylvania
Stephanie M. Engel, PhD

Professor
Gillings School of Global Public Health
University of North Carolina at Chapel Hill
Chapel Hill, North Carolina
Ma hew P. Fox, DSc, MPH

Professor
Departments of Epidemiology and Global Health
Boston University
Boston, Massachuse s
M. Maria Glymour, ScD

Professor
Department of Epidemiology and Biostatistics
University of California, San Francisco
San Francisco, California
Emily W. Gower, PhD

Associate Professor
Sander Greenland, MA, MS, DrPH, C Stat

Professor Emeritus
Department of Epidemiology and Department of Statistics
University of California
Los Angeles, California
Patricia Hartge, MA, ScD

Senior Investigator, Retired
Division of Cancer Epidemiology and Genetics
National Cancer Institute
National Institutes of Health
Bethesda, Maryland
Irva Her -Piccio o, MPH, PhD

Professor
Department of Public Health Sciences
University of California, Davis
Davis, California
Richard S. Hopkins, MD, MSPH

Independent Epidemiologist
Middlebury, Vermont
Frank B. Hu, MD, PhD

Professor and Chair
Department of Nutrition
Krista F. Huybrechts, MS, PhD
Associate Professor of Medicine and Epidemiology
Division of Pharmacoepidemiology
Department of Medicine
Brigham and Women’s Hospital and Harvard Medical School
Anne Marie Jukic, PhD

Investigator
Epidemiology Branch
National Institute of Environmental Health Sciences
Durham, North Carolina
Jay S. Kaufman, PhD

Professor
Biostatistics and Occupational Health
McGill University, Montreal
Quebec, Canada
Katherine M. Keyes, PhD

Associate Professor
Columbia University
Mailman School of Public Health
New York, New York
Guohua Li, MD, DrPH

Mieczyslaw Finster Professor
Departments of Anesthesiology and Epidemiology
Columbia University
New York, New York
Brandon D. L. Marshall, PhD

Associate Professor
Brown University
Providence, Rhode Island
Stephen W. Marshall, PhD

Professor
Departments of Epidemiology and Exercise and Sport Science
Hal Morgenstern, BArch, MRP, PhD

Professor Emeritus
Departments of Epidemiology
Environmental Health Sciences, and Urology
University of Michigan
Ann Arbor, Michigan
Lorelei Mucci, ScD, MPH

Professor
Claire H. Pernar, ScD, MPH

Research Associate
David Richardson, PhD

Professor
School of Public Health
Sebastian Schneeweiss, MD, ScD

Professor of Medicine and Epidemiology
p gy
Division of Pharmacoepidemiology
Brigham and Women’s Hospital and Harvard Medical School
Sharon B. Schwar , PhD

Professor of Epidemiology at CUMC
Columbia University
New York, New York
Henrik Toft Sørensen, MD, PhD, DMSc

Professor, Chair
Department of Clinical Epidemiology
Aarhus University
Aarhus, Denmark
Adjunct Professor
Boston University
Konrad H. Stopsack, MD MPH

Research Associate
Memorial Sloan Ke ering Cancer Center
New York, New York
Ezra S. Susser, MD, DrPH

Professor
Departments of Epidemiology and Psychiatry
Columbia University
New York State Psychiatric Institute
New York, New York
Sonja A. Swanson, ScD
Associate Professor
Erasmus Medical Center
Ro erdam, Netherlands
Duncan C. Thomas, PhD

Professor and Verna Richter Chair in Cancer Research
Department of Preventive Medicine
University of Southern California
Los Angeles, California
Jan P. Vandenbroucke, MD, PhD, FRCP, FRCPE

Emeritus Professor of Clinical Epidemiology
Leiden University Medical Center
Leiden, Netherlands
Professor of Clinical Epidemiology
Aarhus University
Aarhus, Denmark
Honorary Professor
London School of Hygiene and Tropical Medicine
London, United Kingdom
Jon Wakefield, PhD

Professor
Departments of Statistics and Biostatistics
University of Washington
Sea le, Washington
Clarice R. Weinberg, PhD

Senior Investigator
Biostatistics and Computational Biology Branch
Research Triangle Park, North Carolina
Allen J. Wilcox, MD, PhD
Emeritus Investigator
Epidemiology Branch
Durham, North Carolina
Walter C. Wille , MD, DrPH

Professor
Departments of Nutrition and Epidemiology
Lauren A. Wise, ScD

Professor
Boston University School of Public Health
John S. Wi e, PhD
Professor
Department of Epidemiology and Biostatistics
University of California San Francisco
San Francisco, California
PART I
Foundations
CHAPTER 1
The Scope of Epidemiology
Kenneth J. Rothman, Timothy L. Lash, Sebastien Haneuse, and

INTRODUCTION
Epidemiology is the science that studies disease occurrence and
health states in human populations. Descriptive epidemiology (also
known as medical demography) measures how disease frequency
and other population health indicators vary with age, gender,
geographic location, race/ethnicity, and other characteristics of
person, time, and place. Such description can provide critical
insights into the potential causes of disease. For example, early in the
AIDS epidemic, descriptive epidemiology strongly indicated that
AIDS was an infectious disease transmi ed through direct contact
with body fluids. Descriptive epidemiology also provided early
insights into the long latency period of HIV infection, the underlying
cause of AIDS.
Etiologic or analytic epidemiology assesses the effect of exposures,
which include possible causes, on the occurrence of disease.
Exposures can be evaluated on the scale of individual persons, such
as behaviors, occupations, environmental hazards, medical history,
or personal characteristics such as age. They can also be measured
on the microscale, such as a person’s genetics, microbiome, or
metabolic profile. Finally, exposures can be measured on a
macroscale, such as social characteristics like disparities in wealth in
one’s society or the birth cohort to which one belongs.
Some health and medical events, such as an injury or influenza,
may occur within seconds or hours and are said to have rapid or
acute onset. Others, such as atherosclerosis, neurodegenerative
disease, or cancer, may develop gradually over years or decades and
are said to have prolonged or chronic onset. Categorical distinctions
such as macro versus micro level and acute versus chronic onset
reflect underlying continuous scales for exposures and outcome
events that can be investigated with epidemiologic methods. For
example, myocardial infarction is an acute-onset event often arising
from the gradual development of atherosclerosis, which has been
associated with a person’s genetics, lifestyle, social situation, and
environmental circumstances. Regular exercise can reduce the risk of
this event, but the risk can increase for a short time after an
individual episode of vigorous exercise. This example illustrates the
complexities of the etiologic relations measured by epidemiologic
research and hints at the various methodologic challenges that have
been tackled as the science has developed.
The main strength of epidemiology is that it assesses the disease
burden, or exposure-disease association, in the human species. The
evidence from epidemiologic research is therefore directly relevant
to the population of interest. The main limitation is that it is not as
easy as it may seem. At its most fundamental level, epidemiology is
an exercise in counting within groups. But whom to count, how to
count them, when to count them, and how to compare them
introduce complexities well beyond what intuition might suggest.
Epidemiologic investigations that ignore these complexities can
yield misleading measurements, so when would-be epidemiologists
use methods that stem from intuition rather than solid training in
the principles of epidemiology, important errors are likely to occur.
Therefore, until the final part, the focus of this book is on
epidemiologic theory and research methods founded on that theory.
ROOTS OF EPIDEMIOLOGY
Epidemiology has its roots in early a empts to understand and
improve public health. As agriculture replaced hunting, and small
clans began to aggregate into villages and towns, people faced
problems such as acquiring a reliable source of freshwater and
eliminating human waste from their community. These problems
were best dealt with as community projects. Living more densely,
they also became more susceptible to epidemic disease, an important
threat to any established society. For example, during the middle
ages, the growth of cities in Europe was accompanied by epidemics
of leprosy, plague, and other scourges. The Black Death was a
pandemic of what is believed to be bubonic plague that swept
Europe in mid-14th century, killing between one-third and one-half
of the population. Travelers from plague-infested areas were often
barred entry into communities, and patients were sometimes kept
isolated. The term “quarantine” comes from the Italian phrase
“quaranta dei,” referring to the 40 days during which all goods and
travelers were kept in isolation during plague periods in Venice, an
important shipping port.
John Snow, an important early figure in the history of
epidemiology, conducted research on the communication of cholera,
which he believed was spread through exposure to water
contaminated with human waste. His “natural experiment” was a
study of cholera incidence in relation to the consumption of water
from two competing companies, one carrying comparatively clean,
Thames water from upstream of London and the other, water that
was drawn downstream of London and therefore contaminated with
sewage. In some districts of London, the competing water companies
piped their water down the same streets, and, on these streets, most
residents did not know which company supplied their home.
Although Snow’s research design was elegant, it failed to sway the
medical scientists of the time, most of whom held firmly to the view
that cholera was spread through foul air rather than contaminated
water.1
Snow’s work was one of a few examples of excellent
epidemiologic investigations that were conducted before the 20th
century. These examples are, however, isolated events. A
systematized body of principles by which to design and evaluate
epidemiology studies began to form only in the second half of the
20th century. These principles evolved in conjunction with an
explosion of epidemiologic research, the evolution of which
continues today.
Several large-scale epidemiologic studies started in mid-20th
century have had far-reaching influences on health. For example, the
Framingham Heart Study, initiated in 1948, is notable among several
long-term follow-up studies of cardiovascular disease that have
contributed importantly to understanding the causes of this public-
health problem.2 By its 70th anniversary, more than 3,700 scientific
publications have emerged from this one epidemiologic project.
Knowledge from this and similar epidemiologic studies has helped
stem the epidemic of cardiovascular disease in the industrialized
Western world.3, 4
Another example of 20th-century epidemiology with far-reaching
implications was the Salk vaccine field trial of 1954.5 With several
hundred thousand school children as subjects, this study was for
decades the largest formal human experiment ever conducted and
provided the first practical basis for the prevention of paralytic
poliomyelitis. In the 21st century, the DEVTA trial of vitamin A
supplementation and intestinal deworming surpassed the Salk
vaccine trial in size by enrolling two million children in India.
DEVTA ultimately reported no substantial preventive benefit against
childhood mortality associated with either intervention.6, 7
The 20th century also saw the publication of many epidemiologic
studies on the effects of tobacco use. These studies led eventually to
the landmark report, Smoking and Health, issued by the US Surgeon
General.8 The report was the first among many on the adverse effects
of tobacco use on health issued by the Surgeon General.
Since the time of these important studies, epidemiologic research
has steadily a racted greater public a ention. Unlike more basic
science, epidemiologic research is work with which the public and
media can readily connect. Both researchers and news media,
boosted by a rising tide of social concern about health and
environmental issues, have vaulted many epidemiologic studies to
prominence, sometimes well before sufficient evidence had
accumulated to merit consideration of policy implications, as in the
case of a reported outbreak of Hodgkin disease among high-school
students.9
Disagreement about basic conceptual and methodologic points
led, in some instances, to profound differences in the interpretation
of data. An historical example with which students of epidemiology
should be familiar involves a controversy that erupted in the mid-
1970s about whether exogenous estrogens are carcinogenic to the
endometrium. Several case-control studies had reported an
extremely strong association, with up to a 15-fold increase in risk.10-
12 One group, Horwi and Feinstein, argued that a selection bias
accounted for most of the observed association,13 whereas others

argued that the alternative design proposed by Horwi and
Feinstein introduced a downward selection bias far stronger than
any upward bias it removed.14-16 Ultimately, the former view lost
out to proponents of the la er view. Modern students of
epidemiologic methods may be surprised to learn that only 50 years
ago such different views were held by prominent and credible
epidemiologists on a methodologic topic that they would now so
readily understand. Such disagreements about fundamental
concepts in the relatively recent past, at least on the time scale of
scientific inquiry, suggest that the methodologic foundations of the
science had not yet been established and that epidemiology
remained young in conceptual terms.
The last third of the 20th century and the beginning of the 21st
century have seen rapid growth in the understanding and synthesis
of epidemiologic concepts. The main stimulus for this conceptual
growth seems to have been accelerated the growth of epidemiologic
research, coupled with controversy. The explosion of epidemiologic
activity accentuated the need to improve understanding of the
theoretical underpinnings. For example, early studies on smoking
and lung cancer17, 18 were scientifically noteworthy not only for their
substantive findings but also because they demonstrated the efficacy
and great efficiency of the case-control study. Controversies about
proper case-control design led to recognition of the importance of
relating such studies to an underlying source population19-22 (see
Chapter 8). Likewise, analysis of data from the Framingham Heart
Study stimulated the development of multiple logistic regression,23,
24 one of the most popular and enduring modeling methods in
epidemiology (see Chapters 21 and 22).

In the 21st century, epidemiologic concepts have continued to
evolve rapidly, perhaps because the scope, activity, and influence of
epidemiology continue to increase. This rise in epidemiologic
activity and influence has been accompanied by growing pains,
largely reflecting concern about the validity of the methods used in
epidemiologic research and the reliability of inferences drawn from
the results. The disparity between the results of randomized25 and
nonrandomized26 studies of the association between hormone
replacement therapy and cardiovascular disease provided a high-
profile example of hypotheses supposedly established by
observational epidemiology and subsequently contradicted.27, 28 The
conflicting results, however, may have been reconciled by Hernán et
al.,29 who provided evidence that the discrepancies between the
randomized and nonrandomized studies were due to differences in
the populations studied and the length of follow-up. Methodologic
approaches continue to evolve and to be subject to critical debate. In
addition, epidemiologists debate priority areas for their research
endeavors. For example, tensions remain between those who
advocate for molecularly focused epidemiologic research,30
behaviorally focused research,31, 32 and socially focused research.33
It may be discouraging to practice in a field in which basic
concepts are still maturing and in which even prominent
practitioners often disagree on conceptual issues. Furthermore, as
epidemiology is so often in the public eye, it can be a magnet for
criticism. The criticism has occasionally broadened to a distrust of
the methods of epidemiology itself, going beyond skepticism of
specific findings to general criticism of epidemiologic
investigation.34, 35 These criticisms and anxieties, though hard to
accept, should nevertheless be welcomed by scientists. We should
strive to learn from our mistakes and embrace the challenge of
working in so dynamic and prominent a field. There is much that
epidemiologists can do to increase the reliability and utility of their
findings; providing readers the basis for achieving that goal is an
aim of this textbook.
As we prepare to deliver this book to the publisher in mid-2020,
we are in the grip of the COVID-19 pandemic. Epidemiology is
suddenly a field of broad interest. Week after week there are
questions directed at epidemiologists about the Sars-Cov-2 virus,
how to control it, and how to treat the disease that it causes. Who is
most susceptible and why? Should we wear masks? Should our
children a end school? Is it safe to press the elevator bu on in our
building? Should I stop my antihypertensive medication? Will
antimalaria drugs prevent infection? Is it safe to see the doctor or go
to the hospital? If I recover, can I get reinfected? All of these are
questions that epidemiologists can answer, with time, material
support, and patience. Unfortunately, decisions have had to be made
rapidly, often with uncertain evidence, and with the pervasive
influence of politics often weighing as heavily as the science.
In the midst of the pandemic, there has been a flurry of research,
some good, some less than adequate, but all done under the pressure
of a empting to answer vital questions while a deadly pandemic
rages through a susceptible population. Suddenly, the need to
understand the principles of epidemiology has become a priority. In
the years to come, there will be a lot to learn from the actions taken
during the pandemic. The different courses of the pandemic in
countries with strict lockdowns—such as Iceland, South Korea,
Cuba, and Japan—compared with more lax restrictions— such as
Sweden, the US, and Brazil—will provide important lessons. It is
already clear that, as has too often been witnessed, individuals and
nations with the least resources bear an outsized burden. At the
outset of the pandemic, there was li le relevant knowledge to guide
us. Much will be learned by studying the effectiveness of the widely
variant public health and medical responses. Fortunately, for most
diseases that we face, we do not have the time urgency of a deadly
pandemic that raises fresh questions demanding immediate
answers. But whether the questions raised involve treating old
scourges such as atherosclerosis or new threats such as COVID-19,
the underlying principles that we need to apply to find the answers
will be the same. It is those principles that we address in this book.
DESCRIPTIVE VERSUS ANALYTIC
EPIDEMIOLOGY
The first steps in constructing a compendium of epidemiologic
information in a specific disease area constitute descriptions of the
disease epidemiology. This descriptive epidemiology involves
assembling measures of disease occurrence for demographic and
geographic subpopulations. Contrasts of disease incidence for
natalmales and females, by age, by gender identity, by
race/ethnicity, by urban or rural residence, and by time period, are
examples of descriptive epidemiology. Demographic and geographic
pa erns in disease occurrence provide information that is useful
both for public-health programming and for etiologic
understanding. Thus, sex-specific differences in sexually transmi ed
infections may suggest differences in behaviors or differences in
socially pa erned use of condoms, age pa erns may suggest
prenatal or postnatal causes, and geographic pa erns may reflect
differences in sun exposure and concomitant vitamin D sufficiency.
In MacMahon and Pugh’s influential textbook of epidemiology,36
there were separate chapters for “Person,” “Place,” and “Time,”
indicating the importance of describing the epidemiology of any
disease with regard to these fundamental characteristics.
Some epidemiologists divide epidemiology into “descriptive
epidemiology” and “analytic epidemiology.” This division is based
on the notion that descriptive epidemiology serves to generate
hypotheses about the causes of a disease, whereas analytic
epidemiology subjects those hypotheses to more focused and
rigorous tests to weed out the tenable from the untenable
hypotheses. In this book, we do not maintain this division into
descriptive and analytic epidemiology because this mindset
diminishes the importance of descriptive epidemiology and disease
surveillance and because the division is never that clear. The
interplay between generating new hypotheses and subjecting those
hypotheses to rigorous tests exists, or should exist, at all levels of
information, including what is commonly considered descriptive
epidemiology. This division, however, raises a more fundamental
question: what is the logical process by which we can draw
conclusions about the causes of a disease? Below we consider the
question of scientific reasoning in science generally and in
epidemiology in particular.
SCIENTIFIC REASONING AND THE
PHILOSOPHY OF SCIENCE
Because much epidemiologic research is aimed at uncovering the
causes of disease, it is useful for epidemiologists to be familiar with
the basic issues that underlie scientific reasoning. The most
fundamental methodologic questions about interpreting data hinge
on long-standing, well-debated principles that have their roots in the
philosophy of science. Causal inference, which we address in
considerable depth in subsequent chapters, may be viewed as a
special case of the more general process of scientific reasoning. The
literature on this topic is too broad for us to review thoroughly here,
but we will provide a brief overview of certain points relevant to
epidemiology, at the risk of some oversimplification.
Inductivism
Modern science began to emerge around the 16th and 17th centuries,
when the knowledge demands of emerging technologies stimulated
inquiry into the origins of knowledge. An early codification of the
scientific method was Francis Bacon’s Novum Organum, which, in
1620, presented an inductivist view of science. In this philosophy,
scientific reasoning is said to depend on making generalizations, or
inductions, starting from observed pa erns and progressing to
general laws of nature; the observations are said to induce the
formulation of a natural law in the mind of the scientist. Thus, an
inductivist would have said that Jenner’s observation of lack of
smallpox among milkmaids induced in Jenner’s mind the theory that
cowpox (common among milkmaids) conferred immunity to
smallpox.
Inductivist philosophy was systematized in the canons of John
Stuart Mill,37 which evolved into inferential guidelines that are still
in use today, such as those of Bradford Hill.38 These guidelines are
discussed in detail in Chapter 2.
Refutationism
Inductivist philosophy provided numerous important insights.
Nonetheless, in the 18th century, the Sco ish philosopher David
Hume described a disturbing deficiency in inductivism. Hume
showed that an inductive argument carried no logical force in the
deductive sense familiar in mathematics; instead, such an argument
represented an assumption that certain events would in the future
follow the same pa ern as they had in the past. Thus, to argue that if
one threw a ball in the air, it would eventually slow down and
reverse course to fall to earth because that had always been observed
in the past corresponded to an assumption that the pa ern observed
to date (objects thrown upward slow down, reverse course, and
return to earth) would continue into the future. In the same way, to
argue that cowpox caused immunity to smallpox because no one got
smallpox after having cowpox corresponded to an assumption that
the pa ern observed to date (no smallpox after cowpox) would
continue into the future.
Hume pointed out that, even for the most reasonable sounding of
such assumptions, there was no logical necessity behind the
inductive argument. Of central concern to Hume was the issue of
causal inference and failure of induction to provide a foundation for
it39
“Thus not only our reason fails us in the discovery of the

ultimate connexion of causes and effects, but even after
experience has inform’d us of their constant conjunction, ‘tis
impossible for us to satisfy ourselves by our reason, why we
shou’d extend that experience beyond those particular
instances, which have fallen under our observation. We
suppose, but are never able to prove, that there must be a
resemblance betwixt those objects, of which we have had
experience, and those which lie beyond the reach of our
discovery.”
In other words, no number of repetitions of a particular sequence
of events, such as the appearance of a light after flipping a switch,
can prove a causal connection between the action of the switch and
the turning on of the light. No ma er how many times the light
comes on after the switch has been pressed, the possibility of
coincidental occurrence cannot be ruled out. Causal inference based
on mere association of events additionally constitutes a logical
fallacy known as post hoc ergo propter hoc (Latin for “after this
therefore on account of this”). This fallacy is exemplified by the
inference that the crowing of a rooster is necessary for the sun to rise
because sunrise is always preceded by the crowing.
The post hoc fallacy is a special case of a general logical fallacy
known as the fallacy of affirming the consequent. This fallacy of
confirmation takes the following general form: “We know that if H is
true, B must be true; and we know that B is true; therefore H must be
true.” Though a fallacy, this reasoning is often used by scientists in
interpreting data. For example, when one argues as follows: “If
sewer service causes heart disease, then heart disease rates should be
highest where sewer service is available; heart disease rates are
indeed highest where sewer service is available; therefore, sewer
service causes heart disease.” Here, H is the hypothesis “sewer
service causes heart disease” and B is the observation “heart disease
rates are highest where sewer service is available.” The argument is
logically unsound, as demonstrated by the fact that we can imagine
many ways in which the premises could be true but the conclusion
false. For example, economic development could lead to both sewer
service and elevated heart disease rates, without any effect of sewer
service on heart disease. In this case, however, we also know that
one of the premises is not true—specifically, the premise, “If H is
true, B must be true.” This particular form of the fallacy exemplifies
the problem of confounding, which we will discuss in detail in later
chapters.
Since the skeptical writings of Hume, philosophers of science have
tried either to refute the skepticism or to weave it into their thinking.
In the early 20th century, Hume’s thesis began to become accepted.
Available observations, however, are always consistent with several
y
hypotheses that themselves are mutually inconsistent, which
explains why, as Hume noted, scientific theories cannot be
deductively proven to be empirical facts. In particular, consistency
between a hypothesis and observations is no proof of the hypothesis
because we can always invent alternative hypotheses that are also
consistent with the observations.
In contrast to the futility of a empting to prove a hypothesis, one
school of thought, championed by Popper,40 noted that a valid
observation that is inconsistent with a hypothesis implies that the
hypothesis as stated is false. In other words, though proving a
scientific hypothesis deductively is impossible, it is claimed that
refuting one is not. This refutationist viewpoint was illustrated by
Magee,41 who described a hypothetical research program to learn
the boiling point of water. A scientist who boils water in an open
flask and repeatedly measures the boiling point at 100°C will never,
no ma er how many confirmatory repetitions are involved, prove
that 100°C is always the boiling point. On the other hand, merely one
a empt to boil the water in a closed flask or at high altitude will
refute the proposition that water always boils at 100°C.
According to refutationist philosophy, science advances by a
process of “conjecture and refutation.” Scientists form hypotheses
based on intuition, conjecture, and previous experience. Good
scientists use deductive logic to infer predictions from the
hypothesis and then compare observations with the predictions.
Hypotheses whose predictions agree with observations are
confirmed only in the sense that they can continue to be used as
explanations of natural phenomena. At any time, however, they may
be refuted by further observations and might be replaced by other
hypotheses that are more consistent with the observations.
One way to rescue the concept of induction is to resurrect it as a
psychological phenomenon, as Hume and Popper claimed it was,
but one that plays a legitimate role in hypothesis formation. The
philosophy of conjecture and refutation places no constraints on the
origin of conjectures. Even delusions are permi ed as hypotheses
and therefore inductively inspired hypotheses are valid starting
points for scientific evaluation. This concession does not admit a
logical role for induction in definitively establishing scientific
hypotheses, but it allows the process of induction to play a part,
along with imagination, in the scientific cycle of conjecture and
refutation.
The philosophy of conjecture and refutation has profound
implications for the methodology of science. The popular concept of
a scientist doggedly assembling evidence to support a favorite thesis
is objectionable because it encourages scientists to consider their
own pet theories as their intellectual property, to be confirmed,
proven, and, when all the evidence is in, cast in stone and defended
as natural law. Such a itudes hinder critical evaluation, interchange,
and progress. The approach of conjecture and refutation, in contrast,
encourages scientists to be skeptical, to consider multiple
hypotheses, and to seek crucial tests that narrow the pool of
competing hypotheses by falsifying one of them.
Ideally, falsification is not personal. Criticism leveled at a theory
need not be seen as criticism of the person who proposed it. When
used constructively, the refutationist approach can be highly
productive. It has been suggested that the reason why certain fields
of science have advanced rapidly during certain periods while others
languished is that the rapidly advancing fields were propelled by
scientists who were busy constructing and testing competing
hypotheses; the other fields, in contrast, were described as “sick by
comparison because they have forgo en the necessity for alternative
hypotheses and disproof.”42
The refutationist model of science has a number of valuable
lessons for research conduct, especially of the need to seek
alternative explanations for observations, rather than focus on the
chimera of seeking scientific “proof” for some favored theory.
Nonetheless, it is vulnerable to criticisms that observations (or their
interpretations) are themselves laden with theory (sometimes called
the Duhem-Quine thesis).43 Thus, observations can never provide
the sort of definitive refutations that are the hallmark of popular
accounts of refutationism. For example, there may be uncontrolled
and even unimagined biases that have made our refutational
observations invalid; to claim refutation is to assume as true the
unprovable theory that no such bias exists. Refutations depend on
theories, and therefore their foundation is not completely secure. The
net result is that logical certainty about either the truth or falsity of a
scientific theory is impossible.44
Consensus and Naturalism

Some 20th-century philosophers of science, most notably Kuhn,45
emphasized the role of the scientific community in judging the
validity of scientific theories. These critics of the conjecture and
refutation model suggested that the refutation of a theory involves
making a choice. Every observation is itself dependent on theories.
For example, observing the moons of Jupiter through a telescope
seems to us like a direct observation but only because the theory of
optics on which the telescope is based is so well accepted. When
confronted with a refuting observation, a scientist faces the choice of
rejecting either the validity of the theory being tested or the validity
of the refuting observation, which itself must be premised on
scientific theories that are not certain.46 Observations that are
falsifying instances of theories may at times be treated as
“anomalies,” with the theory retained in the hope that the anomalies
may eventually be explained. Of course, anomalies may lead
eventually to the overthrow of current scientific doctrine, just as
Newtonian mechanics was displaced (remaining as a useful
approximation) by relativity theory.
Kuhn asserted that in every branch of science the prevailing
scientific viewpoint, which he termed “normal science,” occasionally
undergoes major shifts that amount to scientific revolutions. These
revolutions signal a decision of the scientific community to discard
the scientific infrastructure rather than to falsify a new hypothesis
that cannot be easily grafted onto it. Kuhn and others have argued
that the consensus of the scientific community determines what is
considered accepted and what is considered refuted, and that
acceptance and refutation are only meaningful in relation to what is
accepted by that community as established knowledge.
A classical view that the ultimate goal of scientific inference is to
capture some objective truths about the material world in which we
live. This view leads to the notion that any theory of inference
should ideally be evaluated by how well it leads us to these truths.
Measurement of how well this ideal has been achieved are extremely
difficult to validate, however, for we have no way of knowing with
certainty that we have found an absolute truth about the world.
Thus, knowledge about the world will always be tentative to a
greater or lesser degree. This uncertainty may be negligible in some
branches of physical science but is so large as to be the motivation
for research in health and medical sciences. Truth arguably still
remains the goal, but our capacity to arrive at it is limited, regardless
of whether consensus beliefs about the truth evolve.
Frequentism
In light of the limits of investigative methods, our inferences and our
store of accepted facts will inevitably contain errors to some
unknown degree. This conclusion, labeled fallibilism, was reached by
the American pragmatic philosopher Charles Sanders Peirce in the
late 19th century.47 To address these limitations, the geneticist and
statistician R. A. Fisher developed a theory and methodology of
inference based on experiments designed to provide known
frequencies of results under explicit, ideal conditions.48, 49
A pivotal requirement of Fisher’s frequentist methodology was that
the experiment incorporate a device or instrument that generated
treatment assignments (allocations) in a random fashion, with
known frequencies for all possible assignment pa erns. This known
behavior of the assignment instrument (also known as the allocation
mechanism) could then be used to compute the probabilities of
subsequent observations under a specific hypothesis about the effect
of treatment, which formed the basis of Fisher’s statistical tests.
Typically, the hypothesis chosen for the computation—the test
hypothesis—was that the treatment had no effect, which today is
called the causal null hypothesis. Other hypotheses could be used
instead, but experimental design and subsequent computations are
simplest for this null hypothesis. In Fisher’s time, before the advent
of electronic computers, this simplicity encouraged a focus on the
null hypothesis—a focus that remains, inappropriately, to the
present day in most statistics texts and analyses.50
Borrowing the terms “statistical significance” and “significance
test” from earlier statistical writers—but not their meaning of the
term—Fisher computed what he called a “level of significance” for
the experimental outcome in relation to the hypothesis tested, which
in more neutral terms is known as a P-value. For simple experiments
designed to “test” the null, this P-value was the frequency
(expressed as a probability) with which one should expect the
experimental design to produce an effect estimate as large as
observed or larger if in fact there was no effect of the treatment.
There are many subtleties and qualifications that should be a ached
to the P-value and this description, which we will review at length in
Chapter 15. For now, the most important one, which Fisher also
emphasized, is that the P-value as Fisher defined it is not the
probability of the tested hypothesis. Unfortunately, it is often
misinterpreted as if it were that probability.
A P-value may, however, be viewed as measuring, under ideal
conditions, the compatibility or consistency between the
experimental outcome and the tested hypothesis, with P = 1
indicating that the outcome is exactly what the hypothesis predicted,
and P = 0 indicating that the outcome is impossible under the
hypothesis. In this usage, it is crucial to note that P = 1 does not mean
the hypothesis is correct, for there may be many other hypotheses
that are also highly compatible with the outcome. In addition, the
results may only reflect departures from the ideal se ing assumed
by the computation of the P-value; the result may have arisen from
invalid assumptions, from computing errors, and in the extreme, a
clever analyst can manipulate the data or methods to produce a large
or small P-value.
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only in undertones, and make no sound, save as their clogs clatter
on stones and gravel.
It is impossible to carry away more than a general and bewildered
impression of the splendid walled and lanterned courts, the superb
gate-ways, and the temples themselves, but certain details, upon
which the guides insist, remain strangely clear in memory. Over the
doors of the stable where the sacred white pony is kept are colored
carvings representing groups of monkeys with eyes, or ears, or
mouth covered with their paws—the signification being that one
should neither see, hear, nor speak any evil. In one superbly-carved
gate-way is a little medallion of two tigers, so cunningly studied and
worked out that the curving grain and knots of the wood give all the
softly-shaded stripes of their velvet coats and an effect of thick fur.
One section of a carved column in this gate is purposely placed
upsidedown, the builder fearing to complete so perfect and
marvellous a piece of workmanship. Above another gate-way curls a
comfortable sleeping cat, which is declared to wink when rain is
coming, and this white cat has as great a fame as anything along the
Daiyagawa.
The strangest hierophant in Nikko is the priestess who dances at
the temple of Iyeyasu. She looks her three-score years of age, and is
allowed a small temple to herself, where she sits, posed like an altar
image, with a big money-box on the sacred red steps before her, into
which the pious and the curious toss their offerings. Then the
priestess rises and solemnly walks a few steps this way, a few steps
that way, poses before each change, shakes an elaborate sort of
baby’s rattle with the right-hand, and gesticulates with an open fan in
the left-hand. The sedate walk to and fro, the movements of the
rattle and fan constitute the dance, after which this aged Miriam sits
down, bows her head to the mats, and resumes her statuesque
pose. She wears a nun-like head-dress of white muslin, and a loose
white garment without obi, over a red petticoat, the regular costume
of the Shinto priestesses. She seems always amiable and ready to
respond to a conciliatory coin, but the visitor wonders that the cool
and shaded sanctuary in which she sits, with nearly the whole front
wall making an open door, does not stiffen her aged joints with
rheumatism and end her dancing days.
GATE-WAY OF THE IYEYASU TEMPLE
A green and mossy staircase, a greener and mossier balustraded

walk, leads up and along the crest of the hill to the final knoll, atop of
which stands the simple bronze urn containing the great Shogun’s
body. A more still and solemn, a more peaceful and beautiful resting-
place could not be imagined, and the peculiar green twilight reigning
under the closely-set cryptomerias, with those long stretches of
stone balustrades and embankments, which the forest has claimed
for its own and clothed in a concealing mantle of the greenest moss,
subdue the most frivolous beholder to silence and seriousness.
On that velvety-green stair-way leading to Iyeyasu’s tomb I met,
one day, a scholar of fine taste and great culture, a man of distinction
in his native West. “I am overwhelmed with the beauty and
magnificence of all this,” he said. “I must concede the greatness of
any religion that could provide and preserve this, and teach its
followers to appreciate it.”
Afterwards, almost on the same step, a dear missionary friend
stopped me, with eyes full of tears. “Oh!” she sighed, “this fills me
with sadness and sorrow. These emblems and monuments of
heathenism! I see nothing beautiful or admirable in those wicked
temples. They show me how hard it will be to uproot such heathen
creeds. I wish I had not come.”
A woodland path leads around the foot of the great hill on which
the Shoguns’ tombs are built, a path laid with large fiat stones and
set with a rough curbing of loose rocks and bowlders, covered—by
the drip and damp and shade of centuries—with a thick green moss.
This silent footway leads past many small temples, stone-fenced
enclosures, moss-covered tombs and tablets, tiny shrines behind
tiny torii, and battered, broken-nosed, and headless Buddhas. Half-
hidden tracks, in that gloomy and silent cryptomeria forest, rough-set
staircases, roads plunging into the deep shadow of the woods entice
the explorer to ever-new surprises. At deserted and silent shrines
heaps of pebbles, bits of paper, or strips of wood painted with a
sacred character attest the presence of prayerful pilgrims, who have
sought them out to register a vow or petition. Tiny red shrines gleam
jewel-like in the far shadows, and fallen cryptomerias make mounds
and ridges of entangled vines among the red-barked giants still
standing. Above a water-fall, all thin ribbons and jets of foam, are
more old temples, where pilgrims come to pray and tourists to
admire, but where no one ever despoils the unguarded sanctuaries.
In one of these buildings are life-size images of the gods of thunder
and the winds. Raiden, the thunder-god, is a bright-red divinity with a
circle of drums surrounding his head like a halo, a fierce
countenance, and two goaty horns on his forehead. Futen, the god
of winds, has a grass-green skin, two horny toes to each foot, and a
big bag over his shoulders. A fine heavy-roofed red gate-way and
bell-tower distinguish another cluster of temples in this still forest
nook, their altars covered with gilded images. One open shrine,
which should be the resort of jinrikisha men, is dedicated to a
muscular red deity, to whom votaries offer up a pair of sandals,
beseeching him for vigorous legs. The whole place is hung over with
wooden, straw, and tin sandals, minute or colossal. Then down
through the wood, past a hoary graveyard, where abbots and monks
of Nikko monasteries were buried for centuries before the Shoguns
came, one returns to the Futa-ara temple and Iyemitsu’s first gate-
way.
In our wanderings we once happened upon an old and crowded
graveyard, with splendid trees shading the mossy tombs and
monuments. The stone lanterns, Buddhas, and images were past
counting, and one granite deity, under a big sun-hat, had a kerchief
of red cotton tied under his chin. His benevolent face and flaming
robes were stuck all over with tiny bits of paper, on which the faithful
had written their petitions, and the lanterns beside him were heaped
with prayer-stones. A Hindoo-looking deity near by sat with uplifted
knee, on which he rested one arm and supported his bent and
thoughtful head.
A hundred stone representatives of Buddha sit in mossy
meditation under the shadow of the river bank, long branches trailing
over them and vines clambering about their ancient brows. Time has
rolled some from their lotus pedestals, beheaded others, and
covered them all with white lichens and green moss, and Gamman,
as this row of Buddhas is named, is the strangest sight among the
many strange sights of the river bank. Custom ordains that one
should count them, and no two persons are believed to have ever
recorded the same number of images between the bridge and Kobo
Daishi’s open shrine.
There is an eta village just below Nikko, peopled by these
outcasts, who follow their despised calling of handling the carcasses
of animals and dressing leather and furs. Their degradation seems to
result not more from that Buddhist law which forbids the taking of
animal life, than from the legendary belief that they are the
descendants of Korean prisoners, long kept as executioners and
purveyors for the imperial falcons. Colonies of etas lived for
centuries without part or lot in the lives of their high-caste neighbors.
After the Restoration, the power of the great nobles was curtailed,
and with the gradual freeing of the lower classes from the tyranny of
caste the eta became a citizen, protected by law. Prejudice still
confines him to his own villages, but when he leaves them salt is no
longer sprinkled on the spot where he stands to purify it.
The most harrowing situation of the old romances was the falling
in love of a noble with a beautiful eta girl. Now the eta children attend
the Government schools on the same terms as their betters. But this
liberality was of slow growth, and in one province, where the stiff-
necked parents withdrew their children because of the presence of
these pariahs, the governor entered himself as a pupil, sitting side by
side with the little outcasts in the same classes, after which august
demonstration of theoretical equality caste distinctions were allowed
to fade.
Nikko becomes a great curio mart each summer, the curios
having, naturally, a religious cast; and bells, drums, gongs, incense-
burners, images, banners, brocade draperies, and priestly fans make
a part of every peddler’s pack, each thing, of course, being certified
to have come from the sacred treasuries near by. The souvenirs,
which the most hardened tourist cannot resist buying, are the Nikko
specialties of trays, cups, boxes, and teapots of carved and
lacquered wood, and of curious roots, decorated with
chrysanthemums or incised sketches of the Sacred Bridge. The
Japanese eye sees possibilities in the most unpromising knot, and
the Japanese hand hollows it into a casket, or fits it with the spout
and handle that turn it into a teapot. All the village street is lined with
these wooden-ware shops, alternating with photograph and curio
marts.
Visitors to Nikko always buy its yuoki, a candy made of chestnuts
and barley-sugar, which comes in slabs an inch square and six
inches long, wrapped in a dried bamboo sheath, and put in the
dainty little wooden boxes which make Japanese purchases so
attractive. It is like a dark-brown fig-paste, and has a flavor of
marrons glaces and of maple-sugar. Flocks of children, with babies
on their backs, hover about the yuoki shop in upper Nikko, and if the
tourist bestows a box on them, their comical bobs and courtesies,
their funny way of touching the forehead with the gift during all the
bowing, and the rapture with which they attack the bar of sweets
express most eloquent thanks.
When rain or fatigue prevented our making any out-door
excursions, the village street furnished us with an all-day occupation.
A mossy and abandoned rice-mill faced us across the road, with a
tiny cascade dripping down from the leafy hill behind it, feeding its
overshot wheel, and dropping by dwarf water-falls to the side of the
road, whence it ran down the slope to add its singing to the water
chorus that makes all Nikko musical. Pack-horses, farmers, pilgrims,
and villagers went picturesquely by, each pedestrian tucking his
kimono in his belt to shorten it, and holding a vast golden halo over
his head in the shape of a flat, oil-paper rain umbrella.
A small garden separated our summer home at Nikko from our
landlord’s house, and from early morning, when his amados
thundered open, until dark, when they rumbled shut, the whole
conduct of Japanese household life lay before us. Our neighbors
came out of doors betimes. A bucket of water from a tiny cascade
filled the broad, shallow copper wash-basin, in which one by one
they washed their faces. Meanwhile the kettle boiled over the
charcoal fire, and some child ran down to a provision-shop for a
square slab of bean-curd, which, with many cups of tea, a little rice,
and shreds of pickled fish, composed their breakfast. Then the
futons were hung over poles or lines to sun; the andons, pillows, and
big green tents of musquito-nets put away; the tatami brushed off,
and the little shop put in order for the day.
The women washed and starched their gowns, pasting them down
on flat boards to smooth and dry; sewed and mended, scrubbed and
scoured in the narrow alcove of a kitchen all the morning; while the
children trotted back and forth with buckets of water to sprinkle the
garden, wash the stones, fill the bath-tubs, and supply the kitchen.
The rice, after being washed and rubbed in the cascade, was soaked
for an hour and then poured into the furiously boiling rice-pot. The
brush fire under the stone frame of the kettle was raked out, and
when the steam came only in interrupted puffs from under the cover,
this was lifted to show a pot full to the brim of snowy-white grains. A
soup had meanwhile been stewing, a fish had been broiled over
charcoal, and, with tea, the noonday dinner was ready. At some hour
of the day offerings of rice and food were mysteriously placed on the
steps of the tiny shrine to the fox-god, chief ornament of the farther
garden. Towards sundown came supper, and then the lighting of the
lamps. Shadow pictures on the shoji repeated the actions and
groupings within, the splash of water betrayed the family bath, and
when all, from grandfather to baby, had been boiled and scrubbed,
the amados banged, and the performance was over until sunrise.
CHAPTER XVI
CHIUZENJI AND YUMOTO
The Inquisition should have been put in possession of the

Japanese kago as a lesser punishment for heretics, so exquisite and
insidious are its tortures. This kago is a shallow basket with a high
back, slung from a pole carried on the shoulders of two men, and in
the mountains and remote districts is the only means of travel,
except by pack-horses. The Japanese double their knees and sit on
their feet with great dignity and apparent comfort; but the greater
size of the foreigner, his stiff joints and higher head, prevent his
fitting into the kago; nor is he much better off when he gets astride,
dangling his long legs over the edges. Moreover, he not only knows
that he looks ridiculous, but suffers the pangs of conscience for
imposing his weight on two small coolies no larger than the ten-year-
old boys of his own land. There are a few arm-chairs on poles, in
which one may ride, like the Pope, or an idol in a procession, but the
long poles, springing with the gait of four bearers, often make the
passenger sea-sick.
FARM LABORERS AND PACK-HORSE
The pack-horse, a slow-moving beast, has a keeper who pulls him

along by a cord, his extended head and reluctant gait making that
seem the only motive power. Horse and leader wear straw shoes,
and new pairs are strung around the high saddle for reshoeing the
beast every few miles. Iron horseshoes are confined to the capital
and the large ports, and the village blacksmith is unknown. Pack-
horses wear a thick straw pad and a high saddle fashioned like a
saw-horse, on which the rider sits aloft, so well forward that his feet
hang over the creature’s neck. This saddle is merely balanced, not
girded on, and the animals are so sleepy, slow-footed, and
stumbling, with a lurching, swinging gait like a camel’s, that riding
one is really a feat.
From Nikko to Chiuzenji you must travel eight miles by kago, pack-
horse, or jinrikisha, the road leading past rich fields of buckwheat,
millet, rice, and potatoes, farm-houses with thatched roofs, wayside
shrines and tea-houses. The ascent of the two thousand feet to the
higher region of the lake is chiefly included in one three-mile stretch,
climbing by easy slopes and broad staircases to the high pass. At
every few feet a stone step was built, or a tree-trunk fastened with a
forked stick and set with small stones. This stair-building, done ages
ago, has become a part of the mountain. At short distances the
staircase enters a little clearing with a rustic tea-house, or the usual
tateba, built of poles, a few planks, branches or mats, and affording
sufficient shelter for summer pilgrims and travellers. The keepers
immediately put out cushions for guests on the edge of the platform
that constitutes the floor of the one room, and bring the tray with its
tiny teapot, thimble cups, and dish of barley-sugar candies. For the
refreshment one leaves a few coppers on the tray, and in mountain
jaunts, where the traveller walks to escape the kago and spare the
coolies, these tiny cups of pale yellow tea are very stimulating. Each
tateba commands some particular view, and even the pilgrim who is
tramping the provinces and living on a few cents a day, will be found
inditing poems to the different water-falls and gorges he looks down
upon.
The head of the pass affords a magnificent view of the valley two
thousand feet below, and presently the woodland path is following
the border of the lake and comes out into the open of Chiuzenji
village. Chiuzenji Lake, three miles wide and eight miles long, is
surrounded by steep and thickly-wooded mountains, the great
Nantaisan grandly soaring nine thousand feet above the sea,
tapering regularly as a pyramid and forested to the summit.
Nantaisan is a sacred mountain, a temple at its foot, shrines all along
the ascent, and at the top an altar on which repentant murderers
offer up their swords. Each August come hosts of pilgrims in white
clothes and huge straw hats, with pieces of straw matting for rain-
coats bound across their shoulders—devout souls, who, after
purification in the lake, pass under the torii, say a prayer in the
temple, and painfully climb to the summit. Only at such fixed
seasons may visitors ascend the mountain, each one paying twenty
cents for the privilege of toiling up its endless flight of steps. With
these fees the priests keep the underbrush trimmed and the path
well cleared, and where the holy guardian unbars the gate and
motions one upward, begins the flight of stone stairs that extend,
with few breaks or zigzags, straight to the top. The whole way is
strewn with the cast-off sandals of the season, and great heaps of
the waraji of past years lie here and there.
The pilgrims sleep in Government barracks in the village, a few
coppers securing a mat on the floor and the use of the common
fireplace. Their vow to Nantaisan being accomplished, they make the
half-circuit of the lake, to visit the hidden shrines and temples of the
forest shores, and then trudge to Yumoto for its hot sulphur baths
and scenery, or home to their ripening rice-fields.
From across the water Chiuzenji village looks a small, yellow
patch, lying between the unbroken green slope of Nantaisan and the
great lake. Its five tea-houses rise straight from the water’s edge,
each with a triple row of outer galleries overlooking it. The way of life
at the Tsutaya, Idzumiya, Nakamarya, and the rest is much more
Japanese than in the frequented inns of Nikko. Chairs and tables are
conceded to foreigners, but everybody must sleep on the floor, wash
face and hands in the common wash-basin in the open court, and go
about the house stocking-footed, or wear the stiff, heelless, monkey-
skin slippers furnished by the inn. To call a servant one claps his
palms, and a long-drawn “Hei!” announces that the rosy-cheeked
mountain maid has heard, and the gentle swaying of the house
proclaims that she is running up the stairs. The washing of rice,
vegetables, fish, kitchen utensils, and family clothing goes on from
the single plank of a pier running from the lowest floor of the house.
Each inn has a similar pier, where sociable maidens chatter as they
stir and wash the rice in bamboo baskets. The servants of the
houses take the whole lake for wash-hand basin and tooth-brush
cup, and the pier is a small stage, upon which these local companies
play their unstudied parts.
As the finest country walk in England is agreed to be that from
Stratford to Warwick, so is the way from Chiuzenji to Yumoto the
finest country walk in Japan, for its eight miles of infinite variety.
First, the broad foot-path wanders for two miles along the shores of
Lake Chiuzenji, which, however, appears only in glimpses of placid
blue through the dense forest, all stillness, coolness, and
enchantment. Then it emerges at the head of the lake in a grove of
pine-trees sheltering a rustic tea-house, which overlooks the bit of
low beach known as the Iris Strand, and all the grand amphitheatre
of mountains walling in Chiuzenji. Farther on are Hell’s River and the
Dragon Head cascade, where a mountain stream slides in many a
separate ribbon down mossy ledges. Thence the foot-path climbs to
a high plain covered with tall grasses and groves of lofty pines—the
famous Red Plain, dyed once with the blood of a conquered army,
and tinged with each autumn’s frost to the same deep hue again.
From the border of this plain rise sombre mountains, Nantaisan a
giant among them, with green and purple veils of shadows and a
crown of floating clouds. No sign of habitation or cultivation marks
the high plain, which, with its loneliness and its scattered pines, is so
much like the valleys of the high Sierras. Everywhere else in Japan
the country is wooded and shaded and cultivated from water’s edge
to mountain-top; but in winter all the region above Nikko is deserted,
and deep snows in the passes shut it off from the rest of the world.
Tea-houses close, the people flee to the valley for warmth, and only
the coming of spring and the tourist restores it again. Even those
wizards, the Japanese farmers, do not attempt to subdue these
solitudes, whose wild beauty delights the whole people.
Beyond this lonely plain the way climbs seven hundred feet along
the face of a precipitous hill to the level of Yumoto Lake, which there
narrows to a few feet and slips down the rocks, a mass of foam,
spray, and steam. The lake—small, uneven, walled by perpendicular
mountain-slopes and forests—is a still mirror of these superb
heights, one of which, Shirane-san, is a slumbering volcano.
Vaporous sulphur springs bubble through the hot crust of earth at the
end of the lake, and boiling sulphur wells up, even in the bed of the
lake itself, and clouds and heats the whole body of water so that no
fish can live there. The two miles of winding forest-path, between the
fall at one end of Yumoto Lake and the village of the same name at
the opposite end, lead through an enchanted forest—a picturesque
tangle of roots and rocks, covered with green moss, wound with
vines, shaded with ferns, and overhung with evergreen branches.
Yumoto has two streets and a dozen tea-houses, whose galleries
are hung with red lanterns, as if in perpetual fête, and an
atmosphere nearly all sulphuretted hydrogen. One of the hot springs
bubbles up at the entrance of the village, filling a tank about ten feet
square, covered by a roof resting on four corner pillars. The sides
are all open to the air, and an Arcadian simplicity of bathing
arrangements prevails. Citizens and sojourners stroll hither, because
the site commands a view of the thoroughfare, remove and fold up
their garments, and sit down in the pool. When sufficiently boiled,
they cool off occasionally on the edge of the tank, and then drop into
the pool again. If the company prove agreeable, the bath occupies
hours. More open-air pavilions are at the end of the village, where
more bronze figures boil and cool themselves in the same exoteric
fashion. The public bath-houses, that alternate with the tea-houses
in the village streets, have roofs and sides of solid wood, except the
street front, which is open and curtainless, and within which men,
women, and children meet in the hot-water tanks, as at the market-
place or street-corners in other countries. To a new-comer this
extraordinary simplicity is startling, but if he stays long enough, he
finds that the childlike innocence and unconcern of the people make
a new code of the proprieties.
These infantile views of the Japanese as to bathing make even the
great pay little attention to the seclusion and inviolateness of the
bath-room. In a high-class Japanese house, or at the best tea-
houses, this is an exquisitely artistic nook, with cement walls and
floors, inlaid with fantastic stones and bits of porcelain. The oval tubs
are of pine, bound with withes, and white with scouring. The doors
are generally sliding paper screens without locks, and the wooden
wall, or door, if there be one, is full of fantastic holes and tiny
windows with no curtain. Often the bath-house is a detached
pavilion, to which you are expected to walk in a special bath gown,
or ukata, meeting, on the way, household and guests, who are
always ready for a friendly chat. Europeans can hardly make a
Japanese servant understand that in their order of arrangements, the
bath and the bath-room are for the use of one person at a time. The
Japanese wooden tub is vastly better than the zinc coffins and
marble sarcophagi in which we bathe. The wood keeps the water
hotter and is pleasanter to the touch. One kind of tub has a tiny stove
with a long pipe in one end, and with a mere handful of charcoal
such a tub is filled with boiling water in the briefest time. Many
bathers have lost their lives by the carbonic acid gas sent off by this
ingenious contrivance. A Japanese hot bath is only a point or two
from boiling. The natives bear this temperature without wincing, and
will step from this scalding caldron out-of-doors, smoking along the
highway on a frosty day, like the man whom Dr. Griffis describes. Our
grave and statuesque landlord at Yumoto, who sat like a Buddha
behind his low table and held court with his minions, once appeared
to us stalking home in the starlight with all his clothes on his arm. His
stride was as stagey and majestic as ever, there being no reason, in
his consciousness, why he should lay off his dignity with his
garments, they representing to him the temporary and accidental,
not the real envelope of the pompous old soul.
PUBLIC BATH-HOUSE AT YUMOTO
At some of the great mineral springs there are now separate pools
for men and women, in deference to foreign prejudice; but more than
one generation will pass before promiscuous bathing is done away
with.
At all medicinal springs the baths are owned and managed by the
Government and are free to the people. Here at Yumoto, men,
women, and children walk into the one large room containing the
pools, undress, lay their clothing in a little heap on the raised bench
or platform running around the edge of the room, and step into the
water; and, as has been said, no one sees any impropriety in this
custom. Women sit or kneel on the edges of the pool, scouring
themselves with bags of rice-bran, and chattering with their friends in
or out of the water. People stop at the open doors, or breast-high
windows, to talk to the bathers, and conduct is as decorous, as
reserved, and as modest as in a drawing-room. The approach of a
foreigner sends all the grown bathers deep into the water, simply out
of respect to his artificial and incomprehensible way of looking at
natural things. They know, though they cannot understand, that the
European finds something objectionable, and even wrong, in so
insignificant a trifle as being seen without clothes.
At our tea-house in Yumoto our three rooms in the upper story
were thrown into one during the daytime, making an apartment open
to the gallery on three sides. Hibachis, or braziers, with mounds of
glowing charcoal, tempered the morning and evening air, and all day
we could sit on piles of futons, and enjoy the superb picture of
mountains and lake before us. We were poled over the placid water
in a queer ark of a boat, and the mountain-paths were always
alluring, the roughest trail often passing under torii, or leading past
some shrine, just when it seemed that no foot had ever preceded
ours. At night, when the chilling air presses the sulphur fumes closer
to earth, Yumoto streets resound with the wailing whistle of the blind
shampooer, or amah. These amah are found everywhere—in the
largest cities and in the smallest mountain villages—and, whether
men or women, are never young, or even middle-aged. Theirs is an
indefinite, unscientific system of massage, and their manipulations
often leave their charges with more lame and aching muscles than
before. But the amah are an institution of the country, and Yumoto
streets would ring with their dreary music, and our screens would be
slipped aside by many an ill-favored crone, as soon as it was time for
the usual evening baths to be prepared at the tea-houses.
Upon another visit to Nikko and Chiuzenji in late October there
was a more splendid autumnal pageant than the most gorgeous hill-
sides of America had ever shown me. Frost had done its most
wonderful work, and the air was exhilarating to intoxication. The
clear and brilliant weather moved the coolies to frisk, play, and chant
like children—even that dignified little man, Ito, relaxing his gravity to
frolic like a boy, and to pry bowlders over the edges of precipices to
hear them crash and fall far below. Chiuzenji looked a vast, flawless
sapphire, and Nantaisan was a mosaic of richest Byzantine coloring.
Kegon-no-taki, the fall of three hundred feet by which the waters of
Chiuzenji drop to the valley in their race to the Daiyagawa, seemed a
column of snow in its little amphitheatre hung with autumn vines and
branches. But we dared not remain, for already Yumoto was closed
and boarded up for the season, and on any day the first of the
blockading snows of winter might shut the door of the one tea-house
left open at Chiuzenji, and end the travel from the Ashiwo copper-
mines.
CHAPTER XVII
THE ASCENT OF FUJIYAMA
It was in the third week of July that we made our long-talked-of

ascent of Fujiyama. There were nine of us, all told, four stalwart
men, three valiant women, and two incomparable Japanese boys, or
valets. For forty miles we steamed down the old line of the Tokaido,
drawing nearer to the sea in its deep indentation of Odawara Bay,
and to the blue bar of the Hakone range that fronts the ocean. At
Kodzu we took wagonettes and rattled over the plain and up a valley
along the Tokaido, children being snatched from under the heels of
the horses, and coolies, with poles and baskets over their shoulders,
getting entangled with the wheels all the way. A Japanese driver is a
most reckless Jehu, and the change to jinrikishas, after the wild ten-
mile charge up the valley, was beatific. Ascending a narrow cañon,
and rounding curve after curve, we saw at last the many lights of
Miyanoshita twinkling against the sky.
Miyanoshita, the great summer resort, is the delight alike of
Japanese and foreigner. It has excellent hotels kept in western
fashion, clear mountain air, mineral springs and beautiful scenery,
and it is the very centre of a most interesting region. All the year
round its hotels are well patronized, the midwinter climate being a
specific for the malarial poison of the ports of southern China.
Famous, too, is the wooden-ware of Miyanoshita, where every house
is a shop for the sale of Japanese games, household utensils, toys
and trifles, all made of the beautifully-grained native woods, polished
on a wheel with vegetable wax. Exquisite mosaics of a hundred
broken patterns amaze one with their nicety of finish and cheapness,
and no one escapes from the village without buying.
Guides and coolies had been engaged for us at Miyanoshita, and
at six o’clock, on the morning after our arrival, the three kagos of the
ladies were carried out, and the four cavaliers, the two boys, and six
baggage coolies followed. The broad path zigzagged upward to the
narrow, knife-edge ride of the mountain range known as the O Tomi
Toge pass. From its summit we looked back along the checkered
green valley to Miyanoshita and Hakone Lake, with the Emperor’s
island palace. Looking forward across a checkered plain, we saw
Fujiyama rise straight before us, its obstinate head still hidden in
clouds. Dropping quickly to the level of the plain, we reached
Gotemba, and, changing to jinrikishas, were whirled away to
Subashiri, six miles distant.
Trains of descending pilgrims and farmers, perched high on the
backs of pack-horses, smiled cheerfully at the procession of
foreigners bound for Fuji, and at each rest-house on the way women
and children, petrified with astonishment, stood staring at us. Black
cinders and blocks of lava announced the nearness of the volcano,
and the road became an inky trail of coal-dust through green fields.
Banks of scoriæ, like the heaps of coal-dust around collieries,
cropped out by the road-side, and the wheels ground noisily through
the loose, coarse slag. The whole of Subashiri, crowding the
picturesque street of a typical Japanese village, welcomed us. In the
stream of running water, on either side of the broad highway danced,
whirled, and spouted a legion of mechanical toys, some for the
children’s pleasure, and others turning the fly-brushes hung over
counters of cakes and sweetmeats. The place looks in perpetual
fête, with the hundreds of pilgrim flags and towels fluttering from
each tea-house, and at the end of the street is a torii, leading to an
ancient temple in a grove, where all Fuji pilgrims pray before
beginning the ascent of the mountain. In the light of the afternoon,
the double row of thatched houses and the street full of bareheaded
villagers looked like a well-painted stage scene. Meanwhile the sun
sank, and in the last crimson glow of its fading the clouds rolled
away, and Fuji’s stately cone stood over us, its dark slopes turning to
rose and violet in the changing light.
We rose with the sun at four o’clock, looked at Fuji, all pink and
lilac in the exquisite atmosphere of the morning, snatched a hasty
breakfast and set off, the women in their kagos and the men on
mettlesome steeds that soon took them out of sight along the broad
cindery avenue leading to the base of the slanting mountain. In that
clear light Fuji looked twice its twelve thousand feet above the sea,
and the thought of toiling on foot up the great slope was depressing.
Instead of a fifteen-mile walk, it looked fifty miles at least. All along
the forest avenue moss-grown stone posts mark the distance, and at
one place are the remains of a stone wall and lantern-guarded gate-
way setting the limit of the mountain’s holy ground. From that point
the soil is sacred, although horses and kagos are allowed to go a
mile farther to a mat-shed station, known as Umagayeshi (Turn Back
Horse). Thence the great Fuji sweeps continuously upward, and a
tall torii at the head of the stone staircase marks the beginning of the
actual ascent, the holy ground on which only sandaled feet may
tread.
In the mat-shed the kagos were stored for a two days’ rest,
luggage was divided and tied on the backs of the coolies, who were
as gayly fringed as Indians on the war-path, with the many pairs of
straw sandals tied at their waists and hanging from their packs. The
coarse cinders cut through boot-soles so quickly that foreigners tie
on these waraji to protect their shoes, allowing eight pairs of the
queer galoshes for the ascent and descent of Fuji. From
Umagayeshi, the path goes up through woods and stunted
underbrush and on over bare cinder and lava, pursuing the even
slope of the mountain without dip or zigzag to break the steady
climb. Three small Shinto temples in the woods invite pilgrims to
pray, pay tribute, and have their staff and garments marked with a
sacred seal. Beyond these temples, ten rest-houses, or stations,
stand at even distances along the path, the first, or number one, at
the edge of the woods, and the tenth at the summit. Priests and
station-keepers open their season late in June, before the snow is
gone, and close in September. In the midsummer weeks the whole
mountain-side is musical with the tinkling bells and staffs of lines of
white-clad pilgrims. Notwithstanding their picturesqueness, these
devotees are objectionable companions, as they fill tea-houses and
mountain stations, devour everything eatable, like swarms of locusts,
and bear about with them certain smaller pilgrims that make life a
burden to him who follows after. Nearly thirty thousand pilgrims
annually ascend Fujiyama. These pious palmers are chiefly from the
agricultural class, and they form mutual pilgrimage associations,
paying small annual dues, from the sum of which each member in
turn has his expenses defrayed. They travel in groups, each man
furnished with his bit of straw matting for bed, rain-coat, or shelter.
They carry, also, cotton towels marked with the crest of their pilgrim
society, to be hung, after using, at temple water-tanks, or as
advertisements of their presence at the tea-houses which they
patronize. At each new shrine they visit the priests stamp their white
clothing with the red seal of the temple.
Fujiyama is invested with legends, which these pilgrims
unquestioningly accept. It is said to have risen up in a single night
two thousand years ago, when a great depression appeared to the
southward, which the waters of Lake Biwa immediately filled. For a
thousand years pilgrims have toiled up the weary path to pray at the
highest shrine and to supplicate the sun at dawn. Fuji-san, the
goddess of the mountain, hated, it is said, her own sex, and stories
of devils, who seize women and fly off into the air with them, still
deter all but the most emancipated Japanese women from making
the ascent. It was after Fuji-san had quarrelled with all the other
gods that she set up this lofty mountain of her own, where she might
live alone and in peace. No horse’s foot is allowed to fall on the
steep approaches to her cloudy throne, and even the sand and
cinders are so sacred, that whatever dust is carried down on the
pilgrims’ feet by day is miraculously returned by night. Even to dream
of the peerless mountain is a promise of good-fortune, and Fuji, with
the circling storks and the ascending dragon, symbolizes success in
life and triumph over obstacles.
Until the year 1500, Fuji wore a perpetual smoke-wreath, and
every century saw a great eruption. The last, in 1707, continued for a
month, and threw out the loose cinders, ashes, and lumps of baked
red clay that still cover the mountain. Ashes were carried fifty miles,
damming a river in their path, covering the plain at its base six feet
deep with cinders, and forming an excrescence on the north side,
which still mars the perfect symmetry of the cone.
Umagayeshi, or Turn Back Horse, is four thousand feet above the
sea, and the other eight thousand feet are surmounted in a distance

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Modern Epidemiology Fourth Edition

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Applying Quantitative Bias Analysis to Epidemiologic

Ethics and epidemiology 2nd Edition Steven S Coughlin

Modern Occupational Diseases Diagnosis, Epidemiology,

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Library of Congress Cataloging-in-Publication Data

Cataloging-in-Publication data available on request from the

Preface and Acknowledgments

1 The Scope of Epidemiology

2 Causal Inference and Scientific Reasoning

3 Formal Causal Models

5 Measures of Effect and Measures of Association

9 Public Health Surveillance

11 Studies Relying on Secondary Data

12 Confounding and Confounders

13 Measurement and Measurement Error

15 Precision and Study Size

16 Fundamentals of Epidemiologic Data Analysis

17 Introduction to Categorical Statistics

18 Stratification and Standardization

19 Categorical Analysis of Polytomous Exposures and

20 Regression Analysis Part I: Model Specification

21 Regression Analysis Part II: Model Fitting and

23 Introduction to Bayesian Statistics

24 Longitudinal and Cluster-Correlated Data Analysis

25 Causal Inference With Time-Varying Exposures

28 Instrumental Variables and Quasi-Experimental

30 Ecologic Studies and Analysis

32 Infectious Disease Epidemiology

38 Injury and Violence Epidemiology

The fourth edition of Modern Epidemiology arrives 35 years after the

Stephanie M. Engel, PhD

Ma hew P. Fox, DSc, MPH

M. Maria Glymour, ScD

Emily W. Gower, PhD

Sander Greenland, MA, MS, DrPH, C Stat

Patricia Hartge, MA, ScD

Irva Her -Piccio o, MPH, PhD

Richard S. Hopkins, MD, MSPH

Frank B. Hu, MD, PhD

Anne Marie Jukic, PhD

Jay S. Kaufman, PhD

Katherine M. Keyes, PhD

Guohua Li, MD, DrPH

Brandon D. L. Marshall, PhD

Stephen W. Marshall, PhD

Hal Morgenstern, BArch, MRP, PhD

Lorelei Mucci, ScD, MPH

Claire H. Pernar, ScD, MPH

David Richardson, PhD

Sebastian Schneeweiss, MD, ScD

Sharon B. Schwar , PhD