American Journal of Epidemiology Vol. 172, No.

6
Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health 2010. DOI: 10.1093/aje/kwq252
Advance Access publication:
August 18, 2010

Commentary

In Snow’s Footsteps: Commentary on Shoe-Leather and Applied Epidemiology

Denise Koo* and Stephen B. Thacker

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* Correspondence to Dr. Denise Koo, Scientific Education and Professional Development Program Office, Centers for Disease
Control and Prevention, 1600 Clifton Road, NE, Mailstop E-92, Atlanta, GA 30333 (e-mail: dkoo@cdc.gov).

Initially submitted July 6, 2010; accepted for publication July 6, 2010.

The term shoe-leather epidemiology is often synonymous with field epidemiology or intervention epidemiology.
All 3 terms imply investigations initiated in response to urgent public health problems and for which the investigative
team does much of its work in the field (i.e., outside the office or laboratory). Alexander D. Langmuir is credited with
articulating the concept of disease surveillance as it is applied to populations rather than individuals. He also
founded the Epidemic Intelligence Service (EIS) Program in 1951, a 2-year training experience in applied epide-
miology that places professionals in the field, domestically and internationally, in real-life situations. Today, 70–90
EIS officers are assigned each year to Centers for Disease Control and Prevention programs and to state and local
health departments to meet the broad spectrum of challenges in chronic disease, injury prevention, violence,
environmental health, occupational safety and health, and maternal and child health, as well as infectious dis-
eases. Throughout their assignments, EIS officers are encouraged to strive for analytic rigor as well as public
health consequence, which requires technical competence blended with good judgment and awareness of context.
Effective applied epidemiologists must have skills beyond just epidemiology to improve a population’s health; the
field of applied epidemiology requires multiple team members, all having different but complementary skills, to be
effective.

book reviews; communicable diseases; disease outbreaks; epidemiologic methods; health personnel; population
surveillance; public health

Abbreviations: CDC, Centers for Disease Control and Prevention; EIS, Epidemic Intelligence Service.

Note from Jonathan M. Samet, Book Review Editor:
The term epidemiology is often preceded by an adjective,
making reference to the topic of its application. One of the
most iconic and dramatic of these adjectival descriptors is
shoe-leather, raising the image of an on-the-ground investi-
gation racing to find a solution to a deadly epidemic. In this
commentary, the authors provide a historical perspective on
the origins and characteristics of shoe-leather and applied
epidemiology. They bring notable clarity to these terms and
remind us of the key role played by Alexander Langmuir in
this area. Following this commentary are reviews of 2 books
on shoe-leather epidemiology, one on the Epidemic Intelli-
gence Service (EIS) of the Centers for Disease Control and
Prevention (CDC) and the other on the CDC’s Public
Health Advisors. The reviews cover books that are replete
with ‘‘real-world’’ stories of epidemiology and epidemiolo-
gists in action. Consider reading these books. The reviews
suggest that those in the applied arena will be reminded of
old stories and colleagues, and those in ‘‘academic epide-
miology’’ will broaden their perspectives on the uses of
epidemiology.
Two book reviews in this issue of the Journal refer to
shoe-leather epidemiology when describing the contribu-
tions of EIS officers and public health advisors (1, 2). The
term shoe-leather epidemiology is often synonymous with
field epidemiology or, in Europe, intervention epidemiology
(3). All 3 terms, especially field epidemiology, imply inves-
tigations initiated in response to urgent public health prob-
lems and for which the investigative team does much of its
work in the field (i.e., outside the office or laboratory) (4).
The primary goal of the field epidemiologist is to provide
information as quickly as possible for the processes of se-
lecting and implementing interventions to lessen or prevent
illness, injury, or death when such problems arise. This

737 Am J Epidemiol 2010;172:737–739

738 Koo and Thacker
Table 1. Comparison of the Characteristics of Applied Epidemiology and Academic Epidemiology
Characteristic Applied Epidemiology
Practice setting More often governmental
Investigative team Physicians and other health professionals,
doctoral degree holders, other team
members; highly interdisciplinary
Immediate drivers/goals Service (public health surveillance, responding
to outbreaks, improving health)
Timeline Frequently urgent
Data quality More variable; data collected in real-life
circumstances at times
Risk factors investigated Sociologic/determinants of health
Scientific values Urgency, speed, practicality, responsiveness,
health impact
Outputs Recommendations, product removal, public
health action
Competencies needed Communication skills and community engagement
as important as analytic skills
Where taught On the job (Epidemic Intelligence Service, Field
Epidemiology Training Programs) and through
graduate student practicum experiences
definition has its roots in the work of John Snow (1813–
1858). However, not all urgent health problems are acute,
and applied epidemiology is a broader term that includes
application and evaluation of epidemiologic discoveries
and methods in public health and health care settings to
improve health (5). What both definitions have in common
is the public health perspective of epidemiology for action,
a concept closely associated with the career of Alexander D.
Langmuir (1910–1993), the first chief epidemiologist at the
Communicable Disease Center (now Centers for Disease
Control and Prevention) (CDC) in Atlanta, Georgia.
Langmuir’s contributions preceded and followed his ten-
ure at CDC (1949–1970), but, during those CDC years, his
critical role in developing applied epidemiology became
evident (6). He is credited with articulating the concept of
disease surveillance as it applies to populations rather than
individuals (7). During the 1955 epidemic of poliomyelitis
associated with the first inactivated poliovirus vaccine, he
established a national surveillance system for daily report-
ing from all US states, laying the foundation for subsequent
national systems (8). Public health surveillance—the ongo-
ing systematic collection, analysis, and interpretation of
health-related data essential to planning, implementing,
and evaluating public health practice—closely integrated
with the timely dissemination of these data to those who
need to know for application to prevention and control, is
now recognized as the cornerstone of public health practice
and the information on which public health programs
around the world are based (9).
Langmuir also founded the EIS Program in 1951, a 2-year
training experience in applied epidemiology that places
young professionals in the field and at CDC headquarters,
domestically and internationally, in real-life situations. EIS
officers learn on the job, applying what they learn to address
real problems in often challenging and sometimes conten-
tious settings (10). In addition to responding to infectious
disease problems, Langmuir’s first EIS officers engaged in
Academic Epidemiology
Schools of public health; other academic settings
Doctoral degree holders; less interdisciplinary
Discovery (identifying etiology, risk factors, causality,
disease modeling)
Rarely urgent
Usually high; data collected in controlled
circumstances
More often biomedical
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Analytic rigor; consistency with prior studies
Contributions to literature and to a body of knowledge
Strong analytic skill set
Academic institutions
family planning, birth defects surveillance, cancer cluster
investigations, and environmental health problems through-
out the world, including global smallpox eradication, all
with the purpose of using the data to control a problem
and prevent future disease, disability, and death.
Today, 70–90 EIS officers are assigned each year to CDC
programs and to state and local health departments to meet
the broad spectrum of challenges in chronic disease, injury
prevention, violence, environmental health, and maternal
and child health, as well as infectious diseases (11). These
officers are trained in the tools of applied epidemiology,
much more sophisticated than those used by Langmuir,
but still in the framework of hands-on learning, solving
the health problems of the present. Nearly half of US State
Epidemiologists (lead epidemiologists in each of the states)
and 4 of the last 7 CDC directors, including current director
Thomas R. Frieden, are EIS graduates. EIS graduates often
populate schools of public health and academic medical
centers and play leadership roles in global health. Multiple
programs around the world are modeled after the EIS
Program (12).
The full meaning of applied epidemiology can perhaps
best be understood by comparing and contrasting the em-
phasis of applied epidemiology and academic epidemiology
(Table 1), the latter referencing epidemiology practiced in
a school of public health or an academic setting (13). These
major categories of epidemiology obviously share 1) basic
methodology and the underlying science, 2) applicability to
a broad range of subject areas, and 3) a need for computer
skills to perform the most sophisticated analyses. However,
we highlight certain differences, or perhaps differences in
emphases, in Table 1.
As underscored by the characteristics shown in Table 1,
applied epidemiology incorporates analytic rigor but must
balance such with the practical application of results.
Applied epidemiology emphasizes use of epidemiology as
a tool to improve health and to have a health impact. When
Am J Epidemiol 2010;172:737–739

we address incoming EIS officers, we stress the importance
of consequential epidemiology, a term coined in 1983 by
William Foege when delivering the Wade Hampton Frost
Lecture at the American Public Health Association meeting.
We exhort them to strive for not only analytic rigor but also
public health consequence. A difference to be a difference
must make a difference. This need, in applied epidemiology,
to account for contextual constraints, public pressures, and
community interests and to implement interventions re-
quires technical competence blended with good judgment
and community engagement (14). CDC and the Council of
State and Territorial Epidemiologists recognized the com-
plementary nontechnical competencies needed by the public
health workforce when they defined competencies for ap-
plied epidemiologists working in governmental public
health agencies (15, 16). Moreover, just as effective applied
epidemiologists must have skills beyond just epidemiology
to improve a population’s health, the field of applied
epidemiology requires multiple team members, all having
different but complementary skills, to be effective.
ACKNOWLEDGMENTS
Author affiliations: Scientific Education and Professional
Development Program Office, Centers for Disease Control
and Prevention, Atlanta, Georgia (Denise Koo); and Office
of Surveillance, Epidemiology, and Laboratory Services,
Centers for Disease Control and Prevention, Atlanta, Geor-
gia (Stephen B. Thacker).
The findings and conclusions in this commentary are
those of the authors and do not necessarily represent the
official position of the Centers for Disease Control and
Prevention.
Conflict of interest: none declared.
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