In this paper the controversy over how to decide whether associations between factors and diseases are causal is placed within a description of the public health and scientific relevance of epidemiology. It is argued that the rise in popularity of the Popperian view of science, together with a perception of the aims of epidemiology as being to identify appropriate public health interventions, have focussed this debate on unresolved questions of inferential logic, leaving largely unanalysed the notions of causation and of disease at the ontological level. A realist ontology of causation of disease and pathogenesis is constructed within the framework of "scientific materialism", and is shown to provide a coherent basis from which to decide causes and to deal with problems of confounding and interaction in epidemiological research. It is argued that a realist analysis identifies a richer role for epidemiology as an integral part of an ontologically unified medical science. It is this unified medical science as a whole rather than epidemiological observation or experiment which decides causes and, in turn, provides a key element to the foundations of rational public health decision making.
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