RETROspective

Once a year, we take the opportunity to look back on some of our favorite PROspective’s. This year, we invited authors from across the Department to contribute – including students – and the result has been a collection of thought-provoking and insightful articles on the experience of studying and practicing epidemiology in a time unlike any other. Below is a selection of must-read PROspective’s from this past year. We hope that these have helped you gain some clarity and perspective on our profession and how to navigate it. 

Sleep Can Be a Privilege

Last August we heard from Dr. Dayna A. Johnson in Sleep Epidemiology: Contributions of Social Determinants. In this article Dr. Johnson highlighted the ways social determinants can influence our health, specifically our sleep. The Quote: 

“Witnessing such injustices, which are the result of racism – a fundamental cause of health inequities, can cause a state of vigilance, which is particularly salient for racial minorities… These are vicarious experiences of racism or discrimination, which are known to affect health, and sleep.” 

Think in Chapters

In this thoughtful and straightforward guide, Dr. Lauren McCullough explains her simple approach Goal Setting, which can be summarized by three questions: Who are you? What do you want? and What is your plan? Without a doubt, you will find yourself coming back to this article again and again throughout your career during those times of transition and self-exploration. The Quote:

“Goal setting is a helpful way to establish a marker for success and measure your progress. Yet, your journey may be inefficient or ill-conceived if your goal setting strategy is missing some crucial steps.”

Should I pursue a PhD?

On the topic of making plans, in After the MPH, is a PhD Next? Dr. Shakira Suglia brought up points to consider for those students considering a PhD. Even if you aren’t considering further studies at this point in your career, its a good idea to understand what these programs offer because you never know how your goals or educational needs might change in the future. The Quote: 

“A PhD changes the types of jobs you are competitive for, you move into a lead role conceptualizing and leading research rather than carrying out the research.” 

Wait… where did I save that?

There is a lot we are expected to keep organized during a masters program – between coursework, REAL job, APE, and Thesis (just to name a few). This past February, Dr. Ashely Naimi taught us how to keep our research life organized, with a focus on practical solutions for file structures, naming conventions, and much more in his article entitled Taming the Chaos. The Quote: 

“Like your living or work space, your project space should be kept neat and tidy so that you know where things are when you need them.”

Epidemiology and Consulting

Cassie Kersten gave us a peak into the life of a Public Health Consultant when she talked about the journey to finding her job with Booz Allen Hamilton in Public Health Consulting. The quote:

“Even as the most junior member of my team and as one of the few without a military background, my input is valued and I have begun taking lead on some product development tasks.”

To Vax or Not to Vax

There is maybe no more prescient a topic today in epidemiology than this. Vaccine hesitancy isn’t anything new, but the ramifications of our response to it right now loom large over our future with the pandemic both in the US and abroad. In March, Dr. Robert Bednarcyzk talked about vaccination behaviors and hesitance in Epidemiology and Vaccine Hesitancy. The quote:

“Epidemiologists cannot remain siloed – interprofessional collaboration is necessary to overcome vaccine hesitance.”

There is no ‘EPI’ without ‘Advocacy’

In this two-part series, Dr. Anke Huels talked about how to engage in health advocacy through epidemiologic research. In From Epi to Advocacy Part 1 Dr. Huels emphasized working with interdisciplinary teams and community stakeholders to make relevant recommendations for action. In part 2 she explained how to ensure your work reaches the right audience and creates an impact. The quote: 

“If you discuss your epidemiologic findings only with other epidemiologists, it is very unlikely that you will reach the general public and decision makers. You can conduct a perfect epidemiologic analysis and write a beautiful research article. However, if you want your work to make a difference, you need to discuss it with people from different fields and have a good answer to the question ‘so what?'”

From everyone at the Confounder, we want to thank our contributing authors from this past year for sharing their voice and insights. Remember, you can also read though past articles anytime on the PROspective page. If you are interested in contributing to PROspective, please send us an email at Confounder [at] emory [dot] edu with your article idea!

Featured Image by engin akyurt on Unsplash

True Grit

In December of 2010, Paramount Pictures released their $38 million remake of the 1969 John Wayne classic, True Grit; this time starring Jeff Bridges, Matt Damon, Josh Brolin, and an absolutely indomitable Hailee Steinfeld. The story follows Mattie Ross (Steinfeld), a 14-year old who contracts a hired gun (Bridges) to pursue her father’s killer (Brolin) through treacherous territory to avenge his murder. You don’t have to be a fan of traditional westerns to appreciate Mattie’s tenacity and determination – the all-too-obvious inspiration for the movie’s title. It’s nothing short of thrilling to watch her railroad seasoned trackers, bounty hunters, thieves and murders in order to ensure she is treated fairly and the journey proceeds ethically in a world normally lacking such luxuries.

Grit is a special kind of character trait – an alphabet soup of bravery, passion, and pure strength of will – guided, at all times, by an unwavering moral compass. It’s the sort of thing that only gets unlocked within us in response to the greatest of tradgdies or injustices, compelling us to rise to a challenge instead of abdicate or resign.

This week, as final exams brought an end to this semester and to the year-of-the-virus that brought it to life, I am reminded of grit because it is this character trait that our community has exhibited so heroically in the face of these truly brutal circumstances. Grit drove students and faculty through a new and complicated months-long experiment in teaching and learning online. Grit helped us to compartmentalize, problem solve, and find gratitude in our shared experience. Grit got you through homeworks, papers, problem sets, and now final exams – while simultaneously applying skills and knowledge to better understand and mitigate the global pandemic. As with our heroine, Mattie Ross, it was nothing short of thrilling to watch your determination in the face of all that stood in front of you this year.

From all of us at the Confounder, congratulations on your accomplishments this semester! Enjoy your time off with the satisfaction of knowing that you faced the challenge with grit and persistence, in service of lessening the suffering of your fellow citizens. 

Happy Holidays!

After the MPH, is a PhD next?

From Dr. Shakira Suglia, Associate Professor of Epidemiology and Director of Graduate Studies (DGS) for the PhD program in epidemiology: 

As the semester starts to wind down, many of us are figuring out what’s next and while a simple answer may be ‘Spring semester is next’ some of you may be considering what’s next beyond the Spring semester. If you have been considering continuing into the PhD as your next career step after the MPH there are a few things worth considering as you embark on this journey.

Should I apply?

When considering applying, think of what you want to do after the PhD, that should drive the reason for applying. Think of your career goals, do you enjoy leading research teams? Developing research projects? Teaching and mentoring? A PhD changes the types of jobs you are competitive for, you move into a lead role conceptualizing and leading research rather than carrying out the research. Think of organizations and positions you may enjoy working in after your PhD, do the people holding those positions have PhDs?

What is getting a PhD like?

Depending on the program and academic institution, the time from start to finish of a PhD can be between 4 and 6 years. Being a PhD student is a full time ‘job’ – in addition to coursework, there are often teaching and research expectations. Compared to a MPH program there is a lot of unstructured time in the PhD program as you work on your dissertation. Some institutions, but not all, provide stipends and may cover tuition and health insurance. It’s important to have a good understanding of what obtaining a PhD is like, so it is a good idea to talk to current doctoral students, postdoctoral fellows or recent grads to learn what their day to day is like.

How do I know where to apply?

Again, do some homework. Research programs websites, read up on the work being done in each institution – are there faculty that do work in the areas that you want to work on? While a perfect match is not necessary, you want to ensure there will be faculty that can mentor you in the work that you want to engage in. If you are interested in something that no one on faculty focuses on, that is not a good match. If you can, try to distinguish between primary faculty and adjuncts who are actively mentoring students. Understand what are the training priorities of each program and how do they align with your priorities. Again throughout the application process you should reach out to faculty, students and alumni of the programs you are considering.

A bit more on the Epi PhD program

The PhD in epidemiology in our institution is offered through Emory’s Laney Graduate School. This program trains students to become independent investigators and to obtain skills to be successful in PhD-level positions in academia, government, and the private sector. Typical time to degree is 5 years, and students typically spend the first 2 years doing coursework and 3 years for dissertation work. Tuition, health insurance and a stipend are provided for students.

You can find more information on our website and you can reach out to sphepidept [at] emory [dot] edu directly with your questions. The application deadline for Fall 2021 matriculation is December 1st, 2020. 

Vote like an Epidemiologist, Vote for Public Health

With election day now just hours away, the Confounder invited Nellie Garlow and Lisa Chung, 2^nd year Epi MPH students and founders of the Rollins Election Day Initiative (REDI), to talk about their motivations for creating the organization and how they view epidemiology and civic engagement as two sides of the same coin. 

Growing up with Civic Engagement

Nellie: When Dean Curran asked a group of students in January of this year, “what can we do right now to solve some of our greatest public health problems?” the first thing that came into my mind was cancelling classes on Election Day. To some, this may have seemed unrelated, but, for me, having grown up right outside of Washington, DC, politics were integral to my world view. From a young age, I attended protests on the national mall, shook the hands of congressmen and congresswomen, and listened in while politics were debated at the dinner table. My parents, who were both federal workers in different public health sectors, not only taught me about the connection between politics and human health, but also showed me how critical it was to engage civically no matter which party was in office.

Lisa: The earliest memory that I have of elections is walking to the polling site with my family of three generations. After voting, we would turn on the news as soon as we were back home and follow the election results as every single ballot was counted until well past midnight. To me, voting was always a family affair. It was only possible with my parents’ busy schedules because the Presidential Election Day is recognized as a national holiday in South Korea. From casting my first ever ballot in Korean Presidential Election to returning my mail-in ballots in Washington state, voting has always been as easy (if not easier!) as running an errand. It is unfathomable to me, to this date, that anyone would ever have to question whether to vote or work (or attend classes) or wait for hours in line. So, once Nellie shared her ideas for the Rollins Election Day Initiative, I knew that this would reduce an enormous potential burden to civic engagement within the Rollins community.

Starting REDI

When the opportunity arose to increase election and civic engagement at Rollins, we knew the fastest way our school could make a difference was to remove synchronous class content from Election Day so that public health students could vote and help others in the community to cast their ballots safely. Together, we would spend the next eight months standing up Rollin’s first non-partisan voting rights organization, the Rollins Election Day Initiative (REDI), in hopes of making a difference in public health. 

Civic Engagement and Epidemiology

As epidemiologists, we have an ethical obligation to act in the best interest of the public’s health and one key way we can do this is by ensuring all people have a say in which politicians make decisions that impact their health directly. When citizens face barriers to voting, they lose that representation on the local, state, and national levels. As with health, a wealth of evidence suggests that disparities in access to voting happen along socioeconomic and racial lines in the US. This is no coincidence, since disparities in both health and voting access are driven by the same structural mechanisms. As those responsible for both elucidating the causal structure of such inequalities and working to undo them, it is thus our responsibility as epidemiologist to also advocate for the elimination of the upstream causes of unequal access to voting.

Another critical reason we as epidemiologists must pay attention to elections and politics is because we hold elected officials to using the best evidence available when making public health decisions. It is not enough to simply produce the evidence of a causal mechanism and then rely on others to ensure its appropriate application – when we see politicians disregarding facts for political gains that negatively impact the public’s health and our own credibility as scientists, it is our obligation to speak up. Epidemiologists must hold our elected leaders accountable.

One thing we cannot compromise on when getting involved in politics is civility. We must remember that there are a wide range of political opinions, both across the US and at Rollins, and it is critical that we listen to one another and convey our opinions respectfully.  As is emphasized from the core of our department, we should approach these conversations with flexibility and empathy, but most importantly with respect to one another. Rather than silencing the views that oppose yours, think about the growth that can be experienced when listening and learning to from others, especially in the moments when it feels most challenging. We can move forward as a nation, as a department, as scientists and individuals, only if we allow ourselves to learn from each other in a civil, respectful manner. Only together, we can grow, flourish, and “redeem the soul of our nation.”

Finally, engaging in politics and elections makes us establish good habits. As Emory professor Carol Anderson writes in her book, One Person No Vote, it is critical we get involved in elections and civic engagement early on and to not take our democracy for granted. This year’s presidential election may seem like a contentious one, but we’re betting it won’t be the last nail-bitter we see in our lifetimes. Furthermore, there will be countless local elections that will have an even greater impact on the public’s health and as public health professionals, we can’t forget those.

As we head into the election, we have a simple message for all of you: get involved on Election Day, stay involved in your local elections, and support your community in the process. To quote, late Congressman John Lewis, “when historians pick up their pens to write the story of the 21^st century, let them say that it was your generation who laid down the heavy burdens of hate at last and that peace finally triumphed over violence, aggression and war.”

If you would like to get involved in REDI’s work or learn more about their efforts, check out their website where you can find all of the resources they have compiled, like a map of ballot drop boxes, nonpartisan fact sheets about what is on the ballot in local elections, and more! Also, be sure to follow REDI on Twitter and Instagram and like their Facebook page. A special thanks to Nellie and Lisa for sharing their stories and to the entire REDI team for the work they continue to do to improve civic engagement at Emory and throughout Georgia!

Goal Setting

From Dr. Lauren McCullough, Assistant Professor, Department of Epidemiology

I love the start of a new semester. As a kid, it meant new school supplies. In college, it was a fresh beginning. Now, it represents an opportunity to reflect on what is important to me. How much progress do I want to make on that research paper? What new skills do I want to learn? A new semester brings a fresh set of goals.

Goal setting is a helpful way to establish a marker for success and measure your progress. Yet, your journey may be inefficient or ill-conceived if your goal setting strategy is missing some crucial steps. Over the years, I have refined my strategy for developing and achieving my professional goals. (1) Who are you? (2) What do you want? (3) What is your plan? Below, I outline some goal setting techniques that are easy to implement and may be useful in your own journey towards success.

Who are you?

The goals and aspirations of your colleagues may be different than your own. Think about what brought you to public health and imagine your future self. This will serve as a guiding light. What are your passions, interests, and values? What skills do you have or want to gain? Staying keenly aware of who you are will allow you to forge a path that is uniquely yours while maximizing the opportunities Rollins and Emory have to offer.

What do you want?

See the long-term goal (the BIG picture) and develop specific short-term goals to get you there. For many of you, this may be a time to figure out the big picture, and that’s ok! During my MSPH, I spent a whole semester conducting informational interviews with professionals I respected and admired to better understand their path, perceived opportunities, and challenges. Guided by my passions, interests, and values, I ultimately figured out what I wanted… to improve cancer outcomes among African-Americans through research. That’s a HUGE goal, and I’m still working at it! So along the way, you should set some short-term SMART goals (Specific, Measurable, Attainable, Relevant, and Time-based) that will get you there. For me, that meant getting research experience—taking an unpaid internship with an epidemiologist at a major cancer center—and finding ways to connect with affected communities. Importantly, think in chapters. You can’t possibly do everything now. Maximize your current environment or opportunity to its fullest potential and know that some things will have to wait until the next chapter.

What is your plan?

The best goals are inconsequential if they can’t be executed, so I consider this last section the most important. Let me start by saying that strategic planning is a SKILL! It requires intentionality, practice, and repetition. Once you have a short-term goal in mind (i.e., reviewing the literature for a thesis project), the planning process can be accomplished in 4 easy stages.

1. Map the steps—these are the specific tasks that are necessary to achieve the short term goal.
2. Integrate into your calendar—allocate specific time to work on these tasks. Literally, put it on your calendar like you would a meeting!
3. Create accountability—check-in with yourself or an accountability partner. Did you accomplish the task? If not, why? If so, find a way to celebrate!
4. Refine and repeat.

Finally, for additional inspiration, take a look at this article from Inc.com on SMART goal setting.

Dr. Lauren E. McCullough is Rollins Assistant Professor in the Department of Epidemiology at the Rollins School of Public Health. Her overarching research interests are in the life-course epidemiology of cancer (breast cancer and lymphoma), specifically the contributions of obesity and physical inactivity to the tumor epigenome and microenvironment, as well as disparities in cancer outcomes. 

Sleep Epidemiology: Contributions of Social Determinants

from Assistant Professor, Dr. Dayna A. Johnson, PhD, MPH, MSW, MS:

The practice of epidemiology applies to many health outcomes (e.g., cardiovascular disease) and types of risk factors (e.g., social) that form the specific areas within epidemiology (e.g., social, environmental, genetic, etc.). In my research, I employ epidemiologic methods to study determinants and consequences of adverse sleep health and sleep disorders; therefore, I identify as a sleep epidemiologist. As defined in the book, The Social Epidemiology of Sleep, sleep epidemiology is “the study of the distribution and determinants of sleep, sleep-related symptoms, and sleep disorders and the application of this study to improve sleep health and sleep-health related conditions, including studies of how sleep influences health and disease”.¹

Sleep involves a dynamic set of neurophysiological and behavioral states. What I find most interesting about sleep, is that it is a physiologic activity that is necessary for health and well-being – everyone must sleep. Healthy sleep is multidimensional involving adequate sleep duration, continuity or efficiency, appropriate and consistent sleep timing, alertness during wakefulness, and individual satisfaction.²  Sleep and sleep patterns are adapted to individual, social, and environmental demands. Similarly, our sleep is shaped by many factors including social, environmental, and genetic. In my research, I primarily study social and environmental determinants of adverse sleep health.

Racism and Sleep

The current climate in the world is truly affecting how we sleep. Individuals around the world have witnessed the heinous killings of George Floyd, Breonna Taylor, Ahmaud Arbery (which occurred in our home of Georgia) as well as many others. Witnessing such injustices, which are the result of racism – a fundamental cause of health inequities, can cause a state of vigilance, which is particularly salient for racial minorities. These brutal acts can be even more traumatic for the individuals who resemble the victims, which can cause one to ruminate over how that could have been them or their spouse, father, brother, sister, friend, etc. These are vicarious experiences of racism or discrimination, which are known to affect health, and sleep. These experiences can lead to stress, anxiety or depression, which can directly affect sleep and/or indirectly through rumination where someone repetitively go overs thoughts or problems, which can inhibit sleep onset or disturb sleep.

Location and Environment

Racism, discrimination, and stress are just a few of the contributing social factors to the high prevalence of sleep deficiencies among racial and sexual minorities as well as individuals of lower socioeconomic status (SES). Another important social factor to consider is where we live. Our household and neighborhood environments contain features such as light, noise, safety, density, cohesion that are associated with sleep health.³ Residential segregation based on race, immigration status, SES has largely determined the resources within neighborhoods. Historical discriminatory policies, such as redlining, unwarrantedly denied racial minorities (mainly Black/African American or Latinx) in urban areas mortgages to purchase a home or loans to renovate homes. Housing discrimination is considered one of the largest contributors to the wealth gap and these effects have lasted across generations. Additionally, these under-resourced environments often house manufacturing companies that emit pollution into the air as well as traffic which promotes noise and pollution. Air pollution is directly related to a common sleep disorder, sleep apnea.⁴ And, noise and light pollution are associated with less sleep and sleep difficulties.⁵ Emerging data suggests that the neighborhood environment partially explains racial disparities in sleep. It is also important to note, that there is evidence suggesting that racial disparities in sleep are minimized when Black and White individuals – for example live in similar environments; thus, underscoring the effect of place as opposed to race.

Sleep can be considered a privilege.

It is important to consider the person that works multiple jobs due to low wages, or lives in a neighborhood with noise, violence and/or a household with interpersonal violence… how will they sleep? Children exposed to high levels of screen time or those without a regular bedtime routine are placed on a trajectory of sleep deficiencies in adulthood, which is related to poor health outcomes such as obesity, diabetes, cancer, cardiovascular disease, cognitive decline and mortality. School start times are another factor that can affect sleep, particularly for the student who must take the bus across town to school who, therefore, has less opportunity for sleep. As seen during COVID-19, racial minorities and individuals of lower SES are more likely to be low wage essential workers without worker protection such as sick leave, thus leading to fear and anxiety and consequently sleep deficiencies. This is important because sleep is necessary for healing. In general, those of higher SES have better sleep health. However, higher SES racial minorities such as Black or African Americans tend to have worse sleep compared to their lower SES counterparts. It is hypothesized that stress may explain this unexpected gradient, but more research is needed to fully understand this association.

Sleep Equity

The social factors referenced above-racism, discrimination, stress, mood, household and neighborhood environment are all understudied determinants of sleep deficiencies. Sleep is socially patterned, therefore exploring and addressing these factors can help decrease the burden of adverse sleep health and sleep disorders as well as reduce health disparities. Targeting sleep may improve overall health, decrease accidents (occupational and motor vehicle), and improve performance (athletic and academic).

Sleep is critical and everyone deserves it! Therefore, as epidemiologists we can shed light on the social factors that are contributing to sleep disparities and inform the policies and interventions that may improve sleep for all individuals.

Sleep well!

References

1. Duncan DT, Kawachi I and Redline S. The Social Epidemiology of Sleep: Oxford University Press; 2019.
2. Buysse DJ. Sleep health: can we define it? Does it matter? Sleep. 2014;37:9-17.
3. Johnson DA, Billings ME and Hale L. Environmental Determinants of Insufficient Sleep and Sleep Disorders: Implications for Population Health. Curr Epidemiol Rep. 2018;5:61-69.
4. Billings ME, Hale L and Johnson DA. Physical and Social Environment Relationship With Sleep Health and Disorders. Chest. 2020;157:1304-1312.
5. Billings ME, Gold D, Szpiro A, Aaron CP, Jorgensen N, Gassett A, Leary PJ, Kaufman JD and Redline SR. The Association of Ambient Air Pollution with Sleep Apnea: The Multi-Ethnic Study of Atherosclerosis. Ann Am Thorac Soc. 2018.

Dr. Dayna A. Johnson, PhD, MPH, MSW, MS is an Assistant Professor in the Department of Epidemiology. Her research is aimed at understanding the root causes of sleep health disparities and their impact on cardiovascular disease by 1) addressing the social and environmental determinants of sleep disorders and insufficient sleep; and 2) investigating the influence of modifiable factors such as sleep disorders and disturbances on disparities in cardiovascular outcomes.

Exit Interviews and Winding Down Your APE

With the Fall quickly approaching, over the next couple of weeks many rising 2^nd year MPH students will be transitioning from their Summer APE projects back to classes, homework, and thesis or capstone research. Throughout the Summer, we have been highlighting many of those exciting APE projects through our #InsideAPE segment in the Confounder, and couldn’t be more proud of the innovative and impactful work our students have been involved with over the last few months. Furthermore, as those APEs come to an end over the next couple weeks, there will be some opportunities for reflection and relationship building that you would be remiss to let pass. In the professional settings, this often takes place through an Exit Interview – and though you probably won’t be having the classic Exit Interview, it is a good exercise to think about some key takeaways from that process and how you can take advantage of those benefits towards the end of your APE.

Ask for feedback

Last year, alumna Elizabeth Hannapel (EPI MPH, 2012) wrote a spectacular PROspective article on Professional Feedback. She highlighted the fact that feedback in the workplace is very different than feedback in the classroom – it requires being proactive and committing to a growth mindset. The Exit Interview is no exception. If your supervisor hasn’t suggested having an Exit Interview, ask for one yourself! During the interview, maintain an open mind and view feedback as an opportunity to grow instead of as a personal affront. You should want to know where your weaknesses lie so that you can spend the next year working to fill those gaps in your skillset. Typically, Exit Interviews are also an opportunity to give feedback to your employer or supervisor directly – but be careful not to complain or vent – keep it focused on the positive and on items that can actually be improved. For more on exit interviews specifically, take a look at this article from Forbes on common pitfalls. 

Develop those relationships

If your APE was with an organization outside of Rollins, chances are that you met a lot of new co-workers and collaborators… virtually. Regardless, individuals you have been working with throughout the summer, including your direct supervisor and even department directors, represent a HUGE opportunity to develop your network. Not so long from now, you will be back in the job market looking for full-time post-graduate work and these individuals already have a good idea of your strengths, weaknesses, and accomplishments. In Getting to ‘Yes’, Dr. Lash talked about how the professional setting is an environment of reciprocation. Ask your supervisor if they would be willing to write recommendations for you in the future and make connections with your co-workers on LinkedIn – but make sure to offer something in return. Developing strong professional relationships takes time and commitment to reciprocating.

Next steps

Your APE doesn’t always end the day you log your 200^th hour – often there is still a manuscript getting submitted for publication or maybe even an ongoing, uncontrolled global pandemic. Opportunities may still abound if you are willing (and have bandwidth) to continue with your team in a different capacity. Either way, it is a very good idea to discuss any outstanding action items and make a clear plan for the hand-over of your duties to the rest of the team. When your project ends, you want to leave your team with a good impression of you, and helping them take over your work seamlessly is a great, proactive way to do just that.

At the end of the day, your APE should be a learning opportunity. That includes learning how to apply those soft skills – asking for feedback, developing relationships, and managing transitions. A little bit of effort in these areas will definitely pay off down the road.

Are you a (social) Epidemiologist?

From Dr. Michael Kramer, Associate Professor, Department of Epidemiology

Are you a (social) epidemiologist? Should you be?

I am. A social epidemiologist that is. I was actually that long before I even knew what the combination of those words – ‘social’ + ‘epidemiology’ – even meant! Just as the notoriety of ‘epidemiology’ has risen in recent pandemic-tainted months (even my stoner neighbor knows what an epidemiologist is now!), so has the discourse around social epidemiology. It seems that the idea of unjust or preventable differences in health outcomes across the social dimensions that shape so much of our modern life – race, ethnicity, class, gender, geography, sexual identity, etc, etc – is having its ‘five minutes of fame’. Pundits, talking heads, and social influencers are suddenly speaking about, and wondering why, communities of color are bearing a disproportionate burden of COVID-19 morbidity and mortality. Following the state-sponsored murder of George Floyd in Minneapolis, it also seems that wide swathes of (white) America are opening their eyes to the longstanding existence of institutionalized and structural racial injustice that has direct (e.g. murder) and less direct (e.g. over policing and mass incarceration, segregation, racism in employment, education, healthcare, etc) consequences for the health of Black and brown communities.

So I ask again, are you a Social Epidemiologist? Or should you be?

Don’t worry, I won’t guilt you into being a ‘Social Epidemiologist’ (with a capital ‘S’)! However I will argue that if you do epidemiology you must be a ‘social epidemiologist’ with a little ‘s’, or else risk making (and re-making) mistakes that have littered the history of epidemiology and public health, and have the potential to cause harm rather than help. To distinguish what I mean between capital-S versus lowercase-s social epidemiology, let’s start by defining our collective work as epidemiologists.

I like the definition of epidemiology from Modern Epidemiology (3^rd edition, p 32): “Epidemiology is the study of the distribution and determinants of disease frequency in human populations” (emphasis added). This definition aligns nicely with John Snow, Cholera and our beloved Origin Story of epidemiology. Measuring the distribution of disease is about describing the who, where, when, and what of population health outcomes, whether infectious, chronic, behavioral or injury related. Describing the determinants of disease is about answering the questions of how and why disease varies between groups and over time. It is here we try to estimate causal effects of exposures or interventions.

Those of us who self-define as Social Epidemiologists are fundamentally epidemiologists. We work in pediatrics and geriatrics; in infectious and chronic disease; and in government, industry, or academic settings. While the health outcomes and occupational settings are diverse, the organizing principle of Social Epidemiology is exposure-oriented. We tailor the focus of our work to study of the social distribution and social determinants of disease. Describing social distributions of disease means intentionally conceptualizing, measuring and reporting disease occurrence along the social lines described above (e.g. race, ethnicity, class, gender, etc). Understanding the social determinants of health between and within populations also requires a shift in the exposures under consideration. Instead of individual behaviors, individual exposures, and inherited genes we might center our attention on social environments, racism & discrimination, political economy, social policy, and health policy as determinants of health overall and specifically of health inequities. 

While the lessons of John Snow – careful observation, shoe leather detective work, intentional contrasting of competing hypotheses – are just as important for Social Epidemiologists as any others, we might look to additional role models as well. Although formally a sociologist, W.E.B. DuBois is arguably the founding father of social epidemiology.¹ In The Philadelphia Negro, DuBois² used systematic quantitative analysis to characterize health and social outcomes as they varied in 19^th Century Philadelphia by race, employment status, and neighborhood segregation level. The modern Social Epidemiologist builds on this early work by recognizing that socially patterned experiences that occur through interpersonal interactions, in the non-random allocation of opportunity or exposure across one’s life span, and even across generations, are literally embodied as altered biological and psychological function.³  Our bodies express the health that is shaped by their continuous and accumulated interaction with a social world. It’s pretty fascinating and important stuff!

But what if Social Epidemiology (with a capital-S) is not your thing? That’s ok. Public health and epidemiology benefit from the big tent under which we all work. However choosing not to center your interest on social determinants of health does not diminish your responsibility to learn about and understand the use and misuse of socially constructed measures in the conduct of epidemiologic analysis. Let’s take, for example, the use of ‘race’ as a variable in epidemiologic analysis. Its use as a ‘confounder’ or even an ‘exposure’ has been ubiquitous across a wide range of study areas for many decades, yet very often the interpretation and meaning imbued into results from such analyses are poorly communicated at best, and in worse circumstances may represent lazy thinking and biased assumptions of the investigator, ultimately causing harm to population health.

While it is common to acknowledge that race is a ‘social construct’, there is often confusion about the implications of this idea for epidemiology. Does the presence of a ‘racial disparity’ in a health outcome mean some people are just born less healthy? Or if we ‘adjust’ for socioeconomic status should we assume that any residual racial difference is suggestive of a genetic cause? Or perhaps if race is ‘socially constructed’ we shouldn’t even be using these variables. Each of these conclusions has been made frequently in epidemiologic research, but rarely are they justified or well-supported either empirically or theoretically. Most of us align ourselves with multiple identities along the lines of race, ethnicity, gender, sexual orientation, religion, etc. Few of us could honestly say that none of these dimensions have any influence whatsoever on our lives and health. Saying that these dimensions are ‘socially constructed’ does not mean they are not real in each of our lives; it simply means that they are not biologically essential, and therefore we would not inevitably expect differences in health simply because of these identities. So what do we make of a significant ‘effect’ of race from an epidemiologic model? That is a subject of ongoing discussion and debate, but one thing most social epidemiologists would agree with is that the interpretation is not simple or simplistic, as it has often been treated in epidemiologic research.

So even if you are defiantly not a Social Epidemiologist, I hope that you will take the initiative and opportunity to educate yourself on the obvious, and not so obvious, ways that population health and health inequities are generated. Learn about the debates about measurement and methods that concern social variation in health, and seek guidance when designing studies, selecting measures, conducting analyses, and interpreting results to reduce the chance that you unintentionally produce spurious or even harmful interpretations of results. At RSPH you can do this in many ways. There are elective courses explicitly in social epidemiology, but the issues of social drivers of the distribution and determinants of health are increasingly evident even in classes without the moniker of ‘social epi’. Talk with faculty, talk with other students, ask questions, but also listen closely. Perhaps we will not all choose to be Social Epidemiologists, but hopefully we can all agree that ‘social’ is critical to all of our work as epidemiologists.

¹Sharon D. Jones-Eversley, Lorraine T. Dean. After 121 Years, It’s Time to Recognize W.E.B. Du Bois as a Founding Father of Social Epidemiology. The Journal of Negro Education. 2018;87(3):230-245. doi:10.7709/jnegroeducation.87.3.0230

²Du Bois W. The Philadelphia Negro: A Social Study. University of Pennsylvania; 1899.

³Krieger N. Epidemiology and the People’s Health: Theory and Context. Oxford University Press; 2011.

Images Sources:

1. https://i.guim.co.uk/img/static/sys-images/Guardian/Pix/pictures/2013/3/14/1363295337709/johnsnowillustration.png?width=300&quality=85&auto=format&fit=max&s=2bdd209b3e9da6c484216f5e69c6bf8c
2. https://compote.slate.com/images/272b872f-3f99-4d4a-aa56-6a5b81d9c33e.jpg

Dr. Kramer is a social epidemiologist in the Department of Epidemiology with particular interest in maternal and child health populations and life course processes.  His current research and teaching interests fall into three areas, and often include the intersection of these areas: Social determinants of health, maternal and child health, and spatial analysis.