These PROspective columns are meant to help RSPH EPI students to be more influential public health practitioners, especially after they graduate and join the public health workforce. Our department works hard to assure that students’ learning experiences prepare them with the knowledge, skills, and philosophy to be influential, but career skills are often as important in determining influence and success once graduated. This week’s PROspective takes on the difficult topic of how to succeed when your workplace supervisor stands in the way.
Supervising in Epidemiology
Poor supervisory skills can emanate from many sources, as described in this article from Harvard Business Review. One possibility, especially in some pubic health workplaces, is that the supervisors have never had any help preparing to manage. They may have risen to their position because of the skills in epidemiology, which typically provide little foundation for managing others well.
So how do you cope in this circumstance? I have written in a previous PROspective column about how to disagree, and many of those same skills may apply here. But beyond disagreeing about work products or workplace priorities, poor supervision often emanates from failure on the supervisor’s part to set clear expectations.
Setting Expectations
Expectations are the sets of goals and standards that your supervisor expects you to achieve, with some understanding of which are most important and should receive most of our effort. Failure to set and enforce standards and expectations is one of the most common management failures. If you are working without a clear understanding of what is expected, then it will be difficult for you to feel satisfied with your work.
Fortunately, failure of your supervisor to set expectations is something that you can help to address. If your supervisor has not set the expectations, you can take the initiative and suggest them. You can write out short and long-term goals and deadlines and ask for your supervisor’s feedback. Be sure that these pertain to the organization’s goals and priorities, and not to your own career aspirations. It’s a good idea to write these down also, and maybe to share them with your supervisor, but that’s a separate task. Hopefully the two will align.
Soliciting Feedback
Failure to provide constructive feedback is a second common failure associated with poor management. Again, it is something that you can help to address. When you reach a milestone, or complete one of the short or long-term goals on the list described in the previous paragraph, you can ask for feedback. Be sure to ask more than “Was my report okay?” You will probably only get back “Yes, it was good.” That’s not feedback that will help you to improve. Ask a question that requires a longer answer, such as “How can I do this task differently next time so that it will be even better?” Importantly, do not tie these requests for feedback to requests for additional compensation or leave time.
Zooming Out
Last, if your workplace dissatisfaction continues, it might be worth a self-check about whether your values align with the values of your supervisor or organization. If your values differ from theirs, it will be hard to ever feel satisfied with your work; a change may be needed.
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.
Map the steps—these are the specific tasks that are necessary to achieve the short term goal.
Integrate into your calendar—allocate specific time to work on these tasks. Literally, put it on your calendar like you would a meeting!
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!
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.
I love the beginning of the semester. As a faculty member, there is so much planning to prepare for the journey and yet I still feel that same excitement I had as a student beginning new classes. As a student, I remember excitedly looking at a syllabus for a new class; the roadmap for the trip a class will take during the semester with highlights and instructions listed. With new colored pens, sticky notes, and new notebooks, I would feel sure this was the semester I would stay organized, keep artfully exquisite notes, and never question my purpose in taking a class.
I also fully recall the feeling when moments of doubt trickle in. That first lecture when concepts no longer click, when your homework answers do not reflect your understanding (or perhaps they fully reflect your lack of understanding), and the dread of the first exam where you will find out how well you have been doing and rank your results against your peers. That dread can also speak to another fear: do I belong here and when will someone realize I don’t – the Imposter Syndrome.
Silent but Pervasive
Imposter syndrome is a common phrase these days and a prevalent feeling in graduate school. Imposter Syndrome is defined as feelings of inadequacy that persist despite evident success. ‘Imposters’ suffer from chronic self-doubt and a sense of intellectual fraudulence regardless of external proof of their competence and, often, their mastery. Ironically, this is more common among high achieving, highly successful people. And to be clear, this is not the same as low self-esteem or a lack of self-confidence. In fact, some researchers have linked it with perfectionism, especially in women and among academics.
At least 30% of millennials currently experience some feelings of imposter syndrome and as much as 70% of people will experience it at least once in their lives.
Recently, you may have seen celebrities normalizing imposter syndrome and sharing that they too suffer from feelings of inadequacy despite their earned position. Michelle Obama discussed still feeling like an imposter in 2018 while sitting on the stage at the Royal Festival Hall in London. That’s right, a lawyer who graduated from Princeton and Harvard Law School, the author of a #1 New York Times bestseller that sold out in a few days, a woman who went on a book tour across the world, and the former first lady doubts her abilities and shares her surprise that people want to listen to her. If you have ever had these feelings of “being found out,” you are in some very good company.
Many studies agree that up to one third of millennials are affected by the phenomenon and some have estimated that 70% of people will experience at least one episode of Impostor Syndrome in their lives (Gravois, 2007), where they doubt their abilities and accomplishments, regardless of how successful they are and despite evidence to the contrary.
“Do I belong here and when will someone realize I don’t?”
Seeking an antidote
So what can you do to mitigate the negative effects of Imposter Syndrome?
First, you need to recognize these feelings for being the undermining forces that they are (several researchers in the UK call them gremlins, and I admit that I love that visual. If you think about the movie, gremlins are small and annoying but not altogether as awful).
Accept that you are not supposed to know everything, especially at the beginning of a semester or graduate program. I have been working in HIV research for two decades and I do not know everything and I never will. No one does. How liberating is that?
Put your feelings in context. Most people have moments where they don’t feel confident and self-doubt can be a normal reaction. Graduate school is a prime opportunity for this. But take a look around you, as you sit in your classrooms, virtually or literally, and settle into the beginning of a semester. If you feel a trickle of doubt about being in the right place or being “found out,” odds are that one of the people on either side of you (socially distance and 6 feet away), is feeling the same. When the doubt hits you, talk to people you are close with and get support. Opening up to someone about being unsure of your abilities in graduate school is good for your mental health and you will almost surely find that you are not alone.
Lastly, be kind to yourself. Self-doubt tears down our confidence and lets those inner (gremlin) voices get loud. Graduate school is hard. Moving to a new city is hard. Being a first generation student is hard. Living through a pandemic is hard and is making all of the other hard things harder. And living at a time in our country where we are confronting racial justice issues brings up insecurities and decades or demeaning messaging. So be kind to yourself and acknowledge this: you are in one of the premier schools of public health in this country at a time when we could not need well-trained, justice-minded epidemiologists more. You are not here by accident. We read your application. We read your recommendations. We picked you and we want you here. We are here to support you, learn with you and from you, and to cheer you on.
Whether you are brand new to Rollins (Welcome Class of 2022!) or returning for your 2nd year after a summer applied practice experience, you’re probably asking yourself, “What does success look like for the Fall 2020 semester?”
Excellent question. No one has ever done this before, so the truth is—no one knows how to make a success of it. We will all be learning, adapting, and improving as we go. That process will accrue benefits most rapidly if we recognize and practice flexibility, empathy, and patience in all of our endeavors and interactions. Humans are remarkably adaptable and resilient, much more so than we sometimes realize, especially when we can recognize common goals, reorient quickly when necessary, and maintain composure in the face of hardship.
With that in mind, I want to take this opportunity to share a few pandemic-adapted suggestions that, in the past, have helped students to make the most of their Fall semester at Rollins.
Stronger Together
One of the great strengths of the science of epidemiology is that those who study it come from widely different personal and professional backgrounds. We embrace the diversity of perspectives as a strength. In our previous educational experiences, some of us studied public health, while others studied biology, mathematics, economics, psychology, languages, or arts, among others. What you already know will help you with your curriculum this semester, so let it shine through. Bring your unique perspectives to your classrooms and share it with others, and listen to the unique perspectives that others will share with you. Realize, also, that because of the differences in earlier education and experiences, some parts of the curriculum will come easier to you and some will be more difficult. This too will be an individualized experience. There is no point in comparing your academic progress with your peers; you will only steal your own joy by making such comparisons.
Commit to growing your network
This semester’s hybrid learning experience will make it more difficult to develop a professional network. We humans are pack animals and having six feet or a computer screen between us is an unnatural way to socialize. It is critical, though, that we adhere to these public health requirements during this pandemic – to protect our own health and the health of our entire community. Finding solutions and strategies for how to develop a social and professional network despite the barriers starts with realizing that it is a problem, and you will have to invest more than the normal effort to solve it. Get to know your peers in the program through the shared experience, even if virtual. Imagine how nice it will be to one day greet them in person, with a smile not hidden behind a face covering. The department’s Canvas site provides guidance on how to network with faculty. The guidance suggests that your initial contact with faculty include a specific request. My friendly amendment is to keep the bar low for that ask. For example, many faculty members hold regular meetings with their research groups. Rather than asking to join their groups, ask to listen in on one of their (now Zoom enabled) research group meetings. That is not difficult to arrange and provides a point of entrée to the group’s network.
Don’t forget career skills
The department’s overriding educational goal is to prepare students to be influential public health practitioners. The knowledge, skills, and philosophies that you will learn in the classrooms will be instrumental in achieving this goal. Important, too, will be the career skills that, despite often being complex and nuanced, are seldom part of the classroom learning experience. This column has often addressed these skills, so I encourage you to read the archives and begin work on honing these professional competencies. Once again, the lack of usual social interactions will make it more difficult to practice these skills during the pandemic. Recognize the problem, and plan to solve it. Realizing the importance of career skills and learning how to practice them will be instrumental in your success while at Rollins and for many years thereafter.
We can do it!
Welcome to the department and thank you for your faith in us to provide an excellent learning experience this semester. The faculty and staff have worked hard to prepare, and are ready to change and improve as the semester progresses. We look forward to working with you to make it a success.
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
Duncan DT, Kawachi I and Redline S. The Social Epidemiology of Sleep: Oxford University Press; 2019.
Buysse DJ. Sleep health: can we define it? Does it matter? Sleep. 2014;37:9-17.
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.
Billings ME, Hale L and Johnson DA. Physical and Social Environment Relationship With Sleep Health and Disorders. Chest. 2020;157:1304-1312.
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.
With the Fall quickly approaching, over the next couple of weeks many rising 2nd 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 200th 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.
Zoom Fatigue. When I first heard someone use this phrase back in the spring, I felt so seen. I breathed a huge sigh of relief when I realized that it wasn’t just me! I had been spending hours a day on Zoom calls, and while this was far more sedentary than my usual routine, I was utterly exhausted at the end of the day. It turns out that the concentration and processing that are required for video conferencing take a toll on us in ways that in-person interactions do not.
I’m still Zooming quite a lot these days, and although I haven’t found a fool-proof way to overcome the realities of zoom fatigue, there are a few strategies that have proven helpful:
Take a Break!
When possible, schedule some time in-between Zoom meetings. If you’re doing the scheduling, you can arrange for 25- or 50-minute meetings (in lieu of the usual 30- or 60-minutes) to allow yourself a chance to stretch your legs, get some water, and even run to the restroom!
Sneak in a Walk
If I’m tuning into a webinar, or a more informal meeting, I often plug in my headphones and listen in while I take my dog for a walk. It’s a win for both of us – we get some exercise, enjoy the outdoors, and I have the satisfaction of having gotten some work done, too!
Create Zoom-Free-Zones
I’m letting the cat out of the bag by sharing this…but I’ve blocked off Wednesdays on my calendar this summer as Zoom-free zones. Certainly, there are times when I can’t avoid it, but I try really hard not to schedule any Zoom meetings on Wednesdays. This gives me a nice breather during the week when I can completely devote my attention to my to-do list and avoid the distraction of hopping on and off Zoom calls. If you can’t block off an entire day, see whether there are regular mornings or afternoons that you can designate as Zoom-free zones.
Go Old School
Not all meetings require video! I’ve had some wonderful work-related phone calls this summer. Not only were they effective in achieving our goals, but they have been a really refreshing break from sitting in front of the computer. An added bonus to taking some meetings by phone is that I can safely multitask on these calls. Whether it’s sorting laundry or prepping for dinner – I’m able to engage in the conversation while also dealing with the realities of working and living all in the same space.
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We’d love to hear from you about ways in which you are fighting Zoom fatigue – please feel free to share with us on Twitter or Instagram! If you’d like to learn more about the reality of Zoom fatigue and ways to combat it, check out this recent article from Harvard Business Review.
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 (3rd 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 19th 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.
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.
I have previously written a few PROspective articles on the importance of developing career skills that will help you to be influential. Today I am flipping the script and writing about how to be influenced.
Changing your mind is an important career skill, and possibly one of the most difficult to accomplish. We all have beliefs and values that developed over a lifetime, and changing them requires us to contemplate the possibility we were wrong. This contemplation poses a threat to our identity, and that’s where the difficulty begins.
To be influenced, we must start by realizing that we will have to let go or modify what we had previously believed. For a scientist, this willingness to change beliefs is inherent to our work. It is our job to change our minds in reaction to accumulating evidence. We can borrow this skill, which we develop as part of our scientific training, and apply it outside of the scientific realm.
Now, of course, we are in the midst of a time of social and cultural change when we must all be prepared to modify our beliefs and values. Borrowing our willingness to learn from our scientific selves and applying it in these other realms should accelerate our progress.
It is most important, then, to listen. Active listening is also an important and learnable skill. This week’s PROspective article provides ten concrete suggestions for how to improve your active listening skills. The article explains the importance of active listening in building relationships: “Active listening builds rapport, understanding, and trust.” It also emphasizes the importance of committing your whole self to listening: “Active listening involves fully concentrating on what is being said rather than passively absorbing what someone is saying… This type of listening involves participating in the other person’s world and being connected to what the other person is experiencing.” In these months of remote communication, #6 has become difficult or impossible (#6: Pay attention to their body language and make appropriate eye contact). This shortcoming requires all the more attention to the other aspects of active listening, especially avoiding internal and external distractions (#1), listening to the tone of voice (#4), and sensing the emotions of the speaker (#5).
Building active listening skills will help you to be rightly influenced, and will improve your ability to fully engage in the needed social and cultural changes that are at the forefront of our national conscience. And, if developed in this context, you will be able to loan your active listening skills to enhance your career as well.
Building partnerships is a skill set that is critical in public health and yet not commonly taught directly. I do not recall ever taking a class that specifically discussed relationship building in graduate school, but now so much of my work and work in the community is based on partnerships. What I do remember is how people dreaded group projects and how students still are not always thrilled when they are presented in class as the next assignment. So why is that? Perhaps it is more efficient to do assignments alone. For that reason, solo work can be great, but for me, the most fulfilling work I have done since graduate school has involved collaboration and connections.
For the past two months, I have been fortunate to be part of a team working on the COVID-19 response in Hall County, a community hard hit by the pandemic. The outbreak in Hall County is centered in the Hispanic community, where close community living and tight working space in factories make social distancing hard. The interesting thing about leading the outbreak response from Emory’s side is that before this partnership, I had no connections to Hall County. Nevertheless, I was able to build this partnership based on previous work in similar communities and a shared common goal: We want to change the course of the COVID-19 epidemic in a hard-hit community that already was struggling with generations of disparities and inequities.
This partnership began with a phone call from a leader in Hall County asking for help with their outbreak response. Not all partnerships begin with a specific request but most are built from some level of need, even if it is for a shared greater good. That first contact should promote open dialogue and explore opportunities of engagement. Allow yourself to imagine a collaboration that doesn’t yet exist. For Hall County, the request was wide open; they sought any kind of support and connection. After listening, doing some research, and setting some overarching goals, our partnership took off and has led to a commitment to working together and building a system of support for a community in need that did not exist before. Even with the acceleration of an outbreak, building this kind of community partnership calls for a few essential building blocks: connection, engagement, and communication.
Build relationships
The best partnerships are sustained by committed relationships. While this is always the important first step, pandemics do not allow for a long ramp of getting to know each other. However, a shared vision of making lives better can quickly set your connection. But even with common goals, a strong, lasting relationship won’t form without actively working on the continuous process of connecting.
Show up and listen
Much of our work in Hall County has been about listening to the need rather than expecting we know what it is. While there are some obvious needs we could anticipate, like the need to reinforce prevention messages, provide COVID-19 testing and tracing, and isolation when needed in high-risk communities, there are nuances to those needs we would not have known if we did not get into the community and talk with its members. We would not have guessed that solid prevention messages, appropriately translated, would still not be hitting their mark because of a lack of literacy that requires messages to be less than five written words. We found that concerns about immigration make options for quarantine incredibly complex. Interventions, even those with the best designs, will likely fail without a dedication to the nuances inherent to that community.
Communicate regularly and with intention
Sharing feedback builds trust and helps us learn and become better leaders and partners. This is a way of keeping communication open so that when problems arise, you can approach the solution together. Especially in a time of fast-paced engagement, be open to quick and varying methods of communication but do not move so fast that you are not consistently communicating.
The last critical component for partnerships is the belief that together we can increase our impact. I have no doubt that the best collaborations create something bigger than what could have been done individually. There has been a lot of trauma in our world this Spring, but there have been some amazing moments to celebrate as well. Collective cooperation working towards a common goal and an energy around building partnerships is certainly a win. We are better together.
EGDRC Seminar: Lynn Aboue-Jaoudé January 14, 2025 at 12:00 pm – 1:00 pm
Seminar Series; tinyurl.com…
Online Location: https://tinyurl.com/Lynn-Abou-JaoudeEvent Type: Seminar SeriesSeries: Health System Users in Vulnerable Situations: Normative Experiences and “New Ways of Life”Speaker: Lynn Abou-JaoudéContact Name: Wendy GillContact Email: wggill@emory.eduLink: https://tinyurl.com/Lynn-Abou-JaoudeDr. Lynn Abou-Jaoudé studies sociocultural challenges in healthcare experiences, focusing on qualitative research and diabetes prevention at the University of Lille’s LUMEN lab.
GCDTR Seminar: Erin Ferranti, PhD, MPH, RN January 21, 2025 at 12:00 pm – 1:00 pm
Seminar Series; tinyurl.com…
Online Location: https://tinyurl.com/ErinFerrantiEvent Type: Seminar SeriesSeries: Cardiometabolic Risk and Resource Connection in Maternal HealthSpeaker: Erin Ferranti, PhD, MPH, RNContact Name: Wendy GillContact Email: wggill@emory.eduRoom Location: RRR_R809Link: https://tinyurl.com/ErinFerrantiDr. Erin Ferranti, Emory Assistant Professor, researches women’s cardiometabolic disease prevention, health inequities, maternal morbidity, farmworker health, diabetes, and hypertension using biomarkers for early risk identification.
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