Seven Things You Should Know about Legal Epidemiology
by Colleen Barbero, Lindsay K. Cloud, Lance Gable, Siobhan Gilchrist, Bethany Saxon
Legal epidemiology is the scientific study of law as a factor in the cause, distribution, and prevention of disease and injury in a population. In the United States, 9 of the top 10 leading causes of death are caused by chronic diseases (cardiovascular disease, cancer, chronic obstructive lung disease, stroke and cerebrovascular diseases, Alzheimer’s disease, diabetes, kidney disease) or are injury-related (accidents, suicide).
Legal frameworks and interventions can be used to address the increasing population health burden from these health conditions and their associated risk factors. Legal epidemiology plays an important role in making it easier to understand the ways laws work and affect health, evaluate the law’s impact, and to develop and share policies to prevent and treat disease.
“Advancing Legal Epidemiology,” the March 2020 supplement of the Journal of Public Health Management and Practice, is the first special supplement addressing this important topic area. It was created to offer practitioners the opportunity to see legal epidemiology in practice by exploring how state and local laws may affect the health of communities and individuals.
Here we provide seven take-away points about legal epidemiology and its application in public health for advancing chronic and non-communicable disease management.
- It’s not just for lawyers, and not just for epidemiologists. Legal epidemiology is a transdisciplinary field that relies on the collaborative efforts of lawyers and non-lawyers to develop, implement, and evaluate the effects of law. Historically, public health law has focused on “what law says,” and legal epidemiology focuses on “what law does” [Burris et al]. Legal epidemiology supports the premise that laws and legal practices can be studied using theory and robust scientific methods, similar to other social phenomenon that are important to population health.
- The field is relatively new, but growing quickly. The Centers for Disease Control and Prevention’s (CDC) Public Health Law Program (PHLP) was established in 2000. Further support for public health law research came from the Robert Wood Johnson Foundation (RWJF) in 2009 when it propelled the field of public health law research by funding the creation of the Public Health Law Research Program (now the Center for Public Health Law Research (CPHLR)) at Temple University’s Beasley School of Law. Since then, the field has continued to expand and advance, and has included partners in an informal network of organizations working in various facets of public health law and legal epidemiology, including the Network for Public Health Law, ChangeLab Solutions, and the Public Health Law Center. Most recently, the field was acknowledged by the National Library of Medicine in its MeSH terms database—an action that makes data and evidence easier to index and find, while validating the field as a whole and making it easier to track its growth in the future [Burris et al].
- The methods transcend specific public health topics or domains. Legal epidemiology methods may be applied to any area of public health. Although this supplement is dedicated to laws that address chronic disease and non-communicable diseases, legal epidemiology studies have been performed on a wide variety of public health topics. CPHLR funded more than 80 legal epidemiology studies between 2009–2016 and has supported studies that covered more than 20 public health topics [Burris et al].
- It’s changing public health and legal education. A number of academic institutions are now conceptualizing courses in legal epidemiology and incorporating these methods in their educational programs. Notably, Temple University’s Beasley School of Law and College of Public Health offer the nation’s first certificate in public health law research, with the first class of students poised to graduate in May 2020. Law schools and schools of public health can further develop the field, by offering legal epidemiology courses to provide the next generation of lawyers a different set of analytical and research skills than those usually covered in law school classes. Schools of public health can expose students to legal epidemiology through courses that “connect the disciplines of law and public health through scientific methodologies that public health students are already learning in other courses” [Gable et al].
- It’s catching on in policy making and practice. In 2016, CPHLR, CDC’s PHLP, ChangeLab Solutions and the Network for Public Health Law partnered with RWJF to develop and implement the Five Essential Public Health Law Services (5EPHLS) model. The 5EPHLS model builds on the legal epidemiology framework to help public health practitioners apply legal interventions and develop the policy infrastructure needed to “build a Culture of Health.” CDC’s PHLP, CPHLR, and ChangeLab Solutions have also been working with health departments to train their teams in policy surveillance and other legal epidemiology methods so they can apply these skills on the ground. Similarly, the de Beaumont Foundation and Kaiser Permanente’s CityHealth project, which uses policy surveillance data to rank the 40 largest US cities on evidence-based policy areas, will be expanding to 75 cities in 2020 because of the strong interest from cities to learn from these data and analyses.
- Policy surveillance data is a game changer. Policy surveillance generates access to the content and substance of law and legal trends over time; and enables everyone whose work depends on knowing exactly what the law says, where the law applies, and how the law is changing over time to do their jobs better. Policy surveillance datasets are at the heart of most legal epidemiology studies because they are nuanced, replicable, and can be applied to any area of law at any jurisdictional level—from municipal ordinances to international law. This supplement includes a variety of examples. Policy surveillance studies are used to determine how insurance covers recommended treatments for chronic conditions [Carr et al]; how state and local laws are designed to encourage population access to reduced-sodium food products [Sloan et al]; how laws and policies related to preventing youth sports concussions are being implemented by states [Sullivan et al]; and to understand Supplemental Security Income for children with mental disorders [Robinson et al], among others.
- Most legal epidemiology resources are in the public domain and are free. Because legal epidemiology has been developed by government and nonprofit organizations, most of the valuable resources produced are freely available. These include data, research results, method descriptions, and training courses. The broad accessibility of these resources presents a great opportunity for researchers, practitioners, policy makers, and the general public to better understand the relationship between law and public health. For examples of the Centers for Disease Control and Prevention, Division for Heart Disease and Stroke Prevention’s work on policy interventions that address health equity and serve priority populations in the prevention, detection, treatment, and control of heart disease and stroke, see https://www.cdc.gov/dhdsp/pubs/policy_resources.htm [cdc.gov].
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Colleen Barbero is a trained policy scientist and program evaluator. She is currently working as a Health Scientist on the Applied Research and Translation Team in the Division for Heart Disease and Stroke Prevention at the Centers for Disease Control and Prevention (CDC). In this role she has studied policy and law aimed at improving chronic disease prevention and management. Dr. Barbero is also serving as a Co-chair of the Community Health Worker Work Group at CDC, and her research interests include promoting health equity and stakeholder engagement in decision making. Prior to working for CDC, Dr. Barbero served as a statistical data analyst at the Center for Public Health Systems Science in the Brown School of Social Work at Washington University in St. Louis. She received her PhD in Public Policy Analysis from Saint Louis University, where she concentrated on community and urban development policy.
Lindsay K. Cloud is the director of the Policy Surveillance Program at the Center for Public Health Law Research (CPHLR) at Temple University Beasley School of Law. Her work focuses on the intersection of law and public health. She has overseen the creation of large-scale public health law research projects using legal epidemiology to scientifically analyze and track state, local, and international policies across various public health law domains, including the regulation of reproductive rights, affordable housing, minimum wage, earned income tax credit, civil commitment, and prior authorization policies for pediatric ADHD medications. In addition to managing the creation of CPHLR projects, Lindsay trains government agencies, policymakers, researchers, and other external organizations on the tools and transdisciplinary methods used in public health law research with an aim towards applying law as an intervention to influence better health, well-being, and equity. She serves as an adjunct professor at Temple University Beasley School of Law teaching courses in public health law and empirical legal research methods.
Lance Gable is an associate professor of law at Wayne State University Law School. An internationally known expert on public health law and bioethics, Gable served as interim dean of Wayne Law from September 2016 to August 2017. A member of the Law School faculty since 2006, he also served as associate dean from June 2014 until his appointment as interim dean in 2016. Prior to that, he was interim associate dean since June 2013. He teaches courses on Public Health Law, Bioethics and the Law, Torts and other health law subjects. His research addresses the overlap among law, policy, ethics, health and science. He has published journal articles on a diverse array of topics, including public health law, ethics and policy; international human rights; bioterrorism and emergency preparedness; mental health; research ethics; and information privacy. He also is co-editor and co-author respectively of two books: Research with High Risk Populations: Balancing Science, Ethics and the Law and Legal Aspects of HIV/AIDS: A Guide for Policy and Law Reform.
Siobhan Gilchrist, JD, MPH, IHRC Inc., has been providing legal epidemiology and policy research and translation expertise to the Centers for Disease Control and Prevention’s Division for Heart Disease and Stroke Prevention’s Applied Research and Translation Team since 2010. She helped expand DHDSP’s policy research portfolio from a single policy tracking database to a comprehensive set of products, including a novel method to synthesize, assess and translate the evidence base for public health policies. She conducts state and local law surveillance to analyze trends in law reflecting uptake of evidence-informed practices and policies. She also works on policy implementation and evaluation studies to understand stakeholder barriers and facilitators to implementing state law and the associated health impact of state laws. Her policy areas of focus include community health worker, nurse practitioner and pharmacist scope of practice, stroke systems of care, and other policy issues related to cardiovascular health. She is licensed to practice law in Georgia, received her law degree from Georgia State University School of Law, and her MPH from Emory University School of Public Health. As an attorney she represented clients for a small firm focused on environmental, zoning and private property interests and provided pro bono representation to victims of domestic violence and other clients in civil proceedings. She also has extensive experience working in public health as an epidemiologist for the Georgia Division of Public Health, the DeKalb County Board of Health, as well as at CDC’s former Epidemiology Program Office.
Bethany Saxon manages all external communication and dissemination activities for the Center for Public Health Law Research and its programs. Ms. Saxon joined the Center in 2011 as the Director of Communications for the RWJF Public Health Law Research Program. Before coming to Temple, Ms. Saxon served as a writer/editor for ICF International, supporting the publications and information resources management contract for the Administration on Developmental Disabilities (ADD), U.S. Department of Health and Human Services. In this position, she managed production for all ADD publications, managed a rebranding initiative and developed content for the agency’s website. She has also previously worked for the International Partnership for Microbicides, a nonprofit product development partnership dedicated to developing a drug to prevent HIV in women. There she supported all communications efforts, both electronically and through traditional print media, across more than 15 research centers and three offices in Africa, Europe and the United States. Throughout her career, Ms. Saxon’s focus has been on external relations ranging from press relations to publication production for online and print, and in-house communications for nonprofit organizations and other institutions working for the public good. Ms. Saxon graduated from Elon University in North Carolina with a bachelor’s degree in journalism. She has a master’s degree in Communications Management from Temple University.