EpiPeoplesHealth #epibookclub discussion

EpiPeoplesHealth #epibookclub discussion


Ellie: Welcome to the final session of the
EpiTwitter book club about Epidemiology and the People’s Health.
Today we have Nancy Krieger here to tell us about the book and answer some questions. Do you want to give a little
short introduction of yourself and why you decided to write this book?
Dr Krieger: Sure. So hello to everybody I’m really delighted Ellie that you’ve taken
the initiative with others to get this Twitter book club going I think it’s a
great service so thank you very much for including me the book. As I mentioned
when I was here last time midway through the book, this book is something that came out of my own curiosity what I wanted to know that I wish I had
been taught and it was about wanting to understand the theories behind the kinds
of questions that epidemiologist posed which is a different question than the
kinds of theories we use to design studies to understand statistics and
many other kinds of theory that feed into the kind of work we do this is
fundamentally about the theories about what explains the people’s health the
who and what behind that so I did lots of reading based on my own background
and interest in history and philosophy of science as well as other biology etc
and then I started teaching in the night of teaching I eventually got to a point
where I could write the book and the book now forms the court of what I
continue to teach and I continued to read actively in all the areas and write
actively in the very different topics that are covered and I’m glad to be able
to contribute one small piece which is about helping to get clarity about the
range of options of theories that people have used sometimes conscious of it
sometimes not as for famous quotes about you know do we all speak prose or poetry
consciously or not and so that’s the origins behind it and it I don’t expect
everyone to agree with the kinds of positions I take on kinds of research
that I do but what I do hope is that everyone gets clarity for understanding
why there is a need for precision about the theories that are used epidemiologic
theories of disease distribution which are not just about mechanism and also
how you use those in concert with the other kinds of theories that are needed
their theories again that are about statistical theory there
are theories about research designed what’s how do you do that there are
theories around causal inference those are not none of them they contribute to
understanding the distribution of health and human societies and also in relation
to the other species which we comb habit this planet but they’re not the same as
those kinds of theories so this is again specifically about theories of disease
distribution and I think for me a very telling change of thinking that happened
was that I can document that one to the mid 90s was not only besides coming up
with eco social theory of disease distribution which I’ve been continuing
to elaborate since I first articulated in 1994 but realize that it was a theory
of disease distribution not as I initially thought a theory of disease
causation called causal mechanisms are one thing but explaining disease
distributions requires more than just understanding mechanisms and that should
come across and I hope that out of this discussion that people realize as
practicing not only epidemiologists but anybody that’s in public health that
there’s a need to be had clarity and precision about the theories that we are
using as well as the methods that we are using and the metrics that we are using
and all of those are theoretically informed but what happens I think a lot
in public health and particularly in epidemiology courses is you get the
methods and the metrics but you don’t get the theories of disease distribution
being taught and that’s not just a quote/unquote social science question
that’s actually a question that fundamentally relies on epidemiologic
knowledge which unites biology and the fact that we live in societies so that’s
the standpoint that I come from with a deep curiosity about both and a
commitment above all to health equity Thanks so I think one of the questions
that kind of came up a couple times in the book club discussions and on Twitter
was around this idea of circle what guy you motivated to write the book and
related to that several people kind of asked the question of the title of the
book is epidemiology and the people’s health and there was some discussion
about whether that choice of people tells rather than population health or
the public health whatever like what was the meaning behind
and what was the sort of the implication that you were trying to get us to think
about by choosing that language so who are the people and caught the calls for
the people comes out of a long social justice tradition and it’s in that
spirit and it’s the same reason why the new book series that I’m editing for
Oxford University Press on small books with big ideas for population health the
first book that was out was political sociology and the people’s health the
second one is climate change and the people’s health those are published the
third one that’s in route that I’m Sharon Schwartz taking the lead and
writing is causal entrance in the people’s health so the emphasis and then
there’s a few others and there’s one that’s in process and epigenetics in the
people’s health so and then I’ve just got in a book contract approved I’m
actually very happy about this and embodiment in people’s health and I’ll
start on that like next year sometime starting to write that and so the idea
behind the people’s health is it has a long history around calls for social
justice and the people’s health and that’s the reason why and people are
always part of populations there can be all kinds of definitions of populations
and I’ve written on that very specifically but to say that people’s
health means something about the polity it means something about the people and
it for me it means a commitment to equity yeah that was sort of what the
sense was in our discussion that that was probably you know an intentional
just sort of highlight the idea of equity and social justice
so you mentioned the Eco social theory and for me that chapter was like totally
resonated with me I I my undergraduate biology and it was mostly on ecology and
I kind of realized reading that chapter that this is truth what I had been
bringing to the table is my background in thinking about Greek public health
before but I’d never really seen it sort of laid out or thought about that way um
so I thought that was really really important and useful and informative
chapter for me I really liked it um and one of the questions that came up in the
book club related to that is I guess maybe two questions so first you know is
this sort of where you think that epi theory is at and should go is with me
like you present a lot of different theories in the book and sort of the
evolution of theories and the Eco social theory is a little bit
the capstone of the book but is that sort of where you think Eppie should go
and that’s like the main theory you think people should be using or is that
sort of one of many and what are kind of things people should think about if
they’re trying to understand how they should sort of choose a theory for their
research so first I’m glad that it resonated with you and I’m glad that you
picked up on the fundamental ecological and biological underpinnings of because
social theory of disease distribution takes evolutionary history really
seriously among other things and that’s got to be part of how we understand the
utter complexity quirkiness and beauty as well as potential destructiveness of
biological phenomena so I think that that’s really important that we bring
that to the table but that’s happening always again in real populations human
and otherwise living in real places in real times and that that’s like
fundamental to understanding disease distributions and how they change and
the change in disease distributions is part of where both the optimist and the
pessimist can come we can watch some diseases there’s a resurgence that
shouldn’t be because of very bad post social policies and we can also watch
some diseases on the decline which are really good and are both because of
conscious Public Health intervention and also the ways that things are way more
complex than with any alleged one well-defined intervention can do which
is another common set of comments to the side that get to the causal inference
debates so I think that for me yes I’m interested in continuing to deepen eco
social theory of disease distribution and I do suggest that it could be of
great utility to epidemiologist to sit down and work with it and use it as a
mental checklist again as I noted in the very beginning of the book theory the
root of that means to see is inner vision that’s like eating logic root of
the word and it’s to give you like you’re saying yes you had a lot of ideas
that were floating around but you can actually anchor those ideas in a theory
and then push yourself so when I do a study I sit down with my little
checklist of key constructs of eco social theory and do i headl am i
applying them in my study check check check check what’s missing oops let me
go back and like rethink this theory should give you that it should give you
not a simplistic mental toolkit but it is a mental tool too just like methods
our part of the toolkit but the theoretical framing is huge now theories
can exist when people will say big is just a multiple levels you can have
macro meso and micro theories so you’re going to be drawing on different kinds
of theories for different bits I do work again on breast cancer I’m going to be
looking at some of the theories that are out there in cancer about cancer
pathology and that’s fine that comes from a very different line but I’m going
to be integrating that with a frame towards understanding population
distributions and which distributions and particularly for me I bring a very
strong health equity focus to what I do so that’s always going to motivate
questions so I would argue strongly for the Eco social theory of disease
distribution but that’s gonna draw on and I said it’s complementary to and
relates to other kinds like political economy of health for example that’s
really crucial and there are theories that I would draw on that are social
science and political theories that help inform again the kinds of questions
raised but I’ll bring with eco social theory a biological edge to that which
is really important in terms of basic things like etiologic period which is
often a surprise to many people that are coming from a more social science
standpoint like oops how could you expect to see an effect and when and
where and all that how do you integrate that so for me it’s a very integrative
theory and it’s complementary to but it’s also in contradiction to biomedical
and lifestyle and those are ones that I think epidemiologists would do I mean
it’s one thing if you’re gonna test a drug for clinical effectiveness and I’m
all in favor of that I just got my flu shot yesterday I was really glad to see
the science and CVS and like I’m very happy I got my flu shot and I’m very
glad they’re very particular kinds of research that go into me getting a shot
and having the flu vaccine widely available that’s wonderful that’s a
piece of the picture it’s not the entire picture and the questions that
epidemiologists focus on go beyond those of clinical medicine but again as
someone who potentially could be and has been a patient in the past I’m very glad
that there’s clinical research that’s critical
but epi has a different job and a related job and it’s understanding that
but I think gets lost in the translation especially when most of the funding for
metru NIH research and others goes in the biomedical vein and not actually too
so this is just about a corrective it’s not saying we don’t need clinical
research but obviously we do but it’s also saying that’s not the same as
public health research or epidemiologic research by itself it’s a fact oh yeah
so bend it so that the funding point raises another fellow question that was
discussed a lot here is the idea of you know how do we fund the development of
theory in a pea and and one of the things kind of relates that I were asked
is so in talking with some sociologists about epi theory some of the pushback I
got was like oh you don’t know you don’t want to go too far down that theory road
like sociology everyone has their own theory and there’s just too much theory
and why why would you need more theory and I think I mean I I’m convinced by
the book that in happy we definitely need more theory and it seems to me that
probably what we need is people who are sort of thinking deeply about that for a
lot of time developing theories and but how how do those people kind of make a
go of it in the current climate so two comments and that one I don’t know that
epidemiology actually needs quote-unquote more theories of disease
distribution what I think is it needs people consciously working with the ones
that exist and pushing on them and seeing what can be refuted what can be
supported what can be worked with so I think that there’s actually a wide
variety of options out there and that there are a lot of people one even using
theory as in lifestyle biomedical but never say it they just are using it but
they’re not talking about it and they’re not therefore dealing with what the
actual restrictive assumptions are so I think actually the bigger challenge for
the discipline right now is using the theories that currently exist as
theories of disease distribution not again narrow mechanisms but theories of
disease distribution and having what’s true in the social sciences is you will
see people often at great length mostly their introductions are like the size of
three epi papers but so they’re a very desire to have a joke a lot with one of
my sociology friends about that I mean art papers are like they’re not having
gotten to clearing their throat yet you know
and a baker but so given those different disciplinary conventions which aren’t
huge right and important to be aware of is that the first thing that is that
they always say a lot in their intros about what theories they’re using and
then eventually motivate the specific hypotheses I think within the terseness
even of the format of most of the articles it is possible in the intro to
saying one sentence it’s not paragraph of using this theory and then having a
table somewhere or a supplementary thing that explains how you’re applying the
constructs of that theory to motivate the specific research questions that
you’re asking so I think that the first corrective
should be not just development of more met theories of disease distribution
because I think there’s a good array out there but rather conscious application
of the ones that do exist and every study saying hello this is the theory of
disease distribution I’m using or the theories of disease distribution I’m
taking bits and pieces because I find that useful and this is how I’m thinking
about it and not framing it narrowly in terms of the quote unquote
tag because part of the thing is that with the dagesh you’re saying what are
the unobserved variables well how do you even think about what the unobserved
variables are if you don’t have a theory of disease distribution to give you that
guidance and if you’re not aware of and are critical about the literature that’s
informing that so the dag may finally get you to where you’re doing modeling
and making you think better about the specific models given the specific
variables you have but it’s not itself the theory that’s going to come from the
broader theory of disease distribution that’s guiding a selection of variables
and saying and if you’re I mean especially if you ever want to make the
claim that there’s no unmeasured confounding it’s like a good luck and B
what what could it be and how do you think about that
systematically so from my own work I will draw a conceptual model first which
is not as restrictive as a dag and that’s going to come later when you get
to the point of actually modeling things but it’s and and having a dialogue
between those two is really important so I just want to flag that as what the
relationship is it’s not an either/or it’s probably a both/and but if you
don’t do the first one of the kinds of the theories of disease distribution
that I’m talking about that frame specific hypotheses that will be tested
and every study of course only frames an hour you know works on a test and narrow
empirical study a narrow set of hypotheses that come from a larger body
that are supported by a theory but to be mindful of what you might be trying to
refute as well as what you’re trying to support and so that’s what I think would
be better than trying to say that they’re supposed to be developing more I
think that people need to be who are epidemiologist much more situa Sande
explicit about using the existing theories and figuring how they’re going
to work with that and doing exercises about how they’re going to apply them
does the follow of course that I teach the first course I teach the fall one is
based predominantly on this book with supplementary readings and fall to have
an advanced seminar and the paper that I assign people to write is to compare to
review articles on the quote/unquote same topic for example let’s just say
tuberculosis in the United States well first paper has to look but they
have to specify where in the world it could be global it could be you know
somewhere in South Africa it could be in Thailand I mean could be wherever but I
have to give the geographic place it’s not just in general or could be global
and then it has to give a time period the first article has to be performed
between 1900 1950 and the second article needs to be 1980 till now and they have
to dissect each article about what were the theories of disease distribution
that informed the review what do you think typically the author doesn’t say
so you how do you piece that together from what kinds of evidence are
presented and what are not how do you look around the article to understand
what the repertoire of ideas and evidence were at the time that gives you
a very critical understanding of how the knowledge at that was seeing Okara has
like the cutting edge of its time was framed by its times what the omissions
and gaps are they won’t see now what that might might mean for research going
forward so that gets the students to very consciously apply the theories of
disease distribution that they’ve learned by trying to figure out what
might have motivated these two different review articles and these are not meant
to be like choices of bad review articles they’re meant to be good review
articles that people can find and think more critically and a review article
really gives you a deeper understanding than any one article does because it
you’re asked to think what is guiding the thought processes of the
or person that wrote the review to critically evaluate the literature and
are their entire blindspots what’s motivating that blindness to the
information that actually is out there versus what does the review actually
help pose as saying whoops we don’t know anything about X Y & Z and who’s the Lea
by the way in that sentence that doesn’t know that and why is that so that’s what
my suggestion is it’s much more at this point I think about the conscious
application testing and use of theories of disease distribution explicitly that
would I think ratchet up and improve the quality of the work and the whole point
is to do better science and that’s that’s the objective here and then to
understand where epidemiologic studies as such can help inform and be engaged
with larger questions of the times about what can be done by whom to improve the
public’s health in the people’s health and particularly in reduce health
inequities so one of the things you mentioned is that when you’re doing a
study you kind of have a checklist to sort of think about how that works with
the eco social theory is that like an actual checklist that’s you yes I
scribbled in my very little handwriting as I work to constructs of embodiment
and I work through the different things that I’m thinking about and I go through
that diagram that people have noted in Chapter seven and I just like how am I
thinking about that for each one and I can tell you and so it really is the
mental checklist and I guess sort of related to that is there your papers are
someone else’s papers that you think it’s kind of a really good example that
people should sort of we could read us a follow up that gives how to present this
in a paper how to link the theory that’s tricky because there are ones that I
write out that are they’re more the conceptual papers I mean there was one
that goes through this like for example which is you know thinking about using
the example of breast cancer estrogen receptor status about how you work in
different kinds of history from you know from individual life course in the
history of the tumor to evolutionary history to bring that into
what the research questions are but that’s not empirical study and then for
the empirical studies because of the brevity of epidemiologic papers usually
there’s not great length of exposition but there is a little in that and so
it’s hard to so I can think more about which papers I’ve done because there’s
like a lot of different ones I think about which would give you what you’re
talking about I do not have paper I have papers in which I show like the diagrams
of for example eco social theory of disease distribution is applies to
understanding racism and health but again then but the paper is usually
given limits of n of tables and whatnot I mean what you’re making me think is I
might for some future papers do that as a supplementary like table or some you
know supplementary figure and table to work that in a little bit more
explicitly to address your concerns but usually I sort of separate the
conceptual papers from the empirical because again of the conventions of our
discipline of the end of words and tables and figures permitted from so so
that’s what I would say to that so uh two more questions and then maybe we’ll
open it up to the audience we’ve been discussing a lot on Twitter lately is
sort of the ethical issues around the sort of stigmatizing impact of certain
research questions and so one that was a really big two that were kind of really
big on Twitter recently is a 2013 study on whether
women with endometriosis are more attractive than women without
endometriosis which the authors argued was a sort of backdoor way to
identifying whether or not there might be a genetic basis for endometriosis and yeah it was kind of a shocking study really
they they even say explicitly but they didn’t tell women the purpose of the
study because in the informed consent because they didn’t want women to like
try to appear more attractive to the Raiders who rated them it sounds like an
IRB was also negligent yeah yeah yeah and then another related study that just
came out was this big jiwa study looking for quote-unquote cagey yeah there’s an
excellent critique of that study that just was published in a blog that I just
posted to the m48 Lister’s hyoni yes front of the epidemiologist at Emory yes
and yes these are very controversial important questions and epidemiologic
studies will be one piece of that and how sankt and theirs will be robust
debate and there ought being yeah so yeah I guess I’m kind of one of the but
it seems like the G wasps they sort of did this they incorporate the community
and whatever and they sort of sort of try to frame asking the question in its
best way they could but they didn’t seem like they stopped and asked whether the
questioner really even was appropriate so I have not read the study in great
depth so therefore I know better than to try to read it so I will stop there I
will flag the one thing that whatever that I have
seen consistently as raised about questions is the definition that was
used for sweat uncle gay which was have you ever had sex with someone of the
same sex and that’s tricky because one you’ve got a lot of people where they
may have had a one-time encounter and ever is not the same as multiple times
and some certainly never the same as identity because what’s clearly in the
literature and this I do know and I’m doing work on discriminates just you
know LGBTQ discrimination right now and health among others is you minimally
have to separate out behaviors identities and desires and those are
like not the same thing and also look at where the data came from and what
countries what context what time periods who’s able to speak out who’s not and to
assume that about gaijin as such is really
complicated and to also think that they’re going to be similar dynamics
around the relationship of behaviors identities and desires stratified by
different permutations of gender identities let alone race ethnicity
socio-economic position and I do not know enough to know how the paper is
dealt with those but I think the thing is is that obviously anything we do as
living creatures has components of our biology in it and it has components of
our society head and you may as well ask you know to what extent is quote-unquote
straight people’s quote unquote behaviors genetically determined what
does that get you and if anyone thinks there are simple political answers to
these questions that they lead that there are some who argue just to be very
clear in the debates that if you say quote unquote
its genetic whatever that means just obviously beyond simplistic as a frame
some people will say great let’s euthanize you now and others and that
was done and Nazi Germany with the yellows you know the pink triangle and
that the whole idea is to prevent the appropriation and others will say great
you shouldn’t be treated again you shouldn’t be discriminated against
because you have something that looks like an illness it’s like well that’s
really thanks a lot sharing and and then there’ll be others
that will say let’s actually look at the extraordinary diversity of sexual
behaviors not only amongst humans but lots of other species and I don’t know
if you saw but there was just recently as yet another example I’ve been
tracking needed and trotted out over the past fifteen years of another gay
penguin couple you know which is how there is like these to rise you know you
do is important each other in a now raising a little penguin egg and and
their shit proving to be as the article is demonstrating at the you know the
like best behaved parents yet of any compared to the quote-unquote
intersexual penguins and so and this happened at the same time this debates
in Australia about the gay marriage referendum and and one level it’s
ludicrous at the other level this is where the state of discourse so
epidemiologist need to know that they walk into this and need to walk into
understanding the complexities and to do anything that would suggest a simplistic
student about causes of anything this complex
that’s by itself unethical and bad science great so we started building on
from that the last question I wanted to ask is about the idea of well-defined
interventions because I think that people would be very interested to hear
your thoughts on that and from from my perspective I think you know if we’re
trying to understand a causal mechanism then we need to ask a specific
well-defined question so that we can put me in on some mechanism but I agree that
we’re not always that’s not always our goal and sometimes we just want to
describe what’s going on and I think you laid out a really good argument that you
know even the mechanism is not enough to understand why the disease is
distributed in the causal methods that’s sort of something that’s being worked on
a lot lately with external validity and transportability and a lot of people are
thinking about how do we take what we learned about one mechanism and think
about it in other populations but so I think this sort of question is when we
start thinking about some of these really complicated so she’s you know
social epi questions about race and racism and social position and things
like this what is that sort of trade-off how do we ask questions that help us do
something or learn something and how should we be thinking about those
trade-offs and we first start with a question like that always Ellie is
asking who’s the we in that sentence because there’s a lot of needs that play
of who has to do what and that’s whatever social theory also helps you
ask more explicitly so there is a job of epidemiologists and producing certain
kinds of knowledge epidemiologists sometimes can be parts of teams that are
making policy recommendations or can be sometimes parts of teams that are
implementing interventions and evaluating them but not always there are
a lot of things that happen that have no input for epidemiologists whatsoever
that are policies one can look at for example most economic policies which
have health impacts that are never considered in
thing that needs to be legally formally assessed even though you will see that
their impact in assessment criteria that would need to be made for environmental
policies so there’s always a question of the we and epidemiologists understanding
that as a field we are but one contributor to the complex phenomena
that are shaping population health sometimes consciously and deliberately
as for the work of health policies in the work of health department’s whether
federal state or local sometimes because of particular studies that are really
trying consciously to do a certain time intervention sometimes we are in the
position that we can help evaluate what’s happened in the real world where
there was not conscious planning but certainly that just because there wasn’t
conscious planning doesn’t mean there’s not lots of consequences right and so
there’s lots that needs to get looked at in that and making judicious choices as
to where one wants to make an impact where it would be helpful to have an
answer and helpful to whom helpful to the community advocates helpful to the
lawyers that are finally finally lawsuits about one kind of environmental
exposure or another helpful to legislators I mean there’s lots of
different potential audiences so there’s never gonna be one simple answer to that
question there is going to be trying to judiciously look where is there an
important gap to knowledge that would be helpful to fill that would be useful as
a policy lever as a place to understand you might want to communicate with
people that are fighting against this particular disease or exposure that it
would be helpful to know this that you need to replicate studies because one of
the key things about science is not one-off studies but actually repeated
replicable results that the originality can sometimes come from understanding
how you can come up with another study that bolsters the evidence that leads to
a deeper understanding of the causal mechanisms of play but it’s not
everything is not a one-off study so that requires knowing what you need to
do for TB and malaria compared to what you need to do for a methane gas
increases given like new policies to potentially change that around what’s
happening with the explosions are affecting there’s going to be so many
different kinds of levels of uncertainty and differences in gaps in knowledge so
there’s not one easy answer there is however having humility which is that
the epidemiologist and epidemiologic evidence is just one piece of the
picture never suggesting that it is the full picture and understanding them with
whom is one engaged as an epidemiologist to better figure out what would be
useful research some of that research may be directly useful you know you you
get this all the time in it configuring your IRB stuff will be directly useful
to the people in the study usually not will it be directly people would be
potentially beneficial to the clinical population overall one hope so how do
you go from making that a hope to an actuality so there’s not going to be an
answer there I think a key thing and getting back to the very first question
at the beginning is that understanding effectiveness of when you give a group
of people a particular pill and/or a particular procedure in a very short
timeframe is really really different than most of the stuff that drives
population health it’s very important because clinical treatment matters if
you’re sick blah blah blah but that said that’s going to give you a
very different understanding of what constitutes a quote/unquote well-defined
intervention and any claim that studies should not be done if they cannot come
up with a well-defined intervention let’s say I want to change the who’s
president of the United States that could be a very well-defined
intervention and I as an epidemiologist that I like be the person that does that
know in terms of the impacts and health policies can I think about that
absolutely and finally West so if you want me to say that’s a well-defined
intervention yeah that’s why we have elections but that’s the way more
complicated messy thing than just saying it at the genealogist is going to create
that intervention so that’s important to keep that in mind the second thing is
that they’re absolutely does need to be room for descriptive work which is
particularly following trends and find an Ida health equity so for example a
big study just got published they now the UK is quote-unquote caught up to the
US and having stagnation and differential by class of life expectancy
they haven’t had that you know we had our running in that like interrupted a
few years ago they’ve just come out with new results about that there was a very
big article in The Guardian that came out two days about about that that’s
like really koruna there’s a colleague of mine as quoted that who was actually
first paying and I looking at that certain specific cities in the UK and
say come this isn’t getting attention it’s
just seen as boring vital statistics it’s like hello this is the fundamental
Dyke measurement of the health of the population what’s going on here having
declines in life expectancy that’s like a big no-no what’s going wrong and then
you will have the usual sense of immediate arguments is that austerity no
it’s people behaving badly you know and that gets back to understand those
arguments is getting back to the kinds of theories that are discussed in my
book I think I have to say I went to this slightly skeptical that I needed to
read this book and I really haven’t gotten a ton out of it and I very much
appreciate that and one of the things that I did not expect the one thing so
it’s really worse gonna do this to think a lot about the definition of
methodology the definition that I have stuck Amanda’s study the distribution of
the terms of diseases the new populations the application of knowledge
the control of disease and I always thought that as a list of things that we
do and when your book is made anything if I want to be your action to does it
make you think that it’s sort of much more of a feedback loop that we study
distributions in part to think about what the determinants are but we study
determinants there are determinants of those
distributions and it seems to me it’s much more of a process rather than a set
of different things that we do and I’m just wondering your thoughts on that
first I’m very glad to hear that the book gave you some new things to think
about that’s always the intent writing and but
you never know until you actually find out I mean yes I teach students but
that’s a little different talking to people that are not better reading it or
not specifically the students I teach secondly like any field the work
is meant to feed on itself and contribute something news and there will
be feedback loops third I think we’re epidemiology is what I mean by being a
reflexive science is it’s one where are we do have an obligation to have our
results make a difference in the real world and that’s partly because we’re in
public health and that’s not the same as a purely theoretical science so that’s
going to be that kind that will be built into the definition also and that’s a
part of the definition to hold on to but absolutely they do feed to each other
and I think that much more understanding of determinants leading to the kinds of
exposure is leaning kind of the changes in population health and having that
very dynamic view dynamic not only in the life course but in historical
generations that’s how we see we have to think in multiple temporal scales to
understand population health and I think the definition and you’re thinking of
feedback loops is part of what helps you see that clearly that’s a very happy
thing to be um I’m gonna fix these everything is done but I do think that
one of the things that seems to be a way to frame many of the social factors is
similar to earlier which is something that you can’t measure the individual
Illumina measured if you’ve measured in the community and I’m wondering if that
is a is a way to conceptualize things that we’d like to measure in the
community didn’t in fact affect the outcome so I mean yes a lot of people in
social at B do refer to the herd immunity idea and that is but the thing
is is that the herd immunity what’s a little tricky is that that is a
contextual measure that arrives in part out of composition so what you’re doing
is you’re figuring out the end of people that are immune versus not in a given
community there are other kinds of measures that are contextual and
structural that can’t be reduced to something that could be measured in or
on people’s bodies and so that’s what herd immunity won’t work for those kinds
of measures so when I tell you an economic policy or an educational policy
that’s effect health outcomes you’re not you will see
the impact of that as it becomes embodied and you will pick that up as
the epidemiologist for your health outcomes but you won’t be able to frame
that quite in the same way as herd immunity because the herd immunity but
what will be similar in those examples is that you’re both in both you need to
define what is the what and who constitutes the community what are the
social and spatial boundaries that say who’s in it versus not in order to have
something that looks like a numerator and denominator and so that will also be
true when you’re saying what’s the impact of an educational policy or of an
economic policy who’s the n of exposed who’s is going to
be affected given exposed blah blah blah so those things will be
similar and none of those can be reduced to the individual level so there will be
multiple levels involved and herd immunity gives an understanding for one
aspect of but that’s again something that becomes a compositional that then
has a contextual effect as a result we’ll have a little bit of time for
discussion I want to thank you again dr. career for coming and talking with us
and for recording this so we can share it with every Twitter use I think very
much enjoy reading the book there’s been a lot of great discussion on there and I
guess just maybe close up by asking what your sort of next step recommendation
would be for someone who’s read this book and now wants to sort of think
about reading a next book or a next paper to work more on incorporating
theory into their work if there’s so one again thank you for having me and having
this discussion today and again it’s been for me very edifying I will now
confess that I’ve been reading what people are posting but I have I do not
have a Twitter account that’s a different conversation
this day I’m like getting hacked a few other details but but it’s been great
for me to actually see how people have engaged and to see what is or isn’t
useful and to see what are and are not concerns that people express that’s
always a great way to learn so I also really appreciate that opportunity for
engagement I think again what I would really really recommend is to take just
as an exercise and I always do this take a theory you hate and try to apply it to
the question that you’re interested in as well as take the theory that you hope
you actually really use see what differences that gets you I mean that’s
what the critique paper that I have students write does that but try saying
here’s a given Jersey given like exposure outcome relationship or here’s
an outcome I’m interested in understanding and why it’s distribution
is what it is what kinds of questions would I ask if I used lifestyle what
kinds of questions would I ask if I use political economy of health what kinds
of questions would I ask if I use Health and Human Rights
what kinds of questions would I ask if I use Eco social theory and actually just
like systematically sit down and do that and do that for like and infectious
disease outcome and do that for like infant mortality and do that for like I
don’t know breast cancer I mean things that you care about whatever they do
that for psychiatric illness of one form or another
think about poops what’s making me think about is this like humans in general or
humans and a particular time and place and which ones try that that that’s the
next best thing which is that just like with methods when you go and learn new
methods you know just like sit and read theory papers about method you go how
can I program this what happens we’re all the bugs Food Program what went
wrong do I have any reason to believe these results probably not what you know
what went wrong again you apply them you apply things to understand how they work
and see you and test their limits and see if it’s good under or under what
circumstances does this work versus not work so you would do that with any
methods that you would do you would look at validity and reliability studies you
would do that with any statistical methods that you use you would say you
would look at that with regard to study designs and say I want
study this what are the right kinds of study designs usually there’s more than
one what would they give you is different purchase to answer the
questions but this is saying step back what are the questions you’re asking
let’s think about how those would connect to what the theories of disease
distribution are and just try it out and that would really be like if people
could conscientiously do that as an exercise that would be a very good thing or a topic on Twitter and try to have
people work through that and was I said what I do with my students consistently
and in this course because I also have one section it’s actually pure
infectious disease it’s only a list of papers on tuberculosis and they’re
comment’ again not to be good papers and say okay what’s the theory of disease
distribution or theories that underlie this paper and they see the completely
different kinds of things that are out there in the real world in the real
journals to say okay oops they didn’t ask about this because they wouldn’t
think about that because they Theory probably didn’t tell them and then also
to see how many of those papers actually bothered to say in somewhere the
introduction we are using this theory of disease distribution typically you’re
not far out if you guess the answer is zero okay thank you very much again for
coming and speaking with us and for the book which I think everybody seemed to
really enjoy so it’s been a great fun thank you very much

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