Invited Commentary: Some Social Epidemiologic Lessons From the COVID-19 Pandemic

Abstract

In their recent article, Dimitris et al. (Am J Epidemiol. 2022;191(6):980–986) presented a series of challenges modern epidemiology has faced during the coronavirus disease 2019 (COVID-19) pandemic, including challenges around the scientific progress, epidemiologic methods, interventions, equity, team science, and training needed to address these issues. Here, 2 social epidemiologists who have been working on COVID-19 inequities reflect on further lessons with an added year of perspective. We focus on 2 key challenges: 1) dominant biomedical individualistic narratives around the production of population health, and 2) the role of profit in policy-making. We articulate a need to consider social epidemiologic approaches, including acknowledging the importance of considering how societal systems lead to health inequities. To address these challenges, future (and current) epidemiologists should be trained in theories of population health distribution and political structures of governance. Last, we close with the need for better investment in public health infrastructure as a crucial step toward achieving population health equity.

This article is linked to 'What Has the Pandemic Revealed about the Shortcomings of Modern Epidemiology? What can We Fix or Do Better?' (https://doi.org/10.1093/aje/kwac012).

Abbreviations

COVID-19

coronavirus disease 2019

Editor’s note: The opinions expressed in this article are those of the authors and do not necessarily reflect the views of the American Journal of Epidemiology.

In a recent article, Dimitris et al. (1) offered a critical reflection on how modern epidemiology succeeded and failed in its mission of protecting the public’s health during the first 18 months of the coronavirus disease 2019 (COVID-19) pandemic. The authors highlighted challenges and lessons about the related scientific process, epidemiologic methods, interventions, equity and the diversity of the epidemiologic workforce, communication, collaboration, and training.

Here we extend their commentary, after an additional year of pandemic experience, to discuss further challenges. We argue that capitalism, and specifically profit-seeking, acts as the underlying force driving COVID-19 narratives and policies and can help explain much of the United States’ failure to prevent widespread death from COVID-19, despite having ample resources to do so. Subsequently, we suggest 3 capacity-building lessons for epidemiologists: 1) population health theory training, 2) integration of governance structures in epidemiologic research, and 3) public health infrastructure investment.

PUBLIC HEALTH NARRATIVES

Sick individuals, sick populations

Understanding the epidemiologic profile of COVID-19 exposure, morbidity, and mortality necessitates consideration of social, political, and economic processes, often seen as outside of epidemiology’s scope (2). We argue that every epidemiologist must consider the principles of social epidemiology (3, 4). A key principle, shown by Geoffrey Rose (5), is the understanding that causes leading to an individual case may differ from those leading to higher population incidence, and that addressing structural determinants is key to reducing incidence.

The initial response to the COVID-19 pandemic showed signs of interventions addressing structural determinants, with implications for population health (6–9). These early interventions recognized the importance of labor relations in driving exposure risk, and they prioritized disease control over capital accumulation; and yet, this structural approach was short-lived. After the first months of the pandemic, the majority of media coverage and of national, state, and local policy reinforced the dominant paradigm that poor health, including sickness and death from COVID-19, was a reflection of personal responsibility, rather than a product of social factors (10). This framing in turn strongly influenced the distribution of the population disease burden (i.e., studies examining the patchwork of state and local economic policies, such as prohibiting indoor dining and closing schools, and their effects on COVID-19 rates and mortality). This individualistic biomedical paradigm is omnipresent and pervasive, especially in the United States, reflecting preexisting dominant narratives among persons with decision-making authority for policy (across the political spectrum). This ideology also permeates academic research (11) and the media in general, determines who and what topics make headlines, and filters into lay thinking about disease causation and effective interventions. At the center of these narratives is the hegemony of an individualistic and neoliberal ethos that rejects indigenous thinking and collectivist approaches to society-building in favor of wealth accumulation and continued national economic growth (12), dominating other societal goals, including prevention of death, sickness, and disability.

Ignoring structural forces

This individualistic paradigm produces inequitable outcomes. After the earliest days of the pandemic, persons with the most political, racial, and economic power were able to largely avoid the worst COVID-19 impacts, placing disproportionate morbidity and mortality burden on the most marginalized, exploited, and economically disenfranchised populations (13). Recognizing inequity as a persistent pandemic and epidemic disease feature (14, 15), many social epidemiologists called for reflection on the otherwise avoidable emergence of inequities if we did not approach COVID-19 interventions from an equity and antiracism framework (13, 16). Yet, as Dr. Nancy Krieger writes, “shared observations of disparities in health, however, do not necessarily translate to common understandings of cause” (17, p. 668). Service workers have some of the highest COVID-19 mortality and morbidity of any population (18); a social production analysis would argue that the current political economy created the conditions that put service workers at disproportionate exposure risk. Alternatively, the more common biomedical individualistic framing argued that disparities did not exist (e.g., the virus did not discriminate), explained disparities on the basis of differences in innate susceptibility, relied on inappropriate adjustments to explain away disparities (19), or ignored very important confounders such as age (20). These narratives about the equal-opportunity virus influenced policies and interventions, despite the reality that the virus infects and kills inequitably (21).

The majority of media coverage and of national, state, and local policy has reinforced the dominant paradigm that poor health, including sickness and death from COVID-19, is a reflection of personal responsibility, rather than a product of social factors (10). Once vaccines were authorized, the pandemic of the unvaccinated dominated common discourse (22). This overreliance on silver bullet (vaccination) thinking, and the desire to return to full economic activity, led to the lifting of nonpharmaceutical interventions while allowing for the continued argumentation that investments in public health continued (through vaccinations). This framed vaccination as an individual choice, ignoring the role of policies (e.g., paid sick leave, vaccination center distribution decisions) and social and economic factors (e.g., lack of trust in government, residential segregation) in creating structural barriers to vaccination. This shift from structural factors towards a dominant individualistic narrative will only make COVID-19 control harder, and disparities more evident.

ROLE OF PROFIT IN POLICY-MAKING

The predominant free-market capitalist political economy of the United States, as well as the commercial determinants of health, or the factors and mechanisms through which corporations affect population health (23), has influenced COVID-19 outcomes and policies. For example, the current 5-day isolation period does not reflect the average period of infectiousness (24) but reflects economic worries about excess absenteeism due to infection (notably, without a national paid sick leave law), linked to lobbying efforts by airlines (25). Social media companies allowed COVID-19 vaccine misinformation to spread for months without taking aggressive action to curb its spread (26). Despite making billions of dollars in profit from their COVID-19 vaccines and receiving substantial public funding, Moderna (Moderna, Inc., Cambridge, Massachusetts) sued Pfizer/BioNTech (Pfizer Inc., New York, New York; BioNTech SE, Mainz, Germany) over patent infringement, and both companies have refused to share their mRNA technology for vaccine production in low- and middle-income countries (27). These profit-seeking actions undermined confidence in public health, including epidemiologic analysis, and contributed to public sentiment moving away from pandemic precautions.

Lessons in capacity-building

Drs. Richard Levins and Richard Lewontin start the conclusion of their book, The Dialectical Biologist, with the quote, “Scientists, like other intellectuals, come to their work with a world view, a set of preconceptions that provides the framework for their analysis of the world. These preconceptions enter at both an explicit and an implicit level, but even when invoked explicitly, unexamined and unexpressed assumptions underlie them” (28, p. 267). To us, this summarizes much of the usual epidemiologic approach to theory. We come with a world view; sometimes we try to make it explicit, but we often have unexamined assumptions about the way the world works (29). The persistence of the biomedical narrative among epidemiologists informing health policy suggests the need for more widespread training in theories of population health.

The theories we rely on to explain the distribution of COVID-19 matter. Social ecological theories, ecosocial theory in particular (30), orient us to examine power, agency, and accountability (30), and integrating social epidemiologic thinking orients us away from quick technocratic interventions and towards interventions aimed at structural and political determinants (31). Yet we have consistently seen the unequal (and unjust) distribution of COVID-19 infection in the population. The basic reproductive number, R₀, is innate to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and its variants. Conversely, the effective reproduction number (R_e), the case rate, the case fatality rate, the hospitalization rate, and positivity have all been influenced by social, political, and economic processes. Epidemiology’s basic tool kit for understanding patterns and causes of an infectious disease are social in nature; our descriptive, causal, and modeling research (32, 33) will benefit from greater inclusion of social factors and social epidemiologic theory. Training in social epidemiology goes beyond methods of analyzing health disparities, which also come with plenty of implicit value judgments (34). We renew calls for the importance of epidemiologic theory (30)—particularly theories that emphasize the social production of disease, including political economy, social determinants of health, and ecosocial theory. Ecosocial theory in particular incorporates the biological, a key feature for an infectious disease, and recognizes sociopolitical determinants in ways that go beyond the scope of social determinants of health.

Integrating governance structures in epidemiology

Integrating social epidemiology into all epidemiologic practice demands we also consider political determinants of health (31). Though epidemiology has typically shied away from examining politics and policy (35, 36), pandemic-related outcome rates result from political choices (21). Implementation of COVID-19 mitigation policies has also reflected political positions and governance structures (37), and willingness to follow nonpharmaceutical interventions and get vaccinated have been strongly associated with political leanings (38).

Integrating politics and policies into epidemiologic work may require partnerships with persons in other disciplines with alternative assumptions and theories, such as sociologists, political scientists, and economists (39, 40). Additional investment in these capacities can include governance structure and policy analysis courses at the master’s and doctoral levels, as well as trainings by epidemiologic societies and at conferences. Together, these can reinforce the idea that these skills are integral to our practice as epidemiologists rather than external to our work. As an example of the potential uses of understanding governance structures, via state and local powers to protect public health, we examined the impacts of indoor dining on COVID-19 case rates, comparing cities that kept indoor dining closed with cities that were prohibited from keeping dining closed (via preemption) (41), by their respective state governments (42). Increasing recognition in research and practice, about the interactions of levels of government in enacting policy (43), will enhance epidemiology’s ability to affect policy and to understand the impacts of policies. Understanding and integrating governance and political factors, however, may not be sufficient to enact change; instead, epidemiologists would benefit from further integration and application of various theories of change and movement-building, including critical pedagogy (44), community organizing (45), and community-building (46) (as well as ecosocial theory’s emphasis on accountability and agency), to mobilize collective power for population health equity.

Investing in public health infrastructure

In our view, the hegemonic biomedical framing contributes to disproportionate investment in health-care provision compared with public health infrastructure. While the United States increased health-care spending between 2008 and 2018, spending on public health remained flat or even dropped (47, 48). This underinvestment in public health infrastructure has debilitated the US response to the pandemic (49). Although Congress allocated trillions of dollars to address the pandemic, much of this money was not accessible for public health investment, and in 2022 Congress stopped allocating money for state and local COVID-19 response (48). Part of this investment deficit relates to the constant drain of public health workers from public service due to lack of salary competitiveness, stressful working conditions, and even harassment and personal safety threats (50, 51).

One lesson we take away from this realization is that as epidemiologists, we can play a larger role in advocating for further investments in federal, state, and local public health. This includes direct advocacy and lobbying at all levels of government (but especially Congress) through public health organizations, an area in which public health activity resoundingly lags behind health care (52, 53). Public health professionals can engage in community organizing and collective action to generate sufficient political power to make political change for further public health investment. Universities can increase collaborations with local health departments, where there is a deficit of epidemiologists (48). Training of epidemiologists to understand and integrate theories of population health can diffuse into the general population’s understanding of health determinants, with care to avoid “health equity tourism” (54)—the process of investigators without the necessary expertise pivoting into health equity research. Shifting public narratives could in turn generate greater public support for public health capacity, as well as investment in social policy and the social safety net more generally. For example, media consumption that promotes the American Dream narrative deeply influences public beliefs about the need for redistributive policies (55), and this narrative may permeate normative understandings of health disparities.

CONCLUSIONS

In summary, and more than 2 years after the beginning of the COVID-19 pandemic, the reflections and recommendations posed by Dimitris et al. (1) remain valid. In particular, a year later, their lessons on acknowledging societal inequities and the role of homogeneity in the epidemiologic workforce in the underrecognition of inequities in exposure and outcomes, and the unsuccessful communication about inequities, are directly linked to our views here. We offer 2 further reflections and 3 lessons. First, we contend that shifting the narrative around the production of health towards its social origins, instead of purely biomedical lifestyle-oriented approaches, will help ensure improved and more equitable population health. Second, as epidemiologists we must grapple with and contest the role of capitalism and profit-making in public health activity and policy. To address these challenges, epidemiology would benefit from 1) improving training in theories of disease distribution, 2) integrating governance structures into epidemiologic work, and 3) strengthening investment in public health infrastructure.