↳ Epidemiology

April 7th, 2020

↳ Epidemiology

Big Horse

BOUND SPREAD

Histories of public health

Comparisons of responses to the Covid-19 crisis across national lines yield as many questions as answers. Divergent histories of public health programs, differences in cultural norms, population density, age distributions, and internal migration patterns create a muddy picture for causal understandings of the national variations in impact.

PETER BALDWIN's Contagion and the State in Europe 1830-1930 provides a fundamental historical study on these questions. The book explores the "reasons for the divergence in public health policies in Britain, France, Germany and Sweden" and the "spectrum of responses to the threat of contagious diseases such as cholera, smallpox and syphilis."

From the book's conclusion:

"Since at least the era of absolutism, preventing and dealing with contagious and epidemic disease have together been one of the major tasks of states. Given that, from the first European cholera epidemics to the cusp of the antibiotical era, the problem faced by each country has been much the same in biological terms, why have they responded in markedly different ways? Especially before the bacteriological revolution, etiological knowledge was inextricably bound up with political, administrative, economic, and geographic factors.

The fundamental implication of a political interpretation of public health is that prophylactic strategy and ideology are correlated. Approaches to prevention may be expected to reflect common assumptions held in a society as to where group and individual interests diverge, how much autonomy citizens can rightfully claim, the power of the community over its members. The right to be spared prophylactic imposition was not the only measure of liberty; there was also the freedom from disease. Traditional conservative quarantinists argued this line. Conversely, liberals objected to such interventions when they impinged on personal liberties too drastically or for insufficiently redeeming purpose. There was, also an understanding of public health that transcended such sterile oppositions between community and individual, holding that society’s concern with public health was a positive freedom that, while limiting absolute individual autonomy, returned to each a higher measure of liberation from affliction.

Such political interpretations of preventive strategies appear, however, to have inverted matters. It was not British liberalism or German interventionism (to take again the outliers) that, by themselves, determined prophylactic strategies, but the imperatives of geoepidemiology, and the associated factors identified here, that helped shape not only the preventive precautions they encouraged, but indeed the very political traditions of these nations."

Link to the book.

  • A new podcast from the Cambridge history department discusses Baldwin's book as a guide for thinking through the present crisis. Link.
  • For the classic international history of public health, see George Rosen's 1958 A History of Public Health. Link. And see his 1947 paper "What Is Social Medicine?" Link.
  • "After yellow fever was firmly ensconsed, it underpinned a military and political status quo, keeping South America under Spanish rule. After 1780, and particularly in the Hatian Revolution, yellow fever undermined the status quo by assisting independence movements in the America tropics." A 1999 article by J.R. McNeill on "Ecology, Epidemics, and Empires." Link.
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March 9th, 2020

Flanked by Two Dolphins

SYSTEM CIRCULATE

An ecosocial theory of disease

The correlation between health, income, and wealth is widely recognized in contemporary research and policy circles. This broadly social understanding of public health outcomes has its origins in a theoretical tradition dating back to the 1970s and 80s, in which scholars began to embed medical research within a political and economic framework.

In a 2001 paper, epidemiologist NANCY KRIEGER seeks to strengthen the theoretical foundations of epidemiological research by linking them back to biological study.

From the paper:

"If social epidemiologists are to gain clarity on causes of and barriers to reducing social inequalities in health, adequate theory is a necessity. Grappling with notions of causation raises issues of accountability and agency: simply invoking abstract notions like 'society' and disembodied 'genes' will not suffice. Instead, the central question becomes who and what is responsible for population patterns of health, disease, and well-being, as manifested in present, past and changing social inequalities in health?

Arising in part as a critique of proliferating theories that emphasize individuals' responsibility to choose healthy lifestyles, the political economy of health school explicitly addresses economic and political determinants of health and disease, including structural barriers to people living healthy lives. Yet, despite its invaluable contributions to identifying social determinants of population health, a political economy of health perspective affords few principles for investigating what these determinants are determining. I propose a theory that conceptualizes changing population patterns of health, disease and well-being in relation to each level of biological, ecological and social organization (e.g. cell, organ, organism/ individual, family, community, population, society, ecosystem). Unlike prior causal frameworks—whether of a triangle connecting 'host', 'agent' and 'environment', or a 'chain of causes' arrayed along a scale of biological organization, from 'society' to 'molecular and submolecular particles'—this framework is multidimensional and dynamic and allows us to elucidate population patterns of health, disease and well-being as biological expressions of social relations—potentially generating new knowledge and new grounds for action."

Link to the piece.

  • Krieger's 1994 article takes a closer look at epidemiological causal frameworks, questioning the adequacy of multiple causation. And her 2012 paper asks: "Who or what is a population?" and articulates the analytical significance of this definition for epidemiological research. Link and link.
  • "Disease epidemics are as much markers of modern civilization as they are threats to it." In NLR, Rob and Rodrick Wallace consider how the development of the global economy has altered the spread of epidemics, taking the 2014 Ebola outbreak as a case study. Link.
  • Samuel S. Myers and Jonathan A. Patz argue that climate change constitutes the "greatest public health challenge humanity has faced." Link.
  • A history of epidemics in the Roman Empire, from 27 BC – 476 AD, by Francois Relief and Louise Cilliers. Link. And a 1987 book by Ann Bowman Jannetta analyzes the impact of disease on institutional development in early modern Japan. Link.
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