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0:00
>> All right, good afternoon or whatever it is in your time zone. Welcome to Preventive Medicine Grand Rounds for October 5, 2022. I'm Antonio Neri from the Division of Scientific Education and Professional Development. The Preventive Medicine Grand Rounds is sponsored by the CDC Preventive Medicine Residency and Fellowship, as well as the Health Resources and Services Administration Bureau of Health Workforce. The PMRF provides 12- and 24-month full-time longitudinal learning
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opportunities with senior public and population health meters for physicians, veterinarians, and nurses who have completed the CDC epidemic intelligence service program, or have equivalent public health experience. We use Zoom for the audio and presentation, and there's a question box in the bottom to pose questions. You can post questions via the text question box at any point during the lecture, and the speakers in this series will work on answering them at the end.
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Note, your name may appear associated with the question you pose. If you do not want your name to be associated with the question, then please check submit anonymously on the box. Continuing education credits are available for the live course up to one month after the presentation date and, for the recorded version, up to two years from the date of the presentation through CDC's Training and Continuing Education online portal. The course code for this Grand Rounds is all capital letters
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CDCPMRF again all caps CDCPMRF. You can find that information on our website cdc.gov/prevmed and under Grand Rounds tab as well. If you have any questions, please contact the program at prevmed@cdc.gov.
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Please remember that the views presented by the speakers are theirs alone and do not necessarily represent CDC, the Department of Health and Human Services and the US Government. Before we start, we'll take our usual moment of silence for our colleagues, friends, and families who've dedicated their time, energy, and sometimes lives fighting the COVID-19 pandemic.
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Okay. Today's presentation will be Public Health Law and Legal Epidemiology by Matthew Penn and colleagues at the CDC Public Health Law Program. Matthew, the stage is yours. Thanks for coming. >> Great. Thank you so much, Tony. Good afternoon, good morning, everyone, depending on where you are. My name is Matthew Penn, and I am the director of the Public Health Law Program here at CDC located in the Center for State, Tribal, Local, Territory Support. And as Tony said, this is Grand Rounds.
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We're going to be talking about public health law, legal epidemiology, health equity, and a host of other topics. So, if you are thinking you are coming into something else, then that's what you're going to hear about today. And hopefully, you'll stay with us to learn a little bit more about these topics that that we work on. Next slide, please. So, a big thanks to the Grand Round folks for having us and a really big thanks to Darian, who you'll meet just a little bit later in a few slides,
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for helping organize us in the Public Health Law Program to get these slides together in the presentation. So, hopefully, you will find today informative and enjoyable. Here's just a bit of a glance, super simple agenda for us. Of course, multiple speakers now allow them to introduce themselves as they go through their slide sets and their presentations. First, we're going to talk a little bit about just an introduction to law as a part of public health. Why do we pay attention?
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Why is it important to pay attention to law when we think about public health and the public health system? We'll then go into a little bit more detail in Introduction to Public Health Law itself and an introduction to legal epidemiology, a little Legal Epi 101. We'll then cover the relationship between public health law, health equity, and legal epidemiology. We'll see some examples of public health law and legal epi in practice. And then finally, we'll look at some examples of the application
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of public health law legal epi to the COVID response through the mitigation policy analysis unit, examples of research that they produced. Next slide, please.
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So, right into it. As I said, my name is Matthew Penn, director here at the Office of Public Health Law Services, aka the Public Law Program. I've been at CDC about 11 years, little over 11 years, and before that, I was a staff attorney with the state public department in South Carolina, so about a 20-year career in public health, and particularly in the sector of public health law. Next slide, please. So, let's dive into the first question, and really a big question, having to do
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with why public health law? Why do we pay attention to public health law? And really, how does law affect health? In the tradition of social epidemiology, health is considered a product, the interaction of our genes, our behavior, and where we spend our time. Health is not simply a consequence of using healthcare services. We've known this in public health for years. Most of the things we do and most characteristics of our environments have some impact on how healthy we are,
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and of course, that translates into population health. And in our society, the process of enacting and enforcing laws is a common approach to shaping environments, behaviors, and ultimately, health. And this is true at the local level, the state level, the tribal level, the territorial level, and of course at the national level. Next slide, please. So, let's talk about law as a factor that affects health. Laws can make us sick. Laws can make us healthy. What does that look like?
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You've probably seen this picture before. Shows life expectancy along a highway in California. And as you can see, the circles here are the life expectancy, and then these rectangles are exit numbers along a limited access highway. And as you can see, there's a 12-year difference in life expectancy between two counties within miles of each other. And a question, as a good public health researcher would ask, why is this? Why such a discrepancy in counties that actually share a border?
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And this is a perfect question for the relationship between law and health, and a good question for legal epi, legal epidemiology to help answer. Legal epi investigates how differences in the existence or the enforcement of certain laws affect health. Merced County may include regulations about smoking, road safety, or clean water, while Fresno County law may not have those same structures. Or maybe Merced County and Fresno County have the same laws, but they differ
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in how they enforce those laws. Of course, there's many confounding factors. There could also be environmental and socioeconomic variables to consider. For instance, you know, is one more rural? Is one more urban? But then I would ask you to think about the socioeconomic factors and environmental factors that surround you, and try to think of some of those that are not some way impacted by local ordinances, city ordinances, county ordinance, or state laws, or federal laws. Next slide, please.
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The five-tier pyramid, the health impact pyramid, from our former boss, Dr. Frieden. The five-tiered pyramid on this slide provides a framework for how to address a whole host of public health issues. When it comes to shaping health outcomes and societal behavior, law has two very important roles. First, law helps build and maintain the social, economic, and physical worlds where we live, learn, work, and play. Again, it's hard to sort of look around where you are and look
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around the worlds where you spend time and think about things that are not shaped by laws. The houses we live in, the buildings we work in, the cars we drive, the playgrounds we access, the open spaces that we access, these are all touched by law in one way or the other. But secondly, law acts as a mechanism for changing social and economic structures, and these changes can affect the distribution of health in a population. For example, the health outcomes for a person considered
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to be poor are shaped by specific experiences with legal rules, institutions, and agents. These experiences may be quite different from the experiences of people who are considered wealthy. Next slide, please.
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Studying how the law affects health presents opportunities and challenges. This is because law can be a natural experiment, a natural experiment where one that occurs in everyday life and a natural experiment we are not randomly assigned to control or treatment groups. Instead, we are affected by laws that expose or subject us to different outcomes. And we know from civics, we'll learn a little bit more about this with Darian's presentation. But there's tremendous variation in this country,
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from jurisdiction to jurisdiction, in laws, how they're written, how they're enforced, and that's what leads to this idea that natural experiment. For instance, we could imagine populations living in different states with different minimum wage laws. There could be different health outcomes associated with higher or lower state minimum wage requirements. Next slide, please. So, from a research perspective, the law, as a natural experiment, presents many opportunities.
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When multiple states pass the same law, studies that assess laws across jurisdictions over time can produce results with strong causal connections. These studies are called quasi-experimental studies. They let us observe the effects of laws before and after these laws were implemented. Once the law goes into effect, we can do qualitative research and look at how the laws are implemented, and then track those impacts over time by creating longitudinal datasets. Next slide, please.
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There are also challenges when relying on the law as a natural experiment. Laws are rarely amenable to true experimental designs, which are those that establish cause and effect relationships. Without an experimental design, it's harder to account for the other confounding factors that I mentioned earlier that may contribute to our natural environment. Even if we can't establish cause and effects, we can still track associations between law and certain outcomes, and certainly create resources
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for jurisdictions on best practices and whatnot. And this contributes to the overall body of evidence on an issue. Next slide, please. So, just, as we go through today, it's helpful to just kind of ground ourselves and take a moment to clarify what we mean by law. We've been discussing the role that law plays in shaping health, but it's important to understand that the law can take many different forms. When we're talking about these things, sometimes we talk
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about the laws on the books and laws as written down in statutes, regulations, judicial opinions, local ordinances. Legal practices include interpretation, implementation, and enforcement of laws on the books and agencies. Practices also include agency-level policies that can organize implementation and enforcement. They're taking and applying the laws on the books. And then, finally, legal perceptions include beliefs about laws and how they enable or prevent agency actions.
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And to be clear, and as an important point, the legal perceptions include beliefs and ideas about the law. These beliefs and ideas can be accurate, and sometimes they can be inaccurate. And in both categories, they can significantly affect the way that laws are implemented. Law has many facets, all of which can impact the public's health. So, as we go through today, we'll learn more about the law itself. We'll learn about legal epi, how we study the law,
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how law factors into health equity, and here's some examples of legal epidemiological research. So, for now, this is it for me. You'll see me again at the end here. But so for an introduction to public health law and legal epi, I'll turn it over to Darian and let her introduce herself. And as mentioned before, we did build in some time for questions at the end. So, next slide and hand over to Darian. Thanks so much. >> Thanks, Matthew. Hello everyone. I'm Darian.
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I'm a staff attorney for the Public Health Law Program, and I'm just going to quickly go over today a brief 101 of public health law and legal epi before we get into more of the applied in practice examples. So, first, what is public health law? When we're thinking of public health law, we typically use the suggested definition provided by Lawrence Gostin at the Georgetown's University of O'Neill Institute for national and global health law. So, public health law is the study of the legal powers
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and duties of the state in collaboration with its partners to ensure the conditions for people to be healthy, and the limitations on the power of the state to constrain the autonomy, privacy, liberty, proprietary, and other legally protected interests individuals for the common good.
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So, many of you are likely somewhat familiar with the 10 essential services of public health. Similarly, we have public health law has its own essential services: access to evidence and expertise, expertise in designing legal solutions, helping to engage communities and build political will, support for enforcement in defense of legal solutions, and policy surveillance and evaluation. As we move forward, it's helpful to keep these in mind because they highlight how legal researched
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and legal epi directly contribute to public health law and inform the field's present and future work. These five services are formed by and in relationship to one another, and they do not operate in isolation. For example, improving public health requires the best available science, the active engagement of community leaders, and the effective use of legal tools to justify and support strategic policy choices, implementation mechanisms, and enforcement structures
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that will ensure the health for future generations. It's also important to note that public health law is really interdisciplinary. So scientific legal, educational and advocacy work are all necessary for the timely adoption and dissemination of effective legal interventions. So, any given activity may involve a variety of leaders, such as researchers, scientists, government officials, businesses, the community, religious organizations, and more.
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So, let's take a few minutes to discuss why law is so important to public health. In public health law, we are commonly using law as a tool of public health. But before law can be used as a tool, we must look at the larger scope of the importance of laws. Specifically, the article below mentioned how law is a social determinant of health and can be associated with health outcomes. So, like I said, law functions as a social determinant of health whether embodied in constitutions, statutes,
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regulations, executive orders, administrative agency decisions, or court decisions. The law plays a profound role in shaping the circumstances of people's lives and, in turn, their health. The ways in which this occurs can be broken down into the four categories seen. First, the law can be used to design and perpetuate social conditions that can have substantial physical, mental, and emotional effects on individuals and populations. Second, the law is a mechanism by which health
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and wellbeing is distributed among populations, and it reflects the society's prejudices. For example, healthcare discrimination and biases can take many forms, can be based on race, ethnicity, disability, age, gender, and class. Third, under-enforcement of laws can determine health. For example, a robust set of housing regulations designed to keep housing units safe and clean are of little value to a community's health if there is neither the will nor the resources to enforce them.
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Finally, the law can be used to structure direct responses to health, harming social needs that result from factors like impoverishness, illness, market failures, and individual behaviors that harm others. So, now that we know a bit about public health law, let's look directly into what is legal epidemiology? So, legal epidemiology really looks at the type of effect law has on health. So, legal epidemiology, also referred to as public health law research,
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is the scientific study and deployment of law as a factor in the cause, distribution, and prevention of disease and injury in the population. It really is a connection of traditional legal study and a study of scientific processes. Merging these two disciplines, epidemiology provides a scientific approach to studying the impact and effectiveness of laws on health. So, studying the law through a scientific lens is very different from the way lawyers analyze law in a traditional legal research.
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Legal research typically is going to focus on how a legal rule may be applied to a particular situation, and it typically focuses on a current law. However, legal epi is going to be additional principles, including being scientific in its approach, systematic, transparent replicable, precise [inaudible] rigorous quality control. And finally, it's measured. It's created to be evaluated. So, as you can see, it really is a measure of legal and scientific work.
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There are checkpoints throughout the process that ensure it's systematic, ensure it's revocable, meaning that if we do the study in 2020, we'll be able to update the study in 2024 by knowing how we did the assessment, what we studied, what were the key factors we were analyzing, so you can easily recreate it with new data. So, now let's go over the different types of legal epidemiology research. So, there are two components to legal epi studies. There is legal mapping and evaluation.
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Legal mapping is a process for capturing important features of laws and policies and for identifying how they vary across jurisdictions or institutions and over time. So, within legal mapping, we have policy surveillance which collects data over time and creates longitudinal datasets. And then we also have Legal assessments, which is going to collect data at one point in time and create a cross-sectional dataset. Then we also have legal evaluation,
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which is the systematic way of collecting, analyzing, and using data to examine the effectiveness of programs. Statisticians and evaluators overlay legal data generated from the legal mapping side with health outcome data to determine whether the law has a positive, negative, or no effect on health. So, evaluation, in this context, may involve exploratory studies. So, it's going to be qualitative, like interviews, surveys. After legal mapping, we might reach out to states
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and conduct interviews to learn what they are actually experiencing, compared to the law itself. And there could be quantitative studies, so the numbers like numerical or economic data. Then we also have explanatory studies. So, to put it into perspective, most, if not all of you, are more familiar maybe with traditional public health law practice, which involves the factors of legal counsel, representation in research. However, legal epi differs in that it's going
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to involve legal etiology, so the study of laws and legal practices as causes of disease and injury. Legal prevention and control, which is the study and application of laws and legal practices as interventions to prevent disease and injury. And then policy surveillance, as I mentioned before, the ongoing systematic collection, analysis, and dissemination of information about laws and other policies important to the health. And again, they certainly overlap each other,
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but there is a slight difference between what we think of as traditional versus legal epi research within public health law.
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So, now that we understand what legal epidemiology is, let's discuss why we might use it. First, legal epidemiology can help us achieve important results. It turns law into data for statistical analysis. It creates valid, replicable studies that inform both legal and public health practice, and it tracks trends across jurisdictions and over time. Legal epidemiology also supports qualitative studies and answers research questions. It shows the impact and effectiveness of laws on health,
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and it informs best practices and research innovation for the field. So, really, it all boils down to legal epidemiology makes the laws more evidence based. So, here's a graphic developed following CDC's 2019 update of a school vaccination law legal epi assessment. This assessment studied the types of exemptions available by state and provides an example of a final deliverable after a completed assessment, the snapshot of the language of laws across time.
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So, you can see, the states are the outside of the circle, and then we have been able to use these colors to show what language might be included within these state's exemption laws.
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Finally, before we move into how legal epi can be applied in practice, I want to highlight a few complexities that come with legal research. It's important to be aware that legal research can be very useful in providing additional data, but takes time and resources to lead to the deliverables as seen with the school vax exemptions. So, to review complexities, I'll go over a few myths that come up with legal research. So, one myth commonly believed is that there may be a single law
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on the topic someone wants to research. However, sadly, this is false. There are many laws on every topic, and it is rarely only one that exists. Thus, deciding what types and categories of laws to scope in and out for a project is a crucial step to narrow down the laws reviewed. Additionally, we take ample time to create a strong search string that eliminates irrelevant laws to narrow down the laws needed for scoping, or else maybe our team will have
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to review thousands of laws for each project. Another myth is that there is a database that has all the laws you need and can be easily downloaded. Sadly, this is partly false. There are legal databases like Westlaw that we use at PHLP that do provide most current laws for states. However, they still require searching to find the relevant section within. Additionally, Westlaw is not always dependable. It does not include things like executive orders and emergency rules.
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The update to laws may be a bit behind, and there's sometimes incomplete information on cases. Additionally, note that it's not simple to google laws either. There are many third-party sources that do collect and report on laws. However, these can really vary dramatically in terms of completeness, how up to date it is, accuracy, and even terminology. The next myth we have is that you just need the law on one topic, so, overall, it should not take much time. Sadly no.
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Assessing laws and their impact on health is a time-consuming process. As we went over, there is no single dataset to begin with, so it takes time to search throughout 50 states and build our data. Additionally, we do continuous quality control over the process to ensure the final dataset is appropriate. So, for example, meeting with subject matter expert groups for feedback during the initial stages takes time to really get through it and is not quick and easy.
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Finally, the last myth is that once we have the laws, it is easy to create a coding scheme to answer yes-or-no questions about the laws. This is also false. We rarely are able to use yes-or-no questions as we are assessing complex topics and this qualitative data of these laws' language. So, many of the laws may fall somewhere in between yes or no, so it's important for our team to continually assess and decide what constitutes each answer choice. Typically by creating a codebook
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for consistency among all coders, we'll go through and decide, yes is going to be defined as these options compared to no would be anything else.
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We also will typically our coding schemes may be comprised of a parent question that has yes or no and then many child and grandchild questions that may use categorical responses like select all that apply. So, with these questions, it's common that they need continuous editing of answer responses because we may begin to read the laws and find out about new choices that should be added to create more of an encompassing answer choices that then have to be recorded.
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So, now I'll transfer it over to Sam that'll discuss more about the topic of legal epidemiology and the intersection of health equity.
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>> Thank you, Darian. Hello everyone. My name is Sam Bent Weber. I'm a lead for research innovation and workforce capacity building with the Public Health Law Program. I'm happy to be here with you all today. Next slide, please.
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So, I'll be talking a little bit about health equity and legal epidemiology and sort of highlighting the relationship between the two. As a starting point, we might define some baseline terms, health equity being the principal one. When we talk about health equity, we're talking about a set of conditions in which all people are able to achieve their best possible health, regardless of their social status, as exemplified by factors like their geographic location, their economic status,
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racial, gender, or other characteristics. Next slide, please. And so with that in mind, we want to think about the relationship between health equity and law. And as we've sort of heard over the course of our time together, we've learned that laws a determinant of health, a foundational determinant of health. And just as law is a set of rules, policies, and practices that can create disadvantage, it can also be imperative to transforming those conditions of disadvantage.
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Law plays a central role in achieving two ends. It can profoundly shape the context in which people live, to increase their access to the things they need, and make it easier for them to make decisions about their health. Law also has the power to redistribute resources and to make the things that people need to live healthful lives more accessible. Next slide, please. And so in recognizing that law is a foundational determinant of health that can be critical to advancing equity,
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we can also imagine that public health practice can be expanded to include a more robust understanding of and engagement with law and policy that's really connected to the principles articulated here by Dr. Liburd about sort of the need for health equity to help us imagine that we can venture beyond our boundaries in public health practice to explore more expansive areas outside of sort of traditional public health spaces or what we might characterize as traditional public health spaces,
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and law is a key feature of that. Next slide, please. And so law can be a key tool for informing and shaping the strategies that public health deploys to change the context in which people make decisions about their health, as well as to address the socioeconomic conditions that give rise to many health inequities. Next slide, please.
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At CDC, we have laid some groundwork for incorporating law into public health practice. Next slide, please. That groundwork includes frameworks and strategies that seek to do more than simply document disparities, so highlight the ways in which particular populations experience and manifest health disparities and inequities, identify and focus on key interventions, and facilitate collaboration across disciplines and areas of expertise, and identify policy solutions that are rooted in science.
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So, as we've been talking about legal epidemiology over the course of the last bit of time, legal epidemiology is a key feature of all of these aims articulated here. Next slide, please. These frameworks also leverage existing approaches to public health practice that center health equity, including the 10 essential public health services, which features law and policy and policy development as a key set of strategies for pursuing and advancing equity, as well as Healthy People 2030.
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Next slide, please.
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And these frameworks also recognize law as a key component of the infrastructure that forms public health efforts to address health equity. Next slide, please.
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And so in summary, what does it mean for a law to fit into public health practice and into the strategic aims that I've highlighted here? Well, law can be studied. As we've been saying, legal epidemiology or the systematic study of laws and policies can help us to trace the relationship between structural conditions and health outcomes to sort of help us pursue that aim of going beyond documenting disparities and identifying root causes for health inequities. Law can also be translated.
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So, when we undertake that research, those systematic analyses, law can actually -- the storytelling dimension of law can actually be a central feature to our strategies for how we tell the stories of the impact of laws and policies on people's health and wellbeing. And law can be a key strategic feature in the way that we pursue and facilitate change in the context of public health practice. Next slide, please. And so here, I'd just like to end with A Pathway
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for Public Health, Law, and Health Equity. This is really meant to inform the work of health department practitioners working in public health departments, but an argument can be made that it can inform the work of all public health practitioners and folks working in public health adjacent settings. So, that pathway includes a few steps, identifying local and beyond health equity challenges. So, really investigating the sources of health inequities
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and the ways that communities identify those inequities and the sources of those inequities. Correspondingly, designating law as a key determinant of health, so recognizing that it is part of the story of both the sources of health inequities in jurisdictions as well as a source of solutions to health inequities. Studying law and its impact on health outcomes, so deploying legal epidemiology and public health law research to not only understand what the law says and what it does
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and how it helps to facilitate health inequities and solutions, but also evaluate those laws and their potential impacts for health and wellbeing. And then use legal concepts and strategies to translate that research and to disseminate that research, drawing upon the voices of communities and practitioners and researchers, diverse transdisciplinary voices, to sort of articulate how the law shapes environments and people's health and wellbeing, and then think about
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and incorporate legal strategies into public health efforts to advance change. I'm going to end there and turn things over to my colleague, Rachel Hulkower, who's going to talk about public health law and practice. Thank you.
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>> Thanks, Sam. Hi everyone. I'm Rachel Hulkower. I'm the lead for Legal Epidemiology Research Design & Implementation in the Public Health Law Program. I'm going to walk us through an example of sort of the full spectrum of a legal epidemiology study, starting with a legal mapping study of 2015 Medicaid prior authorization policies for medication treatment of ADHD in young children, which was accompanied by an evaluation of the impact of a Medicaid prior authorization policy
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on prescription rates of ADHD medication among young children in Illinois, specifically. Next slide, please. So, in 2011, the American Academy of Pediatrics updated its guidelines for the diagnosis and treatment of children with ADHD to recommend that clinicians recur parents of preschoolers, typically aged four to five years, for training and behavior therapy, and subsequently treat with medication if behavior therapy fails to sufficiently improve functioning.
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Data available from just before the release of these guidelines suggested that fewer than half of preschoolers with ADHD received any behavior therapy and about half received medication. And then also about half of those who received medication also received some behavior therapy. So, prior authorization policies for ADHD medication we hypothesized may be a tool for guiding physicians toward prescribing recommended behavior therapy. Characterizing the existing prior authorization policies
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across the country was an important step towards evaluating the impact that these policies might have on treatment patterns. So, we inventoried existing prior authorization policies from Medicaid across the country and characterized policy components to inform future evaluation studies. And in 2017, we found that 27 states had Medicaid policies that prevented approval of pediatric ADHD medication payment without additional provider involvement of some sort. And seven of those 27 states required
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that prescribers indicate first whether non-medication treatments had been considered and tried before Medicaid payment for ADHD medications would be approved. So, from here, our next step was an evaluation to determine if certain policy interventions like this could guide families towards the use of behavior therapy as the first ADHD treatment for young children. Next slide, please, Jarian. The policy evaluated in this analysis was implemented by the Illinois Medicaid program in August of 2009,
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and applied to the prescription of ADHD medications for children younger than six years. The policy required the submission of a set of required clinical information to be reviewed by the State Department of Health Care and Family Services before the physician was authorized to prescribe ADHD medication to a young child. So, we looked at Medicaid analytic extract files, MAX files, which included data from 2007 to 2012, providing information for two full years before the 2009
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policy went into effect and three full years after. The number of children aged two to five years, who received at least one prescription for an ADHD medication in each quarter, was tabulated, and an associated ADHD diagnosis code was not required. Children who were aged six years served as the comparison group because they were not subject to the policy in Illinois. And then trends before and after implementation of the policy were compared using logistic regression controlling per season.
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Next slide, please, Jarian.
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So, these are some of our results. Approximately 6 to 6.5 children per 1,000 age two to five years received ADHD medication each quarter in 2007, compared to 4.3 to 4.9 children per 1,000 in 2012 and three years after the prior authorization policy was implemented for ADHD medication prescribing in this age group.
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So, after policy implementation, this seasonality adjusted decrease in the percentage of young children receiving ADHD medication was larger for children aged two to five years than for children aged six years who were the children not affected by the policy. And these results showed a decrease of 25% among two to five year olds, compared to a decrease of 5% among six-year-olds. Next slide, please, Jarian. And this is continued look at the number of children receiving ADHD medication
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by quarter per 1,000 children in Medicaid before and after the implementation of the prior authorization policy in Illinois. And again, we see that the percentage of children aged two to five who received ADHD medication decreased following the prior authorization policy and demonstrated a larger decrease than the one seen among six-year-olds in the same time period. So, generally, these results suggested that a prior authorization policy could affect the rate
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at which young children receive ADHD medication when compared to the slightly older group of children for which the policy was not applicable. So, that's a general walkthrough of an example of the legal mapping and legal evaluation piece together that we've done in the past, and I'm going to turn it over to Mara Howard-Williams to talk about another example.
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>> Hello, I am Mara Howard-Williams. I led the Mitigation Policy Analysis Unit on CDC's COVID-19 response for quite a while. And our unit was tasked with collecting, coding, and analyzing COVID-19 related laws throughout the pandemic, using legal epidemiology methods to provide up-to-date information on the status of and trends in the law. Today, I'm going to talk about some of the ways that this legal data was used, including measures that were used early on in the response,
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like stay-at-home orders, bars and restaurant closures, gathering bans and mask mandates, as well as some additional newer data that we had from later on in the response. Most of the section is going to look at our publications, but I'd like to briefly cover some other uses. And so our data and studies have been cited in congressional testimony, in judicial opinions and legal briefs submitted to courts, news articles, and an academic research.
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And the public also viewed and used their data directly. Next slide, please. So, we maintain pages on COVID data tracker that used our data to show what state-issued mitigation measures were in place for each day, for each county. As you can see here, even in late 2020, there was considerable variability for bar closures by state and even by county within a state. Measures changed frequently early on, and so we wanted to provide a place where everyone from the general public, to policymakers,
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to researchers could see the status of mitigation measures nationwide. Next slide, please. We also have the county focus points, right, so users could select a specific county to view more details. And that included toggles for other measures with overlays for metrics like case counts and deaths, and even things like mobility to visualize changes over time within that county. As of August 2021, these policy pages on COVID data tracker had been viewed tens of thousands
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of times, indicating its potential utility to the public. Next slide, please.
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So, while legal epi can contribute to scientific literature and inform which laws produce the greatest impact, it can also be used for situational awareness, trend analysis, and for technical assistance. This slide shows an example of a common situational awareness request that we received during the response and using our vaccine mandate data. This shows the number and type of vaccine mandates applicable to different worker groups that were in effect on February 25 of 2022.
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You can see here that there's lots of different worker groups. The different types include those that required vaccination in lieu of recurring testing, vaccination that also you could opt out by using recurring testing. And so, these have changed over time, but many of these are still in effect, though some have since been lifted. And these mandates were implemented using a wide array of legal mechanisms from executive orders to health department orders and emergency rules.
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Some states even modified their licensing requirements as a way of mandating vaccine for worker groups. That was most common with like healthcare workers. But there's a lot of variability even beyond what's portrayed in this slide. So, for instance, some mandates that allowed religious exemptions required a letter from an individual stating that this vaccine conflicts with their religious beliefs. Other jurisdictions required a notarized affidavit
45:22
from a religious leader of a recognized organized religion. You know, graphics like this helps to give an overview, but there is still quite a bit of variability beyond that. And these laws are frequently modified, so we ended up aggregating these weekly and sending out a report to the response leadership and to some colleagues at FDA to keep them up to date on the evolving landscape of these vaccine mandates. We provided this quick look along
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with some more in-depth data with comprehensive tables to inform as decision makers were facing new challenges regarding vaccination rates and what was really happening in the jurisdictions related to vaccinations. But while some of these mandated vaccines, others prohibited entities from requiring their workers to be vaccinated. Next slide, please.
46:13
And so, we also monitored state laws that restricted an entity's ability to mandate vaccinations to different groups of people. You can see three types of those on the slide here. So, those that are outright prohibitions on requiring vaccination. There was a prohibited vaccine task force is what they're very commonly called, or, you know, required proof of vaccination documents, and then also those that would allow any type of exemption. So, you could just say I don't want it
46:40
for philosophical reasons and be exempt from a mandate if one was in place. We tracked these laws over time, and we followed lawsuits against them. Many of these were challenged in courts. And so, we tracked the judicial opinions to give updates to response leadership and to help those that were working in the states kind of understand where these were in the legal cycle, right? Have they been challenged? Have they been challenged and struck down temporarily?
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Have they been struck down permanently? So, providing that on the ground situational awareness.
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Next slide, please. And so now, we're going to turn to how these legal epi data have been used in some publications. So, in a March 2021 MMWR, we looked at two different legal epi variables: mask mandates and restaurants. We found that implementing a mask mandate was associated with a decrease of COVID-19 case and death growth rates within 20 days of implementation. And we also found that lifting restaurant restrictions to allow on-site dining was associated with an increase
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of COVID case and death rates beginning 41 and 61 days after implementation, so 41 for cases, 61 for death. And this publication is widely reported on in the news and may have informed the public about, you know, how these different factors might impact the spread of COVID-19. The next slide, please. In a different analysis, we looked at one aspect of the relationship between mitigation measures and the economy. So, we used county-specific mask mandate data from state-issued executive orders.
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We also use consumer-spending data from Opportunity Insights Economic Tracker, and we used COVID-19 case and depth data from COVID Data Tracker. And so, we compared county-level changes and consumer spending both before and after state-issued closure orders were lifted and assessed the interactive effects of state-issued mask mandates. We found that overall consumer spending increased, but that increase was 1.2 to 1.7 percentage points higher in counties with a state-issued mask mandate in place
48:54
when they reopened than in counties that did not have one in place. So, this suggests that state-issued mask mandates may have assisted economic recovery during the COVID pandemic, making them a strong public health strategy for policymakers to consider now and for future pandemics that result from airborne illnesses. Next slide, please. And yet another study. In this one, we use seroprevalence data, so blood-donor data to assess the prevalence of COVID-19 as an outcome of interact.
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And so and seroprevalence is unique for us to use because it doesn't necessarily indicate a current infection, but it does capture current or past cases for people who may not have gotten tested for COVID, right? If they're asymptomatic and didn't know they were exposed or if they didn't have access to testing, right, all sorts of reasons why that might have happened. So, using this blood-donor data and this [inaudible] data, in our state-issued orders that were coded to the county specificity,
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we looked at the continuous presence or continuous absence of mask mandates, gathering bands, and bar closures.
50:02
The county were included of having a particular policy in place if that policy applied continuously during the study period, which was August 1 of 2020 to March 30 of 2021. We found that, overall, the presence of any mitigation measure was associated with lower seroprevalence and that measures in combination were associated with lower seroprevalence were more -- measures in combination were associated with lower seroprevalence than individual measures alone. So, here on this slide, you can see
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that All Policies line has the lowest seroprevalence overall and that the No Policies line, which actually started out lower than the mitigation measures category ended with the highest rate of seroprevalence. Next slide, please.
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This slide is from the same study, and it shows the seroprevalence rates of counties with continuous mask mandates, as compared to those without them, which is demonstrated to have the largest effect of a single policy in this study. So, as you can see, the difference in seroprevalence rate increases over time, demonstrating the increasing potential impact of sustained mask mandates. Next slide, please. And the last one that I'm going to talk to you about today is a trend analysis.
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So, in this study, we looked at how state-issued orders translated to the percent of US population covered by those orders from March of 2020, to August 15 of 2021. So, this is showing one of the mitigation measures, gathering bands, showing the percent of the US populations that are covered by a gathering restriction that allowed no more than 10 people to gather, or a gathering restriction that allowed more than 10 people to gather, but did have some sort of gathering restrictions still.
51:51
Or, three, there was no gathering restriction in place. So, you can also see overlaid on this chart, so seven-day average of daily COVID cases. We looked at other mitigation measures in this study as well. So, we do have similar graphics for restaurant restrictions, bar restrictions, and masks mandate. But overall, we found that most of the US population was covered by multiple mitigation measures in the March to April timeframe of 2020. States began to relax all of the mitigation measures,
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except for mask mandates, in the summer of 2020 through the first half of 2021, as the COVID case rates began to decrease. But by August 15, 2021, most of the population was not covered by any measure, despite cases increasing, beginning in June of 2021. So, in future pandemics, periods of high disease transmission with low percentages of population covered by mitigation measures might provide an opportunity for officials from other levels of government, such as city,
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county, federal governments to mitigate disease transmission by issuing new prevention policies for their respective jurisdictions. And that sums up some of our use cases for our legal epi data, and I will turn it back to Matthew Penn. >> Oh, great, thank you so much Mara and hello, everyone, again. I'll just wrap things up here, and then we're going to have plenty of time for questions and discussion. And just a kind of a concluding thought, I think one of the things that you're seeing here
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with the presentations today and the development of an evolution of the public health field is, over the past 10 years or so, we've really gone from public health law being seen in a very traditional way similar to other fields of law. So, the idea of law being the domain of lawyers only thinking of law and legal activities within health departments as lawyers representing the health departments in various capacities, including providing legal advice,
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potentially providing litigation services and general counsel to leadership within the health department. And what we've been doing over the past now 10 plus years, little over 10 years, is really expanding the concept of law in a way that it sits within the field of public health. And this is where these ideas of legal epidemiology come in, in thinking of law in a much more holistic way, and understanding the reality that public health law is a transdisciplinary practice.
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One of the questions in the Zoom Q&A was about whether or not you needed a JD to do legal epidemiology. And the answer to that is no, and I would, in fact, go beyond that and say that most of the public health law in this country, in the public health system, is practiced by non-lawyers. You know, when I was in the health department, you know, I tell the story in various presentations like this, you know, I would often be in very large meetings, you know, 15, 20, 30, 50 people.
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And the sole thing on the agenda, sometimes for hours, would actually be public health law, the authorities of the health department, and what do they mean? How do we implement them? How do we amend them to modernize them or make them better? And in this room of many, many, sometimes dozens of people, I would be the only attorney. There would be a sole JD there to assist. And oftentimes, in those meetings, I would actually speak very little. And it was all of the other folks, the leadership
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of the health department, the division directors, the branch chiefs, the sanitarians, who were out in a local health departments doing frontline public health. They would be the one discussing public health law and what it meant and how we used public health law to impact the public health of the folks in South Carolina where I was. So, this idea that public health law is transdisciplinary in its reality is not a new thing. It's just something that we've come to recognize,
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and we've come to understand the importance of calling that out to the public health field at large. And of course, we've added in this idea that we can scientifically study law as a factor in the cause distribution and prevention of disease and injury. Again, we've always used law in that way. And the thing that we're trying to change and what we've been doing with legal epi in developing these methods is making sure that, as we use the law, as we deploy the law to try
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to impact make the public health system better and to try to have positive outcomes on public health outcomes and the public's health. And then also trying to reverse and mitigate the health inequities that we find in our communities, as we use law to do those things, that we have a way to study whether or not we're doing that successfully.
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I think of a thread of American history, as with the law, is really one big experiment. And oftentimes, we pass these laws, we think, anecdotally, we know what they're doing. We may have some intent in mind, and the impact is something very, very different. And once we pass them and put them out on the streets, started implementing them, our systems and our abilities and our methods to study the impact of those laws has been very limited, again, until the past 10 years or so.
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So, I'm going to conclude there. And I'm just going to give you just a little bit about us in the Public Health Law Program. Next slide, please. So, within our office, the Public Health Law Program, we work to improve the health of the public by developing law-related tools and providing legal technical assistance to public health practitioners and policymakers in state, tribal, local, territorial jurisdictions and at CDC. Our mission is to advance the use and understanding of law
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as a public health tool. And we do that through kind of broad buckets of work, training workforce development, partnerships and outreach, and legal research and translation, including conducting and consulting on legal epi studies. Next slide, please. So, our team can help with a variety of projects, so please feel free to reach out to us. We can help identify public health law priorities. We can research laws that may impact the public's health or the public health system,
1:00:00
analyze public health legal preparedness, conduct comparative analyses across jurisdictions. And we, as we're doing all this, we learn stuff. We write it down, like all of us at CDC. And so, we prepare reports and papers, journal articles, things like that. And certainly, part of our business is developing and disseminating public health law curriculum. Next slide, please. So, what does that look like for you? We can do training, again, both here at CDC
1:00:34
and with the state health departments out in the field. Public health law 101, legal epi, health equity, and public health emergency law. We can do legal epi research consultations, including helping folks with project planning, project scoping, question formulation, and thinking about capacity of your department or your team to do a legal epi study and helping plan out the kind of resources that you might need. We provide access to data through Westlaw
1:01:11
and provide the ability to create legal epi datasets through the public health law information port or on other IT systems. Ultimately, our services are geared around collaboration, collaboration with your scientists, collaboration with your attorneys, if you have JDs in your units, with the goal to help form public health law and legal epi questions, help to systematically collect legal data in ways that can be used for your purposes, analyze it, and plan out the documents.
1:01:49
How are you going to present what you learn? So, plan out the documentation of your of your research. So, that, I think here that concludes our formal remarks and even a couple of minutes, a tick under time. So, you know, that's pretty cool. And I think now, because this thing goes till 3:00, if you want to stick around. And now, we have time for questions and answers. And the one thing I don't know, Tony, is necessarily how we're going to drive the Q&A is folks just come off mute,
1:02:34
or maybe you could help folks and us navigate that process? Thank you so much. >> Yeah, thank you, Matthew and team for coming. I very much appreciate it. So, it looks like I've been watching the Q&A. So, you all have some access to it, and you're able to engage with it. I might defer to you, if you wanted to pick out the questions you thought to be germane in there. I'm happy to read them off as well. I did have a question in a broader context,
1:03:01
taking a little bit of proclivities of the moderator, is with modern, a more integrated system, of the world like Internet of things, I'd be interested to hear a little bit about this idea of a more continuous or real-time assessment of laws as they're coming forward. And certainly Mara talked a little bit about being able to procure or identify laws over time, but I would think that there's some work and I imagine the epidemiology is a rich field for things like natural language processing
1:03:39
or web scraping and those activities. And wondered if you could talk a little bit about that. >> Yeah, I can take that one. So, this was a big challenge during COVID because many of the things that Darian mentioned in those myths versus facts, right? So, there is not a legal database that magically gets all of the laws right when they're issued. So, there's a lot of manual web scraping that occurs, and due to the nature of how these laws are issued,
1:04:10
a lot of the technology that we have and traditionally used to do some automated web scraping doesn't really work. These are, you know, often PDF documents that are saved entirely as images. They might be hidden on a county's meeting notes from a town hall on the tiniest website you've ever seen. And so, in the process of trying to search for these laws, we actually came up with a system where we identified the state websites that were most likely to have the information.
1:04:40
There were several states where we would have four or five websites, and we had a team of people that would click on those websites every day and download anything new. Not particularly time efficient, but it was the best way we could come up with. And we have been experimenting more with what to do once we have those laws. So, our dataset actually has over 20,000 laws in it. That's a lot for human beings to read. When we created these time series datasets,
1:05:06
we're really only looking at about five variables out of, you know, a potentially infinite number. And so, we've been experimenting with machine learning techniques where we can code basically a small number of those on a variety of features, right? So, we have actually 42 identifiers. We code those. We feed that into a machine learning algorithm that can then run that through a whole bunch of other laws. So, it is still definitely in the testing process, but it looks really promising.
1:05:32
And so, we're very excited about that and can see future applications if it works well on this one. >> Thank you so much. I thought you all would be a strong program to do a lot more of those type of activities. I feel free text fields are somewhat of the new oil, if one will of epidemiology and certainly legal epidemiology is in that room. Did you guys want to read off some of the questions, where I'm happy -- or did you want me to? >> I was looking at, I think, at least in my view here,
1:06:06
there were a couple at the top asking questions about the school vaccination dataset in the crop circle that we showed earlier, I think Darian showed earlier. And so, the simple answer is we did not use that dataset to then conduct comparative studies. We may do that in the future. I think the longer answer is the way that we have developed the practical application of legal epi methods over the years within the program and in partnering with folks at CDC
1:06:50
and in the field is we really take a very outcome, output, and goal-oriented approach to legal epi. Very practical approach, what is it that you're trying to achieve? And then we sort of go backwards from there. If the goal is to conduct a comparative study, such as was done with some of the work with the Mitigation Policy Analysis Unit, and the study that Rachel covered on ADHD behavioral medication therapies, the way that you approach the collection and the coding
1:07:27
of the data can look very differently and be much more involved than if you have another goal in mind. And the way that the school vax -- sort of tie it back to school vax -- the way that the school vax assessment came about was under the auspices of a kind of different goal. So, it wasn't necessarily collected with an eye towards conducting comparative study. And so, it was much more observational. Here's what it is, of course. It was focused, as the one question emphasizes here,
1:08:05
focused on the exemptions, rather than what are the vaccinations I'm required to get? It was more about the exemptions. There are studies out there that look at the impact of exemption laws, by some good researchers. So, we can either package those up, or I don't think they're too hard to locate as well.
1:08:31
>> And you can post questions in the question-and-answer box in the bottom, and we're starting to have different people on the team type their answers to them. And if you're typing your answer, crew, if you wanted to call out some of the things that the general audience might be interested in as well, that's completely appropriate. >> I can go through some more these. Somebody said, this is so good, and I would say thank you very much. So, I'll address that one live.
1:09:00
The how does a legal epidemiologist engage with policymakers and political leaders to demonstrate their findings without being accused of being politically biased? So, the first thing I got to say is you use the term legal epidemiologists, so job job well done, PHLP team. We have people whom we don't know, anonymous people, using the term legal epidemiologist, so we are making inroads to establishing the field. You know, this is a big question. I don't think there's a clear answer here.
1:09:47
I think legal epidemiologists if, in fact, someone who engaged in a legal epi study is the one to engage with policymakers. So, that's the first question. Are we even talking about the same people? And if they are, I think we do that in the same way that we present other science to policymakers in a way that, you know, are you going to come to an end? Do you have an objective? Is your goal to say that these laws work, if your goal is to reduce this morbidity and mortality?
1:10:31
Here's some legal epi data that can show you how to achieve that. That's the way we tend to do it. If we're writing papers to approach that topic, it's really about, look, it's not necessarily our job within the executive to tell the legislative branch what the goal of legislation necessarily should be for their purposes. I think the goal of the executive branch and the role that we play is that if this is what you're trying to achieve, and I take it in good faith,
1:11:04
based on representations you have made, that this is the goal that you're trying to achieve, here's the information relevant to that goal. And either this proposal is going to get you to where you want to go, or the data shows that this proposal is not going to get you to where you say you want to go. I think the important thing to understand about legal epi is, and why it's such an exciting development within public health, is that we previously have not had
1:11:37
consistent nationwide standards on how to generate that kind of data to feed into the policymaking discussion. And it's certainly within, you know, within our goal set to build that evidence base, both substantively and on the methods side, to better enable us to inform the policymaking process that, you know, it's not just that, you know, putting shots in arms is good for health, right? It's not just that the public health intervention works. It has a positive outcome,
1:12:13
if you're talking about vaccination. It's that that public health intervention wrapped up in a policy either works towards your goal or does not get you to the goal that you want. We wrap these interventions, shots in arms, within laws and policies. And we need to be able to study both with scientific rigor. And legal epi is giving us the tools to be able to do that better than previously.
1:12:49
>> And a little bit following on to that question, some of the questions are about training, right? So, how does one come from an undergrad component up to where you're at? And I know that you've worked arduously over the number of years to build a workforce capacity. I wonder if you could talk a little bit about sort of a career path in public health law, although it's quite broad, I would imagine. But then, also some of the resources you have available
1:13:11
for training and maybe even the conferences. Conferences is such a vague term nowadays with COVID, but where often a lot of people involved in legal epidemiology share their findings.
1:13:28
>> So, I just take a brief intro to that and say it's definitely something that, public law program, we work on. All of us within the program work on this. We have different programs targeted at different points along the career path, both school and once you're in the health department, and then certainly continuing education once you develop some skills and abilities. I don't know if, Mara, you want to talk a little bit about both we have interns, and we have fellowship opportunities
1:14:02
if you wanted to talk about those. And then maybe Sam, Rachel could talk a little bit about the trainings that we do with sort of applied trainees we do with health departments.
1:14:15
>> Yeah, sure. So, we do have a couple of different training options available for current students and some for recent graduates. So, current students are eligible for the intern and externship program as well as the fellowship, and we do also have, for recent graduates that have graduated within the past four years, additional legal epi training through our brand new fellowship program just about to start, so very exciting for us. But those programs really focus on giving a baseline experience
1:14:44
in public health law, open to both law students and masters or PhD students, so it's designed to be interdisciplinary. And they are really designed to give some hands-on experience both legal epi and also, you know, tangibly working with public health departments on the issues that they face and what it's like to be a public health law practitioner. I think that's probably it for an overview of that. I can turn it over to Sam and Rachel.
1:15:15
>> Yeah, we, in addition to the training opportunities that Mara highlighted, we are working pretty closely with public health departments. We've got what's called the STLT Legal Epidemiology Learning Cohort for folks who are based in health department settings, who would like to focus on developing their legal and policy analysis skills. So, it's about a nine-month series of trainings and technical assistance sessions, and we sort of support representatives from the health department
1:15:51
in completing their own legal epidemiology projects. Related to that, and actually, that process, we are in process to begin recruiting fairly soon. So, please reach out to us, if you are from a health department or interested in that. We've also got a number of online trainings that anyone can access through the Public Health Law Academy. They're asynchronous trainings, and you can receive a certificate at the end of completing them. It's a three-part series on legal epidemiology,
1:16:26
as well as other trainings relating to public health law. We're also working right now with some partner organizations to develop additional tools and resources for folks who are in academic settings, including a public health certificate program, as well as we're working pretty closely with some academic partners to develop sort of lengthier legal epidemiology courses. So, if any of that's of interest to you please reach out to us. We're happy to talk about it more.
1:17:02
>> Thank you. Why don't you put the link in to that, where that that's advertized? I put up the general Public Health Law Program link in there somewhere. >> Yes, our fellowship program is so new we don't have a link yet, but we will have the information on the Public Health Law Program page, so that's the best way to get to that information. >> Thank you, thank you. One topic that I try to highlight amongst our learners is really this connection to the community guide.
1:17:34
I was wondering if you could talk a little bit about the relationship between public legal epidemiology and the community guide, the Guide to Community Preventive Services. And then, particularly, where I was very excited to hear a lot about Sam's discussion is -- and I don't know if it's there yet, but the idea of equity in law, and then public health practice and evidence-based interventions that address or improve equity. This is a very difficult question to answer.
1:18:05
But at the same time, I feel the agency over many, many years has done an okay job of identifying inequities, but hasn't been put as much effort into understanding how to address them.
1:18:20
>> So, your question, Tony, is really salient because we've been having a lot of conversations with folks here within CDC, as well as, you know, across the country who actually draw upon the Community Guide for their work, but want to sort of develop more skills to incorporate law and policy into their relationships and ways of supporting communities. And so, we've been thinking. We've been sort of experimenting a little bit with external partners who are doing community level work,
1:19:00
who want to kind of incorporate community engagement and relationship building in their processes to identify legal epidemiology, to sort of use legal epidemiology, what we would call apply to legal epidemiology, to address specific issues that communities are prioritizing. So, some examples are centered on housing, food access policies. We are actually working with an external partner right now who's partnering with the city and has done a tremendous amount
1:19:40
of community engagement that has actually enabled them to use that community engagement to drive the legal epidemiology priorities they're setting and the kinds of research they're doing around issues like food access, housing, and economic development at the city level. So, you know, I think there are lots of opportunities for us to develop relationships with communities for health departments, for other practitioners to develop community relationships and then actually rely upon communities
1:20:17
to drive their priorities and the substance of their legal research. >> Yeah, thank you. I appreciate that. I always think that's incredible work to be able to drive the evidence based and identify the gaps and address them. Thank you so much. Matthew or others, do you see questions you want to answer live in there? >> I just had a quick thought on you had asked about Community Guide and also made me think of Cochrane studies and things like this. And I think the relationship between legal epi
1:20:57
and those methods to conduct systematic reviews to determine the effectiveness of particular policy type strategies, it's a logic model, right? And so, we identify a public health issue, some burden, morbidity, mortality, some health inequity. And we take some sort of policy approach to that. Down that logic model, down the road, then Cochrane and Community Guide, look at whether or not those policy approaches are effective. And they can look at that. And legal epi gives us the way to bridge
1:21:41
between the identification of the problem in something like a Community Guide recommendation or a Cochrane study or like that for policy interventions. So, again, the idea is to create consistent, rigorous methods to be able to conduct those types of studies. And then, you know, part of our goal is that, but then also to disseminate those methods and train people and teach people and build the capacity of the system to be able to do those kinds of studies to then, hopefully,
1:22:12
end up with more Community Guide recommendations and Cochrane studies and things like that, that focus on policy-based interventions. Have a better idea of what works.
1:22:26
>> Yeah, much appreciated.
1:22:29
Are there questions you see you want to answer? I have one more sort of in that line, unless you see one you -- >> I did see one in here that Mara had marked. I wasn't sure how these things work. But anyway, Mara says -- >> Yeah. >> Howard-Williams would like to answer this question live, so go for it. >> I can jump in on that. So, this was responding to the question about Do you have to know how you're going to measure the impact of laws before you start a legal epi project?
1:22:58
which I think is a great question. I wanted to answer it live because there's a lot of considerations here. First and foremost, no, you don't have to know. We could not possibly have imagined all the ways that we would use this COVID legal data at the start of the pandemic when we started collecting it. So, with that said, it sure does help to know. So, there's a lot that goes into dataset generation. You know, we ended up making time series datasets using a couple of different software programs
1:23:27
to develop what informs those COVID Data Tracker graphics, right, that ended up being critical for us to be able to analyze these different measures because we needed to know how long they were in place. And these were measures that were changing multiple times a day, at first. So, you know, trying to figure out what was in place at what time is really tricky without the help of a good like coding platform. And so, you know, we started off in Excel, and that worked well.
1:23:54
But there were many times where we thought to ourselves, it sure would be helpful to have thought about how we wanted to analyze this or to have known how we wanted to analyze this in the beginning because it would have streamline some things, or we might have made some different decisions. So, I think you don't have to know how, but having an idea, at least, of how you will need your data structure to analyze it can be really helpful to address early on,
1:24:20
and it leads to a lot less redoing of work later. So, that often means you need that other dataset, right, that health outcome dataset, something to compare it with to know how you need to structure it. >> Yeah, experience. Yeah, you'll learn, right, as you get further on in those things. So, we're coming close to the top of the hour. I think what, at this point, we'll probably wrap up. And do you have any closing thoughts, Matthew? And I did want to announce next month's Grand Rounds or others.
1:24:53
>> Yeah, Tony, I did want to ask is there a way to -- I'm assuming there's a way to save these questions, or I don't know how we would get them back to the individuals asking them. Please reach out to us if we didn't get to your question. And I so appreciate that I'm showing 20 open questions in my little view here, and I do really appreciate the interest. I did see a couple in here about individuals interested in potentially getting into the public health law field.
1:25:27
And I would say that's something that we are always very excited to see and hear. Mara mentioned internship program and the fellowship program, and we're very interested in the career ladder of folks interested in public health law and legal epidemiology. So, please, please do reach out. I'm assuming our emails are attached to the invite or whatnot, or you reach out to Tony, who could connect you with us. But we talk to folks all the time, informational interviews,
1:25:55
to get to know you and gauge your interest and talk about all the different opportunities, talk about our own paths to this field. Because everybody has a very individual path to this little corner of the world. So, I just encourage you to please reach out to us if you're interested in sort of career path, early career, but also if you're well established and have a clear foundation in public health, and you just want to learn more about how to do public health law and interested
1:26:31
in a potential legal epi study. That's, you know, that's our gig, and we love it, and we love to engage with folks who are interested in that kind of work as well. >> Well, thank you all for coming. I think one of the neatest parts about this series is you find people who are passionate about what they do, and it's clear that you all are passionate about what you do. And very much appreciate all your work, really, genuinely, in all the fields in which you're practicing.
1:27:00
We'll close it out at that moment for us here. We'll be on the first Wednesday of the month, so November 2, I believe is our next Preventive Medicine Grand Rounds. It'll be Abigail Echo-Hawk talking about tribal public health, and so we're excited to have her. I want to extend a sincere thank you to Lillian and Gabby and George and other folks who helped put this together. It doesn't work unless you're all here and functional and very much appreciate everyone's time today. Thank you all.
1:27:30
Take care and stay strong. We'll see you next month. >> Thank you so much. >> Bye bye, everyone.
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