In the latest installment, Kevin Frick, PhD, professor and vice dean for education of the Johns Hopkins Carey Business School speaks with Lorraine Dean, ScD, an associate professor in the Johns Hopkins Bloomberg School of Public Health about her role as a social epidemiologist and her thoughts on the future of the health services research field. You can read the previous installment here.
This conversation has been edited for clarity and brevity.
Dr. Kevin Frick:
The Paradigm Project is attempting to evolve, modernize, and center the field of HSR around people. Are you excited by the prospects?
Dr. Lorraine Dean:
There are a couple of ways that the Paradigm Project resonates with personal interests of mine. One was ensuring HSR is asking the right questions and paying attention to social determinants. I'm a social epidemiologist by training, so social determinants are my primary area of focus and I’m glad to see AcademyHealth embracing that.
I'm very excited that HSR will become more people-focused and that it's interested in becoming more people-focused. A big part of that is the health equity lens. If we make HSR more people-focused, then we can understand the extent to which systems have created disadvantages and disparities beyond just studying if systems have been productive or not.
I don’t think that means we should abandon the systems focus. I think it leads to opportunities for integration. It will give us a complete, accurate picture of what's happening in the world.
I also think that is exactly where people like me, social epidemiologists, play a role—in those opportunities for integration. More and more I see all fields of discipline becoming not just multidisciplinary, but transdisciplinary.
‘Multidisciplinary’ is just pulling from different fields, but transdisciplinary is coming together and saying, "We're all going to create a foundation that we all can work from and agree on to create something new and exciting together that incorporates all of our values and perspectives in an integrated way.”
You're a social epidemiologist. I'm sure there are some in HSR for whom that's not a household word.
Social epidemiology is a close cousin or maybe even a sibling to health economics. Where they differ is social epidemiology is very explicit about the social context for diseases and health behaviors, but we go beyond thinking about individuals operating as individuals and instead think about the entire context of their lives.
Do you have a specific example to illustrate how the questions you bring to HSR differ from the way a health economist might approach a similar question?
One example is work I’ve done on the contribution of credit scores to health outcomes. This is work that you and I have partnered on together. As a social epidemiologist, I thought about it from the perspective of a neighborhood's credit score, rather than an individual’s score, which is where I saw health economists focusing: how does the creditworthiness of your neighborhood influence your health outcomes?
In one study, we found that neighborhood credit scores are associated with health outcomes, but not necessarily with the underlying individual behaviors that might be associated with those outcomes. To me, that relates to the fact that something is happening within the neighborhood context that isn't necessarily explained by the observed individual-level behaviors.
Do you find that policymakers are receptive to social epidemiology or is it easier for them to focus on things that are much easier to control?
One of the critiques that I hear about social epidemiology is, “Why are you studying this if we can't do anything about it?" That question always makes me laugh. I say, "Oh, we can't do anything about poverty? You sure about that?"
I understand what they're saying. If you’re a clinician, you might think, “I can't resolve a patient's poverty.” But I would argue that understanding how people in the context of poverty behave or act can help you as a clinician.
I feel like policymakers might understand our field a bit more because they know that they can do something about neighborhood context. They know that they can do something about poverty. Having the political will to do so, however, is another thing altogether.
You've listed some interesting things that are unique to the way that you bring questions to the table. But what are some of the challenges as social epidemiology tries to marry itself with HSR moving ahead?
The first thing that comes to mind is large-scale data. HSR is used to having it. Social epidemiology hasn’t had that luxury. For example, earlier in my career we looked at the role of neighborhood social capital on health outcomes in Black neighborhoods. If I were to describe social capital to my 12-year old cousins, I would explain it as what resources are available to you because of the groups you are part of – and those resources can be tangible or intangible. There are no national data necessarily on social capital. For many of the exposures that we as social epidemiologists feel are most important, the data just aren’t there.
Would operationalizing surveys and other research instruments to get those large data sets be too hard to do?
I don't think it's a heavy lift. I think it's something that could be added to, for example, the Behavioral Risk Factor Surveillance System or other large scale health surveys that we already do without a lot of additional effort. I think it's just a matter of having the will and people interested to collect and analyze the data.
I will say, however, that I can ask you a survey question about social capital, but if I don't know what the answers are of the people around you, I don't have a sense of the social capital in your neighborhood. So I think the geographic linkage is the most challenging for us to overcome in gathering large data sets.
If you had one piece of advice for people who are just starting out in HSR, what would be that be?
Don't be afraid to blaze a new trail. I think a scholar is someone who's willing to go out on a limb and try to think about something new or take something from a new perspective. If you have a new perspective, embrace that and let that inform your work.
There's an increasing number of HSR professionals outside of academia. Any thoughts for that group who aren’t necessarily scholars, but are using our methods and questions to make healthcare better?
Before I came to academia, I ran Philadelphia’s tobacco control program. The Health Commissioner’s Office and the Mayor’s Office were very invested in having people who worked in city government who could also use these methods. We had someone who modeled what a tobacco tax would look like and what impact that would have. That was used to move policy forward. It was very compelling evidence that the city decision-makers needed to see. So even for people who decide not to go the academic job route, realize that you bring a unique and powerful skillset that can make real change in the world.