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Commentaries

Teaching the Future

Legal Epidemiology as a Model for Transdisciplinary Education

Gable, Lance JD, MPH

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Journal of Public Health Management and Practice: March/April 2020 - Volume 26 - Issue - p S96-S99
doi: 10.1097/PHH.0000000000001135
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The field of public health law may be said to be in a renaissance, one that has arguably spanned the last 25 years.1 The last 2 decades have seen the rapid growth of the field across many dimensions. The growth of public health law spans at least 3 interconnected and mutually reinforcing areas: expansions in professional identification, institutional capacity, and conceptual development. These developments create an important opportunity to reinvigorate and expand the incorporation of public health law into education programs and curricula.

First, public health law has become a recognized specialty area within the professions of law and public health. Increasing numbers of professionals have bridged the historical divide between these 2 fields, aided in part by the growth of joint degree programs that combine Juris Doctor and Masters in Public Health degrees. The expansion of practitioners trained in both law and public health allows organizations, agencies, institutions, and populations served by these dually-trained professionals to benefit from the unique transdisciplinary perspective that public health law expertise offers.

Second, the burgeoning public health law workforce has augmented the institutional capacity for public health law practice, within both governmental agencies and nongovernmental institutions. Some government agencies have recognized the importance of instantiating legal expertise in public health departments. State and local public health agencies have added lawyers to their staffs and the Centers for Disease Control and Prevention's Public Health Law Program has performed robust programmatic and scholarly work on public health law.2,3 Outside of government, a growing cohort of nonprofit organizations, policy think tanks, foundations, and academic centers have emerged to provide legal assistance with and consultation on public health law and to work through challenging law and policy issues related to public health.*

A third important development in the field of public health law involves significant advancement in the conceptual underpinnings of public health law. Public health law scholars have made great strides in articulating new and innovative understandings of the field, recognizing the integral relationship between public health and law.4–6 Theoretical advances have pushed the evolution of the field and have yielded new conceptions of public health law that creatively incorporate the well-established contours of legal analysis and interpretation with new research and scholarly modalities that meld law with empirical methods and scientific rigor. These transdisciplinary models of public health law hold great promise as avenues to better understand the impact of laws on health and to more directly apply scientific methodologies to inform policy making.7

Moreover, conceiving of public health law as a transdisciplinary pursuit provides another opportunity as well. Transdisciplinary models of public health law, including those models grounded in the concept of legal epidemiology, can generate effective approaches to educational pedagogy for both law and public health students by providing a useful means to teach critical thinking and a broader understanding of law- and policy-making for those students.

Legal Epidemiology: Incorporating Public Health and Science With Legal Research

Transdisciplinary models of public health law envision the field as a complex interrelationship between public health law practice and public health law research. Public health law practice has been defined as “the application of professional legal skills in the development of health policy and the practice of public health” through the lawyers' roles as counselor, representative, and researcher.7 These roles remain essential to the day-to-day efforts of most public health law practitioners and comprise the majority of practical efforts to apply law to influence public health. The development of the congruent discipline of public health law research—that is, “whether law can be empirically shown to have an impact on the health of the population”8—expands the field of public health law to include powerful social science tools to study the impact and implications of law using scientific methods.

Legal epidemiology has grown out of efforts to conduct rigorous public health law research. Most succinctly, it is “the scientific study of law as a factor in the cause, distribution, and prevention of disease and injury in a population,” which incorporates studies of legal prevention and control (use of laws to control or limit harm to the population), legal etiology (where laws or legal practices cause disease or injury), and policy surveillance (collection and analysis of laws and policies of importance to health).7

The legal epidemiology approach recognizes that law is an important determinant of health, and researchers can better understand the health impacts of laws and policies through study and analysis using scientific methodologies. Yet, the applications of legal epidemiology go beyond assessment of the likely health effects and consequences of law. Legal epidemiology provides opportunities to increase the scientific rigor and standard of evidence that justify laws and policies. The insights gained from applying legal epidemiology can therefore spur more targeted and effective policies, generate support for changes to law and policy grounded in a more thorough understanding of the effects of these laws and policies, and produce ideas that lead to more successful collaborations to improve health outcomes.

Legal Epidemiology as a Tool for Education and Training

Legal epidemiology presents an approach for analyzing public health outcomes that transcends the rigid silos that often narrow the parameters of subject-specific education and training programs. This is particularly true in graduate-level, postsecondary education, where coursework for masters-level degrees is often specialized and focused.

As an example, law students currently may gain some exposure to how law impacts public health through a specialized course in public health law, if such a course is even offered in the law school curriculum.9,10 Public health law also could be incorporated into health law or environmental law courses, or possibly referenced more indirectly through a course that covers administrative law, constitutional law, torts, evidence, or the regulatory state. The expansion of clinical education in law schools has resulted in a boom in medical-legal partnerships, but for the most part, these programs focus on the health of individuals rather than populations. Consequently, the linkage between law and public health is attenuated or nonexistent in most law students' educations. Similarly, law students are unlikely to encounter any coursework that teaches about evaluating the effectiveness of laws or policies, or knowing how to conduct—or even to understand—social science research. The general law school curriculum leaves prospective lawyers ill-equipped to understand how the laws, policies, and legal precedents they pursue affect health at the population level.

Public health students likewise experience a lack of exposure to law and policy content in their coursework. They may encounter law in a public health law or policy course, but even courses that address the social and structural determinants of health often overlook the important impacts of law and policy on public health outcomes.

The result of this curricular neglect is a missed opportunity to invigorate education in both fields. The transdisciplinary features of legal epidemiology provide a useful and somewhat unique tool for education and training, since they solidify the linkages between law, policy, and population health outcomes, enabling students to understand the real effects of law on public health in a sophisticated way. Transdisciplinary methodologies likewise provide conceptual and methodological insights that can strengthen the analytical and practical skills of students in both professions.

Furthermore, training in legal epidemiology will help professionals across fields to recognize whether an issue would benefit from having input from others with greater expertise and therefore open up more frequent opportunities for collaboration. Having an understanding of the importance of expertise in social science methodologies will incentivize lawyers to more frequently consult with public health experts, just as recognition of the law's connection to social and structural determinants of health will encourage public health officials to seek legal expertise.

Legal epidemiology in law schools

There are numerous ways that incorporating legal epidemiology into law school curricula could benefit the education of future lawyers. Legal epidemiology allows for the development of a different set of analytical skills and research skills than are usually covered in law school classes. For instance, using social science research methodologies to track, compare, and measure the impact of law and policy provisions allows students to obtain a better, more sophisticated understanding of risk, comprehension of the scientific method, application and design of scientific methodologies, and the complex nature of causation.

Legal epidemiology also provides a different perspective than usually offered in legal education on such questions as how to do comprehensive research, how to frame research questions, what evidence is really supportable, and how to analyze and understand scientific studies. Legal epidemiology will inform students to become lawyers who are better able to draft legislation and regulations, to understand the impacts of legal rules and policy provisions on health, and to appreciate implications of legal positions that go beyond textual and economic analysis.

Legal epidemiology could fit well in a number of existing law courses. It would be fairly straightforward to incorporate these concepts into specialized courses in health law, bioethics, public health law, environmental law, or advanced civil procedure or evidence courses. However, legal epidemiology would fit within the scope of more general law courses as well, including constitutional law, administrative law, legislation, state and local government law, torts, criminal law, or evidence. In addition, law school clinical courses or legal research and writing courses could introduce legal epidemiology into practical exercises. Medical-legal partnership clinics have a particularly strong opportunity to include legal epidemiology within their clinical pedagogy to expand the foundation upon which these courses already build cross-disciplinary skills.

Legal epidemiology in public health schools

Legal epidemiology has importance for the education of public health students as well. Law and policy courses exist in most public health curricula but hold less importance to the core public health training than more fundamental courses such as epidemiology and biostatistics. Nevertheless, legal epidemiology can provide important educational and pedagogical benefits to public health students. Exposure to legal epidemiology allows public health students to appreciate the substantial effects that law and policy have on population health outcomes and to connect the disciplines of law and public health through scientific methodologies that public health students are already learning in other courses. Furthermore, adding law and policy to the array of factors that must be considered in protecting and improving population health establishes a more comprehensive and realistic account of relevant determinants of health that these students will have to contend with as professionals. This added context will elevate the capacity for thoughtful and informed policy making by graduates of these programs.

Legal epidemiology could be worked into public health curricula through inclusion in stand-alone courses that already focus on law, policy, or the political, cultural, and social implications of public health. Indeed, legal epidemiology can form an important conceptual bridge between policy-focused and science-focused courses. Existing core courses in the public health curriculum, including epidemiology, biostatistics, environmental health, and social determinants of health, could incorporate examples from legal epidemiology to add context and depth to their coursework. Finally, additional opportunities exist to weave concepts of legal epidemiology into public health internships/externships, practicum courses, and capstone or thesis projects.

Legal epidemiology in other graduate programs, joint programs, and postgraduate education and training

Transdisciplinary models can have educational benefits beyond the fields of law and public health. Educators and scholars seeking to develop new pedagogy using these tools should consider incorporating legal epidemiology into other graduate-level programs, including nursing, medicine, health administration, business, and political science. In addition, these concepts can be introduced in undergraduate coursework or through postgraduate training initiatives. Some experts in the field have begun to develop materials for these varied settings.3,6,11 Establishing coordinated courses within joint degree academic programs could further reinforce the educational impact of legal epidemiology.

Legal epidemiology methodologies provide analytical tools that can be used to assess policy effects and implications far beyond those impacting health. These methods could be utilized in many contexts where legal and policy decisions have effects on risk, influence behaviors, or have differential outcomes across the population. In other words, the effects of policy or law in almost any subject area potentially could be understood more accurately using this approach and applying it to improve and refine policy decisions.

More needs to be done to study existing educational curricula and the current extent of training within the public health law workforce to identify areas that continue to be underserved by trained professionals. Furthermore, public health law educators, practitioners, and scholars should continue to seek additional opportunities for expanding exposure to legal epidemiology among students and practicing professionals. This continual cross-fertilization of law and public health will incentivize more thoughtful and better-informed law- and policy making and hopefully yield a more healthy population as well.

Conclusion

Legal epidemiology provides an important and useful way to understand law's impact as a determinant of health. The methodologies of legal epidemiology establish approaches to law- and policy-making that allow for more coherent scientific and evidence-based evaluations of the impacts of law, measurement of the diffusion and evolution of legal norms across jurisdictions, and examination of the varied effects implicated by differing legal language, structure, and implementation. In short, legal epidemiology creates a new paradigm within which to create, assess, and evaluate law and its impact on public health—one that is essential for students of both law and public health.

Given the potential importance of these methodologies, it is imperative that educators in the fields of law and public health understand legal epidemiology and develop educational programs that can incorporate its concepts and methodologies into curricula at law schools, public health schools, other graduate-level programs, and in continuing professional education in both fields. Developing educational tools for current practitioners will allow for diffusion of these methodologies and understandings to the current and future public health law workforce.

References

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* The work of the Network for Public Health Law, ChangeLab Solutions, Robert Wood Johnson Foundation, De Beaumont Foundation, and numerous academic centers, including those at Georgetown University, Temple University, and Northeastern University, is notable in this regard.
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