“Legal Epidemiology”: the Health Effect of Laws

Since the beginning of the COVID-19 pandemic, the National Institutes of Health (NIH) has contributed more than $3.6 billion to biomedical research projects aimed at understanding and curbing the effects of the SARS-CoV-2 virus. Billions more in funds have gone into the development of vaccines. Yet, as Burris et al. emphasize in a recent Perspective piece in the New England Journal of Medicine, there has been paltry support for studying the health consequences of specific legal practices, or “legal epidemiology,” even as federal, state, and local governments have passed thousands of laws in a span of months pertaining to public health. These have included stay-at-home orders, mask mandates, travel restrictions, and other measures guiding social behavior.¹

While randomized controlled trials may be the gold standard for evaluating the causal effects of interventions like pharmaceuticals, researchers can set up quasi-experimental designs that shed light on the health impact of laws by taking advantage of variations in policies between populations and across time.¹ These have revealed — across different states and countries — the utility of issuing stay-at-home orders early on to quell infection rates, while also pointing to a possible threshold at which the benefits of stay-at-home orders begin to decline.^2,3 Other studies have emphasized the adverse mental health effects associated with these mandates.⁴

Between 1985 and 2014, less than 0.25% of all NIH extramural grants have pertained to legal epidemiology.¹ Research in this field, however, often has profound policy implications. Alexander Wagenaar’s late 1970s study of how drinking age minimums affected rates of car crashes helped promote the widespread increase in the legal drinking age to 21.⁵ In a special February 2020 supplement to the Journal of Public Health Practice and Management, editors assembled over a dozen contemporary articles related to legal epidemiology. One, for example, indicated that increasingly punitive policies around drinking during pregnancy have varying effects on birth outcomes according to the mother’s education status. Future policy interventions should therefore take these discrepancies into account.⁶ In another article, authors argued that legal epidemiology can support state policy decisions to fund a community health worker (CHW) workforce, based on evidence that the presence of CHWs helps prevent and control chronic health conditions in racial/ethnic minorities, people of lower socioeconomic status, and rural populations.⁷

The social determinants of health — including economic context, community support, physical environment, and access to education — are profoundly shaped by governmental policies and legislation. In the 1930s, for example, the federal government used a race-based housing policy to appraise neighborhoods in helping mortgage lenders assess risk. The practice was known as “redlining” because of the red ink used to outline “riskier” neighborhoods. Now, research shows that redlined neighborhoods across the country are frequently hotter than other neighborhoods in the city, sometimes by as much as 13 degrees Fahrenheit, likely because they tend to have fewer trees and are often divided by highway systems. Heat is the leading cause of summertime morbidity, especially for those with pre-existing health conditions, and it is therefore critical to examine the policies that exacerbate and mitigate climate change, especially as it impacts different communities.

Legal epidemiology can help policy makers design legislation that promotes better health outcomes, both within the context of the COVID-19 pandemic and far beyond it. Retrospective research from the past year can examine essential questions raised by Burris et al., including how to increase compliance with public health mandates like masking, optimize costs and benefits associated with remote learning for different grade levels, and protect low-wage workers when reducing in-person commercial activity becomes necessary. As the authors write, “Failure to narrow uncertainty on these points in the aftermath of Covid will cost us dearly again in the future.”¹

References

1. Burris S, Anderson ED, Wagenaar AC. The “legal epidemiology” of pandemic control. N Engl J Med. 2021;384(21):1973-1975.
2. Castillo RC, Staguhn ED, Weston-Farber E. The effect of state-level stay-at-home orders on COVID-19 infection rates. Am J Infect Control. 2020;48(8):958-960.
3. Medline A, Hayes L, Valdez K, et al. Evaluating the impact of stay-at-home orders on the time to reach the peak burden of Covid-19 cases and deaths: does timing matter? BMC Public Health. 2020;20(1):1750.
4. Panchal N, Kamal R, Cox C, and Garfield R. The implications of COVID-19 for mental health and substance use. Kaiser Family Foundation. Published February 10, 2021. https://www.kff.org/coronavirus-covid-19/issue-brief/the-implications-of-covid-19-for-mental-health-and-substance-use/
5. Burris S. Scientific evaluation of law’s effects on public health. In: Regulatory Theory. ANU Press; 2017:555-572.
6. Roberts SCM, Mericle AA, Subbaraman MS, Thomas S, Kerr W, Berglas NF. Variations by education status in relationships between alcohol/pregnancy policies and birth outcomes and prenatal care utilization: A legal epidemiology study: A legal epidemiology study. J Public Health Manag Pract. 2020;26 Suppl 2, Advancing Legal Epidemiology:S71-S83.
7. Fulmer EB, Barbero C, Gilchrist S, et al. Translating workforce development policy interventions for community health workers: Application of a policy research continuum. J Public Health Manag Pract. 2020;26 Suppl 2, Advancing Legal Epidemiology:S10-S18.
8. Hoffman JS, Shandas V, Pendleton N. The effects of historical housing policies on resident exposure to intra-urban heat: A study of 108 US urban areas. Climate. 2020;8(1):12.