Iskandar: Hello, I'm Dr. John Iskandar.
Welcome to CDC Beyond the Data.
I'm here today with Matthew Penn,
a lawyer who directs CDC's Public Health Law program.
Matthew in today's session we heard about the power
of public health law to confront emerging health issues.
I wonder if you could start by reminding us what is the basis
for public health law and at what various levels
of government is this undertaken?
Penn: That's a great question.
The public health law really exists at all level,
of levels of government including the federal level,
the state level, local level,
and including the tribes and the territories.
So at the state and local level the power really comes
through what we call the police powers.
In the police powers are really the power
to help guide the health and welfare of the citizens of state
and local jurisdictions.
Those authorities and powers really preexisted even the U.S.
Constitution that we understand as the basis
of our government today.
And something interesting about the 10th amendment in the Bill
of Rights, 10th amendment to the Constitution,
is it reserved those police powers to the states
and then sometimes delegated to local authorities.
Of course tribes have their own sovereignty
and can pass public-health laws for tribal nations
in Indian country, and territories have authority
to pass public health laws as well.
And at the federal government the power
to pass public health related laws really spring
from the authority of the federal government
to regulate interstate commerce, because, of course,
diseases can go across state lines and effect commerce
if lots of people get sick.
And then also we can tax, bring in revenues
to the federal government and then spend those on things
that we think we're going to help the public's health.
Iskandar: So, as you say, we have distribution of powers
but most, most public-health actions are taken
at local and state levels.
I think this is something that many of us at CDC have to work
with folks to remind them is that we do not, we do not,
we are not the seat
of public-health power for the country.
Penn: That's right.
I think in public health we often talk
about the front lines of public health.
And indeed, for the most part,
the front lines really are state, tribal, local,
and territorial health departments out there,
protecting the health of their populations.
Iskandar: So these powers that are at the state
and local level, what do they give states and cities
and tribes and territories,
what do they give them the authority to do in general?
Penn: Well most states have, coming from the police powers,
they have the authority to pass statutes
and promulgate regulations
and sometimes organize their own internal health department
policies to protect the public's health.
So sometimes this, these are expressed in ways
that we can easily identify.
So in public health while familiar with disease reporting
and then disease investigation and in some cases
if there's some health outbreak, some sort of disease outbreak,
that's going to adversely affect the public's health,
we can bring in disease control measures
such as isolation and quarantine.
Or even sometimes just guidance coming
from the health department.
And of course, the police powers also give rise to things
that in types of laws and regulations
that might not be immediately identified as something
to do with public health.
So things like motor vehicle laws, so seatbelt laws
and texting bans, and even the organization of how we travel
on our roads, stoplights.
So these things affect the public's health as well,
in most of those stem from the police powers.
Iskandar: Yeah, I think it's important
that people understand what that term means, you know,
in this public-health law context.
I think you all did a good job
at today's session of pointing that out.
You introduced another, I think, important concept today,
and that's legal epidemiology.
Could you let our audience know what you all mean by that term
and why it's important for them to understand?
Penn: Yeah, it's a great question
and it's an emerging field in public health practice.
I think at the core of this idea, legal epidemiology,
is the, the very recent recognition
that law really is one of the determinants of health.
So we pass laws, again, back to the motor vehicle example,
we can pass laws that can affect the death and injury
on our highways so people seem to understand the idea
that speed limits are kind of a safety issue
and if we have speed limits say 25 mile-per-hour speed limit the
ideas to try to protect the people in the residential area.
So laws can definitely affect the health of populations.
The idea of legal epidemiology is that we want
to study those laws as a factor in sort of the cause of disease
and injury, the way that disease and injury are spread around
and distributed in our communities and then also
if you look at something
like isolation quarantine may be the way that law can be used
to prevent the spread of disease or maybe prevent disease
from occurring in the first place.
Iskandar: If I can paraphrase, studying not just
which states have which laws but how those are related
to health behaviors and health outcomes and hopefully allow us
to make conclusions about, you know, what types of laws work,
work better to protect public health.
Can you give us just an example of how this concept
of legal epidemiology has been applied in recent years?
Penn: Sure.
So, there's really kind of two components to what we try to do.
The first question is, what does the law say?
So, this is the idea of legal mapping.
We want to go out and say, well,
what jurisdictions have a particular type of law.
And then from there we try to move on to the question,
well how is the law working or what is the impact
that the laws have, that the impact the law's having.
So in the first instance, a good example is,
a during the Ebola outbreak.
We were very interested here at CDC what states were doing,
were going to do to try to control the potential spread
of Ebola in the United States when folks were coming back
from having served in the affected countries in Africa.
So they started putting out policies
and in the public health law program we started
to track what those policies said.
So one of the laws say and how many states have them.
We started to track them and started
to compare them to CDC guidance.
Are they equivalent to CDC guidance?
Are they more stringent?
So that when folks came back
from Africa they would understand what the conditions
were going to be once they returned home.
Interestingly as we study those over time
and started publishing our results we saw
that states were reacting to what we were saying
about their policies and some states started to change the way
that their policies were published so that, to say that,
no actually we want them to be equivalent
and so we'll change the language to make it clear
that were equivalent to CDC guidance.
It was a really nice study
because it was very compressed in time.
The states were passing these policies very quickly
in response to CDC guidance.
So it's great example of not only legal mapping,
so what are the state saying about an issue, but also looking
at it over time in a type of policy surveillance.
Iskandar: Very interesting example because it also brings
in the idea of trying to compare laws to standards
of expert guidance or standards of evidence,
again we would certainly want our public health laws
ultimately I think to be both effective but you know based
on the best scientific evidence and data.
Penn: That's exactly right and of course once we get
into the idea of how is the law working then we want to be able
to compare it to some sort
of external standard whether it's health data,
what are the impact that zoning laws have on violence
or the obesity or physical activity.
But also it can be guidelines and standards established
by public health and medical
and science experts around the world.
Iskandar: So you had mentioned earlier that law can be viewed
as a social determinant of health.
This is a big area of focus for public health right now.
What does public health law have to contribute to the coming era
in public health where we're trying to not only study
but modify those social determinants of health, again,
to result in healthier behaviors and a healthier population?
Penn: That's a great question.
I think it kinda' plays out in two different ways,
and of course, again, this is an emerging field
and so we're working together to try to figure
out exactly what role public-health law
and legal epidemiology will play in this emerging idea
of a new public health system.
So first off I think it's good to recognize, as I said earlier,
that law really is by itself a determinant of health.
So we can do things like take a promising public health
intervention that may be tested or experimented on,
sort of a small population, and if it works then we can roll
that into a statutes regulations or department policies and have
that intervention affect a larger population.
And I think what we're trying
to do now is bring a little bit more rigor into the way
that we study those laws and the impact that they're having.
And in the larger context where we look at social determinants
of health such as education, transportation, and in systems
like this, that we understand that law really is
at the foundation of those systems.
So the transportation in the, transportation system
in the United States really looks and feels
and behaves the way it does because it's built upon a system
of laws at the federal state and local level and what we need
to do is understand what is the impact that the system's having
on the public's health and then start to look at, well,
is there way that we can change the laws in order
to change the system to have better health outcomes
in the end for our populations.
Iskandar: I think the transportation is a very good
example because we can think of ways
that transportation policies affect environmental health
through air pollution, how they affect , you know, you know,
obesity rates, through, you know,
allowing active transportation options,
a lot of potential public health implications there
and again just I guess one way to sort
of bring the conversation back to where we started is
to remind people that these experiments, if you will,
in laws to improve the social determinants
of health are gonna' be played out at the state
and local level primarily.
Penn: That's right.
It's one of the great things about the United States
in that we can have this variation across the states
and allows us to study sort of, differences between the systems
and among the systems and really try to figure
out in this laboratory of democracy, what are the ways,
are there nuances that seem to work better in some areas?
Are there nuances that maybe have detrimental impacts
to the public health?
And then we can study those and try to then reconfigure the laws
in the systems in other states
to of course ultimately the goal is
to have better public health outcomes.
Iskandar: Thank you very much Matthew.
Please join us next month for Beyond the Data.