Why have epidemiological modelers ignored inequality?
February 17, 2022 7:00 PM Subscribe
A new paper in PLOS "came out of a lot of discussion between all of the authors about why the broad majority of infectious disease transmission models have not typically treated equity – the distribution of who gets infected as a function of wealth, race/ethnicity, gender, and on – as a first-class concern alongside population-level patterns of incidence and mortality." Conference talk.
The entire pandemic response has frankly been very "suburban" in its understanding of how people live. The mandates and advice at the federal, state and city levels were all designed almost exclusively for single family homes. They canceled evictions for renters in most places but that was the only pandemic measure they did that was relevent for people in apartment buildings. Elevators? You're on your own. Public areas in your building? You're on your own. Enforcement of any rules was made impossible because the only stick landlords really have, eviction, was taken off the table. It wasn't too awful at first. Mostly because all the kids bailed out to their parents place for the first 6 or 7 months of the pandemic. But then they came back during Chet Hanks' white boy summer.
You'll also notice that the interest in the question of transmission between units in apartments ....simply stopped and it wasn't because the question was answered. It was because the question became moot because it would have already happened. Did I get asymptomatic covid despite sheltering hard because I live in a leaky box in a congregate living situation with hundreds of young idiots? I'll never know!
posted by srboisvert at 9:35 PM on February 17, 2022 [23 favorites]
You'll also notice that the interest in the question of transmission between units in apartments ....simply stopped and it wasn't because the question was answered. It was because the question became moot because it would have already happened. Did I get asymptomatic covid despite sheltering hard because I live in a leaky box in a congregate living situation with hundreds of young idiots? I'll never know!
posted by srboisvert at 9:35 PM on February 17, 2022 [23 favorites]
I for one cannot think of any politician in the world I would trust to take decisions after being presented with research saying that a public health problem was mostly going to hurt people that pay less taxes, don't look like them, and don't tend to vote for their party. In the past that's been implicitly and explicitly a reason for muted responses to crises. The paper says that the "value of these models comes from their potential to force policymakers, practitioners, and the public to envision alternative futures in which infection inequality is both easy to anticipate and possible to prevent" but I would definitely fear the opposite.
posted by Wrinkled Stumpskin at 3:14 AM on February 18, 2022 [9 favorites]
posted by Wrinkled Stumpskin at 3:14 AM on February 18, 2022 [9 favorites]
Getting epidemiologists to consider inequality and other confounding social issues in their models feels akin to the joke about a physicist modeling motion using a spherical cow - in that, you’re unlikely to find one so reductionist in person, but you’d be hard-pressed to figure it out just by looking at their work.
And like most issues at the intersection of public policy and complex data, I suspect that the reason is our policymakers.
They don’t want the data underlying the decisions they have to vote on to be muddied up by such real-world concerns as “poverty” and “compromised immune systems.” Whether that’s because they can’t understand information that dense, can but are afraid voters won’t care, or can but are cynically unconcerned with the plight of the common people, I leave as an exercise to others.
posted by mystyk at 3:40 AM on February 18, 2022 [2 favorites]
And like most issues at the intersection of public policy and complex data, I suspect that the reason is our policymakers.
They don’t want the data underlying the decisions they have to vote on to be muddied up by such real-world concerns as “poverty” and “compromised immune systems.” Whether that’s because they can’t understand information that dense, can but are afraid voters won’t care, or can but are cynically unconcerned with the plight of the common people, I leave as an exercise to others.
posted by mystyk at 3:40 AM on February 18, 2022 [2 favorites]
An urban response would have looked like advice to keep the windows open or temporarily leave the city, and money in a fund to upgrade the ventilation systems in older buildings, probably. Though wasn't there a post on here about how older buildings in NYC ARE well ventilated already bc they were built for the last airborne pandemic.
posted by subdee at 3:52 AM on February 18, 2022 [2 favorites]
posted by subdee at 3:52 AM on February 18, 2022 [2 favorites]
Getting epidemiologists to consider inequality and other confounding social issues in their models feels akin to the joke about a physicist modeling motion using a spherical cow
I saw a tweet going around a little while ago that said "Academic public health is to public health practice as ham is to hamster."
It's interesting to read these links knowing that the epis that I work with (in the public sector) have a keen sense of how inequality drives transmission; over the past two years that's been central to our analysis and understanding of how covid blasted our large American city. But this is surveillance, not modelling. Modelling tends to be the domain of academics. The people who do shoe-leather epidemiology, informatics, and reporting that happens in the public sector? We all know. All of our health maps are actually poverty maps. I don't work with academics; maybe they haven't caught up.
posted by entropone at 5:16 AM on February 18, 2022 [16 favorites]
I saw a tweet going around a little while ago that said "Academic public health is to public health practice as ham is to hamster."
It's interesting to read these links knowing that the epis that I work with (in the public sector) have a keen sense of how inequality drives transmission; over the past two years that's been central to our analysis and understanding of how covid blasted our large American city. But this is surveillance, not modelling. Modelling tends to be the domain of academics. The people who do shoe-leather epidemiology, informatics, and reporting that happens in the public sector? We all know. All of our health maps are actually poverty maps. I don't work with academics; maybe they haven't caught up.
posted by entropone at 5:16 AM on February 18, 2022 [16 favorites]
fwiw i work in academic public health and social determinants of health outcomes is a primary focus. for example, looking at eviction rates and hospitalizations, race/rurality and opioid deaths etc. this is at the family medicine research dept of a med school at a large public university in the us.
posted by AlbertCalavicci at 5:25 AM on February 18, 2022 [21 favorites]
posted by AlbertCalavicci at 5:25 AM on February 18, 2022 [21 favorites]
fwiw i work in academic public health and social determinants of health outcomes is a primary focus.
That makes sense. In the "came out of a lot of discussion" link above, I noticed this sentence:
Transmission modeling arose out of theoretical ecology and population biology, and for a long time evolved on its own track somewhat independent of key subfields of epidemiology, and social epidemiology in particular.
I don't know a lot about these fields but could imagine fields like theoretical ecology and population biology might be very blindered in how it looks for strictly biomedical explanations for things, rather than social explanations.
In my experience with public health, I've noted a schism between the heavily biomedicalized side of the field and the social side (with a much more interdisciplinary and social focus), so maybe I'm just seeing this issue how I'm used to seeing things.
posted by entropone at 5:37 AM on February 18, 2022 [2 favorites]
That makes sense. In the "came out of a lot of discussion" link above, I noticed this sentence:
Transmission modeling arose out of theoretical ecology and population biology, and for a long time evolved on its own track somewhat independent of key subfields of epidemiology, and social epidemiology in particular.
I don't know a lot about these fields but could imagine fields like theoretical ecology and population biology might be very blindered in how it looks for strictly biomedical explanations for things, rather than social explanations.
In my experience with public health, I've noted a schism between the heavily biomedicalized side of the field and the social side (with a much more interdisciplinary and social focus), so maybe I'm just seeing this issue how I'm used to seeing things.
posted by entropone at 5:37 AM on February 18, 2022 [2 favorites]
yes, there's a huge disconnect - even just on campus - between people doing stuff like we are (family physicians interested in public health outcomes) and people doing computationally intensive genomics work, for example.
they also get way, way, way more money than us.
posted by AlbertCalavicci at 5:58 AM on February 18, 2022 [6 favorites]
they also get way, way, way more money than us.
posted by AlbertCalavicci at 5:58 AM on February 18, 2022 [6 favorites]
A couple of things that I found interesting...
In the presentation, the presenter talked about how they had studied both sociology and epidemiology and were fully aware from the sociology side of all kinds of factors related to inequality... but when they started modeling near the start of the pandemic, they went with the epidemiology flow and simply failed to think seriously about all of the stuff from the sociology half of their brain.
From an argument with an anti-abortion racist in the comments: "...there is plenty of evidence to suggest that race/ethnic inequality in health outcomes can’t be reduced to SES inequities and have to be explainable at least in part by the many ways racism is baked (one might even say structured) into social/policy/healthcare systems."
And they also talked about how they thought the biggest reason for higher Black death rates would be higher rates of pre-existing conditions and lower general health, but there was a bigger effect on deaths rates from the fact that Black people do more essential work and, because of lower incomes, live in more crowded conditions.
posted by clawsoon at 7:13 AM on February 18, 2022 [7 favorites]
In the presentation, the presenter talked about how they had studied both sociology and epidemiology and were fully aware from the sociology side of all kinds of factors related to inequality... but when they started modeling near the start of the pandemic, they went with the epidemiology flow and simply failed to think seriously about all of the stuff from the sociology half of their brain.
From an argument with an anti-abortion racist in the comments: "...there is plenty of evidence to suggest that race/ethnic inequality in health outcomes can’t be reduced to SES inequities and have to be explainable at least in part by the many ways racism is baked (one might even say structured) into social/policy/healthcare systems."
And they also talked about how they thought the biggest reason for higher Black death rates would be higher rates of pre-existing conditions and lower general health, but there was a bigger effect on deaths rates from the fact that Black people do more essential work and, because of lower incomes, live in more crowded conditions.
posted by clawsoon at 7:13 AM on February 18, 2022 [7 favorites]
In my very humble opinion, the differences in transmission between various economic and SES groups completely explains the US's disjointed pandemic response.
It is true that for some, this pandemic has been a minor inconvenience and nothing more.
For others, depending on their job or their access to income (or proximity to quality hospital care) it probably still is a daily nightmare.
The fact that the 'minor inconvenience' group is in charge of things in most places, and even the most kind of it are barely aware of how the other half is living is a major problem.
posted by The_Vegetables at 8:54 AM on February 18, 2022 [4 favorites]
It is true that for some, this pandemic has been a minor inconvenience and nothing more.
For others, depending on their job or their access to income (or proximity to quality hospital care) it probably still is a daily nightmare.
The fact that the 'minor inconvenience' group is in charge of things in most places, and even the most kind of it are barely aware of how the other half is living is a major problem.
posted by The_Vegetables at 8:54 AM on February 18, 2022 [4 favorites]
There's a lot to unpack in this idea. First, this recent pandemic is relatively unique in it's scope. From the onset it was quickly seen to have universal infectious potential across obvious vectors such as air travel. This is going to skew the response toward people who can afford air travel and where they go, same with rail -- commuters, going to work Kids going to school, people going to events. those things are much more easy to manage, in terms of policy shutting them down, than immediately looking to re-engineer high density living spaces. We did almost immediately quarantine elder care facilities, but got public resistance to anything more.
With a potential patient pool of 8 billion people, parsing it down to immunocompromised was always going to take longer than figuring out what things work on all people first. We are, after all, still very very early in the history of this disease.
Now, looking at other epidemics. Ebola was always a rural disease, and the response treated it as such. It's been stated before that the African continent seemed to have a model response to Covid based on their handling of Ebola.
AIDS on the other hand, is the absolute model for thinking of the difference between what researchers were doing and what policy makers were doing. At least in the west, where the money for research was.
I think this issue is more nuanced than this article presents, but I also think that among the many many issues that the pandemic has brought to light, the fact that the west has faced so few broad infectious diseases has severely weakened our public health response, and the political power of the public health community.
posted by OHenryPacey at 9:01 AM on February 18, 2022 [4 favorites]
With a potential patient pool of 8 billion people, parsing it down to immunocompromised was always going to take longer than figuring out what things work on all people first. We are, after all, still very very early in the history of this disease.
Now, looking at other epidemics. Ebola was always a rural disease, and the response treated it as such. It's been stated before that the African continent seemed to have a model response to Covid based on their handling of Ebola.
AIDS on the other hand, is the absolute model for thinking of the difference between what researchers were doing and what policy makers were doing. At least in the west, where the money for research was.
I think this issue is more nuanced than this article presents, but I also think that among the many many issues that the pandemic has brought to light, the fact that the west has faced so few broad infectious diseases has severely weakened our public health response, and the political power of the public health community.
posted by OHenryPacey at 9:01 AM on February 18, 2022 [4 favorites]
First, this recent pandemic is relatively unique in it's scope. From the onset it was quickly seen to have universal infectious potential across obvious vectors such as air travel. This is going to skew the response toward people who can afford air travel and where they go, same with rail -- commuters, going to work Kids going to school, people going to events. those things are much more easy to manage, in terms of policy shutting them down, than immediately looking to re-engineer high density living spaces.
I'm sorry but this is exactly what I am talking about. There is very little actual evidence that high density living spaces (apartments), air travel, air conditioning, or commuter rail are legitimate vectors of COVID disease transmission. Rail cars for example have air exchanges of once every 70 seconds, which is amazing, and far better than anyones' home. They are the line at the bottom of this CDC chart.
It's probably better than most hospital isolation/quarantine rooms. The average home is lucky if they do 3-4 per hour. The 'density' argument fell apart as soon as the SES factors kicked in and those rural/suburban areas had higher per-capita rates than major US cities.
IMO (again) setting up hospitals or clinics in underserved and low SES areas would have been a far more effective use of billions in Federal funding, and helped with other health factors too.
Identifying schools in low SES areas and adding portable classrooms to spread them out would have been another. Buying A/Cs for low SES or adding housing units would have been another. Of course adding housing units is seriously constrained by funding, zoning, etc, but those cards were never on the table for discussion.
posted by The_Vegetables at 11:25 AM on February 18, 2022 [3 favorites]
I'm sorry but this is exactly what I am talking about. There is very little actual evidence that high density living spaces (apartments), air travel, air conditioning, or commuter rail are legitimate vectors of COVID disease transmission. Rail cars for example have air exchanges of once every 70 seconds, which is amazing, and far better than anyones' home. They are the line at the bottom of this CDC chart.
It's probably better than most hospital isolation/quarantine rooms. The average home is lucky if they do 3-4 per hour. The 'density' argument fell apart as soon as the SES factors kicked in and those rural/suburban areas had higher per-capita rates than major US cities.
IMO (again) setting up hospitals or clinics in underserved and low SES areas would have been a far more effective use of billions in Federal funding, and helped with other health factors too.
Identifying schools in low SES areas and adding portable classrooms to spread them out would have been another. Buying A/Cs for low SES or adding housing units would have been another. Of course adding housing units is seriously constrained by funding, zoning, etc, but those cards were never on the table for discussion.
posted by The_Vegetables at 11:25 AM on February 18, 2022 [3 favorites]
There is very little actual evidence that high density living spaces (apartments), air travel, air conditioning, or commuter rail are legitimate vectors of COVID disease transmission.
Yes, there's very little evidence now, but we're talking about the response. Public health policy is always going to look at a highly transmissible airborne disease and target transport, because regardless of how it's spread from person to person, they care about how it's spread from place to place. Once it's in a place then there are local agencies whose policies come to bear, and make the inequities more stark.
posted by OHenryPacey at 2:49 PM on February 18, 2022 [5 favorites]
Yes, there's very little evidence now, but we're talking about the response. Public health policy is always going to look at a highly transmissible airborne disease and target transport, because regardless of how it's spread from person to person, they care about how it's spread from place to place. Once it's in a place then there are local agencies whose policies come to bear, and make the inequities more stark.
posted by OHenryPacey at 2:49 PM on February 18, 2022 [5 favorites]
At least in some cases (the Trump administration and the Kemp administration here Georgia), it feels like the inequity was part of the plan.
Among my ATLien friends, this WaPo story from May 2020 about the reopening of a suburban shopping center remains the best explanation of the (lack of) response to the pandemic in Georgia:
Among my ATLien friends, this WaPo story from May 2020 about the reopening of a suburban shopping center remains the best explanation of the (lack of) response to the pandemic in Georgia:
“I think you have to live life,” said Jeff Lampel, taking a sip of beer.posted by hydropsyche at 4:49 AM on February 19, 2022 [4 favorites]
“When you start seeing where the cases are coming from and the demographics — I’m not worried,” agreed his friend Scott Friedel.
nt have is coded data on social determinants of health at the individual level. You ywant that n health departments don't know and believe this, it's that modelers live on Planet Abstraction, along with all the economists with their perfect decision-makers.
Functionally, there's a lack of data that'd allow you to draw -causal- conclusions. We have reams of data showing association, and policymakers (if not corrupt/politically motivated) believe it.
What we dont have is coded data on social determinants of health at the individual level. You want that
posted by esoteric things at 12:46 PM on February 19, 2022
Functionally, there's a lack of data that'd allow you to draw -causal- conclusions. We have reams of data showing association, and policymakers (if not corrupt/politically motivated) believe it.
What we dont have is coded data on social determinants of health at the individual level. You want that
posted by esoteric things at 12:46 PM on February 19, 2022
So does public health. Ask your politicians to *require your health care providers to track SDOH and Medicaid/care/SSI to pay for prescribed evidence-based interventions* like asthma housing, UBI, farmers market dollars or food delivery, WIC , bikes, parks, daycare, education, (free and high quality, with well paid union staff) and supervised injection sites as we see in another thread.
With data we can get even more of that covered, including I think climate justice, reparations, and other things we all agree we need but can't prove causal outcomes.
Health care is a terrible intervention target, but it's the only one we have in the US without political will. I'm not willing to bet on will, but capitalism will get there (see UT's housing interventions for high cost ER visits - talk about a conservative environment!). If we can get rid of capitalism for better, great, but I see this as more short-term viable and it doesn't preclude a kinder system.
posted by esoteric things at 1:00 PM on February 19, 2022
With data we can get even more of that covered, including I think climate justice, reparations, and other things we all agree we need but can't prove causal outcomes.
Health care is a terrible intervention target, but it's the only one we have in the US without political will. I'm not willing to bet on will, but capitalism will get there (see UT's housing interventions for high cost ER visits - talk about a conservative environment!). If we can get rid of capitalism for better, great, but I see this as more short-term viable and it doesn't preclude a kinder system.
posted by esoteric things at 1:00 PM on February 19, 2022
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What does society owe immunocompromised people?
“The Millions Of People Stuck In Pandemic Limbo” :
“That makes at least 7 million immunocompromised people—a number that’s already larger than the populations of 36 states, without even including the millions more who have diseases that also hamper immunity, such as AIDS and at least 450 genetic disorders.”
And the people running the pandemic response are perfectly fine with throwing 7 million people under the bus.
My. God.
Someone, PLEASE, PLEASE, wake me up from this nightmare.
posted by robbyrobs at 8:31 PM on February 17, 2022 [16 favorites]