Title: Public Health Analyst; Lead, Research and Translation Team, CDC’s Public Health Law Program
Education: BA, Wellesley College; MPH, Johns Hopkins Bloomberg School of Public Health; JD, Emory University School of Law
Public Health Law News (PHLN):Please describe your career path and what drew you to public health law.
Ramanathan:I went to work in New York City after college, and 9/11 happened about three months later. While most of the city stood still, I noticed that public health workers worked around the clock to support the individuals and institutions around me. I wanted to contribute to that larger purpose, so I started by volunteering at Ground Zero with emergency responders. Then I assisted a health department with screenings in elder care settings in my free time, and eventually I joined the Peace Corps to work on basic health development in rural Senegal. It didn’t become clear to me until the first policy course of my master’s program that law was fundamental to all of these experiences—and that public health lawyers existed! The first one I got to know was Lainie Rutkow, the teaching assistant for my public health law course who lent me In A Nutshell,a book on becoming a lawyer. She talked to me about her career, work, and research interests. I was sold. That path brought me to CDC in 2009 as an intern for Montrece Ransom, whose guidance and mentorship are two of the main reasons I am part of this field today.
PHLN:What is legal epidemiology, or legal epi, and how did you become interested in it?
Ramanathan:In 2010, I was at a meeting in Washington, DC, with CDC’s Division for Healthcare Quality Promotion (DHQP), for which I was tracking new laws aimed at preventing infections and outbreaks in healthcare facilities. At the table of health department nurses, epidemiologists, lawyers, and others, someone asked, “Which state’s law works best?” None of us knew it at the time, but legal epi helps to answer that question. Legal epidemiology is the scientific study of law as a factor in the cause, distribution, and prevention of disease and injury. Legal epi allows us to understand what the law says, how it works in the jurisdiction or population in which it operates, and what its health consequences or outcomes are.
About 6 months after that meeting, Scott Burris, professor of law and public health at Temple University and director of the Center for Public Health Law Research, came to Atlanta to talk about how to measure law and policy for scientific studies, and a light bulb went off. I submitted a proposal to CDC’s evaluation office to study the impact of healthcare-associated infection (HAI) laws in states. The proposal was funded in mid-2011. That initial project led me and PHLP’s new director, Matthew Penn, to work with DHQP scientists, as well as Scott and his colleagues at Temple University, for more than 5 years, learning how to collect, analyze, and interpret data on HAI laws and policies and what they mean for national prevention efforts.
PHLN:How is legal epi applied at CDC?
Ramanathan:Since those initial HAI studies, PHLP’s team of talented and prolific staff attorneys has grown to support CDC programs in almost every part of the agency, using legal epi. From these efforts, CDC now applies legal epi to dozens of emerging topics of public health importance through comparative law studies, historical analyses, quantitative studies, and qualitative evaluations. CDC also supports a pilot program (the STLTs Legal Epi Project) to introduce legal epi into state, tribal, local, and territorial health departments around the country. CDC also supports a pilot program (the STLTs Legal Epi Project) to introduce legal epi into state, tribal, local, and territorial health departments around the country. With our partners at ChangeLab Solutions and Temple University, PHLP has coached health departments through guided trainings, practice-based tools, and topic-specific technical assistance to help frontline practitioners better understand, use, and improve on their own laws. We all have learned what it takes to use, incorporate, and institutionalize legal epi, and it is incredibly exciting to watch this field grow and take root across the nation.
PHLN:How can applying scientific methods to legal research improve public health outcomes?
Ramanathan:I think we are still learning the answer to this question, but public health practitioners are increasingly asked to provide evidence for laws that work well. For complex, emerging public health issues linked to social determinants of health, the role that law plays in addressing health outcomes is still poorly understood and characterized. Public health has relied on cases like Jacobson v. Massachusettsto justify decades of public health laws covering everything from tobacco and nutrition to intentional and unintentional injuries to antibiotic-resistant infections. Yet we see more local- and state-level litigation and lobbying challenging public health laws as being too broad or too punitive, and many laws are struck down in courts because the evidence doesn’t show why they are effective.
Conceptually, we know that a lot happens between a law being passed and human behavior changing. If we systematically study the impact of a law on the administration of a public health initiative, downstream costs, enforcement activities, or even attitudes about an issue—and then link those effects to behavioral or organizational changes and health outcome data—we can fill in the picture of how the law helps to address a health problem. Rigorous, scientific studies that link different kinds of data, including legal data, can help us understand the relationships between these factors and how to craft the most effective laws to support public health.
PHLN:Do you have to be a lawyer to use legal epi?
Ramanathan:No, but it helps to have a lawyer on hand to find, read, and parse legal language, and apply it to public health issues. PHLP attorneys work daily with scientists, evaluators, policy analysts, communication professionals, and other practitioners to conduct and use legal epi studies to inform public health practice. We have found that these varied perspectives contribute to thorough, well-defined analyses and the translation and dissemination of findings to a wider audience. For those public health professionals who are interested in legal epi, but don’t have a lawyer to collaborate with, don’t hesitate to send a request to PHLP’s legal epi team at PHLawProgram@cdc.gov!
PHLN:The Legal Epidemiology Center (LEC)was launched at the 2018 Public Health Law Conference in October 2018. What is the LEC?
Ramanathan:The LEC is an online resource that helps users to teach and inform the use and understanding of law and policy through the a legal epidemiology lens. As part of the Public Health Law Academy, the LEC hosts trainings, teaching tools, background research and papers, guidance documents, communities of practice, and other resources to bring new practitioners and emerging leaders into the fold.
PHLN:How was the LEC created?
Ramanathan:In 2013, CDC formally funded development of legal epidemiology as a field through a cooperative agreement with ChangeLab Solutions. That funding has brought professionals across disciplines together to examine diverse legal and policy research agendas, develop standardized methods for analyzing and translating legal text, and tailor resources to public health practice.
PHLN:Can anyone access and use the LEC?
Ramanathan:Yes! The LEC is a learning portal for anyone interested in legal research and translation that serves public health purposes. It is a free resource for public health practitioners, educators, researchers, and students—and anyone can access and use the website.
PHLN:How do you hope the LEC will improve public health practice?
Ramanathan:As we began to disseminate LEC materials around the country at various conferences and meetings, people started to approach me and other colleagues to say, “I didn’t know I was a legal epidemiologist until today!” In this way, I expect the LEC will bring professionals from various parts of the country together to share, discuss, and collaborate on new initiatives. I hope it will expand our ability to work together to address social determinants of health and growing health disparities. I also hope it will help us fill needs and gaps in public health practice that are best achieved through law and policy.
PHLN:What is the most challenging part of legal epi?
Ramanathan:I think it is the amount of time it takes to complete a study. It is difficult for many resource-strapped public health practitioners to fit legal epi work into their busy workloads. That said, we are trying to make it an easier task. For one, we are learning through our other work with health departments about how to scope and streamline research so that it complements existing work and takes fewer resources to complete. We also have been thinking through how to tailor methods to be most accessible and how to produce guides specifically for those practitioners who need to create legal data easily and quickly—and translate it for different purposes. Finally, we are trying to increase the number of researchers and practitioners who know how to do this work and can collaborate across organizations or jurisdictions to share the burden. My goal is to give people access to the legal epi tools and community with the hope that they are better able to meet the challenges of public health practice.
PHLN:What other projects are you currently focused on?
Ramanathan:I am really excited about building a national community of practice around legal epidemiology in the coming year. Starting with the three cohorts of STLTs Legal Epi Project jurisdictions, I hope we can incorporate more voices from the field to achieve a better understanding of how legal epi informs practice. So much work in public health and public health law is reactive to new and urgent needs. Having the space to think about novel and strategic uses for legal data will hopefully allow us to plan solutions, and ways to communicate those solutions, to decision makers more effectively.
PHLN:What do you hope will come of this body of work?
Ramanathan:I hope that legal epi is more than an educational tool or even a way to promote collaboration across disciplines. I hope it will help us to tackle systemic problems of disparities and increase civic engagement on issues related to health.
PHLN:What advice would you give to other jurisdiction or individuals interested in undertaking a legal epi project?
Ramanathan:Check out the Legal Epi Center! And please don’t hesitate to reach out to PHLP with questions.
PHLN:Have you read any good books lately?
Ramanathan:Lately, less so, but one of those books I can always come back to for a laugh is Hullaballoo in the Guava Orchardby Kiran Desai.
PHLN:What’s your favorite part of your job?
Ramanathan:The fabulous team at PHLP—hands down, they make coming to work a privilege and something I look forward to every week!
PHLN:Do you have any hobbies?
Ramanathan:I have a newborn daughter, who makes sure that my favorite hobby right now is napping!
PHLN:Is there anything else you’d like to add?
Ramanathan:Thank you for taking the time to read about legal epidemiology!