Legal Epidemiology Lessons Learned

At a glance

• Legal epidemiology is the scientific study of law as a factor in the cause, distribution, and prevention of disease and injury across populations. In plain language, legal epidemiology is about exploring how laws and policies affect health.
• Since 2015, ChangeLab Solutions has partnered with the Office of Public Health Law Services (OPHLS) within the Centers for Disease Control and Prevention’s Public Health Infrastructure Center and, in the early years, the Center for Public Health Law Research at Temple University to run yearlong learning cohorts in which transdisciplinary teams from health departments and organizations across the country engage in hands-on learning about legal epidemiology.
• This article summarizes opportunities and challenges identified by ChangeLab Solutions and OPHLS staff from our experiences across nearly a decade of legal epidemiology learning cohorts, as exemplified by participating teams from the 2023–2024 cohort.

The 2023–2024 Legal Epidemiology Learning Cohort

Do laws related to the transportation of neonates affect infant mortality? How do laws regulating well-water testing affect cancer rates? How can laws enable or prohibit data sharing between state health departments and tribal public health authorities? These are some of the questions that participants in the 2023–2024 Legal Epidemiology Learning Cohort wanted to answer. Through the cohort, they learned the nuts and bolts of legal epidemiology (legal epi for short), which is a scientific approach to tracking and analyzing laws and policies to better understand what they say, how they differ across jurisdictions, and how they affect health.

Since 2015, ChangeLab Solutions has partnered with the Office of Public Health Law Services (OPHLS) within the Centers for Disease Control and Prevention’s (CDC’s) Public Health Infrastructure Center and, in the early years, the Center for Public Health Law Research at Temple University to run yearlong legal epidemiology learning cohorts. The cohorts offer training and mentorship to health departments and partners in adjacent settings (e.g., research institutions, community-based organizations). Participants work in transdisciplinary teams, including members with diverse skill sets and varying degrees of experience with law and policy, to design and conduct legal epidemiology projects that respond to public health challenges facing their communities.

Over the years that we have been running the cohorts, legal epi has been growing as a field of study, and numerous state, tribal, local, and territorial health departments and organizations have expressed interest in developing legal epi skill sets and capacities. Anecdotally, we have observed an uptick in curiosity about this discipline following the COVID-19 pandemic, which shone a light on the foundational role of law and policy in mitigating or exacerbating health inequities.

Keep reading for lessons learned as members of the 2023–2024 Legal Epidemiology Learning Cohort applied their new skills to explore and address health inequities in their states and communities, as well as how they have handled the challenges they encountered along the way.

Lesson 1: Legal epi has practical applications and can address community needs

Participants in our legal epidemiology learning cohorts apply the methods they learn in practical ways to support their core public health roles and responsibilities and to respond to real-world issues affecting the communities they serve. Their projects have not been research merely for research’s sake.

Informing regulatory action to improve infant mortality

One practical way that health departments have applied legal epi methods is to inform regulatory action. For example, the team from the South Carolina Department of Health and Environmental Control (DHEC) systematically mapped across all 50 states the presence or absence of laws governing when a neonate (defined for purposes of this research as an infant under 28 days old) will be transported to a higher-level medical facility to obtain risk-appropriate care. According to the team, South Carolina has one of the highest infant mortality rates in the nation, and within the state, the infant mortality rate is highest for Black and rural populations. The team wanted to explore whether there were opportunities to reduce these health inequities and improve rates of infant mortality overall through use of their regulatory authority as a state agency.

Carlos Avalos, an epidemiologist at DHEC, explains that according to CDC and the World Health Organization, “one way to decrease neonatal mortality is to ensure that babies born with risk factors like congenital malformation, low birth weight, or preterm birth receive adequate care. Unfortunately, not everyone lives close to the highest level of care that they could receive. So that’s one of the main reasons that transfer laws are in effect.”

Although the team is still analyzing and validating their data, one of their preliminary findings is that states with the highest neonatal mortality rates have the lowest prevalence of neonatal transfer laws, whereas states with the lowest neonatal mortality rates have the highest prevalence of neonatal transfer laws. As a next step, the team plans to unpack their data to learn whether nuanced differences across jurisdictions in how neonatal transfer laws are designed — such as whether and when transfers are mandatory versus discretionary — affect outcomes. Such data analysis could help to inform potential modifications to regulations.

Will Britt, DHEC’s chief counsel, summarizes, “[South Carolina’s] transfer laws are in our regulations. So what do the data show? And how can that inform us about what changes we may be able to make to our own regulations to hopefully improve the infant mortality rate in our state?”

Advancing state health plan priorities related to civic engagement

Another practical way that health departments have applied legal epi methods is to support implementation of state health improvement plans, as exemplified by the team from the Wisconsin Department of Health Services (WI DHS). Julia Nagy, population health improvement strategist at WI DHS, explains that her agency is required to periodically complete a state health plan, including a health assessment “to get a wide view on the state of health and well-being in Wisconsin and then a health improvement plan to help us act on those identified priorities.”

Nagy states that over the past several years, WI DHS has been “having many, many conversations with Wisconsinites” to help develop their plan, and “social connectedness and belonging rose up as a priority area. Civic engagement, which is the exercising of the power of community connection, is a sliver that came up as an important aspect and really a leading-edge aspect for public health right now.” She further explains, “We see in research that when communities have higher levels of civic engagement, which is mediated by access to decision-making processes, they have better health outcomes.”

These learnings prompted the team to conduct a legal epi project exploring which of the 12 census-designated Midwestern states allow any type of state-level ballot initiative process — which would allow citizens to propose legislation or constitutional amendments and which the team identified as one specific, tangible aspect of civic engagement. They found that 5 of the states, including Wisconsin, do not allow state-level ballot initiatives.

The team points out that ballot initiatives can be a key lever for adopting health-promoting policies (although this is not always the case and depends on what is being proposed). The team has begun to explore the connections between ballot initiatives and the health policy landscape by looking at Medicaid expansion as one example. They shared that of the 12 Midwestern states, 7 have extended Medicaid to a larger segment of their population via legislative action, 3 have expanded Medicaid via ballot initiatives after multiple failed legislative attempts, and the 2 remaining states — Wisconsin and Kansas — have not expanded Medicaid, although it remains a live policy issue in their legislatures and among members of the public. Both of these states lack state-level ballot initiative processes that might allow a popular vote to override legislative inaction.

Moving forward, the team plans to identify ongoing opportunities to incorporate legal epi methodologies into their state health plan processes and other policy work. Joe Tatar, policy section manager at WI DHS, notes, “This ballot initiative issue is really just the head of a pin when it comes to exploring laws and policies that shape civic engagement.” Even within this single, narrow issue identified in their state health plan, “there are a lot of ways we could use this methodology. Additionally, we are looking for ways we can take what we’ve learned and actually present it to folks here internally so that we can expand our workforce understanding of what legal epi is and how we can partner with each other to apply legal epi to our other policy efforts.”

Lesson 2: Legal epi can promote community engagement

Our learning cohort curriculum emphasizes that community engagement is imperative throughout the entire legal epi process — especially for applied legal epi projects — from selecting a topic and refining a research question to learning about relevant contextual factors that can inform the interpretation of legal data and results. Community engagement can help to minimize unintended negative consequences for people who live in the communities being studied. It is also one way for health departments and organizations to ensure that their policy work has practical value, as described in Lesson 1.

One approach that the 2023–2024 cohort team in Clark County, Washington, took was to discuss possible research areas with community members at the outset of their project. Based on their outreach, they decided to focus on land access for underserved agricultural producers. “Access to farmland remains the number one barrier for aspiring farmers today,” says Lindsey Shankle, strategic initiatives coordinator at Clark County Public Health. “And this barrier is even higher for farmers who are Black, Indigenous, or persons of color (BIPOC).”

The Clark County team focused their research on two interconnected topics: (1) conservation easements as a legal tool to promote affordability of and access to agricultural land, and (2) the legal scope and authority of agricultural advisory bodies (AABs) in Washington State. Because their community partners shared that information about AABs was important and time-sensitive, the team pivoted to a “legal epi lite” approach to answer the AAB question as quickly as possible without sacrificing scientific standards or methodological rigor.

Ed Hamilton Rosales, a core member of the research team and the owner of Western Institute for Agriculture and Food Security, LLC, stated, “Having an NGO attached to this project had multiple benefits that would not have existed without my organization. We had already built relationships within the agricultural community and therefore didn’t need to prove our worth to farmers in order to elicit comments that were truthful and honest during our background research.” Ultimately, obtaining candid feedback from the people most affected by the relevant policies accelerated the Clark County team’s understanding of their topic and the core concepts involved.

Lesson 3: Legal epi can support evidence-based policy development

Public health practitioners can use legal epi to generate reliable, nonpartisan data about the law, which can reveal legal innovations, gaps, and opportunities, as well as support objective studies on laws’ impacts and effectiveness. Legal epi data can be shared with elected officials, changemakers, and others through a variety of dissemination strategies. Although many public health departments express an interest in improving laws and policies that affect community health and well-being, concerns about lobbying restrictions can sometimes stifle action. Legal epi builds on many of public health’s strengths (for example, in data analysis, scientific research, and evaluation) and allows practitioners to contribute to the policy process by sharing data and evidence, without running afoul of lobbying restrictions.

Making the case for stronger well-water testing requirements

One team that has used legal epi to support policy development is from the Lincoln Trail District Health Department, which serves a six-county area in Kentucky. The team was inspired to study state-level laws governing federally unregulated private wells after local community members raised concerns about how the construction of a new electric vehicle battery plant would affect groundwater. Through background research, the team learned that the plant would be located on land near private homes and businesses in an area of the state with the highest concentration of private wells. People who drink water from federally unregulated wells are more likely to be exposed to industrial or naturally occurring contaminants like arsenic, which is associated with health risks like bladder cancer. This issue is of particular concern for the Lincoln Trail team.

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For their legal epi project, the team decided to compare well-water testing requirements in 10 states. The team hypothesized that such laws may significantly affect the number of wells being tested and ultimately reduce harmful exposures and related health risks. Their research revealed that while Kentucky has some requirements to protect the health of people who obtain their drinking water from private wells, there is room for improvement, specifically with regard to regular, ongoing testing.

“We want to share our results with the Kentucky Health Departments Association and other advocacy groups throughout Kentucky to raise awareness that there are no laws that require regular well-water testing or provide any kind of funding to help people who can’t afford testing,” explains Diana Leathers, health equity and community mobilization manager at Lincoln Trail District Health Department. The team also plans to share what they have learned with community members. “We really want people to understand that those who rely on private wells for their drinking water are not covered by the federal Safe Drinking Water Act and give them the why behind regular testing.” In the long run, the team hopes to expand their dataset to include more states and to evaluate the association between well-water testing laws and bladder cancer rates, which could further help to make the case for stronger laws in Kentucky and nationwide.

Partnering with non-governmental organizations to disseminate legal epi data

Using partnerships with non-governmental organizations to disseminate legal epi learnings was a strategy echoed by several teams. This strategy is related to community engagement, which is described in Lesson 2. Joe Tatar from WI DHS notes that his team’s topic — civic engagement and access to democracy — are hot-button issues in public health right now. He observes that when it comes to issues like this, “government institutions aren’t always the best messengers for advocating action. In these cases, it’s important to have partnerships with non-governmental institutions and community-based organizations that can champion policy change in the interest of health.”

In this vein, a cross-sector cohort team in Kansas — including the Kansas Health Institute (KHI), the University of Kansas Medical Center (KUMC), and several local health departments — is exploring the idea of leveraging KHI’s regular webinars to share what they’ve learned through their project, which examined laws in 12 US states that preempt — or prohibit — local governments from establishing a minimum wage that is higher than federal or state standards. The team also hopes to create fact sheets that can help facilitate productive conversations with lawmakers and others about the significant health implications of minimum wage preemption. Vicki Collie-Akers, director of policy and planning at KUMC, summarized, “One of our aspirations . . . is to create something that really benefits Kansans and that we can leverage to strengthen our presence in public health policy in the state.”

Building legal literacy to support policy work

We have also heard from non-lawyers who have participated in the cohorts that the process of learning legal epidemiology by actually doing it helps to demystify the law; in other words, it makes the law feel less abstract and more tangible. “I’m an epidemiologist, and this was my first time ever reading law, so this has really been a great experience,” states Carlos Avalos from the South Carolina DHEC team. And Taylor Pinsent, a senior program analyst who was part of a team from the Council of State and Territorial Epidemiologists, notes that in her role, she often reviews reports from partner associations and national institutions. She says, “Learning legal epi methods has reframed how I read and contribute to those reports.” In particular, she now brings a much more finely attuned eye to the methodologies — or lack thereof — that organizations have used to gather information about laws and policies across jurisdictions. “I find that perspective really valuable.”

Increasing general legal literacy in this way can improve public health practitioners’ ability to engage in policy development activities even outside the context of legal epi research. The Kansas team plans to use their new skills in finding, reading, and analyzing laws and policies to do more regular tracking of proposed state legislation. Hannah Conner, social epidemiologist for the Wyandotte County Public Health Department in Kansas, noted that preemption bills “show up almost every year” in Kansas and often have significant implications for public health. “Last year, a preemption law was passed to prevent all ‘safe and welcoming’ acts after a local county passed one, and this year, there was talk of preemption laws targeting diversity, equity, and inclusion.”

Lesson 4: Legal epi is resource-intensive and complex, making partnerships essential for team success

A common theme expressed across all cohort participants is that getting trained in legal epi methods and pursuing legal epi projects can be personnel- and resource-intensive, and the process can be complex, especially for non-lawyers who have little experience with finding and reading laws and policies. Health department staff often balance significant workloads and competing priorities, so adding legal epi to the mix can prove challenging. Many teams emphasized that building a project team that drew on diverse expertise from across their agencies — including both lawyers and epidemiologists, among other types of professionals — as well as bringing in partners from other government agencies and external organizations were key to getting projects across the finish line.

The cohort teams from Wisconsin and South Carolina, which researched ballot initiatives and neonatal transfer laws, respectively, found an innovative way to increase their capacity by enlisting support from law students and, in the case of South Carolina, an undergraduate student. These relationships were mutually beneficial. Tommy Holter, the South Carolina team’s undergrad partner, explained that it was eye-opening for him to see “the connection between neonatal transport laws and the lives of infants and mothers.” He said he learned “how each word is able to contribute to the interpretation of a law, and you can take that interpretation and connect it to the lives of patients.” He will carry these insights with him as he continues to study the connections between data, government, and our legal system.

Members of the Kansas team emphasized that one of the best parts of participating in the cohort was the opportunity to strengthen relationships with colleagues from multiple local health departments, along with KHI and KUMC. In addition to being enjoyable, the collaboration contributed to the team’s success. Wyatt Beckman, a senior analyst at KHI, noted that at one point, team members from one participating health department were temporarily pulled away to support their agency’s response to a time-sensitive public health issue. He noted that public health practitioners “sometimes have to respond to the unexpected,” and when you have multiple organizations involved with a project, others can pitch in to carry the work forward.

Ultimately, structural changes within the public health workforce will be required in order for health departments to be able to leverage legal epi methods consistently. Additional training in law and policy for both new and seasoned practitioners, as well as career pathways and funding for health department staff working on policies, are some of the changes that would support the uptake and sustainability of applied legal epi as a regular public health practice.

OPHLS and ChangeLab Solutions are working together to support public health professionals at all career stages, from students to leaders, by increasing their ability to engage in equitable policy development in partnership with communities. For example, we are exploring opportunities for master of public health and other academic programs to train future practitioners in public health law. In addition, practitioners at any career stage can participate in the Public Health Law Academy, which offers free, on-demand trainings on the legal system and how it affects public health, including a series on legal epidemiology. In the long run, we hope that the Legal Epidemiology Learning Cohort and resources like these can increase diversity within the public health workforce and prepare the next generation of public health leaders to respond to critical issues by using law and policy tools.

By Katie Hannon Michel, Patrick Glass, Becca Rieckhoff & Jami Crespo

Top image, left to right: Jami Crespo (senior attorney, ChangeLab Solutions); Will Britt (chief counsel for public health, South Carolina Department of Health and Environmental Control); Chelsea Robinson (social determinants of health epidemiologist, Wisconsin Department of Health Services); Natalie Cook (disease investigator, Epidemiology Division, Johnson County Department of Health and Environment); Lyndsey Blair (assistant professor of healthcare administration and public health, Bellarmine University); Becca Rieckhoff (former attorney, ChangeLab Solutions)

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This work was supported by the Centers for Disease Control and Prevention of the US Department of Health and Human Services (HHS) as part of a financial assistance award totaling $200,000 with 100 percent funded by CDC/HHS. The contents are those of the authors and do not necessarily represent the official views of, nor an endorsement, by CDC/HHS or the US Government.

The mark "CDC" is owned by the US Department of Health and Human Services (HHS) and is used with permission. Use of this logo is not an endorsement by HHS or CDC of any particular product, service, or enterprise.

7/11/2024