Jennifer Fraser is an upper-year PhD candidate studying the history of medicine at the University of Toronto’s Institute for the History and Philosophy of Science and Technology. Her dissertation “The Cold War on Cancer: Inuit and the Canadian Epidemiological Imagination” charts the history of Arctic cancer research, focusing particularly on how, during the mid-late twentieth century, Inuit populations came to be seen by Canadian healthcare professionals as crucial sites of cancer knowledge production through which new etiological hypotheses could be tested, epidemiological methods perfected, and diagnostic technologies developed.
A post by Jennifer Fraser
It’s been just over a year since COVID-19 was declared a pandemic, and I don’t think I’ve ever done more imagining. I’ve imagined what it would be like to hug my parents, to go out for dinner, or have coffee with a friend. In fact, as I sit at my messy dining room table, frantically trying to finish this piece, I’m imagining what it would be like to work in an office—or indeed, anywhere—that is not surrounded by a vacuuming husband, a crying toddler, or a barking dog.
It turns out that I’m not the only one that has been using my imagination. Whether it be by planning a future event, fantasizing about a post-COVID-19 world, building a hug-tunnel, or playing Animal Crossing, many of us have used our imaginations to help quell our pandemic-related anxieties, cope with periods of prolonged social isolation, and help ease the tedium that is life under lockdown. The imagination has also played into how we’ve responded to the novel coronavirus on a systems-level.
For instance, imagined scenarios are often invoked to maintain public compliance with a set of increasingly stringent health guidelines (ex. how would you feel if you were from a high-risk group? Or, what will happen if our hospital system gets overburdened?) (Vincent & Slutsky, 2020). They also underlie disease modelling, as projections of infection numbers, vaccine rollout, or ICU-bed availability are, ultimately, reflections of an imagined future (Toon, 2016). Imagination also features prominently in epidemiological discourse. In May of 2020, ex-director of the CDC’s Office of Public Health Preparedness Ali S. Khan stated that imagination was a crucial aspect of strategic decision-making (Quammen, 2020). In October, Harvard professor Bill Hanage critiqued the lack of creative-thinking in the UK government’s lockdown-focused pandemic response plan, lamenting: “Where is the imagination?” (Oluwole, 2020).
Indeed, the imagination has emerged as a key component of individual and collective attempts to to counter the current health crisis. But how do these ideas---epidemiology and the imagination--actually fit together? As a historian of epidemiology, these are questions that have long captured my interest. However, I’ve never had the chance to sit down and think about what the “epidemiological imagination” actually is, or where it comes from. A few months ago, while looking down the barrel of a harsh winter and a months-long national stay at home order, I decided to try and uncover the history of this concept. I wasn’t expecting this to be a difficult task. However, my cursory examination of the literature revealed that tracing the genealogy of the relationship between epidemiology and the imagination would not be as straightforward as I initially anticipated.
I quickly discovered that there was no one overarching definition of the phrase “epidemiological imagination.” In fact, interest in the subject (at a conceptual level) appeared to fall into two distinct, though related, camps, fronted by those involved in the field of epidemiology, and those that write histories about it. Rather than offering complementary views of what is being imagined and who is doing the imagining, these groups seemed to hold drastically different views of what the relationship between epidemiology and the imagination actually is, and (perhaps more importantly) why it matters.
If you Google “epidemiology” and “imagination” you will be faced with a barrage of monographs and scholarly journal articles—many of which written by medical historians and sociologists of science. Historiographical use of the term “epidemiological imagination” can be traced back to at least the 1990s, with the work of Gerald Oppenheimer (Oppenheimer, 1992, 50). Writing at a time where historians were particularly eager to show how medical-knowledge-making was shaped by its larger socio-cultural context, Oppenheimer used the term to try and illustrate the “socially constructed” nature of epidemiological practice, by showing how epidemiological models of and responses to the HIV/AIDS epidemic were enmeshed with contemporary attitudes about sexuality, gender and risk, as well as popular prejudices.[1]
While Oppenheimer might have been one of the first historians to reference the “epidemiological imagination,” he is now in good company. The phrase has become somewhat of a buzzword in health humanities literature. Following Oppenheimer’s lead, historians and sociologists of medicine tend to use the concept to illustrate how the field of epidemiology reflects and reinforces elements of the larger social world. Although an explicit definition of the term is not usually provided, it is clear that when humanities scholars talk about the “imaginary,” they are doing so to challenge existing beliefs that epidemiological data is unproblematically objective and scientific. These scholars are trying to show how epidemiological “facts” are notoriously unreliable and tend to say more about prevailing views about sickness and health than actual distributions of disease (Wailoo, 2011, 7). For instance, historical and sociological research has shown how epidemiology has reproduced existing truths and logics in a variety of contexts, with smallpox epidemics, STI prevention, the formation of obesity risk factors, and the development of cancer surveillance systems being just a few notable examples (Craddock, 2008, 4, 11; Lavin & Russill, 2010; Wailoo, 2011, 61; Raisborough 2016, 59-62; Mika & Vaughan, 2018; Knadler, Stephen, 2019, 25; Mold, Clark, Millward & Payling, 2019; Richardson, 2020, 12; Montgomery & Engelmann, 2020). As we can see, when historians and sociologists speak about the “epidemiological imagination,” it’s usually to shed light on the highly contingent nature of epidemiological knowledge. However, this is not how people working from within the discipline have traditionally understood the concept.
Epidemiologists have been talking about the imagination for almost as long as the field has existed.[2] For instance, Scottish epidemiologist Jerry N. Morris invokes the concept in his 1964 “The Uses of Epidemiology”—a pioneering text, that in many ways, laid the groundwork for the profession (Morris, 1964, 252, 259; Smith, 2001). In his writing, Morris emphasizes the importance of creative and fresh ways of thinking about health problems, and when he alludes to the imagination, he does so in the hope that future epidemiologists will use their cognitive capacities to continue to expand, extend and enact new possibilities for the discipline.
A similar interpretation of imagination can be found in the work of John Ashton, the former Regional Director of Public Health in the North West of England and co-founder of the WHO Healthy Cities Project. In the mid-1990s, Ashton published an edited collection entitled: The Epidemiological Imagination: A Reader (Ashton, 1994). Written largely by and for epidemiologists, Ashton’s compendium celebrates and promotes the discipline by emphasizing the creative and imaginative nature of epidemiologic ways of thinking and doing. In putting the collection together, Ashton was inspired by the American sociologist Charles Wright Mills (Ashton, 1994, ix). In fact, the title of Ashton’s compendium was meant to be a riff on Mills’ The Sociological Imagination—a now-classic text where Mills puts forward a carefully reasoned argument about the nature and aims of sociology and sets out a manifesto and roadmap for the field (Mills, 1959). At its heart, The Sociological Imagination is an attempt to remind sociologists that they should not lose sight of the larger socio-political context in their attempts to explain individual behaviours (Puga & Easthope, 2017). However, this does not seem to be Ashton’s primary take-away from this work. Instead, Ashton was drawn to Mills’ discussion of the specific qualities’ sociologists should exhibit.
Mills believed that good social science was predicated on the ability to pull away from a situation and think about it from an alternative point of view. He thought that this visionary approach (or “sociological imagination”) was the only way that the mundane application of particular techniques could be transformed into a dynamic process capable of deepening our understanding of the human condition. Viewing the social sciences and the epidemiological method as part and parcel of the same culture of enquiry, Ashton was interested in encouraging a similar approach within his own field. He hoped that by highlighting a number of historical and contemporary examples where epidemiologists were particularly innovative in their problem solving, his edited collection would help convey the potential and excitement of the epidemiological method and help instill qualities like resourcefulness, inventiveness, and out-of-the-box thinking in future generations of public health students.
As we can see, historians and epidemiologists have understood and used the concept of “epidemiological imagination” in drastically different ways. Whereas health professionals have used the “imagination” to promote epidemiology’s meaning-making practices, humanities scholars have largely used it to undermine them. Perhaps the best example of this tension can be found in a series of letters published in the American Journal of Epidemiology in 2000. In responding to a commentary written by Jay S. Kaufman and Richard S. Cooper, which critiqued social epidemiology’s tendency to compare health status across groups, well-known social epidemiologists Nancy Krieger and George Davy Smith decried the authors for not exercising enough “epidemiological imagination” (Krieger & Smith, 2000). Krieger and Smith argued that group comparisons were an essential feature of epidemiology. They suggested that, rather than scrapping them completely, researchers should focus their energy on improving the technique since epidemiology would not be the field it is today had epidemiologists and social activists not “dared to imagine” a better future for the field (Krieger & Smith, 2000, 832). In their author response, Kaufman and Cooper took issue with Krieger and Smith’s criticism, arguing that “while a willingness to take on established beliefs and consider radical alternatives is critical to advancing the field, the imagination can lead in many directions” (Kaufman and Cooper, 2000, 833). In their view, certain epidemiological practices were more rooted in cognitive bias than empirical evidence, and that too much imagination was why so many epidemiological methods and findings tend to reinforce racist ideologies and perpetuate health disparities.
The imagination is commonly understood as the opposite of reality. However, these divergent framings of the “epidemiological imagination” have had very real implications for how the discipline is practiced. As we can see from the Krieger, Smith, Kaufman and Cooper example, because of these two competing operational definitions of “epidemiological imagination”, scholars working on the subject tend to talk past each other, and often have difficulty understanding different points of view. Historians and sociologists of medicine, for instance, have not really attended to how ideas about the nature and value of imagination in epidemiological practice have evolved over time. Similarly, epidemiologists have tended to avoid discussions of the role that public health practices play in perpetuating inequities.
So what can be done? Is there a better, more nuanced way of imagining the epidemiological imagination? In many ways, this is an attempt to imagine the unimaginable. However, if there’s one thing I’ve learned from the COVID-19 pandemic, it’s that we’re all actually pretty good at dealing with unforeseen situations. Over the past year we’ve found ourselves adapting our daily lives and considering our collective futures in ways that most of us had never thought of before. As New Yorker staff writer Kim Stanley Robinson has argued: “The virus is rewriting our imaginations. What felt impossible has become thinkable. We’re getting a different sense of our place in history. We know we’re entering a new world, a new era. We seem to be learning our way into a new structure of feeling…We realize that what we do now, well or badly, will be remembered later on. This sense of enacting history matters.” (Robinson, 2020). Over the past few months, we have already seen a variety of attempts to radically reimagine the systems that shape our society. Perhaps the time is also ripe for us to grapple with historiographical renderings of the “epidemiological imagination” and try to think up a more nuanced definition that can better encapsulate the constellation of “bureaucracy, vulnerability, biomedical science, mortality, and hope” that underpins this complex concept which has come to have such an obvious and structuring impact on all of our daily lives (Livingston 2012, 8).
[1] For a good overview of historiographical approaches to the social construction of medical knowledge, see: Ludmilla Jordanova’s “The Social Construction of Medical Knowledge” (1995).
[2] Although the origins of many epidemiological methods and concepts can be traced back to the seventeenth century, epidemiology did not emerge as an academic discipline until the early-mid twentieth century. For more on the history of epidemiology’s professionalization see Alfredo Morabia’s History of Epidemiological Methods and Concepts (2004).
References:
Ashton, John, ed. The Epidemiological Imagination: A Reader. Buckingham: Open University Press, 1994.
Craddock, Susan. City of Plagues: Disease, Poverty, and Deviance in San Francisco. Minneapolis: University of Minnesota Press, 2008.
Jordanova, Ludmilla. “The Social Construction of Medical Knowledge.” Social History of Medicine 8, no. 3 (1995): 361-381.
Kaufman, Jay S and Richard S. Cooper. “The Authors Reply.” American Journal of Epidemiology 151, no. 8 (2000): 832-833.
Knadler, Stephen, Vitality Politics: Health, Debility, and the Limits of Black Emancipation. Ann Arbor: University of Michegan Press, 2019.
Krieger, Nancy and George Davey Smith. “Re: Seeking Causal Explanations in Social Epidemiology.” American Journal of Epidemiology 151, no. 8 (2000): 831-832.
Lavin, Chad, Chris Russill. “The Ideology of the Epidemic.” New Political Science 32, no. 1 (2010): 65-82.
Livingston, Julie. Improvising Medicine: An African Oncology Ward in an Emerging Cancer Epidemic. Durham: Duke University Press, 2012.
Mika, Marissa and Megan Vaughan. “Africa and the Epidemiological Imagination.” Somatosphere, 25 September 2018.
Mills, Charles Wright. The Sociological Imagination. Oxford: Oxford University Press, 1959.
Mold, Alex, Peder Clark, Gareth Millward & Daisy Payling, “Imagining Publics.” In Placing the Public in Public Health in Postwar Britain, 1948-2012, 33-65. London: Palgrave Macmillian, 2019.
Montgomery, Catherine and Lukas Engelmann. “Epidemiological Publics? On the Domestication of Modelling in the Era of COVID-19.” Somatosphere, 10 April 2020.
Morabia, Alfredo. A History of Epidemiologic Methods and Concepts. Basel: Birkhauser Verlag, 2004.
Oluwole, Femi. “I spoke to a Harvard epidemiology professor, who explained why we are getting it so wrong.” The Independent, 12 October 2020.
Oppenheimer, Gerald. “Causes, Cases, And Cohorts: The Role Of Epidemiology In The Historical Construction Of AIDS.” In AIDS: The Making of a Chronic Disease, edited by Elizabeth Fee and Daniel M. Fox, 49-76. Berkley: University of California Press, 1992.
Popay, Jennie. “Qualitative Research and the Epidemiological Imagination: A Vital Relationship.” Gaceta Sanitaria 17, Suppl. 3 (2003): 58-63.
Puga, Ismael and Robert Easthope. An Analysis of C. Wright Mills’s The Sociological Imagination. London: Routledge, 2017.
Toon, Adam. “Imagination in Scientific Modelling.” In The Routledge Handbook of Philosophy of the Imagination, edited by Amy Kind, 451-462. New York: Routledge, 2016.
Quammen, David. “Why Weren’t We Ready for the Coronavirus?” The New Yorker, 4 May 2020.
Raisborough, Jayne. Fat Bodies, Health and the Media. London: Palgrave Macmillan, 2016.
Richardson, Eugene T. Epidemic Illusions: On the Coloniality of Global Public Health. Cambridge, MA: MIT Press, 2020.
Robinson, Kim Stanley, “The Coronavirus is Rewriting our Imaginations.” The New Yorker, 1 May, 2020.
Smith, George Davey. “The Uses of ‘Uses of Epidemiology.’” International Journal of Epidemiology 30 (2001): 1146-1155.
Vincent, Jean-Louis and Arthur S. Slutsky. “Coronavirus: just imagine…” Critical Care 24 (2020): 90.
Wailoo, Keith. How Cancer Crossed the Color Line. Princeton: Princeton University Press, 2011.