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It's Time for a Positive Epidemiology!

"we need to study health and not just disease and risk"

by Tyler J. VanderWeele, Ph.D

About 20 years ago, psychologist Martin Seligman in his 1998 Presidential Address at the American Psychology Association called for more emphasis on what he referred to as “positive psychology,” conceived of as the science of human strengths.

Seligman argued that “although psychology has come to understand quite a bit about how people survive and endure under conditions of adversity, we know very little about how normal people flourish under more benign conditions,” and he proposed ways to build an infrastructure around this “new science and profession of positive psychology.” 

While work on positive aspects of psychology had undoubtedly been taking place for decades previously, this empowering of the positive psychology movement had powerful effects on the way we think about promoting mental health today, and on the discipline of psychology as a whole.

But what about physical health, and what about other disciplines? Today we ask you to consider with us whether a similar perspective change is needed in epidemiology and public health policy. 

Positive Epidemiology? 

Several of us at the Human Flourishing Program, along with our collaborators at Harvard’s Lee Kum Sheung Center for Health and Happiness, just published a commentary entitled Positive Epidemiology? This article is intended to explore this issue of whether epidemiology—the branch of science that deals with the distribution and determinants of disease and health—might itself benefit from a re-balancing of priorities, similar to what has happened in psychology. We believe that it would. 

This is not to deny that epidemiologists or public health officials have indeed sometimes studied the positive aspects of health—sometimes referred to as “health assets”—but, as was the case with psychology, the emphasis has been on reducing the negative elements of health. The focus has been on diseases and their related risk factors. Epidemiologists tend to ask questions about what causes disease, how diseases spread, and other related issues. 

This perspective has tended to predominate, rather than the study of health and health assets. We propose that a shifting of the balance is desirable.

What Is Public Health Missing? 

You may have seen us argue elsewhere that various pathways to flourishing, such as family, religious community, education, and work all contribute substantially to population-level health and well-being.

While education and employment do receive some attention in the epidemiologic literature, family and religious community receive much less.

By neglecting these pathways, we are limiting our understanding of what is shaping health at a population level concerning outcomes ranging from longevity to depression and suicide.

Everyone cares about physical health. But people also care about being happy, having a sense of meaning, trying to be a good person, and having good relationships and community. In neglecting these positive aspects of health and well-being, and by focusing predominantly on disease and risk factors, public health officials and researchers neglect the full range of things that people care about in life.

Furthermore, in our commentary, you will see evidence that these other positive aspects of life also, in fact, shape health and even longevity. 

But these health assets are also sought for their own sake. Moreover, sometimes there are trade-offs between physical health and these other ends. There can be trade-offs, for example, in medical decision-making. And there may be trade-offs in varying associations with specific “exposures.”

Ignoring these trade-offs in our epidemiologic studies and in their interpretation leads to myopic conclusions.

One study published a few years ago reported an association between divorce/separation and reduced body mass index. This may indeed be the case.

But without also examining outcomes such as happiness, mental health, meaning, relationships, and divorce’s effects on children, the study does not give an adequate picture of the full effects on health and well-being, even though there may not be anything wrong with the study scientifically.

A move toward positive epidemiology and an examination of other positive outcomes could help correct this short-sightedness.

The Way Forward

We are certainly not arguing for an abandonment of the more traditional focus of epidemiology on topics such as cardiovascular disease, cancer, and infectious disease. These are critical topics in supporting population health. Recent concerns about coronavirus, and in fact any actual experience of disease, make very clear that considerable weight ought to be given to these topics, as indeed has been the case in the past. However, we do think more research and resources ought to be devoted to “positive” aspects of health as well. 

One way to help facilitate that shift is the inclusion of measures of positive well-being outcomes in our epidemiologic cohort studies. Our own brief flourishing measure, consisting of a total of just 12 short questions, across 6 domains of life, was intended as one straightforward way to facilitate this enhancement. We have also been trying to develop unique data resources specifically oriented to the study of positive outcomes. Epidemiology has a powerful set of methodological tools to uncover causal pathways, and these same tools could be employed to attempt to understand the determinants of not only physical health but also happiness, meaning, character, and close relationships as well.

Open Questions

What are the open questions?

If we are to move forward toward a more positive epidemiology, one important set of questions concerns resource allocation.

Even if a convincing case can be made to invest substantially more in the study of positive health and well-being and positive health assets, how far should the balance really shift? 

Another difficult set of questions concerns disciplinary boundaries. Are these topics truly an appropriate object of study for epidemiology?

Should they not be left to the “positive” psychologists?

While this might seem a reasonable position on the face of it, the fact that we know that various positive psychological and social factors can shape physical health would arguably be reasonable grounds that their study is important for epidemiology. We hope to contribute to interdisciplinary dialogue on these important topics at the Human Flourishing Program.

A final set of difficult questions concerns what we really mean by “positive?” Is employment “positive,” or is it simply to be understood as the absence of unemployment?

Is “positive” simply the absence of the “negative?” And, if so, might our traditional emphases concerning disease and risk factors for disease, in fact, be sufficient? These are difficult conceptual questions.

At the Human Flourishing Program, we do believe that the distinction is important and real. We tend to think of “positive” as that pertaining to some good that is sought as its own end; that which is “negative” is then that which pertains to the loss of some good that is sought as its own end. Happiness, health, meaning, virtue, and relationships are all sought as their own end. Trying to delimit the precise boundaries of what is meant by “positive epidemiology” would undoubtedly require further conceptual work. It would require more reflection, as a community, on goods and on those final ends we are seeking. But that reflection may, in and of itself, also prove valuable.

(originally published and republished with persmission)

Tyler J. VanderWeele, Ph.D., is the John L. Loeb and Frances Lehman Loeb Professor of Epidemiology in the Departments of Epidemiology and Biostatistics at the Harvard T.H. Chan School of Public Health.

The Human Flourishing Program at Harvard University aims to study and promote human flourishing, and to develop systematic approaches to the synthesis of knowledge across disciplines.

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