Dear Epidemiology: a letter from two Māori Researchers

Donna Cormack and Sarah-Jane Paine have a problem with epidemiology, so they wrote it a letter: Please include Māori perspectives.

Posted on
15.05.20

Solidarity is an uneasy, reserved, and unsettled matter that neither reconciles present grievances nor forecloses future conflict.
Eve Tuck and K. Wayne Yang

Amidst the repeated calls over the past weeks for us to “Unite against Covid-19”, various scientists have been proposing what they believe an appropriate pandemic response should be. In mass media and public forums, the coverage of divergent proposed responses has become framed, in some ways, as an issue of ‘good epidemiology/epidemiologists versus bad epidemiology/epidemiologists’. On one level, this framing represents a lifting of the disciplinary covers, providing people with a peek inside and under epidemiology and its myth of a singular objective truth. But for us as Māori health researchers and teachers, it also felt like a broader call to stand in solidarity with the science and the ‘good epidemiologists’, without any acknowledgment that for Indigenous peoples, solidarity, as Eve Tuck and Wayne Yang remind us in their paper “Decolonization is Not a Metaphor”, is “an uneasy, reserved and unsettled matter”. 

As researchers who work in Westernised academic institutions with and alongside epidemiology, the underlying assumptions being revealed about whose lives matter most, who is understood to be deserving and who is seen as dispensable did not seem as marginal as the ‘good epidemiology/bad epidemiology’ frame would have us believe. The practice of an ahistorical epidemiology, that wilfully ignores colonialism, racism and other systems of oppression, felt familiar, and not different from what Ruha Benjamin refers to as the “normal workaday science”1 produced within the discipline of epidemiology.

Epidemiology, in simple terms, is the study of patterns of health and ill-health in populations, including in order to prevent and control disease.2 Western epidemiology is informed by a set of values, principles and ideas that attempt to predict how characteristics of  ‘population groups’, defined by age, gender, nationality, ‘race’ or some other variable, interact with patterns of disease. As a discipline, epidemiology reduces peoples’ complex and interconnected lives to numbers, with the common underlying assumption that this quantitative data is fact or evidence. Many of the techniques used in epidemiology, and particularly the statistical methods that dominate, originated from the thinking that shaped early quantitative approaches to the study of differences between social groups.3 This thinking included racist, ableist and classist beliefs linked to eugenics. These ideas were not without critique: W E B  Du Bois, in his foundational works of the late 19th and early 20th century, modelled a social epidemiology that acknowledged the fundamental role of racism in driving patterns of population health outcomes in the United States.4 Contemporary social and critical approaches to epidemiology continue to challenge some of these practices and patterns of thinking. However, prevailing approaches to epidemiology still tend to leave these matters largely unaddressed in any meaningful way, with an unwillingness to acknowledge, let alone reckon with, the traces of these ways of thinking that remain embedded in today’s epidemiological practices.

Colonialism systematically undermines the place of Indigenous knowledges, presenting eurocentric science as superior to Indigenous ways of knowing. In the current pandemic response, epidemiology’s place in this hierarchy of knowledge seems to have been solidified rather than disrupted. The valorisation of epidemiology, both as a discipline and as a set of experts, was rapid and relatively unquestioned. But why was the public so easily able to get behind epidemiology? It is because this nation has heavily invested in Westernised science since colonisation, spreading the belief that this kind of science can and will save us from ourselves. Epidemiologists, ‘good ones’ that is, are presented in this current crisis as ‘expert knowers’, as credible and reliable. The science they produce is constructed as objective, bias-free and value-neutral.

Colonialism systematically undermines the place of Indigenous knowledges

So what calls to solidarity with epidemiology are being made in this current moment? In calling to Unite against Covid-19, what values, knowledge systems and ways of being are we being called to unite for

For us as Indigenous health researchers, it can feel like a call for solidarity with the discipline of epidemiology and its positioning as a superior knowledge system – a positioning that is arrogant in its assumption that it alone can make sense of the current pandemic, dismissive of Indigenous knowledges that know intimately and deeply what it means to move through crises, that understand the inter-relatedness of peoples and environments, and that are rooted in the collective. It is asking us to accept the dominance of some types of theories about health, rather than encouraging an approach that supports multiple ways of knowing. 

Acting in solidarity with the ‘good science’ requires us to set aside our concerns and aspirations, to sign up wholesale to a value set that is not ours. Solidarity as a value rallies individuals to act in the best interests of the common good, but who is included in that view of the ‘common’? Solidarity assumes a common set of values and goals, and does not necessarily create space to scrutinise or reject these values and goals, or to create new ones. 

Public debate about the vulgarity of an epidemiology that would sacrifice the lives of older people and those with underlying health conditions for the wellbeing of the economy was silent to the fact that epidemiology has shown how the ongoing vitality of capitalism and neoliberal colonial economics trades off Māori lives on the daily. Where is this outrage for the existence of avoidable premature mortality for Māori that existed before and will exist after the current crisis? 

Where is this outrage for the existence of avoidable premature mortality for Māori that existed before and will exist after the current crisis?

These concerns we raise may read as a complete dismissal of epidemiology and epidemiologists or of any contribution to understanding and responding to the current crisis. It is not. We both use epidemiological tools and techniques at times in our own work. Rather, it is a refusal to stand with or for an epidemiology that is uncritical, that wilfully ignores its own whakapapa of thought and history as a discipline, that claims an objective universal truth, and that sees itself as sitting above – not alongside – other systems of knowing.

What we call for below, in our Letter to Epidemiology, is an alternative: a radical, compassionate epidemiology grounded in Kaupapa Māori values and principles of practice.

May 2020

Dear Epidemiology,

We know that you are busy saving the world right now but we wanted to get in touch as see if everything is ok. We know that we’ve talked to you about this before, but we are concerned about the way in which you seem to be reverting to your old ways of thinking. Those ideas from your grandfathers, Darwin and Galton, are deep within your bones.5 We thought you’d got the monkey off your back when you stood behind those who saw the state of our health as a symptom of our societies. You might not like what we have to say, but if you want to keep a place on the podium then you need to pay attention. 

He kanohi kitea. Over the last few weeks our communities have seen you like never before – normally relegated to the pages of academic journals, during the pandemic your models and case rates have spread into our homes and conversations via livestream. And the Level 4 lounge experts really love it – waiting with anticipation for the daily numbers, and grappling with the language of elimination (although as Māori we have been grappling with elimination since 1769). To be honest, we’re sick and tired of it – not of the daily briefings per se, but of the way you let us down on the daily; showing up to the masses, ignorant of our faces, our realities and our priorities. Our scholars and communities have implored you to stand up for us and to represent our right to live in your models. It’s a bit rude, really, given that we have spent the last 20 years or so walking alongside you, providing you with theory and intellectual insights – what a privilege. We saw in you the potential to monitor action and inaction in the face of need. Do you see our potential too?

Titiro, whakarongo… korero. We are inviting you into a conversation not just about a virus but about history, time and context. We know you like holding the mic, but this is a decades-old debate and now it’s our turn to speak. If you really want to be a tool for the people, then you need to be prepared to see the myriad of ideas and actions that have created and reproduced the inequitable conditions that pattern our risks and vulnerabilities.

We see the silence for what it is – another attempt to trample on our Treaty rights.

Community transmission is important – but let's not forget about the ways in which science and policy have been complicit in the intergenerational transmission of racism and structural inequities within our communities. You say it's important to look at the ‘causes of the cause’. Will you listen to what matters for the people who were already struggling to be heard? Will you use your numbers to talk back to the systems that seek to eliminate our rights and interests, and in doing so dominate us? Will you stand with us to ensure that the “keep it out, stamp it out” policy approach applies not only to infectious disease but to the contagion within our health, economic and political systems that is racism? 

Manaaki ki te tangata.

They say “complex problems require complex solutions” – you know, when we say complex, we don’t mean hard (although collaborative, community-based approaches will be difficult for those who are used to working in isolation and not sharing). What we mean is solutions that come from multiple, connected and different worldviews and knowledge systems, not just your monotoned way of thinking. The data that you bring to this journey is crucial, but we also need critical and community theorists, social scientists, the arts and humanities, and creative artists and practitioners to ensure that the waka is well-equipped to care for everyone. We are worried about who will get to the lifeboats. We don’t need another Titanic now, do we? 

One of your distinguishing features is the way you look at the causes of ill-health as though they are all connected together like an intricate web6 – seemingly going to great pains to consider the assumptions that exist within each thread that you spin. But therein lies the problem – the questions that you are asking and the assumptions that you are modelling come from your world, and not ours. Have you thought about the consequences of that? You need to accept that the knowledge you are capable of producing is incomplete without us. Caring for our communities means being cautious about the wisdom you choose to include and that you don’t. 

Kia tupato.

As we move through different levels, the opportunity to research the direct and indirect effects of the pandemic will be vast. But take care – our communities are stretched, under-resourced and under-recognised. We have questions that you can help us answer, but only in partnership with us, and that means giving up some of your power. When we talk about  the importance of seeing us in the numbers and as part of the solutions, we were not recommending you take part in the cultural peep-show that many of your contemporaries believe will solve our health crises. We are asking you to partake in the kind of seeing that happens when your ears are open to hearing when you have been wrong about us (those memories are etched in our histories) and when your mind is open to possibilities you could not dream of but that we do. You do not speak for us, we speak for ourselves, so be careful what you say.

Kaua e takahia te mana o te tangata.

That reminds us – it’s time we talk about Te Tiriti. Its absence from your public discussion has not gone unnoticed. Are you talking about it in private or even factoring it into your decisions? Have you thought about the missed opportunity to remind everyone about our shared responsibilities to not only uphold equity but to make our Treaty rights central in your work?

Knowledge is always collective and intergenerational.

Let's be clear here, we do not need a conversation about equity, as a central tenet within the Treaty, to understand our mana and rangatiratanga. They are inherent and interminable, derived through whakapapa. Beginning long before the arrival of British settlers and their culturally specific ways of observing our world, persisting when objectors fought against our rights to speak our own languages, to access our own shores or to be on our own lands, and existing well beyond the predicted time course of this pandemic. We see the silence for what it is – another attempt to trample on our Treaty rights. Why can’t you see, instead, that the Treaty provides a plan for us to stamp out the virus?

Kia ngakau mahaki.

What we need is a more compassionate epidemiology. We want to get behind a system of enquiry that is pluralistic, inclusive and responsive. A discipline that is about service, not self-promotion or CVs. A producer of knowledge not just to be kind (although that is helpful) but for the purpose of radical transformation. We don’t need solutions that are done to us, that stamp on our mana motuhake. A compassionate epidemiology grounded in social justice provides tools, measures and models that direct discussions and decision making for freedom and rangatiratanga, that upholds the inherent mana of all peoples. Proceed with humility but with both the conviction that this is the right thing to do and the commitment to do right. 

We know you like to think that you know everything. But what you know is just part of the story. It can feel good to be at the top, to be celebrated and rewarded, for what you say and how you say it. But it’s not about you, or it shouldn’t be. Remember what Matua Moana said, that being an expert, to him “is to be the modest carrier of knowledge”. Knowledge is always collective and intergenerational.

Aroha ki te tangata.

Your repeated display and debate about death models fails to recognise the sorrow and distress represented in those data. You’ve been documenting Indigenous stories of pain for centuries but you forget that we are people too. In fact, as the people of the land, we ask you to recreate yourself at pace, so that your pandemic work starts with a love and respect for the dignity and humanity of all people, not just those who think like you. This will mean illuminating the way the systems that you currently serve continue to provide benefit for some people while at the same time unfairly disadvantaging others. It won’t be easy, and they won’t like you for it. But you know what they say – love hurts.


Yours, in sovereignty,

Mauri ora

Donna and Sarah-Jane

Newsletter

1  Benjamin, Ruha. “Informed Refusal: Toward a Justice-based Bioethics.” Science, Technology, & Human Values 41, no. 6 (2015): 131.

2 Bhopal, Raj. Concepts of Epidemiology: Integrating the Ideas, Theories, Principles, and Methods of Epidemiology. Oxford, UK: Oxford University Press, 2016.

3 Zuberi, Tukufu. “Deracializing Social Statistics: Problems in the Quantification of Race.” The Annals of the American Academy of Political and Social Science 568, no. 1 (2000): 172–185.

4Jones-Evearsly, Sharon, and Lorraine Deans. “After 121 Years, it’s Time to Recognize W. E. B. Du Bois as the Father of Social Epidemiology.” Journal of Negro Education 87, no. 3 (2018): 230–245.

5Bonilla-Silva, Eduardo, and Tukufu Zuberi. “Towards a Definition of White Logic and White Methods.” In White Logic, White Methods: Racism and Methodology, edited byTukufu Zuberi and Eduardo Bonilla-Silva (3–27). Lanham, MD: Rowman & Littlefield Publishers, 2008.

6 Krieger, Nancy. Epidemiology and the Web of Causation: Has Anyone Seen the Spider?” Social Science & Medicine 39 (1994): 887–903.