Spring/Summer 2020, Issue 2, pp. 3–9
[Online 8 Mar. 2020, Article A010]
[PDF]
Interview with Dr. Jeff Levin
Auwal Abubakar,[1] Angela Monahan,[2] and Blake Victor Kent[3]
Editors’ Note: We are pleased to present the second in PHRS Bulletin’s series of featured interviews with influential contributors who have shaped the field of public health, religion, and spirituality.
We present an interview with Jeff Levin, PhD, MPH, University Professor of Epidemiology and Population Health, Professor of Medical Humanities, and Director of the Program on Religion and Population Health at the Institute for Studies of Religion, Baylor University. Dr. Levin contributed many pioneering publications in the 1980s and 1990s that formulated conceptual foundations for the study of religion and health. Dr. Levin was interviewed for the PHRS Bulletin by graduate students Auwal Abubakar and Angela Monahan of U. C. Berkeley, working in conjunction with Blake Kent, postdoctoral researcher at Harvard University.
Angela Monahan: In 1987, with Preston Schiller, you published the first comprehensive review of empirical studies on religion and health. How did you get the idea for doing a review like that?
Jeff Levin: Great question! I was a first year MPH student at UNC Chapel Hill in 1982, and I was taking a class taught by the late Bert Kaplan, who along with John Cassel and Leonard Syme, was one of the founding fathers of social epidemiology. We did some readings and one of them was an unusual study that looked at mortality rates broken out by whether people went to church or not. I thought this was the strangest thing and wondered “Why would somebody do a study like that?” But something in me kicked in and I wondered if there were other studies out there like that. Of course, there was no PubMed in those days, so I had to search by hand through the National Library of Medicine’s Index Medicus that came out every quarter. By the end of the semester, I had found about 12 or 15 studies which I presented in class and Bert told me I should write it up and send it to a medical journal. Thinking it would be embarrassing to submit a literature review article saying there were only 15 studies on the topic, when really there were, say, 20, I went back to make sure I had found everything. This turned into a wild goose chase that took my weekends and nights for most of the next four years, and by then, I was getting my PhD at the University of Texas Medical Branch in preventive medicine and community health, so this was a side project.
By the time I was done, around 1986-87, I had found somewhere north of 200 studies in which some sort of measure of religiousness was used in a quantitative analysis in an epidemiology, medical, or biomedical paper. Preston Schiller, my co-author, was one of my UNC professors. We wrote this paper up, sent it in to an epidemiology journal, and got a very skeptical response. So we published it in the Journal of Religion and Health and, naturally, it was well-received there. [see Levin and Schiller (1987) – Eds.]
So that literature review started as a term paper in an MPH class, and I use that example to this day, all these decades later. I tell my own students here at Baylor that as a student, you can do things, you can write a term paper, you can investigate a subject, and it can turn into something. You can publish it and it can even help create a new field.
Angela Monahan: Why were some skeptical when it was published? How did others react to the review?
Jeff Levin: We had sent the paper to Epidemiologic Reviews, the annual review journal of AJE, and we got great reviews. One of the reviewers was George Comstock, long-time chairman of epidemiology at Johns Hopkins and former editor of AJE and who had done many of these studies, and we got great reviews. The editor at the time, whose name I won’t reveal to protect the guilty, sent us a two-page, single-spaced rejection letter. Usually, when you submit something to a journal and it gets turned down, you get a paragraph or so of boilerplate. Well, he had two pages of commentary on how absolutely misguided our paper was, and why would we think religion had anything to do with health or wellbeing, and that the idea of an epidemiology of religion was crazy. He used the word “execrable.” I had to look the word up in the dictionary, I thought it was a scatalogical reference, at first, but it actually means “worthy of being detested, abominated, or abhorred.” Not as bad, I guess!
So, the question of why. A good friend of mine, Larry Dossey, a retired internist and popular writer on medicine and consciousness put it well. Dossey came up with a model of what he called the “Three Eras of Medicine.” Era One was about the body only, Era Two was mind-body-centered, and Era Three, which is ongoing, has folded in consciousness or spirit. Back in the 1980s, medicine was still in transition from an everything-is-biological approach to consideration of the mind-body relationship, psychosomatic medicine, behavioral medicine, and psychoneuroimmunology. Medicine was still negotiating that, and here comes a graduate student from Texas proposing an article that said maybe the mind and body aren’t all there is that impacts on health and we need to fold in this other dimension, the human spirit, and I think that was too much at the time. Nobody knew this research existed and, in fact, many people in academic medicine were still skeptical over the idea of mind-body connections. The idea that our behavior, attitudes, and beliefs, had anything to do with health, health behaviors, or healthcare use, was still considered controversial.
Angela Monahan: You used the phrase “epidemiology of religion” in an early paper but have expressed some concerns about that phrase. Why?
Jeff Levin: I just think the phrase has been so misinterpreted. To some people who aren’t in the public health field, epidemiology is somehow synonymous with demography; so, I think people, including doctors, interpreted “epidemiology of religion” as being about demographic analyses of religion. That has absolutely nothing to do with what I meant. The phrase to me meant studying religion as an independent or exposure variable or construct in relation to morbidity and mortality rates or measures of health and illness, in keeping with the traditional definition of epidemiology, and it somehow got construed into being the quantitative study of religious behavior. That’s something that sociologists and psychologists of religion do, which is fine, but that’s not what I meant by the phrase.
We still don’t have enough good population-health research on religion. By now, yes, thousands and thousands of religion and health studies have been published, but most of them are not really epidemiologic studies; they’re good sociology, psychology, and clinical studies, but not as much longitudinal epidemiologic studies with case-control or cohort designs, and that’s because historically there haven’t been a lot of epidemiologists in the field. Most of the earliest folks that came into this field were medical sociologists or psychologists. Others were physicians like Harold Koenig or Dave Larson. I was different. I was an epidemiologist, who, serendipitously, was originally trained as an undergraduate in religious studies. So I came at this issue from a different perspective. In the last ten years, another trained epidemiologist has entered the field in a big way, Tyler VanderWeele from Harvard, who is just tremendous. I feel like I’ve finally got a disciplinary colleague, a junior colleague, who’s absolutely brilliant and will exceed anything that I’ve been able to do.
Angela Monahan: Thinking about the resources and studies you used back then to evaluate causal relationships, what has changed since then?
Jeff Levin: I think three things have changed. The first thing is that we now have large scale, national, multi-wave population studies in which heath and religion variables are included. That wasn’t the case back then. Now there are wonderful global data sets, like the Gallup World Poll, the World Values Survey, and the European Social Survey in which there are data available to do multi-wave analyses, prospective longitudinal analyses, or time series analyses. That’s the first distinction. The second, speaking methodologically, our bag of tricks is bigger than it was back then. When my mentors and I were trained, epidemiology used to be about manipulating 2×2 tables. With the rise of personal computers and statistical packages, you could learn how to do logistic regression and all those kinds of things. Now there’s more, what with Cox proportional hazards modeling and different types of more sophisticated multivariable and dynamic analytic techniques. There are all sorts of things that we can do to get the most out of our data that simply didn’t exist back then. So, we have access to data, we have a bag of tools to work through the data, and we also have – thanks to Harold Koenig, especially his Handbook of Religion and Health – a bibliographic record of the thousands and thousands of studies that have been done. When I did my literature review in 1987, I found about 200-plus studies. By the turn of the century, Koenig’s first edition of his handbook had around 1200 studies. By his second edition ten years ago, there were an additional 3,000. There are probably 10,000 studies now, and people can go into these bibliographic listings almost as a database, and we could even do meta-analyses and systematic reviews based on Harold’s handbook if we wanted to.[4]
Auwal Abubakar: Can you tell us about how the NIH and other key funding agencies have reacted to this type of work over the years? What was it like in the beginning, and what is it like now?
Jeff Levin: Well, today this is just a topic like any other topic and you can submit an R01, or any other type of grant proposal asking for support for health-related research and development. Back in the day, the topic was considered so strange that I don’t think anybody had ever bothered to submit anything to the NIH. In 1990, I got an R29 grant, a five-year grant for new investigators. I submitted it not through some special RFP or a special request, I submitted it as a regular proposal through one of the existing mechanisms. As a result of my grant and the work of my colleagues, Robert Taylor and Linda Chatters also getting funded, the NIH decided to convene a special conference on the subject. They brought 50 to 60 people together, commissioned some special papers, floated a request for proposals, and created an actual mechanism to fund research on this topic. Ever since then, it’s been onward and upward. Before this, there was no mechanism for this. You could propose research on this topic, like anybody proposing research on anything else, and you would hope that the reviewers who got your proposal didn’t think it was too strange.
I wrote my proposal in 1989, it was funded in 1990, and I think that was the first empirical study that the NIH ever funded on religion and health. That’s not the beginning of the story, though. The NIH, specifically the National Institute of Mental Health, back in about 1980 had published an annotated bibliography by Florence Summerlin, with something like 1,800 references on the topic of religion and mental health. These were books, papers, conference reports, and peer reviewed articles. This was several years before my literature review came out and years before my first NIH grant was funded, so clearly somebody or somebodies were doing research and writing on this subject and somebody at the NIH apparently knew about it, because they published an annotated bibliography on decades of this work. And to reiterate, this was 40 years ago.
What’s so fascinating about those early days, and I’m sure if you were to talk to Ellen Idler or Ken Pargament or David Williams or Harold Koenig or a few other people they would affirm this point: A lot of work had been done, but the people doing the work didn’t necessarily know that other work had been done. Hundreds of studies had been published, but nobody knew they were there, and it took an obsessive graduate student to accumulate all of this. Without the bibliographic tools that we have now, there was no easy way to find out what had been published unless you happened to be surveying the journals regularly. The NIH didn’t jump on this topic until the 1990s, but they knew about it in the 1970s, apparently, when they compiled the religion and mental health annotated bibliography. The American Medical Association even had a committee on medicine and religion, dating to the 1960s, if I recall, so the subject must have been on some folks’ radar, but that doesn’t mean that active researchers were getting studies funded.
Auwal Abubakar: While most of your writing has been theoretical or empirical publications for professional audiences, you’ve also written for broader audiences, as you did in your book, God, Faith, and Health (2001). Why did you write about faith/health for a broader audience?
Jeff Levin: That’s a great question! In 1997, I had been teaching medical school. I left academia, and was kind of getting burnt out from just doing academic biomedical science and producing work maybe 50 people would read. I thought that this work was very important, I thought the field was very important, but at a certain point, I felt, it needed to reach a broader audience – it needed to enter the public consciousness, if you will. While there had been excellent academic books on the topic, I thought there was a need for a popular book, so I wrote God, Faith, and Health. I think a lot of us who are in the academic world become so focused on the narrow, discrete issues involved in our own research, that we lose sight of the bigger picture and lose sight of the importance of communicating what it is we do to the broader audience.
As I’ve gotten older, I’m thinking about these things more. What do I want to leave behind? I’m happy to leave behind 200-plus academic papers, or whatever number I’m up to, but I’d also like to leave behind works that can communicate this information, not just to scientists, psychologists, doctors, and religious scholars, but to lay people and to educated general audiences, because I think the topic is fascinating and it needs a broader airing. A lot of academics write popular books, and psychologists especially have done well in communicating psychological concepts to the general public. Sociologists have done this less so, but epidemiologists and public health professionals hardly do it at all.[5] I think it’s a shame, especially social and behavioral epidemiologists, because the work that we do is so fascinating and so applicable to people’s lives. I wish Len Syme or Lisa Berkman or Sherman James or George Kaplan, or others, would write popular works summing up the research they’ve done throughout their career. I think that would be fabulous and do a lot of good.
Auwal Abubakar: Did it feel like a big change to write for a broader audience?
Jeff Levin: I think where the challenge came in for me was learning how to translate from the academic voice into a voice for the broader audience, but this was a wonderful challenge and it has helped me immeasurably over the years as a lecturer. I think for all of us who are academics, especially academic biomedical scientists, it is in our best interest to take a step back and find ways to put into language what it is that we do so that people who aren’t scientists can understand. Not only would this be helpful from an “evangelistic” standpoint, if that’s the right word, but it also helps our own clarification for ourselves of what it is we’re doing. I’m still doing this, by the way. My latest book, Religion and Medicine [Levin, 2020], is due out with Oxford University Press this spring, and is aimed at a wide audience of both academics and the general public.
Angela Monahan: You recently co-edited the first ever special section on religion in the American Journal of Public Health. How was that whole experience?
Jeff Levin: That was a lot of fun! Ellen Idler at Emory took the lead and then I was involved along with Tyler VanderWeele and the head of the Islamic Relief, Anwar Khan. Editing a special issue of a journal is almost like editing a book, except that you’re soliciting papers and you don’t know what’s going to come in the door. There was a review process to take care of, then we did some of our own writing. It was so exciting because there have been thousands of studies published on this topic and they’ve appeared all over the literature, but to have the pre-eminent public health journal in the world give it’s official imprimatur, for the editor-in-chief of AJPH to say that we’re going to devote a section to the subject, has helped to broaden the platform for this work.
I read Len Syme’s interview that he did for the last issue and one of the questions directed to him was, “Are clinicians more open to this topic than public health people?” and the answer historically is yes, absolutely. Public health professionals tend to be more secular or skeptical of faith issues and more politically progressive, which, at times, we must admit, has gone hand in hand with anti-religious attitudes. The AJPH special section is historically significant because, we hope, it opens the door to more people submitting to AJPH in the future and to other public health and global health journals. That’s would be an exciting development, and long overdue. Within academic medicine this topic is becoming more mainstream. Papers have been published in JAMA, in Archives, in Annals, and all the major medical journals for many decades. But until now, this has not yet been a topic that is widely broached and debated within public health circles. So I think by opening up AJPH as a potential publishing outlet, it does a lot of good.
Angela Monahan: The section focused on faith-based partnerships rather than on the evidence base or on causality. Why?
Jeff Levin: Well, from the standpoint of the special issue, the editor just wanted us to find a way to broach the topic of religion or faith in a way that would be professionally relevant and more easily assimilated among public health scientists and practitioners. So we made the topic about partnerships with faith-based organizations for purposes of disease prevention and health promotion…who’s against that? The aim of the special issue was to talk about the substantial literature of evaluation studies of programs that involve partnerships between faith-based organizations and public health agencies, which is of direct relevance to the delivery of public health and the practice of preventive medicine and health promotion. I think we can appreciate that if we want to reach people, especially underserved communities, we should try to reach them through the institutions in which they are most involved, so these sorts of partnerships and alliances make sense for public health. This is a productive way to broach a connection between faith/religion and health, especially for this audience, rather than going full bore into a theological space or discussing controversial studies of distant prayer, for example. Over the years, AJPH has published some good epidemiologic studies, like the famous study by Strawbridge using Alameda County data to look at the effects of religious involvement on longevity. Additionally, Jeremy Kark published a paper on religion and mortality rates in Israel years ago. So, AJPH has published research on this topic, but not often. For the special issue, I think we made the right decision to focus on interventions and programs. This was a way to help ease the subject of religion into public health discourse without alienating people.
Auwal Abubakar: What are the major obstacles to growth in this field? And also, what has most surprised you in how the field has evolved?
Jeff Levin: I think a major obstacle is really the same obstacle that’s been there since the beginning; it’s the same obstacle that hampers a lot of research in Western biomedicine, and that’s a reticence to think outside the box and to think creatively. It’s much easier to color within the lines and fill in the blanks than to push the envelope. There’s so much wonderful work being done, but there always needs to be a few people in any field that are the ones asking “what comes next, what are the other important questions?”
In recent years there have been some really fascinating studies on religion and health published, and I would love to see them become more prevalent. For years I’ve been saying, publicly, that I’d love to see the independent religion variables get “softer” and the dependent variables get “harder”. By that I mean so much of the work has been about hard behavioral measures of religiousness or spirituality. How many times you go to church? Do you do this, do that? How often do you pray? Do you believe this or that? The outcomes, in turn, have been more subjective measures of well-being or overall health. Nothing wrong with any of this, of course. But I would like to see more of an engagement of the inner spiritual life of people, in terms of concepts like transcendence, one’s connections with God, born-again experiences, spiritual states of consciousness, meditation, and so on. Things that are a little less amenable to easy quantitative counts.
At the same time, I’d like to see more dependent variables assess inside-the-body processes: for example, immune system markers and other physiological, pathophysiological, and psychophysiological outcomes; also more studies of cause-specific mortality rates. This is where I think this field should go. I would also like to see more of an explicit link-up with contemporary understandings from molecular biology and genomics. That’s where the excitement is for me: thinking about how spiritual states and experiences impact on really harder physiological measures of health status or physical functioning, and vice versa. I hope I’m around to see the field evolve in this way.
This interview with Dr. Levin took place on January 27, 2020, via telephone. The transcript has been edited for clarity and brevity.
References
Levin, J. S., & Schiller, P. L. (1987). Is there a religious factor in health? Journal of Religion and Health, 26, 9-36. https://doi.org/10.1007/BF01533291
Levin, J. (2020). Religion and Medicine: A History of the Encounter Between Humanity’s Two Greatest Institutions. New York: Oxford University Press.
Oman, D., & Syme, S. L. (2018). Weighing the evidence: What is revealed by 100+ meta-analyses and systematic reviews of religion/spirituality and health? In D. Oman (Ed.), Why religion and spirituality matter for public health: Evidence, implications, and resources (pp. 261-281). Cham, Switzerland: Springer International. https://doi.org/10.1007/978-3-319-73966-3_15
Wilkinson, R. G., & Pickett, K. (2009). The spirit level: Why greater equality makes societies stronger. New York; London: Bloomsbury.
[1]^ Auwal Abubakar, MBBS, is a trainee in public health, religion, and spirituality who is studying for a Doctor of Public Health degree at the University of California Berkeley (auwal_abubakar@berkeley.edu).
[2]^ Angela Monahan is a trainee in public health, religion, and spirituality who is studying for a Master of Public Health degree in infectious diseases and vaccinology at the University of California Berkeley (angela_monahan@berkeley.edu).
[3]^ Blake Victor Kent, PhD, is Research Fellow, Harvard/MGH Center on Genomics, Vulnerable Populations, and Health Disparities and Research Affiliate, Harvard Human Flourishing Program (bvkent@mgh.harvard.edu).
[4]^ As of two years ago, Oman and Syme (2018) had listed and categorized 33 meta-analyses and 118 systematic reviews published on relations between religion/spirituality and health-related variables. – Eds.
[5]^ Apart from Dr. Levin’s work, another rare example of epidemiologists writing a popular book is Wilkinson and Pickett’s (2009) The Spirit Level: Why Greater Equality Makes Societies Stronger. Both authors are epidemiologists, and the book became an international best-seller. – Eds.