8/13/2019 1 - 2 - Lecture 1 Part 1b

1/7

8/13/2019 1 - 2 - Lecture 1 Part 1b

2/7

problem of health disparities.Why are some people more healthy thatothers?But I'd like to argue to you that socialepidemiology is much broader than justhealth disparities.It's a critical part, but we can do morethan that.We do do more than that.Social epidemiology is not only includinga discussion or a focus on socialproblems, but can be broader.Something does not need to be a socialproblem to be a topic for socialepidemiology.Critically important from my perspectiveis social epidemiology does not rejectcommon understanding of biology,parthenogenesis, other sort ofbiophysical ways that we become sick.Of course, germs cause disease.Of course the body ultimately dies andcells die and all the biology andpathology in there.

Social epidemiology is asking differentquestions but not in a rejection ofconventional epidemiology, and certainlynot in rejection of conventional biology.Let's take a moment and think about thecauses of disease.From my experience, many people think thecause of disease is access to qualityhealth care.That might be true, but I think there's abroader question at foot here.And here's an example from one of mycolleagues, look at the idea of an

aspirin.Well one takes an aspirin if they have aheadache, but one typically does not havea headache because they don't have theaspirin.That is not having healthcare, doesn'tmake you sick to begin with.The trick is to not have the headache tobegin with.If you have a headache, obviously havingan aspirin or, to follow the metaphor, ifyou get sick you want excellenthealthcare.

But from a public health perspective, ourkey idea is to prevent illness for aslong as we can to begin with.So when we talk about public health, wewant to talk primarily about preventionof disease and not treatment.It's not that treatment doesn't matter.Of course it matters.It's about where we want to focus.And what we want to focus has been

8/13/2019 1 - 2 - Lecture 1 Part 1b

3/7

prevention of disease and disability tobegin with.So, various models of the causes ofdisease to begin with.And one model can be God, however youmight define it.God's will, people get sick becausethat's God's will.That's a reasonable interpretation.I want to say however that for,contemporary modern sciences, thatexplanation is not valid.It's not valid within the scientificparadigm as usually discussed.So we'll put that aside for now.What causes disease, then?Germs, bacteria, viruses.Other kinds of bugs.Certainly, these cause disease.Individual choices and behaviors.I chose to smoke cigarettes, you chose tonot where a seat belt, or perhaps youdid.These choices, these behaviors for our

health exercise, not exercise, good foodand so-forth.These things certainly cause disease ornot.Our focus here, however, is on yetanother level.And that is the level of social forces.What do I mean by that?Well, we can talk about the free marketsystem.Globalization of trade.This has an impact on who has resourcesand who doesn't.

So that matters.We can talk about social norms.That norm to that pressure to smoke acigarette when you're an adolescent ornot to.These things have a profound influence onour desire, on our ability to promotehealth and prevent disease.Racial sexual age discrimination.These things are social forces thataffect health.Obviously, policies.The policy can be a policy in the

workplace, a national policy, a globaltrade policy.Policies are rules.Certainly affect our health.And, of course, if you want a technicalterm called government failures.Here's where the central organization,the government, is or is not doingsomething, that some people think ispromoting health or inhibiting it.

8/13/2019 1 - 2 - Lecture 1 Part 1b

4/7

So, social epidemiology will interfacethe causes of disease, at this level.Let me go a little further.When students ask me, what causesdisease.Is it germs?Is it behavior?Is it globalization and market forces?My answer is yes.It's all of those things.So, we can imagine a chain of events,wherefore example, social norms,encourage an adolescent to smokecigarettes.And this behavior then, is smokingcigarettes.And that, of course, causescarcinogenesis, or cancer, in his lungs.Or disrupts his heart.And so that causes disease.But all of these things are in a chain.And the idea of social epidemiology is tounderstand that rich story back to theorigins of why did the young man, in our

example, choose to smoke in the firstplace.His friends encouraged him to.Why did his friends encourage him to?Because they came from families who alsosmoked or the cigarette advertisers gotinto his head.That's what we're studying here.So we can talk about things that areimmediate or proximal causes of disease,the carcinogenisis in the cell thatcauses lung cancer.We can back it all the way up.

Upstream, if you will to social forces,such as norms, market behavior, sexism,all those sociological type things.That yield the behaviors, that yield thebiological breakdowns that are disease.Social epidemiology, since itincorporates these social forces,therefore also incorporates, or mustincorporate ideas and work from socialscience.It's this incorporation of the ideas forsocial science that distinguishes socialepidemiology from most of other parts of

epidemiology.It's also what makes social epidemiologydifficult, because whereas a physicistmight study an atom, might study a law ofnature that doesn't change over time andspace, we study people.And of course, they change constantly.They grow, they evolve, they havedifferent cultural changes and that makesit difficult to study.

8/13/2019 1 - 2 - Lecture 1 Part 1b

5/7

Let's go back to our earlier example ofsome exposure, whatever it might be andasking whether it causes disease?It's a good question that happens all thetime.We can then say, hm, our socialinteractions, some social mores, are theythe direct causes of disease.And they might.It could be that absence of a friendshipnetwork when you're elderly in a nursinghome.You don't have resources, flowers,friends, companionship, that makes youless happy, less fulfilled, and thereforeyou might be more sick.And unfortunately die earlier.So, direct cause of social interaction isquite a reasonable model.But there's more to the idea of socialepidemiology, and that's this.That society or social interactions alterwho's exposed to good things and badthings over place and time.

So we can ask why a person's in somedisadvantaged place not able to have goodresources such as food.It's the social system that puts somepeople in disadvantaged places and otherpeople in advantaged places.And so we can say yes it's true that thebacteria ultimately caused the disease,but why was the bacteria prevalent in onearea and not another?Why were there sewer systems that wereeffective here and not there?This is the component of the social

system.And then further we can ask why are somepeople, why do they have stronger immunesystems than others?Perhaps they're over stressed, they'reworking two or three jobs, they'reworking in a factory night and day, andothers aren't.This is why social epidemiology can studynot only the direct causes of disease,but the things that cause the cause ofdisease, the cause of causes, if youwill.

And that's exactly what this slide shows.So we can ask not only what the exposuresare, the proximal or immediate causes,but where do they come from to beginwith, why are they here and not there,could we alter those things.This is the idea that we're trying to getacross.And some fundamental questions of socialepidemiology.

8/13/2019 1 - 2 - Lecture 1 Part 1b

6/7

How about a concrete example?Here is a man from the Wikipedia websiteon obesity, and clearly he has some extrafat tissue in his mid-region.The question is why is he obese.And there's many examples, manyexplanations.It could be that he's got a geneticproblem with his metabolic ways.He's destined to be fat because of hisnatural-born genes.That's a reasonable explanation.Doesn't seem to be too common, but it'spossible.Many people would say he's obese or fatbecause he ate too much and exercised toolittle.This is a behavioral explanation, quitereasonable and has some truth, probably.We can ask questions about theenvironment in which this man lived,maybe there is no access to healthyfoods.And no way he can get good exercise.

Perhaps he lives in a dangerousenvironment or he cannot get outside ordo whatever he needs to do to exercise.Another reasonable explanation.But social epidemiology will focus onexplanations such as social norms.What do his friends encourage him to eator encourage him to exercise at whatlevel.These social norms are powerfulmotivators for behavior.So it could be quite true that he ate toomuch and exercised too little.

But we can ask the next question.Why did he eat too much and exercise toolittle?That's what social norms do.Further we can ask, why are there grocerystores that are serving healthy or notfood in his area?Why are there places to exercise or notin his area?These next questions are what socialepidemiology addresses.The laws, the social networks, all thisis what social epidemiology is focused

on.So it's not just that the man in ourexample is obese, but we can askdifferent explanations and try to answerthem through our perspective.In fact, ultimately that's what we'retalking about here.Social Epidemiology is a perspective onunderstanding population health.It's not the only perspective, others are

8/13/2019 1 - 2 - Lecture 1 Part 1b

7/7

equally valid.This explanation, in my view, enrichesthe others.It tells us a richer a story, a morecomplete story of health.Health of persons and of populations,more specifically.