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Welcome back, this is Week 7, the finalweek of our course.Thanks so much for staying with me, Ihope you have been enjoying it.I've been having a lot of fun.This lecture this week is an importantone, it's about doing things.Doing things to improve population healthwith the social epidemiologicperspective.It's one of my favorite topics.It's also quite daunting.For this week I assigned four readings.I didn't want you to get off easy.These aren't too hard, fairly accessible,and I hope there's some interestingdiscussion about them on the discussionforum.I want to emphasize that what I'mgoing to offer you, offer in this week isjust a snippet of things I know about fordoing things with social epi.there is all kinds of ways this can be

considered.And I'm only going to offer a little.So, I hope the discussion forums canenhance and elaborate on the stuff we getstarted with in this lecture.Of these three modules for this week, thefirst is background and let's do thattoday.This is one of my favorite quotes.It's apparently coming from, Mark Twainthe American author who said everyonetalks about the weather but no one doesanything about it.

And I think that's an important statementor metaphor for social epidemology.It is really important, sometimes, tolearn about what causes disease.Is it a change in social capital?Is it some discriminatory practice?Is it a social policy?what's happening?So, learning what causes disease iscritically important.But it's also important to think abouthow can we mitigate, remedy, or improvethe health of populations.

This is what we want to talk about inthis week.And, it's a very difficult topic, butit's also, critically important.So, the basic question is, how may we usesocial epidemiology, to improvepopulation health?Look at that.Ever seen Power Point do that?What can we do?

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Well, let's start by going back to one ofthe original slides that we've done.And this is sort of that causation slide.We start with the big D, disease, on theright-hand side, and we say what causedthe disease?Germs, genetics, biology, physiology.Absolutely true.These things certainly cause disease.What alters exposures, and sometimes evenalters genes and even a body'sphysiology?Well, that's behaviors and lifestylechoices and other things in thatdimension.But then we can ask yet another question.What causes behavior?Why are some exposed and others not?And that is the realm of socialepidemiology.The cause of causes.These are things such as social forces,social norms, market power sexism,racism.

All the things we've been talking aboutthrough the entire course.So, when you think about doing things,the question is where do we want tointervene?Where in this big chain should we put ourenergy?Should we alter genes?Should we give people medicines, maybe.And in some cases, yes.In other times, well, we want to alterlifestyles or behaviors, good idea.But social epidemiology's at it's best

when we're working on the upstream, orthe cause of the causes.Let's alter social norms.Let's alter regulatory policy to changewho is exposed and who is not, to giveincentives for others to be healthy.This is social epidemiology at its best.We also want to remember our old bathtub.Remember, things are more multilevel.The group affects the person who may ormay not change.And that person reflects back or affectsthe group.

This is the multi-level concept we'vebeen talking about the whole class.I want to remind you that we talk aboutinterventions.They are often at their best when theyare multi-level.Of course, it's challenging todisentangle the levels, but that doesn'tmean we ought not do things in amulti-level framework.

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So, we want to intervene, we want toalter the social system to improve,usually not inhibit population health.Interventions, therefore, can be at themicro-level and this could be in terms ofmedicines, but who gets the medicines andhow do they get it?That's a social epi question.It's one thing to have a vaccine, it'sanother to distribute it and have peopleactually use it.We can also do things at the meso level.This is the mid, middle level.Here we might be affecting familystructures, doing things at local policy,as we discussed earlier in the course.And, of course, we can discuss things ordo things at the macro-level.This might be state policy.It might be global trade policy, it canbe changing social norms.So, this is where we want to focus ourattention.What's interesting to note is the

macro-level interventions tend to impactmore people.They're macro, so there's more people inthe path, if you will.But over time and over and over again wefind at the micro-level, the individuallevel or sometimes even the biologicalinterventions, tend to have more impact,on health for any given person.So, here's the great tension.Meso, or macro-level interventions affecta lot of people.Micro-level interventions seem to work

better.What can we change in the social system?Lots of things.And I'm sure you have your own ideas.We can educate persons of all places, allkinds females especially, in thedeveloping world.This tends to have profound impact onpopulation health.Of course, we can alter policies andlaws, that might be corporate policies.Of course, they could be governmentalpolicies.

They might even be within householdpolicy.Who does the laundry?Who does the dishes?We can certainly try to affect socialnorms.Social norms, again, are like policies,but they're not written down.And if you want to understand a socialnorm, just do something that's sort of

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confronts your social network's way ofdoing things.And you'll get that look, perhaps thatostracization that will make you sort ofstep out of the group.That's the power of a social norm.Of course, we can also affect physicalenvironments, move the toxic dump, changewhere the nuclear plant is, plant trees.These kinds of things are also upstream,and can be certainly conceived as, socialepi-interventions.One note of caution, it's easy forparticular, particularly people newer tothe discipline, to think we can makeeveryone like each other.Here is a painting, of course, of aGarden of Eden scene.And one the troubles is, we think we cansolve all society's problems if we justchange these norms or just alter thepolicy.The data don't support that, of course.It's tough to get people to behave well

and to like one another.When we think about interventions, Iwant to emphasize, it's criticallyimportant to demonstrate that suchinterventions doing things has an impact.That in fact, it can be demonstrably orscientifically shown to have donesomething.This can create tensions.We've got a great idea to improve heatlh,but if you can't show that it worked,people don't take it seriously.So, we want to have good evaluations or

assessments of the things we're doing.One of the critical ideas in this kind ofevaluation work comes from a late scholarnamed Peter Rossi, who wrote a wonderfulchapter, actually, called The Iron Lawsof Social Program Evaluation.So, Professor Rossi had worked fordecades in trying to understand theimpact of social policies here in Americato improve health, to improve things likepoverty.And of course, this was happening in themiddle and late 1960s.

And what Rossi came up with a bit tonguein cheek was what he called the Iron Lawsof Program Evaluation.The important, first one is, theexpected, measurable impact, of any largescale social program is zero.Rossi was not personally happy about thisconclusion, but after three or fourdecades of work, he had to conclude thatlarge scale social im, impact evaluations

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tend to show no effect.Not all of them, just on average.Further, he goes on, the more rigorous anevaluation, the better study, the morelikely a chance of finding no impact.So, the better the study, the more likelywe see the truth.And finally, the more a program attemptsto change people, and I'll say, adultpeople.If we're trying to change an adultperson, change their behavior, stopsmoking, wear a seat belt, wear a bikehelmet, these kinds of things, the betterchance is you're going to have no result.Changing adult persons behavior is verydifficult.Rossi encouraged us researchers to workin what he called Policy Space.By this he meant, try to imagineinterventions that don't give us theGarden of Eden, but in fact, work onideas that can actually be implemented byyour local community, by your regional

government, by the federal government, ifyou want to.What can really be done, given thepolitical and social context, it'sunlikely we're going to get everyone tolike each other and cooperate fully.Instead, what can actually be done, andthis is the idea of policy space.It can be limiting but it also keeps usnear the closest possible worldassumption that we've talked about in thediscussion of counter factuals.Well, how do we alter social norms?

It's very difficult, but I came acrossthis newspaper or website article a fewdays back and it really struck me.Here, the idea, and I think this appliesmostly for the American audience, of whyis it that young men, typically youngmen, I suppose, are supposed to give ayoung woman of their choosing.And maybe she chooses, him a diamondengagement ring?Where did the social norm for giving adiamond engagement ring come from?And this website from Business Insider,

and you have the link here, has afascinating story about why diamondsaren't actually rare.How the De Beers company bought up allthe diamonds and make them rare throughmonopoly power.And then, did marketing in the 1920s and30s to, say, if you loved your fiance andwanted to marry her, you should, youought to, give her a diamond ring.

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And so, here, we have, if you will bigbusiness altering social norms.And they're very good at it.That's the point of marketing, of course.Another fascinating social norm to thinkabout is what's sometimes called Chinesefoot binding, or foot binding in general.And you may know the story.for a thousand years many persons, were,in certainly China, were having, females,were having their feet bound up.Crushed, actually.And this was a result of some desire toimprove social status.And the idea was one could improve theirdaughter's social status to help hermarry up, if you will, by having her feetbound.And, why did this take off?Because lots of people wanted to havetheir daughter marry up.So, this practice, this rather brutalpractice, went on for 1,000 years.But it was overturned, in fact, in one

generation.So, 1000 years of practice the norm offoot binding was overturned in onegeneration.How?It's a fascinating story, in brief, theparents of girls said we will not bindour girls' feet.And the parents of boys said we will notlet our son marry a girl with bound feet.And pretty soon, poof.That social norm was absolutely turned onits head.

Some great research comes from GerryMackie.This is the American Sociological Review.It's not assigned, you may be interested.There's some also interesting things onthe internet.Another way to alter behavior.We can alter people's information.One way that's being done in America morerecently is to have calories, calories offoods available for purchase at fast foodrestaurants.So, here, we see an example of, of menu,

bored from, some arbitrary fast foodrestaurant.And next to it is not only the price, buthow many calories this product is.This, in this case, salmon club sandwichon a croissant.It sounds good.But it's 770 calories.So, the idea is, if you tell people moreinformation, they will behave

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differently.Unfortunately, this effort does not seemto have much of an impact.Here's a review paper from the RobertWood Johnson, Robert Wood Johnson'sHealthy Eating Research Group.And it's in June 2013.And it's a summary in which says that theimpact of menu labeling is ambiguous.Some studies show as small impact, otherstudies show as no impact.What's fascinating to me is this workconforms exactly to Rossi's rule.The better studies, better qualitystudies methodically show no impact, afascinating tale.Well, no effort for doing things insocial epidemiology would be completewithout talking about the change incigarette smoking use or the prevalenceor incidence of cigarette smoking.And this graph is going to be difficultto see.But as most of you probably know, in

America and the western world, theprevalence, or incidence, depending onhow you want to talk about it ofcigarette smoking has declinedprecipitously from what was 60 and 70% ofthe population down to about 20.That's a massive change, it used to be asmany of you know that it was the smokersright, if you will, to smoke.And persons who didn't like it didn'twant to say anything.That social norm is entirely flipped inAmerica today, where now the non-smokers

hold the social norm power.A smoker needs to ask permission.That's again in about one generation.Fascinating impact.However, the social norm has not beenflipped in every country.And it's going to be impossible for youto see these graphs, but the, on thehorizontal bottom axis, this is justcountries.And the point of this is that by country,smoking prevalence still is high, and itvaries widely.

So, the social norms haven't changedeverywhere.That's the important point.So, when we talk about doing things insocial epi, want to think about smoking,want to think about food consumption.want to think about how marketers usemarketing strategies to say encourage mento buy diamond rings.This is doing stuff in social epi.

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