Welcome back.

We were talking about Robinson Crusoe as a model of health, and what I was saying, if you recall, is that social epidemiology is a perspective on understanding health that is in contrast to that model. We understand, we want to understand how social systems affect health of individuals, but individuals that are embedded in society. In families, in social networks, in nation-states with rules and laws and policies and all the political benefits and shortcomings of any given place. Perhaps just a moment on what social epidemiology is not. Some might reasonably argue that all of epidemiology is social epidemiology because all of epidemiology addresses health of humans at least as framed here. That's reasonable but I think social epidemiology is a distinct sub discipline and its a sub discipline of epidemiology. Just like cardiovascular or genetic epidemiology are valid sub-disciplines. Social epidemiology's not social work. Social workers around the world and for a long time have really helped to improve population health. But social epidemiology is a sub-discipline that uses the tools of epidemiology. And perhaps some from social science that improves the health in a, sort of a different way. Medical sociology is a sub-discipline of sociology that's closely aligned with social epidemiology, but here's the distinction, in my view. Social epidemiology uses or tries to understand the social system for its impact on health. Health is the outcome, the item of interest. Medical sociology, at least in textbooks, is trying to understand the social system by understanding health. So the arrows go back and forth. So in practice, medical sociologists and social epidemiologists are often doing very similar work. So it's a mild disciplinary perspective, but I think the distinction might help you get a better grasp on what we're doing here. Lots of work, and we'll see this in one of the forthcoming lectures in social epidemiology is focused on the important

problem of health disparities. Why are some people more healthy that others? But I'd like to argue to you that social epidemiology is much broader than just health disparities. It's a critical part, but we can do more than that. We do do more than that. Social epidemiology is not only including a discussion or a focus on social problems, but can be broader. Something does not need to be a social problem to be a topic for social epidemiology. Critically important from my perspective is social epidemiology does not reject common understanding of biology, parthenogenesis, other sort of biophysical ways that we become sick. Of course, germs cause disease. Of course the body ultimately dies and cells die and all the biology and pathology in there. Social epidemiology is asking different questions but not in a rejection of conventional epidemiology, and certainly not in rejection of conventional biology. Let's take a moment and think about the causes of disease. From my experience, many people think the cause of disease is access to quality health care. That might be true, but I think there's a broader question at foot here. And here's an example from one of my colleagues, look at the idea of an aspirin. Well one takes an aspirin if they have a headache, but one typically does not have a headache because they don't have the aspirin. That is not having healthcare, doesn't make you sick to begin with. The trick is to not have the headache to begin with. If you have a headache, obviously having an aspirin or, to follow the metaphor, if you get sick you want excellent healthcare. But from a public health perspective, our key idea is to prevent illness for as long as we can to begin with. So when we talk about public health, we want to talk primarily about prevention of 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

prevention of disease and disability to begin with. So, various models of the causes of disease to begin with. And one model can be God, however you might define it. God's will, people get sick because that's God's will. That's a reasonable interpretation. I want to say however that for, contemporary modern sciences, that explanation is not valid. It's not valid within the scientific paradigm 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 to not where a seat belt, or perhaps you did. These choices, these behaviors for our health exercise, not exercise, good food and so-forth. These things certainly cause disease or not. Our focus here, however, is on yet another level. And that is the level of social forces. What do I mean by that? Well, we can talk about the free market system. Globalization of trade. This has an impact on who has resources and who doesn't. So that matters. We can talk about social norms. That norm to that pressure to smoke a cigarette when you're an adolescent or not to. These things have a profound influence on our desire, on our ability to promote health and prevent disease. Racial sexual age discrimination. These things are social forces that affect health. Obviously, policies. The policy can be a policy in the workplace, a national policy, a global trade policy. Policies are rules. Certainly affect our health. And, of course, if you want a technical term called government failures. Here's where the central organization, the government, is or is not doing something, that some people think is promoting health or inhibiting it.

So, social epidemiology will interface the causes of disease, at this level. Let me go a little further. When students ask me, what causes disease. 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 smoke cigarettes. And this behavior then, is smoking cigarettes. And that, of course, causes carcinogenesis, 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 to understand that rich story back to the origins of why did the young man, in our example, choose to smoke in the first place. His friends encouraged him to. Why did his friends encourage him to? Because they came from families who also smoked or the cigarette advertisers got into his head. That's what we're studying here. So we can talk about things that are immediate or proximal causes of disease, the carcinogenisis in the cell that causes 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 the biological breakdowns that are disease. Social epidemiology, since it incorporates these social forces, therefore also incorporates, or must incorporate ideas and work from social science. It's this incorporation of the ideas for social science that distinguishes social epidemiology from most of other parts of epidemiology. It's also what makes social epidemiology difficult, because whereas a physicist might study an atom, might study a law of nature that doesn't change over time and space, we study people. And of course, they change constantly. They grow, they evolve, they have different cultural changes and that makes it difficult to study.

Let's go back to our earlier example of some exposure, whatever it might be and asking whether it causes disease? It's a good question that happens all the time. We can then say, hm, our social interactions, some social mores, are they the direct causes of disease. And they might. It could be that absence of a friendship network when you're elderly in a nursing home. You don't have resources, flowers, friends, companionship, that makes you less happy, less fulfilled, and therefore you might be more sick. And unfortunately die earlier. So, direct cause of social interaction is quite a reasonable model. But there's more to the idea of social epidemiology, and that's this. That society or social interactions alter who's exposed to good things and bad things over place and time. So we can ask why a person's in some disadvantaged place not able to have good resources such as food. It's the social system that puts some people in disadvantaged places and other people in advantaged places. And so we can say yes it's true that the bacteria ultimately caused the disease, but why was the bacteria prevalent in one area and not another? Why were there sewer systems that were effective here and not there? This is the component of the social system. And then further we can ask why are some people, why do they have stronger immune systems than others? Perhaps they're over stressed, they're working two or three jobs, they're working in a factory night and day, and others aren't. This is why social epidemiology can study not only the direct causes of disease, but the things that cause the cause of disease, the cause of causes, if you will. And that's exactly what this slide shows. So we can ask not only what the exposures are, the proximal or immediate causes, but where do they come from to begin with, why are they here and not there, could we alter those things. This is the idea that we're trying to get across. And some fundamental questions of social epidemiology.

How about a concrete example? Here is a man from the Wikipedia website on obesity, and clearly he has some extra fat tissue in his mid-region. The question is why is he obese. And there's many examples, many explanations. It could be that he's got a genetic problem with his metabolic ways. He's destined to be fat because of his natural-born genes. That's a reasonable explanation. Doesn't seem to be too common, but it's possible. Many people would say he's obese or fat because he ate too much and exercised too little. This is a behavioral explanation, quite reasonable and has some truth, probably. We can ask questions about the environment in which this man lived, maybe there is no access to healthy foods. And no way he can get good exercise. Perhaps he lives in a dangerous environment or he cannot get outside or do whatever he needs to do to exercise. Another reasonable explanation. But social epidemiology will focus on explanations such as social norms. What do his friends encourage him to eat or encourage him to exercise at what level. These social norms are powerful motivators for behavior. So it could be quite true that he ate too much and exercised too little. But we can ask the next question. Why did he eat too much and exercise too little? That's what social norms do. Further we can ask, why are there grocery stores that are serving healthy or not food in his area? Why are there places to exercise or not in his area? These next questions are what social epidemiology addresses. The laws, the social networks, all this is what social epidemiology is focused on. So it's not just that the man in our example is obese, but we can ask different explanations and try to answer them through our perspective. In fact, ultimately that's what we're talking about here. Social Epidemiology is a perspective on understanding population health. It's not the only perspective, others are

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