Welcome back. This is part two of lecture one on the course Social Epidemiology.

This part, we're going to address the question of, where did social epidemiology come from? I think it's really important to know where one's comes from, to think about where they're headed. And I also think that understanding where social epidemiology comes from will help you have a deeper understanding of what the sub-discipline is all about. Just a reminder, that for the whole lecture, lecture one, week one, we do have some reading assignments. So, the question for this section or part is where did social epidemiology come from? I want to say this to you, that it's not entirely clear. That it's always a complicated question. You know the old quip. That history is written by the victors. It's certainly true. In general, it's mostly true, not entirely true when it comes to scientific evolution. So, I want to apologize to the great scholars of history. This is my vision of where social epidemiology comes from, and, of course, it's limited by this particular format. In any case, I think this will be instructive. And I hope you can get a better sense of the history and the richness of our sub discipline. Well, modern epidemiology, broadly, sort of began in the mid 1800s, when [INAUDIBLE], when there were cholera epidemics. Raging through Europe and Asia, and ultimately, the United States. Cholera is particularly nasty bacteria, but no one knew it back then. In the 1830s, no one knew, had ever seen in a microscope what the bacteria was. Cholera's particularly disturbing to people, because it came with massive epidemics. Wiped out tens of thousands of people and the way it kills is a little grotesque. Ultimately what happens is, cholera gives one diarrhea until they dehydrate and die. And this can happen within 24 hours. There are still cholera epidemics in enfamished dis, disadvantaged areas

across the globe. In this time of the 1850s, waves of cholera epidemics were sweeping through Europe. At the time, of course, persons were wondering, why are we having these cholera epidemics? Why are tens of thousands of people being killed? And one of the explanations at the time, not surprisingly, was this was God's will, or relatedly, persons who were dying were sinners. And, in fact, this was quite a popular scientific explanation at the time, because cholera epidemics were wiping out people in urban areas, in cities. And recall from demographic history, that at this time cities are becoming large and deeply populated. And so, the idea was that people living in these urban areas were not behaving appropriately, and therefore succumbing to God's will. Due to their sins and cholera was wiping them out. Quite prevalent, quite common explanation in the time. Another competing theory at the time was this idea of Miasma. The Miasma was this unknown sort of unseeable stench, stink. Sort of environmental air pollution. And it depends on who you ask, but it was this idea that dirty areas were causing disease. Now this of course is not far from the truth. Because people again in urban areas were living in densely populated areas. Importantly, before indoor plumbing, before modern pollution systems were in place. And so the streets were filled in London for example, with animal carcasses and human waste and pretty much every other grotesque thing you can imagine. And so certain areas had more of this, the smell must have been awful. And people are getting sick in those very same areas. So, this idea of miasma was the most popular scientific explanation for why people were getting cholera and these epidemics. A related theory was that people at certain elevations, geographic elevations, were getting cholera due to the elevation itself. Again, this is quite a reasonable theory,

persons in the high lands, up on hills in urban areas, were not getting sick. Persons in low areas were getting sick. Of course the persons in high areas were up above the Miasma, better air, better environment, things were rolling down hill. People in a lower area were receiving all that. So, the scientists of the day were wondering, Mm-hm, is it actual geographic elevation, something in the air pressure, perhaps, that was causing the cholera? Cholera was known to be contagious, that's how it spread in an epidemic, one person to another. But exactly how it spread was unknown. You have to remember, this was before anyone looked in a microscope, before Louis Pasteur. Before anyone had any sense of what a bacteria was or a virus was or a virus was. So, the idea of contagion was around, but the mechanisms of the contagion were not understood. This all changed with the origin of modern epidemiology. And we owe a lot of it to this one man, a very handsome fellow, named John Snow. John Snow was a physician, he was an anesthesiologist, someone who gives gas to help someone have surgery, for example. And in fact, he gave gas to the queen of England, and became famous as a result, during her childbirth. That wasn't common in those days. So, John Snow's background in anesthesiology, or the study of gases. Give him great insight into whether Miasma could be causing disease. And in his scientific experience, the stink could not cause the disease of cholera. He knew about gases, and didn't think it was plausible. So, he began to study an alternative theory of the cause of cholera. And ultimately, there was an outbreak in the, let's just call it the 1850s, actually 1854 in London. And people around a given water pump, where someone pumped water to get back to their home, this is prior to indoor plumbing, were all getting sick from Cholera. And this map is the area of London were this was happening. And what Snow noticed was that right

around this particular pump in the bullseye if you will, people were getting sick. And if one moves away from the concentric circle from this area, people were less sick and so Snow said, it must be something in the water in that pump. And the famous pump is called the Broad Street Pump. And the myth, the story of the day, was that John Snow removed the pump, the epidemic went away, he saved the day. And that we understood then, the cause must be in the water, even though Snow and no one else at the time had a microscope to look into the water. So, this is the origin of modern germ theory right now, 1850s. And what happened in the history of the science was everything, every element was then viewed as a contagious element. And everything was thought to be due to some bacteria. It wasn't long after John Snow that Louis Pasteur and other began to look in microscopes, and find and catalog these different infectious agents. Including the bacteria that caused cholera. So, in the 1850s we had the rise of germ theory and this is sort of the rise of modern infectious disease epidemiology. It's a very important period of scientific advancement, and we learned a lot from it. But, importantly, the rise of social epidemiology was struggling. Social epidemiology was actually pushed down in this sphere, in this period instead of, or as a result of, the rise of germ theory. When everything is caused by a germ, there can be no social causes. So, in my view, the great historian, I think, had it right. Let me read this to you. Not surprisingly, the focus became disease and cases, not disease and agentic or acting people, and social institutions. The cause of causes was not entertained as an explanation for cholera in the time period. The historian Hamlin wrote, a political medicine, with the status equal to political economy, the great economists of the day failed to develop. The field of public health, along with medicine more generally, achieved significant autonomy.

Medicine rose and achieved great autonomy. Yet it did so by sacrificing the claim to speak with authority on many social issues. Such as the lack of indoor plumbing, such as disadvantaged lower class people having more toxic pollution in their area. So, this was the rise of germ theory in the 1850s, and social epidemiology had not yet achieved any position of authority. Now, there's nothing wrong with this origin myth, but it's the uncritical adoption. If you think that the story of epidemiology is only about the rise of germ theory, then you're missing something. Let me try to remedy that. It's worth noting however, that in 1854, germ theory or the dominance of germ theory was probably a good thing. And there's some examples of other cholera epidemics. In the time and learning that yes, the bacteria is the cause, is critically important to get indoor plumbing. And that would of course eliminate or mitigate the great cholera epidemics. So we talk about the rise of social epidemiology, I wish to say first that there are many great thinkers throughout history, and you can probably imagine some. That have thought about the ideas of how society should be organized, in order to improve health, or perhaps more broadly, social welfare. And you'll have your own names, here's some from my past experience that I've read. Persons such as Thomas Hobbes and his famous work on leviathan, the government that keeps society together. The philosopher David Hume, Adam Smith and his free market ideas. And Karl Marx, these scholars were thinking exactly like social epidemiologist. It's just that their outcome was not necessarily disease, but a broader concept of welfare, of persons and people. Relatedly, great economist such as Ken Galbraith, Milton Friedman and Frederick Hayek. All from different perspectives offer great insight into how to organize

society to improve welfare. And a key insight from economics of course, was increasing trade, generating wealth, having resources to build sewer systems, hospitals. And so forth, which of course, improves the health of society. But these scholars were not focused on diseases in particular, I dare say they were not epidemiologists, though they were studying similar ideas. More recently, scholars such as Jim Coleman, the late sociologist, Jim Heckman, the great economist. Sam Bowles, Amartya Sen, the philosopher, are all still talking about these very same ideas. But again, while the ideas are there, I wouldn't say that these scholars are epidemiologists. What's the story in epidemiology? Well it does bate, date back quite a bit. And Louis Villerme, a French physician worked on the ideas, wrote extensively about the ideas of poverty and health. Similarly, Virchow, coming out of Germany, yes? Studied Great deal of why certain peoples were getting sick and others weren't. Lemuel Shattuck and Joseph Goldberger in the United States, proto social epidemiologists, if you will. They got the ball moving. But with the rise of germ theory, there wasn't much room for talking about poverty. Above and beyond germs, for talking about social disadvantage, above and beyond germs. Today that's changed quite dramatically. Early scholars of the field of Social Epidemiologist, the founding fathers and mothers if you will. Include John Cassel, Mervin Susser, Len Syme, Sherman James, Sir Michael Marmot. There's plenty of readings from these scholars, you can look on the internet there's some readings in our course materials. These are the founding fathers of social epidemiology, as narrowly and focused defined. They're using the tools of epidemiologists to study how social forces affect disease. More contemporary scholars, and I forgive, forgive me for those who I've just not mentioned. Lisa Berkman, Bruce Link, George Kaplan and so many others, students of the

founding fathers. And then, their students have students and today, every major university across the United States, if not the world, has scholars of socieal epidemiology. And the field is now rich. From my own experience, the Society for Epidemiological Research, the primary American organization of epidemiologists is now loaded with social epidemiology. The national meetings are at least filled, if not perhaps dominated in some sections, by social epidemiologists. And importantly, related work still goes on in allied disciplines, such as sociology, economics, and public policy. The lines between disciplines, between economics and epidemiology, sociology and anthropology are all becoming blurred. And so we're all becoming interdisciplinary, drawing on tools and concepts from one another. As I said earlier, what distinguishes social epidemiology, is the focus on disease and populations. Incorporation of biological phenomena, the mechanisms of disease, if you will. And a deep understanding of the causes of the cause of diseases. That's what distinguishes epidemiology, that's where we've come from. And later on, we'll talk about where we're going. [SOUND]