We finally made it. Part 4 of 4 of the first lecture. Welcome back.

This section is about, where is social epidemiology headed? I want to confess this is my view. Other people have thought about this, written about this, but I want to offer the perspective of the future direction of social epidemiology from Michael Oaks. First, the benefits of social epidemiology. I want to tell you that some of the research has been hard to interpret. Some very difficult questions being addressed and we will talk about these things in the second lecture. But by and large, the chief contribution of social epidemiology as it was done in 1850. And that's being done today in its contemporary form is breaking down the vision of health of one person unto themselves, the old Robinson Crusoe model. Social epidemiology has forced physicians, has forced hospital systems, has offered a new perspective on health to all those interested. That says society social systems, families, racism, bonding. All of these things have a great impact on health. So, while the details can be discussed and debated. I think there's no doubt that the biggest contribution of social epidemiology is the incorporation of the idea. That health is a function not just of island weather and genes, but of social systems. Interestingly, the social scientists, the human, humana, humanists, have always had this view. But what social epidemiologists have done, has to bring the same questions with scientific rigor into the health research framework. In some sense, however, what social epidemiology's done is not that new. Here's a table from an old text about death rates by age in the year 1820. This happens to be from France. And the story being told by these death rates is as old as the human civilization itself. That is, the poor or disadvantaged persons die earlier and more often than the wealthy or advantaged persons.

That idea holds true today. And what's remarkable about this slide published in 1820 is that the rates, the differences between the rich and poor, are very close to what we see today. So when we talk about the future of social epidemiology, a key question can be, what have you done for me lately? I want to talk about that throughout the rest of this little module. Here's a slide that's intentionally drawn in a sort of caricature format. It's a graph, but it's not a very precise statistical graph. I sort of think of it as a drawing on a napkin, and that's because it's not perfect. But it's important to convey an idea. Let me try to explain what I try to use this graph for on this lower axis or line we have some measure of socioeconomic status. Here are disadvantaged or poor people and here are advantaged or high SES people. And we can use educational attainment. We can use income, pretty much any measure we want for how we measure socioeconomic status. On the vertical line, we have some measure of health. It could be risk for cancer. It could be how you feel. It can be pretty much any measure of health that you like. What's critical about this cartoonish-like graph is this black line that we'll call a slope. You see, it sort of looks like a ski slope. And what it says is, for a person with low SES, they have poor health. For a person of high SES, you go all the way up, and they have better or excellent health. And so, this line maps more or less how socioeconomic status relates to health. Now, it's true for different types of diseases and in different societies and in different periods of time. The angle of this slope has been more flat, more vertical, in some cases, it's a little curva-linear, which sort of does something like this. But as a general framework, as a way to conceptualize, what the research and the future of social epidemonology is it's this slope. This is the key idea that as one's SES, socioeconomic status improves their health improves.

And so, what we can see here is a fascinating idea. How do we improve health without moving somewhat up the socioeconomic status ladder? That is, how can we go get my cursor back, how we go from health here to here. notice I'm just going right on this line, here to here without moving horizontally. If you think about it, the prototypical intervention to improve health, without altering socioeconomic status, is vaccinations. Vaccinations are a medical intervention that greatly improves health in many cases. But does not alter the socioeconomic status of persons in a given country, nation, state, or time period. So, this is the medical model of improving health. Having someone's health improve without altering the structure of society which is mapped horizontally. And so, we can see the gap between the less-advantaged people here and the more-advantaged people here. And that gap is the gap in health that we'll come to learn is called Health Disparities. And we'll have a whole lecture on that. But for now, it's important to note that the future of social epidemiology is all about understanding how this, how socioeconomic status is produced. How it relates to improvements of health, and most of the rest of this course will be about that idea. In a very important article in one of the volumes I mentioned earlier, distinguished scholars asked, what is wrong with social epidemiology? George Kaplan said there's poor theory, there's too much individual focus. There's some technical thing called risk-factor thinking, and that it's interdisciplinary. That is, it's hard to do, because social epidemiologists often work with statisticians, economists, anthropologists. And of course, physicians that makes it difficult. Lisa Berkman said there were few too, too few experiments. And that the experimental results, we do have aren't as promising for improving health as we'd hope for. A situation I was confronted with a few years back was when an important person

in a corporate environment said to me. Mike, we would like to improve the health of this area, what should we do? You're the expert, what does the research suggest we should do from a social perspective to improve health? It turns out that this question is not easily answered. Do we improve schools? Do we offer free vaccines, medical care? How about build a park for more exercises? Offer better groceries, better fruits and vegetables. Do we offer more child protection services, police forces? These are some of the enumerate ideas that we could think about to improve the health of populations. The trouble with social epidemiology going forward is it's not clear how we can come up with the best answers. So, when you or I are asked a question, what can you, as a social epidemiologist, recommend to improve population health? So, we can answer that question with science. From my perspective, the threats to social epidemiology are the following, much like Kaplan and Burkman's. Too often, our discipline focuses on what we hope to see. We'd like people to be nicer to one another, to bond more, as opposed to how they are. Technically, this is called a normative or claim instead of what is positive or real. This kind of issue gets all jumbled up often in social epidemiological research. Too often, scholars in my discipline will cherry-pick prior research. That is, pick research that fulfills their need, as opposed to saying, what's out there? If some research suggests that what they're proposing won't work, too often that kind of study is ignored. Too often, social epidemiologists ignore or don't pay attention to the vast amount of research that's been done in social science, economics, sociology, anthropology and so forth. Yet those scholars have made great advances. We could do more. Epidemiologists aren't very good at economic knowledge. So, we can often say that this this bacteria this virus this social

arrangement causes health to be good or bad. But it is not very good at saying, therefore, it's worth investing, there's a good return on investment. So, we need more effort into collaborating this or understanding the cost and the benefits of our imagined improvements for population health. There's some technical stuff that we'll talk about later in the course. Multiple regressions, a kind of statistical technique. We'll talk about why that can undermine social epidemiologic conclusions. And relatedly, there's this idea called SUTVA. What's that? It's jargon. But it has to do with understanding how people interact. And that's a key component of social epidemiology. Yet, when it comes to statistical models, it's very difficult to let that assumption of people interacting enter. How we mathematically or statistically model, or we expect to happen. And finally, I think that so many, too many social epidemiologists have a sense of hubris. That what we're doing has a huge impact on society. I think there's some great strides being made. My personal opinion is a little more humility would help us ask better questions. Tougher questions and better improved population health. So, the future. The future is always about, in social epidemiology, getting us passed the old Robinson Crusoe model. And incorporating that idea of how society, social systems impacts health There's lots of great work being done. There's some challenges for sure. My hope is that with further research, tough self reflection we can do better research that literally improves population health.