Welcome back. This is week two of our course on social epidemiology.

In this week we're going to discuss major issues in social epidemiology, and there's going to be three parts. The first part, which we'll discuss in a moment, is why is social epidemiology so difficult. The second, the key relationship of socioeconomic status and health and the third this idea called multilevel phenomena. I'll explain all these things in their individual modules. Right now, we're going to discuss why is social epidemiology so difficult. As always for this week, we have readings. This time we have three readings. The first one by Link and Phelan, the fundamental causes of disease will be very important for this very first module. The other assignments of course are useful too. But I want to tie this reading with this particular module. So, why is social epidemiology so difficult? Well I want to weigh out two core ideas. There are others but here in my view, are the core ideas of why it's difficult. First, it's difficult to distinguish direct and indirect causes. Second, social systems are dynamic. Let me explain what these are. We'll go back to our original. Now basic model of disease, where disease is caused ultimately by things such as cells dying, which might be a result of germs or physiology or genetics. These things can be enhanced or hampered or caused by behaviors, such as eating more, eating less, exercising. Pulling a trigger of a gun, receiving a gun shot, those kinds of things. Then we can say that the behaviors themselves are a function of the social system. Why do some people have access to good food and others not? Why do some people live near toxic dumps and others not? So the question is with this simple model, does this tell us the story? And with this very first discussion, I want to say no, that in fact, we can elaborate on this simple model and talk

particularly about direct and indirect causes of disease. The causes of cause if you will. And this is a key part of understanding this social epistemology perspective or framework. So, a direct social cause of disease. The idea here is social cause. So a direct social cause of disease could be something like lack of social support. If one lacks social support, they might become blue or a little bit depressed. Their immune system might be compromised. And they can be more susceptible to disease. Ma-, maybe it's a common cold virus or something more deadly. Relatedly, one can be ostracized by society. bullies on a child school playground can ostracize certain children. Upon ostra-, upon being excluded from society then one can become depressed and maybe, they become anxious and god forbid, they end up committing suicide. But you see the idea that the social causes themselves are directly yielding the outcome of the disease. Other examples include foot binding. Indirect causes of disease are more subtle. The challenge here is to understand what the proximal, from our diagram, what the proximal cause of disease is, where it came from. So, why are there germs here and there? Why are the immune systems of these people weak and those people strong? This is the idea of the social system being an indirect or cause of the cause of disease. And examples might include a toxic wor-, workplace, where there's chemicals or some dust in the air that causes a genetic mutation and ultimately leads to cancer. So sure, the toxic chemi, chemicals in the air yield the cancer. But why, in this workplace, are there toxic chemicals, and that workplace none? Is it a lack of regulatory frameworks to rule out, to prevent the cancer, to prevent the toxin in the air that ultimately prevents the cancer? So this is how the social system is indirectly, through the toxins in the air, affecting disease. Other examples include political turmoil, not being able to produce a safe water supply.

An unsafe water supply can have bacteria in it, such as cholera. Cholera can yield death, of course. So the idea here is that the social system, the lack of political efficacy in policy-making, the political turmoil itself, is not causing cholera directly. But it's causing bad water which does contain the cholera and that's the distinction. Other examples, are many. Historical discrimination, prevents some persons of certain race, colors or ethnicities from gaining a valuable education and therefore they have little resources and they can't buy food that they like or live in a nice environment that they wish to. Still others, there can be lack of attention for alcoholism in the family. This can yield childhood abuse and neglect, and then bad things can happen to that child as they get older anxiety, mental health disorders, depression, and so forth. So this is the subtle distinction between the direct and indirect causes of disease. The challenge, the reason why social epi is difficult is it's often difficult to distinguish, to disentangle, to tease out the difference between a direct and indirect cause of disease. Further, some dismiss the indirect cause of disease, the social system, as not being relevant to the discussion. Instead they want to focus on just the germ or just the toxin. And that's true but that's not the complete story of the diseased generation itself. The second reason why social epidemiology can be difficult is that social systems are dynamic. Much like a rubber band, they want to spring back or go back to the original state. An equilibrium state, if you will. But, in addition, social systems are always changing. So we have a very challenging idea here or challenging data problem where social systems are dynamic. But they're also always changing. So what does this mean? Well, for example, we could have a sex education, a healthy sex education program for youngsters. This might create political backlash and therefore remove the funding, the ability

to create those healthy sex education classes. So here the dynamism of the social system makes the social intervention for health. Ineffective. Other examples include trying to remedy urban poverty. We might move, literally, literally move people out of the urban, impoverished environment and place them in the suburb. But all kinds of things can happen due to the dynamism of the system. First, what can happen is, when one moves someone to a better environment those in the receiving neighborhood can say no, I don't want those people in my neighborhood. There can be resentment and pushback. The not in my backyard or nimby phenomena. Second, when someone, someone finally does move, it can leave the original neighborhood more impoverished. Third. Ultimately, some people who do move, might move back to the original neighborhood. This is because that's where their social support is. They know the environment, they have their friendship networks there, babysitting there, job opportunities, food opportunities, it's much more comfortable. So, here is an example where the dynamism of the social system, moving, having some intervention to improve health ends up going right back to the original condition. So why is Social Epi so difficult? Dynamics make it difficult, the system wants to go back to equilibrium. In addition, is the issue of unintended consequences. For example, our health. Sexual health intervention might provoke some youngsters to resist, and maybe begin smoking cigarettes. These kinds of unintended consequences occur, and it makes social epidemiology a challenging topic to research, understand, and do.