What's Wrong with Social Epidemiology, and How Can We Make It Better?

Abstract

It is perhaps ironic that an epidemiologist who has been working in the field of social epidemiology for over a quarter of a century, and who directs a center focused on social epidemiology, should coin a title suggesting that there is something “wrong” with social epidemiology. Perhaps it is even inopportune, as it could provide ammunition to those who believe that the practice of social epidemiology is misguided, unscientific, ideological, or too overreaching (1–3). However, this title was chosen purposely with the hope that identifying some of the critical intellectual, methodological, and empirical lacunae and challenges in social epidemiology might promote continuing development of a social epidemiology that is both scientifically enlightening and useful, productive, and contributory to the public’s health. Indeed, the hope is that the “social” in epidemiology will become so integral a part of epidemiology that the term can be dropped altogether. To assert that all epidemiology is social is not an attempt at intellectual hegemony—that the problems of disease and the distribution of disease in populations over time and space can be understood from a social perspective only or that such information is in some sense more fundamental that other types of information about disease determinants. In the same way that our understanding of the etiology of chronic and infectious diseases benefits from knowledge of the pathobiologic processes involved in such diseases, increased understanding of social factors, broadly considered, may shed light on processes every bit as integral to our understanding of the etiology of those diseases. There is no question that social epidemiology has come of age and that the term “social epidemiology” is being increasingly used to describe examination of the role of a broad array of social factors in the development and progression of many important health problems, and in the natural history of the risk factors for those diseases and conditions. While not all may agree with Geoffrey Rose’s assertion that “the primary determinants of disease are mainly economic and social, and therefore its remedies must also be economic and social” (4, p. 129), there is no question that there has been enormous growth in the study of these economic and social forces on health and disease. Figure 1, which plots growth since 1966 in use of the term “social epidemiology” in article titles, abstracts, and keywords, graphically illustrates this increased interest. Beginning in the early 1980s, growth of such publications increased rapidly, well fit by an exponential curve. In fact, this figure is likely to dramatically underrepresent the growth of social epidemiologists’ interest in the matter; a similar exponential growth pattern has been seen when studies examining socioeconomic position and health (5) and social capital and social relationships (6) were similarly totaled. Other contributions in this volume of Epidemiologic Reviews take up the wide variety of topics that social epidemiologists study. In what follows, I instead touch on a series of issues that highlight some of the critical problems with which social epidemiology must grapple. Many of the issues discussed are not restricted to social epidemiology and have their analogs in other areas of epidemiology. Thus, while the focus of this review is on social epidemiology, it would be misleading to suppose that similar criticisms do not apply to other lines of research. In addition, I want to make it clear that many of the criticisms raised apply to my own work as well as to others’. Because this is an attempt at a form of self-criticism of the field, I do not focus on as extensive citation as other reviews do. Where I do cite the work of others, it should be considered illustrative, not as singling out a particular piece of work. The lessons to be learned hopefully apply to the many. Figures 2, 3, 4, and 5 present a few of the many diagrammatic models that have been used to illustrate recent social epidemiologic approaches to understanding the social determinants of health and health disparities (e.g., Kaplan et al. (7), Marmot (8), House (9), Lynch (10)). These models have many features in common, the most prominent being an emphasis on layered, multilevel understandings; a multiplicity of pathways; and possibilities for reciprocal influences. Such models serve as important metaphors, attempting to portray the component parts of complex processes, their interrelations, and the temporal relations between components. They act as an important caution against the potentially misleading oversimplification that comes from focusing on one level of influence, often the one most proximal to the outcome, and not the flow of information and influence represented by the totality of processes and relations. Similar to a good cartoon, they remove extraneous factors and draw our attention to what is believed to be most critical. While the heuristic utility