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Primer on the topic for folk who are blissfully ignorant of background to these squabbles (by Igor Burstyn and Carl V Phillips); please feel free to skip to the essay below if you already know the history of this. “Social epidemiology” is a term some use to refer to epidemiology that focuses on how social forces and the diversity of social conditions affect health. The clearest examples are how health is affected by community-level variables, such as poverty, walkability, greenness, urbanicity, density of food vendors, and local policies that affect these. Sometimes it is even stretched to include individual-level “identity” variables like race, ethnicity, and sexuality. The research in this area tends to use easily accessible census-type data collected by others for other purposes that allow one to cross-tabulate various things with some dramatic headline-grabbing results: Disparity in disease X among people Y rampant in community Z. Sixteen years ago, the future and merits of social epidemiology was debated on the pages of the International Journal of Epidemiology. Given that the journal is very pro-social epidemiology, the results were predictable: it was basically a mission statement, with token rebuttal. Despite that, it is not clear that the discussion has lead to any evolution in thinking. It merely recording the mood of some epidemiologists who were trying to proliferate the specific perspective that defined their scholarship. This sales pitch for social epidemiology claimed to subsume biology and economics into its sociological approach, when actually it mostly skipped over them. Their notion that poverty causes cancer and heart disease, leaving the biological pathways in between as a black box, fails. This has frequently been likened to miasma theory: a vague construct being blamed for the biological exposures that it is associated with. We know a lot less if we black-box the actual individual exposures and experiences. Of course, all of science involves leaving some aspects of what we are studying as black boxes, at least for purposes of any particular bit of research. There is nothing odd or unscientific about that. However, in this case, glossing over the mediating causal factors turned into an ideology: The teaching and practice of public health adopted its widely-despised social paternalism as a result of focusing on -- and trying to socially engineer -- those upstream factors. It denigrated people to the role of mindless automata who are merely elements of -- or victims of -- their society. So we get claims like people get fat because of what is on store shelves rather than a decision to eat more of it (because it improves their welfare) than they burn up (not everyone likes to exercise, and that is their choice). The following essay that comes next is a general rumination of the topic of social epidemiology, and a belated response to those 16-year-old articles, noting a crucial point that was ignored. (The title of the essay follows, the titles in that series, which were all “Social Epidemiology. X.” where X was No Way!, Way!, A way?, No way back, A promising field,  Keep it broad and deep.) While it is unlikely to have much effect on the ossified debate in epidemiology, let alone the social engineering tendencies of “public health”, it might empower some to see their views reflected. Essay by Igor Burstyn, who is deeply indebted to Carl V Phillips for his wise counsel and editorial guidance, yet again. I recall a scene from Motl, Peysi the Cantor's Son in which a character transplanted to America must tell who he is, starting with the story of his grandparents, in expression of the belief that he – as a person – can only be understood through his social context. To me, this is a shining statement that social forces mould our lives. We are who we are because of community forces that shaped us, either through conforming or rebelling, or a combination of the two. Can anyone argue with this? Do I need to cite a learned authority on the subject to bolster truth of this conjecture? No, because humans are social beings and everything that we do is part of social processes; including all of science, economics, engineering, humanities, politics, etc. Do we need to add the adjective “social” to economics? Do we distinguish between “social” and “nonsocial” literature? Is there a branch of “social” microbiology that is distinct in its language and scholarship from other ways of studying microbes? No. So, why do some people feel compelled to single out a corner of epidemiology as “social”? The conventional wisdom again declares that some of the distribution of disease in a population is determined by community-level forces and social processes. To prove this thesis, we only need one example: My teeth are healthier than those of my parents in part because the social force of persuasive dentists convinced my generation, but not that of my parents, to take better care of our teeth. Brilliant!  Thesis proven. What about other parts of component causes? Well, somebody had to invent, manufacture, market, and distribute oral care products. The communists of my homeland did not do this,but capitalists have managed to do this, thanks to a mixture of social forces, policies and engineering. But also the products had to kill harmful microbes, social disaster for microbes, but a purely biological process not influenced by neighborhood-level factors. Let us examine this dental vignette through the lens of social epidemiologists. I expect them to conclude that capitalism is good for dental health but communism is detrimental. This can even be proven at the individual level: my family’s dental health improved enormously upon emigration from the USSR. Again, no odds ratios are needed to accept this claim as being about as well established to be causal as anything in epidemiologic science. Now imagine someone wanted to apply this knowledge to disparities in dental health in the USA. We have observed that communism has negative effects and the free market works wonders. Armed with this knowledge, a movement of dental health activists decide to put it into action. If the change from communism to free markets has a huge impact, they decide, then freer markets must be better. So they start campaigning for politicians with the most aggressive free-enterprise positions. Perhaps if they are willing to value dental health above all other concerns (a monomaniacal attitude that is not exactly unheard of among public health campaigners), they might start calling for massive deregulation and dismantling of the welfare state. They might try to push this to a global level. The social epidemiology observation, after all, suggests that the Hobbesian anarchy of some Randian fantasy would optimize dental health. Would this work to improve dental health? Obviously not. The intervention ignored the actual physical difference that the social forces created. The transition from an economy that lacks dental care products and ample high-quality dentistry to one that has them was the difference, and not some continuous function of the social phenomenon of the degree of market intervention in markets. One cannot make a fetish of social forces if one wishes to solve a problem in health or any other sphere. The simple reason for this is that there is no phenomenon that is either purely social or nonsocial, as any ecology student should be able to demonstrate. Complex social patterns stem from individual behavior, and most (not quite all) of their impact on health is mediated through individual behavior. Therefore, it is useless to talk about causality by social forces as if they are distinct from a collection of the individual acts that are typically measured in “nonsocial” epidemiology. At the same time, to treat the neglect of dental health by Soviet citizens as if it were merely a collection of individual decisions is also not terribly useful; assuming that showing how to intervene to improve health is the goal of the analysis. To ignore one at the expense of another, is to miss the point and to operate in a distorted and delusional worldview. We observe collections of individual acts as social phenomena precisely because we are social creatures, and that is the only way we can understand the world. But most of our actions are still individual decisions. My grandmother tersely described the USSR as a “society of thieves and prostitutes”.  Compelling as her observation is, it did not help change the country as a whole for the better, but it did help my father succeed in life, in large part through leaving that sick society that he found unpalatable.  Individuals shape their own lives in social context, against and with the forces of history.  To reduce these individuals, as social epidemiologists do, to the ecological strata that they belong to, is to miss that which makes us human, and to go down the path of the same sins (and crimes) as the “social engineers” (i.e. revolutionaries) of my grandparents’ and parents’ world.  Do I really need to cite any authorities to support my claims that it all starts with the individual, including shaping of communities? As for social epidemiology: why such a narrow and isolationist view of the world and scholarship? Can we not do better with all the knowledge and experience of history behind us? Ignoring society-wide phenomena is clearly limiting to the point of absurdity. However, the ghettoization of social epidemiology creates is a potentially bigger problem on the other side, because those who take a narrow view that social forces are important without reference to individual choices will inevitably advocate the disastrous top-down policy-meddling the like of which led to persistence of medieval dentistry under communists. Oy vey…
Serving the community with a smile.......... ................in a Public Healthy kind of way
Social Epidemiology: Oy vey…
Below another guest article submitted to The Fun Police.  This one is by my friend Doctor Igor Burstyn (no twitter)  from Drexel University (who submitted an article before),  with input from his friend Carl V. Philips (@carlvphillips)  (of ‘tobacco harm reduction’-fame). It’s a controversial  one, and I do not necessarily agree with (all of) its  content, but it is intriguing nonetheless. And here we like  a bit of discussion, so have a read!  Also, in the case you do not agree with the below (or you  very much agree with it of course!), do not forget this,  and every other post, has a forum following the article for  you to contribute. Anyway, the guest post about the value of social  epidemiology!
As a sidenote, jf you have any good ideas, but no place to place them, just email me. There is always space available at The Fun Police...
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