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Some Journal readers may wonder what social epidemiology is. Berkman and Kawachi define it as "the branch of epidemiology that studies the social distribution and social determinants of health." The field incorporates the concepts and methods of "disciplines ranging from sociology, psychology, political science, economics, demography and biology." However, more is at stake than broadening the scope of inquiry beyond the usual physical and biologic suspects. At its best (as exemplified repeatedly in this book), social epidemiology embodies a new focus on the community as an entity in itself, an entity more complex than the sum of the individual persons who make it up, but one that acts on and through those people to influence the health status of each. This approach represents a conceptual shift in epidemiologic research and theory. It highlights features of the social world to which biomedical studies are ordinarily blind.
Physicians have known for a long time that the way people live affects their health. Indeed, the author or authors of the Hippocratic treatise Airs, Waters, Places enjoined "whoever wishes to pursue properly the science of medicine" to consider among other features of the place of practice the "mode of life of the inhabitants... whether they are heavy drinkers, taking lunch and inactive, or athletic, industrious, eating much and drinking little." More than two millennia were to pass before these and other intuitive hypotheses (most of which proved to be wrong) were put to the test. It is not news that poverty is associated with poor health, although controversy persists about the direction of causality (from poverty to illness or illness to poverty), about the most effective interventions (social measures or health measures), and about other such matters (which are discussed by Lynch and Kaplan in chapter 2).
It may not be news that people without means have less access to care and that the care they get is of lower quality. But it became news in recent years, and painful news at that, to learn that members of minority groups and women are less likely to receive aggressive medical and surgical interventions even when payment is not an issue (as in the case of patients who are covered by Medicare or enrolled in the Veterans Affairs system). The effect of discrimination on health is thoughtfully examined by Nancy Krieger, who begins chapter 3 with two statements: "Inequality hurts. Discrimination harms health." She then marshals the evidence to document both claims.
But it will be news to most physicians that higher mortality rates are associated with greater social disparity; in other words, the magnitude of the economic differential between the folks at the top and the folks at the bottom of the social ladder influences death rates. For example, in a study of income inequality and mortality in 300 U.S. metropolitan areas, areas with greater inequality between the groups had higher mortality rates than areas with narrower extremes. This is not another of the statistically significant but clinically unimportant findings sometimes reported by large population surveys. The aggregate excess in mortality was as great as the combined loss of life from lung cancer, diabetes, motor vehicle crashes, human immunodeficiency virus infection, homicide, and suicide. What is it about inequality? The short answer is that no one knows. Differences in identified individual risk factors account for less than half the observed disparity. Hypotheses about this phenomenon and ways to test them are incisively presented by Kawachi, Brunner, and Marmot in separate chapters.
Lisa Berkman, senior editor and coauthor of three chapters, is one of the pioneering researchers in social epidemiology. Her first major study, published 20 years ago, is a landmark. In longitudinal research on a randomly sampled population of the community, she identified persons in the top quartile of social connectedness (defined in terms of marital ties, kinship, friendships, and group participation) and found that they were less likely to die during the subsequent nine-year period than the relatively socially isolated persons in the lowest quartile. The statistical significance of the mortality differential held up after adjustment for health status and the risky health behavior recorded at the initial examination. She went on to show that lack of social support decreases the likelihood of survival after myocardial infarction, increases the probability of depression in the elderly, and leads to higher rates of cognitive decline. As an original investigator and careful scholar, she offers an integrated account of the effect on health of cultural, ethnic, and class-related variations in the structure and function of social networks.
The list of authors is a Who's Who of social epidemiology. Each chapter is thorough without being encyclopedic; the bibliographies are comprehensive without being exhaustive. This book gives physicians an intellectual adventure by putting new ways of looking at health problems in context. In addition to such notions as income disparity as a risk factor and social connectedness as a protective factor, Kawachi and Berkman provide a stimulating account of "social capital," a concept that has recently gained prominence and one that they define as "those features of social structures, such as levels of interpersonal trust and norms of reciprocity and mutual aid, which act as resources for individuals and facilitate collective action."
Social capital has a substantial effect on the probabilities of good or bad health. The epidemiologic research carried out by Kawachi and his coworkers has demonstrated significant correlations between health and such indicators of social capital as interpersonal trust, reciprocity, and the extent of membership in voluntary organizations. How might this come about? The possibilities include the placing of social constraints on deviant health behavior (smoking, drinking, and drug abuse), the availability of better community services and amenities as a result of political solidarity, and the provision of emotional support and respect. What maintains social capital? "Trusting social environments...be get trustworthy citizens." Can we design policy to build social capital? Finding ways to do so may be the most important task American democracy faces. This and related issues are addressed in Jody Heymann's splendid chapter on health and social policy.
What do I see for the coming editions? Permit me to be a visionary. These days, just about every physician encounters the word "genomics" and knows that large-scale DNA sequencing is expected to provide the precise structure of the human genome before 2003. Most know that genes specify proteins. However, the three-dimensional structure and function of the proteins cannot be determined from the DNA matrix. Some physicians are beginning to encounter the term "proteomics" -- the large-scale analysis of proteins that will become the scientific frontier of the post-genomic decade. These developments portend exciting times for medicine.
The coming scientific frontier will be some version of "sociobiomics" (a neologism that I hope will not outlive this book review). It will be a long-term, interdisciplinary research project to specify the forces within and among social groups that interact with the biologic uniqueness of each member of those groups (and the environment they inhabit) to determine whether individuals stay well or fall ill. Admittedly, my rhetoric is somewhat overheated, but it is meant to call attention to the context that Social Epidemiology illuminates and that future editions will shine an even brighter light on.
Leon Eisenberg, M.D.
Copyright © 2000 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.
I wish I could return this book. It was really hard to read and hard to follow as well as a bit superfluous.Published on December 4, 2012 by HairJunkie330
the book came in faster than expected and was in excellent condition. Very pleased with the seller.Published on October 3, 2010 by Cgreen