Department of Health and Social Behavior, Harvard School of Public Health, 677 Huntington Avenue, Boston, MA 02115, USA. E-mail: nkrieger{at}hsph.harvard.edu
Perhaps one useful response to the thesis advanced by Zielhuis and Kiemeney, summed up in the article's title, Social epidemiology? No way,1 can be provided by four evidence-based linked logical arguments.217 These are:
Argument #1
Argument #2
Argument #3
Argument #4
Taken together, these arguments imply that epidemiologically adequate explanations of current and changing distributions of population health entail simultaneous social and biological explanations.1819 Thus, training inand application ofsocial and biological theories and reasoning are important for epidemiologists, as is development of an historical perspective on changing epidemiological profiles across diverse societies.2,1822 Also relevant is training in concepts and methods of quantitative population sciences, including but not limited to biostatistics.2,20,2223 Training in or comprehension of solely biomedical sciences is insufficient. The study of biological phenomena is broader than biomedicine: other non-medical aspects of biological sciences are highly relevant, including constructs and content of evolutionary biology and ecology.57
Consider, for example, the challenge of explaining excess hypertension among African Americans.24,25 Despite advances in population genetics, which emphasize the non-biological and social basis of racial categories as well as the tremendous mixing of African, European, and American Indian lineages (by both rape and consensual unions),26,27 biomedical literature remains rife with studies attempting to discern whether raceas an alleged biological traitexplains US black/white disparities in hypertension (not to mention other health outcomes).25,28,29 Hidden from view are other relevant and promising hypotheses, especially regarding the role of racial discrimination in the aetiology of hypertension and other conditions related to chronic exposure to threats to mental and somatic well-being.3035 As the small but burgeoning literature on social inequalities in health reveals, ignoring social determinants of social disparities in health precludes adequate explanations for actual and changing population burdens of disease and death, thereby hampering efforts for prevention.13,36,37
Consider, too, the phenomenon of parity in relation to risk of cancer. The focus of epidemiological research informed solely by biomedical assumptions is on links between parity and risk of cancer via pathways related to pregnancy-induced changes in diverse hormone levels.38,39 Add, however, the question of whether parity reflects social factors that are also determinants of risk of cancer, investigate links between parity and risk of cancer among men, and new knowledge emerges.38 Notably, parity is equally associated, among women and men, with risk of oral and pharyngeal cancer and malignant melanomafor which the parity/risk association had been previously interpreted in other terms. One implication is not to presume parity exerts effects solely by pregnancy-related biological processes; the other is to consider the social meaning of parity even when the biology of pregnancy is relevant. Simplistic divisions of the social and biological will not suffice. Study adrenal glands only among cadavers of the poor, long since hypertrophied due to excess excretion of cortisol, andas occurred in the early 20th centurythe wealthy will be diagnosed with adrenal deficiency disorders.40
In summary, if Zielhuis and Kiemeney choose to conduct epidemiological work premised solely upon biomedical theory, and to castigate social epidemiology for producing trivial statements, useless for society, that is their prerogative. It would, however, be interesting to know what texts Zielhuis and Kiemeney would recommend to aspiring epidemiologists for the study of biomedical theory. As any systematic search of library databases will show, none exist, at least by this name, even as medical textbooks abound. Instead, tenets of biomedicine typically have been named and analysed by its critics who, while generally appreciating the knowledge gained by study of biological phenomena, nevertheless highlight the ignorance produced and knowledge forsaken by restricting inquiry to questions generated by individualistic frameworks which deliberately ignore social determinants of health, disease, and well-being.4144 If logic and an open mind are prized features of scientific inquiry, the illogic and narrowness of Zielhuis and Kiemeney's argument are surely counterproductive to the further development of the enlightening and useful epidemiological research that we all desire.
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