Welcome back. This is the third module or part to lecture one.

And in this section, we're going to talk briefly about what this central questions of social epidemiology are. In a future whole lecture, we're going to go into great depth about social epidemiologic research and activity. Here, I just want to give you a brief introduction to the landscape to familiarize you with what's happening. Again, the basic question for social epidemiology is, how does this social system or society or social arrangements effect health? This is in contrast to our model of Robinson Crusoe. Remember this fictitious character is someone on a island with no other people. His health is determined affected by island weather, maybe a typhoon, germs, bacteria on a rock. That he might cut his toe on. Social epidemiology is not about a Robinson Crusoe model of health. It's about a social systems model of health. Let me now give you a brief introduction into the kinds of research that goes on. The basic question is, again, how does a social system effect the health of populations? There are two ways this can happen. Directly, simply put there's some sort of social arrangement, perhaps of bonding, that affects health. Having emotional support can improve one's health. That's a direct effect of the social system on health. There's also indirect effects. And these are things, like the social system is putting toxic dumps in one area, and not another. The social system is putting persons in an area, a condition, of circumstance of great stress which harms their immune system. Which makes them more susceptible to disease and infections and so forth, than other persons. This is an indirect effect of the social systems on health. Remember our classic example. Here we have some exposure causing disease. This is a basic epidemiologic question. And a social epidemiologists might ask,

how do social interactions, family structures, social support, bonding, these kinds of questions? How did they directly affect one's propensity for disease of ability to fight it off? I think, though, the bigger question for social epy is this one. How does social systems create differential exposures acrof, across different groups of people? So, why are some persons exposed to more toxic chemicals than others? Why are some people having stronger immune systems than others? These are questions about how the social system is altering the conventional ways we understand we get sick. The flu virus, for example, having McDonald's in one area and not another, and changes in obesity. These kinds of questions are the indirect effects of the social system on health. There's been lots of work in social epidemiology, as I mentioned earlier, in it's current form, we could trace it back to say, the 1980s. The classic textbook however, came out in the year 2000 and this is by Berkman and Kawachi. It's still a very valid read. Richard Wilkinson has written extensively his interests tends to be on how social inequality, the gap between the rich and the poor. The advantage and the disadvantage, effect health. There's been volumes of the journal, American Journal of Epidemiology, and others, devoted directly to the questions of social epidemiology. Michael Marman, as I mentioned earlier, distinguished scholar, also writes about how social policy, social systems affect health. These are all books still worth reading today. Ichiro Kawachi, also interested in how social inequality affects health. These questions tend to dominate this sort of work in social epidemiology. Of course, there's trends, but these remain essential questions. Nancy Krieger takes these questions and takes it a step further. How is it exactly that inequality or differences between the rich and the poor, how does this actually get into our bodies? How does it happen physiologically that

inequality makes some people more sick than others? Let's talk about the broad determinants of health, and I want to use the word determinant a little loosely. Obviously, things are probabilistic. That is, just being exposed does not make you sick. But in any case, what are the broad macro ideas? And I have after determinants, a question mark. Because what might be macro to you, could be meso or micro to me. First, global economic forces, how does international trade offer wealth of resources to one country? Global economic trade can also have direct consequences, transferring germs and cargo packages. Religion, how does religion affect health? Religion is a global economic force. Different types of religions, different people believe different things. And practice according to their religion, different diets, different behaviors. So religion is a macroeconomic, excuse me, a macro-cultural force that has a big impact on health. Relatedly, mass culture. How do we understand what's good, what's bad? These things are mass globalization aspects, and they all have an impact on health at the macro level. Ideas of macro forces need not just be ideas themselves, but they can be technologies. Such as, how does the internet, how does Facebook, how does the ability to communicate by email and YouTube and all the rest, and a course like this. How does this affect our understanding and ultimately our actual health? Macro determinants. A little below macro, we might call them middle or meso level. What are some meso levels determinants of health? Local, regional economic forces. Well, there could be global economic forces. But, how does your state deal with unemployment? How does your state deal with taxes? Nations and states, again a level below the global system. Racism, classes, sexism, is it true certain mortgage companies prevented some

people from living in one area or another, the idea of redlining. And how did that alter exposures? How did that alter stress? These are questions at the mezo level, of social determinance of health. Much related school systems, schools offer a chance to climb the social structure, advance through class systems. That schools also offer opportunities for infections and opportunities to halt one's ability to move through the social system. Sports, everything else happens in the schools they are meso levels of determinants of health. Much like schools are work places. Lots happens in the work places, there's lots of social epidemiological research on how work places effect health. Finally, friendship networks. And in this case, since we're at the meso level, I'm talking broad friendship networks. Persons who might be distant friends of yours, maybe Facebook friends of yours. And here, these friendship networks can have subtle influences on health. Finally, the micro or very close determinants of health. What are they? Among them are families. Our families clearly affect how we live, and our health. They do so directly, perhaps offering infections or different types of food. And indirectly, offering social support. Things that enhance our immune system, or not. Friendship networks. Here, I'm talking about friendships that are very close. Your most close friends, your best friends. These friends might induce you to smoke cigarettes or not wear a seat belt. Or wear a seat belt and eat good food. Local, tight, very good friends have an impact on our health. More micro determinants. Our neighborhood context, where we live is there a toxic dump, is there a nice park to exercise. These are all questions that social epidemiologists address. The final microdeterminant in these slides is what I'll call personal choice. This is the most difficult and controversial one, because some people can say, it's all personal choice.

Others can say, there's very little personal choice. So, we'll come back to this in future lectures. For now, let me just leave that. Micro determinants include the controversial question of personal choice. Briefly, what kinds of social epidemiologic studies are done? We'll talk about classes of studies. In future lectures, we'll dig in more deeply. First are kinds of experiments. What's an experiment? An experiment is a technical type of study where there's some sort of intervention. And that intervention is given to persons at random, so the intervention might be a pill, it might be a pill to reduce heart disease. In an experiment that pill is given to persons at random and there's some reasons that happens. And you can think about random as a coin toss, perhaps heads, the person gets it. Tails, the person does not. Those are the core elements of a true experiment. Something happening to persons at random. Another kind of study that social epidemiologists work on are called longitudinal or cohort studies. Here, we follow a bunch of persons through time. There is no extra thing happening to them. Stuff just happens to them. And then, we see what happens. So, cohort studies have neither the advantage of something happening, and something done at random. Now, stuff does happen to people. Naturally, people are exposed to germs, they are exposed to different social circumstances. But the difference between a cohort study and an experiment is, in the experimental condition, the researcher is controlling who gets what, the cohort study does not. Finally and simply, the last class of study is what we'll call a cross-sectional study. Here's sort of a common survey, a slice of time, cross-section. These are studies that just look at things at one point in time, not over time but at one point in time. And these types of studies offer the

weakest but not often. Not necessarily the worst, but the weakest sort of level of research data. So, we can draw conclusions about how the social system affects health. There's increasing work in methods, research techniques in social epidemiology. Here's a book I co-edited with my colleague Jay Kaufman. And more and more work in this area is being done. I'll dare say more work needs to be done. But by and large, the landscape of social epidemiological research is investigating meso, middle, macro, high, and micro forces with different kinds of studies with different kinds of research methodologies. And we'll explore these ideas in detail later in the course.