Policy & Social Epidemiology
🎯 Objectives
● Understand the roles of government, NGOs, and private organizations in public health
● Identify barriers to implementing policy
● Explore causal inference in social epidemiology
● Reimagine traditional epidemiology through the lens of social/structural determinants
🏛️ Public Health Policy
🔑 What is Policy?
● Policy is central to public health success
● Influences environments to promote healthier behavior
● Goes beyond individual interventions to create lasting, population-wide change
💡 Examples of Major Achievements (20th Century)
● Motor vehicle safety
● Vaccination
● Family planning
● Safer workplaces
● Tobacco control
● Clean water & food
🧭 Policymaking
🔄 Types
Public Policy (Big “P”) Private Policy (Small “p”)
Created by government Created by private entities (e.g., schools,
workplaces)
Example: Mask mandates, clean air Example: workplace benefits, university rules
laws
📜 Policy Implementation
● May take form as laws, regulations, agency guidelines, or budget decisions
● Influenced by science, politics, economy, and society
⚠️ Barriers to Policy Implementation
Barrier Example
Lack of emphasis on Few dollars go to population-wide efforts
prevention
Weak evidence base May be outdated or limited
Time mismatch Policy cycles ≠ research timelines
Interest group power “Unhealthy” industries can influence outcomes
Academic isolation Researchers may not engage in policymaking
Complex processes Policymaking can be biased by culture,
stereotypes
🔬 Epidemiology vs. Social Epidemiology
🧪 Traditional Epidemiology
Focuses on:
● Who, what, where, when, how of disease
● Screening, prognosis, transmission, prevalence
🌍 Social Epidemiology
Focuses on:
● Social factors contributing to illness (race, class, gender, policy)
● How society’s structure shapes health
🧓 Origins of Social Epidemiology
Thinker Contribution
Louis-René Villermé Mortality disparities by income
Edwin Chadwick Poor sanitation → disease; promoted public sanitation reforms
Rudolf Virchow Typhus linked to poverty; advocated for social reforms
Louis Pasteur (germ Shifted attention away from social causes—until the 1980s revival
theory) of social epi
🧠 Key Concepts in Social Epidemiology
1. Biopsychosocial Model
● Health = interaction of biological, psychological, and social factors
● Contrasts with biomedical model (purely biological view of disease)
2. Population-Level Focus
● Risk is shaped by population conditions, not just individual behaviors
3. Advanced Statistical Methods
● Multilevel modeling: accounts for individual + neighborhood + system factors
4. Use of Theory
● Social theories guide hypotheses (e.g., "Social Production of Disease")
📊 Areas of Focus in Social Epidemiology
🏷️ Social Stratification
● SES, education, occupation, and income all affect health outcomes
🧑🤝🧑 Race & Ethnicity
● Health disparities shaped by structural racism, not just biology
🧳 Immigration
● Acculturation can worsen health over time (e.g., diet changes)
🤝 Social Capital
● Strong networks and trust = better health outcomes
🏘️ Neighborhood Factors
● Safety, walkability, segregation, and access affect health
💼 Work Environment
● Job demands, control, and reward imbalance are all stressors linked to illness
📚 Case Study: The Whitehall Studies
● British civil servants studied over decades
● Clear social gradient in health: lower job status = higher mortality
● Social class remained a powerful predictor even after accounting for other factors
🧩 Other Key Research Areas
💗 Sex & Gender Disparities
● Women receive less cardiac care; men less dialysis
● Transgender and LGBTQ+ communities face denial of care, mental health burdens, and
systemic bias
🔬 Specific Diseases & Social Determinants
Condition Social Risk Factors
Tuberculosis (TB) Crowding, malnutrition, HIV, smoking
Mental Health Poverty, low education, isolation
Cardiovascular Disease Low SES, unsafe neighborhoods, poor access
Atrial Fibrillation Race, SES, rurality, lack of social support
Type 2 Diabetes Poor housing, food deserts, environmental
toxins
Chronic Kidney Disease SES, race, stress, low education
ESRD Racial disparities in transplants, slower referrals
Breast & Colorectal Cancer Late diagnoses, SES, race, immigration
HIV/AIDS Housing instability, substance use, poor nutrition
🗺️ Local Example: Boston Health Inequities
● Mortality and disease rates differ by zip code
● Dudley Square & Mattapan have:
○ More poverty
○ Higher stress & violence
○ Lower access to care
○ Lower education and employment
○ Poorer housing
● Arlington/Fenway enjoy proximity to major hospitals and wealth
🛠️ What Can We Do?
As Health Professionals:
● Practice justice and cultural humility
● Screen for invisible social determinants:
○ Housing, trauma, support, food insecurity
● Provide culturally and economically appropriate care
● Use tools (GoodRx, SNAP info, evening clinic hours)
As Advocates:
● Address structural inequities
● Push for policy changes that promote health equity