American Journal of Epidemiology Advance Access originally published online on March 20, 2008
American Journal of Epidemiology 2008 167(12):1518-1519; doi:10.1093/aje/kwn059
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BOOK REVIEW |
Macrosocial Determinants of Population Health
Edited by Sandro Galea
Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN 55454-1015
(e-mail: oakes007{at}umn.edu)
ISBN 978-0-38-7708-119, Springer Publishing Company, New York, New York (Telephone 877-687-7476, Fax 212-941-7842, Website: www.springerpub.com, E-mail: contactus{at}springerpub.com), 2007, 502 pp., $69.95 (Hardcover)
The explanandum (or "outcome variable") of epidemiology remains population health, but in just the last few years the permissible set of explanans (or "causal factors") has grown not only in number but in kind. Today, genetic epidemiologists routinely focus on single nucleotide polymorphisms, while social epidemiologists are increasingly comfortable discussing macrosocial or upstream factors. Some may worry that this expansion undermines disciplinary cohesion by forcing subdisciplines to compete for scarce resources and/or by presenting consumers with a mix of explanations for the very same phenomena. Others may embrace the expansion as a sign of disciplinary maturity, strength, and promise: How can a collective effort to elucidate all of the mechanisms (both distal and proximal) of health be anything but helpful? Whatever one's take, this ambitious new volume edited by Professor Sandro Galea (1) certainly aims to expand the set by discussing macrosocial determinants of health and the benefits, if not necessity, of their inclusion in epidemiologic analyses.
For Galea, macrosocial determinants are factors that lie beyond the individual and are thus distal—quite distal—to individual health outcomes. Examples include culture, the economy, and corporate structures. Presumably because they reside at a more meso- or middle level, friendships, families, schools, neighborhoods, and so forth are not viewed as macrosocial phenomena. Consistent with the population health strategy of Rose (2) and contemporary views about the domain of social epidemiology (3), macrosocial determinants of health are properly focused on the health of populations and are thought to provide opportunities for public health intervention through policy or perhaps cultural change.
The 502-page text comprises 20 independently authored chapters categorized into three sections: determinants, methods, and, simply put, interventions. The first section (determinants) includes separate chapters addressing globalization, urbanicity, corporate practices, political economy, climate change, global governance, macroeconomics, culture, taxation, patent law, migration, and the mass media. Each of these topics is conceptual or definitional in nature; there is little empirical analysis linking these factors to specific health outcomes or distributions. The second section (methods) includes chapters on the identification of ecologic effects, ecologic studies, causal inference, cross-sectional time-series estimators, and aggregation issues. These chapters largely stand alone; they do not dovetail or explicitly address the phenomena outlined in the text's previous section. The final section (improving population health) contains two chapters, the first offering a framework for macrosocial intervention and the second offering case studies of the same. Each section concludes with a brief summary/integrative chapter by the editor.
There is much to recommend in this text. Epidemiologists unfamiliar with these constructs will benefit by careful study of the lucid chapters on climate change, culture, taxation, and mass media. Of special note is the chapter on patent law and policy. This scholarly effort illuminates the idea that the "rules of the game" (my words) have broad and deep implications for population health, in terms of both incentives for innovation and the availability of low-cost medicines. The five methodological chapters are all quite strong. Novice methodologists will enjoy the balance between mathematical rigor and accessible explanatory discussions; an abundance of citations are provided for further inquiry. Of special note is the thoughtful chapter on choosing an appropriate level of macro- phenomena for investigation. By describing the many options a macrosocial analyst might adopt as her unit of analysis, this chapter illuminates the challenges posed by underdeveloped theory. The editor's introduction and three summary/integrative chapters may be read together as a review of literature and current scientific thinking on the phenomena under investigation.
I hope that future editions include chapters on war, religion, and consumer demand. It seems to me that these macrosocial phenomena merit careful attention, and this volume could have helped advance our understanding of their impacts on population health. Additionally, I found the politically biased views in some chapters somewhat disappointing. For example, the chapter on corporate practices missed an opportunity to convey insights from the science of corporate action and organizational theory. Instead of addressing governance structures and the efficiency imperative (4), the chapter tends toward a politically leftist rant against the alcohol, automotive, firearms, food, pharmaceutical, and tobacco industries. The second-to-last chapter (conceptual framework for action) also appears to have missed important opportunities by focusing exclusively on the amelioration of health disparities and associated social inequalities. Consideration of the scholarship addressing Rawlsian justice (maximize the welfare of the disadvantaged) or perhaps even utilitarian theory (maximize the greatest good for the greatest number) would have balanced and thus strengthened the arguments made (5).
Just as when advances in biochemistry and single nucleotide polymorphism research extend our understanding of the microscopic processes at work, advances in our understanding of and appreciation for macrosocial determinants of health are healthy for the discipline. Galea's new text certainly represents such an advance and portends a substantial step in a useful direction. That said, I close with two cautions about the broader effort to incorporate macrosocial determinants into epidemiologic analysis. First, it seems clear that the scientific utility of macrosocial determinants will depend on the key, if not impossible, task of explaining exactly how and why these phenomena (e.g., patent laws) emerge and enter the dynamic causal chain that simultaneously affects the health of cells, individuals, and populations. Second, practically speaking, a fundamental question is the extent to which the salubrious influences of macrosocial factors can be increased without yielding unacceptable, if unintended, macrosocial consequences such as economic depression or totalitarian regimes. There is much work to be done.
ACKNOWLEDGMENTS
Conflict of interest: none declared.
References
- Galea S. Macrosocial determinants of population health. (2007) New York, NY: Springer Publishing Company.
- Rose G. The strategy of preventive medicine. (1994) New York, NY: Oxford University Press.
- Oakes JM, Kaufman JS. Introduction: advancing methods in social epidemiology. In: Methods in social epidemiology—Oakes JM, Kaufman JS, eds. (2006) San Francisco, CA: Jossey-Bass/Wiley, Inc. 1–18.
- Williamson OE. The economics of governance. Am Econ Rev (2005) 95:1–18.
- Jenks C. Does inequality matter? Daedalus (2002) 131:49–65.
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