1

A Historical Framework for Social Epidemiology

LISA F. BERKMAN AND ICHIRO KAWACHI

Epidemiology is the study of the distribu 1990). Efforts to improve their physical en
tion and determinants of states of health in vironments (e.g., housing, noxious work en
population,:; (Susser 1973). Ever since John vironments and water supply), sanitation,
Graunt (1662) counted deaths in county nutrition, and access to immunization were
parishes in England in the seventeenth cen the primary focus ot public health profes
tury, social variations in morbidity and sionals. With broad improvements in the
mortality have been observed. Early studies physical environment in the United States,
often centered on the ill effects of poverty, Great Britain, and much of northern Europe,
poor housing conditions, and work envi countrywide increases in life expectancy oc
ronments. By the nineteenth century, physi curred. Based on this observation, many sci
cians such as Villerme (1830) and Virchow entists forecast large-scale reductions of so
(1848) refined observations identifying so cial disparities in health (Kadushin 1964).
cial class and work conditions as crucial de Perhaps no other phenomenon has augured
..
terminants of health and disease (Rosen the need for the perspective of social epi
1963). Durkheim wrote eloquently about demiology as clearly, however, as the con
another profound social experience, that of tinued maintenance and recent growth of
social integration and how it was related to social inequalities in health in many coun
patterns of mortality, especially suicide tries. Thus, while diseases have come and
(1897). So, in many ways, the idea that so gone, some infectious diseases have been
cial conditions influence health is not new. eradicated, others have emerged, and a host
Social epidemiology, however, is. of noninfectious diseases have dominated
As the public health movement developed the profile of causes of death and disability,
in the United States and Great Britain in the social inequalities in health remain. These
nineteenth and early twentieth centuries, at persistent patterns call for an epidemiolog
tention was drawn to the increased risk of ic approach to understanding disease etiol
disease among the poor (Rosen 1975; Duffy ogy that incorporates social experiences as

3
4 SOCIAL EPIDEMIOLOGY

more direct causes of disease and disability size, Rose pointed out that rarely are either
than is the customary view. risk factors or disease binary in nature. In
Fortunately, many forces have converged most cases, risks are distributed along a
to permit the development of this field. continuum and small shifts in the distribu
Among the most critical has been the devel tion of risk throughout a population can
opment of work on stress and physiologic make large differences in the health status of
responses to stressful experiences. Building that population. Furthermore, understand
on the fundamental work by Cannon ing the dynamics of why some populations
(1935) and Selye and Wolff (1973), health have certain distributions leads to very dif
psychologists, neuroendocrinologists, and ferent etiologic questions than asking why
physiologists have made it clear that stress some individuals are in the tails of the dis
ful conditions may exact a direct toll on the tribution. Pursuing this population-based
body, offering powerful biological models strategy, rather than a high-risk strategy,
that link external stressors to physiologic leads to framing very different questions
responses capable of influencing disease de and utilizing very different preventive ap
velopment and prognosis. Work on psycho proaches. The population strategy is of cen
physiology, psychoneuroimmunology, and tral importance to social epidemiology and
most recently on allostatic load has helped it has been traditionally the mainstay of
trace biologic pathways as well as specific public health.
behaviors and exposures to noxious agents The fields of physiology and psychoso
that link social conditions to important matic, social, and preventive medicine as
health outcomes. (Cohen 1988; Kiecolt well as medical sociology and health psy
Glaser et al. 1996, 1997; McEwen 1998). chology have all made important contribu
The second factor has been a progressive tions to the development of social epidemi
increased blurring of the distinction be ology (See Rosen 1975 for an excellent
tween "psychosomatic" illness and other history of preventive medicine in the United
physical illnesses. Whereas it was formerly States). But the seeds of social epidemiolo
believed that some diseases were caused by gy have also grown from within epidemiol
psychological states with little biological ogy itself. In the late 1960s and 1970s, epi
basis and others were purely "physical," we demiologists such as John Cassel, Mervyn
now understand that in almost all cases this Susser, S. Leonard Syme, Saxon Graham,
distinction is false. Most psychosomatic dis Lawrence Hinkle, Al Tyroler, Sherman
eases involve varied genetic and environ James, and Leo Reeder started to develop a
mental determinants, and all states of health distinct area of investigation in epidemiolo
and disease are influenced to some extent by gy centered on the health impact of social
psychosocial conditions. Rarely for any dis conditions, particularly cultural change, so
orders is there a single necessary and suffi cial status and status inconsistency, and life
cient cause of disease. The breakdown of transitions. Their work drew heavily on
this artificial dichotomy is critical to ad that of epidemiologists who worked earlier
vancing knowledge in the coming decades: in the century such as Goldberger and
Diseases are no longer classified as psycho Sydenstricker (Goldberger et al. 1929), who
somatic or not. investigated the etiology of pellagra, and
A third theoretical development in un Wade Hampton Frost, whose work on tu
derstanding the distribution of risk in pop berculosis was seminal (Maxcy 1941). They
ulations further enhances our ability to also drew deeply from medical sociology
launch a solid investigation of social factors (Freeman et al. 1963) and the work of psy
and health. In 1992, Geoffrey Rose (1992), chiatric epidemiologists (Faris and Dunham
an eminent epidemiologist, wrote a small 1939; Hollingshead and Redlich 1958;
book on the strategy of preventive medi Leighton 1959; Srole et al. 1962). Syme
cine. In this landmark work, small only in (1965) explained that investigations of the
 A HISTORICAL FRAMEWORK FOR SOCIAL EPIDEMIOLOGY 5

"social etiology of disease attempted to sys John Cassel (1976) in the fourth Wade
tematically examine variations in the inci Hampton Frost Lecture to the American
dence of particular diseases among people Public Health Association stated that "the
differentially located in the social structure question facing epidemiologic inquiry is, are
and attempt[ed] to explore the ways in there categories or classes of environmental
which their position in the social structure factors that are capable of changing human
tended to make them more vulnerable, or resistance in important ways and making
less, to particular disease." subsets of people more or less susceptible to
In a seminal article, Saxon Graham ubiquitous agents in our environment." In
(1963) discussed the social epidemiology of this classic paper "The Contribution of the
selected chronic illnesses. While never giv Social Environment to Host Resistance," he
ing an explicit definition of social epidemi argued that environmental conditions capa
ology, he suggested that a union of sociolo ble of "producing profound effects on host
gy with the medical sciences would produce susceptibility" involve the presence of other
a new and more successful epidemiology. members of the same species, or more gen
Graham went on to say that achieving a co erally, certain aspects of the social environ
herent and complete theory of disease cau ment (Cassel 1976, p. 108).
sation would require obtaining social and Building on the work of Hinkle (1973)
biological data that are consistent with each and stress researchers such as Cannon
other with regard to a specific disease (Gra (1935), Dubos (1965), and Selye and Wolff
ham 1963, p. 72). Thus, he argued, one (1973), Cassel posited that at least one of
must understand how membership in a so the properties of stressful situations might
cial group relates to behavior patterns, to be that the actor is not receiving adequate
exposure to "vehicles" for transmitting evidence that his actions are leading to an
agents, to direct tissue changes, and finally ticipated consequences. Today we might
to disease. Graham aimed to identify spe cite situations of powerlessness brought on
cific social circumstances that led to a chain by social disorganization, migration, dis
of events in which specific behaviors were crimination, poverty, and low support at
linked to specific diseases. His classic exam work as prime examples of this situation.
ple involved Percival Pott's analysis of scro Cassel also outlined a series of protective
tal cancer in chimney sweeps. Parallel to his factors that might buffer the individual
analysis of Pott's studies, much of his early from the deleterious consequences of stress
work dealt with smoking and dietary and ful situations. The property common to
sexual behaviors that were associated with these processes is "the strength of the social
different social groups and thus more prox supports provided by the primary groups of
imally linked to specific diseases. In seeking most importance to the individual" (Cassel
to understand the large-scale social pattern 1976, p. 113). Thus, consolidating the find
ing of disease in terms of individual behav ings gathered by epidemiologists doing em
iors of group members, Graham's great con pirical work on status and status incon
tribution to epidemiology was his ability to gruity (Syme et al. 1965; Hinkle 1973),
incorporate this multilevel thinking into the rapid social change and disorganization
field. (Cassel et al. 1961; James and Kleinbaum
Almost a decade later, in the mid-1970s, 1976), acculturation and migration (Mar
two epidemiologists, John Cassel and mot and Syme 1976), and social support
Mervyn Susser, more explicitly tackled the and family ties (Nuckolls et al. 1972; Pless
methodologic controversies and paradigm and Satterwaite 1972), Cassel laid out an in
shifts inherent in incorporating a deeper un tellectual agenda for social epidemiology
derstanding of the social influences of dis that provided the groundwork for decades
ease into epidemiologic thinking. Armed to come.
with evidence from the previous decade, In a provocative series of articles, Mervyn
 1 6 SOCIAL EPIDEMIOLOGY
d
Susser has written that epidemiology must on exposures (e.g., environmental or nutri
broaden its base and move beyond its focus tional epidemiology) rather than those areas
on individual-level risk factors and "black devoted to the investigation of specific dis
box epidemiology" to a new "multilevel eases (e.g., cardiovascular, cancer, or psy
ecoepidemiology" (Susser 1994a,b, 1998; chiatric epidemiology). We focus on specif
Susser et al. 1996a,b). The foundations for ic social phenomena such as socioeconomic
much of this framework can be seen in his stratification, social networks and support,
1973 book, Causal Thinking in the Health discrimination, work demands, and control
Sciences: Concepts and Strategies in Epi rather than on specific disease outcomes.
demiology. In the introduction to that vol While future studies may reveal that some
ume, Susser stated that epidemiology shares diseases are more heavily influenced by so
the study of populations, in a general way, cial experiences than others, we suspect that
with other population sciences such as soci the vast majority of diseases and other
ology, human biology, and population ge health outcomes such as functional status,
netics. In affirming common methodologic disability, and well-being are affected by the
and conceptual ground with other sciences social world surrounding us all.
involved in the study of society, he ex Like environmental and nutritional epi
plained that "states of health do not exist in demiology, social epidemiology must inte
a vacuum apart from people. People form grate phenomena at the margins of what is
al societies and any study of the attributes of defined as its domain. For instance, psy
s( people is also a study of the manifestations chological states, behaviors, and aspects of
pl of the form, the structure and the processes the physical or built environment are influ
el of social forces" (Susser 1973, p. 6). In oth enced by social environments and vice ver
pI er chapters, Susser discussed how agent, sa. Borders at the periphery of any field,
tii host, and environment models, the most ba and social epidemiology is no exception,
te sic organizing principles of epidemiology, are bound to be fuzzy. We make no attempt
s( could be framed as an ecological system to draw clean lines encircling the field. Be
ar with different levels of organization. cause it is important for social epidemio-'
at Susser's recent work again emphasizes logists to consider related areas, we have
ul that epidemiology is, in essence, ecological included sections in this volume on psycho
sd since the biology of organisms is determined logical states and behaviors that are close
m in a multilevel, interactive environment. ly related to the social experiences which
w; Identifying risks at the individual level, even are our primary concern. If we err on the
fi~ multiple risks, does not sufficiently explain side of blurring boundaries, we must bal
er interactions and pathways at that level, nor ance that with precision in defining explic
does it incorporate the social forces that in it testable hypotheses in our work. Without
fluence risks to individuals. hypotheses that can be clearly supported or
refuted, without having a clear understand
GUIDING CONCEPTS IN SOCIAL ing of temporal sequencing or biological
EPIDEMIOLOGY plausibility, and without articulated theo
ries and specific concepts to guide empirical
We define social epidemiology as the branch investigation, we will not be able to make
of epidemiology that studies the social dis progress.
tribution and social determinants of states The rest of this chapter outlines several
of health. Defining the field in this way im concepts that are important to the field of
plies that we aim to identify socioenviron social epidemiology. These concepts are not
mental exposures that may be related to a offered as universals to be uncritically ac
broad range of physical and mental health cepted but rather as useful and sometimes
outcomes. Our orientation is similar to oth challenging guides that transcend the study
er subdisciplines of epidemiology focused of any single exposure.
 A HISTORICAL FRAMEWORK FOR SOCIAL EPIDEMIOLOGY 7

A POPULATION PERSPECTIVE
particular individual get sick?" Further
more, as Rose pointed out, the greatest im
Individuals are embedded in societies and provements in population health are likely
populations. The crucial insight provided to derive from answering the first question,
by Rose's (1992) population perspective is because the majority of cases of illness arise
that an individual's risk of illness cannot be within the bulk of the population who are
considered in isolation from the disease risk outside the tail of high risk.
of the population to which she belongs.
Thus, a person living in Finland is more THE SOCIAL CONTEXT

likely to die prematurely of a heart attack OF BEHAVIOR

compared to someone living in Japan, not

just because any particular Finnish individ Over the last several decades, a huge num
ual happens to have a high level of choles ber of clinical trials have been launched to
terol, but because the population distribu modify individual behavioral risk factors
tion of cholesterol levels in Finnish society such as alcohol and tobacco consumption,
as a whole is shifted to the right of the diet, and physical activity. By and large, the
Japanese distribution. The level of choles most successful have been those which in
terol that might be considered "normal" in corporated elements of social organization
Finnish society would be grossly abnormal al changes into interventions. We now un
and a cause for alarm in Japan. Moreover, derstand that most behaviors are not
we know from detailed studies of migrants randomly distributed in the population.
that the basis for these population differ Rather, they are socially patterned and of
ences are not genetic (Marmot and Syme ten cluster with one another. Thus, many
1976). For instance, Japanese immigrants to people who drink also smoke cigarettes,
America take on the coronary risk profiles and those who follow health-promoting di
of their adopted country. etary practices also tend to be physically ac
Although Rose's initial examples in tive. People who are poor, have low levels of
volved the examination of risk factors for education, or are socially isolated are more
heart disease, we now recognize that his in likely to engage in a wide range of risk
sight has broad applicability to a swath of related behaviors and less likely to engage
public health problems, ranging from ag in health-promoting ones (Matthews et al.
gression and violence, mental health, to the 1989; Adler et al. 1994). This patterned be
effects of poverty and material deprivation havioral response has led Link and Phelan
on health. Fundamentally, Rose's insight (1995) to speak of situations that place in
harks back to Durkheim's discovery about dividuals "at risk of risks."
suicide: that the rate of suicide in a society Understanding why "poor people behave
is linked to collective social forces. There poorly" (Lynch et al. 1997) requires a shift
are a myriad reasons why any individual in understanding-specific behaviors once
commits suicide, yet such individuals come thought of as falling exclusively within the
and go while the social rate of suicide re realm of individual choice occur in a social
mains predictable. context. The social environment influences
The crucial implication of Rose's theory behavior by (1) shaping norms, (2) enforc
for social epidemiology is that we must in ing patterns of social control (which may be
corporate the social context into explana health-promoting or health-damaging), (3)
tions about why some people stay healthy providing or not providing environmental
while others get sick. Applying the popula opportunities to engage in certain behav
tion perspective into epidemiological re iors, and (4) reducing or producing stress
search means asking "Why does this popu for which certain behaviors may be an ef
lation have this particular distribution of fective coping strategy, at least in the short
risk?", in addition to asking "Why did this term. Environments place constraints on in
8 SOCIAL EPIDEMIOLOGY

dividual choice. Incorporating the social sures call for innovative methods (Jones
context into behavioral interventions has and Moon 1993; DiezRoux et al. 1997).
led to a whole new range of clinical trials The assessment of exposures at an environ
that take advantage of communities, mental or community level may lead to an
schools, and work sites to achieve behav understanding of social determinants of
ioral change (see Sorensen et al. 1998 and health that is more than the sum of individ
Chapter 11). ual-level measures. Although important
questions remain about the appropriate lev
CONTEXTUAL MULTILEVEL
el of environmental assessment (e.g., neigh
ANALYSIS
borhood, city, state, country), the disentan
gling of compositional versus contextual
The understanding that behavior is condi effects, and the pathways linking such envi
tioned by society yields a more general ap ronmental exposures to individual health
preciation of the need for contextual analy outcomes, ecological analyses offer a valu
sis in epidemiology. As Susser (1998) noted, able research tool to epidemiologists. When
"risk factor epidemiology in its pure form coupled with individual-level data, they of
exploits neither the depth and precision of fer the critical advantages available in the
micro-levels nor the breadth and compass form of multilevel analyses.
of macro-levels." Conceptions of how cul
ture, policy, or the environment influences A DEVELOPMENTAL AND

health remain fuzzy and speculative if one LIFE-COURSE PERSPECTIVE

analyzes only the independent effects of in

dividual-level risk factors. Ecological analy In general, epidemiologists have only crude
sis, a central part of both epidemiology and tools with which to explore developmental
sociology early in this century, offered an and lifecourse issues. Cumulative risk and
approach to the study of environments, but latent periods are familiar terms but we of
it lost" a great deal of respectability because ten lack methods to deal with them ade
of problems related to the ecological fallacy quately. Yet there is intriguing evidence that
(e.g., drawing individual inferences from such perspectives may yield valuable in
grouped data; see Chapter 14). It was diffi sights. In fact, social epidemiologists work
cult, if not impossible, to rule out reverse ing in the 1960s and 1970s implicitly adopt
causation (that the illness influenced resi ed a lifecourse perspective in testing theories
dential relocation) in many studies. In fact, about status incongruity in which the stress
it was this latter problem that plagued many ful experiences being studied resulted from
of the early studies on psychiatric disorder having grown up in one situation or as a
and community disorganization. member of one status group and then hav
In the past few years, however, it has be ing shifted to either a higher or lower status.
come apparent that just as there are ecolog (See Syme et al. 1965 for an excellent dis
ic-level exposures in environmental and in cussion of this.)
fectious disease epidemiology, so are there Three hypotheses have been proposed
valid ecologic-level exposures related to the (Power and Hertzman 1997) to explain
social environment that are not adequately early life influences the onset of disease in
captured by investigation at an individual middle and late life. The first is that some
level (Macintyre et al. 1993; Kaplan 1996; exposure in early childhood could influ
Kawachi and Kennedy 1997; Kawachi et al. ence developmental processes-particular
1997). For example, the number of grocery ly brain development during periods of
stores, parks, the condition of housing great plasticity. By molding patterns of re
stock, and voter participation may be criti sponse during these "critical stages," early
cal determinants of behaviors, access to life experiences would then make the indi
care, or illness. These ecologic-level expo vidual vulnerable or resistant to various
 A HISTORICAL FRAMEWORK FOR SOCIAL EPIDEMIOLOGY 9

diseases in adulthood (Barker 1992). This tors influence disease processes by creating
model is similar to that of latency models. a vulnerability or susceptibility to disease in
The second hypothesis is one of cumulative general rather than to any specific disorder.
disadvantage and is outlined by several According to the general susceptibility hy
medical sociologists (Ross and Wu 1995). pothesis, whether individuals developed
Disadvantage in early life sets in motion a one disease or another depended on their
series of subsequent experiences that accu behavioral or environmental exposures as
mulate over time to produce disease after well as their biological or genetic makeup.
30,40,50, or 60 years of disadvantage. The But whether they became ill or died at ear
third hypothesis is that while early experi lier ages or whether specific socially defined
ences set the stage for adult experiences, it groups had greater rates of disease depend
is really only the adult experiences that are ed on socially stressful conditions.
directly related to health outcomes. For in As originally proposed, the concept of
stance, low educational attainment in earli general susceptibility or psychosocial "host
er life might matter only in so far as it con resistance" was a powerful and intuitively
strains the range of job opportunities and appealing metaphor but not well grounded
job experiences. These three models layout biologically. It was not until research in so
a framework within which to examine life cial epidemiology became more integrated
course issues. Our aim here is not to con with research in neuroscience and psy
clude that there is strong evidence to sup choneuroimmunology that clear biological
port one or another of them, nor in fact to mechanisms were defined, at least as poten
advocate an overly deterministic, develop tial pathways leading from stressful social
mental model of disease causation at all, experiences to poor health. Neuroendocri
but rather to suggest that this perspective nologists had identified classic stress media
provides a lens through which to examine tors such as cortisol and catecholamines as
how social factors may influence adult well as less well understood mediators such
health. as dehydroepiandrosterone (DHEA), pro
lactin, and growth hormone, and they knew
GENERAL SUSCEPTIBILITY
that these affected multiple physiologic sys
TO DISEASE
tems. By linking evidence from both fields,
researchers showed that some stressful ex
Wade Hampton Frost (1937) noted that at periences activate multiple hormones and
the turn of the 20th century there was noth thus might not only affect multiple systems
ing that changed "nonspecific resistance to but could also produce wide-ranging end
disease" as much as poverty and poor living organ damage. Furthermore, recent ad
conditions. In referring to this altered resis vances in understanding variable patterns of
tance, Frost suggested that it was not just in neuroendocrine response with age suggest
creased risk of exposure among the poor that the cumulative effects of stress, or even
that produced high prevalence rates of tu stressful experiences that have taken place
berculosis: It was something about their in during development, may alter neuroendo
ability to fight off the disease-their in crine-mediated biological pathways and
creased susceptibility to disease once ex lead to a variety of disorders from cardio
posed-that contributed to high rates of vascular disease to cancer and infectious
disease in poor populations. disease (Meany et al. 1988; Sapolsky 1996;
Cassel, Syme, and Berkman (Cassel 1976; McEwen 1998).
Syme and Berkman 1976; Berkman and These developments in aging research
Syme 1979) built on this idea when they ob suggest new ways in which stressful experi
served that many social conditions were ences may be conceptualized as accelerating
linked to a very broad array of diseases and the rate at which we age or changing the ag
disabilities. They speculated that social fac ing process itself (Berkman 1988). This con
10 SOCIAL EPIDEMIOLOGY

ceptual shift relates well to earlier notions of Berkman, L. (1988). The changing and hetero
general susceptibility. geneous nature of aging and longevity: a so
cial and biomedical perspective. Annu Rev Jan
Ger Geriatr, 8:37-68.
CONCLUSION Berkman, L., and Syme, S. (1979). Social net
works, host resistance, and mortality: a nine JOIl
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subspecialties such as environmental, nutri Cannon, W.B. (1935). Stresses and strains of Ka
homeostasis. Am] Med Sci, 189:1-14.
tional, clinical, reproductive, and most re Cassel, J. (1976). The contribution of the social Ka
cently, genetic epidemiology (Rothman and environment to host resistance. A]E, 104:
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tions give rise to patterns of health and dis ical studies of culture change: 1. Health status Ka
and recency of industrialization. Arch Envi
ease in individuals and populations-has ron Health, 3:25-33.
been around since the dawn of public Cohen, S. (1988). Psychosocial models of the Kz
health. But the rediscovery of this question role of social support in the etiology of phys
through the lens of epidemiology is a rela ical disease. Health Psycho I. 7:265-97.
tively recent phenomenon. As demonstrat DiezRoux, A.V., Nieto, Ej., Muntaner, C., Ty
roler, H.A., Comstock, G.W., Shahar, E., et Ki
ed in the contributions to this volume, so al. (1997). Neighborhood environments and
cial epidemiologists are now applying coronary heart disease: a multilevel analysis.
concepts and methods imported from a va Am] Epidemiol, 146(1):48-63.
riety of disciplines ranging from sociology, Dubos, R. (1965). Man adapting. New Haven:
psychology, political science, economics, Yale University Press. K
Duffy, ]. (1990). The sanitarians: a history of
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