Titanic-like gradients

In the world of social determinants there is one teaching tool that bests all others.  Deaths on the Titanic were highly skewed towards men and those in the lower classes.  This is an excellent point from which to begin to present information on the manner in which health is patterned by social processes, and disproportionately affects some groups within society.

In recent days there has been a certain amount of publicity surrounding a new paper (gated version, ungated version) by Mikael Elinder and Oscar Erixson at Uppsala University that looks in detail at survival in 18 maritime disasters between 1852 and 2011.  The authors’ goal was to look at gender differences in survival and how this might be linked to social norms.  Their headline result is that women have poorer survival rates than men (by about 20%), although things have been improving over time.  Sadly, as John Timmer at ArsTechnica notes

before we conclude that chivalry was dead and [is now] seeing a revival, we’ll caution you that it may be just that more women now learn how to swim.

My interest, however, is on the social side of things, and here two items jump out at me.

1. First, the authors make the following assertion in the final sentence of their abstract:

Taken together, our findings show that human behavior in life-and-death situations is best captured by the expression “every man for himself.”

However, both Timmer’s commentary and the article itself seem to gainsay this by noting that in cases where the Captain issues the order “Women and children first”, the female survival penalty is roughly halved.  For me, this points to the importance of social control in addition to social norms.   The authors even note elsewhere in their piece:

it seems as if it is the policy of the captain, rather than the moral sentiments of men, that determines whether women are given preferential treatment in shipwrecks.

2. Second, only a minority of ships contain information on class of passenger and the authors look at this only as a footnote.  But, it does appear that being in 1st class was protective relative to being in 2nd or 3rd class overall (there were 7 ships with class info: 3 significantly positive results, 1 significantly negative).  So it does seem that the SDoH classes can keep using this example for now at least.

H/T to Marginal Revolution for drawing me to the paper.

Taking the health impact of economic factors seriously

If (or when) I tire of reading trite articles linking exposure A to outcome B while avoiding even a consideration of context or history, I turn to the International Journal of Health Services.  It is not the best-known journal around, and there are very few quick fixes and takeaway messages.  There are certainly no ‘What this study adds’ boxes à la BMJ stable.  Thank goodness.  The journal provides provocative and deep analysis of the current political and economic system and how it affects health.  Under the editorship of Vincent Navarro the journal has focused on critiquing the mainstream, and while I do not always agree with the views expressed, I always gain something from reading.

For example, the most recent issue contains at least four articles that are now high on my to-read pile.

  1. Nadine Nowatzki takes us down the well-worn path of the cross-national relationship between income inequality and mortality/life expectancy.  She focuses on wealth inequality (perhaps a more insidious form than income, since it is longer-lasting) and finds that while the overall pattern looks similar to that for income inequality, the ordering of nations differs.  Her discussion looks at a range of explanations, including social capital and redistributive policies across classes and the lifecourse.
  2. Carles Muntaner and colleagues continue to consider income inequality, explicitly engaging with Richard Wilkinson and Kate Pickett’s The Spirit Level.  They note that Wilkinson and Pickett focus on psychosocial explanations for the ill-health associated with greater inequality, and go on to challenge the authors on this.  Muntaner et al. prefer to focus on materialist explanations, specifically those which arise from social class in the form of exploitation (cf Erik O Wright), and this leads them to urge greater intervention in the economic structure of societies to improve health.
  3. Gavin Mooney moves us to more conceptual ground.  Mooney’s name is one I know from the Health Economics world, where he has been a careful and trenchant critic of the focus on efficiency over equity in that field.  Now it appears he has a new book out, focusing more on political economy and the impact of neoliberalism on health, and for which this paper is a taster.  The core of his argument (and please note I haven’t read the paper thoroughly yet) appears to be that the WHO and the Breton-Woods institutions (World Bank, IMF) have been co-opted into the global neoliberalist focus on individual rights over communitarian needs and approaches.  And that this has had serious negative effects on health.  Certainly an argument worth engaging with.
  4. Claudio Schuftan considers the links between poverty and broader human rights violations, not so much the direct links but rather the common causes.  She identifies the neoliberal governmental framework, religion and man-made disasters at the fulcrum of the system, driving the failure to implement UN (and other) conventions protecting rights and subsequent powerlessness and resignation amongst the powerless.  These then cascade into numerous direct causes of rights violations, but I’ll leave those for you to read about.  It’s certainly a strongly argued vision of the way the world works, and works to harm the most vulnerable.   This paper in particular, I would like to see linked up with Sen/Nussbaum’s capabilities approach.

All of which adds up to uncomfortable, but (indeed perhaps therefore) important, but never dull, reading.

Why does this blog exist? (in a shallow sense)

One of the main impetuses (aside: why can’t it be impeti?) for my efforts to set up this blog, was that when I googled “social epidemiology” or “social epidemiology blog“, I was severely underwhelmed by what I found. And don’t even get me started on the wikipedia page.  Even looking for “‘social determinants of health’ blog” brings up individual entries, not blogs devoted to the subject.

This was a shame, if not entirely a surprise.  A couple of years back, a group of students in the Department of Society, Human Development and Health at HSPH thought it would be a great idea to set up a group blog (à la scatterplot, among others).  This effort – under the moniker societyandhealth – was sadly rather shortlived.  I think this was partly due to it being started shortly before summer break and partly due to each of us having a slightly different idea what the site might do.

In large part, I think that the lack of material or coherence on the web reflects the breadth of the field and perhaps uncertainty regarding its epistemology.  I have heard it argued that public health in general, and social epidemiology must be a normative science and an activist discipline: if we find things that are causing ill-health, a failure to act on these through communication and policy change is little short of criminal.  Such arguments resonate with the efforts of Mayor Bloomberg.

On the other hand, there is still only a limited amount of actual evidence for health being associated with social conditions – certainly compared to more traditional risk factors such as behaviours and environmental exposures.  Thus there is a more positive science angle that says we need to run more, and better, studies to figure out which exposures cause which outcomes and through which mediating pathways.

It is also notable that social epidemiology aims to shift the discussion regarding causation in public health by changing what is a valid cause of health. (On which topic, if you haven’t heard of this book, you should get thee to a bookshop asap).  It is therefore an aggressive force for epistemological change.  And this is something I love about the field.  It does, however, often make it hard to nail down what is covered within its remit, since that keeps changing too.

All of which makes for a very interesting field, but not an easy one to follow online. Which could probably also be said of this blog post.  My point, however, is that in the absence of a blog devoted to social epidemiology and the social determinants of health, I thought that I might as well cast off from the shore and see where the currents take me.  I think we’re still within sight of the point of embarkation, but hopefully soon there’ll be new lands to discover, and maybe even pirates to fight.   But enough with the extended meataphor.  For now.

P.S.  If I’ve abused the term epistemology, my apologies.  In philosophy as is so much else, a little vocabulary is a very dangerous thing.