THE CHANGING FACE OF EPIDEMIOLOGY

Editors note: This series addresses topics of interest to epidemiologists across a

range of specialties. Commentaries start as invited talks at symposia organized by the
Editors. This paper was presented at the Third North American Congress of Epidemiology
held in Montreal in June 2011.

Social Epidemiology
Questionable Answers and Answerable Questions
Sam Harpera and Erin C. Strumpfa,b

ocial epidemiology encompasses the study of relationships between health and a broad
range of social factors such as race, social class, gender, social policies, and so on. One
could broadly partition the work of social epidemiology into surveillance (ie, descriptive
relationships between social factors and health, tracking of health inequalities over time)
and etiology (ie, causal effects of social exposures on health).1 Many social epidemiologists believe these twin pursuits should ultimately serve to structure interventions aimed
at reducing health-damaging social exposures or increasing exposure to social factors that
enhance health.

SOCIAL EPIDEMIOLOGY RISING

Two decades ago one could have argued that social epidemiology was a fringe subdiscipline; now it is as prominent as any other specialization within epidemiology. Many
schools of public health now offer concentrations in social epidemiology, most countries
have public health goals aimed specifically at reducing social inequalities in health, and no
fewer than three general and two methodological textbooks on social epidemiology are now
in circulation. More importantly, social epidemiology now occupies an important place in
the realm of public health policy. The World Health Organizations landmark Commission
on the Social Determinants of Health Report,2 published in 2008, attempted to bring worldwide attention to social determinants of health and to affect policy decisions in ways that
would reduce social inequalities in health. The Commissions report would not have been
possible without the pathbreaking work on health inequalities that developed in the United
Kingdom after the Black Report3 in 1980, which subsequently led to two full-scale reports
on health inequalities in the United Kingdom.4,5
Each of these reports has used evidence assembled by social epidemiologists to
advocate for policies aimed at reducing health inequalities, and yet, after the most recent
report5which found little evidence that health inequalities in England have decreased
there seems to be considerable consternation about the potential for policies to reduce
social inequalities in health. Johan Mackenbach, who has produced as much evidence on
health inequalities across the European region as anyone, seemed especially pessimistic:
The main conclusion therefore is that reducing health inequalities is currently beyond
our means. That is the sad but inevitable conclusion from the story of the English strategy to reduce health inequalities.6 Echoing these same concerns, Bambra and colleagues
From the aDepartment of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada; and bDepartment of Economics,
McGill University, Montreal, Quebec, Canada.
Supported by a Chercheur Boursier Junior 1 from the Fonds de la Recherche du QubecSant (to S.H.) and from the Fonds de la Recherche du QubecSant
and the Ministre de la Sant et des Services sociaux du Qubec (to E.S.).
Editors note: Related articles appear on pages 785, 787, and 790.
Correspondence: Sam Harper, Department of Epidemiology, Biostatistics & Occupational Health, McGill University, 1020 Pine Avenue West, Purvis Hall, Room
34, Montreal, Quebec, Canada H3A 1A2. E-mail: sam.harper@mcgill.ca.
Copyright 2012 by Lippincott Williams & Wilkins
ISSN:1044-3983/12/2306-0795
DOI:10.1097/EDE.0b013e31826d078d

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Harper and Strumpf

were dismayed by the similarity of the conclusions of each of

the English reports more than 30-odd years and questioned
the purpose of accumulating evidence from social epidemiology, given the fact that the policy conclusions never seem
to change.7 These self-critical remarks among committed
researchers are concordant with evidence from policymakers who charge social epidemiologists (and the broader social
determinants of health movement) with providing policy-free
evidence and the right answers to the wrong questions.8

CRITIQUES OF THE SOCIAL APPROACH

The gap between the questions policymakers want
answered and the kinds of questions social epidemiologists
have been answering is evident in a series of commentaries on the most recent report9 by Michael Marmot on health
inequalities in the United Kingdom. While social epidemiologists largely praised the report (some even chided the
UK committee for not being radical enough in their policy
recommendations),10 others questioned whether the report
had provided sufficient evidence to back its strong policy
recommendations.11,12 Critics accused social epidemiologists
of being casual about causality and argued that there was,
in fact, little evidence to suggest causal effects of income or
education on health (although there is better evidence for the
association between early-life conditions and health in later
life). The discrepant readings of this evidence may be a consequence of social epidemiologists generally answering descriptive questions (whether socially disadvantaged individuals
have poorer health), but interpreting their findings causally
(whether socially disadvantaged individuals would have better health if they were to become advantaged, or vice versa).
Such interpretation implies both an intervention and a causal
effect of that intervention. Social epidemiologists often present their results in counterfactual terms that imply causation:
if clerical workers had the same mortality as administrators,13
if blacks had the same mortality as whites,14 if everyone had
the same mortality rates as those with a university education,15 the reduction in disease burden would be substantial.
Furthermore, such counterfactuals often do not correspond to
any known or feasible interventions. We suggest that the epidemiologic question should be reframed and that changing the
question can make an important difference both to the answer
one gets about the impact of social conditions on health and
to ones ability to provide useful information to policymakers.
Some examples follow.

REFRAMING THE QUESTION

The UK Whitehall studies have provided numerous
analyses demonstrating positive associations between civil
service occupational grade and health, but concerns are often
raised about the potential for social gradients to arise because
of unmeasured confounding or health-related selection.
Whitehall investigators have largely attributed their results to
social causation, arguing that any social selection based on
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health is not strong enough to overwhelm the effect of social

causation.16,17 These studies typically ask the descriptive question of whether those in higher status occupations have better
health (controlling for a range of covariates), rather than the
question of whether intervening to change occupational status
would lead to improved health outcomes. Case and Paxson,18
however, use the Whitehall data to reframe the question and
ask whether changes in occupational grade affect changes in
health and, in a parallel fashion, whether changes in health
affect changes in occupational grade. Using a fixed-effects
design that controls for unmeasured time-invariant individual
characteristics, they find no evidence that civil service grade
affects health, but some evidence that health affects future
employment. They also find that future civil service grade
predicts current health, suggesting health-related selection or
unmeasured confounding. Although this identification strategy trades off a lot of precision for a reduction in bias,19 it is
probably closer to the kind of question that we would ask if
we could design a randomized trial to evaluate the effects of
occupational grade on health.
A second example comes from a randomized trial
called the Moving to Opportunity study. The backdrop here
is an abundance of observational research showing that
neighborhood characteristics such as poverty concentration
are associated with a wide range of health and social
outcomes.20 In the randomized study, nearly 5000 families
living in high-poverty urban neighborhoods in five U.S. cities
were randomly assigned one of two treatments, one of which
required relocating to a more prosperous neighborhood.
The intervention was successful in reducing exposure to
concentrated poverty, but intention-to-treat (ITT) estimates
on social and health outcomes (in the presence of substantial
non-compliance) were largely null.21 Sociologists ClampetLundquist and Massey used the same data but analyzed it
as an observational study, arguing that the ITT estimate can
measure the effects of the policy initiative, but is not well
suited to capturing neighborhood effects.22 This quote seems
to reflect some of the tension mentioned above between the
kind of evidence wanted by policymakers (causal effect
of the policy) and the kind of evidence being delivered by
social epidemiology. The investigators found evidence that
increased exposure to low poverty areas is beneficial
although by breaking the randomization they reintroduced
precisely the same kinds of selection effects that led to the
concerns cited above about being casual about causality.23
This does not mean that randomized experiments are the only
solution. Sampson and colleagues,24 for example, were able to
recover the randomization study estimates on verbal IQ by
explicitly mimicking the design of a trial in observational data
from Chicago neighborhoods.
A third example of reframing concerns the effect of
education on mortality. Countless social epidemiologic studies have followed persons with high versus low education
and found substantially increased mortality among the less
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Epidemiology Volume 23, Number 6, November 2012

educatedan association that is in most cases robust to controls for additional socioeconomic, behavioral, and biologic
factors.25 These observational studies ask whether more educated individuals have lower mortality, but generally do not
ask what policymakers want to know: what would the health
effects be of intervening to increase a persons amount of
education, or their achievement of a certain educational qualification? Most observational study designs cannot answer
this question, because it is very difficult to control for the
multitude of factors that jointly determine both education and
health.26 However, more recent studies have used changes in
schooling policies that are more plausibly independent of
unobserved individual characteristics and their health outcomes (eg, minimum age required for leaving school) to
minimize unmeasured confounding. These studies bring us
closer to answering the question of whether intervening to
increase educational achievement is likely to have effects on
mortality, and the results are decidedly more mixed.25 Several
studies provide evidence that exogenous changes in schooling resulting from policies reduce mortality,2729 but several
other studies do not, even for different analyses of the same
country.2932 The contrast between the consistency of studies
answering descriptive questions and the mixed evidence for
(more approximately) causal questions suggests that this distinction matters.
A final example comes from our own work, but again
reflects the importance of focusing on a well-specified causal
question. A recent article found that U.S. states with medical marijuana laws had higher adolescent marijuana use.33
The authors focused on two comparisons: (1) the difference
in marijuana use between states passing laws and states with
no laws and no history of such laws and (2) the difference in
marijuana use between states that had already passed laws and
states that had never passed a law. Neither of these contrasts
represent the causal question facing policymakers in a state
currently without a medical marijuana law; namely, what is
likely to happen to marijuana use among adolescents if we
legalize medical marijuana? Yet the data do permit asking
precisely this question. Using difference-in-differences estimation, we compared the change in marijuana use among
adolescents after a medical marijuana law is passed to corresponding changes over the same period in states that do not
pass a law and found little evidence of any effect.34 Although
this strategy obviously does not approach randomization to
a medical marijuana law, it provides better control for confounding by unmeasured state characteristics and overall
secular trends. More importantly, the analytic strategy follows
directly from asking a specific question about social policy.

CONCLUSIONS
The above examples illustrate that the manner in which
social epidemiology asks questions has important implications for the evidence it generates. Different questions generate different answers, even with the same data, and if the goal
2012 Lippincott Williams & Wilkins

Social Epidemiology

is to inform policy then our questions should be motivated by

identifying causal relationships that can be of the most use to
policymakers. It goes without saying that in this short essay
we have painted social epidemiology with perhaps too broad
a brushmany social epidemiologists undoubtedly produce
high-quality evidence on the impact of social exposures on
health. Yet, our concern here is that much of social epidemiology is providing questionable answers to important questions,
rather than focusing on answerable questions. Batty35 recently
lamented the lack of interest among the research community
in generating experimental or quasi-experimental evidence on
social determinants of health. To focus on answerable questions, social epidemiologists may need to sharpen their focus
on specific questions that are more narrow in scope, but for
which experimental or quasi-experimental data exist.
The major strength of experimental and quasi-experimental designs lies in their robustness to unobserved confounding. Such designs also have conceptual strengths that
come from asking specific causal questions. Trials have their
own limitations and will never answer some social epidemiologic hypotheses, but attempting to mimic the randomized
trial one would hypothetically conduct to answer an important
question would seem to be a good place to start.36,37 Finally,
we would also argue that greater transparency in methods
and reporting would increase the value of replication studies38 that can directly address the question of how sensitive
research findings in social epidemiology may be to measurement error, model selection, unmeasured confounding, and
other potential biases.39,40 Greater attention to both research
design and rigorous analysis can help social epidemiologists
answer important questions rather than continuing to generate
questionable answers.

ABOUT THE AUTHORS

Sam Harper and Erin Strumpf are Assistant Professors in
the Department of Epidemiology, Biostatistics & Occupational
Health at McGill University, where Erin Strumpf also holds
an appointment in the Department of Economics.
Sam Harper works on measuring social inequalities in
health and how they change over time. Erin Strumpf's research
in health economics focuses on measuring the causal impacts
of health and health care policies on spending and health
outcomes overall, and in inequalities across groups.
REFERENCES
1. Kaufman JS. Social epidemiology. In: Rothman KJ, Greenland S, Lash
TL, eds. Modern Epidemiology. 3rd ed. Philadelphia: Wolters Kluwer
Health/Lippincott Williams & Wilkins; 2008:533548.
2. WHO Commission on Social Determinants of Health. Closing the gap
in a generation: health equity through action on the social determinants
of health. Final Report of the Commission on the Social Determinants of
Health. Geneva, Switzerland: World Health Organization, Commission
on Social Determinants of Health; 2008.
3. Townsend P, Davidson N. Inequalities in Health: The Black Report. Harmondsworth, UK: Penguin Books; 1982.
4. Acheson D. Independent Inquiry Into Inequalities in Health Report. London: Stationery Office; 1998.

www.epidem.com | 797

Harper and Strumpf

5. Marmot M. Fair society, healthy lives: The Marmot Review. Strategic

review of health inequalities in England post-2010. 2010; Available at:
http://www.marmotreview.org/AssetLibrary/pdfs/Reports/FairSocietyHealthyLives.pdf. Accessed May 5, 2011.
6. Mackenbach JP. Has the English strategy to reduce health inequalities
failed? Soc Sci Med. 2010;71:12491253; discussion 12541248.
7. Bambra C, Smith KE, Garthwaite K, Joyce KE, Hunter DJ. A labour of
Sisyphus? Public policy and health inequalities research from the Black
and Acheson Reports to the Marmot Review. J Epidemiol Community
Health. 2011;65:399406.
8. Petticrew M, Whitehead M, Macintyre SJ, Graham H, Egan M. Evidence
for public health policy on inequalities: 1: the reality according to policymakers. J Epidemiol Community Health. 2004;58:811816.
9. Whitehead M, Popay J. Swimming upstream? Taking action on the social
determinants of health inequalities. Soc Sci Med. 2010;71:12341236;
discussion 12541238.
10. Pickett KE, Dorling D. Against the organization of misery? The Marmot
Review of health inequalities. Soc Sci Med . 2010;71:12311233; discussion 12541238.
11. Chandra A, Vogl TS. Rising up with shoe leather? A comment on Fair Society, Healthy Lives (the Marmot Review). Soc Sci Med. 2010;71:1227
1230; discussion 1254.
12. Canning D, Bowser D. Investing in health to improve the wellbeing of the
disadvantaged: reversing the argument of Fair Society, Healthy Lives (the
Marmot Review). Soc Sci Med. 2010;71:12231226: discussion 1254.
13. Marmot MG, Smith GD, Stansfeld S, et al. Health inequalities among British civil servants: the Whitehall II study. Lancet. 1991;337:13871393.
14. Satcher D, Fryer GE, McCann J, Troutman A, Woolf SH, Rust G. What if
we were equal? A comparison of the black-white mortality gap in 1960
and 2000. Health Aff. 2005;24:459464.
15. Woolf SH, Johnson RE, Phillips RL Jr, Philipsen M. Giving everyone
the health of the educated: an examination of whether social change
would save more lives than medical advances. Am J Public Health.
2007;97:679683.
16. Chandola T, Bartley M, Sacker A, Jenkinson C, Marmot M. Health selection in the Whitehall II study, UK. Soc Sci Med. 2003;56:20592072.
17. Elovainio M, Ferrie JE, Singh-Manoux A, et al. Socioeconomic differences in cardiometabolic factors: social causation or health-related selection? Evidence from the Whitehall II Cohort Study, 19912004. Am J
Epidemiol. 2011;174:779789.
18. Case A, Paxson C. The long reach of childhood health and circumstance: evidence from the Whitehall II Study. Econ J (London). 2011;121:F183F204.
19. Kaufman JS. Commentary: why are we biased against bias? Int J Epidemiol. 2008;37:624626.
20. Diez Roux AV, Mair C. Neighborhoods and health. Ann N Y Acad Sci.
2010;1186:125145.
21. Kling JR, Liebman JB, Katz LF. Experimental analysis of neighborhood
effects. Econometrica. 2007;75:83119.
22. Clampet-Lundquist S, Massey DS. Neighborhood effects on eonomic
self-sufficiency: a reconsideration of the moving to opportunity experiment. Am J Sociol. 2008;114:107143.

798 | www.epidem.com

Epidemiology Volume 23, Number 6, November 2012

23. Ludwig J, Liebman JB, Kling JR, et al. What can we learn about neighborhood effects from the moving to opportunity experiment? Am J Sociol.
2008;114:144188.
24. Sampson RJ, Sharkey P, Raudenbush SW. Durable effects of concentrated
disadvantage on verbal ability among African-American children. Proc
Natl Acad Sci USA. 2008;105:845852.
25. Kawachi I, Adler NE, Dow WH. Money, schooling, and health: Mechanisms and causal evidence. Ann N Y Acad Sci. 2010;1186:5668.
26. Cutler DM, Lleras-Muney A. Education and health: evaluating theories
and evidence. In: Schoeni RF, House JS, Kaplan GA, Pollack H, eds.
Making Americans Healthier: Social and Economic Policy as Health
Policy. New York: Russell Sage Foundation; 2008:2960.
27. Lleras-Muney A. The relationship between education and adult mortality
in the United States. Rev Econ Stat. 2005;72:189221.
28. van Kippersluis H, ODonnell O, van Doorslaer E. Long-run returns to
education does schooling lead to an extended old age? J Hum Resources.
2011;46:695721.
29. Cutler DM, Lleras-Muney A. Education and health: insights from international comparisons. National Bureau of Economic Research Working
Paper Series. 2012; No. 17738.
30. Clark D, Royer H. The effect of education on adult health and mortality:
evidence from Britain. National Bureau of Economic Research Working
Paper Series. 2010;No. 16013.
31. Albouy V, Lequien L. Does compulsory education lower mortality? J
Health Econ. 2009;28:155168.
32. Mazumder B. Does education improve health? A reexamination of the
evidence from compulsory schooling laws. Federal Reserve Bank of Chicago Economic Perspectives. 2008;Q2:216.
33. Wall MM, Poh E, Cerda M, Keyes KM, Galea S, Hasin DS. Adolescent
marijuana use from 2002 to 2008: higher in states with medical marijuana
laws, cause still unclear. Ann Epidemiol. 2011;21:714716.
34. Harper S, Strumpf EC, Kaufman JS. Do medical marijuana laws increase marijuana use? Replication study and extension. Ann Epidemiol.
2012;22:207212.
35. Batty GD. We must move on: taking stock (yet again) of the evidence for
socio-economic differentials in health. J Epidemiol Community Health.
2011;65:947948.
36. Hernn MA, Alonso A, Logan R, et al. Observational studies analyzed
like randomized experiments: an application to postmenopausal hormone therapy and coronary heart disease. Epidemiology. 2008;19:
766779.
37. Rubin DB. The design versus the analysis of observational studies for
causal effects: parallels with the design of randomized trials. Stat Med.
2007;26:2036.
38. Hernn MA, Wilcox AJ. Epidemiology, data sharing, and the challenge of
scientific replication. Epidemiology. 2009;20:167168.
39. Lash TL, Fox MP, Fink AK. Applying Quantitative Bias Analysis to Epidemiologic Data. Dordrecht, NY: Springer; 2009.
40. Vanderweele TJ, Arah OA. Bias formulas for sensitivity analysis of unmeasured confounding for general outcomes, treatments, and confounders.
Epidemiology. 2011;22:4252.

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