Population Health: Challenges for Science and Society
David Mechanic, Institute for Health, Health Care Policy and Aging Research,
The Milbank Quarterly - Volume 85 Issue 3 - Page 533-559, September 2007
PDF file [27p.] at: http://www.blackwell-synergy.com/doi/pdf/10.1111/j.1468-0009.2007.00498.x
“…….The emphasis on risk factor intervention at the individual level has predominated in efforts to reduce mortality and promote health. Interest in social and other nonmedical interventions, particularly socioeconomic status (SES) influences, has increased in recent years.
This article focuses on the interaction of social structure and socioeconomic status with other influences in complex pathways to affect health, and their contribution to health disparities. It examines both social class as an explanation of health differences and competing hypotheses concerning prenatal and early nutrition and cognitive capacity.
Although education is associated with income, wealth, occupation, and other SES indicators and may not be the most important SES determinant, it influences a variety of pathways to health outcomes and offers strategic leverage for intervention because of social and political consensus on its value beyond health….”
Annual Matilda White Riley NIH Lecture in the Behavioral and Social Sciences
2006 National Institutes of Health
Available as .Doc file: http://obssr.od.nih.gov/NR/rdonlyres/0ACBBE62-4B36-4004-8399-9DC56F274FC7/0/Mechanic2006.doc
“….I begin by discussing the importance of social selection, and then illustrate how varying influences from early nutrition to broad social factors affect population health and social disparities. I conclude with some thoughts on intervention strategies.
Studies of population health depend substantially on epidemiological inquiries of different cohorts under varying social and environmental circumstances and careful theory and hypotheses are essential.
In this era of computer power and data mining, there is much descriptive epidemiology that is atheoretical, and often lacks even biological and psychosocial plausibility. Such work has rightfully earned a compromised reputation. Alvan Feinstein has noted that such efforts are unable to distinguish truth from false alarms and contribute to an epidemic of apprehension. Underlying many false results is failure to deal realistically with the influence of social selection.
In population health research, where randomized controlled trials are usually impossible, impractical or unethical, we depend on longitudinal studies using multivariate statistical designs, instrumental variables as commonly used in economics, or on natural experiments when such opportunities become available. Taking account of selection biases is imperative but it is important as well to understand how selection processes shape health outcomes…..”
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