American Journal of Epidemiology

The Author 2013. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of
Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Vol. 178, No. 6

DOI: 10.1093/aje/kwt148
Advance Access publication:
September 5, 2013

Commentary
Six Paths for the Future of Social Epidemiology

Sandro Galea* and Bruce G. Link

* Correspondence to Dr. Sandro Galea, Department of Epidemiology, Mailman School of Public Health, Columbia University, 722 W. 168th Street,
Room 1508, New York, NY 10032-3727 (e-mail: sgalea@columbia.edu).

Initially submitted July 20, 2012; accepted for publication January 11, 2013.

Social epidemiology is now an accepted part of the academic intellectual landscape. However, in many ways,
social epidemiology also runs the risk of losing the identity that distinguished it as a field during its emergence. In
the present article, we scan the strengths of social epidemiology to imagine paths forward that will make the field
distinct and useful to the understanding of population health in future. We suggest 6 paths to such a future, each
emerging from promising research trends in the field in which social epidemiologists can, and should, lead in
coming years. Each of these paths contributes to the formation of distinct capacities that social epidemiologists
can claim and use to elaborate or fill in gaps in the already strong history of social epidemiology. They present an
opportunity for the field to build on its strengths and move forward while leading in new and critical areas in population health.
epidemiology; methods; population health; theory

Abbreviation: SES, socioeconomic status.

Editors note: Invited commentaries on this article appear

on pages 850, 852, and 858, and the authors response
appears on page 864.

This was not always the case. Forty years ago, there was
no institutionalized subdiscipline of social epidemiology in
the United States. Certainly, there were practitioners of what
we would now call social epidemiology, but they linked themselves to social medicine or medical sociology instead of
seeking to secure a recognized foothold within the discipline.
However, beginning in the 1980s, a small group started to
dene themselves as social epidemiologists (1) and to press
for recognition in departments of epidemiology, often to fairly
hostile reactions from colleagues in the discipline. One of us
was often told for many years that our department had reached
its quota on social epidemiologists because he was already
there; that is, one social epidemiologist was already enough.
A request to initiate a course in social epidemiology was denied
because we already had a course in psychiatric epidemiology
that dealt with social issues.
This started to change in the 1990s. The 1990s was a period
of high turbulence in epidemiology in general, with a series
of inuential articles that characterized what we might call
the epidemiology wars (2, 3). These papers suggested that
the purpose of epidemiology was to understand causes at all
levels, from individual exposures to societal inuences (4).

Some years ago, one of us was in conversation with a physician colleague when he was asked what he did in epidemiology. When he answered that he considered himself a social
epidemiologist, the colleague replied, But, isnt all epidemiology social?
Social epidemiology is now an accepted part of the intellectual landscape in the United States and is experiencing a
prominence it did not previously enjoy. As evidence of this
broad change, consider that all of the leading epidemiology
conferences in the United States have sections dedicated to
social epidemiology. In some of them, the number of submissions that fall under the label of social epidemiology surpasses even those old epidemiology warhorses: chronic disease
and infectious disease epidemiology. In our own large Department of Epidemiology, social epidemiology competes evenly
with chronic disease and infectious disease epidemiology for
incoming student interest.
843

Am J Epidemiol. 2013;178(6):843849

844 Galea and Link

They offered a blueprint, a raison dtre for the eld of social

epidemiology, suggesting a multilevel framework within which
to think about causation and making it acceptable for social
epidemiologists to make their central focus the study of how
social factors, such as social ties, poverty, and racial segregation, might shape the health of populations. Key theoretical
developments, such as the establishment of the concept of
fundamental causes (5, 6) and webs of causation (7) rounded
out the picture to position the eld at the end of the decade
for what would become an empiric explosion building on the
roadmap that had been charted over the preceding 30 years.
The 2000s brought the rapid introduction of multilevel modeling in the eld (8). Multilevel models were not new; they
had been used in many other social sciences for at least 2 decades, often with different names (principally random-effects
models), but they brought to epidemiology a ready methodological approach to handle thorny issues of clustering around
levels of analyses. Multilevel models offered epidemiologists a way to continue using the dominant tools in their eld
with suitable but relatively straightforward adaptation to the
emerging search for the social factors that caused population health.
This brings us to the present, when social epidemiology holds
appeal for our students, has contributed to a growing awareness of the centrality of social drivers of population health in
many health department agendas, and is a well-accepted subdisciplinary home for epidemiologists in the leading universities in the country.
However, and perhaps with some irony, as social epidemiology has achieved a position of primacy and found its place
among the epidemiologic pantheon, it has also encountered
a distinct dangerlosing the identity that distinguished it as
a eld during its emergence. Simply put, its success is making
trouble for itself, placing it in far more danger than at any
time in its relatively brief history.
To understand this threat, we go back to the question posed
by our physician colleague interlocutor. Is epidemiology not
all social?
As far back as 2004, in an editorial that accompanied the
redo of their groundbreaking 1993 article Actual Causes of
Death in the United States (9), McGinnis and Foege noted
that . . . it is also important to better capture and apply evidence about the centrality of social circumstances to health
status and outcomes. . . (10, p. 1264). Their point that social
circumstances need to be understood even when thinking of
the causes of death was well made; this point was recently
quantied in an article that showed that, using comparable
methods, the number of deaths attributable to some social
(e.g., low educational level) causes are of the same magnitude
as deaths attributable to physiologic (e.g., acute myocardial
infarction) and behavioral (e.g., poor diet) causes (11).
Therefore, to a large degree, epidemiology is indeed all
social, and it has been social epidemiologys triumph that it
has taught this to the discipline at large. It would be hard to
nd an epidemiologist today in any leading academic department who would claim that social factors are not in the
causal chain of factors that lead to the production of health.
Smoking of course causes lung cancer, but social networks
inuence smoking (12), as do advertising, social norms, and

taxation rates (1315). Obesity is not simply a matter of energy

balance. It must be understood by taking into account food
availability, the presence or absence of walkable neighborhoods, the price of vegetables, and social norms about body
size. Epidemiologists have been at the leading edge of demonstrating all these observations (16, 17), and research that
aims to understand these phenotypes (e.g., lung cancer, obesity)
must contend with the social causes as, at the very least, complicating confounders, if not outright causes of causes in
any denitive analysis.
This represents a dramatic shift in the eld and one that
well might obviate the need for social epidemiologists. What
purpose does it serve to label ourselves social epidemiologists if everyone else is also tackling social causes from their
subdisciplinary redoubts? Subdisciplinary labels in our eld
(i.e., cardiovascular epidemiology, respiratory epidemiology)
are fundamentally reinforced by the funding mechanisms at
institutions that reward just this approach (e.g., the National
Heart, Lung, and Blood Institute). What space is there for social
epidemiology as a distinct specialty if cardiovascular, infectious, and pulmonary epidemiologists are themselves studying social causes?
We see our potential redundancy as a useful challenge to
forge a stronger and deeper social epidemiology in the time
ahead. We use the dramatic change in the stature of social epidemiology in the context of the United States as a springboard
for imagining a future for social epidemiology in the time ahead.
Situated in the present, we scan the strengths of social epidemiology to imagine paths forward that will make our subdiscipline distinct and useful to the understanding of population
health. We suggest 6 paths to such a future, each emerging
from promising research trends in the eld, in which social
epidemiologists can, and should, lead in coming years.
MACRO-LEVEL DETERMINANTS OF POPULATION
HEALTH

The roots of social epidemiology lie not too far from early
efforts to understand the development of pathology in the
human body. Some of the earliest inuential articles in the
eld were concerned with how social ties were associated with
survival from cardiovascular disease (18). Subsequent evolution in the eld moved us to neighborhoods and the exponential increase during the past decade of papers that were concerned
with neighborhood characteristics (e.g., poverty, quality of
the built environment) and how they shape population health
(19). Despite some empiric work and some theoretical papers
and books that have made this case, the body of work in the
eld that has explored how truly large-scale (macro-level) forces
shape the health of populations remains disproportionately
limited.
We suggest that there are 2 central reasons for this shortcoming. First, thinking and working at a macro scale are simply
much harder than they are at a more micro level. A concern with
the inuence of urbanicity must, of necessity, involve samples
that are heterogeneous across urban contexts and involve large
samples that are collected across cities. Well-designed epidemiologic studies that tackle globalization, politics, and cultural inuences on health are even harder to enact. Second,
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Future of Social Epidemiology 845

these macro-level structures require an effort of conceptualization and measurement that typically stretches the epidemiologists toolkit (20). Epidemiologists are taught to exercise
an abundance of caution when reducing complicated macrolevel factors to dichotomous, or even scalar, variables in our
analyses. It is a caution that we laud and one of the reasons
why we are both epidemiologists. However, this means that
our understanding of these large-scale forces remains limited
and that epidemiology is simply not at the policy table, or at
best is a junior partner, when taxation or efforts to reshape the
urban environment are part of the national conversation. It also
means that although we understand that these macro-level forces
stand to effectively shift the curves of disease incidence, burden, and duration (21), we have little empiric data that can
motivate nudging these forces in a salutary direction.
We suggest therefore that social epidemiology stands to
play an enormous role in pushing the eld forward if we redened social to extend to and focus on macro-level forces that,
with few exceptions, other phenotype-oriented epidemiologists are not readily addressing. This extends to both investigating the conceptualization of which macro-level factors matter
and understanding how and why they might matter. It has
implications for both how we train our future social epidemiologists, discussed further below, and what is normative in
the eld. We may have to accept more uncertainty, more stochasticity in our observations as we move further away from
the pathophysiologic basis of disease. However, ultimately we
would be tackling issues that are paramount to the production of population health and that are unlikely to be taken up
by any other phenotype-oriented epidemiologists in the near
future. It would also give the eld the depth of expertise in
handling and tackling these issues and, eventually, a voice in
the policy discussions that are inevitably accompanying a rapidly changing world.
METHODOLOGICAL INNOVATION

Social epidemiology has presented some of the thorniest

challenges with which epidemiologists have wrestled over the
past couple of decades. The counterfactual paradigm (22, 23)
has played a central role in clarifying causal thinking in epidemiology. However, the concerns of social epidemiology are
all too often not readily handled within this paradigm. What
does it mean to enter a parallel universe wherein everything
is the same except for ones race (24)? Clearly not much claries the isolated effect of race as a cause of population
health. Similarly, directed acyclic graphs have brought much
needed clarity about causal thinking in epidemiology and
have rapidly gained acceptance in the eld (25, 26). However,
even the best-specied directed acyclic graphs do not fully
capture the scope of social epidemiologists concerns. For one,
the acyclicity of these graphs provided a challenge to many of
the concerns of the social epidemiologist. For surely as social
capital may inuence violence, doesnt violence also inuence
social capital?
This somewhat unhappy turn of events, nudging social epidemiology to the very limits of our epidemiologic armamentarium, may not have been an unalloyed negative. Rather, it
has pushed social epidemiologists to be leaders in innovation in epidemiologic methods or, at the very least, prodded
Am J Epidemiol. 2013;178(6):843849

dyed-in-the-wool methodologists to innovate so that social

epidemiologists may go about their work. We have already
noted the rapid adoption of random-effects models coincident
with our turn to questions about the role of neighborhood
effects. More recently, social epidemiologists have led the
way in pushing the eld to engage with methods, such as systems dynamics methods, that have been used to good effect
in other social and natural sciences but much less so in our
discipline (27, 28). These methods remain limited, their use
in its infancy, and we are not necessarily convinced that they
will lead to widespread transformative use. However, they
do represent a further effort in the eld to push thinking forward, to expand the accepted toolkit, and to ask what can be
done better and what we can do to achieve a stronger, more
versatile set of methodological approaches.
We suggest that social epidemiologists, of necessity and
hopefully by inclination, should lead the way in methodological innovation in the eld. What right do we have to claim
such a role? Social epidemiologys focus on long chains of
causation, operating across social, psychological, and biologic systems, induces a new lens that its practitioners must
adopt to engage the issues they wish to understand. The lens
forces a novel perspective that needs to be used to identify
new strategies for epidemiologic understanding. For example,
understanding how cultural norms inuence health behaviors,
how the 2 interact reciprocally, and how jointly they shape the
incidence of substance abuse takes us far from the 2 2 table
(29, 30). We are not sure where this will push our methods,
but with persistence, social epidemiology can lead in the
development of both the novel approaches and the methods
needed to tackle the central questions about how social circumstances shape the health of populations.
UNDERSTANDING MECHANISMS

Despite the broad acceptance of the roles of causes at multiple levels of inuence in epidemiology, increasing disciplinary subspecialization has led to the separation of epidemiologists
into camps framed by these same levels of inuence, perhaps
with social epidemiologists and molecular epidemiologists
at the 2 poles. Although this may be due in part to the increasing
specialization required of both species of epidemiologist, it has
led social epidemiology further away from a concern with the
mechanisms that underlie the link between social circumstances and the production of health.
In some of our earlier writing, we suggested that risk-factor
mechanisms could not account for health disparities by socioeconomic status (SES) because SES dynamically shapes
exposure to new risk and protective factors over time, recreating the SEShealth association in different places and at
different times (5). Focusing only on risk factor mechanisms
and assuming that they would account for SES-related disparities served to distract us from a core focus on the foundational determinants of population health, the determinants
that if manipulated can stand to shift the disease curve meaningfully for whole populations. That concern remains, but the
discipline has changed. Many epidemiologists have now come
to this view and have seen the need to incorporate social factors
in any full assessment of disease risk (4, 31, 32). Therefore, we
are today at a better point in the history of the eld, one that

846 Galea and Link

can embrace both the study of macro-level conditions and the

study of why and how these forces may matter.
We suggest that although social epidemiologists need to
keep their gaze xed on the social, they simultaneously have
an enormous amount to gain from exploring biologic mechanisms more deeply. This has substantial implications for how
we conceive of the eld and its practitioners. Although over
the past few years there has been some exciting work published
that jointly considers how social inuences work together with
genetic and molecular processes, this work is sparse (33, 34).
Far more dominant is social epidemiologic work that constrains itself outside the skin, with an interest in social processes without much concern with why these processes may
matter. Of the many reasons that social epidemiology might
benet from closer attention to mechanisms, we discuss 4.
First, whatever we presume the root causes to be, in the
end, all disease is biologic; any full accounting must be cognizant of this fact. As a result, any brand of epidemiology (but
especially social epidemiology) needs to carry the implications of the factors it studies to the pathophysiologic processes
that must be traversed for disease to occur. The more adept
we are at showing how social factors inuence biologic processes, the stronger is our case for the health relevance of the
factors we study. Second, as social epidemiology has matured,
so has the range of proposed explanations, that is, the proposed social drivers of disease outcomes. As one might reasonably expect, some of these explanations have collided to
form explanations that compete for primacy in accounting
for particular disease patterns. In many instances, these have
taken the form of classic social selection versus social causation explanations (e.g., neighborhood, SES) (35, 36). Although
many approaches are needed to resolve these debates, attending to mechanisms can provide useful information because the
different explanations frequently imply different mechanisms.
It follows that we can gather evidence about the plausibility of
competing explanations by determining whether the mechanisms each implies are in fact found to exist upon empiric
inquiry. Simply put, attending to mechanisms can help social
epidemiologists sort out which of their plausible social determinants are the most compelling ones. Third, once a mechanistic pathway is discovered, the social, cultural, political,
and economic context shapes the consequences of that discovery. Smoking is an obvious example. This signature epidemiologic discovery has had and continues to have an impact
on population health through a powerful morass of social,
cultural, economic, and political factors. More recently, discoveries concerning infectious disease led to the human papilloma virus vaccine that holds the possibility to powerfully
shape cancer outcomes in the decades ahead. However, its
impact on population health will be shaped by diffusion dynamics
that are strongly inuenced by culture, religion, and politics.
Mechanisms, once discovered, become social, and social epidemiologists should closely attend to them for this reason as
well. Fourth and nally, social epidemiology is in a unique
position to push the population health sciences forward at
the intersection of factors that matter inside and outside the
skin. Doing so would represent perhaps the most radical of
the prescriptions we suggest here for the eld, but it might
also represent the most promising direction, positioning
social epidemiology at the heart of the larger epidemiologic

concern with understanding how causes at multiple levels of

inuence jointly shape health and disease.
SOCIAL INTERVENTIONS

We shall not here retell the now well-worn arguments in

epidemiology about the challenges of drawing inference from
observational studies and about the potential role that interventional research plays in clarifying causal chains (3739).
That story has been written well elsewhere. Taken to the extreme,
this suggests that only experimental approaches can illuminate
our understanding of causes (4042).
We nd this approach unhelpful and think it is wrong.
However, there is little question that there is much that we can
learn from studying interventions and in particular social experiments, many of which will, of necessity, be natural experiments.
Social epidemiologists, particularly social epidemiologists concerned with large-scale social inuences and circumstances, have little opportunity to experimentally manipulate
the conditions in which they are interested. It seems unlikely
that any social epidemiologist will be in a position to experimentally manipulate progressive taxation levels in different
jurisdictions to understand whether the resultant narrowing
in income inequality will also be associated with improved
population health. It is not, however, unlikely that such an opportunity will present itself as a natural experiment, one that can
well be studied to good effect. There are indeed some very
elegant examples in the existing literature that have done just
this: capitalized on natural experiments to understand how manipulating social circumstances does or does not shape the health
of populations. Social epidemiologists will be interested in
these natural experiments to the extent that they reveal whether
and to what extent social factors matter for health outcomes.
At the same time, social epidemiologists can occasionally be
more broadly useful to the discipline because identifying and
studying the consequences of such social experiments can
sometimes provide critically important information for other
areas of epidemiology. For example, the Nazi blockage created
the Dutch famine that led to discoveries relevant to the associations between neural tube defects and schizophrenia (43).
These examples readily convince us that this approach is promising and fruitful. What is perhaps surprising is how few such
illustrations we can identify in the literature.
Social structures change all the time. New laws and regulations are introduced with regularity. Urban renewal efforts
are put in place. Cultural norms shift. These changes lend
themselves to careful, systematic data gathering that can add
insights not otherwise available through observational studies
alone. Linking to some of the areas discussed here, the study
of natural experiments embeds its own conceptual and methodological challenges, further suggesting the inevitability of
the social epidemiologists engagement in these areas.
THE CENTRAL ROLE OF INTERGROUP DIFFERENCES
AND INEQUALITY

The roots of social epidemiology a quarter century ago

were indelibly shaped by a concern over black/white differences in some fundamental health outcomes in the United
States (44). That many of these differences remain as they
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Future of Social Epidemiology 847

were decades later well argues for the continued importance

of health inequalities as a core motivation in the eld. We
argue that it is therefore the natural mtier of social epidemiologists to maintain an abiding interest in intergroup differences in health, or as they are also called, health inequalities
or health disparities. We have little hope that these differences
will vanish any time soon. With some luck and concerted
effort, we may narrow racial differences in health. However,
evidence suggests that socioeconomic differences are, if anything, growing (4547), not to mention international differences in health indicators (48, 49) that are appalling. This
provides sufcient motivation for several lifetimes of work
but can also be clarifying for social epidemiology as a foundational commitment to improving the underlying conditions
that inuence health so as to narrow differences between
groups.
We realize that articulating a values-based commitment to
intergroup equality in health for a scientic discipline may
raise eyebrows. We suggest that what we are proposing is not
particularly different than what is de facto the case in much
of science already, but which is not as explicitly stated. Our
questions are not unbiased. Much as we may like to think that
we are asking questions that are informed only by prior dispassionate knowledge, our preconceptions inevitably frame
our questions and, less felicitously, our answers. It is true that
social epidemiology has always been more susceptible to
this than have other areas in epidemiology. Many people are
drawn to social epidemiology out of a concern for the social,
a desire to understand and improve social conditions that may
inuence health. Few of us are neutral about social conditions
in our nonprofessional lifves. Our values around the importance of a market-orientation to our economy determine for
whom we vote. To some degree, this sets social epidemiologists apart from, for example, occupational epidemiologists.
Our sentiments about ceramics are likely less a part of our
civilian engagement than are our sentiments about income
inequality. This indeed raises the bar for social epidemiologists engagement with our data, to force us to apply a gimlet eye
to our work and that of our colleagues and to make sure, above all,
that we interpret data clearly, minimizing bias and providing
reliable and valid inference that can usefully inform intervention. Indeed, this is the only approach that can help us achieve
what might have drawn us to social epidemiologywe will
do little to advance any values we hold if we get our science
wrong.
However, recognizing that social conditions may engage
the epidemiologist does not suggest that social epidemiologists need to shed their concern about the very social conditions that motivated us in the beginning. Rather, we suggest
that such efforts are futile and that social epidemiologists
would do better to recognize our driving inuences in this
area and elevate them, as appropriate, to a motivating concern
that shapes our work.
THEORY AND THE HEALTH OF POPULATIONS

Epidemiology has long ourished as a black-box discipline. We have applied our methods, with notable success,
to isolate factors that co-vary with disease and aimed to intervene on these factors without a good grasp on why they might
Am J Epidemiol. 2013;178(6):843849

matter. The isolation of folic acid as a determinant of neural

tube defects is a well-recognized case in point (5052). It can
be argued, however, that these cases are not normative. Rather,
particularly as we expand the scope of epidemiology to take
into account a broad range of factors, a black-box approach
may lead us to the isolation of spurious associations or to a
chase for associations where there are none.
As we see it, the only alternative to this conundrum is a
deeper engagement for the eld in theory, a richer grounding
in an understanding of why particular factors may matter,
and the condence to articulate a priori hypotheses about
what social conditions might matter, leading to testing through
observational or experimental studies. This will require not only
a deeper grounding in theory borrowed from other disciplines
but also development of a theory of the production of population health that stands on its own. With a few notable exceptions, epidemiology remains quite poor in this regard.
We see this as both a critical area for the development of
the eld and a central opportunity for social epidemiology to
help population health science transcend some of the individualistic thinking inherited from the medical sciences that
at times holds back epidemiology as a whole. Population health
science needs to be rooted in an understanding of the drivers
of the health of populations. These drivers, the factors that
shift the curve of disease incidence, severity, and duration are
by denition outside the curve, exerting their inuence on
whole populations rather than on individuals. Similarly, our
methods in the eld are population-based methods, having
little utility for individual diagnosis and prediction. However,
conation of population-based and individual-based inference is commonplace in biomedical research. We argue that
a clearer articulation of the concepts that underlie social epidemiology and how that shapes our questions and our inference can further help clarify our concern with populations
and with the social drivers thereof.
IMPLICATIONS FOR THE NEXT GENERATION OF
SOCIAL EPIDEMIOLOGISTS

Our prescriptions for the eld represent a tall order, one

that is too tall, in fact, for any one social epidemiologist to
embrace. Perhaps it is a sign of the maturity of the subdiscipline that it can move forward in so many directions, well
beyond the scope of any one persons research. The approach
proposed here does have clear implications for both how we
practice the eld today and, perhaps more importantly, for
how we train the next generation of social epidemiologists.
Aspiring to be forward-looking, we suggest 3 particular
areas that bear careful consideration in the education of the
next generation of social epidemiologists. First, we must train
social epidemiologists to be comfortable across levels of inuence. This does not mean that all social epidemiologists could
or should move comfortably between studies of the role of
the urban environment in shaping health and studies about
how exogenous stressors induce epigenetic changes that can
modify gene expression and hence physiologic processes.
However, we suggest that all future social epidemiologists
need to at least understand both the social conditions that are
foundational and the causal links that result in the embodiment of health. So doing will lead us to ask better questions

848 Galea and Link

and focus on plausible answers. It also represents an opportunity to bring a measure of synthesis to the broader discipline
of epidemiology that currently is pursuing all these strands,
often resulting in diverging and poorly cohering patterns.
Second, we need a generation of social epidemiologists
that is comfortable with and can push the limits of our disciplinary methods. This does not necessarily mean that social
epidemiologists will or should become epidemiologic methodologists. However, it does mean that we need a generation
that is not content with the constraints of our current methods
and that is comfortable working with peers in biostatistics,
mathematics, and computer science to nd or develop better
tools. We might suggest that this should be a feature of all
future epidemiologists. Perhaps, but, relevant to this essay, it
suggests that social epidemiologists need to be trained not
simply to adapt methods but to critically understand and challenge methods. That is indeed a different orientation than our
current training in the eld, and it suggests a training that
is in informed by propulsive questioning and that encourages
emerging scholars not to settle for our current methods but
rather to seek their own.
Third, it is incumbent upon us to embed the training of
social epidemiologists in a deeper appreciation of theory (and
inevitably history of that theory) than we currently do. Because
the eld has emerged rapidly over the past 2 decades, much
social epidemiology is informed by theory, but that theory is
at best grafted onto the eld from other disciplines, sometimes
tting poorly. We aspire to a generation of social epidemiologists that asks why we are asking the questions we ask, to the
end of asking very different questions and identifying better
answers than the ones we have produced thus far.

CONCLUSION

We return to the question framed by our physician colleague.

If epidemiology is all social, or perhaps more accurately, if
all epidemiologists are concerned with social circumstances
as at least part of the causal chain, how then does a social epidemiologist distinguish herself?
We suggest here that we do so through clarity of focus on
understanding the macro-level factors that matter, how they
affect biologic processes with the body, and the methods that
help us articulate these answers. We think that well distinguishes social epidemiologists from other epidemiologists
who are, correctly for their subdiscipline, concerned centrally with the interface between exposure and pathogenesis,
focusing on specic disease processes. Although there are 6
paths identied, they all have much in common. Each of these
paths contributes to the formation of distinct capacities that
social epidemiologists can claim and use to elaborate or ll
in the gaps in the already strong history of social epidemiology. They present then an opportunity for the eld to build
on its strengths and move forward while leading in new, critical areas in population health.
There is a danger in our prescriptions: In attempting to do
all of this, social epidemiologists run the risk of dabbling,
developing a limited understanding of social circumstances,
biologic processes, theory, and methods. A vigilant eld can
avoid this pitfall. We can give our emerging scholars the

foundations they need to then pursue any of the 6 paths we

outline here. We suggest that doing so will lead to a generation of scholars and scholarship that can move social epidemiology in exciting and fruitful new directions.

ACKNOWLEDGMENTS

Author afliation: Department of Epidemiology, Mailman

School of Public Health, Columbia University, New York,
New York (Sandro Galea, Bruce G. Link).
Dr. Galea is funded in part by National Institutes of Health
grants MH 095718, MH 082729, MH 082598, and
DA034244 and Department of Defense grant W81XWH-071-0409. Dr. Link is funded in part by National Institutes of
Health grant HD 058515 and Robert Wood Johnson Foundation grants RWJF 67952, RWJF 69247, and RWJF 70281.
We thank Laura Sampson for her research assistance on
the preparation of this manuscript.
Conict of interest: none declared.

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