—from Epidemiological Bulletin, Vol. 23 No. 2, June 2002—
A Glossary for Social Epidemiology
Nancy Krieger, PhD
Harvard University School of Public Health
Boston, Massachussets, United States
Part II
Race/ethnicity and racism
Race/ethnicity is a social, not biological, category, referring to
social groups, often sharing cultural heritage and ancestry, that are forged
by oppressive systems of race relations, justified by ideology, in which one
group benefits from dominating other groups, and defines itself and others through
this domination and the possession of selective and arbitrary physical characteristics
(for example, skin colour).(6, 13) Racism refers to institutional and individual
practices that create and reinforce oppressive systems of race relations (see
“discrimination”, above).(6, 15, 41) Ethnicity, a construct originally
intended to discriminate between “innately” different groups allegedly belonging
to the same overall “race”,(42, 43) is now held by some to refer to groups allegedly
distinguishable on the basis of “culture”(44); in practice, however, “ethnicity”
cannot meaningfully be disentangled from “race” in societies with inequitable
race relations, hence the construct “race/ethnicity”.(6, 42)
Two diametrically opposed constructs are thus relevant to understanding research
on and explaining racial/ethnic disparities in health.(6, 45) The first is:
racialised expressions of biology, whereby measured average biological
differences between members of diverse racial/ethnic groups are assumed to reflect
innate, genetically determined differences (premised, in the first instance,
on the arbitrary phenotypic characteristics seized upon to define, tautologically,
racial categories). The second is: biological expressions of racism (see
“biological expressions of social inequality”, above). For example, following
dominant ideas construing “race” as an innate biological characteristic, epidemiological
research has been rife with studies attempting to explain racial/ethnic disparities
in health in relation to presumed genetic differences, absent consideration
of effects of racism on health.(6, 45–46, 47) Alternatively, considering lived
experiences of racism as real but the construct of biological “race” as spurious,
social epidemiological research investigates health consequences of economic
and non-economic expressions of racial discrimination.(6, 13, 45–48)
Sexualities and heterosexism
Sexuality refers to culture bound conventions, roles, and behaviours
involving expressions of sexual desire, power, and diverse emotions, mediated
by gender and other aspects of social position (for example, class, race/ethnicity,
etc).(49) Distinct components of sexuality include: sexual identity, sexual
behaviour, and sexual desire. Contemporary “Western” categories by which people
self identify or can be labelled include: heterosexual, homosexual, lesbian,
gay, bisexual, “queer”, transgendered, transsexual, and asexual. Heterosexism,
the type of discrimination related to sexuality, constitutes one form of abrogation
of sexual rights(50) and refers to institutional and interpersonal practices
whereby heterosexuals accrue privileges (for example, legal right to marry and
to have sexual partners of the “other” sex) and discriminate against people
who have or desire same sex sexual partners, and justify these practices via
ideologies of innate superiority, difference, or deviance. Lived experiences
of sexuality accordingly can affect health by pathways involving not only sexual
contact (for example, spread of sexually transmitted disease) but also discrimination
and material conditions of family and household life.(49, 50)
Society, social, societal, and culture
Society, originally meaning “companionship or fellowship”, now stands
as “our most general term for the body of institutions and relationships within
which a relatively large group of people live and as our most abstract term
for the condition in which such institutions and relationships are formed”.(51)
Social, as an adjective, likewise has complex meanings: “as a descriptive
term for society in its now predominant sense of the system of common
life”, and also as “an emphatic and distinguishing term, explicitly contrasted
with individual and especially individualist theories of society”
[italics in the original].51 Societal, in turn, serves as a “more neutral reference
to general social formations and institutions”.(51)
By this logic, social epidemiology and its social theories of disease
distribution stand in contrast to individualistic epidemiology, which
relies on individualistic theories of disease causation (see “theories of disease
distribution”, below).
Culture, originally a “noun of process” referring to “the tending of
something, basically crops or animals,”(51) presently has three distinct meanings:
“(i) the independent and abstract noun which describes a general process of
intellectual, spiritual, and aesthetic development . . .; (ii) the independent
noun, whether used generally or specifically, which indicates a particular way
of life, whether of a people, a period, a group, or humanity in general; and
. . . (iii) the independent and abstract noun which describes the work and practices
of intellectual and especially artistic activity”.(51) In social epidemiology,
meaning (ii) predominates, with “culture” typically conceptualised and operationalised
in relation to health related beliefs and practices, especially dietary practices.
By this logic, “acculturation” (or, perhaps more accurately “deculturation”
(45)) refers to members of one “culture” adopting beliefs and practices of another
(and typically dominant) “culture”.(52, 53) Related, examples abound (44, 53)
in epidemiological literature whereby the construct of “culture” is conflated
with “ethnicity” (and “race”) and together are inappropriately invoked to explain
socioeconomic and health characteristics of diverse population groups on the
basis of “innate” qualities, rather than as a consequence of inequitable social
relationships between groups.(52)
Social class and socioeconomic position
Social class refers to social groups arising from interdependent
economic relationships among people.(51, 54–56) These relationships are determined
by a society’s forms of property, ownership, and labour, and their connections
through production, distribution, and consumption of goods, services, and information.
Social class is thus premised upon people’s structural location within the economy—as
employers, employees, self employed, and unemployed (in both the formal and
informal sector), and as owners, or not, of capital, land, or other forms of
economic investments. Stated simply, classes—like the working class, business
owners, and their managerial class—exist in relationship to and co-define each
other. One cannot, for example, be an employee if one does not have an employer
and this distinction—between employee and employer—is not about whether one
has more or less of a particular attribute, but concerns one’s relationship
to work and to others through a society’s economic structure.
Class, as such, is not an a priori property of individual human beings, but
is a social relationship created by societies. As such, social class is logically
and materially prior to its expression in distributions of occupations, income,
wealth, education, and social status. One additional and central component of
class relations entails an asymmetry of economic exploitation, whereby owners
of resources (for example, capital) gain economically from the labour or effort
of non-owners who work for them.
Socioeconomic position, in turn, is an aggregate concept that includes
both resource-based and prestige-based measures, as linked to both childhood
and adult social class position.(54-56) Resource-based measures refer to material
and social resources and assets, including income, wealth, and educational credentials;
terms used to describe inadequate resources include “poverty” and “deprivation”
(see “poverty”, above). Prestige-based measures refer to individuals’ rank or
status in a social hierarchy, typically evaluated with reference to people’s
access to and consumption of goods, services, and knowledge, as linked to their
occupational prestige, income, and educational level. Given distinctions between
resource-based and prestige-based aspects of socioeconomic position and the
diverse pathways by which they affect health, epidemiological studies should
state clearly how measures of socioeconomic position are conceptualised. The
term socioeconomic status” should be eschewed because it arbitrarily (if not
intentionally) privileges “status”—over material resources—as the key determinant
of socioeconomic position.(54)
Social determinants of health
Social determinants of health refer to both specific features of
and pathways by which societal conditions affect health and that potentially
can be altered by informed action. (4, 24, 57) As determinants, these social
processes and conditions are conceptualised as “essential factors” that “set
certain limits or exert pressures”, albeit without necessarily being “deterministic”
in the sense of “fatalistic determinism”.(51) Historically contingent, social
determinants of health, broadly writ, include:
(a) a society’s past and present economic, political, and legal systems, its
material and technological resources, and its adherence to norms and practices
consistent with international human rights norms and standards; and
(b) its external political and economic relationships to other countries, as
implemented through interactions among governments, international political
and economic organisations (for example, United Nations, World Bank, International
Monetary Fund), and non-governmental organisations.
One term appearing in social epidemiological literature to summarise social
determinants of health is “social environment”.(4, 7, 57) This metaphor invokes
notions of “environment”, a term literally referring to “surroundings” and initially
used to denote the physical, including both “natural” and “built”, environment.
Both “social environment” and the related metaphor “social ecology” are problematic
in that they can conceal the role of human agency in creating social conditions
that constitute social determinants of health.(1)
Social inequality or inequity in health and social equity in health
Social inequalities (or inequities) in health refer to health disparities,
within and between countries, that are judged to be unfair, unjust, avoidable,
and unnecessary (meaning: are neither inevitable nor unremediable) and that
systematically burden populations rendered vulnerable by underlying social structures
and political, economic, and legal institutions.(21, 58, 59) As such, social
inequalities (or inequities) in health are not synonymous with “health inequalities”,
as this latter term can be interpreted to refer to any difference and not specifically
to unjust disparities.(58, 59) For example, recently proposed measures of “health
inequalities” deliberately quantify distributions of health in populations without
reference to either social groups and or social inequalities in health.(59–62)
Social equity in health, in turn, refers to an absence of unjust health
disparities between social groups, within and between countries.(58) Promoting
equity and diminishing inequity requires not only a “process of continual equalization”
but also a “process of abolishing or diminishing privileges”.(51) Thus, pursuing
social equity in health entails reducing excess burden of ill health among groups
most harmed by social inequities in health, thereby minimising social inequalities
in health and improving average levels of health overall.(21)
Social production of disease/political economy of health
Social production of disease/political economy of health refers to
related (if not identical) theoretical frameworks that explicitly address economic
and political determinants of health and distributions of disease within and
across societies, including structural barriers to people living healthy lives.(1,
63–66) These theories accordingly focus on economic and political institutions
and decisions that create, enforce, and perpetuate economic and social privilege
and inequality, which they conceptualise as root—or “fundamental”(67)—causes
of social inequalities in health. Although compatible with the ecosocial theory
of disease distribution, they differ in that they do not systematically seek
to integrate biological constructs into explanations of social patternings of
health.(1, 2)
Social production of scientific knowledge
Social production of scientific knowledge refers to ways in which
social institutions and beliefs affect recruitment, training, practice, and
funding of scientists, thereby shaping what questions we, as scientists, do
and do not ask, the studies we do and do not conduct, and the ways in which
we analyse and interpret data, consider their likely flaws, and disseminate
results.(68–71)
That scientists’ ideas are shaped, in part, by dominant social beliefs of their
times is well documented.(3, 72–74) Relevant to social epidemiology, a substantial
body of literature demonstrates how scientific knowledge and, more importantly,
real people, have been harmed by scientific racism, sexism and other related
ideologies, including eugenics, which justify discrimination and discount the
importance of understanding and ameliorating social inequalities in health.(6)
Tellingly, as of the year 2000, only 0.05% of the approximately 34 000 articles
indexed in Medline by the keyword “race” had explicitly investigated racial
discrimination as a determinant of population health.(6)
Stress
Stress, a term widely used in the biological, physical, and social
sciences, is a construct whose meaning in health research is variously defined
in relationship to “stressful events, responses, and individual appraisals of
situations”.(75) Common to these definitions is “an interest in the process
in which environmental demands tax or exceed the adaptive capacity of an
organism, resulting in psychological or biological changes that may place persons
at risk for disease” [italics in original].75 An “environmental stress perspective”
focuses on “environmental demands, stressors, or events”(75); a “psychological
stress perspective”, on “an organism’s perception and evaluation of the
potential harm posed by objective environmental exposures”(75); a “biological
stress perspective”, on “activation of the physiological systems that are particularly
responsive to physical and psychological demands”.(75) Whether social epidemiological
research conceptualises stress in relation to structural, interpersonal, cognitive,
or biological parameters, and whether it uses “environment” as a term or metaphor
that reveals or conceals the role of human agency and accountability in determining
distributions of “stress”, depends on the underlying theories of disease distribution
guiding the research (see “theories of disease distribution”, below, and “social
determinants”, above).
Theories of disease distribution
Theories of disease distribution seek to explain current and changing
population patterns of disease across time and space and, in the case of social
epidemiology, across social groups (within and across countries, over time).(1)
Using—like any theory(51, 71)—interrelated sets of ideas whose lausibility can
be tested by human action and thought, theories of disease distribution presume
but cannot be reduced to mechanism oriented theories of disease causation.(1)
Explicit attention to aetiological theory is essential, because shared observations
of social disparities in health do not necessarily translate to common understandings
of causes.(1) Excess risk of HIV/AIDS among poor women of colour, for example,
is attributed to social inequity by ecosocial and social production of disease
theories of disease distribution, but is attributed to “bad behaviours” by biomedical
lifestyle theories of disease causation.(1, 76)
References:
(1) Krieger N. Emerging theories for social epidemiology in the 21st century:
an ecosocial perspective. Int J Epidemiol (in press).
(2) Krieger N. Epidemiology and the web of causation: has anyone seen the spider?
Soc Sci Med 1994;39:887–903.
(3) Krieger N. Epidemiology and social sciences: towards a critical reengagement
in the 21st century. Epidemiol Rev 2000;11:155–63.
(4) Berkman L, Kawachi I, eds. Social epidemiology. Oxford: Oxford University
Press, 2000.
(5) Yankauer A. The relationship of fetal and infant mortality to residential
segregation: an inquiry into social epidemiology. Am Sociol Review 1950;15:644–8.
(6) Krieger N. Discrimination and health. In: Berkman L, Kawachi I, eds. Social
epidemiology.Oxford:Oxford University Press, 2000:36–75.
(7) Sydenstricker E. Health and environment. New York: McGraw-Hill, 1933.
(8) Morris JN. Uses of epidemiology. Edinburgh: Livingston, 1957.
(9) Jary D, Jary J, eds. Collins dictionary of sociology. 2nd ed. Glasgow, UK:
HarperCollins Publishers, 1995.
(10) Marshall G, ed. The concise Oxford dictionary of sociology. Oxford: Oxford
University Press, 1994.
(11) Susser M, Susser E. Choosing a future for epidemiology: II. from black
boxes to Chinese boxes and eco-epidemiology. Am J Public Health 1996;86:674–7.
(12) McMichael AJ. Prisoners of the proximate: loosening the constraints on
epidemiology in an age of change. Am J Epidemiol 1999;149:887–97.
(13) Krieger N, Rowley DL, Herman AA, et al. Racism, sexism, and social class:
implications for studies of health, disease, and well-being. Am J Prev Med 1993;9
(suppl):82–122.
(14) Fausto-Sterling A. Sexing the body: gender politics and the construction
of sexuality. New York: Basic Books, 2000.
(15) Essed P. Diversity: gender, color, and culture. Amherst, MA: University
of Massachusetts, 1996.
(16) Ruiz MT, Verbrugge LM. A two way view of gender bias in medicine. J Epidemiol
Community Health 1997;51:106–9.
(17) Kravdal O. Is the relationship between childbearing and cancer incidence
due to biology or lifestyle? Examples of the importance of using data on men.
Int J Epidemiol 1995; 4:477–84.
(18) United Nations. Universal declaration of human rights. GA Res 217A(III),
UN GAOR, Res 71, UN Doc A/810, 1948.
(19) Gruskin S, Tarantola D. Health and human rights. In: Detels R, McEwen J,
Beaglehole R, et al, eds. The Oxford textbook of public health. 4th ed. New
York: Oxford University Press (in press).
(20) Mann JM, Gruskin S, Grodin MA, et al, eds. Health and human rights. New
York: Routledge, 1999.
(21) UNDP 2000: United Nations Development Programme (UNDP). Human development
report 2000:Human rights and human development. New York: Oxford University
Press, 2000.
(22) Boucher D, Kelly P, ed. Social justice: from Hume to Walzer. London: Routledge,
1998.
(23) Krieger N, Birn A-E. A vision of social justice as the foundation of public
health: commemorating 150 years of the Spirit of 1848. Am J Public Health 1998;88:1603–6.
(24) People’s Health Assembly 2000. People’s charter for health. Gonoshasthaya
Kendra, Savar, Bangladesh December 4–8, 2000. At: http://www.pha2000.org [last
accessed: 11 Feb 2001].
(25) Kuh D, Ben Shlomo Y, eds. A lifecourse approach to chronic disease epidemiology.Oxford:Oxford
University Press, 1997.
(26) Davey Smith G, Gunnell D, Ben-Shlomo Y. Life-course approaches to socio-economic
diVerentials in causespecific adult mortality. In: Leon D, Walt G, eds. Poverty,
inequality, and health: an international perspective. Oxford: Oxford University
Press, 2001:88–124.
(27) Barker DJP. Mothers, babies, and health in later life. 2nd ed. Edinburgh:
Churchill Livingston, 1998.
(28) Blalock HM Jr. Contextual-eVects models: theoretic and methodologic issues.
Annu Review Sociol 1984;10:353–72.
(29) Bryk AS, Raudenbush SW. Hierarchical linear models: applications and data
analysis methods. Newbury Park, CA: Sage, 1992.
(30) Diez-Roux AV. Bringing context back into epidemiology: variables and fallacies
in multilevel analysis. Am J Public Health 1998;88:216–22.
(31) Macintyre S, Ellaway A. Ecological approaches: rediscovering the role of
the physical and social environment. In: Berkman L, Kawachi I, eds. Social epidemiology.
Oxford: Oxford University Press, 2000:332–48.
(32) Spicker P. Definitions of poverty: eleven clusters of meaning. In: Gordon
D, Spicker P, eds. The international glossary on poverty. London: Zed Books,
1999:150–62.
(33) Gordon D, Spicker P, eds. The international glossary on poverty. London:
Zed Books, 1999.
(34) Townsend P. The international analysis of poverty. New York: Harvester/Wheatsheaf,
1993.
(35) Shaw M, Dorling D, Davey Smith G. Poverty, social exclusion, and minorities.
In: Marmot M, Wilkinson RG, eds. Social determinants of health. Oxford: Oxford
University Press, 1999:211–39.
(36) Elstad JI. The psycho-social perspective on social inequalities in health.
In: Bartley M, Blane D, Davey Smith G, eds. The sociology of health inequalities.
Oxford: Blackwell, 1998: 39–58.
(37) Kawachi I, Berkman L. Social cohesion, social capital, and health. In:
Berkman L, Kawachi I, eds. Social epidemiology. Oxford: Oxford University Press,
2000:174–90.
(38) Wilkinson RG. Unhealthy societies: the aZictions of inequality. London:
Routledge, 1996.
(39) Lynch JW, Davey Smith G, Kaplan GA, House JS. Income inequality and mortality:
importance to health of individual incomes, psychological environment, or material
conditions. BM J 2000;320:1200–4.
(40) Kunitz SJ. Accounts of social capital: the mixed health effects of personal
communities and voluntary groups. In: Leon D, Walt G, eds. Poverty, inequality,
and health: an international perspective. Oxford: Oxford University Press, 2001:159–74.
(41) Essed P. Understanding everyday racism: an interdisciplinary theory. London:
Sage, 1992.
(42) Statistics Canada and US Bureau of the Census. Challenges of measuring
in an ethnic world: Science, politics, and reality. Washington, DC: US Government
Printing OYce, 1993.
(43) Hobsbawm EJ. Nations and nationalism since 1780: programme, myth, reality.
2nd ed. Cambridge: Cambridge University Press, 1992.
(44) Haynes MA, Smedley BD, eds. The unequal burden of cancer: an assessment
of NIH research and programs for ethnic minorities and the medically underserved.
Washington, DC: National Academy Press, 1999.
(45) Krieger N. Refiguring “race”: epidemiology, racialized biology, and biological
expressions of race relations. Int J Health Services 2000;30:211–16.
(46) Williams DR. Race, socioeconomic status, and health. The added effects
of racism and discrimination. Ann NY Acad Sci 1999;896:173–88.
(47) Lillie-Blanton M, LaVeist T. Race/ethnicity, the social environment, and
health. Soc Sci Med 1996;43:83–92.
(48) Davey Smith G. Learning to live with complexity: ethnicity, socioeconomic
position, and health in Britain and the United States. Am J Public Health 2000;90:1694–8.
(49) Parker RG, Gagnon JH, eds. Conceiving sexuality: approaches to sex research
in a post-modern world. New York: Routledge, 1995.
(50) Miller AM. Sexual but not reproductive: exploring the junction and disjunction
of sexual and reproductive rights. Health and Human Rights 2000;4:68–109.
(51) Williams R. Keywords: a vocabulary of culture and society. Revised ed.
New York: Oxford University Press, 1983.
(52) Kunitz SJ. Disease and social diversity: the European impact on the health
of non-Europeans. New York: Oxford University Press, 1994.
(53) Lin SS, Kelsey JL. Use of race and ethnicity in epidemiologic research:
concepts, methodologic issues, and suggestions for research. Epidemiol Rev 2000;22:187–202.
(54) Krieger N, Williams D, Moss N. Measuring social class in US public health
research: concepts, methodologies and guidelines. Annu Rev Public Health 1997;18:341–78.
(55) Wright EO. Class counts: comparative studies in class analysis. New York:
Cambridge University Press, 1997.
(56) Lynch J, Kaplan G. Socioeconomic position. In: Berkman L, Kawachi I, eds.
Social epidemiology. Oxford: Oxford University Press, 2000:13–35.
(57) Marmot M, Wilkinson RG, eds. Social determinants of health. Oxford: Oxford
University Press, 1999.
(58) Whitehead M. The concepts and principles of equity and health. Int J Health
Services 1992;22:429–45.
(59) Leon DA, Walt G, Gilson L. International perspectives on health inequalities
and policy. BMJ 2001;332:591–4.
(60) Murray C, Gakidou EE, Frenk J. Health inequalities and social group differences:
what should we measure? Bull WHO 1999;77:537–43.
(61) Murray CJL, Frenk J, Gadikou EE. Measuring health inequality: challenges
and new directions. In: Leon D, Walt G, eds. Poverty, inequality, and health:
an international perspective. Oxford: Oxford University Press, 2001:194–216.
(62) Braveman P, Krieger N, Lynch J. Health inequalities and social inequalities
in health. Bull WHO 2000;78:232–4.
(63) Doyal L. The political economy of health. London: Pluto Press, 1979 (1935).
(64) Breilh J. Epidemiologia, economia, medicina y politica. 4th ed. Mexico
City, Mexico: Distribuciones Fontamara, 1988.
(65) Conrad P, Kern R, eds. The sociology of health and illness: critical perspectives.
New York: St Martin’s Press, 1981.
(66) Navarro V. Crisis, health, and medicine: a social critique. New York: Tavistock,
1986.
(67) Link BG, Phelan JC. Editorial: understanding sociodemographic differences
in health—the role of fundamental social causes. Am J Public Health 1996;86:471–3.
(68) Fleck L. Genesis and development of a scientific fact. Chicago: University
of Chicago University Press, 1979.
(69) Rose H, Rose S, eds. Ideology of/in the natural sciences. Cambridge, MA:
Schenkman, 1979.
(70) Haraway D. Primate visions: gender, race, and nature in the world of modern
science. New York: Routledge, 1989.
(71) Ziman JM. Real science: what it is, and what it means. Cambridge: Cambridge
University Press, 2000.
(72) Fee E. Disease and discovery: a history of the Johns Hopkins School of
Hygiene and Public Health, 1916–1936. Baltimore: Johns Hopkins University Press,
1987.
(73) Rosenberg CD,Golden J, eds. Framing disease: studies in cultural history.
New Brunswick, NJ: Rutgers University Press, 1992.
(74) Porter D. Health, civilization, and the state: a history of public health
from ancient to modern times. London: Routledge, 1999.
(75) Cohen S, Kessler RC, Underwood L. Measuring stress: a guide for health
and social scientists. New York: Oxford University Press, 1995.
(76) Fee E, Krieger N. Understanding AIDS: historical interpretations and the
limits of biomedical individualism. Am J Public Health 1993;83:1477–86.
Source: This article was initially published in the Journal of Epidemiology and Community Health (J Epidemiol Community Health 2001;55:693-700). It is reproduced with permission of the British Medical Journal Publishing Group. The first part was published in the Epidemiological Bulletin 2002;23(1):7-11
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Epidemiological Bulletin, Vol. 23 No. 2, June
2002
