"PC M D " ' D O A

RIP

J a y s. K a u f m a n A

c l e v e r b u t d i s i n g e n u o u s d e b a t e r may set up a "straw man," a w e a k a r g u m e n t a t t r i b u t e d to an o p p o n e n t that can be easily d e m o l i s h e d in ord e r to s c o r e a s h o w y victory. It is c l e a r t h a t Sally Satel has set up s u c h a " s t r a w man" in d e v o t i n g h e r essay largely to c o u n t e r i n g t h e i m p o s s i b l e thesis that social s t r u c t u r e is t h e sole d e t e r m i n a n t of h e a l t h status. 1 k n o w of no r e s e a r c h e r in t h e field of p u b l i c h e a l t h w h o b e l i e v e s that individual b e h a v i o r plays no role; after all, e v e r y s c h o o l of p u b l i c h e a l t h m a i n t a i n s a d e p a r t m e n t of h e a l t h behavior. N o n e t h e l e s s , Satel is c o n s u m e d w i t h the task of d e m o n s t r a t i n g t h e o b v i o u s , that individuals take p a r t in h e l p i n g to s h a p e t h e i r i m m e d i a t e e n v i r o n m e n t . In b a t t l i n g w i t h this " s t r a w man" of a thesis, t h e s t r i k i n g t h i n g a b o u t Satel's a t t a c k is t h a t she d o e s s u c h a m u d d l e d a n d c o n f u s e d j o b of a t t e m p t i n g to refute it. A l t h o u g h she c o n c e d e s r e p e a t e d l y t h a t social s t r u c t u r e is an i m p o r t a n t p r e d i c t o r of h e a l t h status, she s e e m s to be m o s t a g i t a t e d by t h e prosp e c t t h a t a t t e n t i o n to this r e l a t i o n m i g h t d e t r a c t from the important work of"holding individuals a c c o u n t a b l e " for t h e i r c h o i c e of b e h a v i o r s . Perh a p s h e r i n t e n t is to a s s e r t m e r e l y t h a t t h e relative i m p o r t a n c e of social o r g a n i z a t i o n in s h a p i n g h e a l t h o u t c o m e s has b e e n e x a g g e r a t e d by s o m e p u b l i c h e a l t h r e s e a r c h e r s , relative to t h e role of i n d i v i d u a l b e h a v i o r s . T h i s c o u l d be a s o m e w h a t useful h y p o t h e s i s , if f o r m u l a t e d m o r e specifically, a n d is o n e t h a t several s e r i o u s r e s e a r c h e r s have o n l y b e g u n to p u r s u e convincingly. If this is h e r c o n t e n t i o n , h o w e v e r , Satel c i t e s no c o n v i n c i n g q u a n t i t a t i v e a r g u m e n t to s u p p o r t such a p o s i t i o n , n o r d o e s she a d v o c a t e for b e t t e r r e s e a r c h on social f a c t o r s a n d h e a l t h t h a t w o u l d serve to estim a t e t h e effects of i n t e r e s t w i t h g r e a t e r validity o r p r e c i s i o n . I s u s p e c t t h a t t h e p o v e r t y of h e r arg u m e n t on this t o p i c r e v e a l s s o m e c o n s i d e r a b l e c o n f u s i o n b y t h e a u t h o r h e r s e l f on w h a t e x a c t l y

she m e a n s b y t h e "effects" of s o c i a l f a c t o r s a n d o f b e h a v i o r s , a n d in w h a t s e n s e she s e e k s to establish t h e i m p o r t a n c e of i n d i v i d u a l v o l i t i o n as a fact o r i n d e p e n d e n t of social o r g a n i z a t i o n or c o n t e x t . C o n s i d e r t h e h i g h l y s i m p l i f i e d causal s t r u c t u r e s h o w n in t h e Figure. Several of t h e causal effects d e p i c t e d b y d i r e c t e d arcs are of i n t e r e s t to social e p i d e m i o l o g i s t s , i n c l u d i n g t h e total effect of s o m e a s p e c t of social s t r u c t u r e a n d t h e p a r t i t i o n i n g of this t o t a l e f f e c t i n t o t h e p o r t i o n o f t h e e f f e c t mediated by some specific health behaviors and the p a r t t h a t is n o t . A total e f f e c t for a p a r t i c u l a r a s p e c t of s o c i a l s t r u c t u r e is s i m p l y s o m e c o n t r a s t in t h e h e a l t h o u t c o m e d i s t r i b u t i o n s a c h i e v e d und e r o n e s p e c i f i c social p o l i c y r e g i m e c o m p a r e d to t h a t a c h i e v e d u n d e r a n o t h e r . If t h e a s p e c t o f s o c i a l s t r u c t u r e u n d e r c o n s i d e r a t i o n is i n c o m e d i s t r i b u t i o n , for e x a m p l e , w e m i g h t w e l l p o s i t t h e contrast between two particular policy regimes, say, o n e in w h i c h w e m a i n t a i n an " e a r n e d i n c o m e t a x c r e d i t " a n d o n e in w h i c h w e do not. We m a y t h e n e s t i m a t e , b y m e a n s of an e x p e r i m e n t or o b s e r v a t i o n a l study, s o m e f u n c t i o n of a h e a l t h o u t c o m e d i s t r i b u t i o n , for e x a m p l e a morFigure

Schematic Representation of Causal Pathways to Health Status

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tality proportion for some specified population and time period, under each policy regime, and w e m a y d e f i n e t h e r e l e v a n t t o t a l c a u s a l e f f e c t as s o m e c o n t r a s t b e t w e e n t h e s e t w o o u t c o m e dist r i b u t i o n s , s u c h as a r a t i o o r d i f f e r e n c e o f m o r t a l ity p r o p o r t i o n s . U n d e r s o m e additional a s s u m p t i o n s , p e r t a i n i n g to i n t e r a c t i o n s a n d to t h e roles o f o t h e r m e a s u r e d a n d u n m e a s u r e d variables, w e m a y t h e n go o n to e s t i m a t e w h a t p o r t i o n o f t h i s e f f e c t is mediated by the effect of social structure on health behaviors (arcs a and d) and what portion o c c u r s t h r o u g h o t h e r c a u s a l p a t h w a y s ( a r c b). T h e e p i d e m i o l o g i c a l task is m e r e l y d e f i n i n g a n d e s t i m a t i n g t h e v a r i o u s c a u s a l e f f e c t s . T h i s is n o m e a n task, a n d t h e i n f e r e n t i a l c h a l l e n g e s a r e c o n siderable, especially when we must rely on obs e r v a t i o n a l s t u d i e s , as is so o f t e n t h e c a s e f o r soc i a l e p i d e m i o l o g y in c o n t r a s t w i t h s e t t i n g s in w h i c h w e c a n r a n d o m i z e s t u d y s u b j e c t s to o n e o r a n o t h e r t r e a t m e n t , as f o r e x a m p l e in t h e s t u d y of medical interventions.The challenges involved in c a u s a l i n f e r e n c e f r o m o b s e r v a t i o n a l d a t a , h o w e v e r f o r m i d a b l e , a r e b y n o m e a n s u n i q u e t o social e p i d e m i o l o g y , a n d f u r t h e r m o r e a r e w e l l described in a rich theoretical and statistical literature. Several formalizations of these issues, including those from statisticians, economists, and epidemiologists, are widely studied and applied. N o t o n l y are s t a t i s t i c a l a s s u m p t i o n s n e c e s s a r y for this k i n d o f w o r k , b u t b e c a u s e t h e a n a l y s i s is unavoidably premised on background knowledge, and because the analyst must choose the contrasts o f i n t e r e s t f r o m a m o n g a large n u m b e r o f possibilities, social t h e o r y a n d values b e c o m e c r i t i c a l elem e n t s as well. F o r s o m e s p e c i f i c a s p e c t o f social s t r u c t u r e that is a m e n a b l e to i n t e r v e n t i o n , t h e causal effect o n a d e f i n e d h e a l t h o u t c o m e in a p a r t i c u l a r p o p u l a t i o n a n d in a p a r t i c u l a r t i m e p e r i o d h a s a lat e n t t r u e value, a n d this v a l u e c o u l d b e o b s e r v e d d i r e c t l y if t h e w o r l d c o u l d b e v i e w e d a l t e r n a t e l y u n d e r e a c h o f t h e t w o p o l i c y r e g i m e s a n d t h e obs e r v e d h e a l t h o u t c o m e d i s t r i b u t i o n s c o n t r a s t e d . It is b e c a u s e w e c a n n o t r e w i n d t i m e a n d v i e w t h e world again under the alternate scenario that c a u s a l e f f e c t s are n o t d i r e c t l y o b s e r v a b l e , a n d t h i s is w h y all c a u s a l e f f e c t e s t i m a t e s are p r e m i s e d o n theoretical assumptions about the subject matter at hand, in a d d i t i o n to t h e statistical a s s u m p t i o n s i n v o l v e d in a g i v e n m o d e l o f t h e o b s e r v e d d a t a . B e c a u s e o f this f u n d a m e n t a l r o l e o f b a c k g r o u n d subject matter knowledge, severe disagreements m a y a r i s e h o n e s t l y b e t w e e n r e s e a r c h e r s w i t h different beliefs about the nature of the world.Value

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SOCIETY 9 MAY/JUNE 2002

j u d g m e n t s c o m e i n t o p l a y n o t o n l y in d e f i n i n g t h e r e s e a r c h q u e s t i o n at t h e o u t s e t , b u t also in c h o o s ing the particular function of the health outcome d i s t r i b u t i o n o n w h i c h t o f o c u s . F o r e x a m p l e , if one chooses a measure of central tendency for t h e o u t c o m e d i s t r i b u t i o n s u m m a r y , s u c h as a sample mean, a contrast might reveal no causal effect, whereas choosing a measure of spread, s u c h as a s a m p l e v a r i a n c e o r t h e o b s e r v e d p e r c e n t falling b e l o w s o m e c r i t i c a l m i n i m u m v a l u e , could reveal a profound effect. O n c e a c a u s a l e f f e c t is e s t i m a t e d , a r r i v i n g at a p o l i c y d e c i s i o n in l i g h t o f t h e e s t i m a t e is e v e n more value dependent.All causal effects that one m i g h t s t u d y p e r t a i n to s p e c i f i c c o n t r a s t s o f p o l i cies o r i n t e r v e n t i o n s , a n d t h e s e h a v e c o s t s , b r o a d l y defined, that must be estimated.The financial costs may be relatively easy to specify, whereas the quantification of other negative impacts (e.g., ancillary consequences or unintended side-effects) generally involves value judgments for which consensus may be impossible to achieve. Likewise, the health outcome distribution entails financial consequences, and rational values for q u a n t i t i e s s u c h as p r e v e n t a b l e y e a r s o f l o s t p r o d u c t i v e life h a v e b e e n p r o p o s e d . T h e " c o s t s " o f pain, suffering, and any number of other humanistic c o n s e q u e n c e s (e.g., loss o f f r e e d o m , loss o f indep e n d e n c e , loss o f dignity, e t c . ) are virtually i m p o s sible to q u a n t i t y in a n y o b j e c t i v e way, h o w e v e r , a l t h o u g h h e a l t h e c o n o m i s t s a n d p o l i c y m a k e r s are f o r c e d to m a k e s u c h c a l c u l a t i o n s e v e r y day. To t h e e x t e n t t h a t t h e s e v a r i o u s t y p e s o f inputs and consequences may be quantified according to some commensurate scale, the utility of the p o l i c y r e g i m e in q u e s t i o n c o u l d b e r e a d i l y c a l c u l a t e d a n d t h e d e c i s i o n o f w h i c h to i m p l e m e n t would be straightforward. In practice, however, subjective or valued judgments must often overwhelm the epidemiological evidence.The probl e m is s u f f i c i e n t l y d i f f i c u l t w h e n t h e i n t e r v e n t i o n in q u e s t i o n is at t h e i n d i v i d u a l level, s u c h as a medical treatment decision.When the causal quant i t y u n d e r s t u d y is i n s t e a d a n a s p e c t s o c i a l s t r u c t u r e , for w h i c h a p o l i c y c o n t r a s t w o u l d e n t a i l a n immense number of diverse consequences, any hope of achieving a consensus around a cost/benefit c a l c u l a t i o n a p p e a r s far r e m o v e d . W i t h this f o r m a l s t r u c t u r e in p l a c e , w e c a n n o w see the clear deficiency of Satel's line of attack. Over and over again, she emphasizes the obvious points that individuals have some degree of cont r o l o v e r t h e i r b e h a v i o r (arc c) a n d t h a t b e h a v i o r s

in t u r n have an i m p o r t a n t i m p a c t o n h e a l t h (arc d). D e s p i t e h e r c o n c e r t e d effort to s u g g e s t o t h e r w i s e , h o w e v e r , t h e e x i s t e n c e o f s u c h effects says n o t h i n g at all a b o u t relative i m p o r t a n c e of" social s t r u c t u r e " o n b e h a v i o r s (arc a ) o r o n h e a l t h o u t c o m e s via o t h e r p a t h w a y s (arc b). F o r o n e t h i n g , a t t r i b u t a b l e p r o p o r t i o n s d o n o t s u m to 100% b e c a u s e o u t c o m e s can have several necessary causes. As K e n n e t h R o t h m a n h a s n o t e d in a w e l l known epidemiological example, onset of severe m e n t a l r e t a r d a t i o n d u e to h y p e r p h e n y l a l a n i n e m i a a m o n g p h e n y l k e t o n u r i c s ( P K U ) is b o t h 100% gen e t i c a n d 100% e n v i r o n m e n t a l , in t h a t 100% o f the cases are dependent upon the presence of a m u t a n t a l l e l e at t h e p h e n y l a l a n i n e h y d r o x y l a s e l o c u s , a n d 100% o f t h e c a s e s a r e d e p e n d e n t u p o n exposure to dietary phenylalanine. Analogously, health outcomes can be determined by social s t r u c t u r e w h i l e at t h e s a m e t i m e b e i n g 100% m o d i f i a b l e b y c h a n g e s in i n d i v i d u a l b e h a v i o r . F o r e x a m p l e , s u p p o s e t h a t it w e r e t r u e , as r e c e n t l y r e p o r t e d in The A m e r i c a n J o u r n a l o f P u b l i c Health, t h a t for e a c h 10% t h a t w e i n c r e a s e t h e sales t a x o n a p a c k o f c i g a r e t t e s , t h e p r o p o r t i o n o f p r e g n a n t w o m e n w h o s m o k e is r e d u c e d b y 7%. This aspect of social policy would therefore have a real c a u s a l e f f e c t o n t h e r e l e v a n t o u t c o m e dist r i b u t i o n , w h i l e in n o w a y d e n y i n g t h a t e v e r y w o m a n in t h e p o p u l a t i o n h a s t h e f r e e w i l l to dec i d e w h e t h e r s h e will s m o k e o r n o t . W h e r e a s Satel a p p e a r s to b e f i x a t e d o n t h e n o t i o n t h a t w e m u s t h o l d i n d i v i d u a l s " a c c o u n t a b l e " for a b e h a v i o r a l c h o i c e s u c h as s m o k i n g , t h e r e is n o l o g i c a l reas o n w h y a s o c i a l p o l i c y c h o i c e t h a t h a s t h i s demonstrable impact on aggregate behavior should n o t b e v i e w e d as e q u a l l y " a c c o u n t a b l e . " O n e d i m e n s i o n o f s o c i a l s t r u c t u r e t h a t is disc u s s e d w i t h p a r t i c u l a r c l u m s i n e s s b y Satel is racial classification. Racial categories are indisputa b l y an a s p e c t o f s o c i a l s t r u c t u r e b e c a u s e t h e y h a v e n o o b j e c t i v e e x i s t e n c e in t h e n a t u r a l w o r l d , b u t r a t h e r e x i s t as c r e a t i o n s o f h u m a n h i s t o r y a n d culture. Biological anthropologists and population g e n e t i c i s t s a r e in b r o a d a g r e e m e n t t h a t t h e r e is no significant aggregation of biological variation w i t h i n s u b c a t e g o r i z a t i o n s o f h o m o sapiens; rather, t h e r e is c l i n a l v a r i a t i o n (a g r a d e d v a r i a t i o n in a p h y s i c a l t r a i t a c r o s s a g e o g r a p h i c r a n g e ) a n d clustering of superficial characteristics, which physical a n t h r o p o l o g i s t C. L o r i n g B r a c e h a s r e f e r r e d to as "familial r e s e m b l a n c e w r i t large." S a t e l ' s gene r a l r e a c t i o n t o t h e s u b s t a n t i a l r a c i a l / e t h n i c disp a r i t i e s t h a t e x i s t for v a r i o u s h e a l t h o u t c o m e s is

to a s s e r t t h a t t h e s e a r i s e l a r g e l y f r o m p o o r c h o i c e s in l i f e s t y l e a n d b e h a v i o r . H e r i n t e n t i o n t h e r e f o r e s e e m s t o b e to d e - e m p h a s i z e a r c b in t h e F i g u r e in f a v o r o f a r c s a a n d d. As n o t e d p r e v i o u s l y , a reasonable relative weighting of these two pathw a y s is still a n a s c e n t r e s e a r c h a g e n d a , a n d o n e t o w h i c h Satel m a k e s n o s i g n i f i c a n t c o n t r i b u t i o n . The important realization that one may obtain from cursory inspection of the Figure, however, is t h a t b o t h o f t h e s e p a t h w a y s a r e c o n s t i t u e n t s o f t h e t o t a l e f f e c t o f s o c i a l s t r u c t u r e o n h e a l t h . To clarify this point, consider making a similar cont r a s t d e f i n e d n o t b y r a c e , b u t b y s o m e r e a l biologic entity that carries no significant socio-structural baggage, such asABO blood type.Those with Type O blood exhibit no excess of poor health b e h a v i o r s in c o m p a r i s o n w i t h T y p e s A o r B, o f course, and no deficit of volitional control over such behaviors. That such profound differences in h e a l t h s t a t u s s h o u l d e x i s t in t h e U n i t e d S t a t e s b e t w e e n t h o s e s o c i a l l y r e c o g n i z e d as " b l a c k " a n d t h o s e s o c i a l l y r e c o g n i z e d as " w h i t e , " r e g a r d l e s s o f whether these differences are mediated by behavi o r s u n d e r v o l i t i o n a l c o n t r o l o r not, s p e a k s d i r e c t l y to the profound impact of social structure on h e a l t h t h a t Satel s e e k s to d e r i d e . In l i g h t o f t h e s e f u n d a m e n t a l d e f e c t s in t h e logic of Satel's arguments, the most interesting t h i n g a b o u t h e r w o r k is t h a t it a t t r a c t s a n y serio u s a t t e n t i o n w h a t s o e v e r . T h e b o o k PC., M.D.:

H o w Political Correctness is C o r r u p t i n g Medicine is v e r y c l e a r l y d i r e c t e d to a p o p u l a r , r a t h e r than a professional, audience, and her related publ i s h e d w o r k h a s a p p e a r e d in j o u r n a l i s t i c r a t h e r t h a n s c i e n t i f i c v e n u e s . D e s p i t e h e r s t r i d e n t critic i s m o f v a r i o u s s c i e n t i f i c p u b l i c a t i o n s in h e r essays a n d in h e r b o o k , it a p p e a r s t h a t Satel has p u b l i s h e d n o c r i t i q u e in a p e e r r e v i e w e d s c i e n t i f i c j o u r n a l , n o r e v e n p u b l i s h e d a L e t t e r to t h e E d i t o r in r e s p o n s e to any o f t h e s c i e n t i f i c a r t i c l e s t h a t s h e d i s p a r a g e s . I f s h e is u n w i l l i n g o r u n a b l e t o c o n d u c t a f o r m a l a r g u m e n t at t h e l e v e l o f p r o f e s s i o n a l scie n t i f i c d i s c o u r s e , t h e a p p r o p r i a t e q u e s t i o n for p u b lic h e a l t h r e s e a r c h e r s is w h y t h e y s h o u l d d e i g n to give h e r w o r k a n y c o n s i d e r a t i o n w h a t s o e v e r . T h e i n c l i n a t i o n t o s i m p l y d i s m i s s t h i s w o r k as f a c i l e a n d i r r e l e v a n t w o u l d a p p e a r to b e c o n t r a i n dicated, however, by the glowing reviews on the dust-jacket of her book contributed by the former editor of a prestigious medical journal, the chairman of a celebrated medical school department, and the president of an important private health foundation, among others.The salient issue with

"P.C., M.D.": D.O.A., R.I.P.

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w h i c h w e n e e d to c o m e to g r i p s , t h e r e f o r e , is n o t the content of Satel's critique, which unfortunately offers no particularly useful insights into the matter of social causation of disease. Rather, it is t h e p o p u l a r i t y o f Satel's a r g u m e n t , to t h e ext e n t t h a t it e n j o y s a n y w h a t s o e v e r . T h i s is a s o c i o logical question, involving the nature of scientific d i s c o u r s e in t h e m o d e r n m e d i a era, t h e c o n t e m porary understanding of personal responsibility a n d f r e e d o m , a n d t h e social u s e s o f m e d i c a l k n o w l e d g e .Towards an i m p r o v e d u n d e r s t a n d i n g o f t h e s e b r o a d e r s o c i o - p o l i t i c a l q u e s t i o n s , Satel's w o r k h a s t h e p o t e n t i a l to c o n t r i b u t e g r e a t l y as a n e x a m p l e , a n d d e s e r v e s c a r e f u l s t u d y in t h a t c a p a c i t y .

SUGGESTED FURTHER READINGS

POLITICALPHILOSOPHY AND CULTURALRENEWAL

COLLECTEDESSAYSOFFRANCISGRAHAMWILSON Francis G r a h a m W i l son H. Lee Cheek, Jr., M. Susan Power, and Kathy B. Cheek, editors 0-7658-0045-4(cloth)2000 263 pp. $49.95/ s

THE RADICALRIGHT THIRD EDITION

Daniel Bell, editor With a new introduction by David Plotke, and an afterword by Daniel Bell 0-7658-0749-1 (paper) 2000 570 pp. $29.95 / s

Greenland S. Causality t h e o r y for p o l i c y uses of epidemiological measures. In: Murray CJL, Mathers C, Salomon J, Lopez AD. Lozano R (eds): Summary Measures of Population Health. Geneva: UN World Health Organization, forthcoming, 2002. Kaufman JS, Kaufman S.Assessment of s t r u c t u r e d soc i o e c o n o m i c effects on health. Epidemiology 2001 Mar; 12(2): 157-67. Kaufman JS, Poole C. Looking back on "Causal Thinking in the Health Sciences". Annual Review of Public Health. 2000; 21:101-19. Krieger N.Theories for social e p i d e m i o l o g y in the 21 st century: an ecosocial perspective. International Journal of Epidemiology 2001 Aug;30(4):668-77. Link BG, Northridge ME, Phelan JC, Ganz ML. Social e p i d e m i o l o g y and the fundamental cause concept: on the structuring of effective cancer screens by s o c i o e c o n o m i c status.Milbank Quarterly 1998; 76(3): 375-402. Robins JM. Data, design, and b a c k g r o u n d k n o w l e d g e in e t i o l o g i c i n f e r e n c e . Epidemiology. 2001 May;12(3):313-20. Singer B, Ryff C. Racial and ethnic inequalities in health: Environmental, psychosocial, and physiological pathways. In: Devlin B, Fienberg SE, Resnick DP, Roeder K (eds). Intelligence, Genes, & Success. N e w York: Springer-Verlag, 1997, pp. 89-122.

Jay s. K a u f m a n is assistant professor in the Dep a r t m e n t o f Epidemiology at the University of North Carolina School of Public Health, a n d fellow of the Carolina Population Center

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SOCIETY 9 MAY/JUNE 2002

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THE NEW AGRARIANMIND THE MOVEMENT TOWARD DECENTRALIST THOUGHT IN TWENTIETH-CENTURY AMERICA

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