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October 10, 2008


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I think I understand what you're getting at here and agree with it. But how would one characterize, say, a decision not to smoke, drink (alchohol), attend carefully to one's diet (in my case, a vegetarian trying to cut back on dairy products, refined foods high in sugar, etc.), regularly exercise, and so forth? In other words, under what heading do we put individual attention to (personal responsibility for) "healthy habits" and lifestyle decisions. Are these not indicative of "preventive medicine" in the old-fashioned sense? The focus, in this instance, is still on individual risk factors, but that does not preclude a corresponding focus, at the collective level, on "SDOH in context of the public health...model of prevention," indeed, I can imagine the latter allowing for and reinforcing the former. Perhaps this goes without saying but I thought to ask anyway!


Those are good questions. Starfield et al's critique, which supports but is not identical to some of the arguments sketched above, is that the focus on individual risk factors is silly because population health operates as a system, which means that risk factors aggregate and influence each other, such that isolating any particular individual risk factor is counterproductive. As evidence, Starfield et al. demonstrate the tenuous connection between any individual risk factors for many chronic diseases and population health outcomes.

The argument is not, of course, that individual risk factors do not exist. It's that if we want to have an impact on public health via prevention, policy must focus on the aggregate risk factors which collectively seem to exert a much stronger influence on health than individual risk factors.

The focus on the individual risk factors is, of course, more consistent with an acute care medical model than a public health model, though -- and here comes disease causality again -- public health as currently practiced can fairly be criticized for relying on a similarly flawed notion of linear, static systems and causes.

In a larger sense, my argument, along with many SDOH commentators, is not that lifestyle does not matter in disease. We've known for over 300 years it matters tremendously. The insight is that social and economic conditions exert an enormous influence on the choices and lifestyles people have. Smoking may lead to disease; but why is it that smoking prevalence is much higher among populations with low SES?

Lifestyle is important, but it is totally insufficient to reduce that to a purely individual basis, which is a tremendous problem with much of what passes for contemporary health promotion, in my view.

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