Recent Advances in Social Science and Public Health

Recent Advances in Social Science and Public HealthAuthor(s): ALEXANDER ROBERTSONSource: Canadian Journal of Public Health / Revue Canadienne de Sante'e Publique, Vol. 56, No.9 (SEPTEMBER 1965), pp. 365-371Published by: Canadian Public Health AssociationStable URL: http://www.jstor.org/stable/41983773 .

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Canadian Journal of

PUBLIC HEALTH

VOLUME 56 SEPTEMBER 1965 NUMBER 9

Recent Advances in Social Science and

Public Health1

ALEXANDER ROBERTSON,2 M.D.

T SPEND at lot of my life nowadays -*■ either in or with people from what are known as developing countries - mostly in Latin America, but also from other parts of the world. The interest which they show in learning from Canada is immense. They admire not only your balanced stability in a world of extremes, but more particularly, in public health they admire your ability to have moved so steadily forward in the conception and in the application of newer and better forms of health service.

In the opening pages of the Royal Com- mission on Health Services Report the reasons why the subject upon which you have asked me to speak is of so much concern are made very clear.

The Commissioners based almost all that they subsequently had to say in the way of recommendations upon their clear prior acceptance, as I see it, of two things. First, every man's right to health and to the best in the way of health service that society can devise and provide. This is an important question, but it is a philosophi- cal one upon which I do not wish to .expand today. Secondly, however, the Commissioners recognized "the gap that exists between scientific knowledge and its application in the service of mankind".

# Presented at the 56th annual meeting of the Cana- dian # Public Health Association held in Edmonton, Alberta, May 31-June 3, 1965. 2Executive Director, Milbank Memorial Fund, 40 Wall Street, New York 10005, N.Y., U.S.A.

That second point alone makes it important to stress the role of the social sciences in public health.

The title which I have been given "Re- cent Advances in Social Science and Pub- lic Health" has presented me with a serious challenge, and I have had some difficulty in ordering my thoughts concerning the relationships between the social sciences and public health as I see them with the exact wording of that title.

Let me assure you that I accepted the suggested title some time ago and thus I am criticizing myself as much as anyone when I now express doubt as to whether it is not a rather unrealistic title.

I believe that what we, as public health people, have most to concern ourselves with is not to find out about "recent advances" in the social sciences, not at any rate in the sense that we can do so in the biological and in the physical sciences, but rather that we should consider yet again, for this has been attempted often before, how the basic concepts of the social sciences and the basic objectives of public health have been, are, and should be related to one another.

This I shall try to do, and in doing so I must rely heavily on the writings of others qualified in the social sciences - which I am not; I am merely one who seeks to build bridges between them and medicine.

365



366 CANADIAN JOURNAL OF PUBLIC HEALTH Vol 56

First let me attempt to clarify what I mean when I speak of the social sciences. With Dr. George Rosen of Columbia Uni- versity, who has addressed this gathering in the past and written extensively on the subject, I would distinguish six broad divisions of social science - history, economics, political science, sociology, psychology and anthropology - with many overlapping refinements of title such as social psychology, social or cultural anthropology.

Writing of three of the social sciences, the three which he considers most highly relevant to the public health, Rosen re- marks that while they are easy to label, sociology, social psychology, and cultural anthropology are less easily described and quite resistant to precise differentiation.

Rosen goes on: "Consider their similari- ties first. Most of the scientists in these fields have the same natural habitat - a college or university department - and their activities tend to focus on teaching and research. As knowledge in each of these disciplines increases, they are marked by burgeoning specialization. Thus, the social sciences face the same problem as does public health, namely, to educate people who will be generalists and yet have specialist training. Furthermore, and this is crucial in understanding the strengths and the limits of social scientists as a group, their dominant orientation is to further 'basic' psychology, sociology, or anthropology, while the endeavour to 'apply' social science knowledge and skills to problems of health or industry, although undoubtedly of growing interest, is still secondary and derivative.

"When one considers the differences between the three social sciences of concern here, it is essential to realize at the outset that logic cannot explain what must be understood historically. Each of the sciences have traversed distinct and some- what isolated routes of development. . . .

"To reduce rather complicated geneo- logies to frankly oversimplified terms, sociology grew out of various currents of social reform and theories intended to explain growth and change in society, social psychology from the work of early experi- ments in individual and group psychology, and anthropology from the observations of geographers, explorers, and travelers. Al- though each discipline has traveled far

from its beginnings, each bears characteristic ancestral features.

"The various social sciences differ among themselves with respect to the data with which they deal. History, economics, and political science tend to rely to a larger extent on library materials and statistical compilations, although even here there are no hard and fast lines. History depends in part on archeologie data, i.e., on data dug up in the field, and some of this is of public health interest. Economists concerned with medical care make field studies, and this is increasingly true of empirically-minded political scientists. Thus, the distinction between these sciences and sociology, social psychology, and cultural anthropology with respect to their data is in some measure a matter of degree. Yet the degree is significant, for the latter fields tend to develop their data empirically and in field studies. However, even these empirically-minded sciences differ to a certain extent as to the kinds of primary data they produce. . . .

"In addition to the peculiarities of method characteristic of the respective fields, each discipline is oriented around a different central concept. For anthropology, the unifying concept is that of culture, which refers broadly to the habits, values and way of life of a people. In social psychology, the concept of motive is central; this is the internal drive, in complex interaction with external and other internal factors, which constitutes an important determinant of the individual's behaviour. Sociology, numerically the largest of the disciplines discussed here, is centrally concerned with the study of patterned relationships within and between groups. These come under the concepts of social organization, institutional structure, and social change. The term institution refers not to things like hospitals and jails, but to those points in the flow of human affairs around which develop enduring patterns of interaction and mutual expec- tation." (1)

I do not apologize for quoting at such length from an invaluable article on this subject, not out of date, which was published by Dr. George Rosen in the Ameri- can Journal of Public Health in April 1959 called, "A Bookshelf in the Social Sciences and Public Health", for I believe that one of the major problems that confronts the



September 1965 SOCIAL SCIENCE 367

social scientist and the public health man when they try to work together is the latter's ignorance of what the former is either knowledgeable about or interested in.

George Foster, Professor of Anthro- pology in the University of California at Berkeley, has thrown light on another vital facet of this problem of how the social sciences relate to public health (2).

Professor Foster reminds us that the three social sciences - anthropology, sociology and psychology - which he singles out from the others and labels "behavioural sciences" (as opposed to Rosen who merely looks upon them as the social sciences most related to public health), along with public health are all sciences. Professor Foster considers, however, that, though each of these three and public health is a science, the ways in which each operates are very different.

Psychology, sociology and anthropology are seen by Foster as being what he calls "disciplines", as opposed to public health which he describes as a "profession".

Foster writes: "The underlying assump- tion that characterizes academic disciplines is that the search for knowledge represents the highest value. The work of this kind of a scientist is exploratory; he wants to find out, to know, he wants to order knowledge in meaningful patterns; he wants to build theory. He is not immediately concerned, as a scientist, with the goodness or badness of his discoveries, nor with their immediate practical utilization.

"The practice of public health, on the other hand, is a profession. It draws upon the scientific knowledge of a number of fields, especially medicine and engineering, but it differs from academic disciplines in that it is a directly applied venture. The existence of a public health organization means that health problems have been defined, that it has been deemed desirable to solve these problems and that a bureau- cracy has been created to work toward the solution of these problems. A basic value judgment is implicit in all work: health is better than illness, and every effort should be made to banish the latter.

"In other words, an academic discipline stresses theoretical research, while a profession stresses goal-directed practice. The two aims are by no means mutually exclu- sive, but they are different. When the two

aims are pursued in a common project, a reconciliation of interests is essential, and this reconciliation is best spelled out in the planning stage, rather than at a later time when program participators realize they are working toward very different ends.

"Not only are the aims of disciplines and professions distinct, but the ego- satisfying criteria are also different. Public health personnel feel gratified when they know they have raised the level of health in their jurisdiction through their efforts, and that this success is recognized by their colleagues. Behavioural scientists feel gratified when they feel they have made new contributions to basic science, and when these contributions are acknowledged by their colleagues. The distinct ways in which professionals and research scientists achieve status in their fields obviously have an important bearing on how they view their roles, and what they hope to accomplish, in a co-operative program."

Difficulties in comprehending each other's basic concepts and objectives, as well as that confusion over language that sometimes comes when different people use the same words to describe different things, have been perhaps the major bar- riers in the past to securing the most profitable of relationships between social scientists and public health people. An- other major difficulty, I believe, has lain in the mistaken belief that the social scientist can only be of help in dealing with problems like the organization and distribution of health services, with the acceptance of programs by those of different cultures and so forth. Foster, for example, has said that "there are some kinds of health problems in which the behavioural scientist can be of great help: there are others where his contribution will be minimal".

"Speaking now as an anthropologist", Foster says, "... I would say that problems where behavioural scientists can help are most apt to be found in the fields of sanitation, mental health, tuberculosis, maternal and child health, and perhaps aging and dental health. The subjects that afford least opportunity appear to be air pollution, medical and surgical care for the indigent, radiological health, rehabilita- tion, urban and suburban expansion, and safety. The common characteristic of the first category is that success is marked by



368 CANADIAN JOURNAL OF PUBLIC HEALTH Vol 56

changes in individual and small group behaviour. That is, the target is immediate, tangible, and personal. ... In the second category the targets are less tangible, and more impersonal, coercive legislation is often present, and major but specialized financial appropriations are required to push forward the work. Legal, political, and economic factors intrude in the second category to a far greater extent than in the first."

Foster considers the social scientist especially well equipped to work in those situations in which there is a "cultural chasm separating the innovating and the recipient groups. . . . We perform better", he says, "in situations where social, cultural and psychological factors hold the key, rather than where legal, political and economic factors are dominant."

Foster believes that, while mutually profitable research can be designed around such problems as control of tuberculosis or improvement of maternal and child health services, he doubts that in the immediate future the behavioural scientist can be of much help on air or water pollution, for example.

I would disagree with Professor Foster's statement on at least two counts.

First, and I mention this most briefly because it seems to me that in this audience the usefulness of social science concepts here will be so obvious, I am certain that it is in helping understand how to communicate with populations and with communities in regard to the accep- tability of, say, water supply and sewage disposal systems that the concepts of the social scientist have often been and are often being most useful.

But secondly, and much more seriously, I believe that in the comments I have quoted from Foster he ignores the entire potential contribution of the social sciences to the problem of defining cause.

Professor Foster is not alone in appear- ing to disregard this aspect of the potential contribution of his science, and perhaps here we have another problem that we can profitably discuss for a moment.

The profession of public health, led (though not originally stimulated) by men and women of basically biological training, and concerned first and foremost to discover causes that it may the better in- vent the means not only of cure but

preferably of prevention, has been misled, due in part to the rapid advances in the biological sciences, into classifying "disease" in erroneous terms.

Dr. Anthony Payne, head of the School of Public Health at Yale, in a recent scholarly address which he called "Innova- tion Out of Unity", has made so clear to me the vital relationship of the social sciences to public health in this context of classification, and thus the proper identifi- cation of "cause" as opposed to what Dr. Payne calls "mechanism", that I would like to quote at some length from him (3).

"Thirty years ago - and even today in many places - the concept of the specific etiology of disease was unquestioned. It originated from the discoveries during the era of Koch and Pasteur - although, as far as I know, Pasteur himself never pro- posed it. According to this hypothesis, the cause of an infectious disease is the agent; all else is of secondary importance. On its basis, immense advances were made which, in the light of available knowledge, seemed to confirm it. The same hypothesis was therefore extended to a wide variety of other diseases, and medical scientists engaged in a search for the cause of cancer, heart disease, nutritional disorders, mental diseases, metabolic disorders, etc. They made many important and valuable discoveries, but if these are examined closely, they are concerned more with the mechanisms of disease processes rather than their causation .

"Today we know that the concept of the specific etiology even of infectious disease is incorrect except in the semantic sense. By definition one cannot have tuberculosis without the tubercle bacillus nor, for that matter, can one have an automobile accident without an automobile, though the automobile itself is seldom the cause of the accident. This arises from the present method of classifying infectious disease on the basis of the concept of specific etiology. With increasing knowledge of the variety and behaviour of infectious agents and of the response of man under a variety of circumstances, it is apparent that it is a gross oversimplification - not that it was completely wrong, but the factual complex upon which it was based was seriously incomplete. It ignored the influence of other factors, many of which had indeed been recognized for 2,000




years, since the time of Hippocrates. These include many environmental and behavioural elements which, however, were much more vague and therefore less Scientific' than the discoveries of the natural scientists.

"The scientific mind has a natural love of order. It tends to ignore fields in which order is not readily apparent. Emphasis has therefore been on subjects that can be studied in the laboratory, and the trend has been to stress the study of smaller and smaller fragments of the whole organism. Even when the whole organism is being studied, it is carefully isolated from the influence of the natural environment. Al- though this approach has greatly increased our understanding of fundamental mechanisms, it tells us little about the external factors which may trigger them. To cite an extreme example, one can even question the validity of many of the findings of bacteriology. Here one of the first moves is to establish a pure culture. This represents a very highly selected sample derived from perhaps one or a very few out of the original population of billions of organisms of all kinds. It is a little like making pronouncements about the people of New York from a study of, say, two persons; if we did that we would not even be sure of discovering that there were two sexes. An epidemiologist would not keep his job long if he did that. Yet data are coming to light which show that organisms grown in pure culture behave differently from mixed cultures - which is what is always found in nature. This is so even when the mixture is just of different strains of the same organism. For instance, virulence seems to be profoundly influenced by the degree of admixture of virulent and avirulent strains, and this is not merely a matter of the proportion of each, but is due to differences in certain biochemical processes in virulent and avirulent strains which inter- act with each other. The same kind of interaction occurs in populations of whole animals and especially of man with the immensely greater complexity of his mental processes and the social and environmental conditions under which he lives. Only here the interaction is primarily psychological and social, not biochemical. Of course, there are also important physical, chemical and biological interactions; man infects his neighbor, covers his cities

with smog, and pollutes his water supplies. These must be and are being studied."

Perhaps an indication of pride that pre- vents the natural scientist from exploring more complex circumstances outside his confined and refined laboratory or some fear of tackling the infinitely more complex problems of society.

In the same address, Dr. Payne gives a cogent illustration of the fallacies that arise from the misconceptions revealed in his previous argument: "Endemic infantile paralysis, as it used to be called, is an infection which rarely results in disease and is Caused' by the polio virus. Epidemic paralytic poliomyelitis on the other hand is a social disease, resulting from delay in primary virus infection until an age when paralysis follows infection much more fre- quently than when it occurs in infancy. This delay is caused by the social organization and application of sanitary measures designed to prevent the spread of intestinal infections. As countries have improved their hygiene and sanitation in the course of socio-economic development, poliomyelitis has passed into the epidemic phase in a predictable way. There have of course been a few exceptions to these predictions as would be expected in any such complex biological-social system. Some of these we can explain within the present theory; others can be explained on the basis of assumptions which we cannot test with the tools presently available. If these should be disproved, we may have to revise our present theory to take into account the new data. In the meantime the concept has proved to be of considerable value.

"We may therefore turn this round and say that one of the diseases which will result from socio-economic development, if no steps are taken, is epidemic paralytic poliomyelitis, and we can predict on the basis of indices of socio-economic development roughly at what stage it is likely to appear. Using the same indices we can predict that certain other diseases will decrease in importance, the intestinal disorders of infancy for instance. You will note that I call these intestinal disorders, not infections. Actually, we can identify pathogenic organisms in only about one- quarter of the cases. We do not really understand the relative roles of infection, nutrition, electrolyte balance and other



370 CANADIAN JOURNAL OF PUBLIC HEALTH Vol. 56

physiological and psychological disturb- ances in the other three-quarters. But essentially these are all social diseases which can be corrected by social measures without recourse to any specific antibac- terial measures."

I do not want to quote further from Dr. Payne, except in order to give you the hypothesis to which, in the foregoing ex- tracts, he was leading, which was that "by examining social factors, especially chang- ing factors, by quantifying them as best we can and relating them to the accompany- ing changes, both favourable and un- favourable, in human well-being, we may be able to classify departures from the latter in terms of the social factors which brought them about, rather than in terms of a so-called specific agent, infectious or otherwise".

We have looked at what the social scientists are, examined some of their ways of working; now let us spend a moment considering how they and we in public health can work together.

Robin F. Badgley, in a paper to this association three years ago, suggested that the courtship of public health and social science had been a long one with honour- able intentions on both sides, but that only recently had a formal union occurred. Dr. Badgley had begun the same paper by referring, as has often been done, primarily to that same plea implied in the opening pages of the report of the Royal Commis- sion on Health Services: Help us "to close the gap between scientific techniques and their application for human welfare" (4).

I wonder if a union whose onset arose from such a plaintive cry of dependence would be considered by the clinical psy- chologists to have much hope?

"I do not know you and I have done very little to find out about you; but you look impressive and you are very learned - please help me solve my problems" is an unlikely basis upon which to build a mar- riage that will be either fruitful or stable.

The social scientist is primarily a scholar, as Professor Foster made so clear in the first paper that I referred to.

We in public health, practitioners as we are, are asking for his help to solve problems which we have defined as being problems. Let us be sure that we know what he has to offer us. Let us not be satisfied thereafter to decide for ourselves

what our problems are but rather enlist his help in redefining them.

Then perhaps, particularly if we use some of the knowledge and skill about learning and about communication that our social science colleagues can offer us, we may be able to work together suffi- ciently well to solve them.

Of course, the public health man and the social scientist, however closely they may work together, cannot alone solve all the problems of ill health that beset mankind. The biological sciences are making at the present time actual advances in new knowledge that are so very real, and so are the physical sciences, and tomorrow we can expect to hear about these. In biology and in the physical sciences new and con- crete advances are arising in a sense that in the social sciences does not apply.

In the social sciences it is quite different. Concepts of culture, of community, of society, and of change are not "new" in the sense that a new drug is "new" or discovery concerning the intricate myster- ies of cell structure is "new". What is "new" in the field of which we are talking, or at least "newly important", is the urgency with which, if we are to solve the health problem of today and advance to a healthy society tomorrow, we must make use of the increasingly well-defined concepts of the social sciences to help us.

In the span of the history of human knowledge, it is not long at all since medicine first used the infant sciences of physics and chemistry and botany and zoology and later biochemistry, bacteriology and pathology and all the subdif- ferentiations of these as tools to start to solve some human problems.

Not so very long ago those problems were very different from what they are now.

It is a very short time ago, indeed, that the largest single causes of death in this country were those which operate today in Asia, Africa and Latin America, the so-called "infectious diseases of child- hood", as we have hitherto defined them. Today, here, despite our relative ignorance about the "causes" of those diseases, death between the ages of one month and 15 years, except from accident and other forms of violence, is a relatively rare phenomenon.

It is not long ago that among adults the




major problems that we were facing were problems of episodic disease, acute illness coming on rapidly, not preventable by known techniques and requiring urgent emergent action of some kind or another, action which of course we were barely able to take until almost yesterday.

The infectious diseases retain great importance, but today in this country the pattern of disease, the human problems that we in public health face, arise from different sources.

There are three major instigators of ill health and death in our modern society.

First, those which operate in the peri- natal period. Secondly, those that are of social and psychogenic origin. Thirdly, the chronic degenerative diseases, cancer, heart disease and the like.

The rate at which the proportion of illness and of death in this country, as in all countries including the poorest, is mov- ing into these three areas in enormously rapid.

Dr. Payne also identified three major social phenomena which he believes are of the ultimate importance to our present world. He call them the three eruptions: "the population explosion, the rising tide of expectations, and, behind them, the bomb". It is not hard, surely, to see the utility of a predominantly social science approach to the solution either of the triad of major health threats as I have briefly outlined them or to the triad of social catastrophe to which Dr. Payne alluded.

"Innovation out of unity" - Dr. Payne was referring there to what he called "a unity of approach between the health pro-

fessions and the social and political sciences" from which we had to seek innovation.

I would suggest that Dr. Payne's unity can come only from mutual understanding through constant interchange of knowledge and ideas, through respect for differing concepts, through understanding between all kinds of scientists, in order that all kinds of knowledge may grow.

His innovations are ultimately those towards which all public health people work - the goal of a society in which all have an equal opportunity to secure a form of health which transcends the ab- sence of disease and embraces true well- being.

No matter how long we may stare down the barrels of a microscope we will not see the ways to change behaviour and so to alter society that the health of man is properly guarded. We may cure through using and applying what we see in the microscope. We can only come before or prevent in the true sense if first we go out and seek, in the stern environment in which man lives, to discern the patterns and the laws that govern that environment. That is what happened, after all, in the physical and biological sciences - pains- taking revelation of structure followed by rigorously precise description of function.

The social sciences are infinitely more capable of this today than they were only a short time ago. We do need their help. Let us do them the justice of trying to understand them and of working with them wisely.

REFERENCES

1. Rosen, George and Welling, Edward: Amer. J. Public Health, 1959, 49: 441.

2. Foster, George: Amer. J. Public Health, 1961, 51: 1286.

3. Payne, Anthony M. M.: "Innovation out of Unity" address delivered at the Six-

tieth Anniversary Conference of the Milbank Memorial Fund, New York, April 1965 (in press).

4. Badgley, Robin F.: Cañad. J. Public Health, 1963, 54: 147.



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