I think that social epidemiology's challenge is less that it does not recognize nuance and complexity fo what drives behavior and more that it does not have effective tools for addressing the social forces that drive health. That's why drugs like ozempic are attractive - it is a tool that can be identified and purchased.

At the same time, I think public health as a whole has drifted away from a foundational tenets and toolkits - like sanitation, surveillance and population-level intervention. In our "post-war" condition, why are we not throwing weight behind air cleaning both for infectious disease and pollutants? Why have we allowed our surveillance systems been undercut and diminished? Why do we promote individual health risk assessment without offering either adequate (fulsome!) education on what risk looks like or simple, data-based tools in order to effectively evaluate it? People are TRYING, but public health has gone quiet.

I think public health practitioners, because they are scientists, are afraid to get political, but it is clear that certain political-economic forces (eg, capitalism) are killing people. At least in the US, the population is begging for enlightened leadership and radical challenges to the status quo. We have worker shortages, drops in test scores, chronic absenteeism, people demonstrating in the streets, soaring rates of mental health issues, dire climate reporting, rampant mistrust of government, etc, there is only opportunity here for public health to step in and show a better path forward.

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"In my academic and professional life, I have been, broadly defined, a social epidemiologist, concerned with the social structures that generate health"

White men account for 75% of suicides, White women account for another 15% of suicides, and men of all races account for 80% of suicides. Have you studied the disproportionate suicidality of those demographics?

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I very much appreciated this nuanced read. It strikes me that in both the example of obesity drugs, and structural factors, that both perhaps fail to see the individual as a potential protagonist. In the first instance, it is a matter of a prescription, by a medic, of a drug, produced by a company, a wider system and series of experts that hand down a cure. In the latter, we speak of the role of structural factors, which are certainly indisputable, but again, are sometimes framed as forces that the individual can't possibly overcome, as if they had already won or lost the lottery of chance. The impacts of both on health are indisputable, but surely, the goal ultimately of health, is as a means to an end, and that end being that one can be a protagonist in ones own destiny. Perhaps a more equitable health will not be a matter of winning arguments among experts, but a matter of more and more people being empowered to be a protagonist in the nations health. I like to think that these blogs are an effort to empower more and more people with the understanding of what truly generates health, so that they can be a protagonist in improving it, wether it is through their work, their relationships, their vote, or even just their beliefs.

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Appreciate this attention to personal agency, always considering individuals' true ability to have a choice and then to make the right choice in their time, place, culture, system, etc.

The posting got me thinking of Dr. Walter Willett's interesting list of the top eight ways to live a healthy life, wondering how many are grounded in behavioral choices.

ChatGPT produced the following list, and caveat at the end:

"Pick your parents well: Acknowledges the role of genetic factors and family history in health outcomes.

Don't smoke: Avoid tobacco use in any form, as smoking is a significant risk factor for numerous diseases.

Be physically active: Engage in regular exercise and maintain an active lifestyle to promote cardiovascular health and overall well-being.

Eat a healthy diet: Emphasizes the importance of consuming a balanced diet rich in fruits, vegetables, whole grains, lean proteins, and healthy fats while minimizing processed foods, sugary drinks, and excessive sodium intake.

Maintain a healthy weight: Strive to achieve and maintain a body weight that is appropriate for your height, age, and body composition.

Drink alcohol in moderation: If you choose to consume alcohol, do so in moderation, following recommended guidelines and being mindful of potential risks and health consequences.

Protect yourself from the sun: Take appropriate measures to protect your skin from harmful ultraviolet (UV) radiation, such as wearing sunscreen, seeking shade, and using protective clothing.

Get enough sleep: Prioritize adequate sleep duration and quality, as proper rest is crucial for overall health, cognitive function, and emotional well-being.

It's important to note that while these components are generally associated with Dr. Walter Willett, variations of this list may exist with different authors or sources."

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Thanks for your comment, which reminded me of David Gordon's alternative 10 tips for better health:

1. Don't be poor. If you can, stop. If you can't, try not to be poor for long.

2. Live near good supermarkets and affordable fresh produce stores.

3. Live in a safe leafy neighborhood with parks and green space nearby.

4. Work in a rewarding and respected job with good compensation, benefits and control over your work.

5. If you work, don’t lose your job or get laid off.

6. Take family vacations and all the benefits

you are entitled to.

7. Make sure you have wealthy parents.

8. Don’t live in damp, low-quality housing, next to a busy road or near a polluting factory.

9. Be sure to own a car if you have to rely on neglected public transportation.

10. Learn how to fill in the complex housing benefit application forms before you become homeless and destitute.

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In the context of variables that affect health, we do have to recognize the impact of large corporations that market food, tobacco and drinks that can be harmful to health. The record of the tobacco companies is clear, from developing an addictive product, marketing by giving free samples to soldiers in WWII and later, and then selling their brands with proven techniques. Food companies have done the same with calorie dense snack foods, marketed effectively and developed to appeal to tastes preferences. There is targeted marketing toward certain groups (e.g. menthol cigarettes marketed to African American communities). This is a variable outside socioeconomic status, genetics and other factors you have named and in some ways the most difficult to manage.

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White men account for 75% of suicides, White women account for another 15% of suicides, and men of all races account for 80% of suicides. Suicide is in the top 10 causes of death in the USA for men. Unfortunately, Dr. Galea didn't mention this issue.

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When speaking about genetic traits making people act in a certain way that can termed as good or bad behavior in terms of Health choices. It is important to recognize and understand the role of the interplay of nature vs nurture that determines phenotype variability: Penetrance and expressivity.

An individual born with a genetic trait for healthy habits and a healthy body may get influenced by the nurturing that decides the outcome to have healthy habits or not. So the genes are for healthy behavior but the expressivity is not. That can also be related to the theory of acquired and inherited traits, the classical example being the Lysenko affair. Another aspect could be providing choices in terms of greater autonomy in terms of education, better living conditions, equitable distribution of wages, and removing racial biases that together account for a healthy mindset leading to healthy habits. An example that we both can relate to, i.e. forcing an international student to study a subject that one is not interested that minimizes the chances of the success of the student, especially when one is about to graduate in a few months. Such an action disturbs the mental health of an individual despite the fact the individual is overall healthy and zealous to take on life challenges. But the sudden change disturb the pace of the student, making it difficult to decide whether the change was necessary or had some vested interests putting the student in a state of limbo. That makes it even more difficult to decide from where the problem of bad behavior is stemming from and affecting whom, whether in an active or passive manner. A certainly very good point to reflect on.

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