Can health equity survive epidemiology? Standards of proof and social determinants of health

Abstract

Objective: This article examines how epidemiological evidence is and should be used in the context of increasing concern for health equity and for social determinants of health. Method: A research literature on use of scientific evidence of “environmental risks” is outlined, and key issues compared with those that arise with respect to social determinants of health. Results: The issue sets are very similar. Both involve the choice of a standard of proof, and the corollary need to make value judgments about how to address uncertainty in the context of “the inevitability of being wrong,” at least some of the time, and to consider evidence from multiple kinds of research design. The nature of such value judgments and the need for methodological pluralism are incompletely understood. Conclusion: Responsible policy analysis and interpretation of scientific evidence require explicit consideration of the ethical issues involved in choosing a standard of proof. Because of the stakes involved, such choices often become contested political terrain. Comparative research on how those choices are made will be valuable.