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England: Oxford University Press;1997:169-198.

22. Kuh D, Ben-Shlomo Y, eds. A LifeCourse Approach to Chronic Disease Epi-demiology. Oxford, England: OxfordUniversity Press; 1997

23. Power C, Matthews S. Origins ofhealth inequalities in a national popula-tion sample. Lancet. 1997;350:1584-1589.

24. Laurier E, McKie L, Goodwin N.Daily and bfecourse contexts of smoking.SodolHealth Illn. 2000;22:289-309.

25. Krumeich A, Weijts W, Reddy P,Meijer-Weitz A. The benefits of anthro-

pological approaches for health promo-tion research and practice. Health Educfles. 2001;16:121-130.

26. Garcia A. Is health promotion rele-vant across cultures and the socioeco-nomic spectrum? Fam CommunityHealth. 2005;29:20S-27S.

27. Caplan R. The importance of socialtheory for health promotion: from de-scription to reflexivity. Health PromotInt. 1993;8:147-157

28. Bottoroff JL, Oliffe J, Kalaw C,Carey C, Mroz L. Men's constructions ofsmoking in the context of women's to-bacco reduction during pregnancy and

postpartum. SocSdMed. 2006;62:3096-3108.

29. Health Disparities Task Group ofthe Federal/Provincial/Territorial Advi-sory Committee on Population Healthand Health Security. Redudng HealthDisparities—Roles of the Health Sector.Discussion paper, 2005. Available at:http://www.phac-aspc.gc.ca/ph-sp/disparities/pdfD6/disparities_recommended_policy.pdf Accessed Jan-uary 4, 2008.

30. Secretariat for the Healthy LivingNetwork. The integrated pan-Canadianhealthy living strategy, 2005. Available

at: http://www.phac-aspc.gc.ca/hl-vs-strat/pdf/hls_e.pdf. Accessed October18, 2007

31. Hogstedt C, Lundgren B, Moberg H,Pettersson B, Agren G. Forward. ScandJPublic Health. 2004;32:3.

32. Tackling Health Inequalities: A Pro-gram for Action. London, England: UKDepartment of Health; 2003.

33. Potvin L. Managing uncertaintythrough participation. In: McQueen DM,Kickbusch 1, Potvin L, Ftelikan JM, Balbo L,Abel T, eds. Health & Modernity: TheRole of Theory in Health Promotion. NewYork, NY: Springer; 2007:103-128.

Proximal, Distal, and the Politics of Causation: What's LevelGot to Do With It?

Nancy Krieger, PhD

Causal thinking in publichealth, and especially in thegrowing literature on social de-terminants of health, routinelyemploys the terminology ofproximal (or downstream) anddistal (or upstream).

I argue that the use of theseterms is problematic and ad-versely affects public healthresearch, practice, and causalaccountability. At issue aredistortions created by conflat-ing measures of space, time,level, and causal strength.

To make this case, I draw onan ecosocial perspective toshow how public health gotcaught in the middle of theproblematic proximal-distaldivide—surprisingly embracedby both biomedical and socialdeterminist frameworks—andpropose replacing the termsproximal and distal with ex-plicit language about levels,pathways, and power. {Am J

Public Health. 2008;98:221-230.doi:10.2105/AJPH.2007.111278)

PROXIMAL. DISTAL. UPSTREAM.

Downstream. Risk factor. Determi-

nant. Level. Multilevel. These terms

feature prominently in currentdiscussions of causal pathwaysand public health, especially inwork on the social determinantsof health. A central focus is onhow "upstream" societal influ-ences—typically referred to asdistal—shape "downstream," orproximal, exposures, therebyaffecting population health.'"'®Exemplifying this line of thoughtare recent reports issued by theWorld Health Organization Com-mission on Social Determinantson Health^ and the WorldHealth Organization RegionalOffice for Europe.'' Commonassumptions are that (1) diseases

are attributable to many causes,located outside and within thebody; (2) the social lies in therealm of the distal; (3) the bio-logical belongs to the proximal;and (4) the distal and proximalare connected by levels, e.g., soci-etal, institutional, household, in-dividual, which can be conceptu-alized as near to or far from thecauses under consideration. Forexample, as discussed in both re-ports, "distal" societal factorsdrive the risk of smoking; howsmoking harms health involves"proximal" biology.̂ '̂ Whatcould be more obvious?

Yet what seems clear-cut canbe deceiving. I argue that al-though notions oi proximal,distal, and level all matter for elu-cidating causal pathways, clearthinking—and, hence, publichealth research, practice, andcausal accountability—is distorted

by conflating measures of space,time, level, and causal strength.When it comes to causation, it isone thing to think about nearand far in relation to space andtime; it is another matter entirelyto do so for levels. To make thisintellectual argument, I draw onan ecosocial perspective''""^' toshow how public health gotcaught in the middle of the prob-lematic proximal-distal divide-surprisingly embraced by bothbiomedical and social deterministframeworks—and propose replac-ing the terms proximal and distalwith explicit language about lev-els, pathways, and power.

PROXIMAL AND DISTAL INPUBLIC HEALTH THOUGHT

The idea that disease etiologyand distribution are attributableto causes deemed "far" from and

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"near" (including within) thebody is ancient^^"^'; Hippocratictradition, in the 5th century BCE,famously invoked both atmos-phere and individual constitutionas explanations for epidemic dis-ease.̂ '̂̂ ^ By contrast, the ideathat there is a causal etiologicalhierarchy, spanning from distal toproximal, is relatively new. It be-came a core part of the publichealth canon only in themid-20th century CE. How thischange happened and its publichealth implications have been lit-tle discussed.

Strand 1.19th CenturyEmergence of Proximal andDistal as Scientific Terms forSpatiotemporal Scale

Only in the early 19th centuryCE did the terms proximal anddistal enter the scientific dis-course.^^ Invented to describeanatomical location and distance,as measured on a spatial scale,these words were coined by biol-ogists at a time when compara-tive anatomy occupied a keyplace in debates over the classifi-cation and nature of species.^ '̂̂ "Proximal, derived from the Latinnoun proximus ("nearest"), tookon the meaning "situated towardthe center of the body, or thepoint of origin or attachment of alimb, bone, or other structure."^*Its antonym, distal, derived fromdistant, was intended to echo 2other widely used biological con-cepts: ventral and dorsal.^^ Soonother natural sciences adoptedthe terms, albeit 'with some criti-cal modifications. In geology, forexample, the terms took on atemporal as well as a spatial di-mension, reflecting how adjacent

geological strata typically are"close" in time as well as inspace.

The moment time entered thepicture, however, the terms prox-imal and distal were primed todevelop new meanings. This isbecause of the ubiquitousmetaphorical linkage of time,space, and causal reason-

guages, temporal events are de-scribed in spatial terms; Timemoves through space.^"'''̂ "" Thismetaphorical relationship, as ar-gued by the linguist Deutscher, isessential to causal reasoning, be-cause it enables us to "talk freelyabout one thing coming 'from'another, 'out of another, or hap-pening 'through' another, to ex-press abstract chains of causeand event."3"P'̂ '̂

New European scientific dis-coveries of powerful physicallaws for gravity, electricity, andmagnetism''^"•''' further affectedscientific thinking about causa-tion. These inverse square laws,expressed as pithy equations,clarified that force depends ondistance; The more proximal themass or the charge of the inter-acting objects, the greater theforce—and the more powerfulthe effect. It was a short stepfrom here to equate distancewith causal strength, in not onlythe physical but also the life

Strand 2. FromSpatiotemporai Scaie toCausal Hierarchies andLeveis

Not until the later 19th cen-tury, however, did the scientificmeanings of proximal and distal

leap from referring only to spa-tiotemporal scale to also describ-ing levels and causal hierarchies. Intheir new usage, the "closeness"—or "distance"—of levels defined anew type of proximify, one thatcould be measured only concep-tually, not in meters or minutes.

Initially, this conceptualchange occurred within disci-plines focused on a differenttype of body: that of bodypolitic, i.e., the social sci-ences.''^"''^ In books with suchtitles as Social Pathology*' andOrganism and Society,'*'^ influen-tial late-19th century sociolo-gists drew parallels between thebiologically nested hierarchies ofcell-organism-species and thesocially nested hierarchies ofindividuals-families-societies.'^^'.•i6.37(pp4-8).38(pp231-323).40-42 r

their view, just as organs, com-posed of their constituent cells,must collectively work togetherfor an organism to survive, sotoo do social groups and theirconstituent individuals have com-plementary roles they must per-form for society to thdve.̂ '̂̂ * '̂"''̂ ^The intent was counter not onlyto the ruthless competition ofSocial ^ '

contending Marxist view that classconflict determined societies'structure and development.^^'37(pp4-8).41.42(pp 182- 186).43.44(ppl78-179)

Borrowing biological terminol-ogy, these sociologists newly de-ployed the terms proximal anddistal to describe societies' struc-tural "levels."""™"' Ranging fromindividual to institutional, theselevels and the "distance" be-tween them became definedby their nested relationships:

Adjacent levels were "close," andnonadjacent levels were "far."

Meanwhile, biologists likewiseexpanded the use of the termsproximal, distal, and level, bring-ing these terms explicitly intotheir thinking about causal dis-tance. As part of the early 20thcentury modem evolutionarysynthesis, which integrated Dar-winian evolutionary biology,paleontology, and Mendelian ge-netics,'«'«'''«PP5»3-^^"'-'̂ these bi-ologists newly contrasted whatthey termed "proximate" (physio-logical) versus "ultimate" or "distal"(evolutionary) ^35.46(pp,340-,343).47

recognized that asking how a bi-ological event occurs (e.g., amuscle contraction) is not thesame as asking why a biologicalphenomenon exists (e.g., musclesenable locomotion to find foodand flee predators). Drawing onholistic thinking,''̂ '̂ ^ they arguedthat valid explanations could co-exist across levels (e.g., species,organism, ceU, molecule) and in-volve the distant past (evolution)and the immediate present (cur-rent stimulus). In the instant of amuscle contraction, both proxi-mal and distal causes were atplay.

The IVIid-20th Century PublicHealth Embrace of Proximaland Distal

By mid-2 0th century, to beclose or far could thus refer tospace, to time, to lineage, or tolocation in hierarchical concep-tual levels. The terms proximaland distal thus became 'widelyencompassing terms to express—and contest—causal conceptionsin both the social and the natural

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sciences. Amid these divergentuses, the terms proximal and dis-tal finally entered the publichealth causal lexicon.

Prompting their adoption wasgrowing recognition that the fieldof public health, still riding thecrest of enonnous success againstinfectious diseases in the 19thand 20th centuries CE, had tomove beyond a monocausal to amultifactorial account of diseasecausation, which involved notonly the agent but also the hostand the environment'"'^"''''''"^'As exemplified by the findings ofthe Framingham study of heartdisease, rising rates of chronicdisease and cardiovascular mor-tality seemed to be attributablenot to any one single exposurebut instead to a variety offactors,^'"''' leading the Framing-ham researchers to coin the termrisk factor to describe thesepartial—i.e., not sufficient, not al-ways necessary, but nonethelesscontributing—componentcauses.^''

It was through the multifactor-ial perepective that the termsproximal and distal emerged asterms for the discussion of causal-ity in the public health litera-ture.'^ Unfortunately, however,their new usage drew on shallowunderstandings of the terms nearand far that impeded rather thandeepened multilevel thinking.The essential features of themultifactorial framework remainwell-sketched by the still highlyinfluential spiderless" "web ofcausation," Bret articulated in the1960s^'' and which, as I havepreviously argued,'^ (1) leveledall exposures to a single plane;(2) defined "proximal" factors to

be those operating directly on orwithin the body, and relegated allother exposures to the murkyrealm of "distal"; (3) linked causalpotency to distance—i.e., the"closer" the cause, the greater theeffect (following the logic of thepreviously described physical in-verse squcire laws); (4) held thatdistal causes necessarily exertedtheir influence through succes-sively more proximal factors;

(5) took a studied agnosticism asto what accounted for the arrayof exposures included in the weband eschewed any discussion ofpower or injustice; and, hence,(6) adopted a narrow stance ofwhat may best be termed causalpragmatisrr?^'^'''' that prioritizedfocusing on what they consideredto be "proximal" factors ostensi-bly amenable to control by eitherindividuals or by public health ormedical professionals (includingby health education) rather thanwhat they termed the more "dis-tal" determinants requiring socie-tal change.

The use of the terms proximaland distal persists to this day. Itunderlies the 21st century suc-cessor to the web of causation—that is, the "gene-environmentinteraction" framework,̂ ^~^°which posits that the occurrenceof common and complex dis-eases reflects the interplay of in-dividual genetic variability withan array of exogenousexposures.^^"''" Work in this areais chiefly engaged^^""" (albeitwith some exceptions"'"*^ )̂ in thequest to discover genetic deter-minants of biological susceptibil-ity and to develop pharmacologi-cal interventions that can blockdeleterious gene expression.'

The proximal-distal discourselikewise pervades the social de-terminants of health perspec-tive,'""^ which holds that "distal"institutional priorities and prac-tices of government and the pri-vate sector shape people's cumu-lative exposure, across the lifecourse via intermediary path-ways, to the proximal physical,behavioral, psychosocial, and bio-logical exposures that triggerpathogenic processes (includinggene expression), thereby causingdisease. Secondarily, once illnessoccurs, the social determinants ofhealth framework asks how prog-nosis is affected by socially pro-duced inequities in access toneeded medical care.'"'"

In both cases, causal distancestill matters for causal strength:In the gene-environment interac-tion model, "proximal" causes re-main most potent, whereas forthe social determinants of healthperspective, "distal" causes aredecisive. Despite their fundamen-tally different approaches, bothframeworks cling to the proxi-mal-distal divide. This little re-marked convergence hints thatsome causal logic may be askew.

AN ALTERNATIVEECOSOCIAL APPROACHTO LEVELS, EMBODIMENT,AND ACCOUNTABILITY

I suggest that one reason theproximal-distal terminology canbe so readily used by such totallydisparate frameworks is theirnow deeply enti'enched confla-tion of relationships amongspace, time, distance, levels, andcausal potency. Three examples,based on arguments offered from

an ecosocial perspective (Figure 1,Table l),''^""^' supplemented bythe conceptual clarifications pro-vided in Box 2, illustrate theproblems that can arise whenlogics of scale are confused withanalysis of levels and when dis-tance is conflated with power.

The basic point is that societalpatterns of disease represent thebiological consequences of theways of living and working dif-ferentially afforded to the socialgroups produced by each soci-ety's economy and political pri-orities.''^"^' Class and racialinequality, for example, differen-tially affect the living standards,working conditions, and envi-ronmental exposures of thedominant and subordinatedclasses and racial/ethnic groups,thereby creating class and ra-cial/ethnic health disparities.Stated more generally, a soci-ety's economic, political, and so-cial relationships affect bothhow people live and their eco-logic context, and, in doing so,shape patterns of disease distri-bution. The understanding ofthe societal distributions ofhealth thus cannot be divoi'cedfrom considerations of politicaleconomy and political ecol-ogy.'""^' Driving health in-equities are how power—bothpower over and power to do,''''"*'*including constraints on andpossibilities for exercising eachtype—structures people's engage-ment with the world and theirexposures to material and psy-chosocial health hazards. Notably,neither type of power readilymaps onto a metric of proximalor distal. Nor do they neatly par-tition across levels. A critical

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ECOSOCIAL THEORY:LEVELS, PATHWAYS & POWER

Levels: societal& ecosvstem

Processes:production,exchange,consumptions,reproduction

-Embodiment-Pathways of embodiment-Cumulative interplay of exposure,

susceptibility & resistance-Accountability

racial/ethinequality global

national

regionalPopulationdistribution

of heaithinequalityarea or group

household

individuai

historicalcontext +

generationgender

inequalityLifecourse:

in utero infancy childhood adu thoodNote. To explain current and changing population distributions of disease, inciuding health inequities, and who and what is accountable for the societal patterning of health, it is necessary toconsider causal pathways operating at multiple leveis and spatiotemporal scales, in historicai context and as shaped by the societal power relations, material conditions, and sociai and biologicaiprocesses inherent in the political economy and ecology of the populations being analyzed. The embodied consequences of societal and ecologic context are what manifest as popuiationdistributions of and inequities in health, disease, and well-being.Source. See references 1,17-21.

FIGURE 1-A heuristic diagram for guiding ecosociai anaiyses of disease distribution, popuiation iieaitii, and heaitii inequities.

corollary is that, contrary to thelogic of the proximal-distal di-vide, within the very phenom-ena of disease occurrence anddistribution—just as in a musclecontraction—the distal and theproximal are conjoined.

Example 1. WhySpatiotemporai Scaie Is Notthe Same as Level

The first example, drawn fromecology, the original multilevel

science, clarifies why populationsciences cannot afford to confusemetrics of spatiotemporal scalewith the phenomena of levels.The example concerns, literally,the forest and the trees. Forestsare levels within ecosystems,which involve not only trees butalso the other plants and animalsthat inhabit them.'̂ ''-̂ ^ Notably,forests can be lai^e or small(a spatial metric), as well as old oryoung (a temporal metric). Indeed,

one key issue in conservationecology today, spurred by intensi-fied commercially driven loggingand deforestation, forest fragmen-tation, habitat degradation, andspread of zoonoses (e.g., Lyme dis-ease), is just what size, spatially, anexpanse of woods needs to be—and how close it needs to be toother such expanses—to lunctionas a particular type of forest^^"'^Too small, with the ratio of edge-to-interior too high, or too spatially

isolated, without connecting corri-dors, and its species compositionwill change, often losing diversity,including to the point of outrightextinction.''^"'''

The phenomenon of a forest(a level), and interactions amongboth the entities that constitute itand also between the forest andits environs, is affected by, butnot identical to, the forest's size(spatiotemporal scale). Similarly,for measles to become endemic

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TABLE 1-Core Constructs of Ecosociai Theory-an Epidemioiogicai Theory of Disease Distribution-andSome Predictions

Construct Elaboration

Pathways of embodiment

Embodiment A concept that refers to how we literally incorporate, biologically, the material and social world in

which we live, from in utero to death; a coroliaiy is that no aspect of our biology can be

understood absent knowledge of history and individual and societai ways of living.

Epidemiologicaily, "embodiment" is thus best understood:

(1) As a construct, process, and reaiity, contingent upon bodily existence;

(2) As a multilevel phenomenon, integrating soma, psyche, and society, within historical and

ecological context, and, hence, an antonym to disembodied genes, minds, and behaviors;

(3) As a clue to life histories, hidden and revealed; and

(4) As a reminder of entangled consequences of diverse forms of social inequality.

Causal pathways that involve exposure, susceptibility, and resistance (as both social and biological

phenomena), structured simultaneously by (1) societai arrangements of power, property, and

contingent patterns of production, consumption, and reproduction, and (2) constraints and

possibilities of our biology, as shaped by our species' evolutionary history, our ecologic context,

and individual histories, that is, trajectories of biological and sociai development, and that

involve gene expression, not just gene frequency.

Expressed in pathways of embodiment, with each factor and its distribution conceptualized at multipie

levels (individual, neighborhood, regional or political jurisdiction, national, international, or

supranational) and in multiple domains (e.g., home, work, school, other pubiic settings), in relation

to relevant ecoiogic niches, and manifested in processes at multiple scales of time and space.

Refers to who and what is responsible for social inequaiities in heaith and for rectifying them, as well

as for the overall current and changing contours of population health, as expressed in pathways

of and knowledge about embodiment. At issue are the accountability and agency of not only

institutions (government, business, and pubiic sector), communities, households, and individuals,

but also of epidemiologists and other scientists for theories used and ignored to explain social

inequalities in health.A corollary is that, given likely complementary causal explanations at

different scales and levels, epidemioiogicai studies should explicitly name and consider the

benefits and limitations of their particular scale and level of analysis.

Determinants of disease distribution (a population-level phenomenon) presume but are not reducible

to mechanisms of disease causation (which occur within individuals' bodies). Key contingent

hypotheses are: (1) population patterns of health and disease constitute the embodied biologicai

expression of ways of living and working differentially afforded by each society's political economy

and political ecology, and (2) policies and practices that benefit and preserve the economic and

sociai priviieges of dominant groups simultaneously structure and constrain the living and working

conditions they impose on everyone else, thereby shaping particular pathways of embodiment.

Source. See references 1,17-21.

Cumulative interplay among exposure,

susceptibility, and resistance

Accountability and agency

Analytic implications and predictions

with a community (a level),community size (a scale) mustexceed 250000 people.'""Hence, argument 1: Confusescale and level—or consider onlyone, not both—and understand-ing of population phenomenawill be undermined.

Example 2. On Nonlinear

Causal Pathways, With

immediate and Long-Term

Effects

The second example illus-trates that levels need not playby the proximal-distal schemathat the path from what is

considered "far" to "near" nec-essarily travels through what istermed "intermediate." This isbecause events at one level candirectly and profoundly affectnonadjacent levels, instantlyand persistently, without

Consider, for example, the1973 US Supreme Court rulingthat legalized abortion, on thegrounds of individuals' rights toprivacy.*" Here, the levels atissue were defined jurisdiction-ally, with the federal judicial rul-ing on individual constitutionalrights overturning federal andstate laws that interfered with in-dividual privacy by prohibitingabortion. In this case, the so-called distal determinant (1) di-rectly affected individual girls'and women's reproductive rightsand (2) reverberated up to otherlevels, by requiring changes instate laws and by expanding thepermitted range of services thatcould be provided by health pro-fessionals and health facilities.

The positive health conse-quences were both immediateand long-term: US girls andwomen alike no longer wereforced, by law, to face the risk ofhaving an unsafe illegal abortionand they were also less likely tobear unwanted children, therebyreducing risks of adverse mater-nal and birth outcomes.*'"*''More recent US Supreme Courtdecisions restricting the right toabortion likewise illustrate thisprinciple of skipping levels, withcontrary effects.*^*'*

Analogous examples can read-ily be drawn from the health andhuman rights literature, wherebystate obligations to respect, pro-tect, and fulfill individuals' humanrights affect policies and interven-tions at multiple levels.**' The im-plication, argument 2, is that non-adjacent levels can have directcausal relationships, an insightobscured by the proximal-distallogic.

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TABLE 2-Proximai and Distai, Spatiotemporai Scaie Versus Levei-iVieanings, Contrasts, and Causai impiications

Spatiotemporai Scaie

Categoiy Space Time tevel

Metric of distance Units of spatial distance, measured in nested increments;

examples include: kilometer-meter-miilimeter-

micron; or miie-foot-inch

Units of temporal distance, measured In nested

increments; examples include: miliennium-

century-year-day-hour-minute-second-

miliisecond

"Near"

"Far"

Strength of effect

Typicai causal

inference

Proximal, near in space, close

Distal, distant in space, far away

Usually inverse relationship of spatial distance and force:

closer "Stronger, hence

proximal-powerful;

farther-weaker, hence

distal-dilute

Proximal-stronger cause

Oistai-weaker cause

Proximal, near in time, recent

Distal, distant in time, long ago

Usually inverse relationship of temporal distance

and force:

closer-stronger, hence

proximal-powerful;

farther-weaker, hence

distal-dilute

Proximal - stronger cause

Distal-weaker cause

Relationship to Physical distance is a spatial dimension distinct from

space and time, but space and time can be reiated

time mathematically, e.g., distance = speed xtime

(and the length of a meter is now defined in

relation to time and the speed of

Chronological distance is a temporal dimension

distinct from space, but time and space can

be reiated mathematically, e.g., t ime-

distance/speed (and initiai time units were

based on the earth's rotation, involving

spatial distance^

Adjacency of levels, which can be organized-theoretically,

conceptually, or structurally-as nested or nonnested

hierarchies; examples include:

(1) nested: nation-region-city-neighborhood-househoid;

or ecosystem-species-organism-organ

system-organ-cell;

(2) nonnested: school | workplace | neighborhood-individual

Conceptual or stmctural nonscalar relationship: adjacent levels

Conceptual or structural nonscalar relationship: nonadjacent levels

Cannot predict "strength" of "effect" based solely on ievel: a

given phenomenon at any given level potentially can powerfully

or weakly affect or be affected by phenomena at the same

level, adjacent levels, and nonadjacent leveis

Causal inference depends on level of question being asked: There

may be different explanations for phenomena at different

leveis, and explanations for events observed within any given

level may involve solely phenomena within that level or also

interactions between levels; adjacency of levels may or may not

predict causal strength of cause-effect relationship

Level is not a spatiotemporal phenomenon. It is, instead, a conceptual

nonspatiotemporal relational construct that organizes and

distinguishes (conceptually or structurally) different orders

of hierarchically linked systems and processes (including

both nested and nonnested hierarchies). "Distance" for

levels does not involve spatiotemporal separation: For any

phenomenon at any given point in space and time, all levels

co-occur simultaneously, even though some levels may be

more causally relevant than others to phenomena occurring

at any given level. Space and time nevertheless do matter

for ieveis in the case of nested hierarchies, whereby units

within lower-order ieveis typically are smaller and involve

faster processes than units in higher-order levels.

Exampie 3. On Leveis and

the Perils of Commodity

Fetishism—the Simultaneity

of iVIateriai Properties and

Sociai Reiations

The third example involves akey problem that permeates

the proximal-distal divide: itsincompatibility with truly multi-level thinking. This problem canbe likened to the old-fashionederror of "commodity fetishism,"albeit multiplied. In its originalusage, this concept, introduced

by Karl Marx (1818-1883),referred to how the value ofcommodities was mistakenly as-sumed to be an intrinsic prop-erty, rather than a consequenceof the complex relationships ofownership, labor, and exchange

inherently involved in theirproduction, sale, and consump-

ever, in both directions, whetherlooking up or down levels, theproximal—distal divide simultane-ously does the following:

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(1) It promotes analysis ofspecific exposures and their bi-ological embodiment strippedfrom the political economy, so-cial relations, actual labor, andengagement with the materialworld that set the basis fortheir existence (the error ofbiomedical individualism anddecontextualized "lifestyle"analyses'-^''*^-^') and

(2) It encourages analysis ofpopulation health as if all thatmatters are social hierarchies, andnot also the tangible properties ofthe commodities, i.e., goods andservices, at issue (the error of

public health nihili

Thus, on the proximal side, of-ficial conventional reports^ '̂̂ ^urge individuals to avoid specificrisk factors without mention ofthe societal changes needed tocurtail these factors' production,distribution, and consumption(precisely what the social deter-minant of health Iramework ap-propriately criticizes),'"^'whereas on the distal side, somecontend that public health initia-tives that focus on specific riskfactors or diseases are futile aslong as "distal" or "fundamental"causes are at play.'̂ '̂ '̂ ^"^^

But insofar as health is con-cerned, the material substancesand the social relations inherentin any given product or processboth matter, precisely because ofthe physical and social exposuresinvolved. To focus on only one orthe other misses the fact we em-body both.''^-^''^^'oo-'o^ To takebut one example, consider thepolitical economy and ecology oftobacco products and their em-bodied health consequences. A

cigarette (or Freud's infamouscigar'"^) is simultaneously:

(1) A combustible mass of to-bacco leaves and additiveswhose burning smoke transportspsychoactive and addictivechemicals (e.g., nicotine) and car-cinogens deep down the respira-tory tract to the inneniiost partsof the lung and its alveolar capil-laries, thereby increasing risk ofcancer, cardiovascular and pul-monary disease, and other smok-ing-related ailments, and

(2) A highly profitable productwhose production, distribution,advertisement, and consumptioninvolves relentless corporatemarketing (including manipula-tion of ideologies involving free-dom, class, gender, sexuality, andrace/ethnicity and targeting ofmarginalized groups), govern-ment regulation and taxation, to-bacco farmers and workers, landownership, trade agreements,and international treaties.'"^"'"^

Consequently, as recognizedby several new sophisticatedmultilevel initiatives (e.g., Swe-den's 2003 new public healthpolicy,"" the American LegacyFoimdation's Truth Campaign,'"and the Corporations and HealthWatch project"^), effective actionto curb tobacco use and socialdisparities in tobacco-related dis-eases requires integrated, multi-faceted, multilevel campaignsthat are relentlessly honest aboutwho gains and who loses fromthe status quo. The same couldbe said for any other publichealth concerns deemed "proxi-mal" or "dovmstream," whetherabout environmental and

occupationalaccess to safe water,'"'"* accessto affordable nutritious food,"**'̂ "or violence,'̂ '"'̂ ^—just as couldbe said for efforts focused onsuch ostensibly "distal" or "up-stream" social determinants aseconomic poverty.'^''~'^°

Hence, argument 3: Unlikedistal and proximal events sepa-rated by space or time, levels co-exist simultaneously, not sequen-tially, and exert influenceaccordingly. The proximal-distaldivide, however, inherentlycleaves levels rather than con-nects them, thereby obscuringthe intermingling of ecosystems,economics, politics, history, andspecific exposures and processesat every level, macro to micro,from societal to inside the body.As William Blake (1757-1827)famously put it, the challenge in-stead is "to see a world in agrain of sand"'^'—because it isthere.

SCALE, LEVEL, AND THEPOLITICS OF CAUSATION

In summary, efforts to ad-vance public hecilth thinking andwork about the causes of diseasedistribution, including health in-equities, would do well to aban-don the deeply confused lan-guage of the terms proximal anddistal The point is not simply se-mantic. Clear action requiresclear thinking. By deleting theterms proximal and distal Iromthe public health lexicon, wewould have to expose our causcilassumptions and also promotegreater accountability for thepublic's health, both within ourfield and more broadly.

A final example suffices. In re-cent years, the Bill and MelindaGates Foundation has become anenormous presence in work onglobal health,'̂ ^-'̂ = funding tech-nically oriented'^'' research andmedical interventions to addressmalaria, tuberculosis, HIV/AIDSand other diseases that dispropor-tionately burden poorer regionsof the world. In January 2007,however, the Los Angeles Timespublished a 2-part expose,'̂ '̂̂ ®"showing that the foundationreaps vast financial gains everyyear from investments that con-travene its good works. "'•'̂ Thefoundation's response'''":

"The stories you told of peoplewho are suffering touched us all.But it is naive to suggest that anindividual stockholder can stopthat suffering. Changes in our in-vestment practices would havelittle or no impact on these is-sues. While shareholder activismhas worthwhile goals, we believea much more direct [italicsadded] way to help people is bymaking grants and working withother donors to improve health,reduce poverty and strengtheneducation."'""

The foundation's view that itsreal-world health portfolio some-how includes only its explicitbiomedical research and healthintervention projects and notalso the health impacts of its fi-nancial investment strategies isthe mind-set fostered by theproximal-distal divide. The dis-tance and contradictions createdby the proximal-distal discourse-in conceptual understanding andin professional and politicalaccountability—are unacceptable.The extensive reach of this

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flawed logic is made only themore manifest by its equal useamong those who profess a nar-row biomedical vantage andthose who articulate a more ex-pansive social determinants ofhealth framework. I accordinglypropose that we banish theterms proximal and distal fromthe public health lexicon andrefer instead explicitly to levels,pathways, and power, as onesmall but needed step towarddeveloping better thinking andstrategies for leveling healthinequities. •

About the AuthorNancy Krieger is with the Department ofSodety, Human Development, and Healthat the Harvard School of Public Health,Boston, Mass.

Requests for reprints should be sent toNancy Krieger, PhD, Professor, Depart-ment of Sodety, Human Development,and Health, Harvard School of PubiicHealth, Kresge 717, 677 Huntington Ave,Boston, MA 02115 (e-mail: nkrieger@hsph.harvard.edu).

This article was acceptedjune 7,2007

AcknowledgmentsThe author thanks the fottowing cot-leagues for useful discussions about theideas in this article: George DaveySmith, Mary Bassett, Madeline Drexler,Sofia Grusttin, and Elizabeth Barbeau.

Human Participant ProtectionNo research on human subjects wasperformed.

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