Trying to prevent the transmission of infectious disease involves us in the social world. While clinical medicine focuses on individuals, public health continually traverses between individuals, populations, and their social and environmental contexts. But what tools do we have for exploring the social relations that connect individuals, populations, and contexts? The need to focus on the social relations that bind and fragment people clearly emerged in Coleman et al.’s groundbreaking study (Medical Innovation: A Diffusion Study. New York, NY: The Bobbs-Merrill Company; 1966) of how doctors started prescribing new drugs. While individual factors (e.g., integration in a professional community) and structural factors predicted some change in prescribing habits, the more substantial change was best explained by the relationships between doctors. Importantly, the mechanisms entailed in these social relationships were not universal—for example, in some cities friendships between doctors mattered more than professional relations, in others vice versa. This finding indicates that, akin to epidemiological outbreak investigations, social relations are questions that demand exploration. Using arrows in a model to represent the relations between individuals, communities, populations, and contexts misleadingly evokes predictable, causal relationships; social relations are better represented with question marks.

Hence, “knowing your epidemic” involves not only understanding the virus, individuals’ experiences, and the socioenvironmental determinants that emerge in the patterning of disease; it entails understanding the continually shifting social connections involved in transmission, practices that have shared or different meanings for the people involved, and meanings that are more or less integral to transmission, and which may ultimately refuse to be fixed. As virologists studying emergence have done, it is time to forgo any assumptions that social relations are fundamentally predictable.

Coleman et al.’s study only takes us so far. Infectious disease occupies the terrain of ordinary, everyday connections between people, one organized very differently from that of medicine in the 1960s. For Coleman et al., what was being introduced (the new drug) was unquestionably innovative, but public health interventions into infectious disease may miss their mark if what counts as innovative is already decided. Understanding infectious disease involves asking in what directions (which are often numerous, disparate, and contested) relevant social practices are moving, and why the people involved see these trajectories as more or less promising, more or less innovative.

What has been called a social public health (Henderson K, et al. Enhancing HIV prevention requires addressing the complex relationship between prevention and treatment. Global Public Health. 2009;4[2]:117–130) follows New Public Health's interest in empowered communities. But there is a difference: New Public Health interventions ultimately aim to ensure that individuals (think of those models of concentric circles), by virtue of their place in an empowered community and enabling contexts, are able to choose to act appropriately. Intervention success boils down to individuals’ choices. By contrast, social public health aims to insert interventions into the relations between people: as their adoption into people's lives involves discussion (and contestation) these interventions are necessarily transformed. For instance, HIV testing and counseling has morphed into a range of social practices, including “negotiated safety” between regular partners who test negative and serosorting between either HIV-negative or -positive people in a range of sexual relationships. Intervention success hinges not only on its insertion into relations but the often unpredicted trajectories it follows once embedded. For this reason, the full impact and life of public health interventions can only be understood by tracing and continuously responding to the creative ways in which they become embedded in people's social practices.

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Niamh Stephenson, PhDSchool of Public Health and Community Medicine, University of New South Wales “A Social Public Health”, American Journal of Public Health 101, no. 7 (July 1, 2011): pp. 1159-1159.

https://doi.org/10.2105/AJPH.2011.300240

PMID: 21653243