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Nancy Krieger, PhD

Nancy Krieger is with the Department of Society, Human Development, and Health at the Harvard School of Public Health, Boston, Mass.

Correspondence: Requests for reprints should be sent to Nancy Krieger, PhD, Professor, Department of Society, Human Development, and Health, Harvard School of Public Health, Kresge 717, 677 Huntington Ave, Boston, MA 02115 (e-mail: nkrieger{at}hsph.harvard.edu).

Causal thinking in public health, and especially in the growing literature on social determinants of health, routinely employs the terminology of proximal (or downstream) and distal (or upstream).

I argue that the use of these terms is problematic and adversely affects public health research, practice, and causal accountability. At issue are distortions created by conflating measures of space, time, level, and causal strength.

To make this case, I draw on an ecosocial perspective to show how public health got caught in the middle of the problematic proximal–distal divide—surprisingly embraced by both biomedical and social determinist frameworks—and propose replacing the terms proximal and distal with explicit language about levels, pathways, and power.