HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Figures Only Full Text Full Text (PDF) All Versions of this Article: AJPH.2007.111278v1 98/2/221    most recent Submit a response Purchase Article View Shopping Cart Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via ISI Web of Science (5) Citing Articles via Google Scholar Google Scholar Articles by Krieger, N. Search for Related Content PubMed PubMed Citation Articles by Krieger, N. Related Collections Social Science Epidemiology Other Environment History Public Health Practice Socioeconomic Factors

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.

This article has been cited by other articles:

				J. Y. Taylor Commentary on "How Family, Community, and Work Structured High Blood Pressure Accounts: From African Americans in Washington State" J Holist Nurs, September 1, 2008; 26(3): 183 - 184. [PDF]

				C. M. Schooling Explanations in practice J. Public Health Med., September 1, 2008; 30(3): 226 - 227. [Full Text] [PDF]

				A. Lippman Human papillomavirus (HPV) vaccination and the development of public policies J. Epidemiol. Community Health, July 1, 2008; 62(7): 570 - 571. [Full Text] [PDF]