Prisoners of the Proximate: Loosening the Constraints on Epidemiology in an Age of Change

"Modern epidemiology" has a primary orientation to the study of multiple risk factors for chronic noncommunicable diseases. If epidemiologists are to understand the determinants of population health in terms that extend beyond proximate, individual-level risk factors (and their biological mediators), they must learn to apply a social-ecologic systems perspective. The mind-set and methods of modern epidemiology entail the following four main constraints that limit engagement in issues of wider context: 1) a preoccupation with proximate risk factors; 2) a focus on individual-level versus population-level influences on health; 3) a typically modular (time-windowed) view of how individuals undergo changes in risk status (i.e., a life-stage vs. a life-course model of risk acquisition); and 4) the, as yet, unfamiliar challenge of scenario-based forecasting of health consequences of future, large-scale social and environmental changes. The evolution of the content and methods of epidemiology continues. Epidemiologists are gaining insights into the complex social and environmental systems that are the context for health and disease; thinking about population health in increasingly ecologic terms; developing dynamic, interactive, life-course models of disease risk acquisition; and extending their spatial-temporal frame of reference as they perceive the health risks posed by escalating human pressures on the wider environment. The constraints of "the proximate" upon epidemiology are thus loosening as the end of the century approaches.