“PROXIMAL, DISTAL, AND THE

POLITICS OF CAUSATION: WHAT’S

LEVEL GOT TO DO WITH IT?”
Nancy Krieger

Clarice Amorim
Levels of Causation in Public Health
“Although notions of proximal, distal, and level
all matter for elucidating causal pathways, clear
thinking […] is distorted by conflating measures
of space, time, level, and causal strength.

When it comes to causation, it is one thing to

think about near and far in relation to space and
time; it is another matter entirely to do so for
levels.”
Spatiotemporal Scales
• The terms “proximal” and “distal” were originally used to
describe anatomical location and distance, as measured
on a spatial scale.

• These terms primed to develop new meanings the

moment time entered the picture; temporal events are
described in spatial terms.

• It was a short step to equate distance (in time or space)

with causal strength.

• In causal hierarchies, “closeness” and “distance” can

only be measured conceptually.
Mutually Exclusive Causes?
“In the instant of a muscle contraction, both proximal and
distal causes were at play.”
Web of Causation Proximal factors These are
operate directly on also “easier”
or within the body. to address.
All exposures are on
a single plane.

Where are
“power” and
“injustice?

Distal factors exert their influence

through proximal factors.
These require societal change.
Social Determinants of Health
Cumulative
exposures

Disease
triggers

Where are
“power” and
“injustice?
Ecosocial Approach
• Combustible mass of tobacco
leaves and additives whose
burning transports nicotine and Levels coexist simultaneously!
carcinogens into one’s body,
increasing the risk for cancer
and other chronic diseases.

• Highly profitable product whose

production, distribution,
advertisement, and consumption
involves relentless corporate
marketing, government
regulation and taxation, famers
and farmworkers, trade
agreements and international
treaties.
Ecosocial Approach

• Economic, political, and social relationships affect

how people live; therefore, the social distribution of
health cannot be divorced from political economy and
political ecology.

• Power drives inequities in health; it does not directly

translate into “proximal” or “distal” and does not neatly
partition across “levels”.
Ecosocial Approach
Core Constructs
• Embodiment: people incorporate biologically the material and social
world in which they live.
• Pathways of embodiment: involve exposure, susceptibility, and
resistance structured by societal arrangements of power and constraints in
our biology.

• Cumulative interplay: exposure, susceptibility, and resistance

interplay on multiple levels and domains, across time and space.

• Accountability and agency: who and what are responsible for

social inequities in health.

• Analytic implications and predictions: determinants of disease

distribution are not reducible to mechanisms of disease causation.
 THE THEORY OF TRIADIC INFLUENCE
Levels of Intrapersonal Stream Social/Normative Stream Cultural/Attitudinal Stream
Causation Biological/Nature Nurture/Cultural

Ultimate
Causes
BIOLOGY/ SOCIAL CULTURAL
PERSONALITY SITUATION ENVIRONMENT
1 2 3 4 5 6
a f
Social/
b c d e
Personal Sense of Social Interpersonal Others’ Interactions w/ Information/
Self/Control Competence Bonding Beh & Atts Social Instit’s Opportunities
Nexus

Distal
Influences
7 8 9 10 11 12
g h i p q r
k n
Expectancies Self Skills: j Motivation l m Perceived o Values/ Knowledge/
Determination Social+General to Comply Norms Evaluations Expectancies
& Evaluations

13 14 15 16 17 18
s x
Affect and SELF-EFFICACY t u SOCIAL v w ATTITUDES
Cognitions BEHAVIORAL NORMATIVE TOWARD THE
CONTROL BELIEFS BEHAVIOR
Proximal
19 20 21
Predictors
Decisions DECISIONS/INTENTIONS
A B C I H G
D E F 22
Trial Behavior
EXPERIENCES: Expectancies -- Social Reinforcements -- Psychological/Physiological
Experiences 23 K
Related Behaviors
J
13
Discussion

• Should researchers in the field of health promotion stop

using the terms “proximal” and “distal”?

• In what ways can we make the role of power in driving

health inequities more explicit?