Public Health's Next Step in Advancing Equity: Re-evaluating Epistemological Assumptions to Move Social Determinants From Theory to Practice

The field of public health has increasingly promoted a social ecological approach to health, shifting from an individual, biomedical paradigm to a recognition of social and structural determinants of health and health equity. Yet despite this shift, public health research and practice continue to privilege individual- and interpersonal-level measurements and interventions. Rather than adapting public health practice to social ecological theory, the field has layered new concepts ("root causes," "social determinants") onto a biomedical paradigm-attempting to answer questions presented by the social ecological schema with practices developed in response to biomedicine. This stymies health equity work before it begins-limiting the field's ability to broaden conceptions of well-being, redress histories of inequitable knowledge valuation, and advance systems-level change. To respond effectively to our knowledge of social determinants, public health must resolve the ongoing disconnect between social ecological theory and biomedically-driven practice. To that end, this article issues a clarion call to complete the shift from a biomedical to a social ecological paradigm, and provides a basis for moving theory into practice. It examines biomedicine's foundations and limitations, glosses existing critiques of the paradigm, and describes health equity challenges presented by over-reliance on conventional practices. It then offers theoretical and epistemological direction for developing innovative social ecological strategies that advance health equity.