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Etiology
Etiology
Etiology
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Etiology (/ˌiːtiˈɒlədʒi/; alternatively spelled aetiology or ætiology) is the study of causation or origination. The word is derived from the Greek word αἰτιολογία (aitiología), meaning "giving a reason for" (from αἰτία (aitía) 'cause' and -λογία (-logía) 'study of').[1] More completely, etiology is the study of the causes, origins, or reasons behind the way that things are, or the way they function, or it can refer to the causes themselves.[2] The word is commonly used in medicine (pertaining to causes of disease or illness) and in philosophy, but also in physics, biology, psychology, political science, geography, cosmology, spatial analysis and theology in reference to the causes or origins of various phenomena.

In the past, when many physical phenomena were not well understood or when histories were not recorded, myths often arose to provide etiologies. Thus, an etiological myth, or origin myth, is a myth that has arisen, been told over time or written to explain the origins of various social or natural phenomena. For example, Virgil's Aeneid is a national myth written to explain and glorify the origins of the Roman Empire. In theology, many religions have creation myths explaining the origins of the world or its relationship to believers.

Medicine

[edit]
Main article: Cause (medicine)

In medicine, the etiology of an illness or condition refers to the frequent studies to determine one or more factors that come together to cause it. Relatedly, when disease is widespread, epidemiological studies investigate what associated factors, such as location, sex, exposure to chemicals, and many others, make a population more or less likely to have an illness, condition, or disease, thus helping determine its etiology. Sometimes determining etiology is an imprecise process. In the past, the etiology of a common sailor's disease, scurvy, was long unknown. When large, ocean-going ships were built, sailors began to put to sea for long periods of time, and often lacked fresh fruit and vegetables. Without knowing the precise cause, Captain James Cook suspected scurvy was caused by the lack of vegetables in the diet. Based on his suspicion, he forced his crew to eat sauerkraut, a cabbage preparation, every day, and based upon the positive outcomes, he inferred that it prevented scurvy, even though he did not know precisely why. It took about another two hundred years to discover the precise etiology: the lack of vitamin C in a sailor's diet.

The following are examples of intrinsic factors:

  • Inherited conditions, or conditions that are passed down to you from your parents. An example of this is hemophilia, a disorder that leads to excessive bleeding.
  • Metabolic and endocrine, or hormone, disorders. These are abnormalities in the chemical signaling and interaction in the body. For example, Diabetes mellitus is an endocrine disease that causes high blood sugar.
  • Neoplastic disorders or cancer where the cells of the body grow out of control.
  • Problems with immunity, such as allergies, which are an overreaction of the immune system.[3]

Mythology

[edit]
Main article: Origin myth

An etiological myth, or origin myth, is a myth intended to explain the origins of cult practices, natural phenomena, proper names and the like. For example, the name Delphi and its associated deity, Apollon Delphinios, are explained in the Homeric Hymn which tells of how Apollo, in the shape of a dolphin (delphis), propelled Cretans over the seas to make them his priests. While Delphi is actually related to the word delphus ('womb'), many etiological myths are similarly based on folk etymology (the term Amazon, for example). In the Aeneid (published c. 17 BC), Virgil claims the descent of Augustus Caesar's Julian clan from the hero Aeneas through his son Ascanius, also called Iulus. The story of Prometheus' sacrifice trick at Mecone in Hesiod's Theogony relates how Prometheus tricked Zeus into choosing the bones and fat of the first sacrificial animal rather than the meat to justify why, after a sacrifice, the Greeks offered the bones wrapped in fat to the gods while keeping the meat for themselves. In Ovid's Pyramus and Thisbe, the origin of the color of mulberries is explained, as the white berries become stained red from the blood gushing forth from their double suicide.

See also

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References

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Etiology

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Etiology (/ˌiːtiˈɒlədʒi/) is the study of causation or the causes of phenomena, encompassing the origins and reasons behind events, processes, or conditions across various disciplines. While prominently applied in to investigate origins, it also features in (theories of cause and effect), mythology and (etiological narratives explaining or natural features), and scientific fields like and physics. The term derives from aitiología, combining aitía ("cause") and -logía ("study of" or "discourse"), literally meaning "giving a reason for" something. In medical contexts, etiology involves identifying the specific agents or conditions responsible for illness, such as infectious pathogens, genetic mutations, environmental exposures, toxins, or behavioral factors. Diseases are often classified by their etiologies, including intrinsic causes (internal, like genetic disorders), extrinsic causes (external, such as infections or trauma), and idiopathic cases (unknown cause). Understanding etiology is crucial for , treatment, and prevention, revealing disease development mechanisms. The concept of etiology has roots in and mythology, but in , a pivotal advancement came in the with the , demonstrating that specific microorganisms—primarily —invade the body and cause infections. Developed by and , this shifted paradigms from humoral theories to microbial causation, enabling , , and antisepsis. Contemporary etiology recognizes multifactorial causation in many phenomena, involving interactions of biological, environmental, and social factors; for example, chronic diseases like and heart disease stem from genetic and elements. Progress in , , and related sciences refines causal understanding, supporting targeted interventions and interdisciplinary approaches.

Etymology and General Usage

Etymology

The term "etiology" originates from the aitiología (αἰτιολογία), a compound word formed from aitía (αἰτία), meaning "" or "responsibility," and -logía (-λογία), derived from lógos (λόγος), signifying "study," "account," or "." This etymological structure thus conveys the notion of an "account of causes" or the systematic inquiry into causation. The Greek term aitía itself appears prominently in the (384–322 BCE), where it denotes the underlying reasons or principles explaining natural phenomena, as explored in his philosophical treatises on causation. The compound aitiología entered as aetiologia during , often in philosophical and early medical writings that emphasized explanatory accounts of events or conditions. Adopted into English in the mid-16th century through and scholarly translations, the word's earliest recorded use appears before 1555 in the writings of the Protestant reformer , reflecting its initial application in discussions of causation within theological and contexts. variations developed over time, with "aetiology" retaining the digraph "ae" in (in line with conventions) and "etiology" simplifying to a single "e" in by the . By that period, the term had evolved from a broader philosophical usage to a predominantly sense, denoting the investigation of causes amid advances in scientific .

Core Definition and Scope

Etiology is the systematic study of the causes or origins of phenomena, events, or conditions, encompassing a rigorous investigation into the factors that bring about specific outcomes rather than mere descriptive accounts. This discipline prioritizes causal mechanisms and historical antecedents to explain why things occur, drawing from and logical inference across diverse contexts. A fundamental distinction exists between etiology, which focuses on causal explanations rooted in origins and processes, and , which emphasizes purpose or goal-oriented interpretations. For instance, an etiological approach to a biological condition might identify infectious agents or genetic mutations as the triggers for onset, whereas a teleological perspective would explore the functional role of symptoms, such as how fever aids . This separation underscores etiology's commitment to mechanistic over intentional or adaptive ends. The scope of etiology extends broadly across intellectual domains, from the natural sciences—where it elucidates the origins of natural events like through environmental and biological interactions—to the , where it unpacks the causal foundations of cultural practices via narratives that attribute societal customs to historical or mythical events. This interdisciplinary reach fosters predictive and preventive insights, allowing for the anticipation of outcomes and the design of interventions based on causal understanding. Central to etiological are principles such as multifactorial causation, recognizing that most phenomena arise from the interplay of multiple interdependent factors rather than singular agents. Complementing this is the differentiation between proximate causes, which address immediate triggers like physiological responses, and ultimate causes, which trace evolutionary or historical roots to explain deeper origins. These concepts provide a structured lens for dissecting complex causal chains.

Medical Etiology

Historical Evolution in Medicine

The concept of etiology in medicine originated in with the Hippocratic school around the 4th century BCE, which proposed the humoral theory as the primary framework for understanding disease causation. According to this theory, health depended on the balance of four bodily humors—, , , and black bile—while illness resulted from their imbalance, influenced by diet, environment, and lifestyle. This approach shifted causation away from supernatural forces toward natural, observable imbalances, laying foundational principles for empirical medical inquiry. During the medieval and periods, medical thought evolved but retained humoral influences, with a growing emphasis on environmental factors; by the , the dominated, positing that diseases arose from "bad air" emanating from decaying organic matter or polluted environments. This view was widespread in and explained epidemics through airborne miasmas rather than direct contagion. A pivotal challenge came during the 1854 London cholera outbreak, where physician mapped cases around a contaminated water pump on Broad Street, demonstrating that spread via waterborne transmission rather than miasmatic vapors, thus undermining the theory through epidemiological evidence. The late 19th century marked a revolutionary milestone with the establishment of germ theory by and , who identified microorganisms as specific causes of infectious diseases. Pasteur's experiments in the 1860s and 1870s disproved and linked germs to and , extending the idea to disease pathology. Koch advanced this by isolating bacteria like those causing and , formalizing causal criteria in his 1884 postulates: the microorganism must be present in all diseased individuals but absent in healthy ones; it must be isolated and grown in pure culture; of a healthy host must reproduce the disease; and the same microorganism must be re-isolated from the newly diseased host. These principles provided a rigorous method to prove microbial etiology, transforming medicine from speculative to experimental science. By the early , etiology began transitioning toward multifactorial models, recognizing interactions between infectious agents, , and environment, particularly in diseases like . Following Koch's 1882 identification of as the primary cause, researchers debated hereditary predispositions alongside environmental triggers such as poor and , which exacerbated susceptibility during industrialization. This shift acknowledged that while the was necessary, host genetic factors and socio-environmental conditions determined disease progression, influencing strategies like and efforts.

Contemporary Concepts and Frameworks

In contemporary medical etiology, plays a central role in establishing causal relationships between exposures and through rigorous study designs such as cohort studies, which follow populations over time to observe outcomes, and case-control studies, which compare individuals with and without a to identify risk factors. calculations quantify the strength of associations, for instance, by comparing incidence in exposed versus unexposed groups, aiding in the differentiation of correlation from . A seminal framework for assessing is the , introduced in 1965, which include nine viewpoints such as strength of association, consistency across studies, specificity, temporality, biological gradient, plausibility, coherence, experiment, and analogy to guide inferences in observational data. Molecular and genetic approaches have revolutionized etiological research by pinpointing specific genetic alterations underlying diseases, with genomics enabling the identification of mutations and pathogens at the DNA level. For example, harmful variants in the BRCA1 and BRCA2 genes, discovered in the mid-1990s, significantly elevate lifetime risks of breast and ovarian cancers—up to 72% and 69% for breast cancer in carriers, respectively—by impairing DNA repair mechanisms, thus serving as key etiological factors in hereditary breast cancer syndromes. The completion of the Human Genome Project in 2003 provided a comprehensive reference sequence, accelerating the identification of such variants and facilitating large-scale genomic studies that link genotypes to disease phenotypes. Multifactorial disease models recognize that most common conditions arise from complex interactions among genetic, environmental, and lifestyle factors, rather than single causes, emphasizing gene-environment interplay in etiological pathways. In cardiovascular disease, for instance, genetic predispositions like polymorphisms in lipid metabolism genes interact with environmental factors such as high-fat diets and smoking to promote atherosclerosis and thrombosis, with studies showing that these interactions can amplify risk by 2- to 5-fold in susceptible individuals. This framework underscores the need for holistic assessments, where relative contributions of factors are weighed to inform prevention strategies. Emerging frameworks in etiological research leverage to model diseases as dynamic networks of causal interactions, integrating multi-omics data to map how perturbations in one component propagate through biological systems. Causal network approaches, such as those using Bayesian or graph-based models, reconstruct directed relationships among genes, proteins, and environmental inputs, revealing hidden etiologies in complex disorders like cancer or neurodegeneration. These methods build on post-genomic tools to prioritize interventions targeting network hubs, enhancing precision in identifying disease origins.

Etiology in Philosophy and Science

Philosophical Foundations

The philosophical foundations of etiology trace back to ancient inquiries into causation, most notably articulated by Aristotle in his work Physics. There, he proposed four types of causes to explain why things exist or change: the material cause, which refers to the substance or matter from which something is composed (e.g., bronze for a statue); the formal cause, pertaining to the structure, form, or essence that defines it (e.g., the shape of the statue); the efficient cause, the agent or process that brings about the change (e.g., the sculptor's action); and the final cause, the purpose or end toward which it aims (e.g., to honor a deity). These categories provided a comprehensive framework for etiological analysis, integrating explanation across natural and artificial phenomena and influencing subsequent Western thought on causality. In the 18th century, challenged the deterministic underpinnings of such etiological models in his Enquiry Concerning Human Understanding. Hume argued that causation is not a necessary connection observable in objects but rather a psychological formed by repeated associations of events, where constant conjunction leads to the expectation of one event following another. This skeptical view, detailed in Section VII of the work, undermined claims of inherent necessity in causes, positing instead that our belief in causation arises from custom and experience rather than rational insight, thereby complicating traditional etiological pursuits of objective explanations. Immanuel Kant responded to Hume's with a synthesis in his , published in 1781, where he positioned causation as one of the a priori categories of the understanding essential for organizing sensory into coherent . Kant contended that while we cannot know causation as it exists in itself (noumena), it functions as a necessary condition for synthetic a priori judgments, such as "every event has a cause," enabling the possibility of etiological by bridging phenomena and the structures of human . This transcendental approach reconciled Humean with Aristotelian explanatory ambitions, framing etiology as dependent on innate mental faculties rather than purely empirical observation. Contemporary philosophical debates on etiology continue to grapple with versus probabilism in causation, particularly influenced by quantum indeterminacy, which introduces inherent unpredictability at fundamental levels. These discussions highlight ongoing tensions between necessary connections and stochastic processes, shaping modern interpretations of causal inquiry across disciplines.

Applications in Scientific Disciplines

In and , etiological approaches investigate the causal origins of and dynamics through evolutionary mechanisms. Charles Darwin's theory of , outlined in his 1859 work , posits that adaptive traits arise from differential survival and reproduction driven by environmental pressures, thereby explaining the etiology of species origins without invoking design. This framework has been foundational in ecology, where causal analyses trace patterns to historical contingencies like and predator-prey interactions, emphasizing gradual, non-teleological processes. In physics and chemistry, etiology manifests in the study of causal sequences governing physical transformations and reactions. , formulated by in 1884, describes how chemical equilibria respond to perturbations—such as changes in temperature, pressure, or concentration—by shifting to counteract the stress, thereby revealing underlying causal dynamics in reversible systems. This principle underpins etiological inquiries into reaction pathways, where causal chains are dissected to predict outcomes in processes like or phase transitions, prioritizing energetic and entropic drivers over events. Earth sciences employ etiological methods to elucidate the origins of planetary features through tectonic and geodynamic causes. The theory of , developed in the 1960s, attributes the etiology of earthquakes and volcanic activity to the movement and interaction of lithospheric plates driven by , as proposed in Harry Hess's 1962 hypothesis of . This causal model integrates paleomagnetic, seismic, and bathymetric evidence to explain and , shifting from earlier fixist paradigms to a unified view of Earth's dynamic surface evolution. Probabilistic models enhance etiological analysis across sciences by accommodating uncertainty in causal attributions. , rooted in Thomas Bayes's theorem but widely applied since the mid-20th century, enables scientists to update beliefs about causal probabilities iteratively as new evidence emerges, avoiding deterministic absolutes in favor of posterior distributions that quantify evidential support. In fields like and , this approach models complex causal networks—such as climate impacts on —by incorporating prior knowledge and likelihoods, thus providing robust frameworks for testing amid incomplete data.

Etiology in Mythology and Religion

Mythological Narratives

In mythology, etiological narratives serve as traditional stories that explain the origins of phenomena, social , or existential conditions through the actions of divine or heroic figures, often embedding cultural values and moral lessons. These myths typically attribute to anthropomorphic agents, such as gods or beings, who shape the world in ways that account for its current state. A prominent example from is the tale of stealing fire from the gods, which provides an etiology for the origins of human civilization and technological progress. In Hesiod's (lines 507–616), , a Titan, deceives during a sacrificial division at Mekone; in retaliation, withholds fire from humanity, prompting to steal it from Olympus using a stalk, thereby enabling humans to cook, craft, and advance. This act not only explains fire's role in human society but also establishes the adversarial relationship between gods and mortals as the cause of ongoing divine punishments. Similarly, the myth of , detailed in Hesiod's (lines 42–105), etiologizes human suffering and the presence of evils in the world. Crafted by the gods as a beautiful but deceptive gift in revenge for 's theft, opens a (often mistranslated as a "box") releasing all ills—disease, toil, and sorrow—while hope remains trapped inside, thus accounting for humanity's mixed existence of hardship tempered by optimism. In Norse mythology, the prophecy of Ragnarök offers a causal explanation for the cyclical nature of the cosmos, including its periodic destruction and renewal, stemming from conflicts among the gods. Described in Snorri Sturluson's Prose Edda (Gylfaginning, chapters 51–53), Ragnarök unfolds as a cataclysmic battle triggered by Loki's betrayal and the release of monstrous forces like Fenrir and Jörmungandr, leading to the gods' deaths—Odin slain by the wolf Fenrir, Thor by the serpent—and the world's submersion in floodwaters, only for it to emerge reborn with surviving deities like Baldr and new human progenitors. This narrative etiologizes the inevitability of cosmic endings as a consequence of divine oaths broken and familial rivalries, underscoring themes of fate (wyrd) and renewal in the natural order. Indigenous Australian mythologies, particularly those of the Aboriginal peoples, feature Dreamtime stories that etiologize the formation of landscapes through the travels and actions of ancestral beings. In the Dreamtime, or Alcheringa, these spirit ancestors—often hybrid forms of animals, humans, and landscapes—emerge from the earth to shape features like rivers, mountains, and rock formations during a foundational era, leaving behind sacred sites (songlines) that map their paths and encode laws for living. For instance, among the people of , ancestral beings like the Rainbow Serpent carve waterways and create waterholes through their movements, explaining the continent's topography as direct results of these creative journeys while establishing totemic connections between people, land, and morality. Across these traditions, common motifs in etiological myths include anthropomorphic causes, where gods or ancestors act with human-like intentions and flaws to drive events, and moral etiologies, portraying natural or social states as consequences of ethical breaches or heroic deeds. In Greek and Norse tales, divine misdeeds—such as Prometheus's defiance or Loki's treachery—precipitate enduring conditions like labor or , reinforcing communal norms. Similarly, Dreamtime narratives link landscape origins to ancestral conduct, emphasizing harmony with the environment as a . These patterns highlight mythology's role in providing coherent, agent-driven explanations for an otherwise inscrutable world.

Religious and Theological Interpretations

In religious and theological traditions, etiology often manifests through narratives attributing the origins of the world, humanity, and to divine actions or moral failings. The Biblical creation narrative in Genesis, composed during the 6th to 5th century BCE, presents the universe's formation as a series of deliberate acts by God over six days, establishing order from chaos and explaining the structured origins of heavens, earth, light, seas, land, plants, animals, and humankind as the pinnacle of creation. This account serves as an etiology for the world's existence and its inherent goodness prior to human intervention, emphasizing divine sovereignty as the ultimate cause. Similarly, the narrative of the Fall in Genesis 3 depicts and Eve's disobedience—eating from the forbidden —as the originating cause of human mortality, toil, pain in , and expulsion from paradise, thereby etiologically linking to the broader of and . Islamic theology, rooted in the revealed in the 7th century CE, offers etiologies centered on divine creation and testing. Surah Al-Baqarah (2:30–39) describes God's formation of from clay (tin), breathing life into him, and appointing him as a (khalifah) on , with angels commanded to prostrate in recognition of . This narrative etiologically accounts for humanity's earthly role and diversity, while the subsequent temptation by () and Adam's lapse lead to descent to as a of , framing human struggles, mortality, and moral challenges as divinely ordained tests rather than inherent flaws. Theological interpretations further elaborate these etiologies, often connecting natural and moral disorders to divine justice. In his City of God (composed 413–426 CE), interprets calamities such as the sack of Rome and natural disasters as providential chastisements arising from the collective sin of humanity post-Fall, affecting both the wicked as punishment and the righteous as purification or trial to foster virtue. This framework etiologically ties environmental upheavals and societal ills to the original sin, portraying them as mechanisms of divine correction within a fallen creation. Comparatively, in and , the doctrine of karma provides an etiological lens for as a causal chain governed by moral actions across lifetimes. In , karma—actions and their consequences—explains (duhkha) as the fruition of past deeds, whether in this life or previous ones, linking ethical conduct to the cycle of rebirth (samsara) and ultimate liberation (). adapts this, emphasizing intentional actions (karma) as the root cause of within the interdependent arising (pratityasamutpada), where and craving perpetuate the cycle, making not punitive but a natural outcome of volitional patterns resolvable through enlightenment.

Etiology in Other Fields

In , etiology involves the systematic determination of the through autopsies, which integrate physical examinations, histological analysis, and ancillary tests to classify deaths as , , , natural, or undetermined. For instance, plays a crucial role in identifying substances like drugs or poisons that may indicate intentional harm versus accidental exposure, thereby distinguishing between and accidental manners of death. In legal contexts, etiology manifests as doctrines of causation in tort law, where courts assess whether a defendant's actions etiologically link to the plaintiff's harm. The "but-for" test establishes factual causation by evaluating whether the harm would not have occurred absent the defendant's conduct, serving as a foundational threshold in negligence claims. , conversely, limits liability to foreseeable consequences, as articulated in the landmark case Palsgraf v. Long Island Railroad Co. (1928), where the held that a railroad employee's negligent assistance to a passenger did not proximately cause injury to a distant bystander, emphasizing that liability extends only to risks within the scope of reasonable foreseeability. Contemporary applications of etiology appear in , where forensic techniques trace pollution sources to hold violators accountable, often relying on chain-of-custody protocols to ensure integrity from collection to presentation. These methods, including isotopic fingerprinting and contaminant tracking, enable regulators to etiologize discharges from industrial sites, as seen in investigations of illegal dumping. Proving multifactorial etiologies poses significant challenges in court, particularly in product liability suits alleging defective designs, where plaintiffs must disentangle the product's role from concurrent factors like or environmental influences to establish causation. Courts often require robust expert testimony to demonstrate that the design defect was a substantial contributing factor, yet alternative causation theories frequently complicate verdicts and lead to dismissals if the evidentiary burden is not met.

Social and Cultural Applications

In social and cultural studies, etiology extends beyond biomedical models to encompass how societies attribute causes to health issues, behaviors, and social phenomena, reflecting broader worldviews and power structures. This approach highlights the interplay between individual experiences and collective beliefs, where explanations of origins influence treatment, stigma, and policy. For instance, cultural interpretations of causation often integrate environmental, emotional, and elements, shaping community responses and health-seeking behaviors. A central concept in is ethno-etiology, which examines culturally embedded theories of illness causation. These frameworks contrast with Western biomedical views by incorporating social, spiritual, and environmental factors. George M. Foster identified two primary types in non-Western systems: personalistic and naturalistic etiologies. Personalistic etiologies attribute illness to the deliberate actions of supernatural agents, such as spirits, witches, or deities, often requiring rituals or shamanic intervention to appease or expel the agent; for example, among the Azande of , misfortune including disease is seen as sorcery orchestrated by enemies. Naturalistic etiologies, by contrast, explain disease through impersonal natural forces or imbalances, such as humoral disequilibrium or environmental pathogens; in , illness arises from disruptions in yin-yang balance, treated via herbal remedies and dietary adjustments. Building on Foster's work, later classifications include emotionalistic etiologies as a variant of naturalistic explanations, where strong emotions like , , or precipitate illness by disrupting bodily harmony. A prominent example is in Latin American indigenous communities, where a fright causes the soul to separate from the body, leading to symptoms like and appetite loss, addressed through herbal baths and soul-retrieval ceremonies. These ethno-etiologies underscore how cultural narratives not only diagnose but also socialize responses to , often blending with biomedical practices in pluralistic systems. In , etiological analysis focuses on social determinants as fundamental causes of health disparities and disease patterns. Bruce G. Link and Jo Phelan's theory posits that socioeconomic resources—such as knowledge, money, power, and prestige—underlie multiple disease outcomes by enabling access to like safe housing and quality care, persisting even as medical technologies advance. For chronic conditions like , social variables including income inequality and contribute to etiology, exacerbating risks through pathways like poor and limited healthcare. This perspective informs interventions, emphasizing structural reforms over individual blame, as seen in efforts to address racial health inequities rooted in historical discrimination and segregation. Culturally, etiological frameworks influence social norms and , particularly in . In collectivist societies, illness may be etiologically linked to familial disharmony or ancestral displeasure, promoting community-based healing over isolation; for example, in some South Asian contexts, depression is attributed to karmic imbalances, treated through spiritual counseling alongside . Such applications reveal etiology's role in perpetuating or challenging cultural stigmas, as biomedical dominance can marginalize indigenous explanations, leading to culturally insensitive care. Overall, these social and cultural lenses enrich etiological inquiry by revealing how causation is not merely scientific but deeply embedded in human relations and histories.

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  64. https://pubmed.ncbi.nlm.nih.gov/3515570/
  65. https://www.who.int/health-topics/social-determinants-of-health
  66. https://kidsnewtocanada.ca/culture/How-Culture-Influences-Health
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