Meet David Rehkopf: How society shapes longevity

Photo by Andrew Brodhead

New faculty Q&A

What determines how long or how well we live?  For social epidemiologist David Rehkopf, the answer lies partly in social conditions that shape our lives long before they show up in the doctor’s office. 

Rehkopf, who recently joined Stanford Sociology faculty, is director of the Stanford Center on Longevity. This winter, he will teach the second course in our department’s Statistics for an Open Science sequence for graduate students.  

His research combines biological information with social and economic data  to understand why some populations are healthier than others. He uses molecular indicators such as telomere length and epigenetic clocks to examine how social conditions, including public policy and chronic stress, “get under the skin” to shape our biology.  Whether it is wages or the character of neighborhoods, his work explores how inequality leads to a greater gap in health outcomes, especially among working- and middle-class populations as they age.

We spoke to Rehkopf, who holds a Doctor of Science (ScD) and faculty appointments across Sociology, Epidemiology and Population Health, and Medicine, about his path to sociology, his findings on the "forgotten middle," and why living longer, healthier lives means looking beyond individual choices. 

This interview has been edited for length and clarity

Your work bridges molecular biology and sociology using cellular markers to measure population health. What inspired you to bring these two seemingly different fields together?

There’s a certain amount of randomness involved. I first became interested in molecular biology because I wanted to understand how it could improve health. I see health as a fundamental endowment, something that makes education, relationships, and participation in society possible. At the time, though, I thought about health primarily as a biomedical question.

That began to change when I stumbled upon Sociology as an undergrad at the University of Puget Sound. I needed a social science course and sociology happened to fit my schedule. I found it surprisingly interesting, which led me to medical sociology courses taught by George Guilmet. His small seminars showed me a different way of thinking about health. 

Later, while researching malaria, I learned about epidemiology and began to see how strongly health is shaped by people’s behavior and opportunities available to them. When I moved into public health and started working with a social epidemiologist, I became interested in the field and temporarily stopped working in molecular biology. 

Eventually, I began to see how the two could come together. Our health is shaped by biological processes and by the social worlds in which we live. Biological markers give us a way to study how social conditions may affect health, sometimes long before the disease appears. That ability to connect what is happening in people’s lives with what is happening biologically is what drew me to bringing the two fields together.

Health and longevity are often presented as matters of personal choice. Your research emphasizes the social and economic conditions that shape the health of entire populations. Why is it important to look beyond the individual?

People try to change their behavior all the time, but change is extraordinarily difficult when their environment remains the same. Our social connections, economic circumstances, and access to opportunities shape the choices we are able to make. 

I do not want to discount individual agency. People can and do make changes. But it can be an uphill battle, especially for those managing financial pressures, demanding work schedules, family responsibilities, or other stress. When people have so much on their plates, prioritizing health becomes more difficult.

The goal should not be to dictate how people live, but to create conditions that give them meaningful choices and real opportunities to thrive.

That is why focusing only on personal choice can become a form of blaming the victim. People who enjoy good health often live in environments that make it possible. The goal should not be to dictate how people live, but to create conditions that give them meaningful choices and real opportunities to thrive. To me, that is fundamentally a sociological question:  Who has those opportunities, who does not, and what constraints stand in the way.

Your research shows increasing health differences among lower-middle-income adults in mid-life, a group you call “forgotten middle.” Why has this group been overlooked, and where might policies make a difference? 

We have devoted considerable attention to developing programs and policies for people living below the poverty line, though much more needs to be done. What has received less attention is a longer-term shift in the relationships between income and health. 

Poor health was once concentrated mainly among people below the poverty line. Since the 1970s, that disadvantage has expanded upward to include people whose incomes approach the median. Those above the median are doing relatively well on average, but the population experiencing poor health has become both wider and deeper, as described by George Kaplan, an epidemiologist whom I greatly admire. 

The “forgotten middle” refers to people whose incomes fall between the poverty line and the median. They may earn too much to qualify for many forms of assistance but still lack the resources and opportunities to support good health. We need to ask what opportunities this group is missing and how social and economic policies could better reach them. 

At this point, I do not think we know which single policy would make the greatest difference. I have examined hundreds of state policies, and no one intervention stands out as a clear answer. One promising area is social connection. In our research, people in the forgotten middle who were more socially isolated and who reported greater financial and other stresses experienced more health problems than those at the same income level with  stronger social connections. These findings are descriptive rather than causal, but they suggest an important direction for further study.

In analyzing large population datasets, is there a finding from your research that consistently surprises people?

One finding that consistently surprises people is how strongly where someone lives can predict their health. In a recent study, we compared individual characteristics, such as education and income, with characteristics of the census tract or neighborhood where that person lived. The neighborhood predicted many health outcomes just as well, and sometimes better than, individual characteristics. 

We usually think about health as a very personal issue. A sociological perspective is something that has to be learned. When I talk about something like tax policy and then connect it to epigenetic markers, people’s eyes sometimes glaze over. They think, “What? How are those things connected?”

If people begin with an individualized understanding of health, we need to show them how something like tax policy or neighborhood conditions, like air and water pollution, affects people’s lives and ultimately their biology. It takes extra effort to draw those connections, but it helps bring people along with the insights sociology has to offer. 

Aside from packing up and moving to a Blue Zone, what can people do to modify  their own environments to promote healthier, longer lives? 

Think about changing your environment rather than trying to change yourself through willpower alone. It’s less about pulling yourself up by your bootstraps every day and more about reshaping  small daily environments, like how you socialize, interact with other people, and whether your surroundings make physical activity, healthy eating, and social connection easier. 

Social connection can have spillover effects by reducing stress and encouraging other healthy habits. Becoming preoccupied with making the right individual choices can be stressful itself.  The goal is to set up your environment so that healthier choices happen more naturally; this does not mean you have to move. Positive changes can come from adjusting your home, daily habits, and how you relate to others.