-
1. Social Conditions as Fundamental Causes of Health Inequalities
- Vanderbilt University Press
- Chapter
- Additional Information
3 1 Social Conditions as Fundamental Causes of Health Inequalities Bruce Link, Columbia University and New York State Psychiatric Institute Jo Phelan, Columbia University We review in this chapter developments over the past fifteen years in the theory of fundamental social causes of health disparities, specify some issues that arise when the theory is applied to specific as opposed to general health outcomes (i.e., incidence or mortality due to a particular disease versus self-rated health and all-cause mortality), identify evidence that evaluates the theory, and indicate that we view the theory as a sociological “theory of the middle range” (Merton 1968). Explicating theTheory Can the Risk-Factor Model Account for Health Inequalities? The theory of fundamental social causes of health inequalities emerged in the 1990s in response to the powerful and very successful risk-factor approach that dominated medicine and epidemiology at the time (House 2002). The risk-factor model’s explanation for health inequalities proceeds according to a seemingly persuasive logic: social conditions are related to health because of their influence on a host of risk factors that lie between social conditions and disease in a chain of causality. Today we might think of intervening risk factors associated with diet, smoking, exercise, pollution, and preventive health behaviors. To improve health and eliminate health inequalities, the risk-factor model tells us to focus on “modifiable” intervening risk factors like these. If we do, two important accomplishments will be ours. First, if we identify all the intervening risk factors, we will understand why social conditions are related to health. We will be able to tell our colleagues, inform our families, and help our students understand why some social groups are healthier than others. Second, our work will offer the medical and public-health communities actionable evidence about which risk factors are the major culprits in producing health inequalities. Then, our model tells us, if we can eliminate these intervening risks, health inequalities will disappear. The risk-factor approach and public-health initiatives based on it have been enormously successful in at least one way—interventions based on more proximal, behavioral, and biomedical factors have had a very positive effect on population health. Although we cannot be sure which aspects of new knowledge or which specific interventions are accountable, human health has improved dramatically over the past century or so. Huge declines in the infectious disease killers of the nineteenth century were followed by equally impressive declines in major chronic disease killers such as heart disease, stroke, and, since the 4 Handbook of Medical Sociology 1990s, cancers (NCHS 2006). But with respect to health inequalities, the risk-factor model comes up short in at least two important ways. First, social conditions powerfully shape the capacity to modify or eliminate identified risk factors, rendering less than fully effective an approach that addresses only risk-factor mechanisms . Instead we need to also address what Rose (1992) called the “causes of causes” and what Link and Phelan (1995) deemed factors that put people “at risk of risk.” Put simply, the reason a risk-factor model fails to address health inequalities is that it is difficult to decouple the identification of risk and protective factors and the deployment of knowledge and technology based on those factors from social conditions. Second, in an ironic twist, rather than addressing health disparities, the identification of risk factors can actually increases such disparities (Link and Phelan 1995; Phelan et al. 2004). As we develop the ability to control disease and death, the benefits of this newfound capacity are not distributed equally throughout the population , but are instead harnessed more securely by individuals and groups who are less likely to be exposed to discrimination and who have greater access to knowledge, money, power, prestige, and beneficial social connections. Accordingly, whatever health differences between advantaged and disadvantaged groups might have existed before a health-enhancing discovery, the uneven distribution of new knowledge and technology results in a powerful social shaping of health disparities. From this vantage point, major health disparities by race, ethnicity, and socioeconomic status are social products, brutal facts that we create (Link 2008; Link and Phelan, in press). Why Are Social Conditions Fundamental Causes of Health Inequalities? The short answer to this question is that connections between social conditions and health are reliably reproduced under circumstances that involve vastly different risk and protective factors and completely different diseases. Their persistence under changing circumstances tells us that the observed connections are not reducible to the risk-factor...