Social Conditions as Fundamental Causes of Disease*

Transcription

Social Conditionsas FundamentalCauses of Disease*
BRUCE G. LINK
Institute
andNewYorkStatePsychiatric
ColumbiaUniversity
JO PHELAN
Los Angeles
University
ofCalifornia,
ofHealthandSocialBehavior1995,(ExtraIssue):80-94
Journal
Over the last several decades, epidemiologicalstudies have been enormously
riskfactorsfor major diseases. However,most of this
successfulin identifying
proximalcauses of
on riskfactorsthatare relatively
researchhasfocusedattention
disease such as diet, cholesterollevel, exercise and the like. We questionthe
riskfactorsand argue thatgreaterattention
emphasison such individually-based
mustbe paid to basic social conditionsif healthreformis to have its maximum
effectin thetimeahead. Thereare tworeasonsfor thisclaim. Firstwe argue that
riskfactors mustbe contextualized,by examiningwhat puts
individually-based
and improvethe
interventions
people at riskof risks,if we are to crafteffective
nation'shealth.Second, we argue thatsocial factorssuchas socioeconomicstatus
and social supportare likely'fundamentalcauses" of disease that,because they
resources,affectmultipledisease outcomesthrough
embodyaccess to important
maintainan associationwithdisease even
multiplemechanisms,and consequently
when interveningmechanisms change. Withoutcareful attentionto these
intervention
strategies
possibilities,we runtheriskof imposingindividually-based
and of missingopportunitiesto adopt broad-based societal
thatare ineffective
thatcouldproduce substantialhealthbenefits
interventions
for our citizens.
Epidemiologyhas been enormouslysuccessfulin heighteningpublic awareness of risk
and prominently
publicizedin the mass
factorsfordisease. Researchfindingsare frequently
healthnewsletters.Moreover,thereis
university-based
media and in rapidlyproliferating
to
evidencethatthe messagehas been receivedand thatmanypeople have at least attempted
quit smoking,includemoreexercisein theirdailyroutine,and implementa healthierdiet.
Withfewexceptions,however,thenew findingsgeneratedwithinthefieldof epidemiology
have focusedon riskfactorsthatare relativelyproximate"causes" of disease, such as diet,
fields,lack of exercise,and so on. Social factors,
electromagnetic
cholesterol,hypertension,
' This focuson
whichtendto be moredistalcauses of disease, have receivedfarless attention.
or bias,
moreproximatelinksin thecausal chainmaybe viewedby many,notas a limitation
causal
to understanding
of sciencefromidentifying
correlations
butas therightful
progression
relationships(e.g., Potter 1992). In fact, some in the so-called "modem" school of
epidemiology(e.g., Rothman1986) have explicitlyargued that social conditionssuch as
socioeconomicstatusare mere proxiesfortruecauses lyingcloser to disease in the causal
chain.
This focus on proximaterisk factors,potentiallycontrollableat the individuallevel,
resonateswiththevalue and beliefsystemsof Westernculturethatemphasizeboththeability
of the individualto controlhis or her personalfateand the importanceof doing so (Becker
* We thank
This
comments.
andSarahRosenfield
forhelpful
SharonSchwartz,
BernicePescosolido,
toBruce
communications
MH46101andMH13043.Address
inpartbyNIMHgrants
workwassupported
31D, New York,NY
of MentalDisorders,100 HavenAvenue,Apartment
G. Link,Epidemiology
10032.
80
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FUNDAMENTAL CAUSES OF DISEASE
81
1993). This affinity
betweenculturalvalues and the focus of contemporary
epidemiology
undoubtedlycontributesto the level of public interestin epidemiologicalfindings,and
probablyinfluencesfundingpriorities
as well. Thus modemepidemiologyand culturalvalues
riskfactorsand away fromsocial
conspireto focusattention
on proximate,individually-based
conditionsas causes of disease.
This is notto say thattheroleof social factorsin disease causationhas been neglectedin all
quarters. Medical sociologists and social epidemiologistshave kept alive classical
epidemiology's(e.g., Susser,Watson,and Hopper 1985) concernwithsocial conditionsand
have made major stridestowarddocumentingand understanding
the connectionsbetween
social factorsand disease. However,we believe thereare conceptualpitfallsthatsometimes
lead medical sociologistsand social epidemiologiststhemselvesto unwittingly
reinforcethe
riskfactors.One ofthesepitfallsis that,in theprocess
emphasison proximate,
individual-level
of elucidatingthemechanismsconnecting
social conditionsto healthand illness-an important
in and come to neglecttheimportance
and desirableactivity-we may,overtime,lose interest
of the social conditionwhose effecton healthwe originallysoughtto explain. Also, our
tendencyto focus on the connectionof social conditionsto single diseases via single
mechanismsat singlepointsin timeneglectsthe multifaceted
and dynamicprocessesthrough
which social factorsmay affecthealth and, consequently,may result in an incomplete
and an underestimation
of theinfluenceof social factorson health.
understanding
Our purposeshereare to highlight
the accomplishments
of medical sociologistsand social
of social conditionsas causes of disease, to
epidemiologistsin advancingour understanding
underscorethe criticalimportanceof continuedwork in this direction,and to offertwo
thatwe hope will facilitate
and enhancethisresearch.First,we discuss
conceptualframeworks
of "contextualizing"
theimportance
riskfactors--that
to understand
how people
is, attempting
come to be exposed to individually-based
riskfactorssuch as poor diet, cholesterol,lack of
exercise,or highblood pressure-so thatwe can designmoreeffectiveinterventions.
Second,
we introducethenotionthatsome social conditionsmaybe "fundamental
causes" of disease.
A fundamentalcause involves access to resources,resourcesthat help individualsavoid
diseases and theirnegativeconsequencesthrougha varietyof mechanisms.Thus, even if one
effectivelymodifiesinterveningmechanismsor eradicatessome diseases, an association
betweena fundamental
cause and disease will reemerge.As such,fundamental
causes can defy
to eliminatetheireffectswhenattemptsto do so focussolelyon the mechanismsthat
efforts
happen to link themto disease in a particularsituation.We conclude by discussingthe
of theseideas forresearchand social policy.
implications
EVIDENCE LINKING SOCIAL CONDITIONS TO DISEASE
We begin witha briefreviewof the evidence concerningthe connectionbetweensocial
conditionsand illness. For the purposesof thispaper,we definesocial conditionsas factors
that involve a person's relationshipsto other people. These include everythingfrom
withintimates
to positionsoccupiedwithinthesocial and economicstructures
of
relationships
society.Thus, in additionto factorslike race, socioeconomicstatus,and gender,we include
stressful
lifeeventsof a social nature(e.g., thedeathof a loved one, loss of a job, or crime
as well as stress-process
variablessuch as social support.
victimization),
Fortyyearsof medicalsociologyhave uncoverednumerousexamplesofthesocial patterning
of disease. Most obvious is the ubiquitousand oftenstrongassociationbetweenhealthand
socioeconomicstatus.Lower SES is associated withlower life expectancy,higheroverall
ratesand higherratesof infantand perinatalmortality
mortality
(Buck 1981; Dutton 1986;
Illsley and Mullen 1985; Adler et al. 1994; Pappas et al. 1993). Moreover,low SES is
associated with each of the 14 major cause-of-deathcategories in the International
Classificationof Diseases (Illsleyand Mullen 1985), as well as manyotherhealthoutcomes,
includingmajor mentaldisorders(Dohrenwendet al. 1980; Kessler et al. 1994). Other
of disease are plentiful.Males have highermortality
ratesat
examplesof thesocial patterning
all ages (Walsh and Feldman 1981), as well as higherratesof coronaryheartdisease (Syme
and Guralnik1987), chronicrespiratory
diseases (Colley 1985) and ulcers(Gazzard and Lance
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JOURNAL OF HEALTH AND SOCIAL BEHAVIOR
in ratesof variousformsof cancer (Prout,
1982). There are pronouncedgenderdifferences
Colton,and Smith1987) and mentaldisorder(Dohrenwendet al. 1980; Kessleret al. 1994).
and infantmortality
(Dutton 1986;
AfricanAmericanshave higherratesof overallmortality
Miller1987), renalfailure(Challahand Wing 1985), and stroke(Pedoe 1982a) thando Whites,
but lowerratesof coronaryheartdisease (Pedoe 1982b); cancerratesalso differby race and
ethnicity
(Proutet al. 1987). Both physicaland mentaldisordersvarywithmaritalstatusand
populationdensity(Kelsey 1993; Benenson 1987; Robins et al. 1984), and certainreligious
have lowerrisksof sometypesof cancer
groupssuchas Mormonsand SeventhDay Adventists
(Saracci 1985).
In addition, the tremendousgrowthand success of the stress paradigmhave added
considerablyto the evidence for an association between social conditionsand disease
(Dohrenwendand Dohrenwend1981; Pearlinet al. 1981; Turnerand Marino 1994; Turner,
Wheaton,and Lloyd 1995). Stressfullifeeventshave been linkedto heartdisease, diabetes,
(Miller 1987;
cancers,stroke,fetaldeath,majordepression,and low birthweightin offspring
Brownand Harris 1989; Shroutet al. 1989). Researchhas also extendedto the domainsof
social support(Berkmanand Syme 1979; House, Landis, and Umberson1988; Thoits 1982;
and Phillips 1990; Turnerand Marino 1994) and coping
Turner1981; Turner,Grindstaff,
(Pearlin and Schooler 1978), which have been shown to be associated with health and
well-beingin theirown right.
The evidencereviewedto thispointclearlyestablishesa strongand pervasiveassociation
betweensocial conditionsand disease. But medical sociologistsand social epidemiologists
of disease.
have takenthe field considerablybeyonda descriptionof the social patterning
advancesin establishinga causal role forsocial factorshave focusedon two major
Important
issues-the directionof causationbetweensocial conditionsand healthand the mechanisms
thatexplainobservedassociations.In whatfollowswe presentprominent
examplesof workon
thesetwo issues.
controversiessurroundsome of the
Concerningthe issue of causal direction,important
betweensocial conditionsand health.For example,does low SES cause poor
relationships
health,or does poor healthcause downwardmobility?Does social supportreducemorbidity
and mortality,
or does illness restrictsocial interactionand therebylead to social-support
have used threegeneralstrategiesto addressthesequestions.
deficits?Social epidemiologists
strategieswhich involve locatingconditionsunder
One approachuses quasi-experimental
which alternativeexplanationsmake differentpredictionsabout observable facts. This
designedto test social
approachis exemplifiedby Dohrenwend's(1966) quasi-experiment
selectionand social causationexplanationsfortheassociationbetweenSES and specificmental
disorders.The two explanationsmake differentpredictionsabout rates of disorder in
ethnicgroups,whensocioeconomicstatusis heldconstant.The
advantagedand disadvantaged
recent culminationof Dohrenwend's work on this problem, based on a large-scale
epidemiologicalstudyin Israel(Dohrenwendet al. 1992), concludedthatsocial causationwas
thansocial selectionin producingtheinverseassociationof SES to majordepression
stronger
in men.For schizophrenia,
in women,and substanceabuse and antisocialpersonality
however,
theevidencewas moresupportiveof the social-selectionexplanation.
medical sociologistsand social epidemiologistsidentifysocial risk
In the second strategy,
factorsthatcannotreasonablybe conceivedas havingbeen caused by an individual'sillness
thisstrategy
is a studyby Hamiltonand colleagues(1990) concerning
condition.Exemplifying
the effectsof plant closings on auto-workers'mentalhealth. The investigators
compared
workerswho werelaid offbecause of a plantclosing,workerswho anticipatedbeinglaid off,
and workerswhose plantwas not closing,and foundthatthose laid offwere morelikelyto
if theywere minoritiesand of
consequences-particularly
experiencenegativemental-health
low SES. Since theillnessconditionof theworkerscannotbe thoughtof as havingcaused the
betweenthegroupsstudiedare moreclearlyinterpretable
as the
plantclosing,thedifferences
was also employedby Fenwickand Tausig
effectsof social conditionson health.This strategy
rateforan individual'soccupation
(1994) in a studythatused theCensus-basedunemployment
is higher,workers'job satisfaction,
in a longitudinal
designto show thatwhenunemployment
decision-making
latitude,and well-beingare lower.Again,since workers'healthcannotcause
as demonstrating
theaggregateunemployment
rate,theresultsare morereadilyinterpretable
83
the influenceof social conditionson health-related
outcomes.Finally,studiesof stressful
have used thisstrategy
"fateful"life eventsthatare unlikelyto
circumstance
by identifying
havebeencausedby an individual'sbehavior(e.g., deathof spouse,plantclosing).Thuswhen
Shroutet al. (1989) foundtheodds of developingmajordepressionto be morethanthreetimes
a recentfateful
as highamongpeopleexperiencing
lifeevent,theassociationwas moreclearly
interpretable
as an effectof social conditions.
The thirdstrategy
adoptedby social epidemiologists
to clarifycausal directioninvolvesthe
use of longitudinal
designs.Whensuchdesignscan clearlyplace theemergenceof an illnessor
an illnessexacerbationbeforeor afterthe social conditionunderstudy,a greatdeal can be
of cause betweenthetwo. Unfortunately,
somelongitudinal
learnedaboutthedirection
studies
do not providethe definitive
do not allow clear inferencesabout time orderand therefore
to them(see Linkand Shrout1992). Still,
evidenceaboutcausalitythatis sometimesattributed
social conditionsthatclearlypredatehealthoutcomesand
somenotablestudieshave identified
show thatthe social conditionspredictmorbidity
and mortality
even when competingrisk
factorsare heldconstant.For example,Berkmanand Syme(1979) used baselinedataon social
networks,
collectedin 1965, to predictmortality
duringthesubsequentnineyears.Theyfound
indexas compared
a neardoublingof riskformortality
amongthoselow on a social-network
formanycompeting
risks(smoking,
to thosehighon theindex.Althoughthisstudycontrolled
obesity,physicalactivity,
etc.), it did notincludemeasuresderivedfroma physicalexam. A
subsequentstudyby House, Landis, and Umberson(1988) did includea baseline physical
exam and controlledforblood pressure,cholesterollevels, and otherbiomedicalvariables.
These investigators
foundassociationsbetweensocial relationships
and mortality
thatwere
similarto thosereportedby Berkmanand Syme. This line of workhas continuedto become
moreand morerefined.For example,in a recentlongitudinal
study,Berkmanand colleagues
(1992) have shownthata measureof perceivedsupportcollectedbeforethe occurrenceof a
heart attack predictssurvivalfollowingthe heart attack net of an impressivearray of
biomedical and psychosocial control variables. Other social variables have also been
effectively
studiedwithlongitudinaldesigns. For example,Catalano and colleagues (1993)
of alcoholabuse,andLin andEnsel (1989)
relatedjob layoffsto theemergenceorreemergence
circumstances
and Ensel and Lin (1991) showedthatstressful
predictedsubsequenthealthand
mental-health
outcomes.
have notdeniedthepossibility
Thus, whilemedicalsociologistsand social epidemiologists
thatillnessaffectssocial conditions(Johnson1991), theyhave,at thesametime,demonstrated
a substantial
causal role forsocial conditionsas causes of illness.
themechanisms
Researchidentifying
linkingsocial conditionsto diseasehas also donemuch
of social patterns
of disease. Consider,for
to movesocial epidemiology
beyondthedescription
example, the job-stressmodel of Karasek and colleagues thatprovidesevidence for one
have shown
mechanismlinkingSES to coronaryheartdisease amongmen.These investigators
that "job strain,"characterizedby a combinationof highjob demandsand low decision
latitude,is morecommonin lower statusjobs and is associatedwithcoronaryheartdisease
blood pressure
(Karasek et al. 1988; Schnall et al. 1990) and elevatedlevels of ambulatory
bothon and offthejob (Schnallet al. 1992). Anotherexampleis theworkof Mirowskyand
thatmightaccountforsocial patterns
of distress.
Ross (1989), who elucidatethemechanisms
They presentevidenceshowingthatalienationand perceivedcontrolover lifecircumstances
underliemanysocial conditionsthatput people at riskforelevatedlevels of psychological
distress.Consideras a finalexamplea studyby Rosenfield(1989) thatsoughtto understand
in symptoms
of depressionand anxiety.Rosenfield
mechanismsproducinggenderdifferences
shows thatwomenhave highersymptomsof depressionand anxiety.This workshows that
womenhave highersymptomlevels thanmen whentheyare overloadedby workand family
demandsor when theyexperiencelow power as a consequenceof being out of the labor
low power and role overload is a
market.Moreover,the commonmechanismunderlying
decreasedsense of personalcontrol,whichis in turnrelatedto symptomsof anxietyand
depression.
Link and Dohrenwend(1989) explicitlyadvocatethe approachof elucidatingmechanisms
therelativemeritofcompeting
forsocial patterns
becauseof itsvalue in clarifying
explanations
of disease. The rationaleis thatalternativeexplanationsfor these patterns,such as social
84
JOURNALOF HEALTH AND SOCIAL BEHAVIOR
intervening
mechanisms.Thus,
causationand social selection,frequently
implydifferent
mechanismsaccountforthe associationcan help answer
evidenceabout whichintervening
causal directionand othercompetingexplanations.Moreover,if causal
questionsconcerning
linksbetweendistalfactors(e.g., SES) and moreproximalfactors(e.g., occupationalstress,
diet)can be drawn,as Karaseket al. (1988), Mirowskyand Ross (1989), Rosenfield(1989),
and others(Lennon 1987; Pearlin et al. 1981; Link, Lennon, and Dohrenwend1993;
clear thatsocial
Umberson,Wortman,and Kessler 1992) have done, it becomesincreasingly
indirect
effectson diseaseoutcomes,ratherthanmereproxiesas
are causes exerting
conditions
Rothman(1986) and othersmightclaim.
and undesirable
But are thereunintended
consequencesof an approachthatfocuseson interof suchan approach,it
We believethereare. Despitetheobviousbenefits
veningmechanisms?
to thefocuson factorsthatare
one mayinadvertently
contribute
is possiblethatin itsenactment,
becomesthenew and exciting
mechanism
closerto diseasein thecausal chain.The intervening
becometheold, passe "starting
point."
"nextstep,"whilethesocial conditions
of
The evolutionofthestressparadigmis a good exampleofsuchan inadvertent
downgrading
selection
theissue whichprovidedthe initialimpetusforresearch.The social causation/social
theassociation
betweensocioeconomic
statusandmentaldisorder
spawned
controversy
concerning
of the adversity
in stressful
lifeeventsas a directoperationalization
thatmightbe
an interest
in lowerSES contexts(Dohrenwendand Dohrenwend1969, 1981). Whena conexperienced
eventsandillnesswas identified
sistent
butmodestassociationbetweenstressful
(see Rabkinand
elaboratedthe model to considersocial supportand copingas
Struening1976), investigators
areinvestedin understanding
themechanisms
Now researchers
modifiers.
linkingthese
potential
factors
withdisease.Also, researchon thebiologicalconsequencesofstress(e.g., immunestatus
andelevatedcatecholamines)
is seenas an excitingnew development
(e.g., Cohen,Tyrrell,and
has followedthe mostrecentstepin theprogression
toward
Smith1991). In general,interest
toa pointwheresomeexpress
diseaseoutcomes,whileconcernwiththeearlierfocihas dissipated
in factorssuchas thecausation/selection
issue and therole of stressful
lifeeventsin
disinterest
and Klusman[1987] for
causingillness(butsee Pearlin1989; Dohrenwend1990; Angermeyer
and Klusman(1987) documented
a sharpdeclinein the
dissenting
views). IndeedAngermeyer
focusedon social class and mentaldisorderin theperiodfrom1966 to
numberof publications
disorders
increasedrapidlyduringthe
1985,whilethenumberofarticleson stressandpsychiatric
in mechanisms
increasesat theexpenseof morefundasameperiod.To theextentthatinterest
contribute
to the emphasison
mentalsocial conditions,medicalsociologistsmay unwittingly
andplayintothehandsofthosewhoarguethatsocialfactors
haveonlya modest
individual
factors
rolein diseasecausation.
ofsocialconditions
as causesofdisease
To thispoint,we havedescribedtwocharacterizations
or inadvertently
One of theseis theoutright
thateitheradvertently
downplaytheirimportance.
declarationthatsocial factorsare onlyproxiesfortruecauses. This positionis demonstrably
of medicalsociologyand social epidemiology
overthepast
unwarranted
giventheachievements
whichmaybe partially
fewdecades.The othercharacterization,
constructed
by medicalsociolis theviewthatsocialfactors
serveas starting
points
ogistsandsocialepidemiologists
themselves,
to moreproximalriskfactors.We takesharpissue
is to pointthedirection
whosemainfunction
In the nexttwo sections,we developtwo conceptsthat
withbothof thesecharacterizations.
thecriticalimportance
of socialfactorsin diseasecausation,provideconceptualframeillustrate
thatmayensueiftheroleofsocial
researchinthisarea,andpointtotheproblems
worksforfuture
andpolicymakers.
These aretheideas of "contextualizing
is neglectedbyresearchers
conditions
causes."
riskfactors"and "fundamental
CONTEXTUALIZING RISK FACTORS
We suggest that medical sociologistsand social epidemiologistsneed to counterthe
risk factorsthat are increasingly
trajectoryof modem epidemiologytoward identifying
proximateto disease-ones forwhich"biologicalplausibility"can be argued.One way they
risk factors.By this we mean that
can do this is by "contextualizing"individually-based
framework
to understand
must(1) use an interpretive
whypeople come to be
investigators
85
exposed to risk or protectivefactorsand (2) determinethe social conditionsunderwhich
individualriskfactorsare relatedto disease. We presentexamplesthatillustrateboththese
principles.
First, an importantstrategyfor reducingthe threatof AIDS is to educate the public
or
concerningthe steps theymust take as individualsto reduce theirrisk of contracting
otherswiththe HIV virus. Clearly,however,some people are betterable to take
infecting
riskfactorsforAIDS, we maybe
thanothers.By contextualizing
advantageof thisinformation
whysome people cannotavoid therisk. For example,homelessor other
able to understand
maynothave theoptions
as a survivalstrategy
poorwomenwho turnto prostitution
extremely
or resourcesthatwould enablethemto refuseto engagein riskysexual behaviors,no matter
theymaybe abouttheriskstheyface. This examplesuggeststhatmedical
how well informed
riskfactorsby askingwhatit is
need to contextualize
sociologistsand social epidemiologists
thatshapestheirexposureto suchriskfactorsas unprotected
aboutpeople's lifecircumstances
homelife.
lifestyle,or a stressful
poordiet,a sedentary
sexual intercourse,
Our second example concernsthe increasingattentionbeing paid to the public health
of meat, poultry,and eggs withE. coli and salmonella
problemposed by contamination
and to
bacteria.The publichas been warnedto rinseand cook meatand poultrythoroughly
carefullywash hands,knives,cuttingboards,and so on. Because some followthesesafety
guidelinesmoreassiduouslythanothers,one can imaginea riskprofileof individualbehaviors
are onlynecessary,however,whenthe
These precautions
thatmightpredictbacterialinfection.
actions in the 1980s that
food thatreaches the marketplaceis contaminated.Government
industry
inspectorsand deregulatedthe meat-processing
reducedthe numberof government
approachto the
havecreatedtheneedforvigilanceon thepartof individuals.Whilethecurrent
problemfocuseson the individual,it can readilybe seen thateconomicand politicalforces
shape individuals'exposureto thisrisk.This examplesuggeststhatmedicalsociologistsand
needto contextualize
by askingunderwhatsocial conditionsindividual
social epidemiologists
risk factorslead to disease and whetherthereare any social conditionsunderwhich the
riskfactorswouldhave no effectat all on disease outcome.
individual-level
riskfactorsmay seem obvious,if we takea hard
of contextualizing
While theimportance
areas of researchin medicalsociology,we will find
look at even some of themostinfluential
is needed.Consideragainthestressparadigm.
thatmuchmoreof thiskindof contextualizing
to health
circumstances
Whilethereare hundredsif notthousandsof studiesrelatingstressful
of Turnerand colleagues(Turnerand Marino1994; Turner,
outcomes,untiltherecentefforts
data aboutthesocial origins
Wheaton,and Lloyd 1995), therewas verylittleeven descriptive
circumstances
of stressful
(butsee Smith1992; Goldbergand Comstock1980).
riskfactors?One reasonis thatefforts
thatwe striveto contextualize
Whyis it so important
to reduce risk by changingbehaviormay be hopelesslyineffectiveif thereis no clear
of theprocessthatleads to exposure.For example,thereare powerfulsocial,
understanding
cultural,and economic factorsshaping the diet of poor people in the United States.
themto
abouthealthydietto poorpeople and exhorting
providinginformation
Consequently,
of the
follownutritional
guidelinesis unlikelyto have muchimpact.Withoutan understanding
forreducingtheriskis leftwiththeindividual,and
contextthatleads to risk,theresponsibility
factorsthatputpeople at riskof risks.
nothingis done to alterthemorefundamental
shouldturn
This lineof thinking
suggeststhatmedicalsociologistsand social epidemiologists
to examineriskfactorsthatare evercloserto diseasein a
tendency
on itshead thenow-popular
and search
to facetheotherdirection
causal chain.Rather,it suggeststhatit is justas important
bothto explorethesocial
forthefactorsthatputpeople at riskof risks.It exhortsresearchers
in the
riskfactorsare context-dependent
individually-based
originsof risksand to ask whether
healthoutcomesonlywithinthecontextofa specificsetofsocialconditions.
senseofinfluencing
FUNDAMENTAL CAUSES
riskfactors,medicalsociologistsand social
In additionto theobviousneedto contextualize
of social
consideration
andthorough
needto takeas theirtasktheidentification
epidemiologists
conditionsthat are what we term "fundamentalcauses" of disease. We call them
86
"fundamental"
causes because, as we shallsee, thehealtheffectsof causes of thissortcannot
themechanisms
thatappearto linkthemto disease. The possibility
be eliminated
by addressing
qualitywithregardto healthwas first
thatsome social conditionshave this fundamental
presentedby House and colleagues in a discussionof potentialreasons for the persistent
associationbetweenSES and disease (House et al. 1990, 1994). We elaborateupontheseideas
social causes of disease.
to buildourconceptof fundamental
The Case of SES and Disease. The idea thatsocial conditionsmightinfluencehealthwas
assertedby nineteenth-century
physicianswho foundedthefieldof social medicine.
forcefully
Virchow(1848), forexample,declaredthat"medicineis a social science." And, of course,it
was in partthestrongassociationbetweenindicatorsof povertyand healththatsupportedthis
to be apparent,residingin
claim. The reasonsforthepowerfulassociationwerealso thought
thedire housing,sanitation,and workconditionsof poor people at the time(Rosen 1979).
Withtremendous
medicaladvances and extensivepublic healthinitiatives,the incidenceof
such diseases as diphtheria,measles, typhoidfever,tuberculosis,and syphilisdeclined
In addition,in modernwelfarestates,poor people's access to care increased
dramatically.
as linkingSES to
substantially.
By the 1960s, manyof the factorsthathad been identified
diseasehad been addressed,and one mighthave expectedtheassociationto wane and perhaps
Indeed,thisis exactlytheconclusionthatCharlesKadushinreachedin a
disappearaltogether.
1964 articlein Sociological Inquiry(Kadushin 1964). Startledthatsocial scientistshad not
recognizedthedemiseof theSES gradientin health,Kadushinremindedhis readersthatmost
in healthin theUnitedStateshad been
to produceSES differences
of themechanismsthought
addressedand that "as countriesadvance in theirstandardof living, as public sanitation
proceeds,and as Dr. Spock becomesevenmorewidelyread,
improves,as mass immunization
the grossfactorswhichintervenebetweensocial class and exposureto disease will become
more and more equal for all social classes" (1964:75). As a result,Kadushindeclared,
Americansfromthe lowerclasses are no morelikelyto developdisease thanthosefromthe
middleor upperclasses.
incorrectas indicatedby
Of course, Kadushin'spredictionturnedout to be dramatically
an enduringor even an increasing(Pappas et al. 1993)
studies(cited above) documenting
associationbetweenSES and manydisease outcomes.But whatwas wrongwithKadushin's
reasoning?Hadn't he engagedin logic thatmostof us notonlyacceptbut takeforgranted?
drawnthepathmodelwithSES as thedistalfactorthatis linkedto disease
Havingimplicitly
by moreproximalriskfactors,and havingobservedthattheproximalriskfactorsin themodel
had been largelyeliminatedas causal agents,he concludedthatthe SES-disease association
shouldhave disappeared.But it didn't.
turnedout to be wrongis readily
On theface of it, thereasonKadushin's 1964 prediction
risk
riskfactorshe consideredto theintervening
apparentwhenone comparestheintervening
factorsidentified
by Adlerand colleaguesin their1994 reviewof socioeconomicstatusand
thatKadushinmentionedare
and immunization
health.The "gross" riskfactorsof sanitation
replacedin theAdlerandcolleagues'reviewbyriskfactorsthatincludesmoking,exercise,and
theevidencesuggeststhatseveralof theriskfactorsmentioned
by
diet,amongothers.Further,
mechanismswhen Kadushin wrote.
intervening
Adler and colleagues were not important
Beforethe1960s,forexample,therewas no evidencethatratesof smokingwerehigheramong
lowerSES individuals.Rather,the associationemergedduringthe 1960s because people of
highersocioeconomicstatuswerelikelyto startsmokingand morelikelyto quit if theyhad
started(Ernster1988; Novotnyet al. 1988). Similarchangeshave occurredin otherrisk-related
behaviors.For example,in consideringthe strongevidencethatdeclinesin coronaryheart
disease have been greatestamongpeople of highersocioeconomicstatus,Beaglehole(1990)
aboutand moreable
pointedto thefactthathigherSES individualshave been betterinformed
to implement
changesin healthbehaviorslike smoking,exercise,and diet.The resulthas been
a wideningof the gap in ratesof heartdisease betweenthe rich and the poor (Beaglehole
1990). Thus studiesof theassociationbetweenSES and disease overthepast severaldecades
revealan important
fact-the riskfactorsmediatingthe associationhave changed.As some
riskfactorswere eradicated,othersemergedor were newlydiscovered.As new riskfactors
becameapparent,people of higherSES weremorefavorablysituatedto knowabouttherisks
to avoid them.
efforts
and to have theresourcesthatallowedthemto engagein protective
87
Fromone vantagepoint,thisaccountof theassociationbetweenSES and disease mightbe
seen as a curiousstoryin the historyof social epidemiology-an instancein whichunique
putforward
historicaleventspulledtherugoutfromunderan otherwisereasonablehypothesis
by Kadushinin 1964. Far morelikely,however,is the possibilitythattheeffectof SES on
riskfactors-because a deeper
disease has endured-despiteradical changesin intervening
sociologicalprocess is at work. If so, what happenedover the past severaldecades will
of
pointin time,we presumethatan understanding
continueto happenand if,at thisparticular
thatcurrently
appearto linkthetwo,
theSES-disease associationlies intracingthemechanisms
timewill proveto be as wrongas Kadushinwas. This will occur,we argue,because SES is a
cause of disease.
fundamental
FundamentalSocial Causes ofDisease. Our discussionof SES to thispointhas focusedon
mechanisms.However,
associationwithdisease despitechangesin intervening
its persistent
cause, mightmaintainthis
we have notyetexplicitlyindicatedwhySES, or anyfundamental
withdisease.
relationship
kindof enduring
social
associations,and theessentialfeatureof fundamental
The reasonforsuchpersistent
causes, is thattheyinvolveaccess to resourcesthatcan be used to avoid risksor to minimize
the consequencesof disease once it occurs. We defineresourcesbroadlyto includemoney,
resourcesembodiedin theconcepts
knowledge,power,prestige,andthekindsof interpersonal
of social supportand social network.Variableslike SES, social networks,and stigmatization
to directlyassess theseresources2
are used by medicalsociologistsand social epidemiologists
causes. However,othervariables
and are therefore
especiallyobviousas potentialfundamental
and
examinedby medical sociologistsand social epidemiologists,such as race/ethnicity
gender, are so closely tied to resources like money, power, prestige,and/orsocial
causes of disease as
thattheyshouldbe consideredas potentialfundamental
connectedness
well.
causes to emergeis changeover
An additionalconditionthatmustobtainforfundamental
humans,therisksforthosediseases,knowledgeaboutrisks,or
timein thediseases afflicting
fordiseases. If no new diseases emerged(such as AIDS), no
of treatments
theeffectiveness
new risksdeveloped(such as pollutants),no new knowledgeaboutrisksemerged(as about
were developed(such as
cigarettesmokingin the 1950s and 1960s), and no new treatments
social causes would notapply.In such a static
theconceptof fundamental
hearttransplants),
betweena social cause and disease are blocked,the
system,as riskfactorsknownto intervene
associationbetweenthesocial cause and diseasewoulddeclinein lockstep.But,ofcourse,this
withregardto health.In thecontext
is nothinglike thesituationhumanshave everconfronted
of a dynamicsystemwithchangesin diseases, risks,knowledgeof risks,and treatments,
causes are likelyto emerge.The reasonis thatresourceslikeknowledge,money,
fundamental
fromone situationto another,and
are transportable
power,prestige,and social connectedness
situationschange,thosewho commandthe mostresourcesare best able to
as health-related
whatthecurrent
profile
avoidrisks,diseases,andtheconsequencesofdisease. Thus,no matter
of diseases and knownriskshappensto be, those who are best positionedwithregardto
by disease.
social and economicresourceswill be less afflicted
important
causes. Because a
of fundamental
attributes
The foregoingreasoningsuggeststwo further
cause involvesaccess to broadlyserviceableresources,it influences(1) multiple
fundamental
observation,because it
riskfactorsand (2) multipledisease outcomes.This is an important
cause and disease can be
thattheassociationbetweena fundamental
alertsus to thepossibility
or in theoutcomes.The idea thatmultiple
changeseitherin themechanisms
preservedthrough
to a persistent
associationbetweena cause and an effectcomes
mechanismsmay contribute
fromsociologistStanleyLieberson.Lieberson(1985) proposedthatsome causes, whichhe
effectson a dependentvariablebecause, whentheeffect
called "basic causes," have enduring
We
of one mechanismdeclines,the effectof anotheremergesor becomes moreprominent.
have already describedthe example of the changingrole of mechanismslike smoking,
exercise,and diet in relationto the associationbetweensocioeconomicstatusand disease.
While these variables were no doubt always linked to disease, their connectionto
socioeconomicstatuschanged when knowledgeabout theirimportancein healthbecame
available. We take the idea thata cause can affectmultiplehealthoutcomesfromsocial
JohnCassel. Cassel (1976) pointsoutthatsomesocial factorsmakeindividuals
epidemiologist
88
vulnerable,notto a specificdisease,butto a wide arrayof diseases. As a result,investigations
of such social factorsto specificmanifestations
of therelationship
of disease are of limited
utility.Since onlyone manifestation
of the social cause is measuredin such studies,thefull
impactofthesocial cause goes unrecorded
(also see Aneshensel1992; Aneshensal,Rutter,and
Lachenbruch1991; Cullen 1984). However,in additionto underestimating
thefullimpactof
social causes at anygiventime,a narrowfocuson one disease at a timemissesthepossibility
that changes in particulardisease outcomes can lead to enduringassociationsbetween
fundamental
causes anddiseaseoverall.Whenhealthsurveillance
or immunization
systemsfail
and old diseases begin to reemerge(TB, measles) or whennew diseases entera population
(AIDS), theydo so in thecontextof existingsocial conditionsthatare ripeenvironments
for
social causes to new or reemerging
producingmechanismsthatlink fundamental
diseases.
use of drugs,whichin turn
Thus,forexample,before1980,SES was linkedto theintravenous
had negativehealthconsequences.But withthe emergenceof AIDS, this SES-linkedrisk
factorcame to have an even morepotenteffecton health.Indeed,AIDS will likelybecomea
in the time ahead due to the rapid
in mortality
contributor
to SES differentials
significant
in low-incomeareas(Brunswicket al. 1993). Similarly,
thereemergence
of
spreadof infection
is striking
drug-resistant
tuberculosis
poor inner-city
populationsto a fargreaterextentthanit
is higher-status
suburbanareas.
In sum,a fundamental
social cause of diseaseinvolvesresourcesthatdetermine
theextentto
and mortality.3
which people are able to avoid risks for morbidity
Because resourcesare
important
determinants
of risk factors,fundamental
causes are linkedto multipledisease
mechanisms.Moreover,because social and economic
outcomesthroughmultiplerisk-factor
fundamental
social causes have
resourcescan be used in different
ways in different
situations,
effectson disease even whentheprofileof riskfactorschangesradically.It followsthatthe
effectof a fundamental
cause cannotbe explainedby theriskfactorsthathappento linkit to
disease at anygiventime.
even those of us who believe that social
Research Implications.All too frequently,
forhealthare lulledintothinking
thatthebestway to understand
and
conditionsare important
theintervening
addresstheeffectsof social conditionsis to identify
links.Indeed,it
ultimately
is preciselythisreasoningthatAdlerand colleaguesuse to assertthatpsychologists
have an
importantrole to play in addressingthe SES-disease association-the risk factorsthey
were individually-based
behaviorsthatpsychologists
are well-equippedto address.
identified
But theconceptof a fundamental
cause sensitizesus to thepossibility
thatfundamental
social
causes cannotbe fullyunderstoodby tracingthe mechanismsthatappear to link themto
disease. To be sure, a focus on mechanismscan help identifyvariablesmore proximalto
health,and if suchrisksare addressed,thehealthof thepubliccan be improved.However,in
thecontextof a dynamicsystemin whichriskfactors,knowledgeof riskfactors,treatments,
and patterns
of disease are changing,theassociationbetweena fundamental
social cause and
to new situations.If one
disease will endurebecause theresourcesit entailsare transportable
genuinelywantsto altertheeffectsof a fundamental
cause, one mustaddressthefundamental
cause itself.
There are two implicationsof this reasoning.First, medical sociologistsand social
and communicating
themeaningof research
need to be carefulin interpreting
epidemiologists
and disease. Specifically,ifthesocial factor
involvingsocial factors,intervening
mechanisms,
is a fundamental
cause, one cannot claim to have accountedfor its effectsby having
variablesin a pathor regression
"explained"its associationwiththeinclusionof intervening
model. Second, to understand
associationsbetweenfundamental
causes and disease, medical
of theresourcesthatfundamental
causes
sociologistsneed to examinethebroaderdeterminants
entail. This distinctlysociological enterprisewill link medical sociologiststo the broader
how generalresourceslikeknowledge,
disciplinein a productive
way as we seekto understand
into the health-related
money,power, prestige,and social connectionsare transformed
of morbidity
and mortality.
resourcesthatgeneratepatterns
89
POLICY IMPLICATIONS
Mechanicand Aiken (1986) arguethat,ratherthanleadingto specificpolicies, the main
of social science researchto social changeis throughits influenceon the way
contribution
and thegeneralpublicthinkaboutsocial and healthproblems.This paperaimsto
policymakers
to theprogressmade by medicalsociologists
by drawingattention
make such a contribution
risk
theconceptsof "contextualizing
in recentyearsand by offering
and social epidemiologists
causes."
factors"and "fundamental
risk factorsthat has dominatedmuch
On its own, the focus on individually-based
medicalresearchin recentyearsis inadequate.4To be sure,thisfocusis a
population-based
since the findingsit generatesare highlyrelevantto any given
compellingattention-getter,
in fatintake,a little
individual.Theycan lead to "personalpolicy"changessuchas a reduction
exercise,or an aspirina day-actions thatindividualpeople can controlpersonally.But those
limitedto a focus
whocraftpolicyforpopulationscan be led astrayiftheirpurviewis narrowly
riskfactors.This paperrevealstworeasonswhythisis so. First,without
on individually-based
risk factors,
the social conditionsthatexpose people to individually-based
understanding
will
will failmoreoftenthantheyshould.This will occurbecause interventions
interventions
reasons.The consequence
to changeforunrecognized
to behaviorsthatareresistant
be targeted
will be thatlives and moneyare wasted,and theAmericanpublicwill lose confidencein our
changesthatreallyimprovehealth.Second, some social conditionsare
abilityto implement
the
addressedby readjusting
causes of disease and as such cannotbe effectively
fundamental
mechanismsthatappearto linkthemto disease in a givencontext.If we
individually-based
of disease, we mustdo so by directly
wish to alterthe effectsof thesepotentdeterminants
in waysthatchangethesocial conditionsthemselves.
intervening
shoulduse
The issuesaddressedin thispapersuggestthreegeneralcriteriathatpolicymakers
in evaluatingwhetherto commitfundsto a proposedhealthintervention:
riskfactors,policymakers
shouldrequirethat
withtheidea of contextualizing
(1) Consistent
all interventions
seekingto changeindividualriskprofilescontainan analysisof factorsthat
of interventions
aimed at changing
putpeople at riskof risks.This will avoid the enactment
If the
influencedby factorsleftuntouchedby the intervention.
behaviorsthatare powerfully
of a riskfactor,
manipulation
evidenceis to come fromstudiesthatinvolvetheexperimental
works outside of the
policymakersshould require confirmationthat the intervention
theriskfactor
manipulating
context.The reasonforthisis that,byexperimentally
experimental
thesocial factorsthat
have removedfromconsideration
(e.g., dietor exercise),theresearchers
Outsidethe experimental
determineexposureto the risk factorin the naturalenvironment.
in theintervention's
context,thefactorsthatputpeopleat riskofrisksmaydominate,resulting
ultimatefailure.
shouldconsider
withtheconceptof fundamental
causes, healthpolicymakers
(2) Consistent
becauseof
willhave an impactonjust one diseaseor whether,
whether
a proposedintervention
thathas
cause, it will affectmanydiseases. An intervention
its influenceon a fundamental
than one thathas a
even a modestimpacton manydiseases may be far more important
relativelystrongimpacton just one.
concernedwithbroadsocial conditionsas causes of disease should
(3) Healthpolicymakers
variablesbut claim to
thatfocus only on intervening
regardwith skepticisminterventions
that addressesthe
addressthe broadersocial condition.Even an "effective"intervention
social
riskfactorwill, in thelong run,failto eliminatetheeffectof a fundamental
identified
theresourcesthataccrueto themoreadvantagedallow
condition.In a changingstateofaffairs,
bytheintervention.
themto regainthehealthadvantagethatmayhavebeendentedtemporarily
mustaddressinequality
social causes, theintervention
If one wishesto addressfundamental
causes entail.Many people and some medicalsociologists
in theresourcesthatfundamental
believethatthisis impractical-evento thinkabout-because, forthem,inequalityis so firmly
thatnothingmuchcan be done aboutit. Believingthis,theonlyreasonablethingto
entrenched
riskfactors,even if doing so has little
do is to focus on moreproximalindividually-based
social causes and disease.
long-runbearingon theassociationbetweenfundamental
Thereare manypoliciesthathave a directbearingon the
But thisreasoningis shortsighted.
social
extentof inequalityin oursocietyand thuson theextentto whichpeople fromdifferent
90
have access to health-related
circumstances
resources.To be sure, thesepolicies are rarely
discussedwithreferenceto theirhealthimplications.Still, policies relevantto fundamental
causes ofdiseaseforma majorpartof thenationalagenda,whether
thisinvolvestheminimum
wage, housingforhomelesspeople, capital-gains
taxes,parenting
leave, head-start
programs,
or otherinitiatives
of thistype.Such policyinitiatives
oftenlie outsidetherealmof influence
and expertiseof healthpolicyexperts.Yet if fundamental
causes are potentdeterminants
of
disease, the potentialhealth impact of these broad policies needs to be thoroughly
understood-ataskthatmedicalsociologistsand social epidemiologists
shouldtakeup more
than they have. Ideally, a research-based"health impact statement"should
thoroughly
accompanysuch plans, and healthexpertsshouldbe trainedin the skillsneededto produce
sucha statement.
CONCLUSION
The dominantfocus in epidemiologyand perhapsthe Americanculturein generalis on
riskfactorsthatlie relativelyclose to disease in a causal chain. But this
individually-based
focusoverlooksimportant
sociologicalprocessesand, as a result,could lead us to actionsthat
limit our abilityto improvethe nation's health. We have focused on two conceptsriskfactorsand fundamental
causes-that directourattention
contextualizing
topreciselythose
factors
thatareleftunexaminedin thecurrently
dominant
orientation
to researchon riskfactors
fordisease. If futureresearchby medicalsociologistsand social epidemiologists
increasesour
of the processesimpliedby theseconcepts,we will be betterpositionedas a
understanding
societyto further
improvethenation'shealth.
NOTES
1. Using the American Journal of Epidemiologyas an indicationof the currentemphasis of
epidemiologicalresearch,we. reviewedthe 240 articlespublishedbetweenNovemberof 1992 and
1993. Excludingmethodologicalreports(N=44) and studies focused exclusivelyon descriptive
epidemiology
(N = 15), we foundthatonly13.3 percent(24/181)of thearticlesfocusedon riskfactors
thatcould be construedas social in nature.Moreover,because manyof thesearticlesexaminedrace,
or gender,withoutexplicitreference
to thesocial aspectsof thesecharacteristics,
ethnicity
our figure
estimateof thejournal'sfocuson social factors.
of 13.3% shouldbe consideredan upper-bound
because it is so closelytiedto theprestigesystem(Goode 1978). Prestige,
2. We includestigmatization
or thegeneralstandingthatan individualholds in theeyes of others,is an important
resourcethatis
likelyto havemanyimplications
forhealth-eitherindirectly
through
resourceslikemoney,power,or
whata personand/orthosearoundhim/her
social connections,
or moredirectlythrough
believehe/she
is important
because itinvolvesthedenialof the
deservesfromthesocial environment.
Stigmatization
benefitsof prestige.
3. We focus here on fundamental
social causes of disease. It is possible to conceive of fundamental
psychologicalor biological causes as well. For example, at the psychologicallevel, one might
considera masteryorientation
to be a resourcethatwouldbe linkedto manymechanismsand thusto
manydiseases. Similarly,at the biologicallevel, the immunesystemmightbe conceptualizedas a
resourcethatwouldinfluencemanyspecificmechanismsand thusmanydiseaseoutcomes.In eitherof
cause (masteryor immunesystem)and disease
thesecases, theassociationbetweenthefundamental
outcomeswould likely endureeven if the specificmechanismswere to change. Our main point
causes shouldbe takenseriously
social factorsas fundamental
causes is notthatfundamental
regarding
becausetheyare oftensocial, butratherthatsocial conditionsneed to be takenseriouslybecause they
are oftenfundamental
causes.
to recall thatthisindividually-based
risk
4. In additionto thefactorswe considerhere,it is important
an excessiveportionof theblame to the
factorapproachcan also have deleteriouseffectsby shifting
on individually-based
individual.Whenresearchfocusesattention
causes of disease, theonus is often
taken off broader-basedconditions.Morbidityand mortalitydue to tobacco is attributed
to an
bad habit ratherthan to a heavily advertised,government-subsidized,
individually-based
highly
killerindustry.
profitable
91
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94
and researchscientistat
Bruce G. Link is associateprofessorof publichealthat ColumbiaUniversity
typesof
thesourcesof particular
lie in understanding
Institute.
His interests
New York StatePsychiatric
of healthand
and its consequencesas these bear on the social patterning
inequality,its legitimation,
is reflectedin his workon theassociationbetweensocioeconomicstatusand major
illness.This interest
mentaldisordersand thepossiblerolethatoccupationalconditionsmayplay in thisassociation,research
on the healthand well-beingof homelesspeople, and researchon the social and economicadversities
engenderedby the stigmaof mentalillness.
of California,Los Angeles. Her research
Jo Phelan is assistantprofessorof sociologyat theUniversity
interests
includehomelessness,social stigma,the impactof social conditionson healthand illness,and
concerninginequalityand itslegitimacy.
attitudes

Social Conditions as Fundamental Causes of Disease*

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