Social Conditions as Fundamental Causes of Health Inequalities

Introduction

  • The fiftieth anniversary of the Medical Sociology Section of the American Sociological Association.

  • The critical problem: Socioeconomic disparities in health and mortality.

    • Poorer, less privileged members of society experience worse health and die younger.

    • Socioeconomic inequalities are robust, well-documented, and persistent since at least the early nineteenth century.

Health Disparities Overview

  • Age-adjusted risk of death:

    • Individuals at the lowest socioeconomic level have a risk of death that is double to triple that of those at the highest level (Antonovsky 1967; Sorlie et al. 1995; Kunst et al. 1998).

  • Example statistics from 2005 regarding age-adjusted death rates for individuals aged 25-64 based on education level:

    • Men:

    • < 12 years: 821 per 100,000

    • 12 years: 605 per 100,000

    • > 12 years: 249 per 100,000

    • Women:

    • < 12 years: 472 per 100,000

    • 12 years: 352 per 100,000

    • > 12 years: 165 per 100,000

  • Similar inequalities exist across different income groups.

Persistence of Socioeconomic Inequalities

  • Despite eradication of diseases that historically affected lower SES due to poor living conditions, mortality inequalities persist due to new causes of death (e.g., cancer, cardiovascular diseases) exacerbated by poor lifestyle factors common in lower SES groups.

  • Health inequalities have not diminished despite the establishment of universal healthcare systems like the UK's National Health Service (Black et al. 1982).

Theory of Fundamental Causes

  • Developed by Link and Phelan (1995) to explain persistence of health inequalities despite changing disease profiles.

  • Key assertions:

    • Socioeconomic status (SES) embodies resources (money, knowledge, prestige, power, beneficial social connections).

    • These resources protect health over time, regardless of the underlying disease mechanisms.

  • Components of the theory:

    1. Influences multiple disease outcomes.

    2. Affects health via multiple risk factors.

    3. Involves access to resources that mitigate risks or health consequences.

    4. Reproduces health disparities through changing risk and protective mechanisms over time.

Flexible Resources

  • SES is linked to multiple diseases and pathways due to flexibility of resources:

    • Examples:

    • Cholera: Wealthy individuals can avoid high-risk areas.

    • Heart disease: Wealthy individuals can access healthier lifestyles and medical care.

  • Resources are vital for maintaining health and address health disparities.

  • Strong connection to social stratification theories shows how these resources emerge from societal structures.

Empirical Evidence Supporting the Theory

  1. Multiple Disease Outcomes: Low SES relates to various diseases (chronic, communicable, and injuries), impacting mortality rates across the board (Pamuk et al. 1998; National Center for Health Statistics 2008).

  2. Multiple Risk Factors: Low SES correlates with health risks such as smoking, poor nutrition, and lack of preventative care (Lantz et al. 1998).

  3. Resource Deployment: Studies demonstrate that higher SES groups leverage resources effectively to enhance health outcomes.

  4. Reproduced SES-Health Associations: Revised health mechanisms reveal that some diseases' relationships with SES persist despite new advancements and knowledge.

Mechanism Creation and Demise

  • Exploring the emergence of new mechanisms that link SES and health by analyzing treatment advancements and their equal distribution.

  • Case studies showing how improvements in treatment have often favored those with higher SES underscores the focus on equitable resource access.

  • Examples include:

    • Breast cancer rates post-hormone therapy studies (Carpiano and Kelly 2007).

    • Events following the establishment of effective treatment for conditions like cholera and heart disease highlight SES gradients in health outcomes.

Refinements to Fundamental Cause Theory

  • The model's prediction that higher SES provides health advantages will remain as long as resource disparities exist.

  • The emergence of new knowledge triggers shifts in health gradients favoring higher SES groups, affecting mortality rates positively.

  • Continual evolution of disease mechanisms must be considered for future research.

Limitations of the Theory

  • Recognition of countervailing mechanisms that compete with health motivations:

    • Example: Pursuit of status over health outcomes as a detriment to health decisions (Lutfey and Freese 2005).

  • Social conditions may create conditions when SES does not operate as a cause of health and mortality but still reflects broader life chances.

Policy Implications

  • Empirical findings inspire distinct policy recommendations diverging from traditional risk-factor models:

    1. Aim to reduce resource inequalities at a systemic level (e.g., minimum wage adjustments, social support services).

    2. Contextualize individual risk factors by identifying influencing factors such as environmental conditions and stressors.

    3. Prioritize health interventions that are universally applicable, reducing reliance on individual resources for successful health outcomes.

    4. Focus on developing cost-effective interventions likely to be accessible for lower SES groups to diminish health disparities.

Conclusion

  • Fundamental causes posit that entrenched socioeconomic inequalities persist and evolve especially as new health technologies emerge.

  • Advocates for both improving general public health and decreasing inequalities in health.

  • Future work should enhance empirical evidence and refine theory to address pervasive inequalities in health outcomes alongside simultaneous public health advancements.