The Social Causes of Health The Social Causes of Health and Disease in the United and Disease in the United

StatesStatesAlexis de Tocqueville Lecture Series:

Questions on American SocietyUniversity of Montreal

January 2006

William C. Cockerham, PhDDistinguished Professor of Sociology

University of Alabama at Birmingham

IntroductionIntroductionPast literature does not characterize social

factors as primary contributors of health and illness.– Yet, these factors have a direct causal effect on

health and longevity.

Society may make you sick, or promote your health.

BackgroundBackgroundEmile Durkheim (1897)

– Applied basic sociological principles to the problem of suicide.

– Such principles helped explain suicide patterns by identifying factors external to the individual.

A bold model for medical sociology?– This model never fully emerged in medical

sociology as the functionalist paradigm had fallen out of favor by the 1970s.

BackgroundBackground Phelan and her colleagues suggest a new approach

to studying disease and mortality.

Structural variables are correlated with many diseases but are considered causally related to very few.– Modern epidemiology considers social conditions as

proxies for true causes of disease.

As a result, the effects of social systems are often ignored, even though social conditions may be responsible for causing health problems.

A New ParadigmA New Paradigm A more comprehensive approach to health and

mortality research that considers the impact of structural variables is needed.

This is a challenge because of difficulties in linking the social with the biological.

Finding social factors at the aggregate level that determine individual-level health is problematic.– Simple association does not always imply causality.

The Epidemiological TriadThe Epidemiological Triad Agent, host, and environment.

– Interaction of agents and hosts within an environment serves as the mechanism for action.

Agents are social in the health effects of class, occupation, or lifestyle on individuals.

Hosts reflect traits that are both biological (age, sex, etc.) and behavioral (habits, customs, lifestyles, etc.).

The Epidemiological TriadThe Epidemiological Triad Features of the environment may also be social.

– Living conditions, norms, values, and attitudes within a particular social and cultural context.

Health-related lifestyles are particularly important as social mechanisms that produce positive or negative outcomes.

Lifestyles have multiple roles as they serve as a collective pattern of behavior (agent) that is normative (environment) for the individual (host). – These lifestyles may be decisive determinants of health

and longevity.

Support for Social MechanismsSupport for Social Mechanisms The validity of social mechanisms and their impact on

health has yet to be established.

Effective methodologies for testing these hypotheses have been developed.– Multi-level analyses using HLM, VARCL, and MLn.

Some question whether empirical support for social mechanisms and their role in determining health outcomes will be important.– This is an important critique that should be considered.

Recent Epidemiological Recent Epidemiological TrendsTrends

Thisted (2003) maintains that the differences in percentage of deaths in the black and white populations of the US is not extreme for:– Hypertension, HIV, diabetes, and homicide.

While a disadvantaged social situation may cause many African Americans to have greater exposure to these ailments than whites, most individuals of both races do not die from diabetes and homicide.

Recent Epidemiological TrendsRecent Epidemiological TrendsTABLE 1. Age-Adjusted Death Rates for Selected Causes of Death, 2002

Non-Hisp. Non-Hisp. Hispanic Asian/ Am. Ind./

Whites Blacks Pac. Isl. Alaskan

All causes 837.5 1083.3 629.3 474.4 677.4

Heart Disease 239.2 308.4 180.5 134.6 157.4

Cerebrovascular Dis. 54.6 76.3 41.3 47.7 37.5

Cancer 195.6 238.8 128.4 113.6 125.4

Pulmonary Dis. 46.9 31.2 20.6 15.8 30.1

Pneumonia/Influenza 22.6 24.0 19.2 17.5 20.4

Liver Dis./Cirrhosis 9.0 8.5 15.4 3.2 22.8

Diabetes 22.2 49.5 35.6 17.4 43.2

Accidents 38.0 36.9 30.7 17.9 53.8

Suicide 12.9 5.3 5.7 5.4 10.2

Homicide 2.8 21.0 7.3 2.9 8.4

HIV/AIDS 2.1 22.5 5.8 0.8 2.2

* Deaths per 100,000 population. Source: National Center for Health Statistics, 2005.

Notable Trends – United StatesNotable Trends – United States Non-Hispanic blacks exhibit the highest all-cause

mortality rates.

Particularly striking are the exceptionally high death rates for non-Hispanic blacks for heart disease, cerebrovascular disease, cancer, diabetes, homicide, and AIDS.

While it is true that most individuals do not die from diabetes and homicide, they do die from heart disease, cancer, and cerebrovascular diseases.– African Americans are well ahead of whites in these

causes of mortality.

Case Study – Diabetes in the U.S.Case Study – Diabetes in the U.S. Rates are significantly increasing in the United States.

20.8 million Americans have diabetes and 41 million more are in a pre-diabetic stage.

One in three children born in 2001 can expect to become diabetic.– May be as high as one in every two Hispanic children.

Number of diabetics in New York City has increased 140 percent in the last decade – one in every eight residents, or about 800,000.

Diabetes in the U.S.Diabetes in the U.S. Genetics appear to play a critical role in that diabetes

tends to be more prevalent in certain families and groups than others.– Recent trends cannot be explained by genetics alone.

The primary determinant appears to be social behavior and is inextricably linked to race and income.– Low income is important because of poor diets, lack of

exercise, and inadequate medical care.– Race is important because blacks and Hispanics are

twice as likely as whites to become diabetic.– Race is typically used as a proxy for class.

Diabetes in the U.S.Diabetes in the U.S. The social mechanism triggering this disease is health

lifestyles, notably poor diet and lack of exercise.

“Listen, if I want to eat a piece of cake, I’m going to eat it. No doctor can tell me what to eat. I’m going to eat it, because I am hungry. We got too much to worry about. We got to worry about tomorrow. We got to worry about the rent. We got to worry about our jobs. I’m not going to worry about a piece of cake.” (Female diabetic)

Diabetes in the U.S.Diabetes in the U.S.

Asians are New York City’s fastest growing racial minority and are especially susceptible to Type 2 diabetes.

- 60 percent more likely to get the disease than whites.

Again, health lifestyles are primary determinants.– Rejection of traditional Chinese diet and rapid adoption of

high-calorie, processed foods, large food portions, and a sedentary lifestyle characteristic of American culture.

Case Study – HIV/AIDS in the U.S. Case Study – HIV/AIDS in the U.S. HIV/AIDS offers another example of race and class as a

social determinant.

By the 1990s, the magnitude of the epidemic had shifted especially to non-Hispanic blacks and to Hispanics.

There are no known biological reasons why race should enhance the risk of HIV/AIDS.

Segregation is also a factor, in addition to poverty, joblessness, minimal access to quality medical care, and stigma.

Race EffectsRace Effects Laumann and Youm (2001) found that blacks have

the highest rates of STD infection because of the “intra-racial network effect.”

Blacks are highly segregated in American society, and the high number of sexual contacts between an infected black core and an uninfected periphery acts to contain infection within the black population.

The core (agent), the periphery (host), and the intra-racial network (environment).

Social Determinants of DiseaseSocial Determinants of Disease The seminal paper on social conditions and disease in

medical sociology is that of Link and Phelan (1995).

Social factors like class and social support are fundamental causes of disease because they signify access to resources, affect multiple disease outcomes, and maintain an association with disease over time.

Social conditions are factors that involve a person’s relationships to other people.

Social Determinants of DiseaseSocial Determinants of Disease

Stressful life events, stress-process variables, and one’s sense of personal control all qualify as social factors.

Persons at the bottom of the social hierarchy are less able to control their lives, have fewer coping resources, live in more unhealthy situations, face barriers in adopting a healthy way of life, and die earlier.

Socioeconomic StatusSocioeconomic Status Study after study in the U.S. finds that lower

socioeconomic status (SES) promotes lessened life expectancy, higher mortality rates, and poorer health.

Phelan et al. (2004) tested SES as a fundamental cause of mortality and found a strong relationship between SES and deaths from preventable causes.

Persons with higher SES had higher probabilities of survival from preventable causes of death because they are able to better utilize their greater resources.

Socioeconomic StatusSocioeconomic Status Lutfey and Freese (2005) found support for SES as a

fundamental causal factor in health outcomes in diabetic patients in a large Midwestern city.

Not surprisingly, higher-SES patients had significantly better glucose management, health, and survivability.

Mechanisms influencing diabetes control included the organizational features of clinics, external constraints on patients, and influences on patient motivation and cognitive abilities.

Social CapitalSocial Capital “A community-level resource reflected in social

relationships involving networks, norms, and levels of trust” (Putnam 2000).– “connections among individuals – social networks and the

norms of reciprocity and trustworthiness that arise from them” (Putnam 2000).

Accrues to individuals as a protective factor as a result of membership in groups (Bourdieu 1986).

Positive influences on health are derived from enhanced self-esteem, sense of support, access to group and organizational resources, and its buffering qualities in stressful situations.

Social CapitalSocial Capital One of the most powerful determinants of an

individual’s health (Putnam 2000).

Persons who are socially disconnected are between two to five times more likely to die from all causes when compared to individuals with close ties to family, friends, and community

Significance of social capital was first established in the Roseto study begun in the 1950s.

Neighborhood DisadvantageNeighborhood Disadvantage Neighborhoods can be rated on a continuum in terms

of order and disorder that are visible to its residents (Ross 2000).

Orderly neighborhoods are clean and safe, houses and buildings are well-maintained, and residents are respectful of each other and each other’s property.

Disorderly neighborhoods reflect a breakdown in social order – noise, litter, vandalism, graffiti, crime, and fear.– Consistently linked to poor physical and mental health.

Neighborhood DisadvantageNeighborhood Disadvantage As Pearlin et al. (2005:208) conclude:

“the pattern of status attainments can funnel people into the contexts that surround their lives, most conspicuously the neighborhoods in which they come to reside. When neighborhoods are predominantly populated by people possessing little economic or social capital, they have a notable impact on health independent of individual-level socioeconomic status.”

Health LifestylesHealth Lifestyles Collective patterns of health-related behavior based

on choices from options available to people according to their life chances.

Lifestyles thus have two components:– Life choices and life chances.

Individual choices are a process of agency by which people critically evaluate and choose a course of action.

Life chances refer to the structural probabilities of an individual finding satisfaction.

Health LifestylesHealth Lifestyles Choices concerning alcohol use, smoking, diet, and

exercise, along with choices on rest and relaxation, drug abuse, seat belt use, preventive checkups, and similar health-oriented behaviors all constitute health lifestyle practices.

Practices are either constrained or empowered by a person’s life chances, which are largely determined by class position.

Weber notes the dialectical interplay of choice and chance in lifestyle determination.

Health LifestylesHealth Lifestyles It may be said that people have a range of freedom,

yet not complete freedom, in choosing a lifestyle.

Individual choices in all circumstances are confined by two sets of constraints.

(1) Choosing from what is available, and,

(2) Social rules or codes determining rank order and appropriateness of preferences (Bauman 1999).

Health LifestylesHealth Lifestyles Discussions of lifestyle within the current socio-

medical discourse tend to focus on individual behavioral patterns that affect disease status.

Such an approach neglects the collective features of health lifestyles.

Example of Archer’s (1995) concept of upwards conflation.

This conception is reflected in standard methods of public health.

Lifestyle Theory – Max WeberLifestyle Theory – Max Weber In many studies, the term “lifestyle” has taken on a

very different meaning than the meaning intended by Max Weber.

In addition to “bottom-up” methodologies, Weber emphasized a structural approach in showing how collectivities could be powerful influences on individual behavior.

Weber’s focus was on how people act in concert, not only as individuals.

Lifestyle Theory – Pierre BourdieuLifestyle Theory – Pierre Bourdieu Bourdieu’s (1984) concept of the habitus can be

described as an organized repertoire of perceptions that guide and evaluate behavioral choices and options.– It is a mindset that produces an enduring framework of

dispositions to act in particular ways, originating through socialization and experience consistent with one’s class circumstances.

These dispositions generate stable and consistent lifestyle practices that reflect the normative structure of the prevailing social order and/or some group or class in which the individual has been socialized.

Lifestyle Theory - CockerhamLifestyle Theory - Cockerham

The work of Weber and Bourdieu provide the foundation for my model of health lifestyles.

The model depicts that manner in which social structural variables shape health lifestyle practices in their role as a determinant of individual health.

The Health Lifestyles ParadigmThe Health Lifestyles ParadigmSocializationExperience

Class CircumstancesAge, Gender, Race/Ethnicity

CollectivitiesLiving Conditions

Life Choices(Agency)

Life Chances(Structure)

Interplay

Dispositions to Act (Habitus)

Practices (Action)

Health Lifestyles(Reproduction)

Alcohol UseSmoking

DietExercise

CheckupsSeatbelts

Etc.

ConclusionConclusion This presentation has focused on the importance of a

paradigm shift in medical sociology from individualistic explanations of disease toward including full consideration of social causes of disease.

While genetic and biological factors, along with poor choices about health, are direct causes of disease, social factors including poverty, living conditions, stress, and social class are also important causal factors in determining health and mortality.

ConclusionConclusion Structural influences on health can be significant in a variety

of disease outcomes.– Such influences may be decisive in some circumstances.

In the United States, poverty and social inequality are obvious social causes of ill health.– About 12.5% of the population lives below the poverty

level, including 24.4% of blacks and 22.5% of Hispanics.

Many of the 16.6% without health insurance are at risk as well.

Medical sociologists and health researchers alike must therefore incorporate considerations of social causation into studies of health and disease.