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The Social Causes of Health and Disease in the United States


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Title: The Social Causes of Health and Disease in the United States

The Social Causes of Health and Disease in the
United States
  • Alexis de Tocqueville Lecture Series
  • Questions on American Society
  • University of Montreal
  • January 2006
  • William C. Cockerham, PhD
  • Distinguished Professor of Sociology
  • University of Alabama at Birmingham

  • Past literature does not characterize social
    factors as primary contributors of health and
  • Yet, these factors have a direct causal effect on
    health and longevity.
  • Society may make you sick, or promote your health.

  • Emile Durkheim (1897)
  • Applied basic sociological principles to the
    problem of suicide.
  • Such principles helped explain suicide patterns
    by identifying factors external to the
  • 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.

  • 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 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
  • Simple association does not always imply

The 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 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
  • These lifestyles may be decisive determinants of
    health and longevity.

Support 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

Recent Epidemiological Trends
  • 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

Recent Epidemiological Trends
  • TABLE 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
  • Cerebrovascular Dis. 54.6
    76.3 41.3 47.7
  • Cancer 195.6 238.8
    128.4 113.6 125.4
  • Pulmonary Dis. 46.9
    31.2 20.6 15.8
  • Pneumonia/Influenza 22.6
    24.0 19.2 17.5
  • Liver Dis./Cirrhosis 9.0
    8.5 15.4 3.2
  • Diabetes 22.2
    49.5 35.6 17.4
  • Accidents 38.0 36.9
    30.7 17.9 53.8
  • Suicide 12.9 5.3
    5.7 5.4
  • Homicide 2.8 21.0
    7.3 2.9
  • HIV/AIDS 2.1 22.5
    5.8 0.8
  • Deaths per 100,000 population. Source
    National Center for Health Statistics, 2005.

Notable 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
  • African Americans are well ahead of whites in
    these causes of mortality.

Case Study Diabetes in the U.S.
  • Rates are significantly increasing in the United
  • 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
  • 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.
  • 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
  • The primary determinant appears to be social
    behavior and is inextricably linked to race and
  • 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.
  • The social mechanism triggering this disease is
    health lifestyles, notably poor diet and lack of
  • Listen, if I want to eat a piece of cake, Im
    going to eat it. No doctor can tell me what to
    eat. Im 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. Im not going to
    worry about a piece of cake. (Female diabetic)

Diabetes in the U.S.
  • Asians are New York Citys fastest growing racial
    minority and are especially susceptible to Type 2
  • - 60 percent more likely to get the disease
    than whites.
  • Again, health lifestyles are primary
  • 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.
  • 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
  • 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 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
  • The core (agent), the periphery (host), and the
    intra-racial network (environment).

Social 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
    persons relationships to other people.

Social Determinants of Disease
  • Stressful life events, stress-process variables,
    and ones 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 Status
  • Study after study in the U.S. finds that lower
    socioeconomic status (SES) promotes lessened life
    expectancy, higher mortality rates, and poorer
  • 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 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 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 Capital
  • One of the most powerful determinants of an
    individuals 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

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

Neighborhood Disadvantage
  • As Pearlin et al. (2005208) 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 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

Health 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 persons life chances, which are largely
    determined by class position.
  • Weber notes the dialectical interplay of choice
    and chance in lifestyle determination.

Health Lifestyles
  • It may be said that people have a range of
    freedom, yet not complete freedom, in choosing a
  • Individual choices in all circumstances are
    confined by two sets of constraints.
  • Choosing from what is available, and,
  • Social rules or codes determining rank order and
    appropriateness of preferences (Bauman 1999).

Health 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 Archers (1995) concept of upwards
  • This conception is reflected in standard methods
    of public health.

Lifestyle 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.
  • Webers focus was on how people act in concert,
    not only as individuals.

Lifestyle Theory Pierre Bourdieu
  • Bourdieus (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 ones class
  • 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 - 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 Paradigm
Class Circumstances Age, Gender,
Race/Ethnicity Collectivities Living Conditions
  • Socialization
  • Experience

Life Choices (Agency)
Life Chances (Structure)
Dispositions to Act (Habitus)
Alcohol Use Smoking Diet Exercise Checkups Seatbel
ts Etc.
Practices (Action)
Health Lifestyles (Reproduction)
  • 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
  • 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.

  • Structural influences on health can be
    significant in a variety of disease outcomes.
  • Such influences may be decisive in some
  • In the United States, poverty and social
    inequality are obvious social causes of ill
  • 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