The Social Causes of Health and Disease in the United States

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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

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Introduction

• Past 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.

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Background

• Emile 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.

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Background

• 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.

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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
  problematic.
• Simple association does not always imply
  causality.

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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.).

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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
  (host).
• These lifestyles may be decisive determinants of
  health and longevity.

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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
  considered.

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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
  homicide.

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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
  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.

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

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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.

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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.

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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, 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)

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Diabetes in the U.S.

• Asians are New York Citys 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.

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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.

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

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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.

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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.

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Socioeconomic 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.

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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.

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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.

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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
  1950s.

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

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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.

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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
  satisfaction.

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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.

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Health 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.
• Choosing from what is available, and,
• Social rules or codes determining rank order and
  appropriateness of preferences (Bauman 1999).

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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
  conflation.
• This conception is reflected in standard methods
  of public health.

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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.

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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
  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.

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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.

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The Health Lifestyles Paradigm
Class Circumstances Age, Gender,
Race/Ethnicity Collectivities Living Conditions

• Socialization
• Experience

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

• 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.

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Conclusion

• 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.