Title: The Social Causes of Health and Disease in the United States
1The 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
2Introduction
- 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.
3Background
- 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.
4Background
- 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.
5A 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.
6The 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.).
7The 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.
8Support 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.
9Recent 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.
10Recent 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.
11Notable 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.
12Case 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.
13Diabetes 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.
14Diabetes 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)
15Diabetes 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.
16Case 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.
17Race 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).
18Social 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.
19Social 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.
20Socioeconomic 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.
21Socioeconomic 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.
22Social 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.
23Social 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.
24Neighborhood 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.
25Neighborhood 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.
26Health 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.
27Health 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.
28Health 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).
29Health 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.
30Lifestyle 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.
31Lifestyle 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.
32Lifestyle 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.
33The Health Lifestyles Paradigm
Class Circumstances Age, Gender,
Race/Ethnicity Collectivities Living Conditions
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)
34Conclusion
- 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.
35Conclusion
- 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.