Download 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
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.
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.
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.
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.
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 (host).
– 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 considered.
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.
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.
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.
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.

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.

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.

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.

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 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 intraracial 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 person’s
relationships to other people.
Social 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 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 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
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 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 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 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 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 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 Lifestyles

Discussions of lifestyle within the current sociomedical 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 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 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 - 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)
Interplay
Life Chances
(Structure)
Dispositions to Act (Habitus)
Practices (Action)
Health Lifestyles
(Reproduction)
Alcohol Use
Smoking
Diet
Exercise
Checkups
Seatbelts
Etc.
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.
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.