Social Conditions As Fundamental Causes of Disease

Author(s): Bruce G. Link and Jo Phelan

Source: Journal of Health and Social Behavior, Vol. 35, Extra Issue: Forty Years of Medical
Sociology: The State of the Art and Directions for the Future (1995), pp. 80-94
Published by: American Sociological Association
Stable URL: http://www.jstor.org/stable/2626958
Accessed: 25/10/2010 12:29

Your use of the JSTOR archive indicates your acceptance of JSTOR's Terms and Conditions of Use, available at
http://www.jstor.org/page/info/about/policies/terms.jsp. JSTOR's Terms and Conditions of Use provides, in part, that unless
you have obtained prior permission, you may not download an entire issue of a journal or multiple copies of articles, and you
may use content in the JSTOR archive only for your personal, non-commercial use.

Please contact the publisher regarding any further use of this work. Publisher contact information may be obtained at
http://www.jstor.org/action/showPublisher?publisherCode=asa.

Each copy of any part of a JSTOR transmission must contain the same copyright notice that appears on the screen or printed
page of such transmission.

JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range of
content in a trusted digital archive. We use information technology and tools to increase productivity and facilitate new forms
of scholarship. For more information about JSTOR, please contact support@jstor.org.

American Sociological Association is collaborating with JSTOR to digitize, preserve and extend access to
Journal of Health and Social Behavior.

http://www.jstor.org
Social Conditionsas FundamentalCauses of Disease*

BRUCE G. LINK
Institute
andNewYorkStatePsychiatric
ColumbiaUniversity
JO PHELAN
Los Angeles
ofCalifornia,
University

ofHealthandSocialBehavior1995,(ExtraIssue):80-94
Journal

Over the last several decades, epidemiologicalstudies have been enormously

successfulin identifying riskfactorsfor major diseases. However,most of this
researchhasfocusedattention proximalcauses of
on riskfactorsthatare relatively
disease such as diet, cholesterollevel, exercise and the like. We questionthe
emphasison such individually-based riskfactorsand argue thatgreaterattention
mustbe paid to basic social conditionsif healthreformis to have its maximum
effectin thetimeahead. Thereare tworeasonsfor thisclaim. Firstwe argue that
individually-based riskfactors mustbe contextualized,by examiningwhat puts
people at riskof risks,if we are to crafteffectiveinterventionsand improvethe
nation'shealth.Second, we argue thatsocial factorssuchas socioeconomicstatus
and social supportare likely'fundamentalcauses" of disease that,because they
embodyaccess to important resources,affectmultipledisease outcomesthrough
multiplemechanisms,and consequently maintainan associationwithdisease even
when interveningmechanisms change. Withoutcareful attentionto these
possibilities,we runtheriskof imposingindividually-based intervention strategies
thatare ineffective and of missingopportunitiesto adopt broad-based societal
interventions thatcouldproduce substantialhealthbenefits for our citizens.

Epidemiologyhas been enormouslysuccessfulin heighteningpublic awareness of risk

factorsfordisease. Researchfindingsare frequently and prominently publicizedin the mass
media and in rapidlyproliferating university-based healthnewsletters.Moreover,thereis
evidencethatthe messagehas been receivedand thatmanypeople have at least attempted to
quit smoking,includemoreexercisein theirdailyroutine,and implementa healthierdiet.
Withfewexceptions,however,thenew findingsgeneratedwithinthefieldof epidemiology
have focusedon riskfactorsthatare relativelyproximate"causes" of disease, such as diet,
cholesterol,hypertension,electromagnetic fields,lack of exercise,and so on. Social factors,
whichtendto be moredistalcauses of disease, have receivedfarless attention.' This focuson
moreproximatelinksin thecausal chainmaybe viewedby many,notas a limitation or bias,
butas therightful progressionof sciencefromidentifying to understanding
correlations causal
relationships(e.g., Potter 1992). In fact, some in the so-called "modem" school of
epidemiology(e.g., Rothman1986) have explicitlyargued that social conditionssuch as
socioeconomicstatusare mere proxiesfortruecauses lyingcloser to disease in the causal
chain.
This focus on proximaterisk factors,potentiallycontrollableat the individuallevel,
resonateswiththevalue and beliefsystemsof Westernculturethatemphasizeboththeability
of the individualto controlhis or her personalfateand the importanceof doing so (Becker

* We thank andSarahRosenfield
SharonSchwartz,
BernicePescosolido, forhelpful This
comments.
workwassupported
inpartbyNIMHgrants MH46101andMH13043.Address toBruce
communications
of MentalDisorders,100 HavenAvenue,Apartment
G. Link,Epidemiology 31D, New York,NY
10032.
80
FUNDAMENTAL CAUSES OF DISEASE 81
1993). This affinity betweenculturalvalues and the focus of contemporary epidemiology
undoubtedlycontributesto the level of public interestin epidemiologicalfindings,and
probablyinfluencesfundingpriorities as well. Thus modemepidemiologyand culturalvalues
conspireto focusattention on proximate,individually-based riskfactorsand away fromsocial
conditionsas causes of disease.
This is notto say thattheroleof social factorsin disease causationhas been neglectedin all
quarters. Medical sociologists and social epidemiologistshave kept alive classical
epidemiology's(e.g., Susser,Watson,and Hopper 1985) concernwithsocial conditionsand
have made major stridestowarddocumentingand understanding the connectionsbetween
social factorsand disease. However,we believe thereare conceptualpitfallsthatsometimes
lead medical sociologistsand social epidemiologiststhemselvesto unwittingly reinforcethe
emphasison proximate, individual-levelriskfactors.One ofthesepitfallsis that,in theprocess
of elucidatingthemechanismsconnecting social conditionsto healthand illness-an important
and desirableactivity-we may,overtime,lose interest in and come to neglecttheimportance
of the social conditionwhose effecton healthwe originallysoughtto explain. Also, our
tendencyto focus on the connectionof social conditionsto single diseases via single
mechanismsat singlepointsin timeneglectsthe multifaceted and dynamicprocessesthrough
which social factorsmay affecthealth and, consequently,may result in an incomplete
understanding and an underestimation of theinfluenceof social factorson health.
Our purposeshereare to highlight the accomplishments of medical sociologistsand social
epidemiologistsin advancingour understanding of social conditionsas causes of disease, to
underscorethe criticalimportanceof continuedwork in this direction,and to offertwo
conceptualframeworks thatwe hope will facilitate and enhancethisresearch.First,we discuss
theimportance of "contextualizing" riskfactors--that is, attemptingto understand how people
come to be exposed to individually-based riskfactorssuch as poor diet, cholesterol,lack of
exercise,or highblood pressure-so thatwe can designmoreeffectiveinterventions. Second,
we introducethenotionthatsome social conditionsmaybe "fundamental causes" of disease.
A fundamentalcause involves access to resources,resourcesthat help individualsavoid
diseases and theirnegativeconsequencesthrougha varietyof mechanisms.Thus, even if one
effectivelymodifiesinterveningmechanismsor eradicatessome diseases, an association
betweena fundamental cause and disease will reemerge.As such,fundamental causes can defy
effortsto eliminatetheireffectswhenattemptsto do so focussolelyon the mechanismsthat
happen to link themto disease in a particularsituation.We conclude by discussingthe
implications of theseideas forresearchand social policy.

EVIDENCE LINKING SOCIAL CONDITIONS TO DISEASE

We begin witha briefreviewof the evidence concerningthe connectionbetweensocial

conditionsand illness. For the purposesof thispaper,we definesocial conditionsas factors
that involve a person's relationshipsto other people. These include everythingfrom
relationships withintimates to positionsoccupiedwithinthesocial and economicstructures of
society.Thus, in additionto factorslike race, socioeconomicstatus,and gender,we include
stressful lifeeventsof a social nature(e.g., thedeathof a loved one, loss of a job, or crime
victimization), as well as stress-processvariablessuch as social support.
Fortyyearsof medicalsociologyhave uncoverednumerousexamplesofthesocial patterning
of disease. Most obvious is the ubiquitousand oftenstrongassociationbetweenhealthand
socioeconomicstatus.Lower SES is associated withlower life expectancy,higheroverall
mortality ratesand higherratesof infantand perinatalmortality (Buck 1981; Dutton 1986;
Illsley and Mullen 1985; Adler et al. 1994; Pappas et al. 1993). Moreover,low SES is
associated with each of the 14 major cause-of-deathcategories in the International
Classificationof Diseases (Illsleyand Mullen 1985), as well as manyotherhealthoutcomes,
includingmajor mentaldisorders(Dohrenwendet al. 1980; Kessler et al. 1994). Other
examplesof thesocial patterning of disease are plentiful.Males have highermortalityratesat
all ages (Walsh and Feldman 1981), as well as higherratesof coronaryheartdisease (Syme
and Guralnik1987), chronicrespiratory diseases (Colley 1985) and ulcers(Gazzard and Lance
82 JOURNAL OF HEALTH AND SOCIAL BEHAVIOR
1982). There are pronouncedgenderdifferences in ratesof variousformsof cancer (Prout,
Colton,and Smith1987) and mentaldisorder(Dohrenwendet al. 1980; Kessleret al. 1994).
AfricanAmericanshave higherratesof overallmortality and infantmortality(Dutton 1986;
Miller1987), renalfailure(Challahand Wing 1985), and stroke(Pedoe 1982a) thando Whites,
but lowerratesof coronaryheartdisease (Pedoe 1982b); cancerratesalso differby race and
ethnicity (Proutet al. 1987). Both physicaland mentaldisordersvarywithmaritalstatusand
populationdensity(Kelsey 1993; Benenson 1987; Robins et al. 1984), and certainreligious
groupssuchas Mormonsand SeventhDay Adventists have lowerrisksof sometypesof cancer
(Saracci 1985).
In addition, the tremendousgrowthand success of the stress paradigmhave added
considerablyto the evidence for an association between social conditionsand disease
(Dohrenwendand Dohrenwend1981; Pearlinet al. 1981; Turnerand Marino 1994; Turner,
Wheaton,and Lloyd 1995). Stressfullifeeventshave been linkedto heartdisease, diabetes,
cancers,stroke,fetaldeath,majordepression,and low birthweightin offspring (Miller 1987;
Brownand Harris 1989; Shroutet al. 1989). Researchhas also extendedto the domainsof
social support(Berkmanand Syme 1979; House, Landis, and Umberson1988; Thoits 1982;
Turner1981; Turner,Grindstaff, and Phillips 1990; Turnerand Marino 1994) and coping
(Pearlin and Schooler 1978), which have been shown to be associated with health and
well-beingin theirown right.
The evidencereviewedto thispointclearlyestablishesa strongand pervasiveassociation
betweensocial conditionsand disease. But medical sociologistsand social epidemiologists
have takenthe field considerablybeyonda descriptionof the social patterning of disease.
Important advancesin establishinga causal role forsocial factorshave focusedon two major
issues-the directionof causationbetweensocial conditionsand healthand the mechanisms
thatexplainobservedassociations.In whatfollowswe presentprominent examplesof workon
thesetwo issues.
Concerningthe issue of causal direction,important controversiessurroundsome of the
relationships betweensocial conditionsand health.For example,does low SES cause poor
health,or does poor healthcause downwardmobility?Does social supportreducemorbidity
and mortality, or does illness restrictsocial interactionand therebylead to social-support
deficits?Social epidemiologists have used threegeneralstrategiesto addressthesequestions.
One approachuses quasi-experimental strategieswhich involve locatingconditionsunder
which alternativeexplanationsmake differentpredictionsabout observable facts. This
approachis exemplifiedby Dohrenwend's(1966) quasi-experiment designedto test social
selectionand social causationexplanationsfortheassociationbetweenSES and specificmental
disorders.The two explanationsmake differentpredictionsabout rates of disorder in
advantagedand disadvantaged ethnicgroups,whensocioeconomicstatusis heldconstant.The
recent culminationof Dohrenwend's work on this problem, based on a large-scale
epidemiologicalstudyin Israel(Dohrenwendet al. 1992), concludedthatsocial causationwas
stronger thansocial selectionin producingtheinverseassociationof SES to majordepression
in women,and substanceabuse and antisocialpersonality in men.For schizophrenia, however,
theevidencewas moresupportiveof the social-selectionexplanation.
In the second strategy, medical sociologistsand social epidemiologistsidentifysocial risk
factorsthatcannotreasonablybe conceivedas havingbeen caused by an individual'sillness
condition.Exemplifying thisstrategy is a studyby Hamiltonand colleagues(1990) concerning
the effectsof plant closings on auto-workers'mentalhealth. The investigators compared
workerswho werelaid offbecause of a plantclosing,workerswho anticipatedbeinglaid off,
and workerswhose plantwas not closing,and foundthatthose laid offwere morelikelyto
experiencenegativemental-health consequences-particularly if theywere minoritiesand of
low SES. Since theillnessconditionof theworkerscannotbe thoughtof as havingcaused the
plantclosing,thedifferences betweenthegroupsstudiedare moreclearlyinterpretable as the
effectsof social conditionson health.This strategy was also employedby Fenwickand Tausig
(1994) in a studythatused theCensus-basedunemployment rateforan individual'soccupation
in a longitudinal designto show thatwhenunemployment is higher,workers'job satisfaction,
decision-making latitude,and well-beingare lower.Again,since workers'healthcannotcause
theaggregateunemployment rate,theresultsare morereadilyinterpretable as demonstrating
FUNDAMENTAL CAUSES OF DISEASE 83
the influenceof social conditionson health-related outcomes.Finally,studiesof stressful
circumstance have used thisstrategy by identifying "fateful"life eventsthatare unlikelyto
havebeencausedby an individual'sbehavior(e.g., deathof spouse,plantclosing).Thuswhen
Shroutet al. (1989) foundtheodds of developingmajordepressionto be morethanthreetimes
as highamongpeopleexperiencing a recentfateful lifeevent,theassociationwas moreclearly
interpretableas an effectof social conditions.
The thirdstrategy adoptedby social epidemiologists to clarifycausal directioninvolvesthe
use of longitudinaldesigns.Whensuchdesignscan clearlyplace theemergenceof an illnessor
an illnessexacerbationbeforeor afterthe social conditionunderstudy,a greatdeal can be
learnedaboutthedirection of cause betweenthetwo. Unfortunately, somelongitudinal studies
do not allow clear inferencesabout time orderand therefore do not providethe definitive
evidenceaboutcausalitythatis sometimesattributed to them(see Linkand Shrout1992). Still,
somenotablestudieshave identified social conditionsthatclearlypredatehealthoutcomesand
show thatthe social conditionspredictmorbidity and mortality even when competingrisk
factorsare heldconstant.For example,Berkmanand Syme(1979) used baselinedataon social
networks, collectedin 1965, to predictmortality duringthesubsequentnineyears.Theyfound
a neardoublingof riskformortality amongthoselow on a social-network indexas compared
to thosehighon theindex.Althoughthisstudycontrolled formanycompeting risks(smoking,
obesity,physicalactivity, etc.), it did notincludemeasuresderivedfroma physicalexam. A
subsequentstudyby House, Landis, and Umberson(1988) did includea baseline physical
exam and controlledforblood pressure,cholesterollevels, and otherbiomedicalvariables.
These investigators foundassociationsbetweensocial relationships and mortality thatwere
similarto thosereportedby Berkmanand Syme. This line of workhas continuedto become
moreand morerefined.For example,in a recentlongitudinal study,Berkmanand colleagues
(1992) have shownthata measureof perceivedsupportcollectedbeforethe occurrenceof a
heart attack predictssurvivalfollowingthe heart attack net of an impressivearray of
biomedical and psychosocial control variables. Other social variables have also been
effectively studiedwithlongitudinaldesigns. For example,Catalano and colleagues (1993)
relatedjob layoffsto theemergenceorreemergence of alcoholabuse,andLin andEnsel (1989)
and Ensel and Lin (1991) showedthatstressful circumstances predictedsubsequenthealthand
mental-health outcomes.
Thus, whilemedicalsociologistsand social epidemiologists have notdeniedthepossibility
thatillnessaffectssocial conditions(Johnson1991), theyhave,at thesametime,demonstrated
a substantial causal role forsocial conditionsas causes of illness.
Researchidentifying themechanisms linkingsocial conditionsto diseasehas also donemuch
to movesocial epidemiology beyondthedescription of social patternsof disease. Consider,for
example, the job-stressmodel of Karasek and colleagues thatprovidesevidence for one
mechanismlinkingSES to coronaryheartdisease amongmen.These investigators have shown
that "job strain,"characterizedby a combinationof highjob demandsand low decision
latitude,is morecommonin lower statusjobs and is associatedwithcoronaryheartdisease
(Karasek et al. 1988; Schnall et al. 1990) and elevatedlevels of ambulatory blood pressure
bothon and offthejob (Schnallet al. 1992). Anotherexampleis theworkof Mirowskyand
Ross (1989), who elucidatethemechanisms thatmightaccountforsocial patterns of distress.
They presentevidenceshowingthatalienationand perceivedcontrolover lifecircumstances
underliemanysocial conditionsthatput people at riskforelevatedlevels of psychological
distress.Consideras a finalexamplea studyby Rosenfield(1989) thatsoughtto understand
mechanismsproducinggenderdifferences in symptoms of depressionand anxiety.Rosenfield
shows thatwomenhave highersymptomsof depressionand anxiety.This workshows that
womenhave highersymptomlevels thanmen whentheyare overloadedby workand family
demandsor when theyexperiencelow power as a consequenceof being out of the labor
market.Moreover,the commonmechanismunderlying low power and role overload is a
decreasedsense of personalcontrol,whichis in turnrelatedto symptomsof anxietyand
depression.
Link and Dohrenwend(1989) explicitlyadvocatethe approachof elucidatingmechanisms
becauseof itsvalue in clarifying therelativemeritofcompeting explanations forsocial patterns
of disease. The rationaleis thatalternativeexplanationsfor these patterns,such as social
84 JOURNALOF HEALTH AND SOCIAL BEHAVIOR
causationand social selection,frequently implydifferent intervening mechanisms.Thus,
evidenceabout whichintervening mechanismsaccountforthe associationcan help answer
questionsconcerning causal directionand othercompetingexplanations.Moreover,if causal
linksbetweendistalfactors(e.g., SES) and moreproximalfactors(e.g., occupationalstress,
diet)can be drawn,as Karaseket al. (1988), Mirowskyand Ross (1989), Rosenfield(1989),
and others(Lennon 1987; Pearlin et al. 1981; Link, Lennon, and Dohrenwend1993;
Umberson,Wortman,and Kessler 1992) have done, it becomesincreasingly clear thatsocial
conditions are causes exerting indirect effectson diseaseoutcomes,ratherthanmereproxiesas
Rothman(1986) and othersmightclaim.
But are thereunintended and undesirable consequencesof an approachthatfocuseson inter-
veningmechanisms? We believethereare. Despitetheobviousbenefits of suchan approach,it
is possiblethatin itsenactment, one mayinadvertently contributeto thefocuson factorsthatare
closerto diseasein thecausal chain.The intervening mechanism becomesthenew and exciting
"nextstep,"whilethesocial conditions becometheold, passe "starting point."
The evolutionofthestressparadigmis a good exampleofsuchan inadvertent downgrading of
theissue whichprovidedthe initialimpetusforresearch.The social causation/social selection
controversy concerning theassociation betweensocioeconomic statusandmentaldisorder spawned
an interest in stressfullifeeventsas a directoperationalization of the adversity thatmightbe
experienced in lowerSES contexts(Dohrenwendand Dohrenwend1969, 1981). Whena con-
sistentbutmodestassociationbetweenstressful eventsandillnesswas identified (see Rabkinand
Struening1976), investigators elaboratedthe model to considersocial supportand copingas
potentialmodifiers. Now researchers areinvestedin understanding themechanisms linkingthese
factorswithdisease.Also, researchon thebiologicalconsequencesofstress(e.g., immunestatus
andelevatedcatecholamines) is seenas an excitingnew development (e.g., Cohen,Tyrrell,and
Smith1991). In general,interest has followedthe mostrecentstepin theprogression toward
diseaseoutcomes,whileconcernwiththeearlierfocihas dissipated toa pointwheresomeexpress
disinterestin factorssuchas thecausation/selection issue and therole of stressful lifeeventsin
causingillness(butsee Pearlin1989; Dohrenwend1990; Angermeyer and Klusman[1987] for
dissenting views). IndeedAngermeyer and Klusman(1987) documented a sharpdeclinein the
numberof publications focusedon social class and mentaldisorderin theperiodfrom1966 to
1985,whilethenumberofarticleson stressandpsychiatric disorders increasedrapidlyduringthe
sameperiod.To theextentthatinterest in mechanisms increasesat theexpenseof morefunda-
mentalsocial conditions,medicalsociologistsmay unwittingly contribute to the emphasison
individual factors andplayintothehandsofthosewhoarguethatsocialfactors haveonlya modest
rolein diseasecausation.
To thispoint,we havedescribedtwocharacterizations ofsocialconditions as causesofdisease
thateitheradvertently or inadvertentlydownplaytheirimportance. One of theseis theoutright
declarationthatsocial factorsare onlyproxiesfortruecauses. This positionis demonstrably
unwarranted giventheachievements of medicalsociologyand social epidemiology overthepast
fewdecades.The othercharacterization, whichmaybe partially constructed by medicalsociol-
ogistsandsocialepidemiologists themselves, is theviewthatsocialfactors serveas starting points
whosemainfunction is to pointthedirection to moreproximalriskfactors.We takesharpissue
withbothof thesecharacterizations. In the nexttwo sections,we developtwo conceptsthat
thecriticalimportance
illustrate of socialfactorsin diseasecausation,provideconceptualframe-
worksforfuture researchinthisarea,andpointtotheproblems thatmayensueiftheroleofsocial
conditions is neglectedbyresearchers andpolicymakers. These aretheideas of "contextualizing
riskfactors"and "fundamental causes."

CONTEXTUALIZING RISK FACTORS

We suggest that medical sociologistsand social epidemiologistsneed to counterthe

trajectoryof modem epidemiologytoward identifying risk factorsthat are increasingly
proximateto disease-ones forwhich"biologicalplausibility"can be argued.One way they
can do this is by "contextualizing"individually-based
risk factors.By this we mean that
investigatorsmust(1) use an interpretive
framework to understand whypeople come to be
FUNDAMENTAL CAUSES OF DISEASE 85
exposed to risk or protectivefactorsand (2) determinethe social conditionsunderwhich
individualriskfactorsare relatedto disease. We presentexamplesthatillustrateboththese
principles.
First, an importantstrategyfor reducingthe threatof AIDS is to educate the public
concerningthe steps theymust take as individualsto reduce theirrisk of contracting or
infecting otherswiththe HIV virus. Clearly,however,some people are betterable to take
advantageof thisinformation thanothers.By contextualizing riskfactorsforAIDS, we maybe
able to understand whysome people cannotavoid therisk. For example,homelessor other
extremely poorwomenwho turnto prostitution as a survivalstrategy maynothave theoptions
or resourcesthatwould enablethemto refuseto engagein riskysexual behaviors,no matter
how well informed theymaybe abouttheriskstheyface. This examplesuggeststhatmedical
sociologistsand social epidemiologists need to contextualize riskfactorsby askingwhatit is
aboutpeople's lifecircumstances thatshapestheirexposureto suchriskfactorsas unprotected
sexual intercourse, poordiet,a sedentary lifestyle,or a stressfulhomelife.
Our second example concernsthe increasingattentionbeing paid to the public health
problemposed by contamination of meat, poultry,and eggs withE. coli and salmonella
bacteria.The publichas been warnedto rinseand cook meatand poultrythoroughly and to
carefullywash hands,knives,cuttingboards,and so on. Because some followthesesafety
guidelinesmoreassiduouslythanothers,one can imaginea riskprofileof individualbehaviors
thatmightpredictbacterialinfection. These precautions are onlynecessary,however,whenthe
food thatreaches the marketplaceis contaminated.Government actions in the 1980s that
reducedthe numberof government inspectorsand deregulatedthe meat-processing industry
havecreatedtheneedforvigilanceon thepartof individuals.Whilethecurrent approachto the
problemfocuseson the individual,it can readilybe seen thateconomicand politicalforces
shape individuals'exposureto thisrisk.This examplesuggeststhatmedicalsociologistsand
social epidemiologists needto contextualize by askingunderwhatsocial conditionsindividual
risk factorslead to disease and whetherthereare any social conditionsunderwhich the
individual-levelriskfactorswouldhave no effectat all on disease outcome.
While theimportance of contextualizing riskfactorsmay seem obvious,if we takea hard
look at even some of themostinfluential areas of researchin medicalsociology,we will find
thatmuchmoreof thiskindof contextualizing is needed.Consideragainthestressparadigm.
Whilethereare hundredsif notthousandsof studiesrelatingstressful circumstances to health
outcomes,untiltherecentefforts of Turnerand colleagues(Turnerand Marino1994; Turner,
Wheaton,and Lloyd 1995), therewas verylittleeven descriptive data aboutthesocial origins
of stressfulcircumstances (butsee Smith1992; Goldbergand Comstock1980).
Whyis it so important thatwe striveto contextualize riskfactors?One reasonis thatefforts
to reduce risk by changingbehaviormay be hopelesslyineffectiveif thereis no clear
understanding of theprocessthatleads to exposure.For example,thereare powerfulsocial,
cultural,and economic factorsshaping the diet of poor people in the United States.
Consequently, providinginformation abouthealthydietto poorpeople and exhorting themto
follownutritional guidelinesis unlikelyto have muchimpact.Withoutan understanding of the
contextthatleads to risk,theresponsibility forreducingtheriskis leftwiththeindividual,and
nothingis done to alterthemorefundamental factorsthatputpeople at riskof risks.
This lineof thinking suggeststhatmedicalsociologistsand social epidemiologists shouldturn
on itshead thenow-popular tendency to examineriskfactorsthatare evercloserto diseasein a
causal chain.Rather,it suggeststhatit is justas important to facetheotherdirection and search
forthefactorsthatputpeople at riskof risks.It exhortsresearchers bothto explorethesocial
originsof risksand to ask whether individually-based riskfactorsare context-dependent in the
senseofinfluencing healthoutcomesonlywithinthecontextofa specificsetofsocialconditions.

FUNDAMENTAL CAUSES

In additionto theobviousneedto contextualizeriskfactors,medicalsociologistsand social

epidemiologists andthorough
needto takeas theirtasktheidentification considerationof social
conditionsthat are what we term "fundamentalcauses" of disease. We call them
86 JOURNALOF HEALTH AND SOCIAL BEHAVIOR
"fundamental" causes because, as we shallsee, thehealtheffectsof causes of thissortcannot
be eliminated by addressingthemechanisms thatappearto linkthemto disease. The possibility
thatsome social conditionshave this fundamental qualitywithregardto healthwas first
presentedby House and colleagues in a discussionof potentialreasons for the persistent
associationbetweenSES and disease (House et al. 1990, 1994). We elaborateupontheseideas
to buildourconceptof fundamental social causes of disease.
The Case of SES and Disease. The idea thatsocial conditionsmightinfluencehealthwas
forcefullyassertedby nineteenth-century physicianswho foundedthefieldof social medicine.
Virchow(1848), forexample,declaredthat"medicineis a social science." And, of course,it
was in partthestrongassociationbetweenindicatorsof povertyand healththatsupportedthis
claim. The reasonsforthepowerfulassociationwerealso thought to be apparent,residingin
thedire housing,sanitation,and workconditionsof poor people at the time(Rosen 1979).
Withtremendous medicaladvances and extensivepublic healthinitiatives,the incidenceof
such diseases as diphtheria,measles, typhoidfever,tuberculosis,and syphilisdeclined
dramatically. In addition,in modernwelfarestates,poor people's access to care increased
substantially.By the 1960s, manyof the factorsthathad been identified as linkingSES to
diseasehad been addressed,and one mighthave expectedtheassociationto wane and perhaps
disappearaltogether. Indeed,thisis exactlytheconclusionthatCharlesKadushinreachedin a
1964 articlein Sociological Inquiry(Kadushin 1964). Startledthatsocial scientistshad not
recognizedthedemiseof theSES gradientin health,Kadushinremindedhis readersthatmost
of themechanismsthought to produceSES differences in healthin theUnitedStateshad been
addressedand that "as countriesadvance in theirstandardof living, as public sanitation
improves,as mass immunization proceeds,and as Dr. Spock becomesevenmorewidelyread,
the grossfactorswhichintervenebetweensocial class and exposureto disease will become
more and more equal for all social classes" (1964:75). As a result,Kadushindeclared,
Americansfromthe lowerclasses are no morelikelyto developdisease thanthosefromthe
middleor upperclasses.
Of course, Kadushin'spredictionturnedout to be dramatically incorrectas indicatedby
studies(cited above) documenting an enduringor even an increasing(Pappas et al. 1993)
associationbetweenSES and manydisease outcomes.But whatwas wrongwithKadushin's
reasoning?Hadn't he engagedin logic thatmostof us notonlyacceptbut takeforgranted?
Havingimplicitly drawnthepathmodelwithSES as thedistalfactorthatis linkedto disease
by moreproximalriskfactors,and havingobservedthattheproximalriskfactorsin themodel
had been largelyeliminatedas causal agents,he concludedthatthe SES-disease association
shouldhave disappeared.But it didn't.
On theface of it, thereasonKadushin's 1964 prediction turnedout to be wrongis readily
apparentwhenone comparestheintervening riskfactorshe consideredto theintervening risk
factorsidentified by Adlerand colleaguesin their1994 reviewof socioeconomicstatusand
health.The "gross" riskfactorsof sanitation and immunization thatKadushinmentionedare
replacedin theAdlerandcolleagues'reviewbyriskfactorsthatincludesmoking,exercise,and
diet,amongothers.Further, theevidencesuggeststhatseveralof theriskfactorsmentioned by
Adler and colleagues were not important intervening mechanismswhen Kadushin wrote.
Beforethe1960s,forexample,therewas no evidencethatratesof smokingwerehigheramong
lowerSES individuals.Rather,the associationemergedduringthe 1960s because people of
highersocioeconomicstatuswerelikelyto startsmokingand morelikelyto quit if theyhad
started(Ernster1988; Novotnyet al. 1988). Similarchangeshave occurredin otherrisk-related
behaviors.For example,in consideringthe strongevidencethatdeclinesin coronaryheart
disease have been greatestamongpeople of highersocioeconomicstatus,Beaglehole(1990)
pointedto thefactthathigherSES individualshave been betterinformed aboutand moreable
to implement changesin healthbehaviorslike smoking,exercise,and diet.The resulthas been
a wideningof the gap in ratesof heartdisease betweenthe rich and the poor (Beaglehole
1990). Thus studiesof theassociationbetweenSES and disease overthepast severaldecades
revealan important fact-the riskfactorsmediatingthe associationhave changed.As some
riskfactorswere eradicated,othersemergedor were newlydiscovered.As new riskfactors
becameapparent,people of higherSES weremorefavorablysituatedto knowabouttherisks
and to have theresourcesthatallowedthemto engagein protective efforts to avoid them.
FUNDAMENTAL CAUSES OF DISEASE 87
Fromone vantagepoint,thisaccountof theassociationbetweenSES and disease mightbe
seen as a curiousstoryin the historyof social epidemiology-an instancein whichunique
historicaleventspulledtherugoutfromunderan otherwisereasonablehypothesis putforward
by Kadushinin 1964. Far morelikely,however,is the possibilitythattheeffectof SES on
disease has endured-despiteradical changesin intervening riskfactors-because a deeper
sociologicalprocess is at work. If so, what happenedover the past severaldecades will
continueto happenand if,at thisparticular pointin time,we presumethatan understanding of
theSES-disease associationlies intracingthemechanisms thatcurrently appearto linkthetwo,
timewill proveto be as wrongas Kadushinwas. This will occur,we argue,because SES is a
fundamental cause of disease.
FundamentalSocial Causes ofDisease. Our discussionof SES to thispointhas focusedon
its persistent associationwithdisease despitechangesin intervening mechanisms.However,
we have notyetexplicitlyindicatedwhySES, or anyfundamental cause, mightmaintainthis
kindof enduring relationshipwithdisease.
The reasonforsuchpersistent associations,and theessentialfeatureof fundamental social
causes, is thattheyinvolveaccess to resourcesthatcan be used to avoid risksor to minimize
the consequencesof disease once it occurs. We defineresourcesbroadlyto includemoney,
knowledge,power,prestige,andthekindsof interpersonal resourcesembodiedin theconcepts
of social supportand social network.Variableslike SES, social networks,and stigmatization
are used by medicalsociologistsand social epidemiologists to directlyassess theseresources2
and are therefore especiallyobviousas potentialfundamental causes. However,othervariables
examinedby medical sociologistsand social epidemiologists,such as race/ethnicity and
gender, are so closely tied to resources like money, power, prestige,and/orsocial
connectedness thattheyshouldbe consideredas potentialfundamental causes of disease as
well.
An additionalconditionthatmustobtainforfundamental causes to emergeis changeover
timein thediseases afflicting humans,therisksforthosediseases,knowledgeaboutrisks,or
theeffectiveness of treatments fordiseases. If no new diseases emerged(such as AIDS), no
new risksdeveloped(such as pollutants),no new knowledgeaboutrisksemerged(as about
cigarettesmokingin the 1950s and 1960s), and no new treatments were developed(such as
hearttransplants), theconceptof fundamental social causes would notapply.In such a static
system,as riskfactorsknownto intervene betweena social cause and disease are blocked,the
associationbetweenthesocial cause and diseasewoulddeclinein lockstep.But,ofcourse,this
is nothinglike thesituationhumanshave everconfronted withregardto health.In thecontext
of a dynamicsystemwithchangesin diseases, risks,knowledgeof risks,and treatments,
fundamental causes are likelyto emerge.The reasonis thatresourceslikeknowledge,money,
power,prestige,and social connectedness are transportable fromone situationto another,and
as health-related situationschange,thosewho commandthe mostresourcesare best able to
avoidrisks,diseases,andtheconsequencesofdisease. Thus,no matter whatthecurrent profile
of diseases and knownriskshappensto be, those who are best positionedwithregardto
important social and economicresourceswill be less afflicted by disease.
The foregoingreasoningsuggeststwo further attributes of fundamental causes. Because a
fundamental cause involvesaccess to broadlyserviceableresources,it influences(1) multiple
riskfactorsand (2) multipledisease outcomes.This is an important observation,because it
alertsus to thepossibility thattheassociationbetweena fundamental cause and disease can be
preservedthrough changeseitherin themechanisms or in theoutcomes.The idea thatmultiple
mechanismsmay contribute to a persistentassociationbetweena cause and an effectcomes
fromsociologistStanleyLieberson.Lieberson(1985) proposedthatsome causes, whichhe
called "basic causes," have enduring effectson a dependentvariablebecause, whentheeffect
of one mechanismdeclines,the effectof anotheremergesor becomes moreprominent. We
have already describedthe example of the changingrole of mechanismslike smoking,
exercise,and diet in relationto the associationbetweensocioeconomicstatusand disease.
While these variables were no doubt always linked to disease, their connectionto
socioeconomicstatuschanged when knowledgeabout theirimportancein healthbecame
available. We take the idea thata cause can affectmultiplehealthoutcomesfromsocial
epidemiologist JohnCassel. Cassel (1976) pointsoutthatsomesocial factorsmakeindividuals
88 JOURNALOF HEALTH AND SOCIAL BEHAVIOR
vulnerable,notto a specificdisease,butto a wide arrayof diseases. As a result,investigations
of therelationship of such social factorsto specificmanifestations of disease are of limited
utility.Since onlyone manifestation of the social cause is measuredin such studies,thefull
impactofthesocial cause goes unrecorded (also see Aneshensel1992; Aneshensal,Rutter,and
Lachenbruch1991; Cullen 1984). However,in additionto underestimating thefullimpactof
social causes at anygiventime,a narrowfocuson one disease at a timemissesthepossibility
that changes in particulardisease outcomes can lead to enduringassociationsbetween
fundamental causes anddiseaseoverall.Whenhealthsurveillance or immunization systemsfail
and old diseases begin to reemerge(TB, measles) or whennew diseases entera population
(AIDS), theydo so in thecontextof existingsocial conditionsthatare ripeenvironments for
producingmechanismsthatlink fundamental social causes to new or reemerging diseases.
Thus,forexample,before1980,SES was linkedto theintravenous use of drugs,whichin turn
had negativehealthconsequences.But withthe emergenceof AIDS, this SES-linkedrisk
factorcame to have an even morepotenteffecton health.Indeed,AIDS will likelybecomea
significant contributor to SES differentials in mortality in the time ahead due to the rapid
spreadof infection in low-incomeareas(Brunswicket al. 1993). Similarly, thereemergence of
drug-resistant tuberculosis is strikingpoor inner-city populationsto a fargreaterextentthanit
is higher-status suburbanareas.
In sum,a fundamental social cause of diseaseinvolvesresourcesthatdetermine theextentto
which people are able to avoid risks for morbidity and mortality.3 Because resourcesare
important determinants of risk factors,fundamental causes are linkedto multipledisease
outcomesthroughmultiplerisk-factor mechanisms.Moreover,because social and economic
resourcescan be used in different ways in different situations, fundamental social causes have
effectson disease even whentheprofileof riskfactorschangesradically.It followsthatthe
effectof a fundamental cause cannotbe explainedby theriskfactorsthathappento linkit to
disease at anygiventime.
Research Implications.All too frequently, even those of us who believe that social
conditionsare important forhealthare lulledintothinking thatthebestway to understand and
ultimately addresstheeffectsof social conditionsis to identify theintervening links.Indeed,it
is preciselythisreasoningthatAdlerand colleaguesuse to assertthatpsychologists have an
importantrole to play in addressingthe SES-disease association-the risk factorsthey
identified were individually-based behaviorsthatpsychologists are well-equippedto address.
But theconceptof a fundamental cause sensitizesus to thepossibility thatfundamental social
causes cannotbe fullyunderstoodby tracingthe mechanismsthatappear to link themto
disease. To be sure, a focus on mechanismscan help identifyvariablesmore proximalto
health,and if suchrisksare addressed,thehealthof thepubliccan be improved.However,in
thecontextof a dynamicsystemin whichriskfactors,knowledgeof riskfactors,treatments,
and patterns of disease are changing,theassociationbetweena fundamental social cause and
disease will endurebecause theresourcesit entailsare transportable to new situations.If one
genuinelywantsto altertheeffectsof a fundamental cause, one mustaddressthefundamental
cause itself.
There are two implicationsof this reasoning.First, medical sociologistsand social
epidemiologists need to be carefulin interpreting and communicating themeaningof research
involvingsocial factors,intervening mechanisms, and disease. Specifically,ifthesocial factor
is a fundamental cause, one cannot claim to have accountedfor its effectsby having
"explained"its associationwiththeinclusionof intervening variablesin a pathor regression
model. Second, to understand associationsbetweenfundamental causes and disease, medical
sociologistsneed to examinethebroaderdeterminants of theresourcesthatfundamental causes
entail. This distinctlysociological enterprisewill link medical sociologiststo the broader
disciplinein a productive way as we seekto understand how generalresourceslikeknowledge,
money,power, prestige,and social connectionsare transformed into the health-related
resourcesthatgeneratepatterns of morbidity and mortality.
FUNDAMENTAL CAUSES OF DISEASE 89
POLICY IMPLICATIONS

Mechanicand Aiken (1986) arguethat,ratherthanleadingto specificpolicies, the main

contribution of social science researchto social changeis throughits influenceon the way
policymakers and thegeneralpublicthinkaboutsocial and healthproblems.This paperaimsto
make such a contribution by drawingattention to theprogressmade by medicalsociologists
and social epidemiologists in recentyearsand by offering theconceptsof "contextualizing risk
factors"and "fundamental causes."
On its own, the focus on individually-based risk factorsthat has dominatedmuch
population-based medicalresearchin recentyearsis inadequate.4To be sure,thisfocusis a
compellingattention-getter, since the findingsit generatesare highlyrelevantto any given
individual.Theycan lead to "personalpolicy"changessuchas a reduction in fatintake,a little
exercise,or an aspirina day-actions thatindividualpeople can controlpersonally.But those
whocraftpolicyforpopulationscan be led astrayiftheirpurviewis narrowly limitedto a focus
on individually-based riskfactors.This paperrevealstworeasonswhythisis so. First,without
understanding the social conditionsthatexpose people to individually-based risk factors,
interventions will failmoreoftenthantheyshould.This will occurbecause interventions will
be targeted to behaviorsthatareresistant to changeforunrecognized reasons.The consequence
will be thatlives and moneyare wasted,and theAmericanpublicwill lose confidencein our
abilityto implement changesthatreallyimprovehealth.Second, some social conditionsare
fundamental causes of disease and as such cannotbe effectively addressedby readjusting the
individually-based mechanismsthatappearto linkthemto disease in a givencontext.If we
wish to alterthe effectsof thesepotentdeterminants of disease, we mustdo so by directly
intervening in waysthatchangethesocial conditionsthemselves.
The issuesaddressedin thispapersuggestthreegeneralcriteriathatpolicymakers shoulduse
in evaluatingwhetherto commitfundsto a proposedhealthintervention:
(1) Consistent withtheidea of contextualizing riskfactors,policymakers shouldrequirethat
all interventions seekingto changeindividualriskprofilescontainan analysisof factorsthat
putpeople at riskof risks.This will avoid the enactment of interventions aimed at changing
behaviorsthatare powerfully influencedby factorsleftuntouchedby the intervention. If the
evidenceis to come fromstudiesthatinvolvetheexperimental manipulation of a riskfactor,
policymakersshould require confirmationthat the intervention works outside of the
experimental context.The reasonforthisis that,byexperimentally manipulating theriskfactor
(e.g., dietor exercise),theresearchers have removedfromconsideration thesocial factorsthat
determineexposureto the risk factorin the naturalenvironment. Outsidethe experimental
context,thefactorsthatputpeopleat riskofrisksmaydominate,resulting in theintervention's
ultimatefailure.
(2) Consistent withtheconceptof fundamental causes, healthpolicymakers shouldconsider
whether a proposedintervention willhave an impactonjust one diseaseor whether, becauseof
its influenceon a fundamental cause, it will affectmanydiseases. An intervention thathas
even a modestimpacton manydiseases may be far more important than one thathas a
relativelystrongimpacton just one.
(3) Healthpolicymakers concernedwithbroadsocial conditionsas causes of disease should
regardwith skepticisminterventions thatfocus only on intervening variablesbut claim to
addressthe broadersocial condition.Even an "effective"intervention that addressesthe
identified riskfactorwill, in thelong run,failto eliminatetheeffectof a fundamental social
condition.In a changingstateofaffairs, theresourcesthataccrueto themoreadvantagedallow
themto regainthehealthadvantagethatmayhavebeendentedtemporarily bytheintervention.
If one wishesto addressfundamental social causes, theinterventionmustaddressinequality
in theresourcesthatfundamental causes entail.Many people and some medicalsociologists
believethatthisis impractical-evento thinkabout-because, forthem,inequalityis so firmly
entrenched thatnothingmuchcan be done aboutit. Believingthis,theonlyreasonablethingto
do is to focus on moreproximalindividually-based riskfactors,even if doing so has little
long-runbearingon theassociationbetweenfundamental social causes and disease.
But thisreasoningis shortsighted. Thereare manypoliciesthathave a directbearingon the
extentof inequalityin oursocietyand thuson theextentto whichpeople fromdifferent social
90 JOURNALOF HEALTH AND SOCIAL BEHAVIOR
circumstances have access to health-related
resources.To be sure, thesepolicies are rarely
discussedwithreferenceto theirhealthimplications.Still, policies relevantto fundamental
causes ofdiseaseforma majorpartof thenationalagenda,whether thisinvolvestheminimum
wage, housingforhomelesspeople, capital-gains taxes,parenting leave, head-start
programs,
or otherinitiatives
of thistype.Such policyinitiatives
oftenlie outsidetherealmof influence
and expertiseof healthpolicyexperts.Yet if fundamental causes are potentdeterminants of
disease, the potentialhealth impact of these broad policies needs to be thoroughly
understood-ataskthatmedicalsociologistsand social epidemiologists shouldtakeup more
thoroughly than they have. Ideally, a research-based"health impact statement"should
accompanysuch plans, and healthexpertsshouldbe trainedin the skillsneededto produce
sucha statement.

CONCLUSION

The dominantfocus in epidemiologyand perhapsthe Americanculturein generalis on

individually-based riskfactorsthatlie relativelyclose to disease in a causal chain. But this
focusoverlooksimportant sociologicalprocessesand, as a result,could lead us to actionsthat
limit our abilityto improvethe nation's health. We have focused on two concepts-
contextualizing riskfactorsand fundamentalcauses-that directourattention topreciselythose
factorsthatareleftunexaminedin thecurrently dominant orientation to researchon riskfactors
fordisease. If futureresearchby medicalsociologistsand social epidemiologists increasesour
understanding of the processesimpliedby theseconcepts,we will be betterpositionedas a
societyto further improvethenation'shealth.

NOTES
1. Using the American Journal of Epidemiologyas an indicationof the currentemphasis of
epidemiologicalresearch,we. reviewedthe 240 articlespublishedbetweenNovemberof 1992 and
1993. Excludingmethodologicalreports(N=44) and studies focused exclusivelyon descriptive
epidemiology (N = 15), we foundthatonly13.3 percent(24/181)of thearticlesfocusedon riskfactors
thatcould be construedas social in nature.Moreover,because manyof thesearticlesexaminedrace,
ethnicityor gender,withoutexplicitreference to thesocial aspectsof thesecharacteristics, our figure
of 13.3% shouldbe consideredan upper-bound estimateof thejournal'sfocuson social factors.
2. We includestigmatization because it is so closelytiedto theprestigesystem(Goode 1978). Prestige,
or thegeneralstandingthatan individualholds in theeyes of others,is an important resourcethatis
likelyto havemanyimplications forhealth-eitherindirectly through resourceslikemoney,power,or
social connections, or moredirectlythrough whata personand/orthosearoundhim/her believehe/she
deservesfromthesocial environment. Stigmatization is important because itinvolvesthedenialof the
benefitsof prestige.
3. We focus here on fundamental social causes of disease. It is possible to conceive of fundamental
psychologicalor biological causes as well. For example, at the psychologicallevel, one might
considera masteryorientation to be a resourcethatwouldbe linkedto manymechanismsand thusto
manydiseases. Similarly,at the biologicallevel, the immunesystemmightbe conceptualizedas a
resourcethatwouldinfluencemanyspecificmechanismsand thusmanydiseaseoutcomes.In eitherof
thesecases, theassociationbetweenthefundamental cause (masteryor immunesystem)and disease
outcomeswould likely endureeven if the specificmechanismswere to change. Our main point
regarding social factorsas fundamental causes is notthatfundamental causes shouldbe takenseriously
becausetheyare oftensocial, butratherthatsocial conditionsneed to be takenseriouslybecause they
are oftenfundamental causes.
4. In additionto thefactorswe considerhere,it is important to recall thatthisindividually-based risk
factorapproachcan also have deleteriouseffectsby shifting an excessiveportionof theblame to the
individual.Whenresearchfocusesattention on individually-based causes of disease, theonus is often
taken off broader-basedconditions.Morbidityand mortalitydue to tobacco is attributed to an
individually-based bad habit ratherthan to a heavily advertised,government-subsidized, highly
profitablekillerindustry.
FUNDAMENTAL CAUSES OF DISEASE 91
REFERENCES

Adler, Nancy E., Thomas Boyce, MargaretA. Chesney,Sheldon Cohen, Susan Folkman,RobertL.
Kahn, and S. Leonard Syme. 1994. "Socioeconomic Status and Health: The Challenge of the
Gradient."AmericanPsychologist49:15-24.
Aneshensel,Carol S. 1992. "Social Stress: Theory and Research." Annual Review of Sociology
18:15-38.
Aneshensel,Carol, CarolynRutter,and PeterLachenbruch.1991. "Social Structure, Stressand Mental
Health." AmericanSociologicalReview56:166-78.
Angermeyer,Matthias and Dietrich Klusman. 1987. "From Social Class to Social Stress: New
Developmentsin PsychiatricEpidemiology."Pp. 2-13 in From Social Class to Social Stress:New
Developmentsin PsychiatricEpidemiologyeditedby M. Angermeyer. New York: Springer-Verlag.
Beaglehole, Robert. 1990. "InternationalTrendsin CoronaryHeartDisease Mortality, Morbidity,and
Risk Factors."EpidemiologicReviews12:1-16.
Becker,MarshallH. 1993. "A Medical SociologistLooks at HealthPromotion."JournalofHealthand
Social Behavior34:1-6.
Benenson, AbramS. 1987. "InfectiousDiseases." Pp. 207-26 in Epidemiologyand Health Policy,
editedby S. Levine and A. Lilienfeld.New York: Tavistock.
Berkman,Lisa and Leonard Syme. 1979. "Social Networks,Host Resistance, and Mortality:A
Nine-Year Follow-Up Study of Alameda CountyResidents." AmericanJournalof Epidemiology
109:186-204.
Berkman,Lisa, Linda Leo-Summers,and Ralph Horwitz.1992. "EmotionalSupportand Survivalafter
MyocardialInfarction: A Prospective,Population-BasedStudyof the Elderly." Annals of Internal
Medicine117:1003-9.
Brunswick,Ann, Angela Aidala, JayDobkin, JoyceHoward, StephenTitus, and JaneBanaszak-Hall.
1993. "HIV-1 Seroprevalence and RiskBehaviorsin an UrbanAfricanAmericanCommunity Cohort."
AmericanJournalof Public Health 83:1390-94.
Buck, Carol W. 1981. "Prenataland PerinatalCauses of Early Death and Defect." Pp. 149-66 in
Preventive and Community Medicine,2d ed., editedby D.W. Clarkand B. MacMahon. Boston,MA:
Little,Brown,and Company.
Cassel, John.1976. "The Contribution oftheSocial Environment to HostResistance."AmericanJournal
of Epidemiology104:107-23.
Catalano,Ralph, David Dooley, GeorjeanaWilson, and RichardHough. 1993. "JobLoss and Alcohol
Abuse: A Test Using Data fromtheEpidemiologicCatchmentArea Project." Journalof Health and
Social Behavior34:215-25.
Challah, Sabri and AnthonyJ. Wing. 1985. "The Epidemiologyof Genito-Urinary Disease. " Pp.
181-202 in OxfordTextbookof Public Health, editedby W.W. Holland, R. Detels, and G. Knox.
Oxford,England:OxfordUniversity Press.
Cohen,Sheldon,David Tyrrell,and AndrewSmith.1991. "PsychologicalStressand Susceptibility to the
CommonCold." The New EnglandJournalof Medicine325:606-12.
Colley,J.R.T. 1985. "Respiratory System."Pp. 145-66 in OxfordTextbookofPublic Health,editedby
W.W. Holland,R. Detels, and G. Knox. Oxford,England:OxfordUniversity Press.
Cullen, FrancisT. 1984. Rethinking Crime and Deviance Theory:The Emergenceof a Structuring
Tradition.Totowa, NJ:Rowan and Allenheld.
Dohrenwend,Bruce P. 1966. "Social Statusand PsychologicalDisorder:An Issue of Substanceand an
Issue of Method." AmericanSociologicalReview31:14-34.
. 1990. "Socioeconomic Status and PsychiatricDisorders:Are the Issues Still Compelling?"
Social Psychiatry and PsychiatricEpidemiology25:41-47.
DohrenwendBruce P. and BarbaraS. Dohrenwend.1969. Social Statusand PsychologicalDisorder.
New York: Wiley.
. 1981. "Part 2. HypothesesAbout StressProcessesLinkingSocial Class to VariousTypes of
Psychopathology." AmericanJournalof Community Psychology9:146-59.
Dohrenwend,Bruce P., BarabaraS. Dohrenwend,MadelynGould, Bruce Link, RichardNeugebauer,
and RobinWunsch-Hitzig.1980. MentalIllnessin theUnitedStates:EpidemiologicalEstimates.New
York: Praeger.
Dohrenwend,Bruce P., ItzhakLevav, PatrickShrout,SharonSchwartz,Guedalia Naveh, Bruce Link,
Andrew Skodal, and Ann Stueve. 1992. "Socioeconomic Status and PsychiatricDisorders:The
CausationSelectionIssue." Science 255:946-51.
Dutton,Diana B. 1986. "Social Class, Health,and Illness." Pp. 31-62 in ApplicationsofSocial Science
to Clinical Medicineand Health Policy,editedby L. Aiken and D. Mechanic.New Brunswick,NJ:
RutgersUniversity Press.
92 JOURNALOF HEALTH AND SOCIAL BEHAVIOR
Ensel, Walterand Nan Lin. 1991. "The StressParadigmand PsychologicalDistress." The Journalof
Healthand Social Behavior32:321-41.
Ernster,VirginiaL. 1988. "Trends in Smoking,Cancer Risk, and CigarettePromotion."Cancer
62:1702-12.
Fenwick,Rudyand MarkTausig. 1994. "The MacroeconomicContextof JobStress." JournalofHealth
and Social Behavior35:266-82.
Gazzard,B.G. and P. Lance. 1982. "PepticUlceration."Pp. 211-19 inEpidemiology ofDiseases, edited
by D.L. Millerand R.D.T. Farmer.Oxford,England:BlackwellScientificPublications.
Goldberg,Evelyn L. and George W. Comstock. 1980. "Epidemiologyof Life Events: Frequencyin
GeneralPopulations."AmericanJournalof Epidemiology111:736-52.
Goode, William. 1978. The Celebrationof Heroes: Prestige as a ControlSystem.Berkeley,CA:
University of CaliforniaPress.
Hamilton,V. Lee, CliffordBroman,WilliamHoffman,and Deborah Renner.1990. "Hard Times and
VulnerablePeople: InitialEffectsof Plant Closings On Autoworkers'Mental Health." Journalof
Healthand Social Behavior31:123-40.
House, JamesS., Karl R. Landis, and Debra Umberson.1988. "Social Relationshipsand Health."
Science 241:540-45.
House, JamesS., JamesM. Lepkowski,Ann M. Kinney,RichardP. Mero, Ronald C. Kessler,and A.
Regula Herzog. 1994. "The Social Stratification
of Agingand Health." Journalof Healthand Social
Behavior35:213-34.
House, JamesS., RonaldC. Kessler,A. Regula Herzog,RichardP. Mero, AnnM. Kinney,and Martha
J. Breslow. 1990. "Age, Socioeconoimic Status, and Health." The Milbank Memorial Fund
68:383-411.
Illsley,Raymond.and Ken Mullen. 1985. "The HealthNeeds of DisadvantagedClientGroups." Pp.
389-402 in OxfordTextbookof Public Health, editedby W.W. Holland, R. Detels, and G. Knox.
Oxford,England:OxfordUniversity Press.
Johnson,Timothy.1991. "Mental Health, Social Relations, and Social Selection: A Longitudinal
Analysis."Journalof Health and Social Behavior32:408-23.
Kadushin, Charles. 1964. "Social Class and the Experience of Ill Health." Sociological Inquiry
35:67-80.
Karasek,Robert,Tores Theorell,JosephSchwartz,PeterSchnall,Carl Pieper,and JohnMichela. 1988.
"Job Characteristics in Relation to the Prevalenceof Myocardial Infarctionin the U.S. Health
ExaminationSurvey(HES) and theHealthand Nutrition ExaminationSurvey(HANES)." American
Journalof Public Health 78:910-18.
Kelsey, JenniferL. 1993. "Breast Cancer Epidemiology: Summary and Future Directions."
EpidemiologicalReviews15:256-63.
Kessler,Ronald, KatherineMcGonagle, ShanyangZhao, Christopher Nelson, Michael Hughes, Susan
Eshleman,Hans-UlrichWittchen,and KennethKendler.1994. "Lifetimeand 12-MonthPrevalenceof
DSM-III-R Psychiatric Disordersin theUnitedStates:ResultsfromtheNationalComorbidity Survey."
Archivesof GeneralPsychiatry 51:8-19.
Lennon, Mary Clare. 1987. "Sex Differencesin Distress:The Impactof Genderand Work Roles."
Journalof Healthand Social Behavior28:290-305.
Lieberson,Stanley.1985. Makingit Count:The Improvement ofSocial Researchand Theory.Berkeley,
CA: University of CaliforniaPress.
Lin, Nan and Walter Ensel. 1989. "Life Stress and Health: Stressorsand Resources." American
Sociological Review54:382-99.
Link, Bruce, and Bruce Dohrenwend.1989. "The Epidemiologyof MentalDisorders."Pp. 102-27 in
TheHandbookofMedical Sociology,4thed., editedby H. Freemanand S. Levine. EnglewoodCliffs,
NJ:PrenticeHall.
Link, Bruce and PatrickShrout.1992. "SpuriousAssociationsin LongitudinalResearch." Researchin
Community and MentalHealth 7:301-21.
Link, Bruce, Mary Clare Lennon, and Bruce Dohrenwend. 1993. "Socioeconomic Status and
Depression:The Role of OccupationsInvolvingDirection,Control,and Planning."AmericanJournal
of Sociology98:1351-87.
Mechanic,David and Linda H. Aiken. 1986. "Social Science,Medicine,and HealthPolicy." Pp. 1-9 in
Applicationsof Social Science to Clinical Medicineand Health Policy,editedby L. Aiken and D.
Mechanic.New Brunswick,NJ: RutgersUniversity Press.
Miller,C. Arden. 1987. "Child Health." Pp. 15-54 in Epidemiologyand Health Policy, editedby S.
Levine and A. Lilienfeld.New York: Tavistock.
Mirowsky,Johnand CatherineE. Ross. 1989. The Social Causes of PsychologicalDistress.New York:
Aldinede Gruyter.
FUNDAMENTAL CAUSES OF DISEASE 93
Novotny,ThomasE., KennethE. Warner,Juliette S. Kendrick,and PatrickRemington.1988. "Smoking
by Blacks and Whites:Socioeconomicand DemographicDifferences."AmericanJournalof Public
Health 78:1187-89.
Pappas, Gregory,Susan Queen, WilburHadden, and Gail Fisher. 1993. "The IncreasingDisparityin
MortalityBetween Socioeconomic Groups in the United States." The New England Journalof
Medicine329:103-109.
Pearlin,Leonard. 1989. "The Sociological Studyof Stress." Journalof Health and Social Behavior
30:241-56.
Pearlin,Leonardand CarmiSchooler. 1978. "The Structure of Coping." Journalof Health and Social
Behavior19:2-21.
Pearlin,Leonard,MortonLieberman,ElizabethMenaghan,and JosephT. Mullen. 1981. "The Stress
Process." Journalof Healthand Social Behavior22:337-56.
Pedoe, H. Tunstall.1982a. "Stroke." Pp. 136-45 in Epidemiologyof Diseases, editedby D.L. Miller
and R.D.T. Farmer.Oxford,England:BlackwellScientificPublications.
. 1982b. "CoronaryHeartDisease." Pp. 103-21 in Epidemiologyof Diseases, editedby D.L.
Millerand R.D.T. Farmer.Oxford,England:BlackwellScientificPublications.
Potter,JohnD. 1992. "Reconcilingthe Epidemiology,Physiology,and Molecular Biology of Colon
Cancer." Journalof theAmericanMedical Association268:1573-77.
Prout,MarianneN., TheodoreColton,and RobertA. Smith. 1987. "Cancer Epidemiologyand Health
Policy." Pp. 117-56 in Epidemiologyand HealthPolicy,editedby S. Levine and A. Lilienfeld.New
York: Tavistock.
Rabkin,Judithand ElmerStruening.1976. "Life Events,Stress,and Illness." Science 194:1013-20.
Robins,Lee, JohnE. Helzer,MyrnaM. Weissman,Helen Orvaschel,ErnestGruenberg, JackD. Burke,
and DarrelA. Regier. 1984. "LifetimePrevalenceof SpecificPsychiatric Disordersin ThreeSites."
Archivesof GeneralPsychiatry 41:949-58.
Rosen, George. 1979. "The Evolutionof Social Medicine." Pp. 23-50 in The Handbookof Medical
Sociology,3d ed., editedby H. Freeman,S. Levine, and L. Reeder. EnglewoodCliffs,NJ: Prentice
Hall.
Rosenfield,Sarah. 1989. "The Effectsof Women's Employment: PersonalControland Sex Differences
in MentalHealth." Journalof Health and Social Behavior30:77-91.
Rothman,Kenneth.1986. ModernEpidemiology.Boston,MA: Little,Brown,and Company.
Saracci, Rodolfo. 1985. "Neoplasms." Pp. 112-29 in OxfordTextbookof Public Health, edited by
W.W. Holland,R. Detels, and G. Knox. Oxford,England:OxfordUniversity Press.
Schnall,Peter,Carl Pieper,JosephSchwartz,RobertKarasek,Y. Schlussel,R. Devereux,M. Alderman,
KatherineWarren,and Thomas Pikering.1990. "The RelationshipBetween'Job Strain,'Workplace
Diastolic Blood Pressure,and Left VentricularMass Index." Journal of the AmericanMedical
Association263:1929-35.
Schnall, Peter,JosephSchwartz,Paul Landsbergis,KatherineWarren,and Thomas Pickering.1992.
"RelationBetweenJobStrain,Alcohol, and Ambulatory Blood Pressure."Hypertension 19:488-94.
Shrout,Patrick,Bruce Link, Bruce Dohrenwend,AndrewSkodal, Ann Stueve, and JeroldMirotznik.
1989. "CharacterizingLife Eventsas Risk FactorsforDepression."JournalofAbnormalPsychology
98:460-67.
Smith,Tom W. 1992. "A Life EventsApproachto Developingan Indexof SocietalWell-Being."Social
Science Research21:353-79.
Susser, Mervyn,WilliamWatson,and Kim Hopper. 1985. Sociologyin Medicine. New York: Oxford
UniversityPress.
Syme, S. Leonard and JackM. Guralnik.1987. "Epidemiologyand Health Policy: CoronaryHeart
Disease." Pp. 85-116 in Epidemiologyand HealthPolicy,editedby S. Levine and A. Lilienfeld.New
York: Tavistock.
Turner,R. Jay and Franco Marino. 1994. "Social Support and Social Structure:A Descriptive
Epidemiology."Journalof Health and Social Behavior35:193-212.
Turner,R. Jay, Blair Wheaton, and Donald Lloyd. 1995. "The Epidemiologyof Social Stress."
AmericanSociological Review60:104-25.
Umberson,Debra, Camille Wortman,and Ronald Kessler. 1992. "Widowhood and Depression:
ExplainingLong-TermGenderDifferencesin Vulnerability." Journalof Health and Social Behavior
33:10-24.
Virchow,Rudolf. 1848. "The Public HealthService" (in German).MedizinischeReform5:21-22.
Walsh, JoyceK. and JosephG. Feldman. 1981. "Health of the U.S. Population." Pp. 583-602 in
Preventiveand Community Medicine,2d ed., editedby D.W. Clarkand B. MacMahon. Boston,MA:
Little,Brown,and Company.
94 JOURNALOF HEALTH AND SOCIAL BEHAVIOR
Bruce G. Link is associateprofessorof publichealthat ColumbiaUniversity and researchscientistat
New York StatePsychiatric Institute.His interests thesourcesof particular
lie in understanding typesof
inequality,its legitimation, of healthand
and its consequencesas these bear on the social patterning
illness.This interestis reflectedin his workon theassociationbetweensocioeconomicstatusand major
mentaldisordersand thepossiblerolethatoccupationalconditionsmayplay in thisassociation,research
on the healthand well-beingof homelesspeople, and researchon the social and economicadversities
engenderedby the stigmaof mentalillness.

of California,Los Angeles. Her research

Jo Phelan is assistantprofessorof sociologyat theUniversity
includehomelessness,social stigma,the impactof social conditionson healthand illness,and
interests
concerninginequalityand itslegitimacy.
attitudes