William C. Cockerham - The Social Causes of Health and Disease

This theory seemed a representative summary of epidemiological trends until the 1970s and 1980s when there was a surprisingly rapid decline in deaths from cardiovascular disease, followed by the arrival of new infectious diseases in the late 1990s and early 2000s – such as West Nile, SARS, Ebola, and Zika (Armelagos and Harper 2016). These changes led some to propose modifications in the theory. This included adding newly emerging infectious diseases to the third stage, since these diseases had made an unexpected and deadly appearance, and creating a new fourth stage, such as a “Hybristic [or Mixed] Age” in which individual behaviors and lifestyles are added to heart disease and cancer as another major cause of mortality (Rodgers and Hackenberg 1987), an “Age of Delayed Degenerative Diseases” in which chronic diseases like heart disease and cancer do not result in death until increasingly older ages (Olshansky and Ault 1986), or the “Age of the Cardiovascular Revolution” during which improvements in medicine pertaining to heart disease continue to reduce mortality and improve life expectancy (Meslé and Vallin 2006).

In a yet to be decided Stage Four, social factors are especially relevant regardless of whether it is a case of “Hybristic (Mixed) Causes” featuring risky behaviors (i.e., lifestyles) as a major cause of death, “delayed degenerative diseases” in which the biological effects of aging or the physical “weathering” of the body caused by social stress and the consequences of unhealthy lifestyle practices are postponed as life expectancy increases, or the “cardiovascular revolution” where health lifestyles are again paramount in mortality outcomes because of their close association with heart disease. In this new fourth stage, smoking, obesity, and unhealthy behavior, along with the addition of climate change, will likely be important, along with newly emerging infectious diseases like Zika and especially the coronavirus (COVID-19). The addition of newly emerging infectious diseases suggests a partial return to Stage 1 and the “Age of Pestilence,” further signaling a much needed revision of epidemiologic transition theory. What is obvious is that this current stage of epidemiological transition needs to take cognizance of the fact that good or bad behavioral practices cause good or bad health.

As for heart disease, Porter (1997: 585) notes the comments of a leading British medical doctor who observed in 1892 that cardiac deaths were “relatively rare.” However, within a few decades, heart disease had become the leading cause of death throughout Western society as life expectancy increased. New diagnostic techniques, drugs, and surgical procedures including heart transplants, by-pass surgery, and angioplasty were developed in response. Porter also finds that greater public awareness of risk factors like smoking, poor diet, obesity, and lack of exercise along with lifestyle changes made a fundamental contribution to improving cardiovascular health.

The transition to chronic diseases meant medicine was called upon to confront the health problems of the “whole” person, which extend well beyond singular causes of disease such as a virus that fit the biomedical model. As Porter pointed out, even though the twentieth century witnessed the most intense concentration of attention and resources ever on chronic diseases, they have nevertheless persisted. “It can be argued,” states Porter (1997: 594), “that one reason why there has been relatively little success in eradicating them is because the strategies which earlier worked so well for tackling acute infectious diseases have proved inappropriate for dealing with chronic and degenerative conditions, and it has been hard to discard the successful ‘microbe hunters’ formula.”

Consequently, modern medicine is increasingly required to develop insights into the social behaviors characteristic of the people it treats. According to Porter, it is not only radical thinkers who appeal for a new “wholism” in medical practice that takes social factors into consideration, but many of the most respected figures in medicine were insistent that treating the body as a mechanical model would not produce true health. Porter (1997: 634) states:

Disease became conceptualized after 1900 as a social no less than a biological phenomenon, to be understood statistically, sociologically, and psychologically – even politically. Medicine’s gaze had to incorporate wider questions of income, lifestyle, diet, habit, employment, education, and family structure – in short, the entire psychosocial economy. Only thus could medicine meet the challenge of mass society, supplanting laboratory medicine preoccupied with minute investigation of lesions but indifferent as to how they got there.

Contemporary physicians now treat many health maladies that are aptly described as “problems of living,” dysfunctions that may involve multiple sources of causation, including those that are social in origin and part of everyday life. This includes social structural factors like class, living conditions, and social capital that can cause health or illness. These factors are causal because good or bad health originates from their influence. Consider, for example, the problem of low birth-weights among newborn babies. Such babies are more likely to have health problems than infants with normal birth-weights and less likely to survive the postnatal period. In researching this situation, Dalton Conley, Kate Strully, and Neil Bennett (2003) determined that if there are two groups of couples – one with high incomes and the other with low incomes – and each group has the same 20 percent biological predisposition toward having a low-birth-weight baby – the high-income group has a very high probability of counteracting their biological predisposition with better nutrition and prenatal care. In this instance, social factors – namely, income and how it translates into better education, living situations, jobs, quality medical care, and a good diet and other healthy lifestyle practices – reverse the biological risk. In the low-income group, the biological risk proceeds unimpeded. In both groups, social factors are causal in that biological predispositions are blunted in the high-income group and do not allow the biological risk to be countered in the low-income group. In fact, it could be argued that low income and how it signifies poor education, less healthy living situations, inadequate employment, less quality medical care, and poor diets along with less healthy lifestyle practices like smoking and alcohol abuse, promotes the biological risk into reality.

Social factors not only can determine whether or not a person becomes sick, but also shape the pattern of a population’s health and disease, as well as how people experience illness. These direct effects of social factors on health and disease are depicted in figure 1.1. First, social factors can mold the illness experience, for example, in helping or hindering adaptation, alleviating or exacerbating symptoms by making remedies more or less accessible, providing therapeutic or detrimental environments, or in causing good or poor health care to be available. Second, social factors determine the patterning of health, disease, and mortality at the population level. This is seen in studies of population health displaying patterns and trends occurring at particular times and in specific geographical places (Hummer and Hamilton 2019). Invariably, these patterns illustrate the influence of social variables – such as income, education, race, and gender – in determining their direction and profile.

Third, is the topic of this book: the social causation or determinants of health and disease to be discussed in this and forthcoming chapters. Social factors can have a direct effect on health by acting as a determinant or cause. According to the World Health Organization (2011), the social determinants of health are “the conditions in which people are born, grow, work, live, and age, and the set of forces and systems shaping the conditions of daily life.” As determinants of health, the “social” refers to social practices and circumstances (such as inequality, lifestyles, living and work situations, neighborhood characteristics, poverty, and environmental pollution), socioeconomic status, social stressors, and racial discrimination, along with economic (e.g., unemployment), political (e.g., government policies, programs, and public health insurance benefits), and religious (e.g., piety, proscriptions against smoking and drinking alcohol) factors that affect the health of individuals, families, groups, and communities – either positively or negatively (Cockerham et al. 2017c). Social determinants can have a causal role in fostering illness and disability but, conversely, can promote prospects for preventing disease and maintaining health.