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SOC364H1 Chapter Notes -Social Epidemiology, Coronary Artery Disease, Social Medicine

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Jooyoung Lee

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Social Conditions As Fundamental Causes of Disease - Bruce G. Link and Jo Phelan
(May 14, 2014)
- With few exceptions, however, the new findings generated within the field of
epidemiology have focused on risk factors that are relatively proximate "causes" of
disease, such as diet, cholesterol, hypertension, electromagnetic fields, lack of exercise,
and so on. Social factors, which tend to be more distal causes of disease, have received
far less attention
- In fact, some in the so-called "modem" school of epidemiology have explicitly argued
that social conditions such as socioeconomic status are mere proxies for true causes
lying closer to disease in the causal chain
- This focus on proximate risk factors, potentially controllable at the individual level,
resonates with the value and belief systems of Western culture that emphasize both the
ability of the individual to control his or her personal fate and the importance of doing so
-Thus modem epidemiology and cultural values conspire to focus attention on
proximate, individually-based risk factors and away from social conditions as
causes of disease.
- we define social conditions as factors that involve a person's relationships to other
oThese include everything from relationships with intimates to positions occupied
within the social and economic structures of society. Thus, in addition to factors
like race, socioeconomic status, and gender, we include stressful life events of a
social nature (e.g., the death of a loved one, loss of a job, or crime victimization),
as well as stress-process variables such as social support
- Moreover, low SES is associated with each of the 14 major cause-of-death categories in
the International Classification of Diseases, as well as many other health outcomes,
including major mental disorder
- Important advances in establishing a causal role for social factors have focused on two
major issues-the direction of causation between social conditions and health and the
mechanisms that explain observed associations. In what follows we present prominent
examples of work on these two issues
- Concerning the issue of causal direction, important controversies surround some of the
relationships between social conditions and health. For example, does low SES cause
poor health, or does poor health cause downward mobility? Does social support reduce
morbidity and mortality, or does illness restrict social interaction and thereby lead to
social-support deficits? Social epidemiologists have used three general strategies to
address these questions
- Research identifying the mechanisms linking social conditions to disease has also done
much to move social epidemiology beyond the description of social patterns of disease.
Consider, for example, the job-stress model of Karasek and colleagues that provides

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evidence for one mechanism linking SES to coronary heart disease among men. These
investigators have shown that "job strain," characterized by a combination of high job
demands and low decision latitude, is more common in lower status jobs and is
associated with coronary heart disease and elevated levels of ambulatory blood
pressure both on and off the job
- To this point, we have described two characterizations of social conditions as causes of
disease that either advertently or inadvertently downplay their importance. One of these
is the outright declaration that social factors are only proxies for true causes. This
position is demonstrably unwarranted given the achievements of medical sociology and
social epidemiology over the past few decades. The other characterization, which may
be partially constructed by medical sociologists and social epidemiologists themselves,
is the view that social factors serve as starting points whose main function is to point the
direction to more proximal risk factors. We take sharp issue with both of these
- One way they can do this is by "contextualizing" individually-based risk factors. By this
we mean that investigators must (1) use an interpretive framework to understand why
people come to be exposed to risk or protective factors and (2) determine the social
conditions under which individual risk factors are related to disease. We present
examples that illustrate both these principle
oFirst, an important strategy for reducing the threat of AIDS is to educate the
public concerning the steps they must take as individuals to reduce their risk of
contracting or infecting others with the HIV virus.
oThis example suggests that medical sociologists and social epidemiologists need
to contextualize risk factors by asking what it is about people's life circumstances
that shapes their exposure to such risk factors as unprotected sexual intercourse,
poor diet, a sedentary lifestyle, or a stressful home life.
- Our second example concerns the increasing attention being paid to the public health
problem posed by contamination of meat, poultry, and eggs with E. coli and salmonella
bacteria. The public has been warned to rinse and cook meat and poultry thoroughly and
to carefully wash hands, knives, cutting boards, and so on. Because some follow these
safety guidelines more assiduously than others, one can imagine a risk profile of
individual behaviors that might predict bacterial infection.
- These precautions are only necessary, however, when the food that reaches the
marketplace is contaminated. Government actions in the 1980s that reduced the number
of government inspectors and deregulated the meat-processing industry have created
the need for vigilance on the part of individuals. While the current approach to the
problem focuses on the individual, it can readily be seen that economic and political
forces shape individuals' exposure to this risk. This example suggests that medical
sociologists and social epidemiologists need to contextualize by asking under what
social conditions individual risk factors lead to disease and whether there are any social
conditions under which the individual-level risk factors would have no effect at all on
disease outcome
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