race (and class) serves as a social determinant of health in the United States. In the beginning (the mid-1980s), HIV/AIDS was a disease most characteristic of white homosexual males. But gay men, many of whom are affluent and well-educated, were the first to change their social behavior by adopting safe sex techniques in large numbers and the pattern of the disease changed dramatically. By the 1990s, the magnitude of the epidemic – even though it began to decline after 1995 – had shifted especially to non-Hispanic blacks but also to Hispanics. In 2016, the most recent year data were available as this book goes to press, African Americans accounted for 41.1 percent of all HIV diagnoses and Hispanics for 16.1 percent, followed by 12.6 percent for multiracial persons, 9.9 percent for Native Hawaiians and Pacific Islanders, 8.8 percent for American Indians and Native Alaskans, and 5.1 percent for both Asians and whites. Some 81 percent were male and 70 percent gay or bisexual. Most women contract HIV through sexual intercourse with infected men.
There are no known biological reasons why the shift from a predominately white infected population to one that is largely black and other racial minorities took place or why racial factors should enhance the risk of HIV/AIDS. Simply being poor and living in economically disadvantaged areas is not the entire answer as many Hispanics and whites are poor but have lower rates. In addition to poverty, joblessness, minimal access to quality medical care, and a reluctance to seek treatment because of stigma, social segregation is also a factor. Edward Laumann and Yoosik Youm (2001) concluded years ago that blacks have the highest rates of sexually-transmitted diseases because of the “intra-racial network effect.” They point out that blacks are more segregated than other racial groups in American society and the high number of sexual contacts between an infected black core and a periphery of yet uninfected black sexual partners act to contain the infection within the black population. Laumann and Youm determined that even though a peripheral (uninfected) black has only one sexual partner, the probability that partner is from the core (infected) group is five times higher than it is for peripheral whites and four times higher than for peripheral Hispanics. In this instance, the core is the agent, the periphery the host, and the intra-racial network the environment.
Social Determinants of Disease: Fundamental Cause Theory
The seminal theoretical work on the role of social factors in disease causation in medical sociology is that of Bruce Link and Jo Phelan (1995, 2000; Carpiano, Link, and Phelan 2008; Phelan and Link 2013, 2015; Phelan, Link, and Tehranifar 2010). Link and Phelan maintain that social conditions are fundamental causes of disease. In order for a social variable to qualify as a fundamental cause of disease and mortality, Link and Phelan (1995: 87) hypothesize that it must (1) influence multiple diseases, (2) affect these diseases through multiple pathways of risk, (3) be reproduced over time, and (4) involve access to resources that can be used to avoid risks or minimize the consequences of disease if it occurs. They define social conditions as factors that involve a person’s relationships with other people. These relationships can range from ones of intimacy to those determined by the socioeconomic structure of society.
Link and Phelan conclude that there is a long and detailed list of mechanisms linking socioeconomic status with mortality. In addition to stratification variables such as class, race, and gender, stressful life events and stress-process variables like social support qualify as social factors. Also included is a sense of control over one’s life because people with such control typically feel good about themselves, cope with stress better, and have the capability and living situations to adopt healthy lifestyles. This situation may especially apply to people in powerful social positions. “Social power,” state Link and Phelan (2000: 37), “allows one to feel in control, and feeling in control provides a sense of security and well-being that is [health-promoting].” Persons at the bottom of society are less able to control their lives, have fewer resources to cope with stress, live in more unhealthy circumstances, and face powerful constraints in adopting a healthy way of life, and die earlier. Consequently, Link and Phelan argue that broadbased societal interventions may be able to produce more substantial health benefits than individually-based intervention strategies in many situations.
Of particular interest as a structural variable is social class or socioeconomic status (SES). A person’s class position influences multiple diseases in multiple ways and the association has endured for centuries. Numerous studies have linked low SES with worse health and higher mortality throughout the life course (Atkinson 2015; Carr 2019; Laditka and Laditka 2019; Marmot 2015). Even accounts of the black or bubonic plague (Yersina pestis) in Europe in the fourteenth century describe how the poor were more heavily afflicted than the rich and note that the common people suffered the most (Cantor 2015). In advanced societies like the US and Britain, people generally live 30 more years on the average than they did in 1900. Over 80 percent of all deaths occur past the age of 65, with poor people living longer today than the wealthy did in past historical periods. But the gap remains the same in that while everyone typically lives longer today, people in the upper social strata live the longest. Consequently, Link and Phelan argue that the level of socioeconomic resources a person has or does not have, such as money, education, status, power, and social connections, either protects his or her health or brings on sickness and premature mortality. Phelan et al. (2004: 267) state:
These resources directly shape individual health behaviors by influencing whether people know about, have access to, can afford and are motivated to engage in health-enhancing behaviors. Current examples include knowing about and asking for beneficial health procedures; quitting smoking; getting flu shots; wearing seat belts and driving a car with airbags; eating fruits and vegetables; exercising regularly; and taking restful vacations. In addition, resources shape access to broad contexts such as neighborhoods, occupations, and social networks that vary dramatically in associated profiles of risk and protective behaviors. For example, low-income housing is more likely to be located near noise, pollution, and noxious social conditions and less likely to be well served by police, fire, and sanitation services; blue-collar jobs tend to be more dangerous and stressful than white-collar and to carry inferior health benefits; and social networks with high status peers are less likely to expose a person to second-hand smoke, more likely to support a health enhancing lifestyle, more likely to inform a person of new health-related research, and more likely to connect him or her to the best physicians.
Phelan et al. confirmed their thesis that socioeconomic status is a fundamental cause of mortality by finding a strong relationship between SES and deaths from preventable causes. For deaths from less preventable causes about which little is known in terms of prevention and treatment, the relationship was less strong. However, people with higher SES had significantly higher probabilities of survival from preventable causes of death because they were able to use their greater resources to that end. Their enhanced access to and effective use of resources (money, knowledge, etc.) served as the social mechanism allowing them to obtain greater longevity. Such resources also shape broader contexts affecting health like jobs, neighborhoods, and social networks that vary dramatically in promoting protection or risk. These resources are flexible because they can be used in varied circumstances. Their availability is central to understanding the operation of the theory at both individual (micro) and contextual (macro) levels because the deployment of resources is critical to health. At the individual level, Phelan et al. (2010: S30) describe flexible resources as the “causes of causes” or “risks of risk” that influence individual health behaviors with respect to whether people know about, have access to, can afford, and are motivated to engage in health-promoting practices, as well as determining access to jobs, neighborhoods, and social networks that vary dramatically in the amount of risk and protection they provide. Resources and the ability to use them are most effective for preventable causes of mortality and less so or ineffective for those that are not preventable or treatable, such as diseases and disabilities associated with aging.
Fundamental cause theory and its concept of flexible resources can also be applied to an infectious disease like COVID-19, as people with such resources were better able to successfully socially distance themselves from others and utilize their socioeconomic advantages to have food and medicine delivered, be entertained and communicate electronically, have teleconferences with health care professionals when required, and know what to do to avoid infection
