1. The Social Production of Disease and Illness

2. Disease vs. Illness
Disease: biophysiological phenomena that manifest themselves as changes in and malfunctions of the human body
a physiological state (objective)
Illness: the experience of being sick or diseased
a social-psychological state, presumably caused by the disease (subjective)
Illness is a social construction based on human judgments of some condition

3. Medical vs. Sociological model
Medical model focuses on organic pathology in individual patients, rarely taking societal factors into account
Sociological model focuses on societal factors

4. Pathologists and public health doctors deal with disease
Patients experience illness
Clinical physicians, ideally, treat both

5. morbidity: disease rate
mortality: death rate

6. “Medical Measures and the Decline in Mortality”
McKinlay & McKinlay, 1977

7. 1900–1976: precipitous decline in mortality in US
Start of sharp rise in medical care expenditures happens after 92% of modern decline in mortality already occurred
Most of decline in mortality is due to rapid disappearance of major infectious diseases
article focuses on 11 conditions for which there were identifiable medical interventions

8. Infectious vs. chronic disease
Infectious diseases including HIV/AIDS, tuberculosis, malaria, polio, and several neglected tropical diseases are easily spread through personal contact, water, and air (transmitted by mosquitoes, flies, etc)
Infectious disease no longer as deadly as before, having been “conquered” in the developed world, although they continue to be a significant problem in developing countries
Chronic or non-communicable diseases (NCDs) such as cancer, heart disease, lung disease, stroke, and diabetes now major causes of death in US
By 2020, NCDs are expected to account for 7 of every 10 deaths in the world, as they already do in the U.S.
These projections suggest that NCDs and the death, illness, and disability they cause will soon dominate health care costs
According to statistics from the World Health Organization, NCDs account for 63% of deaths worldwide, double the number from infectious diseases (including HIV/AIDS, TB, and malaria), maternal and perinatal conditions, and nutritional deficiencies combined

9. ‘Limitations of medicine’ argument
‘Limitations of medicine’ argument gives more credit to social improvements than medical advances for decline in infectious disease, e.g.,
public health measures
sanitation
improved housing and nutrition
rise in standard of living

10. Limitations of mortality stats
Changes in registration area in US in early 20th century
Often no single disease, but a complex of diseases may be responsible for death
Inaccuracies in the recording of causes of death
Changes in diagnostic trends
Changes in disease classifications, etc.

11. Social conditions as fundamental causes of health inequalities
Bruce Link and Jo Phelan

12. Past epidemiological studies have identified risk factors for major disease, but focus has been on proximal causes
Proximal: close to the body (vs. distal, which are often more social factors)
e.g., diet, cholesterol level, exercise, etc.
Focus on proximate causes resonates with Western values such as ability and importance of controlling one’s own health

13. Risk-factor model
Risk-factor model: explains health disparities by specifying risk factors in causal chain between social conditions and disease

14. Successes & Shortcomings of risk-factor model
Successes: interventions based on more proximal, behavioral, and biomedical factors have had positive impact on population health
Declines in infectious disease in 19th century and declines in chronic disease in 20th, e.g., heart disease, stroke, and, since 1990s, cancer
Shortcomings: social conditions shape capacity to modify risk factors, making approach less effective than focusing on risk-factor mechanisms
Need to address ‘causes of causes,’ factors that put people ‘at risk of risk’
Identification of risk factors can actually increase health disparities
Uneven distribution of knowledge & technology shapes disparities
We see major disparities by race, ethnicity, and SES

15. social conditions as fundamental causes of health inequalities
Connections between social conditions and health hold regardless of context, involving vastly different risk/protective factors and completely different diseases
Social conditions are ‘causes of causes’ or ‘risks of risk’
Connections between SES and mortality persist across time and space
Evidence shows robust connections between mortality and education, occupation, and income
Connections persist even with the lowering of risk factors

16. Resources shape capacity to take advantage of new knowledge & technology
When new knowledge about risk and protective strategies emerges, people use the resources available to them to take advantage of new knowledge or technology, e.g.,
Cancer screening: SES  Access to Life-Saving Screening  Health
Smoking knowledge & behavior: SES  Knowledge of link b/w smoking & lung cancer  Health
Resources/SES also relate to:
Access to best doctors
Knowing about and asking for beneficial health procedures
Having friends and family who support healthy life styles
Quitting smoking
Getting flu shots
Wearing seat belts
Eating fruits & vegetables
And exercising regularly; living in neighborhoods where garbage is picked up, interiors are lead-free, streets are safe,; having children who bring home health info from school; working in safe environment; taking restful vacations

17. We must pay greater attention to social conditions over individual risk factors if health reforms are to have real impact
Individual-based risk factors must be contextualized, by examining what puts people at risk of risks
Social factors such as SES and social support are likely “fundamental causes” of disease that, because they embody access to important resources, affect multiple disease outcomes through multiple mechanisms, and consequently maintain an association with disease even when intervening mechanisms change
Social conditions: factors that involve a person’s relationships w/others
intimate relationships to positions in socioeconomic structure, membership in racial, ethnic, sex, and gender categories
ALSO: stressful life events, social support, ways of coping that are collective/community- based

18. Stress paradigm SES  stressful life events  mental disorder
focus shifted to ways to modify stress, e.g., coping & social support
focus also turned to biological consequences of stress
But very little study of origins of stressful circumstances
Risk factors must be contextualized

19. to contextualize a risk factor:
Use an interpretive framework to understand why people come to be exposed to risk or protective factors
Determine the social conditions under which risk factors are related to disease
AIDS: educate the public about risks of contracting disease and ways to protect yourself, but some people are better able to take advantage of info than others
some people cannot avoid risk, e.g., some homeless or extremely poor women use prostitution as a survival strategy
Bacterial infection (E coli or salmonella) from contaminated meat, poultry, and eggs: people are warned to rinse and cook meat thoroughly, wash hands, knives and cutting boards – but these precautions are only necessary when the food in the marketplace is already contaminated
public health officials focus on individual risk factors and individual behaviors NOT the political economic context which since the 1980s has deregulated industry and reduced government inspections
Political/economic forces shape exposure to risk!

20. conclusion
If one wants to alter the effects of a fundamental cause, one must address the fundamental cause itself

21. Policy implications
Factors that put people at risk of risks may dominate, resulting in intervention’s ultimate failure
Policymakers should consider whether a proposed intervention will have an impact on just one disease or many diseases – a modest impact on many diseases may be relatively more important than a strong impact on just one
Regard with skepticism interventions that focus only on intervening variables but claim to address broader social conditions
Include health impact statements with all kinds of public policy proposals