Health Disparities Test 1

Flexible Resources

"Fundamental-cause theory claims that new mechanisms arise because persons of higher socioeconomic status are able to deploy a wide range of resources—including knowledge, money, power, prestige, and beneficial social connections—that can be used individually and collectively in different places and at different times to alive disease and death. Because they can be applied in very different circumstances, we call them flexible resources. Thus when new knowledge about risk and protective strategies emerges, people use the resources available to them to harness the benefits of that new knowledge. People with more resources are able to benefit more, thereby creating a new mechanism linking social conditions to morbidity and mortality Examples of protective strategies: ⁃ Cancer screening, smoking knowledge, gaining access to best doctors, having family members who support healthy behaviors, getting flu shots, wearing seat belts, eating fruits and vegetables ⁃ Some of these examples depend on individual initiative (e.g., getting a flu shot), and some do not (e.g., having supportive family members).

Biomarkers - Why?

"The Application of Biomarker Data on the Study of Social Determinants of Health" by Shih, Fernandes, and Bird Why study biomarkers in a health disparities class? • Remember... we just learned that medicalization is proceeding most strongly through biotechnology. • The move to incorporate biomarkers in health research is an example of this trend. • My prediction: Legitimizing the research on health disparities will more and more require the use of biomarkers. • Of course... this may or may not be advantageous to the social determinants approach.

Medicalization

"The Social Construction of Illness: Medicalization and Contested Illness" by Kristin Barker Goal of Article = Using the case of contested illness to explain medicalization in terms of social constructionism. Why should we care? ⁃ This class is about health disparities. But who decides what health is? ⁃ The way we define health will influence how it is distributed in the population. Examples of deviance becoming illness: ⁃ Drunk becomes alcoholic. ⁃ Gambler becomes addict. ⁃ Heaviness becomes obesity. ⁃ Hatred becomes antisocial personality disorder. Medicalization exists on a gradient. ⁃ Some conditions are more medicalized than others. ⁃ Ex. Shortness is not highly medicalized (because most people are not treated for it). ⁃ Ex. Celiac disease is somewhere between medicalized and nonmedicalized (because it requires no direct medical intervention).

Exceptions to Fund. Cause Theory

1) Having medical knowledge does little good because it is so sparse (e.g., brain and pancreatic cancer). 2) Adopting current practice is directly harmful (e.g., hormonereplacement therapy to treat heart disease increased risk of cancer). 3) Acting on correct knowledge is harmful in other ways (e.g., having children earlier benefits long-term maternal health but may impede career advancement). These exceptions are not fatal to the main argument because each scenario still involves the basic driver of flexible resources, which become blocked in their capacity to deliver benefits.

Alternatives to Fund. Cause Theory

1) Risk Factor Approach = Eliminating risk factors breaks the connection between social factors and health outcomes. 2) Marmot and Wilkinson = Stress of lower placement in social hierarchy is the source of the SES-health association 3) Gottfredson = Intelligence is key flexible resource that drive both SES attainment and wise health behaviors. 4) Heckman = Noncognitive traits (e.g., conscientiousness, perseverance, time horizon) are key flexible resources that drive both SES attainment and wise health behaviors.

Questions from Social Constructionism

1) What is an illness? OR What is a disease? 2) Why does an illness appears in one place and not another? 3) Why does an illness appears and disappears in the same place? Constructionist Answers ⁃ Barker: "The task is not necessarily to determine which of the two societies has the correct ideas about illness, or which of the illnesses found only in certain places or at certain times are real. Instead, the task is to determine how and why particular ideas about illness appear, change, or persist for reasons that are at least partly independent of their empirical adequacy vis-a-vis biomedicine.

British Med Sociology

1940s = establishment of National Health System in 1948 (without input from sociologists) ⁃ 1950s = med soc first appears, largely confined to London School of Economics ⁃ 1960s = med soc gains strength, increases presence in wider university system More applied than theoretical (similar to U.S.). ⁃ Ex. Focus on improving patient care, solving health inequities, contributing to health policy.

Diabetes and Genetics

A variant of gene TCF7L2, which increases the risk of Type 2 diabetes, is carried by 1/3 of the U.S. population. ⁃ However this gene has been around for generations, and rapid rise of new cases cannot be explained genetically (because the human gene pool does not change that fast).

HIV Triad

AIDS Triad ⁃ Host = periphery (not carrying HIV) ⁃ Agent = core (carrying HIV) ⁃ Environment = intra-racial network

Advantages of Biomarkers

Advantages of Biomarkers: 1) Can avoid bias from self-reported health. ⁃ Often assessed using questions such as, "Has a doctor ever diagnosed you with diabetes?" 2) Can be used in conjunction with self-reported health. ⁃ Ex. Contrast between self-reported symptoms and underlying condition may spark insight. Advantages of Biomarkers cont. 3) Can help identify causal mechanisms and pathways. ⁃ Ex. "How does social environment factor X affect the biological pathway to disease Y?" 4) Can help asses long-term and chronic illness. ⁃ Shih, Fernandes, and Bird: "Biomarkers may be most useful when the effects of a disease process or risk factors do not occur immediately but over longer periods of time, as is the case for many chronic diseases such as diabetes."

Agency Oriented Theory

Agency = individual's capacity to freely select behavior ⁃ Agency-oriented theorists emphasize ability of individual to choose actions regardless of structural constraints. Cockerham: "Social reality is therefore created by people choosing their own behavior and acting accordingly, not by large-scale social processes and structures channeling their activities down more or less option-less pathways." Being agency-oriented does NOT imply that structure is unimportant. ⁃ Ex. Mead's concept of "generalized other." ⁃ Cockerham: "Mead defines the generalized other as the organizational attitudes of a community as a whole and the social process through which 'the community exercises control over the conduct of its individual members.'"

Social Constructionism

Arises from the Sociology of Knowledge ⁃ Study of IDEAS as "realized expression of particular social interests within particular social systems and contexts" rather than "true or false expressions of the world." Def. of a Social Construction ⁃ Barker: "an idea that appears to refer to some obvious, inevitable, or naturally given phenomenon, when in fact that phenomenon has been (in full or part) created by a particular society at a particular time." Example of a Social Construction ⁃ Feminist claim that gender is a social construction = norms about gender are not biologically mandated and are therefore alterable. Social Constructionism in Medical Sociology ⁃ Begins with Parsons's 1951 concept of "sick role" (i.e., illness = medically sanctioned deviant behavior with rights and obligations to ensure sickness doesn't disrupt social order). Example of Epilepsy ⁃ Barker: "All illnesses, not just those that are contested, are in some general sense socially constructed. Without exception, the meaning and experience of all illness is innately social. In this regard we can speak of the social construction of epilepsy. To be sure, seizures are real. At the same time, however, the meaning of seizures (possession vs. disease) and their experience (stigmatized vs. medicalized) is socially contingent.

Contested Illness Cont.

Barker: "Resistance is what defines contested illness." ⁃ Ex. Medical practitioners calling multiple chemical sensitivity a "cult" or denying existence of fibromyalgia. ⁃ Contested illnesses are illnesses that you must fight to get. ⁃ This explains the 1) rise of support groups and 2) the importance of online connection for people on illness pilgrimage. Are "contested" illnesses simply conditions that have a lot of uncertainty? No. Why? Conditions that are NOT contested have plenty of uncertainty. ⁃ Ex. Difficult to diagnose = asthma, osteoarthritis, rheumatoid arthritis ⁃ Ex. Uncertain causal mechanisms = lupus, multiple sclerosis, scoliosis, allergies ⁃ Ex. Low response to treatment = Alzheimer's, pancreatic cancer ⁃ All of these conditions are uncertain... but none are discredited.

US Sociology

Basic argument of this section: ⁃ The history of theorizing in the U.S. has diminished the ability to think structurally in medical sociology. European founders often ignored medicine. ⁃ Why? Medicine not thought to influence social structures or behavior like religion, politics, law, economics, and other fundamental institutions. Rise of U.S. Sociology ⁃ In 1893 = first sociology department at University of Chicago ⁃ By 1901 = 169 institutions of higher learning offered sociology courses ⁃ Around 1901 = division between "pure sociology" (sociological analysis) and "applied sociology" (social problems) ⁃ American sociology focused on empirical research and analysis of contemporary social life (unlike German sociology, which focused on historical and philosophical speculation). Theories in U.S. Medical Sociology Structural functionalism = early but short-lived influence of macro theorizing ⁃ Ex. Talcott Parsons's sick role in 1951 Symbolic Interactionism = individual, agentic, micro approach ⁃ Ex. Becker and Strauss's "Boys in White" documented physician training in 1961 ⁃ Ex. Becker's labeling theory (i.e., deviant behavior results from being defined as deviant by others) applied to mental patients Symbolic Interactionism declined in 1980s because it could not explain the... 1) causes of deviance (other than reactions of other people). ⁃ Ex. Labeling theory ignored how people shared characteristics relevant to their deviance (e.g., poverty, stress, social backgrounds) 2) relationships between institutions and societal-level processes that influence each other (and not just individuals). ⁃ Ex. Mead's "generalized other" showed how groups influence the individual but not how individuals influence the generalized other or how generalized others influence each other. Postmodern theory never gained a foothold in medical sociology. ⁃ Why? It's tools of deconstruction provide little assistance in accounting for the structure and character of society after the transition from modernity to postmodernity.

Conflict Theory

Basics of Conflict Theory ⁃ All societies have inequality, which causes conflict that produces social change. ⁃ Norms and values are NOT the glue that produces consensus in society (as in structural functionalism) but are imposed on lower classes by dominant groups. ⁃ Social processes = struggles over limited resources (which drives change in society). ⁃ Ex. Friedrich Engels = work on health disparities among English working class

Recap of 7 Theories of Cause of Illness

Biomed Model Key factor = RISK FACTORS. • Social conditions —> risk factors —> disease • Examples of risk factors = diet, smoking, exercise, pollution, preventive health behaviors • Fix disease by eliminating risk factors (i.e., proximal, behavioral, biomedical). • If you're climbing a ladder and fall off, your health is determined by the fall itself Absolute Deprivation (3 Theories) Key factors = AMOUNT of deprivation. 1) Link/Phelan = Fundamental Cause Approach ⁃ SES —> lack of flexible resources —> disease ⁃ To qualify as fundamental cause, social condition must influence multiple diseases, affect them through multiple pathways of risk, be reproduced over time, and involve access to flexible resources. ⁃ Key factor = absolute amount of SES (need enough to gain flexible resources) ⁃ Ladder represents SES. Health is determined by climbing to a height that allows one to reach flexible resources. 2) Gottfredson = Intelligence Approach ⁃ Intelligence —> both SES and health behaviors (and therefore health outcomes) ⁃ Key factor = absolute amount of intelligence ⁃ If true, this means that the relationship between SES and disease in the fundamental cause approach is spurious. ⁃ Ladder represents both SES and health behaviors. Both health and SES are determined by climbing to the height of set intelligence. 3) Heckman = Noncognitive Approach ⁃ Noncognitive traits (e.g., conscientiousness, perseverance, time horizon) —> both SES and health behaviors (and therefore health outcomes) ⁃ Key factor = absolute amount of noncognitive factors. ⁃ NOTE: Just like Gottfredson except you trade noncognitive traits for cognitive ones. ⁃ Ladder represents both SES and health behaviors. Both health and SES are determined by climbing to the height of noncognitive traits. Relative Deprivation (3 theories) Key factor = COMPARISON of deprivation. 1) Marmot = Whitehall Approach ⁃ Lower occupational status (compared to others) —> stress (e.g., lack of autonomy) —> disease ⁃ Stress of lower placement in social hierarchy is the source of the SES-health association. ⁃ Ladder represents occupational status. Health is determined by position in relation to other people climbing the ladder. 2) Black = Materialist Approach ⁃ Lower income (compared to others) —> stressors (e.g., diet, housing, work danger) —> disease ⁃ Finding = health differences emerge from the specific cause of income differences. Why? Income differences determine diet, housing quality, pollutant exposure, dangerous work... and eventually health outcomes. ⁃ NOTE: Very similar to Whitehall approach, except focus is on income rather than occupational status. ⁃ Ladder represents income. Health is determined by position in relation to other people climbing the ladder. 3) Wilkinson = Post-Marxist approach ⁃ Increasing inequality (distance between top and bottom) —> stress —> disease ⁃ Transition to high living standards improves health of population. ⁃ However, high levels of within-nation inequality reduce health outcomes that have a social gradient for all citizens. ⁃ Ladder represents income. Your health is determined by the overall length of the ladder and by your position on it.

Biomedical Model

Biomedical model = every disease has a specific pathogenic origin whose treatment can best be accomplished by removing or controlling its cause using medical procedures. ⁃ Main pathogenic origins = germ, virus, cancer, or genetic pattern ⁃ Main medical procedures = pharmaceuticals, surgery Overwhelming in the Western World ⁃ By 1960s = near eradication of polio, smallpox. ⁃ How? Through drugs (e.g., microbiology, biochemistry) and by improving living conditions (e.g., diet, housing, public sanitation).

Bryan Turner

Bryan Turner (1945-) ⁃ "Body and Society" published in 1984. ⁃ Focus on social control of the body by the wider society (e.g., state, religion, family). ⁃ Seminal work on sociology of the body, a subspecialty in medical sociology with an agentic slant. ⁃ Strong reaction against Foucault.

SES as a Social Condition

Class influences multiple diseases in multiple ways over multiple centuries. ⁃ Multiple studies have linked lower SES with worse health outcomes. ⁃ Example = the poor were more heavily affected by bubonic plague in 14th century Europe. When fundamental cause theory is reduced to its most basic proposition, it is the idea that resources consisting of money, knowledge, power, prestige, and social connections are vital to maintaining a health advantage.... Conversely, an absence or shortage of these resources causes poor health outcomes and earlier deaths." (Link and Phelan)

Social Constructionism

Core theoretical approach in British medical sociology = social constructionism ⁃ Cockerham: "Social constructionism maintains that scientific knowledge and biological discourses about the body, health, and illness are produced by subjective, historically determined human interests and are subject to change and reinterpretation." ⁃ Ex. Bryan Turner = things are not discovered but are socially produced An illness, for example, is socially constructed in that the expression of symptoms is shaped by cultural norms and values, experienced through interaction with other people, and influenced by particular beliefs and definitions of health and illness.... A diagnosis represents the transformation of physiological symptoms into socially appropriate behavior for the person who has been diagnosed and carries with it a changed social status."

Critiques of Structural Functionalism

Critics of Structuralism ⁃ 1960s = critics begin to point out flaws in structural theories. ⁃ Methodological individualists = structuralism is inexact about how social change occurs (e.g., why do individuals choose to facilitate the process of social change?). ⁃ Conflict theorists = structuralism justifies maintenance of status quo (e.g., 1960s civil rights, women's movement, anti-war). ⁃ Symbolic interactionists = structuralism diminishes individual agency and micro-level social processes.

Contested Illness

Defining Contested Illness ⁃ Barker: "Contested illnesses are conditions in which sufferers and their advocates struggle to have medically unexplainable symptoms recognized in orthodox biomedical terms, despite resistance from medical researchers, practitioners, and institutions." Trend = number of contested illnesses is increasing. ⁃ In U.S. tens of millions each year are diagnosed with syndromes characterized by clusters of diffuse symptoms. ⁃ Ex. chronic fatigue, fibromyalgia, irritable bowel, multiple chemical sensitivity ⁃ Particularly common among women (who have higher rates of morbidity). Diagnosing Contested Illness ⁃ In general, both practitioners and patients desire a diagnosis. Legitimizes relationship Diagnosing Contested Illness cont. ⁃ But no contested illnesses are associated with a specific organic abnormality. ⁃ How so? Not detectable with any known diagnostic test (e.g., x-rays, blood tests, CAT scans). Contested illnesses are diagnosed... 1) through clinical observation and patients' subjective reports of symptoms. 2) by exclusion (when other possible explanations are ruled out).

Social Network Theory

Defining Social Networks ⁃ Component = subgroup of directly or indirectly connected actors ⁃ Clique = subgroup in which every actor is directly connected ⁃ Centrality = measure of network prominence or influence (e.g., number of direct ties) Types of health-related ties: ⁃ Direct personal interaction (e.g., sex, smoking, drinking, dining, exercise) ⁃ Transfer of material goods or information (e.g., discussions of important matters) ⁃ Role-based ties (e.g., kin relationships, friendships) The relationship between networks and health is reciprocal. ⁃ Social networks shape health behaviors and outcomes. ⁃ Health contributes to the formation, maintenance, and dissolution of networks Networks can influence health through the... 1) strength of connection or isolation from other people. 2) position within one's overall network. 3) quality of one's network (e.g., cohesion, distance, reachability, density). 4) flow of helpful and harmful substances through one's network.

Demedicalization

Demedicalization ⁃ Medicalization is a bidirectional process. ⁃ Demedicalization = condition has lessening of medical oversight and regulation. ⁃ Ex. homosexuality, masturbation, natural childbirth movement

Structural Functionalism

Dominant theoretical approach in 1950s-1960s when medical sociology is established as an academic specialty. ⁃ Structuralist theories (e.g., Durkheim, Parsons, LeviStrauss, Braudel, Saussure, Barthes) minimize (or deny) individuals' roles in social processes. Talcott Parsons builds his structural functionalist approach on Durkheim. ⁃ Sick Role = Parsons's main contribution to medical sociology in 1951. ⁃ Specified normative behavior of ill people and their family members, peers, and caregivers. ⁃ Ex. People in the sick role have social imperative to try to get well.

SNT - Food Consumption

Eating has historically been an important social activity. ⁃ Companion = Latin: with bread ⁃ Meal sharing has been used to define ties. ⁃ Only recently have humans eaten alone so often. The example of vegetarianism: ⁃ Vegetarian diet may be protective of health. ⁃ However, network mechanisms may also be at work: 1) Social Context: Vegetarians place high value on having other vegetarians in their networks. 2) Social Class: Vegetarians tend to be middle class, allowing for discretionary food preferences. 3) Social Location: Vegetarians tend to live in metropolitan areas, providing food options. Isolation and health: ⁃ Individual isolation = associated with elevated hunger and risk of being overweight in general population. ⁃ Individual isolation = associated with insufficient food intake among elderly. ⁃ Lack of collective efficacy within neighborhoods = associated with obesity risk Food selection: ⁃ Different aspects of food selection (e.g., snacks, calories, fats) are influenced by different networks. ⁃ Ex. Friends are important for adolescents' caloric intake and snack sharing. ⁃ BUT households are more important for deterring adolescents' consumption of fats. Body weight changes: ⁃ Social influences may cause changes in body weight. ⁃ BUT changes in body weight may also influence participation in social networks. ⁃ Lovasi, Adams, and Bearman: "An individual who is both isolated and overweight may have gained weight in response to isolation, become isolated because of weight status, or had a combination of these two reinforcing processes. Likewise, friends who have similar weight status may have influenced each other to become more similar, chosen to be friends because of their similarity, or both." Body weight mechanisms ⁃ Lovasi, Adams, and Bearman: "This suggests that changes in body size within one's social network may act through changing body-size norms and subsequent attention (or inattention) to dietary or physical activity choices." ⁃ Model = body size changes —> body size norms —> diet and exercise choices

Pitfalls of SNT

Endogeneity ⁃ Endogeneity = explaining an outcome by describing a factor that is not sufficiently separate from that outcome. ⁃ Ex. Explaining individuals' weight loss by reference to weight loss in his/her social network. ⁃ There may actually be some outside factor influencing all of the weight loss that occurs within the network. Bidirectionality ⁃ Lovasi, Adams, and Bearman: "Social ties form and dissolve in ways that respond to health or health behaviors, even as the ties themselves influence health."

Chronic Illness

Epidemiological shift = major threat to health changed from infectious disease to chronic illness. ⁃ Chronic illness = long-term and incurable (e.g., cancer, heart disease, stroke) ⁃ This shifted medical attention from battling specific pathogens to treating the "whole person." Rise of chronic illness —> recognition of causal role of social factors Social factors directly effect... 1) the EXPERIENCE of illness (e.g., helping or hindering adaptation, alleviating or exacerbating symptoms, making remedies more or less accessible, providing therapeutic or detrimental environments, causing good or poor health care options to be available). 2) the social PATTERNING of population health and disease (e.g., creating social hierarchies in which social gradients of health and longevity arise). 3) the CAUSATION of health and disease (which will be explained throughout this course).

Triad examples

Ex. Cholera seems like a biomedical slam dunk! ⁃ What causes cholera? Biomedical model says the cause is Vibrio cholerae bacteria. ⁃ What causes people to get the Vibrio cholerae bacteria? Poor sanitation. ⁃ What causes poor sanitation? Poverty and lack of infrastructure. ⁃ Model = poverty (macro environment) —> lack of sanitation (micro environment) —> bacteria (agent) —> cholera (in host) How about other diseases? ⁃ Most individuals (of all races) die from heart disease, cancer, and cerebrovascular diseases. ⁃ But African Americans have higher death rates from these diseases than do whites. ⁃ These differences in rates cannot be explained by biology alone. ⁃ In many cases the decisive factors are social.

Obstacles to Structural Thinking

Ex. Peggy Thoits: "Despite attributions of the origins of stress to large-scale social structures or processes, few investigators have attempted to examine the links between macro-level factors and micro-level experiences, preferring to assess, for example, status variations in role strains, powerlessness, or lack of control at the individual level only." Public health studies followed a similar approach, producing prevention programs aimed at motivating people to abandon or minimize risk behaviors. Until Link and Phelan in 1995, the idea that social structural factors were causal was ignored. 1) Assault on structural functionalism by microsociological revolution in 1960s (mainly by symbolic interactionists). 2) Assault on Marxism fueled by intellectual and political dissatisfaction with it. 3) Shift in understanding of culture away from social structural influences toward psychological emphasis on how culture influences personal identity.

Contested Illness Behavior

Experience of Contested Illness ⁃ Barker: "Living with a contested illness, therefore, meansmanaging a constellation of chronic and often debilitating symptoms, as well as coping with medical uncertainty, skepticism, and disparagement. Indeed these conditions are called 'contested' illnesses precisely because of the clash between medical knowledge and patient experience." ⁃ Researchers and practitioners often FRAME contested illnesses as illegitimate, difficult, psychosomatic, or nonexistent. ⁃ Thus it is often sufferers—not medical personnel—who demand medicalization. Pattern of Contested Illness Behavior ⁃ Person suffers unpleasant symptoms (e.g., pain and fatigue = most common symptoms among general public). ⁃ Person turns to medical institution for explanation and remedy. ⁃ Extensive and expensive tests do not locate biomedical etiology. ⁃ Person is told "nothing is wrong" by each new medical practitioner. > ⁃ Person attempts to reconcile subjective experience with lack of objective medical evidence. ⁃ Person goes on a "pilgrimage" through series of medical practitioners, searching for insight. ⁃ Person's credibility is called into question. ⁃ Sometimes... person receives diagnosis, which brings coherence to symptoms and validates the suffering. ⁃ Only after a diagnosis can the person receive health care, disability compensation, etc.

Durkheim Suicide

Four types of suicide = anomic, egoistic, altruistic, fatalistic. Suicide rates in 19th century Western Europe result from social facts (e.g., religious background). Ex. Protestant areas have higher suicide rates than Catholic areas due to lower social integration among Protestants. Cockerham: "Much of the attractiveness of Durkheim's work for sociologists is that it maintains society exists external to the individual to constitute a reality of its own having a strong capacity to influence individual social behavior.

Link and Phelan

Fundamental Cause Theory Seminal work on role of social conditions in disease causation. Social Conditions ⁃ Social conditions = factors that involve relationships with other people ⁃ Social conditions can range from personal (e.g., intimacy) to structural (e.g., economics). Examples = class, race, gender, stressful life events, social support quality, sense of control over one's life, etc. ⁃ Thesis = social conditions are FUNDAMENTAL causes of disease. ⁃ Application = broad-based social interventions may produce more substantial health benefits than individually-based interventions. To qualify as a fundamental cause, a social condition must... ⁃ Influence multiple diseases. ⁃ Affect these diseases through multiple pathways of risk. ⁃ Be reproduced over time. ⁃ Involve access to resources that can be used to avoid risks or minimize consequences of disease if it occurs.

Fund. Cause Theory Predictions

Fundamental Cause Theory does NOT predict that... 1) associations between fundamental causes and health outcomes will always be of the same magnitude. 2) it is impossible to influence the relationship between fundamental causes and health outcomes. Fundamental Cause Theory DOES predict that the relationship between social factors and health disparities will weaken when... 1) Social factors are improved. ⁃ Ex. Ending racial segregation in U.S. reduced resource disparities, which reduced health disparities. 2) Universal interventions (which do NOT rely on flexible resources) are provided. ⁃ Ex. Installing airbags rather than relying on seat belt usage. ⁃ Other examples include outlawing lead paint, offering school vaccinations, requiring window guards in high-rises, inspecting meat, fluoridating water, etc. 3) Interventions are aimed at helping people adopt new knowledge and technology. ⁃ It's one thing to make a medical breakthrough. It's another to provide info about that breakthrough. It's even another thing to aim interventions at helping people receive and apply the information about the breakthrough.

Four Components of Fund. Cause Theory

Fundamental Cause Theory has four critical components: 1) A fundamental cause is related to multiple disease outcomes. 2) Fundamental causes operate through multiple risk-factor mechanisms. 3)3) Link/Phelan: "New intervening mechanisms reproduce the association between fundamental causes and health over time." 4) Link/Phelan: "The essential feature of fundamental social causes is that they involve access to resources that can be used to avoid risks or to minimize consequences of ease once it occurs."

Mediation of Stress

Health effects of stress can be mediated, confounded, or modified by... 1) Individual factors (e.g., individual's perception of stress, personal characteristics, such as sense of humor). 2) Social factors (esp. social isolation and social support). 3) Environmental factors (e.g., low SES, poor neighborhood quality, high residential segregation, environmental toxins, such as lead, air pollution). 4) Genetic factors (e.g., genetic susceptibility that is triggered by environment).

Diabetes Triad

Host = genetically predisposed individuals ⁃ Agent = negative health lifestyle ⁃ Environment = socially and economically disadvantaged neighborhoods ⁃ NOTE: The agent in this model is not a pathogen or gene.

Smoking

How do people decide to start smoking? ⁃ Almost all smoking behavior begins SOCIALLY (in groups). ⁃ Rarely does anyone take up smoking alone. ⁃ Rather smoking typically originates in adolescent peer groups, in which teens emulate adults or older teens. ⁃ Smoking itself is used to promote social relationships, reinforce personal bonds, and express group affiliation. The process of quitting smoking is similarly social in origin. ⁃ Most people who quit are connected in strong and weak social networks of people who have decided to quit at around the same time. ⁃ Those who quit often run out of people with whom to smoke. ⁃ Those who don't quit are often marginalized from networks where quitting is occurring.

Response to alt Theories

In response to alternative theories, fundamental cause theory predicts that... 1) SES association will be stronger for diseases that we have substantial capacity to prevent or cure than for diseases we know little about. ⁃ Empirical evidence suggests that SES-mortality association is stronger for preventable as opposed to less-preventable causes of death. In response to alternative theories, fundamental cause theory predicts that... 2) Introducing new medical knowledge and technology will widen the gap in health disparities between people at the top and bottom. ⁃ Health inequalities emerged for diseases where medical progress was made (e.g., heart disease, lung cancer, colon cancer) but not for diseases where must less progress was made (e.g., brain, ovarian, pancreatic cancer). 3) Intelligence is a flexible resource rather than a cause of both SES attainment and health outcomes. ⁃ Gottfredsson = intelligence —> BOTH socioeconomic status AND health outcome ⁃ Link/Phelan = social factors —> flexible resources (including intelligence!) —> health outcomes ⁃ Link/Phelan: "The analysis found little evidence of a direct effect of intelligence on health once adult education and income are held constant. In contrast, the significant effects of education and income on health change very little when intelligence is controlled." 4) Noncognitive traits alone do not explain health outcomes. ⁃ Link/Phelan: "While the evidence concerning the role of non cognitive traits in socioeconomic attainment is arguably strong, the evidence linking them to health, particularly with adequate consideration of socioeconomic status, is both thin and weak."

Criticism of Social constructionism

Lacks uniformity. ⁃ Social constructionism can be more agentic (e.g., Berger and Luckmann) or structural (e.g., Foucault). ⁃ Fails to acknowledge biological reality of illness. ⁃ Rejects possibility that knowledge can be discovered. ⁃ Claims no form of knowledge is more valid than another (which is self-contradictory).

SNT - Sex

Many network studies focus on... 1) sexually transmitted infections (esp. HIV/AIDS). 2) sexual health and reproduction more generally. Thus health research played major role in development of network analysis. Topics of interest = sexual debut, frequency, and partners ⁃ Ex. debut = predicts life trajectories and behaviors (e.g., delinquency, condom use, risky practices) ⁃ Ex. partners = both number across lifetime and overlapping concurrent partnerships are important for predicting risk of STIs Partner Selection: ⁃ Lovasi, Adams, and Bearman: "Social networks play an important role in shaping the nature, timing, and extent of individuals' sexual behavior, along with the patterning of those relationships among potential partners. Peer groups frequently exhibit similarity or homophily across a range of sexual behavior patterns, such that friends and other closely connected peers are alike in timing of their sexual debuts... the number of lifetime sexual partners they accumulate... and the types of behavior they engage in within those partnerships." Partner Selection: ⁃ Network research routinely finds that local networks having high probability of social closure (e.g., a friend of a friend is a friend). ⁃ However, local closure is almost always forbidden in romantic relationships (e.g., teens avoid partnering with former partners' current partners' former partners). STIs The structure of sexual networks can... 1) describe epidemic risk for entire populations. 2) help estimate individual risk based on network position. 3) help make recommendations for preventing spread of STIs (often by targeting individuals with multiple partners). STIs Two drawbacks to network analysis. 1) Simple network summaries (e.g., number of partners) can overestimate a population's epidemic potential. 2) Simulations show that reducing the number of high-risk actors can actually increase population-level risk under. Why? Under some conditions it might be more effective to target the entire population.

Upward Conflation

Margaret Archer warns of "upward conflation." ⁃ Obviously... this is the opposite of "downward conflation." ⁃ Cockerham: Upward conflation describes "behavioral models in which individuals monopolize causal power that operates in a oneway, upward direction and seems incapable of acting back to influence individuals."

Downward Conflation

Margaret Archer's term for theories that portray society "unilaterally molds individuals to act in particular ways and has a complete monopoly over causation."

American Med Soc

Medical sociology influenced more by medicine than by sociology. 19th Century ⁃ First use of term "medical sociology" was by Charles McIntire in 1894. ⁃ Defined it as "the science of the social phenomena of the physicians themselves as a class apart and separate; and the science which investigates the laws regulating the relations between the medical profession and human society as a whole;... and indeed everything related to the subject." 20th Century 1920s ⁃ First work from sociological perspective = Bernard Stern's "Social Factors in Medical Progress" in 1927. 1930s ⁃ Most important early work = Lawrence Henderson's paper on physicians and patients in the social system in 1935. ⁃ Why important? Influenced Henderson's Harvard student named Talcott Parsons. 1940s ⁃ Federal agencies and private foundations begin to fund joint research by physicians and sociologists. ⁃ Due to this funding, research in medical sociology begins to take off. 1950s ⁃ Talcott Parsons publishes "The Social System" in 1951, which discusses the sick role. 1960s-1970s ⁃ Symbolic interactionism = biggest theoretical influence in 1960s-1970s

Medicalization and Gender

Medicalization and Gender ⁃ Modernity = medicalization of natural reproduction ⁃ Ex. More medical oversight of pregnancy, childbirth, menstruation, menopause. ⁃ Women have often contributed to this medicalization (perhaps as way to address needs and access resources).

Medicalization Cont.

Medicalization in the 20th century shaped mainly by... 1) decline in professional power of physicians. 2) rise in power of biotechnology (e.g., pharmaceuticals and genetics) and corporate health industry (e.g., managed care organizations). ⁃ Barker: "The availability of a drug or other biotech treatment for a complaint significantly increases the likelihood that the complaint will be medicalized." ⁃ NOTE: The expansion of power granted to biotech and corporate health industry results mainly from consumer demand by patients in the market. Three Problematic Results 1) ACCURACY = Barker: "By defining disease as a biological disruption residing with an individual human body, medicalization obscures the social forces that influence our health and well-being." 2) ACTION = Barker: "Medicalization is depoliticizing: it calls for medical interventions (medication, surgery, etc.) when the best remedy for certain types of human suffering may be political, economic, or social change." 3) AUTHORITY = Barker: "Medicalization can also grant the institutions of medicine undue authority over our bodies, minds, and lives, thereby limiting individual autonomy and functioning as a form of social control."

HIV/AIDS

Mid 1980s = beginning of epidemic ⁃ Disease most characteristic of white gay men. ⁃ But these men were more affluent and educated— and therefore more likely to adopt safer sex practices. 1990s = dramatic shift ⁃ After 1995, magnitude of epidemic began to decline. ⁃ Disease shifted to non-Hispanic blacks and Hispanics.

Incorporating Biomarkers

Most data sets with SES variables do NOT include biomarkers. ⁃ Authors list 9 longitudinal studies that do. ⁃ Some started collecting biomarkers at beginning; some added them later. ⁃ Most collect biomarkers from adults; but more are collecting from children and adolescents. Four factors that determine type and frequency of biomarker collection: 1) Burden and invasiveness to participants ⁃ Ex. Hormone biomarkers require multiple collections as levels fluctuate over course of the day 2) Logistical feasibility ⁃ Ex. Sampling, processing, shipping, storage, analysis 3) Costs ⁃ Ex. Survey admin must determine if biomarker collection outweighs extra expenditure. 4) Ethical considerations ⁃ Ex. Medical sociologists often interested in disadvantaged populations—which are more likely to feel pressured to consent to biomarker collection. Argument for Biomarker Inclusion ⁃ Shih, Fernandes, and Bird: "Medical sociology research involving biomarkers may have a greater potential to inform policy in part because it can demonstrate the impact of social disparities and actionable social factors on illness trajectories with known social and economic costs and consequences. Using biomarkers can allow sociological work to speak to a larger audience of researchers, policy makers, and clinicians."

Critiques of Conflict Theory

Not as influential on medical sociology as structural functionalism. ⁃ Another example of "downward conflation" in which individual behavior is determined from above. ⁃ Conflict may be important in some—but not all— health situations. ⁃ Conflict theory is contradictory = accuses medical profession of being BOTH expansionist (taking control over more social problems) AND exclusivist (discriminating against the poor). Critics of Conflict Theory cont. ⁃ Marxism, which provided much underpinning for conflict theory, lost influence from 1970s onward. ⁃ Actually existing Marxist states failed to provide health social conditions and adequate health care delivery. ⁃ Ex. Lacked administrative flexibility needed to shift from treating infectious to chronic illness.

Durkheim

Origin of theoretical support for causal role of social factors in health outcomes. ⁃ Social facts = structures that are external to and constraining of individuals ⁃ Ex. Norms and values are external to individuals and can constrain their behavior. Structures are sui generis (Latin = of its own kind). ⁃ Cockerham: "According to Durkheim, societal reality emanates from macro-level social structures constituting a system of interrelated parts functioning together to produce stability, order, and integration." Functionalism Functional systems produce social order. ⁃ When dysfunctional processes—such as crime or illness—produce instability, restorative or punitive institutions—such as criminal justice or health care— emerge to restore balance. Durkheim's main contribution to medical sociology = work on suicide.

Risk Factor Approach

Portrays a chain of causality: social conditions —> risk factors —> disease ⁃ Examples of risk factors = diet, smoking, exercise, pollution, preventive health behaviors ⁃ Fix disease by eliminating risk factors (i.e., proximal, behavioral, biomedical). Evaluation of risk factor approach Success = has had positive effect on population health Shortfall #1 = downplays social conditions, which shape capacity to modify or eliminate risk factors Shortfall #2 = identification of risk factors can actually increase health disparities (because medical interventions are not distributed equally in the population). ⁃ Interventions are available and utilized by groups less likely to experience discrimination and have greater access to knowledge, money, power, prestige, and beneficial social connections. Imagine model = SES —> risk factors —> mortality ⁃ If we eliminate risk factors, we would expect SES-mortality connection to disappear. ⁃ However, SES disparities in mortality have persisted in several important instances even after eliminating major proximal risk factors. As old risk factors are eliminated or contained, new risk factors emerge. FUNDAMENTAL CAUSE THEORY CAME AS A RESPONSE TO RISK FACTOR APPROACH

Biomarkers

Problems with the current state of research: 1) Most health outcomes are limited to a) psychological conditions, b) self-rated health, c) or mortality. ⁃ Ex. of self-rated health = symptoms, functioning, clinical records 2) Lack of biological measures to identify physiological mechanism. ⁃ Therefore physiological pathways are simply inferred. What are biomarkers? ⁃ Shih, Fernandes, and Bird: "Biological measures of physiologic function do exist and are increasingly used in medical, clinical, and immunology fields as screening tools for diagnosis and as markers for disease severity.... Known more simply as biomarkers, these biological measures assess the byproducts of the body's responses to physiological processes that lead to identifiable health outcomes." What are some examples of biomarkers? ⁃ Common biospecimen sources = blood, saliva, urine ⁃ Common biomarkers = hormones, enzymes, genes

Recap of Contested Illness

Recap of Argument Barker: "It is worth restating what it means to call contested illnesses socially constructed. As they currently exist, these diagnoses are best understood as intellectual categories whose social etiological [sic] is more clearly understood than is their biomedical etiology. The diagnostic criteria for these illnesses are descriptive, subjectively determined, and inexactly and inconsistently applied.... Calling these syndromes socially constructed, however, does not deny the reality of their symptoms. It is clear that the suffering of those so diagnosed is real: their quality of life is significantly eroded and they would do almost anything to be well."

Structural Effects

Recognizing the effects of social conditions has been difficult because they are hard to isolate methodologically. Qualitative studies (e.g., participant observation) face shortcomings in determining effects of structures on people. Quantitative studies require the construction of independent variables having collective properties. Example = difficult to measure influence of "class" because the usual socioeconomic variables of income, education, and occupational prestige can be depicted as individual characteristics. ⁃ Possible solution = measure class as feature of family or household (with highest level of labor market participation in household as master social status of entire household). ⁃ Possible solution = measure education with respect to prestige of institution attended ⁃ Possible solution = measure living conditions by average value of homes in a census tract Statistical Methods ⁃ Hierarchical linear models (HLM) test the strength of interaction between variables describing individuals at one level, structural entities (e.g., households) at the next level, and sequentially higher levels (e.g., neighborhoods, communities, social classes, nations). STILL DONT ABANDON MICRO TECHNIQUES

Cardiovascular Health

Research has begun to identify link between stressors and cardiovascular health. ⁃ Basic model: psychosocial stressors —> increased activity of sympathetic nervous system —> cardiovascular disease ⁃ Ex. Neighborhood-level indicators of SES and stress linked to inflammatory markers relevant to cardiovascular disease. ⁃ Other stressors linked to heart disease = high violent crime rates, calls to city agencies about street problems, large-scale social instability (e.g., Russian life expectancy dropped sharply in four-year period after collapse of communism).

Response to social constructionism critiques

Responses to Critiques 1) Phenomena can be both biophysically "real" and socially constructed. 2) To say that ILLNESS is socially constructed usually means that the EXPERIENCE of illness is shaped by its social and cultural context. ⁃ Ex. Experience of cancer, epilepsy, and anxiety differs greatly over time, place, and culture. 3) To say that medical KNOWLEDGE is socially constructed means that it is framed within the dominant mindset (currently = biomedical model).

British Sociology

Sociology in general was resisted by Oxford and Cambridge. ⁃ Why? Political philosophy was deeply engrained in classical education of 19th century. ⁃ So new style of thinking sociologically was not immediately embraced.

Stress

Stressors = factors that stimulate psychological and physiological stress response ⁃ Ex. Racial discrimination, caring for ill family member ⁃ Factors that protect against stressors include high SES, positive social support, variation in perception of stressor. ⁃ Stressors and stress responses can be acute or chronic. Allostasis = response to stress ⁃ Shih, Fernandes, and Bird: "Allostasis... refers to the ability of the body to activate neuronal, endocrine, and immune processes in response to external stress. While allostatic responses are an evolutionary survival mechanism, they can become less efficient with repeated exposures to a stressor. Allostatic load = impact of stress ⁃ Shih, Fernandes, and Bird: "The cumulative biological burden or wear and tear resulting from inefficient allostatic responses is referred to as allostatic load... and can have consequential impacts on physiology and health." Stress is especially salient during young and old ages. ⁃ Ex. Childhood stress = strong predictor of adult health outcomes (e.g., coronary heart disease).

British Agency

Strong agency-orientation (even more than in U.S.). Top two British theorists emphasize agency. ⁃ Ex. Anthony Giddens's structuration theory was designed to solve agency-structure conundrum (but ends up prioritizing agency). ⁃ Ex. Margaret Archer's critical realism, which focuses on the ability of the individual to withstand or strategically minimize the effects of structure. ⁃ Neither theory has been specifically influential in medical sociology, but both are examples of strong agency orientation among the Brits. Core topics in current British medical sociology: ⁃ Sociology of the body ⁃ Subjective experience of illness ⁃ Gender, race, and class health inequalities ⁃ Emotions ⁃ Provision of formal and informal health care ⁃ Healthy policy and politics ⁃ Pharmaceuticals ⁃ Health risks ⁃ Internet medicine

Symbolic Interactionism

Symbolic Interactionism ⁃ Flourished from 1963 to 1970. ⁃ Leading agency-oriented approach (with some influence on medical sociology). ⁃ Major figures = George Herbert Mead, Herbert Blumer Based in social psychology of group behavior. ⁃ Focus on development of individual's self concept with reference to social experience. ⁃ Individuals interacting with each other construct social reality based on shared meaning. ⁃ Both objects in the material world and people's selfconcepts must be given meaning through social interaction. Peter Berger (1929-2017) and Thomas Luckman (1927-2016) ⁃ "Social Construction of Reality" published in 1967. ⁃ Grounded in symbolic interactionism. ⁃ Agentic approach to social constructionism. Michel Foucault (1926-1984) ⁃ "History of Sexuality" published in 1979. ⁃ Influenced work on social constructionism, medicalization, and sociology of the body. ⁃ Structural approach to social constructionism (nightmare version). What is the main outcome of the dominance of Symbolic Interactionism in medical sociology? ⁃ Cockerham: "Despite its currently lessened status, symbolic interaction theory nevertheless played a prominent role in advancing an agency orientation in American medical sociology. And in doing so, it undermined the pursuit of a social causation thesis because of its success in rendering structural-functionalism impotent." NOTE: Cockerham's use of "impotent" is a medical metaphor.

Proving Causation

To prove that social factors are causal, one must show how social mechanisms at the aggregate level influence health and disease at the individual level. One solution = using traditional epidemiological triad of agent, host, and environment. ⁃ AGENT = immediate or proximal causes, which can be biological, nutritional, chemical, physical, or social. ⁃ HOST = people susceptible to the agent ⁃ ENVIRONMENT = factors external to the host (including agents) that cause or influence health problems Social factors influence all three parts of the model. ⁃ Agents can be social (as when health effects are generated by class position, occupations, neighborhoods, lifestyles). ⁃ Hosts reflect both biological traits (e.g., age, sex, immunity) and social traits (e.g., habits, customs, norms). ⁃ Environments are both physical and social (e.g., poverty, segregation, networks, relationships). NOTE: Most attention is given to LIFESTYLES as a social mechanism producing positive and negative health outcomes.

Critiques of social constructionism

Two Major Critiques: 1) It denies existence of natural world. 2) It produces a false dichotomy between the "real" (entirely biophysical) and "socially constructed" (having no biophysical basis). Examples of Critiques ⁃ Barker: "Don't some ideas about illness more accurately reflect the truth than others? Doesn't the scientific disease model better explain and treat illness than folkloric or religious approaches? Isn't death definitive proof that illness isn't simply a social construction?" ⁃ My question as a grad student: "If you really believe in social construction, would you allow me to point a gun at your head and pull the trigger?" Both/And Approach ⁃ Barker: "A disease does not exist, so to speak, until the social institution of medicine creates a representative diagnostic category.... We can claim that a disease as defined in a diagnostic category is a social construction without implying that the suffering it represents has not biological basis.... Medical sociologists and anthropologists clearly recognize the possibility that a condition can be both real and socially constructed."

Why does it matter>

Why does it matter who is correct? Our view of causes will direct our intervention efforts. ⁃ If you think risk factors are key, then you will try to eliminate proximal causes. ⁃ If you think stratification stress is key, then you will try to shrink inequality. ⁃ If you think intelligence is key, then not much can be done. ⁃ If you think noncognitive resources are key, then you will try to address deficits in them. ⁃ BUT if you think social factors are key, then you will try to increase flexible resources. Fundamental cause theory has a difficult time explaining why... 1) women live longer than men. 2) some immigrant groups have better health than native-born Americans.

Biomarkers - Why (cont.)

Why should medical sociologists care about biomarkers? ⁃ Shih, Fernandes, and Bird: "Biomarker data in the context of medical sociology can provide insight into the inner workers of the body's responses to psychosocial stressors— from depression to racial discrimination.... Such stressors have documented effects on physiologic function and may contribute to morbidity and mortality." The authors focus on biomarkers of stress. Why? ⁃ Shih, Fernandes, and Bird: "An observed change in a biomarker due to change in stressor exposure lends credence to the physiological effects of these more distal social risk factors of interest to medical sociologists."

SNT - Social Support

Why study social support in medical sociology? ⁃ Social isolation (i.e., complete absence of social support) = linked to psychological disturbance and increased mortality. ⁃ Even moderately cohesive networks promote a number of positive health outcomes Possible models of social integration ⁃ Supportive social ties —> positive health behaviors —> positive health outcomes ⁃ Supportive social ties —> stress reduction —> positive health outcomes ⁃ Supportive social ties —> direct effect on biological systems involved in repair and maintenance NOTE: These explanations are NOT mutually exclusive Social support can be helpful for managing chronic disease and surviving major health events (e.g., heart attack). ⁃ However attempts at increasing secondary prevention (e.g., second heart attack) by improving social support have not reduced mortality. ⁃ Lovasi, Adams, and Bearman: "These results raise the possibility that the beneficial effects of social support may accumulate across the life course such that new connections (or newly activated connections) late in life do not benefit otherwise isolated individuals." Social support may mediate or modify health effects of economic deprivation or inequality. Social support may sometimes backfire. ⁃ Lovasi, Adams, and Bearman: "Conspicuous support may increase distress by reminding stressed individuals about the source of stress, or a failure to adequately cope with the stress on their own." Social support needs more research. ⁃ Social isolation is clearly linked to worse health outcomes. ⁃ However, it's unclear which types of social connection are most beneficial for health.

Network Interventions

health can involve... 1) altering the network structure. ⁃ Ex. Promoting network activation and social integration. ⁃ Ex. Building coalitions with common interest in health promotion. 2) using network leverage points strategically. ⁃ Ex. Locating high-risk individuals by using contact tracing and quarantine to disrupt spread of infection, which is a classic epidemiological strategy. ⁃ Ex. Targeting influential individuals to distribute health information (e.g., diet, smoking, STIs).

Social gradient

lower-status persons have significantly greater risk of becoming arthritic.

Richard Wilkinson

post-Marxist approach ⁃ Transition to high living standards improves health of population. ⁃ However, high levels of within-nation inequality reduce health outcomes that have a social gradient for all citizens. ⁃ Critics claim that Wilkinson's research has not been replicated and is flawed

Social factors

stress, poverty, low SES, unhealthy lifestyles, unpleasant living and work conditions, etc. influence the health and illness of individuals, groups, and communities. BUT social factors are usually thought to be distant or secondary influence on health and illness. Why? Because social factors (e.g., living conditions, lifestyles, norms, values, attitudes) are neither pathogens (e.g., germs, viruses) nor physical conditions (e.g., cancer cells, clogged arteries). BUT physical factors such as viruses and cancer cannot cause illness when they are quarantined (e.g., in a lab). • That is to say that physical factors are not causes in an of themselves. • To be CAUSAL, such material factors must be introduced to human bodies. Social factors can initiate the onset of the pathology and in this way serve as a direct cause for a number of diseases. ex. Smoking - Cockerham: "There is a social pattern to smoking that indicates tobacco use is not a random, individual decision completely independent of social structural influences." ⁃ Smoking has a social gradient, meaning that the behavior is rarer among upper classes and concentrated among lower classes. Even illnesses thought to be exclusively biological (e.g., rheumatoid arthritis) are grounded in SES.

Bordieu

⁃ Only recently attracting attention in medical sociology. ⁃ "Distinction" published in 1984. ⁃ Concepts of lifestyles, habitus, and field have been applied to health behaviors and health care delivery.

Counterarguments to Fundamental Cause Theory

⁃ Possible counterargument = biomedical model accounts for the advancements in disease containment in the modern world. ⁃ Example = polio vaccine in 1950s quickly leveled disparities between the upper and lower classes because it was administered universally. ⁃ BUT the introduction of statins has not leveled disparities in heart disease between the classes. ⁃ Why? Because high income people are far more likely to use them. Only recently have low-cost, generic statins come to the market. Mechanisms ⁃ The counterargument may be made that class or SES cannot be a causal factor because it is too difficult to identify a specific causal mechanism. ⁃ This assumes that a single causal mechanism can produce only a single outcome. ⁃ BUT Link and Phelan argue that social conditions are FUNDAMENTAL causes because they cause morbidity and mortality in multiple (not singular) ways.

Diabetes and Race

⁃ Rates of diabetes are rising in the U.S., and race is a key factor in this development. ⁃ How so? African Americans and Hispanics are twice as likely to become diabetic. ⁃ Race is salient because African Americans and Hispanics are overrepresented among lowerincome groups. ⁃ Low income is associated with diabetes risk factors: high sugar and high fat diet, little or no exercise, and inadequate medical care.

Materialist Explanation

⁃ Seen as alternative to social causes approach. ⁃ Evolved from 1980 Black Report on class disparities in health. Finding = health differences emerge from the specific cause of income differences. ⁃ Why? Income differences determine diet, housing quality, pollutant exposure, dangerous work... and eventually health outcomes. ⁃ Similar to social causes approach, but specifically focused on income.

HIV and Race

⁃ Why should blacks have higher rates? ⁃ SES alone is NOT the answer because Hispanics and poor whites have lower rates than do blacks. ⁃ Intra-racial network effect = blacks are more segregated than other racial groups High number of sexual contacts between infected black CORE and a PERIPHERY of uninfected black sexual partners act to contain infection within the black community. ⁃ Even if a single African American from the periphery has only one sexual partner, the probability that the partner is from the core is 5 times higher than it is for peripheral whites and 4 times higher than for peripheral Hispanics.