“Fundamental Causes” of Social Inequalities in Mortality: A Test of the Theory∗

By J. Phelan, Bruce G. Link, Ana V. Diez-Roux, Ichiro Kawachi, B. Levin. Journal of Health and Social Behavior, 2004

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Medicine and epidemiology currently dominate the study of the strong association between socioeconomic status and mortality. Socioeconomic status typically is viewed as a causally irrelevant “confounding variable” or as a less critical variable marking only the beginning of a causal chain in which intervening risk factors are given prominence. Yet the association between socioeconomic status and mortality has persisted despite radical changes in the diseases and risk factors that are presumed to explain it. This suggests that the effect of socioeconomic status on mortality essentially cannot be understood by reductive explanations that focus on current mechanisms. Accordingly, Link and Phelan (1995) proposed that socioeconomic status is a “fundamental cause” of mortality disparities—that socioeconomic disparities endure despite changing mechanisms because socioeconomic status embodies an array of resources, such as money, knowledge, prestige, power, and beneficial social connections, that protect health no matter what mechanisms are relevant at any given time. We identified a situation in which resources should be less helpful in prolonging life, and derived the following prediction from the theory: For less preventable causes of death (for which we know little about prevention or treatment), socioeconomic status will be less strongly associated with mortality than for more preventable causes. We tested this hypothesis with the National Longitudinal Mortality Study, which followed Current Population Survey respondents (N = 370,930) for mortality for nine years. Our hypothesis was supported, lending support to the theory of fundamental causes and more generally to the importance of a sociological approach to the study of socio-economic disparities in mortality.

Subfields: General Health Professions, Health

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Citations in the corpus

Systemic racism and U.S. health care. (2014, background): “Phelan and Link (2004) have pioneered in a fundamental-cause-of-disease theory seeking to explain socioeconomic and racial disparities.”
Toward Some Fundamentals of Fundamental Causality: Socioeconomic Status and Health in the Routine Clinic Visit for Diabetes1 (2005, background): “Moreover, variation in the magnitude of the association within subclasses may provide important indications regarding how the fundamental relationship is preserved, as when Phelan et al. (2004) found the SES-mortality gradient to increase with the relative “preventability” of different causes of dea”
Socio-economic position and quality of life among older people in 10 European countries: results of the SHARE study (2007, background): “Some studies have shown that socio-economic differences in morbidity and mortality converge in the higher age groups (House et al. 1994; Huisman, Kunst and Mackenbach 2003; Phelan et al. 2004), while others have described a continuation of the social gradient of morbidity and mortality into old age ”
Social Conditions as Fundamental Causes of Health Inequalities: Theory, Evidence, and Policy Implications (2010, methodology): “Examples are situations in which prevailing medical recommendations are subsequently discovered to be harmful (Carpiano and Kelly 2007) and the case of old age, when the growing frailty of the body may place limits on the effectiveness of interventions (Phelan et al. 2004).”
Education, cumulative advantage, and health (2005, background): “Education acts as a root cause of good health (Mirowsky & Ross, 2003; Phelan et al., 2004).”
The persistence of health inequalities in modern welfare states: the explanation of a paradox. (2012, background): “The association between socioeconomic status and health is reproduced over time via the replacement of intervening mechanisms, and as opportunities for avoiding disease continue to expand so will health inequalities continue to exist (Link & Phelan, 1995; Phelan et al., 2004, 2010).”