The Social Causes of Health and Disease

William C. Cockerham

• Publisher: Polity
• Year: 2021
• Print ISBN: 9781509540365, 9781509540358
• eBook ISBN: 9781509540372
• Edition: 3
• Topic: Social Sciences
• Subtopic: Sociology
• Index: Social Sciences

This stimulating book has become a go-to text for understanding the role that social factors play in the experience of health and many diseases. This extensively revised and updated third edition offers the most compelling case yet that stress, poverty, unhealthy lifestyles, and unpleasant living and working conditions can all be directly associated with illness.

The book continues to build on the paradigm shift that has been emerging in twenty-first-century medical sociology, which looks beyond individual explanations for health and disease. As the field has headed toward a fundamentally different orientation, William Cockerham's work has been at the forefront of these changes, and he here marshals evidence and theory for those seeking a clear and authoritative guide to the realities of the social determinants of health. Of particular note in the latest edition is new material on the relationship between gender and health, implications of the life course for health behavior, the health effects of social capital, and the emergence of COVID-19.

This engaging introduction to social epidemiology will be indispensable reading for all students and scholars of medical sociology, especially those with the courage to confront the possibility that society really does make people sick.

1
The Social Causation of Health and Disease

The capability of social factors to make people ill seems to be widely recognized by the general public. Ask people if they think society can make them sick, and the probabilities are high they will answer in the affirmative. Stress, poverty, low socioeconomic status, unhealthy lifestyles, and unpleasant living and work conditions are among the many inherently social variables typically regarded by lay persons as causes of ill health. However, with the exception of stress, this view is not expressed in much of the research literature. Studies in public health, epidemiology, behavioral medicine, and other sciences in the health field typically minimize the relevance of social factors in their investigations. Usually social variables are characterized as distant or secondary influences on health and illness, not as direct causes (Link and Phelan 1995, 2000; Phelan and Link 2013). Being poor, for example, is held to produce greater exposure to something that will make a person sick, rather than bring on sickness itself. However, social variables have been found to be more powerful in inducing adversity or enrichment in health outcomes than formerly assumed. Society may indeed make you sick or, conversely, promote your health.

It is the intent of this book to assess the evidence indicating that this is so. It is clear that most diseases have social connections. That is, the social context can shape the risk of exposure, the susceptibility of the host, and the disease’s course and outcome – regardless of whether the disease is infectious, genetic, metabolic, malignant, or degenerative (Holtz et al. 2006). This includes major afflictions like heart disease, Type 2 diabetes, stroke, cancers like lung and cervical neoplasms, HIV/ AIDS and other sexually-transmitted infections, pulmonary diseases, kidney disease, and many other ailments. Even rheumatoid arthritis, which might at first consideration seem to be exclusively physiological, is grounded in socioeconomic status, with lower-status persons having a significantly greater risk of becoming arthritic than individuals higher up the social scale (Bengtsson et al. 2005; Pederson et al. 2006). Consequently, the basic thesis of this book is that social factors do more than influence health for large populations and the lived experience of illness for individuals; rather, such factors have a direct causal effect on physical health and illness.

How can this be? Just because most diseases have a social connection of some type does not necessarily mean that such links can actually cause a disease to occur – or does it? Social factors such as living conditions, lifestyles, stressors, norms, social values, and attitudes are obviously not pathogens like germs or viruses, nor are they cancer cells or coagulated clots of blood that clog arteries. Yet, quarantined in a laboratory, viruses, cancers, and the like do not make a person sick. They need to be exposed to a human host and assault the body’s physiological defenses in order to be causal. However, assigning causation solely to biological entities does not account for all of the relevant factors in a disease’s pathogenesis, especially in relation to the social behaviors and conditions that bind the person to the disease in the first place. Social factors can initiate the onset of the pathology and, in this way, serve as a direct cause for several diseases. Two of many examples are the coronavirus and smoking tobacco.

Coronavirus

Coronavirus (COVID-19) unleashed itself on the world in the fall of 2019 in Wuhan, China, a city of 11 million. It subsequently spread across the globe as the most widely contagious pandemic yet to come since the Spanish flu of 1918. By the summer of 2020, over 10 million people were confirmed to have been infected, more than 500,000 were thought to have died, and trade and travel were severely disrupted on a global basis. Final tallies on the disease’s deadly and varied effects are not available as the pandemic is ongoing as this book goes to press. However, it was nevertheless clear at the time that COVID-19 ranks as an event of historic proportions. Nearly every country in the world was affected, air travel and cruise ships were shut down, public gatherings cancelled, businesses and schools closed, stay-at-home orders issued, unemployment soared, and the 2020 Olympics postponed for a year.

Does the “social” have a causation role with respect to COVID-19? The answer is clearly “yes,” as seen in the stringent requirement for “social distancing” (keeping away from other people) and the likely causal trail. Early information indicated that the coronavirus originated in bats in China that likely infected an anteater-like creature known as a pangolin. The evidence comes from testing the genome sequence of the coronavirus in bats and pangolins, which was found to be almost identical with the virus’s genome in infected humans (Andersen et al. 2020; Zhou et al. 2020). If the coronavirus had stayed isolated among bats and pangolins in the wild, it would have remained a biological anomaly. But it didn’t. As a result of urbanization, globalization, and climate change in recent decades, wildlife habitats have been affected and exposed various species to greater contact with humans (Armelagos and Harper 2016; Cockerham and Cockerham 2010).

At the point pangolins became infected, the “social” began to take over as a cause of the pandemic. Pangolins are a desired food delicacy in China and sold in Wuhan’s Huanan Seafood Wholesale Market where live wild animals can be purchased for human consumption. Just as the SARS (severe acute respiratory syndrome) pandemic of 2002–3 began in China’s live wild animal “wet” markets, coronavirus apparently took a similar transmission path from bats through animals (pangolins instead of civets and raccoon dogs) to reach humans in a crowded marketplace. Lax health and safety regulations, combined with ineffective local government inspections in such markets, likely made transmission easier. Regardless of where it originated, a human became sick. The first case (the so-called patient “zero”?) was allegedly a 55-year-old Chinese man in Hubei Province where Wuhan is located. He was hospitalized in mid-November 2019 with a previously unknown pneumonia. By December 8, there were more patients.

No public alarm was sounded until December 30, 2019, when Dr. Li Wenliang, a 34-year-old ophthalmologist at Wuhan Central Hospital, began noticing some of his patients had a viral infection. He thought it was a reoccurrence of SARS and began alerting his colleagues through social media. The Wuhan police took Dr. Li into custody the first week of January 2020 for spreading a false rumor. They required him to sign a confession admitting his alleged deception before releasing him. A month later (February 7), he died from the coronavirus after catching it from a patient he was treating for glaucoma, becoming one of the real heroes of the pandemic.

A travel ban to and from Wuhan was issued on January 23, 2020, but by that time, infected Chinese had traveled to cities throughout the country and abroad. The Wuhan Municipal Health Commission informed the World Health Organization on January 31 of an epidemic caused by a new virus that was initially named the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). WHO changed the name to COVID-19 on February 12. By mid-February, the coronavirus had erupted into a full-scale epidemic, centered in Wuhan, infecting some 90,000 people and killing at least 4,600 in China while dispersing worldwide through tourism, business travel, and community spread. The Chinese government took Draconian measures to restrict people inside their homes, close whole regions of the country to travel, and mobilize medical resources to test for the virus and treat it as best they could since no cure was available. By mid-March, the situation in China improved.

Yet other countries began having severe problems, especially Iran in the Middle East and Spain and Italy in Europe. The problem in Italy, as it was in China, was a late start in isolating affected areas and restricting movement. The first known patient, a 38-year-old man in the Lombardy region in northern Italy, had not been to China and was thought to have contracted the virus from another European. He refused hospitalization and went home before returning a second time, infecting several people at the hospital and others he visited, conducting an active social life and playing on a soccer team while contagious. The spread of the disease was so quick that in the next 24 hours some 36 additional patients were admitted to the hospital, none of whom had any direct contact with the first patient. Out of some 234,000 confirmed cases in Italy in late spring 2020, more than 34,000 died. Spain had even more cases, nearly 287,000, with fewer than 30,000 deaths. Britain later moved to the top in deaths in Europe and then Russia.

The United States, with its large number of international visitors and travelers, was impacted the most. Nearly 2.5 million people were confirmed as infected by late June with over 126,000 deaths. However, the number of cases changes daily as the pandemic is ongoing and are likely to be even higher by the time this book is published. The coronavirus first appeared on the West coast in the state of Washington, and soon after that, California. The hardest-hit state was New York, with more than 30 percent of all cases nationwide. COVID-19 apparently arrived there by way of a traveler from Europe. By late June, New York’s more than 395,000 confirmed cases were greater than those of most countries except the US as a whole, Brazil, Russia, and India. Males were more likely to be infected than females and older people age 65 and above with pre-existing health problems such as obesity, hypertension, heart disease, diabetes, dementia, atrial fibrillation, and chronic obstructive pulmonary disease (COPD) were especially subject to infection and death. Nursing homes were major sites for infection, with about 20 percent of all deaths nationwide. Fortunately, children were the least affected. One reason Italy had such a high mortality rate was because of its large, disproportionately elderly population. The final story on the 2019–20 coronavirus pandemic has yet to be written at this time, but it serves as an example of the social causation of disease as “social distancing” and “stay at home” measures become the primary means of preventing infection, or conversely, acquiring it through close social proximity.

Smoking

Smoking is associated with more diseases than any other health-related lifestyle practice. Smoking tobacco or using tobacco products in any form harms health (Cockerham 2013b). Autopsies on heavy smokers show lung tissue that transformed from a healthy pink to gray and brownish white in color. Smoking also affects the body in other ways, such as damaging the cardiovascular system, causing back pain, and producing increased risk of loss of cartilage in knee joints through osteoarthritis. The physiological damage caused by smoking cigarettes is due to the irritant and carcinogenic material (“tar”) released by burning tobacco into smoke that is inhaled in the lungs and enters the blood stream where it is spread throughout the body. Persons who die from lung cancer are increasingly less able to breathe and feel suffocated as their lungs lose the capacity to transfer oxygen to the blood.

In Britain, some 114,000 people die annually from smoking. In the United States, with its much larger population, about 480,000 Americans die each year from smoking-related causes, including some 41,000 dying from exposure to second-hand smoke. Smoking promotes heart attacks and strokes, narrows and hardens arteries, damages blood vessels and causes them to rupture (aneurysms), and brings on high blood pressure. Habitual smoking regularly results in premature death, as smokers typically die 10 years earlier than non-smokers in the US. How do social variables enter into this disease pattern in a causal role? At one level it looks like the causal factors are all biology: tar in smoke causes cancer and impairs blood circulation. But tar by itself is not causal. It has to enter the human body to have any effect. What is ultimately causal is the human being – both as a host inhaling the smoke and as a producer of a smoking-prone social environment. There is a social pattern to smoking that indicates tobacco use is not a random, individual decision completely independent of social structural influences.

However, smoking and other risky behaviors have not been viewed in a broad social context by researchers as much as they have been characterized as situations of individual responsibility. If people wish to avoid the negative effects of smoking on their health, it is therefore reasoned that they should not smoke. If they choose to smoke, what happens to them is no one’s fault but their own. This victim-blaming approach does not explain why people, especially those from socially disadvantaged circumstances, are drawn to poor health habits like smoking and the types of social situations that promote this behavior. Today, smoking is highly unusual among persons at the higher and middle levels of society and is concentrated among people toward the bottom of the social ladder. Persons in higher socioeconomic groups were the first to adopt smoking in the early twentieth century and other social classes followed, but growing publicity about the harmful effects of cigarettes in the 1960s led to a shift in smoking patterns over time as better educated and more affluent groups began abandoning the practice (Antunes 2011; Cockerham et al. 2017b; Ho and Fenelon 2015; Narcisse et al. 2009; Pampel 2009). By the early twenty-first century, smoking patterns had drastically changed.

According to Mieke Thomeer and her associates (Thomeer et al. 2019), social connections are key predictors of smoking. Thomeer et al. found that the social connections in one’s life (i.e., parents, peers) were most important in influencing an individual to smoke or, conversely, avoid smoking. For those who quit smoking or relapsed after having stopped, the primary motivation was found to be changing social connections in adulthood (such as finding a new job with different co-worker friendships or the ending of an intimate relationship). One man, for example, starting smoking at age 11 because his father smoked, and he thought it was “cool.” A woman said she never smoked because her grandmother used to blow smoke in her face as a child and she couldn’t stand the smell. Smoking in these accounts typically begins and ends as an activity that involves other people. Among adolescents, however, the influence of peers is stronger in initiating smoking rather than ending it. As Steven Haas and David Schaefer (2014: 126) determined in a nationwide study in the US: “Adolescents rarely initiate smoking without peer influence but will cease smoking while their friends continue smoking.”

The social process of becoming a smoker was aptly described by Jason Hughes (2003) several years ago, who determined that confirmed smokers pass through five stages in their smoking career: (1) becoming a smoker, (2) continued smoking, (3) regular smoking, (4) addicted smoking, and, for some, (5) stopping smoking. Based on interviews with both smokers and ex-smokers in Britain, Hughes determined that the first experience people have with smoking cigarettes in the initial stage of becoming a smoker is typically unpleasant. The smoker usually feels nauseated. One respondent told Hughes (2003: 148) that she really did not like her first cigarette, describing it as “foul.” This raises a crucial question: If the first experience is unpleasant, why do people continue? Hughes’s answer is that people learn how to smoke by having other individuals interpret the experience for them and tell them how to distinguish the desired sensations from the undesirable. Specifically, they are taught how to inhale properly and pull the smoke into their lungs. One woman in the Hughes (2003: 149) study reported on what it was like being a smoker when she first started: “it was quite exciting. I thought I’d grown up! It was something new. And it is a skill that you have to learn to do it properly so that people don’t say, ‘she’s not inhaling properly, she’s not smoking.’ You have to learn how to do it.” Hughes explains that, initially, smoking is a social activity carried out with other people. It typically has its origins in adolescent peer groups, in which teens imitate adult or older teen behavior (de la Haye et al. 2019). Teens smoke to “connect with,” “fit in,” and “impress” their friends. Joy Johnson and her colleagues (Haines, Poland, and Johnson 2009; Johnson et al. 2003) studied teen smoking in Canada and found that adolescents are more socially than physically dependent on cigarettes in the beginning.

The social setting, namely relaxing with peers, caused smoking more than wanting to inhale tobacco smoke. Often the teen did not smoke when friends were not around. But when friends were present, new smokers used cigarettes primarily to connect with them socially, project an image of being “cool,” and express solidarity. Three teenagers in the Johnson et al. (2003: 1484–6) study analyzed smoking in their peer groups this way:

Like it [smoking] is a social aspect of their life that they have become dependent on, as much as the nicotine, you know. I think almost the social setting of it is something that is somewhat addictive itself. (17-ye...

Table of contents

• Cover
• Dedication
• Title Page
• Copyright
• Preface
• 1 The Social Causation of Health and Disease
• 2 Theorizing about Health and Disease
• 3 Health Lifestyles
• 4 The Power of Class
• 5 Class and Health: Explaining the Relationship
• 6 Age
• 7 Gender
• 8 Race and Ethnicity
• 9 Living Conditions and Neighborhood Disadvantage
• 10 Health and Social Capital
• Concluding Remarks
• References
• Name Index
• Subject Index
• End User License Agreement