Book Cover
William C. Cockerham

Social Causes of Health and Disease, 2nd Edition
Polity, Cambridge, UK, 2012, Paperback
ISBN: 9780745661209

Reviewer: Sasha Scambler
King's College London, UK
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The central thesis of this book is that social factors have a ‘direct causal effect on physical health and illness’. In this book William Cockerham makes a compelling case that takes us beyond the widely accepted assertion that most diseases have social connections. There is plenty of evidence that the social context can shape an individual or population’s risk of exposure to disease, can shape an individual’s susceptibility to developing the disease and can affect the course and outcome of diseases. And the evidence shows that this is true regardless of whether the disease is infectious, long-term, degenerative or genetic. In this second edition of the book, Cockerham uses a plethora of updated evidence from the US and UK to make the argument that biological entities (viruses, cancers etc.) work in conjunction with social conditions to create the environment in which disease occurs.

In the first chapter Cockerham draws on case studies of smoking, diabetes and HIV/AIDS to illustrate the direct causal power of social factors. Taking the example of diabetes, he shows that diabetes rates are soaring in the US and that the growth rate is socially patterned with higher rates amongst the poor, blacks and Hispanics. Whilst genetics plays a critical role, the acceleration of new cases cannot be explained by genetics alone. Poverty linked social behaviours (around diet, exercise and access to and use of medical care) have been identified as the culprits. But interestingly race has also emerged as a significant factor with working class white areas experiencing moderate rates of diabetes whilst low income black and Hispanic areas have a ‘virtual epidemic’. These patterns are acknowledged but the focus of health research has been firmly entrenched within the biomedical model looking for biological causes of disease and factors which might influence these and leading to an individualised approach which largely ignores structural factors. Cockerham argues that we need to build on Link & Phelan’s Fundamental Cause Theory (1995) and the body of work that followed on from it and focus in on the structural factors which shape health and illness. He suggests that this paradigm shift has started in the US and UK but needs to be built on.

The second and third chapters build on this thesis, setting the scene for an exploration of the empirical evidence in relation to structure. In the second chapter the argument is made that the unique contribution of medical sociology is the use of theory to explain the interplay between individuals and society that emerges through empirical studies. The main theories that have been used within medical sociology are outlined. Cockerham suggests that the tendency to focus on agency and social construction over structural theories has led to a situation where the effects of social structures on health are largely ignored. He notes, however, that re-emergence of the structure/agency debate is providing opportunities to bring structure back in. An example of this is presented in the next chapter where the Health Lifestyles Model (Cockerham 2005) is presented as a way of challenging the trend towards the individualisation of health lifestyles research. The Health Lifestyles Model is presented as a way of acknowledging and seeking to understand the impact of structural factors on the practices that are usually the focus of lifestyles research (alcohol use, smoking, diet etc.).

Each of the following chapters of the book focuses on a neo-structural component (class, age, gender, race/ethnicity, neighbourhood and social capital) to assess the evidence with regards to the causal qualities of structure in relation to health and disease. The chapters on social class conclude that suggesting the relationship between class and health is just an association overlooks the power of class to sort people in to categories which have better or worse health/longevity. Class clearly meets all of the requirements laid out by Link and Phelan to qualify as a fundamental cause. Empirical evidence is used to demonstrate the role of gender as a fundamental cause through the process of socialisation and the cohort effect demonstrates the equivalent for age. Race/ethnicity, however, are socially constructed categories which do not meet the criteria and it is argued that their effects can be accounted for through class. Both the environmental conditions that individuals live in – external to themselves but largely shaped by social circumstances – and the social capital networks available are presented to demonstrate further the interaction between individual level and structural level factors in creating health and disease and the need for further work, particularly around the concept of social capital.

This book calls for a paradigm shift away from methodological individualism towards a more balanced approach that includes ‘a renewed focus on structural effects. The causal power of class in particular is so pervasive that it produces effects in other structural factors (age, gender and race/ethnicity) over and above the effects of these factors themselves. Cockerham makes a compelling argument, drawing on the latest research from the US and the UK to make his case and calling on medical sociologists to utilise their unique theoretical expertise to challenge the methodological individualism that is pervasive in the field of health. Overall this book is highly recommended and a must read for those working and/or studying in the fields of medical sociology and public health.

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