Abstract
In order to enhance the “structural competency” of medicine—the capability of clinicians to address social and institutional determinants of their patients’ health—physicians need a theoretical lens to see how social conditions influence health and how they might address them. We consider one such theoretical lens, fundamental cause theory, and propose how it might contribute to a more structurally competent medical profession. We first describe fundamental cause theory and how it makes the social causes of disease and health visible. We then outline the sorts of “fundamental interventions” that physicians might make in order to address the fundamental causes.
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Notes
There are some circumstances, of course, in which resources are negatively associated with health outcomes—what Lutfey and Freese (2005) call “countervailing mechanisms.” For example, goals considered even more important than health may cause those with more resources to use them in ways that negatively influence health—as when men fail to use sunscreen as part of their achievement of masculinity (Courtenay 2000). Nevertheless, as Lutfey and Freese observe, such countervailing mechanisms do not threaten the validity of fundamental cause theory since they are cumulatively smaller than the “massive multiplicity” of mechanisms that support the association between resources and health (see also Phelan, Link, and Tehranifar 2010).
Mortality data might be biased with respect to the accurate designation of the cause of death for minorities (Wailoo 2011). Moreover, the cause of death of minorities may not have been investigated as thoroughly as the mortality of whites, especially in earlier decades. Nevertheless, if this were true we would expect other causes of death to show similar patterns by race. Yet mortality rates due to diseases such as pancreatic cancer—for which we have not yet developed specific prevention strategies or effective treatment options—fail to show crossover like lung cancer and colon cancer (Rubin, Clouston, and Link 2014). More recent data concerning HIV/AIDS mortality demonstrates a similar pattern—the spread of antiretroviral drugs in the mid-1990s corresponds with a substantial increase of the relative risk of mortality associated with race over time (Rubin, Colen, and Link 2010). Thus, while there may be problems with mortality data, the preponderance of the evidence is suggestive of processes associated with fundamental causes.
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Reich, A.D., Hansen, H.B. & Link, B.G. Fundamental Interventions: How Clinicians Can Address the Fundamental Causes of Disease. Bioethical Inquiry 13, 185–192 (2016). https://doi.org/10.1007/s11673-016-9715-3
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DOI: https://doi.org/10.1007/s11673-016-9715-3