Emerging Trends in The Social and Behavioral Sciences

Health and Social Inequality

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Health and Social Inequality

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Health and Social Inequality
BERNICE A. PESCOSOLIDO

Abstract
The link between social cleavages and life chances has been a mainstay of sociology,
social science, and public health’s contribution to understanding well-being, morbidity, and mortality. From early classic work to the most recent studies, inequality
has been associated with the incidence and prevalence of disease, access to health
care, and higher-than-expected death rates, even for infants. Importantly, these differences have been documented for individuals, for neighborhoods, and for nations.
On all of these key indicators, there is a clear gradient, whether measured by socioeconomic status (SES), education, or even social networks. Recent work has restated
and expanded the impact of inequality through the Theory of Fundamental Causes
and a focus on “health disparities.” The latter targets group membership by race, ethnicity, and/or gender, to name a few social characteristics. However, challenges arise
from pushing our understandings of the role of inequalities further as status configurations, for example, only proxy the social interactions, social conditions, and social
experiences that produce inequality. New theoretical and empirical research also
suggests that incorporating biology into our understanding of how social inequality translates into poor health, unequal treatment, and premature death can be done
by synthesizing new visions of sociocultural embeddedness with biological embedding into a complex systems framework for health and health care research. This
integration dismisses the “old silos” and calls for increased collaborations across the
sociomedical sciences, medicine, and genetics.

INTRODUCTION
Questions of who is healthy and who gets sick, who receives care and who
is denied access to care, and who lives and who dies have always provided a
powerful window into understanding how social inequality works in human
societies. From the beginnings of social and behavioral science up through
the present, research has demonstrated that factors that tap into one’s place
in the social hierarchy; that is, their social status, are associated with health,
with illness (what individuals feel), disease (what doctors diagnose), with
treatments offered and received, and with outcomes (recovery, disability,
and death). These include, but are not limited to, education, income, gender,

Emerging Trends in the Social and Behavioral Sciences. Edited by Robert Scott and Stephen Kosslyn.
© 2015 John Wiley & Sons, Inc. ISBN 978-1-118-90077-2.

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culture, social networks, and race/ethnicity. Much research focuses on an
individual’s or a family’s socioeconomic status (or SES for short), examining
how this affects a wide range of health conditions and health care.
But the impact of inequality goes beyond the individual. Both classic and
recent research have demonstrated that the neighborhood, the community,
and political units (e.g., states in the United States) where a person lives
also shape physical and mental well-being, in part by marking the kinds
of social, economic, and cultural conditions, experiences, and resources
they can access. At an even larger scope, the overall level of inequality in
a society is associated with measures of health and well-being, including
infant mortality and rates of major diseases. This is particularly important
because it helps to understand why the United States, while among the
richest countries on the globe, consistently reports lower levels of population
health.
Many researchers believe that inequality, characteristic of every society that
has ever existed, is the single most important factor that marks a person’s
fate in terms of well-being, life, and death. However, inequality not only
lays bare the health consequences of social stratification but is also a key to
understanding some underlying causes. One of the omnipresent debates is
captured by the difference between “social causation” and “social selection.”
The “social causation hypothesis” argues that the conditions of living in
the lower social classes, even before a person is born, influences health
through resources, experiences, and exposures. Poor health, particularly
mental health and mental illness, is concentrated among individuals with
low SES. The “social selection hypothesis,” also referred to as the social drift
hypothesis, suggests that the onset of illness can have a negative effect on
social class, often causing downward mobility, or a loss of social status,
because illness and disease, in and of themselves, interfere with a person’s
ability to remain in their current social class. Recent research has shown,
for example, that child and adolescent mental health issues translate into a
lower probability of completing high school or of entering college, both of
which are known correlates of adult SES. Further, issues of prejudice and
discrimination are involved in drift hypothesis because the stigma attached
to illness, disease, and disability may influence employment opportunities,
housing options, and general community acceptance. In the end, however,
this debate reveals a complexity, with research showing that both social
processes are most likely at work and that the type, severity, and length
of illness may be crucial in determining which of these social processes
predominates. In the case of schizophrenia, for example, the drift hypothesis
is particularly powerful but for depression, social causation appears to
be more influential. Findings are not definitive, however, and the debate
continues.

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FOUNDATIONAL RESEARCH
Early in the history of social science, German sociologists Karl Marx and
Max Weber argued that SES was a basic cause of health and illness. With
the coming of the industrial revolution, Marx focused on the impact of social
class, arguing that the modern conditions of work determined social status
but also directly influenced morbidity (disease), mortality (death), and treatment. Along with Engles, he documented that the conditions of labor in the
working classes (in mines, in the new industrial factories) put them at direct
risk for diseases. Just as importantly, the wages they received meant that they
were likely to live in overcrowded, unsanitary, and poor conditions, not only
affecting their health, but the life chances of their children.
Building on these early ideas, Weber described how life chances (including
health) and life styles (including what people eat; whether they exercise)
reflected the opportunities they have. By opportunities, Weber targeted
access to resources including food and housing, but also education, work,
and health care. He also looked to more subjective factors, such as beliefs,
values, and attitudes, as having the potential to shape what individuals did
and what happened to them. Even early physicians of “social medicine”
(e.g., Rudolf Virchow) recognized that inequality both predisposed people
to disease and denied them access to modern medical care either geographically or economically.
Later researchers showed how geography or “place” mattered as part of the
way inequality influenced peoples’ lives, especially their health. Robert Park
and Ernest Burgess drew concentric circles on a map of the city of Chicago
in the early part of the twentieth century. Starting with the center point in
the area of greatest poverty and working outward, they were able to show
a direct decrease in morbidity and mortality as distance from the city center increased. In fact, Park and Burgess argued that as people moved up in
social class, they also moved away from the city center and improved their
life chances. They saw these neighborhood conditions which marked wealth
or poverty as more important than any other factors including ethnicity, race,
or religion.
While the pure concentric geographic approach fell out of favor as being
too simplistic, research on social class continued to document the importance
of residence. In the classic study Social Class and Mental illness, sociologist
August Hollingshead and psychiatrist Fredrick Redlich developed and used
a three factor measure of social class (education, occupation, and neighborhood of residence) to examine whether social class was related to mental illness and treatment. Interviewing all individuals who were treated for mental
health problems in New Haven, Connecticut, in a single year, they documented that the prevalence of mental illness was higher among individuals

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in the lower classes and that they tended to be diagnosed with more serious
problems as they were defined at the time (“psychosis” being more serious
than “neurosis”). Further, they were less likely to receive any treatment at
all or, if they did, they were more likely to receive care in public institutions
and through the most constraining and intrusive treatments, including cold
packs, electroshock, and lobotomies (as opposed to psychotherapy).
In a later study, also in New Haven, Hollingshead worked with physician
Raymond Duff to look more broadly at how social class shaped treatment.
They documented several ways that hospitals reflected and reproduced
inequality. Physicians came from the professional classes; others who
worked in hospitals did not. Inequality in medical work also drew on
gender differences where nurses’ subordinate position to physicians was
in evidence, despite nurses’ greater knowledge about a patient’s status,
given their involvement in day-to-day care. Even the physical design of
the early modern hospital reflected the status hierarchy of society, with the
operating theater, where the most prestigious members of the medical profession (surgeons) worked, being on the rooftop level, the private medical
rooms closer to the top, semiprivate in the middle, and rooms for those
without means in lower floor wards. Room assignments, made primarily
according to ability to pay, did not reflect differential treatment, per se, but
private accommodations certainly afforded more personal attention and
better conditions for patients and families. More importantly, however, this
sociologist-physician team did document that ward patients encountered
more treatment difficulties, at first because their financial situations (no or
limited insurance) translated into delay in being admitted, with concomitant
greater severity upon admission. Further, the aftermath of hospitalization
rippled through the lives of the lower class patients more dramatically,
affecting their savings, housing, and even their children’s ability to stay in
school.
Standing conceptually between these two studies were community studies such as those of Earl L. Koos’ 1954 Health of Regionville or Leighton’s
1959 My Name is Legion (one of three books documenting the Stirling County
Study of Psychiatric Disorder and Sociocultural Environment). In the Elmira,
New York study, Koos documented that social class shaped more than health
care access or illness prevalence. The influence of social class extended to
the very way that individuals understood health problems and responded
to them. Individuals categorized as living in the lowest class in Elmira did
not believe that medical care should be sought for a wide range of symptoms
including back pain or persistent cough, symptoms to which nearly all of the
respondents in the highest social class indicated that they would seek out a
physician. Social class influence on the cultural construction of “need” was
only eliminated when symptoms of unexplained bleeding were offered.

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These studies reflected inequalities in the social and cultural access to
care before the advent of important social programs such as US Medicaid
and Medicare or Atlantic Canada’s provincial insurance systems. However,
research continues to document the association of inequality with health
problems, with the individual’s response to them, with the ability to receive
treatment, and with the aftereffects of catastrophic illness on the economic
and social conditions of people’s lives. In fact, the robust body of research
showing how inequality translates into poor health, into lack of access to
care, and premature death and disability was instrumental in garnering
support for public programs in North America.
CUTTING-EDGE RESEARCH
While there have been dramatic changes in society and the way we study
health, illness, and healing, the relationship between inequality and health
persists. As physician-sociologist Howard Waitzkin recently pointed out:
“Conditions of society that generate illness and mortality have become
largely forgotten and rediscovered with each succeeding generation.” (2011,
p. 9) In recent years, this reminder has come in the form of two important
sets of concepts and theories that now dominate the way we think about
and talk about these issues—fundamental causes and health disparities.
THE THEORY OF FUNDAMENTAL CAUSES
The classic 1995 paper by Bruce Link and Jo Phelan was in part a review
of the clear and substantial body of research showing the inequality-health
link, and in part, a conceptualization of why that link persists despite efforts
to eliminate or reduce it. They argue that mechanisms to intervene in the link
will always be frustrated by the ability of inequality to find a way to affect
differential mortality and morbidity. Power and resources, including money,
knowledge, and social networks central to life chances, will be denied, to one
extent or another, to those at the bottom of the social ladder.
The Theory of Fundamental Causes had three effects on understanding
health and inequality beyond providing a clear conceptual restating and
expansion. First, it spurred a new wave of research that demonstrated that
inequality remains a major predictor of health, morbidity, and mortality
in contemporary times, despite continued improvements in medical technology. Second, it led to research that moved beyond examining causes
(epidemiological studies) to how later process (health service studies)
continued to translate inequality into diminished life chances. Third, it
raised the question of what other forces and factors could be considered
fundamental causes of differential health and health care outcomes.

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On the first, the range and scope of studies exploded across the medical,
social science, and public health fields. The findings of the inequality-health
relationship were and continue to be very robust across time, across diseases, and across countries. On the second, and despite Link and Phelan’s
concern that intervening mechanisms will never erase inequalities, studies
elaborated how health outcomes, and not just onset of health problems, were
shaped by social class. Using cases of diabetes care by class and heart disease
by gender, Karen Lutfey and her colleagues have demonstrated that status
differences not only preserve but also exacerbate the initial effects through
how providers decide on treatment regimes for individuals. For example,
while maintaining the Theory of Fundamental Cause’s insistence that
inequality cannot be distilled down to or reduced in any long-term way by
proximate mechanisms, Lutfey considered the social contexts within which
proximate risk factors operate. In two diabetes clinics, populated by patients
with diverse social class backgrounds, the less socially advantaged were
given less complex treatment regimes which influenced long-term average
glucose levels, and in turn heightened the risk of adverse health outcomes.
On the third, and in concert with this resurgence of attention to inequality,
David Williams and his colleagues turned their attention to the role of race
and ethnic differences. While also a long-term focus and not independent
of inequality defined by economic status, this area gained new energy and
attention, flourishing under the new moniker of “health disparities,” now a
large part of the research agenda on health and inequality.
THE RISE OF HEALTH DISPARITIES
In the broadest manner, health disparities signal differences in mortality
and morbidity between groups of people, including race, ethnicity, gender,
and other social designations such as rural residence. These other social
categories mark differences in power, privilege, and esteem that translate
into differences in life style and life chances. They define the social fault
lines of society. Health care disparities refer to the unequal treatment of
individuals in health care systems based on these characteristics. In 2002,
the US Institute of Medicine characterized this type of disparity as a
difference in treatment not justified by underlying health conditions or
patient preferences. However, social scientists have argued that excluding
health preferences is problematic because they already reflect the operation
of cultures shaped by status differences such as race, class, and gender.
Because everything from lack of insurance coverage to physician practice
patterns, differentially acquired or enacted by social characteristics, reflect
inequalities, health disparities broaden the focus from economic inequality
to social inequalities.

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THE FOCUS ON SOCIAL RELATIONSHIPS
In addition to the reassertion of the power of inequality, in whatever form and
defined by whatever social cleavages, contemporary research has revealed in
no uncertain terms that social connections to others matter. Since social science embarked on the impact of social factors on health, the role of personal
ties has been central. In the classic work on suicide by Emile Durkheim, how
well-integrated we are to one another in terms of love, care, and concern, as
well as how well we are regulated by others in terms of guidance, cooperation, and even coercion, shape health, health care, and their outcomes. While
this has been long accepted, perhaps even underlying the human mechanisms of inequality, privilege and disadvantage, the 1970s saw the beginnings
of the direct documentation of how social ties matter in preventing heart disease and shepherding individuals to or away from health care systems. On
a basic level, research documented that loneliness is responsible for more
deaths, directly and indirectly, than smoking. Social networks protect individuals from the onset of stressful life events and help to buffer their effects
when they do occur. Social connections link individuals together in social
support groups, discourage unhealthy behaviors, and help lay the pathways
to care. However, social networks can have a dark side as well because it is
what they hold, in terms of cultural beliefs, values, and attitudes, as well as
what they recommend, that matters. For example, while the health benefits of
marriage have been debated, the results from research are complex. Marriage
may benefit men, but men married too young may be more predisposed to
suicide. The nagging of spouses on health behaviors, an important accompaniment to the love and concern of marriage, help to explain its overall
salubrious effects. But marriages with toxic relationships can have opposite,
and often deadly, effects on life and well-being. Attachment to families, more
generally, may provide support and care in the face of illness, but network
members may also try to hide illness, keeping family out of treatment for fear
of the prejudice and discrimination attached to stigmatized conditions.
In the most powerful demonstration of late, Christakis and Fowler resuscitated and reworked unique data in the Framingham Heart Study to show
not only the association between social ties and risk factors such as obesity,
loneliness, and smoking, but also how changing networks are associated
with health status and health behavior change. Similarly, social ties have
long been seen as underlying response to mechanisms in individuals’
illnesses—knowledge of options, recommendations for health and illness
behaviors, advocacy during hospitalization, and monitoring follow-through
on treatment recommendations embedded in community ties. In fact, newer
approaches, such as the Network Episode Model, developed in light of
the poor explanatory power of sociodemographic characteristics to explain

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who seeks formal care, the kinds of pathways to care followed, and how
outcomes unfold. Inequality itself is embedded in these social networks and
helps to form the mechanisms through which fundamental causes translate
into health disparities. The NEM, for example, began with the premise
that responding to illness or prevention is a phenomenon structured and
given meaning through a social process managed by individuals’ social
networks in the community and the treatment system. Because individuals
have both agency and habit (i.e., practical consciousness), they pragmatically improvise and routinize within the possibilities and limits of social
network structures in their community, organizations, and historical period.
However, as part of a society that includes institutions of social control,
they may also encounter the health care system with resistance and under
coercive requirements (e.g., required examinations for employment or
sports; involuntary commitment for mental health problems). All of these
reflect vectors of social inequality.
KEY ISSUES FOR FURTHER RESEARCH
Contemporary research has set a solid foundation for linking social stratification and life chances, including health. It has provided a clear understanding that inequality exists in health and health care outcomes. It has
revitalized theory and research on the role of SES and pushed our understanding of how other social characteristics, including race/ethnicity, gender,
and social relationships represent important cleavages that divide those who
have from those who have not. These are fundamental causes that predispose individuals to living a healthy life, being relatively free from disease
and disability, and avoiding premature death. When these factors cumulate
in a negative direction, health and health care disparities widen between individuals, groups, communities, and global borders.
While there is no indication that research on fundamental causes, health
disparities or even the fundamental causes of health disparities has provided
all the answers or all of the solutions, there is also no indication that the intellectual energy devoted to these issues, is slowing down. However, with the
basics reaffirmed in contemporary research, at least two looming questions
arise as challenges for the next era of research. First, given the complexity
of the social factors and forces that shape health and health care inequalities, how can we conceptualize and study the way inequality, for example,
among individuals, neighborhoods, and nations, works together in concert
or opposition? And, can we embrace new biological and genetics findings as
part of how social inequality matters in health? Second, even in light of the
Theory of Fundamental Causes, can we get underneath how factors such as
SES or race/ethnicity shape the social and cultural landscape that reinforces

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how sociodemographic and socioeconomic characteristics come to have consequences for health?
PUTTING IT ALL TOGETHER
Given the visibility and magnitude of scientific resources devoted to genetic
and biological factors in health and health care outcomes, how can we
integrate the power of social inequality into a fuller understanding of how
health and disease emerge? Since World War II, a major push in medical
sciences has been unlocking the genetic code, expecting that the keys to
understanding and developing medicine would follow. In fact, the Human
Genome Project has been completed, and much has been discovered.
However, compared to the initial hope, the results have pointed to few
clear links between candidate genes and disease, slowing the move to
personalized medicine that was expected to eliminate many inequalities.
Now, more complicated ideas around copy number variants (CNVs, i.e.,
additions or deletions in gene sequences) or systems of genes are being
pursued. From the point of view of the sociomedical sciences, the most
interesting discoveries have centered on the power of epigenetics to reveal
how biological foundations are shaped by nonbiological factors. The contemporary and widely held view is that environments, including the social
environment, affect the chemical coating on the genome (through histones
and methylation–demethylation processes), leaving the genome intact but
turning genes “on” or “off.”
How do we incorporate our understandings of inequality’s influence on
health under this new model now that the old nature–nurture debate has
been rendered scientifically obsolete? A three-part approach lies in bridging
insights across research communities from the social, biological, and medical
sciences. The biological/genetic part has been summarized in briefest terms
above. More relevant to this entry are two other pieces of the whole that have
been conceptualized: biological embedding and social embeddedness.
BIOLOGICAL EMBEDDING
Biological embedding, first coined by anthropologist and public health
researcher Clyde Hertzman in 2010, targets how social factors and processes
“get under the skin” to affect health and development. Hertzman developed
this idea to explain the nearly universal social class gradient in health,
hypothesizing that individuals’ developmental, material experiences and
psychosocial conditions interact to “sculpt” the brain in childhood. Both
immediate and prolonged interactions between defense systems and the
brain respond to the adverse psychosocial experiences, often associated

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with disadvantaged social position. This elevates disease risk in childhood
and cumulates to a trajectory of greater morbidity and early mortality in
adulthood. In sum, biological embedding alters biological processes caused
by social experiences and circumstances, and in turn, either protects or
predisposes individuals to health and disease.
SOCIAL EMBEDDENESS
While biological embedding results from day-to-day experiences as well
as exceptional traumas, the social environment is intricate, dense, and
multifaceted, requiring a way to conceptualize how inequality matters.
Introduced by sociologist Mark Granovetter in 1985, the concept of social
embeddeness takes into account how the different levels of society and the
advantage and disadvantage part and parcel of them, are fundamentally tied
together and can be traced through individuals’ personal networks. What
individuals know, how they evaluate the potential efficacy and suitability of
a range of behavior, and what they eventually do are fundamentally tied to,
negotiated in, and given meaning through social interactions. Individuals’
social ties describe their place in the community as well as individuals’
access to and participation in rich, supportive, advantaged environments
or decimated, difficult, and disadvantaged ones known to be associated
with well-being or disease risk. In health care, this includes patterned
interactioned experiences that Lutfey’s diabetes patients from different SES
backgrounds experienced in clinical settings.
In fact, the recent concern with intersectionality (holding particular constellations of class, race, gender, sexual orientation, etc.) reflects a classic
prediction in social network theory that such configurations only offer a
crude way to track the kinds of social interactions that individuals have.
When David Williams reinvigorated the work on race/ethnicity and health
inequalities, he answered the question of whether SES played a role. In fact,
it did but it was not the only fundamental cause; it did not “explain” racial
disparities in health and health care. Much to the surprise of many who
thought it impossible, Williams was able to document that culture mattered.
Individuals’ reports of their experiences of discrimination, which can only
be enacted through social interactions and networks of relationships in families, workplaces, and communities, had a direct explanatory power. In such
issues, forces that tap into stigma have proved to be powerful forces in the
illness experience and health/health care outcomes. This greater emphasis
on culture—attitudes, beliefs, values, norms—of those who suffer from ill
health and those who care for them are socially embedded. Too often, social
characteristics themselves are relied upon to proxy culture. As Williams’
research has shown, it is not being African-American, per se, that results

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in poor health, but the combination of SES disadvantage and day-to-day
stigmatizing experiences that combine to create health disparities.
Together, understanding biological starting points that will be shaped by,
and in turn, shape structures and meanings of inequality in which individuals are embedded offer a new and exciting challenge. Discarding the old
either-or mentality of past debates means that we can begin to unlock the
inequality in both material and nonmaterial resources. In seeing biology and
social embeddedness working through the dynamics of biological embedding, a new challenging agenda comes into focus, suggesting new frameworks such as the Social Symbiome, which synthesizes disciplinary findings
and novel conjectures through a networked lens in which the biomedical and
sociomedical sciences work together, understanding the way that inequality
shapes health takes on renewed perspective, calling for theoretical, methodological, and analytic developments to match the intricacy of unraveling the
roots of life chances.
FURTHER READING
Alegria, M., Pescosolido, B. A., Williams, S., & Canino, G. (2011). Culture,
race/ethnicity and disparities: Fleshing out the socio-cultural framework for
health services disparities. In B. A. Pescosolido, J. D. McLeod, J. K. Martin, & A.
Rogers (Eds.), The handbook of the sociology of health, illness, & healing: Blueprint for
the 21st century (pp. 361–380). New York, NY: Springer.
Christakis, N. A., & Fowler, J. H. (2007). The spread of obesity in a large social network over 32 years. New England Journal of Medicine, 357(4), 370–379.
Link, B. G., & Phelan, J. C. (1995). Social conditions as fundamental causes of disease.
Journal of Health and Social Behavior (Extra Issue), 80–94.
Lutfey, K. E., & Freese, J. (2005). Toward some fundamentals of fundamental causality: Socioeconomic status and health in the routine clinic visit for diabetes. American Journal of Sociology, 110(5), 1326–1372.
Pescosolido, B. A. (2006). Of pride and prejudice: The role of sociology and social
networks in integrating the health sciences. Journal of Health & Social Behavior, 47,
189–208.
Waitzkin, H. (2011). Medicine and public health at the end of empire. Boulder, CO:
Paradigm Press.

BERNICE A. PESCOSOLIDO SHORT BIOGRAPHY
Bernice A. Pescosolido is Distinguished and Chancellor’s Professor of Sociology at Indiana University. She is also Founding Director of the Indiana
Consortium for Mental Health Services Research (ICMHSR). As a medical
sociologist, her major foci have been on health care utilization, the epidemiology of suicide, and the stigma of mental illness. In all of these, she has

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been focused on how social networks are key vectors of social and cultural
influence for individuals, organizations, and geographic areas. She has been
engaged in theorizing about and building cross-disciplinary collaborations to
study how multiple influences work together or in opposition to shape the
causes of and response to ill-health. Much of her work has been published
in sociology, social science, public health, and medical journals and she has
edited several handbook volumes that provide foundational references for
the subfields of medical sociology and the sociology of mental health. She
routinely teaches courses aimed at preparing future faculty in sociology, in
general and in areas of medical sociology and social networks, as well as
future medical providers, administrators, and social scientists in matters of
health and health care, designing both undergraduate and graduate minors
in Medicine and Society.
ICMHSR Website: http://www.indiana.edu/∼icmhsr/
RELATED ESSAYS
Telomeres (Psychology), Nancy Adler and Aoife O’Donovan
Inefficiencies in Health Care Provision (Economics), James F. Burgess et al.
Self-Fulfilling Prophesies, Placebo Effects, and the Social-Psychological
Creation of Reality (Sociology), Alia Crum and Damon J. Phillips
State of the Art in Competition Research (Psychology), Márta Fülöp and
Gábor Orosz
Political Inequality (Sociology), Jeff Manza
Immigrant Health Paradox (Sociology), Kyriakos S. Markides and Sunshine
Rote
Rationing of Health Care (Sociology), David Mechanic
The Role of Cultural, Social, and Psychological Factors in Disease and Illness
(Sociology), Robert A. Scott
AIDS and Social Networks (Sociology), Alexander Weinreb et al.
Incarceration and Health (Sociology), Christopher Wildeman



Health and Social Inequality
BERNICE A. PESCOSOLIDO

Abstract
The link between social cleavages and life chances has been a mainstay of sociology,
social science, and public health’s contribution to understanding well-being, morbidity, and mortality. From early classic work to the most recent studies, inequality
has been associated with the incidence and prevalence of disease, access to health
care, and higher-than-expected death rates, even for infants. Importantly, these differences have been documented for individuals, for neighborhoods, and for nations.
On all of these key indicators, there is a clear gradient, whether measured by socioeconomic status (SES), education, or even social networks. Recent work has restated
and expanded the impact of inequality through the Theory of Fundamental Causes
and a focus on “health disparities.” The latter targets group membership by race, ethnicity, and/or gender, to name a few social characteristics. However, challenges arise
from pushing our understandings of the role of inequalities further as status configurations, for example, only proxy the social interactions, social conditions, and social
experiences that produce inequality. New theoretical and empirical research also
suggests that incorporating biology into our understanding of how social inequality translates into poor health, unequal treatment, and premature death can be done
by synthesizing new visions of sociocultural embeddedness with biological embedding into a complex systems framework for health and health care research. This
integration dismisses the “old silos” and calls for increased collaborations across the
sociomedical sciences, medicine, and genetics.

INTRODUCTION
Questions of who is healthy and who gets sick, who receives care and who
is denied access to care, and who lives and who dies have always provided a
powerful window into understanding how social inequality works in human
societies. From the beginnings of social and behavioral science up through
the present, research has demonstrated that factors that tap into one’s place
in the social hierarchy; that is, their social status, are associated with health,
with illness (what individuals feel), disease (what doctors diagnose), with
treatments offered and received, and with outcomes (recovery, disability,
and death). These include, but are not limited to, education, income, gender,

Emerging Trends in the Social and Behavioral Sciences. Edited by Robert Scott and Stephen Kosslyn.
© 2015 John Wiley & Sons, Inc. ISBN 978-1-118-90077-2.

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culture, social networks, and race/ethnicity. Much research focuses on an
individual’s or a family’s socioeconomic status (or SES for short), examining
how this affects a wide range of health conditions and health care.
But the impact of inequality goes beyond the individual. Both classic and
recent research have demonstrated that the neighborhood, the community,
and political units (e.g., states in the United States) where a person lives
also shape physical and mental well-being, in part by marking the kinds
of social, economic, and cultural conditions, experiences, and resources
they can access. At an even larger scope, the overall level of inequality in
a society is associated with measures of health and well-being, including
infant mortality and rates of major diseases. This is particularly important
because it helps to understand why the United States, while among the
richest countries on the globe, consistently reports lower levels of population
health.
Many researchers believe that inequality, characteristic of every society that
has ever existed, is the single most important factor that marks a person’s
fate in terms of well-being, life, and death. However, inequality not only
lays bare the health consequences of social stratification but is also a key to
understanding some underlying causes. One of the omnipresent debates is
captured by the difference between “social causation” and “social selection.”
The “social causation hypothesis” argues that the conditions of living in
the lower social classes, even before a person is born, influences health
through resources, experiences, and exposures. Poor health, particularly
mental health and mental illness, is concentrated among individuals with
low SES. The “social selection hypothesis,” also referred to as the social drift
hypothesis, suggests that the onset of illness can have a negative effect on
social class, often causing downward mobility, or a loss of social status,
because illness and disease, in and of themselves, interfere with a person’s
ability to remain in their current social class. Recent research has shown,
for example, that child and adolescent mental health issues translate into a
lower probability of completing high school or of entering college, both of
which are known correlates of adult SES. Further, issues of prejudice and
discrimination are involved in drift hypothesis because the stigma attached
to illness, disease, and disability may influence employment opportunities,
housing options, and general community acceptance. In the end, however,
this debate reveals a complexity, with research showing that both social
processes are most likely at work and that the type, severity, and length
of illness may be crucial in determining which of these social processes
predominates. In the case of schizophrenia, for example, the drift hypothesis
is particularly powerful but for depression, social causation appears to
be more influential. Findings are not definitive, however, and the debate
continues.

Health and Social Inequality

3

FOUNDATIONAL RESEARCH
Early in the history of social science, German sociologists Karl Marx and
Max Weber argued that SES was a basic cause of health and illness. With
the coming of the industrial revolution, Marx focused on the impact of social
class, arguing that the modern conditions of work determined social status
but also directly influenced morbidity (disease), mortality (death), and treatment. Along with Engles, he documented that the conditions of labor in the
working classes (in mines, in the new industrial factories) put them at direct
risk for diseases. Just as importantly, the wages they received meant that they
were likely to live in overcrowded, unsanitary, and poor conditions, not only
affecting their health, but the life chances of their children.
Building on these early ideas, Weber described how life chances (including
health) and life styles (including what people eat; whether they exercise)
reflected the opportunities they have. By opportunities, Weber targeted
access to resources including food and housing, but also education, work,
and health care. He also looked to more subjective factors, such as beliefs,
values, and attitudes, as having the potential to shape what individuals did
and what happened to them. Even early physicians of “social medicine”
(e.g., Rudolf Virchow) recognized that inequality both predisposed people
to disease and denied them access to modern medical care either geographically or economically.
Later researchers showed how geography or “place” mattered as part of the
way inequality influenced peoples’ lives, especially their health. Robert Park
and Ernest Burgess drew concentric circles on a map of the city of Chicago
in the early part of the twentieth century. Starting with the center point in
the area of greatest poverty and working outward, they were able to show
a direct decrease in morbidity and mortality as distance from the city center increased. In fact, Park and Burgess argued that as people moved up in
social class, they also moved away from the city center and improved their
life chances. They saw these neighborhood conditions which marked wealth
or poverty as more important than any other factors including ethnicity, race,
or religion.
While the pure concentric geographic approach fell out of favor as being
too simplistic, research on social class continued to document the importance
of residence. In the classic study Social Class and Mental illness, sociologist
August Hollingshead and psychiatrist Fredrick Redlich developed and used
a three factor measure of social class (education, occupation, and neighborhood of residence) to examine whether social class was related to mental illness and treatment. Interviewing all individuals who were treated for mental
health problems in New Haven, Connecticut, in a single year, they documented that the prevalence of mental illness was higher among individuals

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EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

in the lower classes and that they tended to be diagnosed with more serious
problems as they were defined at the time (“psychosis” being more serious
than “neurosis”). Further, they were less likely to receive any treatment at
all or, if they did, they were more likely to receive care in public institutions
and through the most constraining and intrusive treatments, including cold
packs, electroshock, and lobotomies (as opposed to psychotherapy).
In a later study, also in New Haven, Hollingshead worked with physician
Raymond Duff to look more broadly at how social class shaped treatment.
They documented several ways that hospitals reflected and reproduced
inequality. Physicians came from the professional classes; others who
worked in hospitals did not. Inequality in medical work also drew on
gender differences where nurses’ subordinate position to physicians was
in evidence, despite nurses’ greater knowledge about a patient’s status,
given their involvement in day-to-day care. Even the physical design of
the early modern hospital reflected the status hierarchy of society, with the
operating theater, where the most prestigious members of the medical profession (surgeons) worked, being on the rooftop level, the private medical
rooms closer to the top, semiprivate in the middle, and rooms for those
without means in lower floor wards. Room assignments, made primarily
according to ability to pay, did not reflect differential treatment, per se, but
private accommodations certainly afforded more personal attention and
better conditions for patients and families. More importantly, however, this
sociologist-physician team did document that ward patients encountered
more treatment difficulties, at first because their financial situations (no or
limited insurance) translated into delay in being admitted, with concomitant
greater severity upon admission. Further, the aftermath of hospitalization
rippled through the lives of the lower class patients more dramatically,
affecting their savings, housing, and even their children’s ability to stay in
school.
Standing conceptually between these two studies were community studies such as those of Earl L. Koos’ 1954 Health of Regionville or Leighton’s
1959 My Name is Legion (one of three books documenting the Stirling County
Study of Psychiatric Disorder and Sociocultural Environment). In the Elmira,
New York study, Koos documented that social class shaped more than health
care access or illness prevalence. The influence of social class extended to
the very way that individuals understood health problems and responded
to them. Individuals categorized as living in the lowest class in Elmira did
not believe that medical care should be sought for a wide range of symptoms
including back pain or persistent cough, symptoms to which nearly all of the
respondents in the highest social class indicated that they would seek out a
physician. Social class influence on the cultural construction of “need” was
only eliminated when symptoms of unexplained bleeding were offered.

Health and Social Inequality

5

These studies reflected inequalities in the social and cultural access to
care before the advent of important social programs such as US Medicaid
and Medicare or Atlantic Canada’s provincial insurance systems. However,
research continues to document the association of inequality with health
problems, with the individual’s response to them, with the ability to receive
treatment, and with the aftereffects of catastrophic illness on the economic
and social conditions of people’s lives. In fact, the robust body of research
showing how inequality translates into poor health, into lack of access to
care, and premature death and disability was instrumental in garnering
support for public programs in North America.
CUTTING-EDGE RESEARCH
While there have been dramatic changes in society and the way we study
health, illness, and healing, the relationship between inequality and health
persists. As physician-sociologist Howard Waitzkin recently pointed out:
“Conditions of society that generate illness and mortality have become
largely forgotten and rediscovered with each succeeding generation.” (2011,
p. 9) In recent years, this reminder has come in the form of two important
sets of concepts and theories that now dominate the way we think about
and talk about these issues—fundamental causes and health disparities.
THE THEORY OF FUNDAMENTAL CAUSES
The classic 1995 paper by Bruce Link and Jo Phelan was in part a review
of the clear and substantial body of research showing the inequality-health
link, and in part, a conceptualization of why that link persists despite efforts
to eliminate or reduce it. They argue that mechanisms to intervene in the link
will always be frustrated by the ability of inequality to find a way to affect
differential mortality and morbidity. Power and resources, including money,
knowledge, and social networks central to life chances, will be denied, to one
extent or another, to those at the bottom of the social ladder.
The Theory of Fundamental Causes had three effects on understanding
health and inequality beyond providing a clear conceptual restating and
expansion. First, it spurred a new wave of research that demonstrated that
inequality remains a major predictor of health, morbidity, and mortality
in contemporary times, despite continued improvements in medical technology. Second, it led to research that moved beyond examining causes
(epidemiological studies) to how later process (health service studies)
continued to translate inequality into diminished life chances. Third, it
raised the question of what other forces and factors could be considered
fundamental causes of differential health and health care outcomes.

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EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

On the first, the range and scope of studies exploded across the medical,
social science, and public health fields. The findings of the inequality-health
relationship were and continue to be very robust across time, across diseases, and across countries. On the second, and despite Link and Phelan’s
concern that intervening mechanisms will never erase inequalities, studies
elaborated how health outcomes, and not just onset of health problems, were
shaped by social class. Using cases of diabetes care by class and heart disease
by gender, Karen Lutfey and her colleagues have demonstrated that status
differences not only preserve but also exacerbate the initial effects through
how providers decide on treatment regimes for individuals. For example,
while maintaining the Theory of Fundamental Cause’s insistence that
inequality cannot be distilled down to or reduced in any long-term way by
proximate mechanisms, Lutfey considered the social contexts within which
proximate risk factors operate. In two diabetes clinics, populated by patients
with diverse social class backgrounds, the less socially advantaged were
given less complex treatment regimes which influenced long-term average
glucose levels, and in turn heightened the risk of adverse health outcomes.
On the third, and in concert with this resurgence of attention to inequality,
David Williams and his colleagues turned their attention to the role of race
and ethnic differences. While also a long-term focus and not independent
of inequality defined by economic status, this area gained new energy and
attention, flourishing under the new moniker of “health disparities,” now a
large part of the research agenda on health and inequality.
THE RISE OF HEALTH DISPARITIES
In the broadest manner, health disparities signal differences in mortality
and morbidity between groups of people, including race, ethnicity, gender,
and other social designations such as rural residence. These other social
categories mark differences in power, privilege, and esteem that translate
into differences in life style and life chances. They define the social fault
lines of society. Health care disparities refer to the unequal treatment of
individuals in health care systems based on these characteristics. In 2002,
the US Institute of Medicine characterized this type of disparity as a
difference in treatment not justified by underlying health conditions or
patient preferences. However, social scientists have argued that excluding
health preferences is problematic because they already reflect the operation
of cultures shaped by status differences such as race, class, and gender.
Because everything from lack of insurance coverage to physician practice
patterns, differentially acquired or enacted by social characteristics, reflect
inequalities, health disparities broaden the focus from economic inequality
to social inequalities.

Health and Social Inequality

7

THE FOCUS ON SOCIAL RELATIONSHIPS
In addition to the reassertion of the power of inequality, in whatever form and
defined by whatever social cleavages, contemporary research has revealed in
no uncertain terms that social connections to others matter. Since social science embarked on the impact of social factors on health, the role of personal
ties has been central. In the classic work on suicide by Emile Durkheim, how
well-integrated we are to one another in terms of love, care, and concern, as
well as how well we are regulated by others in terms of guidance, cooperation, and even coercion, shape health, health care, and their outcomes. While
this has been long accepted, perhaps even underlying the human mechanisms of inequality, privilege and disadvantage, the 1970s saw the beginnings
of the direct documentation of how social ties matter in preventing heart disease and shepherding individuals to or away from health care systems. On
a basic level, research documented that loneliness is responsible for more
deaths, directly and indirectly, than smoking. Social networks protect individuals from the onset of stressful life events and help to buffer their effects
when they do occur. Social connections link individuals together in social
support groups, discourage unhealthy behaviors, and help lay the pathways
to care. However, social networks can have a dark side as well because it is
what they hold, in terms of cultural beliefs, values, and attitudes, as well as
what they recommend, that matters. For example, while the health benefits of
marriage have been debated, the results from research are complex. Marriage
may benefit men, but men married too young may be more predisposed to
suicide. The nagging of spouses on health behaviors, an important accompaniment to the love and concern of marriage, help to explain its overall
salubrious effects. But marriages with toxic relationships can have opposite,
and often deadly, effects on life and well-being. Attachment to families, more
generally, may provide support and care in the face of illness, but network
members may also try to hide illness, keeping family out of treatment for fear
of the prejudice and discrimination attached to stigmatized conditions.
In the most powerful demonstration of late, Christakis and Fowler resuscitated and reworked unique data in the Framingham Heart Study to show
not only the association between social ties and risk factors such as obesity,
loneliness, and smoking, but also how changing networks are associated
with health status and health behavior change. Similarly, social ties have
long been seen as underlying response to mechanisms in individuals’
illnesses—knowledge of options, recommendations for health and illness
behaviors, advocacy during hospitalization, and monitoring follow-through
on treatment recommendations embedded in community ties. In fact, newer
approaches, such as the Network Episode Model, developed in light of
the poor explanatory power of sociodemographic characteristics to explain

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EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

who seeks formal care, the kinds of pathways to care followed, and how
outcomes unfold. Inequality itself is embedded in these social networks and
helps to form the mechanisms through which fundamental causes translate
into health disparities. The NEM, for example, began with the premise
that responding to illness or prevention is a phenomenon structured and
given meaning through a social process managed by individuals’ social
networks in the community and the treatment system. Because individuals
have both agency and habit (i.e., practical consciousness), they pragmatically improvise and routinize within the possibilities and limits of social
network structures in their community, organizations, and historical period.
However, as part of a society that includes institutions of social control,
they may also encounter the health care system with resistance and under
coercive requirements (e.g., required examinations for employment or
sports; involuntary commitment for mental health problems). All of these
reflect vectors of social inequality.
KEY ISSUES FOR FURTHER RESEARCH
Contemporary research has set a solid foundation for linking social stratification and life chances, including health. It has provided a clear understanding that inequality exists in health and health care outcomes. It has
revitalized theory and research on the role of SES and pushed our understanding of how other social characteristics, including race/ethnicity, gender,
and social relationships represent important cleavages that divide those who
have from those who have not. These are fundamental causes that predispose individuals to living a healthy life, being relatively free from disease
and disability, and avoiding premature death. When these factors cumulate
in a negative direction, health and health care disparities widen between individuals, groups, communities, and global borders.
While there is no indication that research on fundamental causes, health
disparities or even the fundamental causes of health disparities has provided
all the answers or all of the solutions, there is also no indication that the intellectual energy devoted to these issues, is slowing down. However, with the
basics reaffirmed in contemporary research, at least two looming questions
arise as challenges for the next era of research. First, given the complexity
of the social factors and forces that shape health and health care inequalities, how can we conceptualize and study the way inequality, for example,
among individuals, neighborhoods, and nations, works together in concert
or opposition? And, can we embrace new biological and genetics findings as
part of how social inequality matters in health? Second, even in light of the
Theory of Fundamental Causes, can we get underneath how factors such as
SES or race/ethnicity shape the social and cultural landscape that reinforces

Health and Social Inequality

9

how sociodemographic and socioeconomic characteristics come to have consequences for health?
PUTTING IT ALL TOGETHER
Given the visibility and magnitude of scientific resources devoted to genetic
and biological factors in health and health care outcomes, how can we
integrate the power of social inequality into a fuller understanding of how
health and disease emerge? Since World War II, a major push in medical
sciences has been unlocking the genetic code, expecting that the keys to
understanding and developing medicine would follow. In fact, the Human
Genome Project has been completed, and much has been discovered.
However, compared to the initial hope, the results have pointed to few
clear links between candidate genes and disease, slowing the move to
personalized medicine that was expected to eliminate many inequalities.
Now, more complicated ideas around copy number variants (CNVs, i.e.,
additions or deletions in gene sequences) or systems of genes are being
pursued. From the point of view of the sociomedical sciences, the most
interesting discoveries have centered on the power of epigenetics to reveal
how biological foundations are shaped by nonbiological factors. The contemporary and widely held view is that environments, including the social
environment, affect the chemical coating on the genome (through histones
and methylation–demethylation processes), leaving the genome intact but
turning genes “on” or “off.”
How do we incorporate our understandings of inequality’s influence on
health under this new model now that the old nature–nurture debate has
been rendered scientifically obsolete? A three-part approach lies in bridging
insights across research communities from the social, biological, and medical
sciences. The biological/genetic part has been summarized in briefest terms
above. More relevant to this entry are two other pieces of the whole that have
been conceptualized: biological embedding and social embeddedness.
BIOLOGICAL EMBEDDING
Biological embedding, first coined by anthropologist and public health
researcher Clyde Hertzman in 2010, targets how social factors and processes
“get under the skin” to affect health and development. Hertzman developed
this idea to explain the nearly universal social class gradient in health,
hypothesizing that individuals’ developmental, material experiences and
psychosocial conditions interact to “sculpt” the brain in childhood. Both
immediate and prolonged interactions between defense systems and the
brain respond to the adverse psychosocial experiences, often associated

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EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

with disadvantaged social position. This elevates disease risk in childhood
and cumulates to a trajectory of greater morbidity and early mortality in
adulthood. In sum, biological embedding alters biological processes caused
by social experiences and circumstances, and in turn, either protects or
predisposes individuals to health and disease.
SOCIAL EMBEDDENESS
While biological embedding results from day-to-day experiences as well
as exceptional traumas, the social environment is intricate, dense, and
multifaceted, requiring a way to conceptualize how inequality matters.
Introduced by sociologist Mark Granovetter in 1985, the concept of social
embeddeness takes into account how the different levels of society and the
advantage and disadvantage part and parcel of them, are fundamentally tied
together and can be traced through individuals’ personal networks. What
individuals know, how they evaluate the potential efficacy and suitability of
a range of behavior, and what they eventually do are fundamentally tied to,
negotiated in, and given meaning through social interactions. Individuals’
social ties describe their place in the community as well as individuals’
access to and participation in rich, supportive, advantaged environments
or decimated, difficult, and disadvantaged ones known to be associated
with well-being or disease risk. In health care, this includes patterned
interactioned experiences that Lutfey’s diabetes patients from different SES
backgrounds experienced in clinical settings.
In fact, the recent concern with intersectionality (holding particular constellations of class, race, gender, sexual orientation, etc.) reflects a classic
prediction in social network theory that such configurations only offer a
crude way to track the kinds of social interactions that individuals have.
When David Williams reinvigorated the work on race/ethnicity and health
inequalities, he answered the question of whether SES played a role. In fact,
it did but it was not the only fundamental cause; it did not “explain” racial
disparities in health and health care. Much to the surprise of many who
thought it impossible, Williams was able to document that culture mattered.
Individuals’ reports of their experiences of discrimination, which can only
be enacted through social interactions and networks of relationships in families, workplaces, and communities, had a direct explanatory power. In such
issues, forces that tap into stigma have proved to be powerful forces in the
illness experience and health/health care outcomes. This greater emphasis
on culture—attitudes, beliefs, values, norms—of those who suffer from ill
health and those who care for them are socially embedded. Too often, social
characteristics themselves are relied upon to proxy culture. As Williams’
research has shown, it is not being African-American, per se, that results

Health and Social Inequality

11

in poor health, but the combination of SES disadvantage and day-to-day
stigmatizing experiences that combine to create health disparities.
Together, understanding biological starting points that will be shaped by,
and in turn, shape structures and meanings of inequality in which individuals are embedded offer a new and exciting challenge. Discarding the old
either-or mentality of past debates means that we can begin to unlock the
inequality in both material and nonmaterial resources. In seeing biology and
social embeddedness working through the dynamics of biological embedding, a new challenging agenda comes into focus, suggesting new frameworks such as the Social Symbiome, which synthesizes disciplinary findings
and novel conjectures through a networked lens in which the biomedical and
sociomedical sciences work together, understanding the way that inequality
shapes health takes on renewed perspective, calling for theoretical, methodological, and analytic developments to match the intricacy of unraveling the
roots of life chances.
FURTHER READING
Alegria, M., Pescosolido, B. A., Williams, S., & Canino, G. (2011). Culture,
race/ethnicity and disparities: Fleshing out the socio-cultural framework for
health services disparities. In B. A. Pescosolido, J. D. McLeod, J. K. Martin, & A.
Rogers (Eds.), The handbook of the sociology of health, illness, & healing: Blueprint for
the 21st century (pp. 361–380). New York, NY: Springer.
Christakis, N. A., & Fowler, J. H. (2007). The spread of obesity in a large social network over 32 years. New England Journal of Medicine, 357(4), 370–379.
Link, B. G., & Phelan, J. C. (1995). Social conditions as fundamental causes of disease.
Journal of Health and Social Behavior (Extra Issue), 80–94.
Lutfey, K. E., & Freese, J. (2005). Toward some fundamentals of fundamental causality: Socioeconomic status and health in the routine clinic visit for diabetes. American Journal of Sociology, 110(5), 1326–1372.
Pescosolido, B. A. (2006). Of pride and prejudice: The role of sociology and social
networks in integrating the health sciences. Journal of Health & Social Behavior, 47,
189–208.
Waitzkin, H. (2011). Medicine and public health at the end of empire. Boulder, CO:
Paradigm Press.

BERNICE A. PESCOSOLIDO SHORT BIOGRAPHY
Bernice A. Pescosolido is Distinguished and Chancellor’s Professor of Sociology at Indiana University. She is also Founding Director of the Indiana
Consortium for Mental Health Services Research (ICMHSR). As a medical
sociologist, her major foci have been on health care utilization, the epidemiology of suicide, and the stigma of mental illness. In all of these, she has

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EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

been focused on how social networks are key vectors of social and cultural
influence for individuals, organizations, and geographic areas. She has been
engaged in theorizing about and building cross-disciplinary collaborations to
study how multiple influences work together or in opposition to shape the
causes of and response to ill-health. Much of her work has been published
in sociology, social science, public health, and medical journals and she has
edited several handbook volumes that provide foundational references for
the subfields of medical sociology and the sociology of mental health. She
routinely teaches courses aimed at preparing future faculty in sociology, in
general and in areas of medical sociology and social networks, as well as
future medical providers, administrators, and social scientists in matters of
health and health care, designing both undergraduate and graduate minors
in Medicine and Society.
ICMHSR Website: http://www.indiana.edu/∼icmhsr/
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