Fundamental Sources of Health Inequalities

Much work now focuses on economic and racial and ethnic disparities in health and health care. Bruce Link and Jo Phelan address the fundamental causes of health inequalities and raise important questions about the models through which we view the causes of disease.

As they note, the dominant epidemiological model identifies risk factors proximate to the disease outcome and seeks policies and programs to reduce such risks. These authors, however, observe that risk factors change from one period to another, but socioeconomic status—which is associated with such risks at any single point in time—remains strongly related to health outcomes even as risk factors change. Link and Phelan argue that social status is the more fundamental influence because, regardless of the risks, persons with more resources, information, power, and useful networks are better able to marshal these resources to take advantage of what is known about preventing disease and maintaining health. Thus, they argue, we should identify policies that can equalize such coping advantages so that one's socioeconomic status is not such a powerful determinant of health.

Link and Phelan's analysis has some important and perhaps counterintuitive implications for our understanding of social, racial, and ethnic disparities. One might assume that any major health advance, over the long run, would help reduce disparities in health outcomes. But if Link and Phelan are right, any new health opportunity that gives those with money, power, information, and other resources unequal opportunities will widen health disparities, at least initially. Those with resources will be better located to adopt such interventions, whether they are new forms of health screening, preventive opportunities, or innovative treatments.

This argues for seeking interventions that are more universal and depend less on the resources of individuals, or at least compensate those most disadvantaged through special targeting efforts. From Link and Phelan's perspective, designing safer vehicles and road systems is more effective in reducing disparities than trying to teach people to drive more safely; fluoridating water is more effective than encouraging better tooth brushing and flossing; and providing healthy foods and opportunities to exercise safely and pleasantly in schools and communities could be more effective than encouraging people to lose weight.