Annals of Health Law
INTERVENING AT THE RIGHT POINT
The first answer to the question of “which determinants?” is the social
and economic conditions in which people work, play, and live. The
evidence is overwhelming that these conditions are the prime determinants
of health and its distribution in human societies.42 Although there are
myriad points of great contention within the social epidemiologic evidence
base regarding the connections between social position, material
deprivation, and health, the general idea that the first two profoundly
determine the third is by this point beyond dispute.43 This paper will touch
more on these social determinants and their impact on clear thinking about
global pain later, but for now, we can say that the “causes of the causes” are
those social and economic conditions that determine the distribution of
particular diseases. Thus, insofar as we have reason to believe that such
conditions are significant determinants both of absolute burdens of pain and
of its relative distributions – which we do, as noted above – then it follows
that it is social and economic conditions which are the causes of the causes.
For example, while it is well known that a major cause of chronic low-back pain is repetitive and stressful lifting,44 it is crucial to consider the
kinds of life experiences that make it more likely that a particular person or
group will be exposed to such repetitive and stressful lifting. Rudolf
Virchow, a physician, anthropologist, and the founder of social medicine,
adduced the same underlying point in his seminal 1848 report On the
Conditions of a Typhus Epidemic in Upper Silesia.45 Therein, Virchow
observed the destitution and sickness among Silesian miners, an
unsurprising finding given the hazards of the occupation.46 Yet Virchow
42. See generally WHO CSDH, Final Report, supra note 17.
43. Indeed, Bernardino Ramazzini formally noted the connections between occupation
and health status in 1713, and the foundations of modern public health in the West are
literally built upon such recognition (although certainly many if not most modern public
health reformers were not motivated primarily by a desire to improve the lives of the least
well-off). On Ramazzini, see generally GEORGE ROSEN, A HISTORY OF PUBLIC HEALTH 71-2
(Expanded ed.,The John Hopkins Univ. Press 1993) (1958). On the motivations of early
public health reformers, see generally CHRISTOPHER HAMLIN, PUBLIC HEALTH AND SOCIAL
JUSTICE IN THE AGE OF CHADWICK: BRITAIN, 1800-1854 (1998).
44. See Joan M. Stevenson, A Longitudinal Study of the Development of Low Back Pain
in an Industrial Population, 26(12) SPINE 1370 (2001); J.W. Frymoyer et al., Risk Factors in
Low-Back Pain: An Epidemiological Survey, 65(2) J. BONE AND JOINT SURGERY 213 (1983).
45. See generally Rex Taylor and Annelie Rieger, Medicine as Social Science: Rudolf
Virchow on the Typhus Epidemic in Upper Silesia, 15(4) INT’L J. HEALTH SERVICES 547
(1985). See Howard Waitzkin, One and a Half Centuries of Forgetting and Rediscovering:
Virchow ‘s Lasting Contributions to Social Medicine, 1(1) SOCIAL MED. 5 (2006) (discussing
the impact of Virchow’s theory of social medicine).
46. See Leon Eisenberg, Foreword, in FORMATIVE YEARS: CHILDREN’S HEALTH IN THE
UNITED STATES, 1880-2000 xiv (eds. Alexandra Minna Stern & Howard Markel 2002).
Mining remains extremely dangerous, widely acknowledged as one of if not the most
hazardous occupation(s) in the world. See, Mining, INTERNATIONAL LABOUR ORGANIZATION