Annals of Health Law
INTERVENING AT THE RIGHT POINT
Phelan’s fundamental cause theory.52 Proposed in 1995, Link and Phelan
argue that social conditions are fundamental causes of disease.53 Link and
Phelan note several key characteristics of such causes. First, fundamental
causes tend to cause multiple diseases.54 Second, fundamental causes
contextualize multiple risk factors.55 Third, fundamental causes tend to
persist.56 Fundamental causes involve access to resources that can be used
to avoid risks or minimize the consequences of disease once it develops.57
Link and Phelan give the example of an individual forced into prostitution
as a subsistence strategy; such a person may be entirely unable to avoid
known risks.58 But – and this is the key – the sex acts themselves are
merely risk factors; they are intervening mechanisms rather than the
upstream cause, which in the case of forced prostitution would likely be
some combination of material deprivation, lack of adequate income, sexist
and oppressive power structures, etc.59 These factors, of course, are causes
of the causes. A sufficient level of socioeconomic status (“SES”) is a
fundamental cause of sexually-transmitted disease, as the evidence
documenting stark social gradients in such diseases implies.60
Moreover, such social gradients are robustly correlated with all manner
of diseases in both the global North and the global South, as to both
52. See generally Bruce G. Link and Jo C. Phelan, Social Conditions as Fundamental
Causes of Disease, 35(Extra) J. HEALTH AND SOC. BEHAV. 80 (1995); see also Andrew Wang
et al., Fundamental Causes of Colorectal Cancer: The Implications of Informational
Diffusion 90(3) MILBANK Q. 592 (2012); Jo C. Phelan, Bruce G. Link, and Parisa Tehranifar,
Social Conditions as Fundamental Causes of Health Inequalities: Theory, Evidence, and
Policy Implications, 51(Supp.) J. HEALTH AND SOC. BEHAV. S28 (2010); Virginia W. Chang
& Diane S. Lauderdale, Fundamental Cause Theory, Technological Innovation, and Health
Disparities: The Case of Cholesterol in the Era of Statins, 50(3) J. HEALTH AND SOC. BEHAV.
245 (2009); Andrea E. Willson, ‘Fundamental Causes’ of Health Disparities: A
Comparative Analysis of Canada and the United States, 24(1) INT’L SOCIOLOGY 93 (2009);
Karen Lutfey & Jeremy Freese, Toward Some Fundamentals of Fundamental Causality:
Socioeconomic Status and Health in the Routine Clinic Visit for Diabetes, 110 AM.
SOCIOLOGY REV. 1326 (2005); Jo C. Phelan et al., “Fundamental Causes” of Social
Inequalities in Mortality: A Test of the Theory, 45 J. HEALTH AND SOC. BEHAV. 265 (2004).
53. Link and Phelan, Social Conditions as Fundamental Causes of Disease, supra note
54. Id. at 87.
56. See id.
58. Id. at 85.
60. See Hazel D. Dean and Kevin A. Fenton, Addressing Social Determinants of Health
in the Prevention and Control of HIV/AIDS, Viral Hepatitis, Sexually Transmitted Infections,
and Tuberculosis, 125 PUB. HEALTH REP. 1, 2-3 (Supp. 4 2010); See also WHO CSDH,
Final Report, supra note 23, at 145-154.