Annals of Health Law
INTERVENING AT THE RIGHT POINT
which is independently associated with adverse health).
The third characteristic of a fundamental cause of disease is that it
persists over time. This is easy to perceive with regard to SES. Link and
Phelan explain that in the 19th century, one of the most significant risk
factors for disease was access to adequate sanitation and sewerage.70
Availability of sanitation followed a social gradient, with the affluent
having more and better access to such sanitation, and hence typically
experiencing lower rates of waterborne disease.71 As sanitation perfused
through the social hierarchy, it ceased to act as a widespread and
penetrating risk factor for disease. But the link between SES and disease
persisted because new mechanisms arose that mediated the relationship
(e.g., smoking and poor nutrition).72
Increasing empirical evidence bears out Link and Phelan’s theory,73
although, like any good theory, there remain both skeptics and a host of
unanswered questions.74 Regardless, rather than perceiving it as a grand
unified theory of disease and social epidemiology, seeing a fundamental
cause framework as offering a useful contribution to thinking through the
problem of global pain may help illuminate more and less promising L&P
interventions.
IV. PAIN, FUNDAMENTAL CAUSES, AND PREFERENCE FOR POPULATION
HEALTH STRATEGIES IN GLOBAL PUBLIC HEALTH LAW
Understanding fundamental cause theory has stark implications both for
thinking about global pain and for prioritizing remedial interventions. In
the first case, it underscores the danger of medicalizing public and
population health problems. It is here that the artificial distinction between
clinical care and population health becomes quite meaningful. The mere
fact that clinical medical interventions are undeniably important in treating
pain does not establish that improving access to such interventions is the
best pathway towards ameliorating burdens of pain and its inequitable
distribution across the globe. In fact, moving from evidence of clinical
Class, and Health Among Ethnic Minority Groups, 92(4) AM. J. PUB. HEALTH 624 (2002);
Sandra J. Eades, Reconciliation, Social Equity and Indigenous Health, 24(3) ABORIGINAL
AND ISLANDER HEALTH WORKER J. 3, 3-4 (2000).
70. Link and Phelan, Social Conditions, supra note 52, at 86.
71. See generally Simon Szreter, HEALTH AND WEALTH: STUDIES IN HISTORY AND
POLICY (2004); Hamlin, supra note 43.
72. Link and Phelan, Social Conditions, supra note 52, at 86.
73. See Link and Phelan, Social Conditions, supra note 52.
74. See, e.g., Johan P. Mackenbach, The Persistence of Health Inequalities in Modern
Welfare States: The Explanation of a Paradox, 75(4) SOC. SCI. & MED. 761, 764 (2012)
(contending that fundamental cause theory does not identify specific pathways linking
socioeconomic conditions to health).
