Book Review
Social Causes of Health and Disease
William C Cockerham
ISBN: 978-0-7456358-8-0; 2007; vii+232 pages; Polity Press;
Mildred Blaxter
Department of Social Medicine, University of Bristol, United Kingdom
This book begins by stressing the point that though it is generally acknowledged most disease has social connections, social variables are usually characterised as intermediary or secondary influences, not direct causes. However, not all diseases can be accounted for by considering biological causes only. Cockerham's main theme is that many social factors are not simply epidemiological associations or statistical correlations in the development of ill health, but directly causal. A paradigm shift is emerging in medical sociology which acknowledges the limitations of the biomedical model and looks beyond individual causes to stress the societal. The publisher's note suggests the book will be indispensable for ‘those with the courage to confront the possibility that society really does make people sick'.
So far, although Cockerham writes eloquently, this may not seem to be news to medical sociologists, or even to those in public health or epidemiology, in Europe or in Australia. That it needs to be said may feed a reader's prejudiced view that though medical sociology had classic beginnings in the middle of the last century in the United States, it has not been a particularly powerful discipline there in more recent decades. However, it would be a grave mistake not to persevere beyond this first chapter. In fact, the book is an outstanding account of contemporary medical sociology and a really excellent introduction to the subject. I would recommend it highly as a textbook.
For instance, I know no other text which manages, succinctly and clearly, to demonstrate the contribution of medical sociology to social epidemiology, through all its schools of thought - structural functionalism on the one hand and symbolic interactionism on the other, by way of social construction and post-structuralism - from its beginnings to the present day. Cockerham's diagram, in his second chapter on ‘Theorising about health and disease', which shows the historical and theoretical connections between Durkheim, Marx, Parsons, Mead, Merton, Becker, Scheff, Blumer, Freidson, Navarro, Foucault, Bourdieu, Turner and others from the late nineteenth century onwards, is the deceptively simple diagram which I have vainly been trying to produce for teaching purposes for many years. Unusually, theory and data from the US, the UK and Europe are thoughtfully combined.
The third chapter, on ‘Health lifestyles', offers a similarly scholarly but accessible account of lifestyle models and the agency-structure debate, choice and chance, habitus and health practices. Again, this is an outstanding international summary. These chapters make the book a particularly good text for a module on medical sociology for undergraduate students, or for specialist MA courses in the sociology of health. They also, however, provide an excellent introduction to up-to-date social aspects of epidemiology for health professionals.
The following three chapters on class, age, gender and race/ethnicity, are perhaps the empirical core of the book, and as a British reader I found them refreshing. There is no doubt that British work on inequality in health, with its particular view of one model of class, has tended sometimes to the parochial (as, of course, has the American view in a different way). Here, an impressive breadth of scholarship utilises the latest research in both the US and the UK, and other nations, to give a coherent and wider account. In order to qualify as causal, a social variable must meet four requirements: it must influence multiple diseases, through multiple pathways, which are reproduced over time, and which involve access to resources. All these conditions are meticulously examined, and the conclusion is that in this context social class or social status is the most powerful variable, ‘the strongest predictor of health, disease causation, and longevity' (2007: 75).
In the final two chapters, Cockerham turns to the level of groups, neighbourhoods and populations, focusing first of all on the health effects of ‘place' and living conditions, and then on the community-level resources of social relationships and ‘social capital'.
His ‘Concluding remarks' summarise the author's case clearly and convincingly. The evidence has shown that, while some research may suggest individual behaviour or ‘agency' is in some circumstances more important for health than structural variables, ‘structure is always present and its effects still need to be taken into account in order to provide complete explanations of the social phenomena being studied' (2007: 186). Agency and structure operate on a continuum in which agency is stronger at the lower end of the socio-economic scale, and structure at the higher end, but the relative contributions of both need to be analysed. When their relative strengths are considered, the effects of structure can not only out-weigh agency, but render it relatively powerless. This does not mean a return to rigid structural theories, or imply that micro-level or qualitative studies are not valuable, but it does demand a new sophistication in the study of social factors as causes of disease.
One residual problem, in this as in all epidemiological thinking, lies in the tricky nature of the concept of ‘cause'. In the central chapters, Cockerham touches on, but does not elaborate, the mechanisms in individual physiology and psychology (for instance, in the neuro-endocrine system), which are increasingly showing that social factors can lead directly to ill-health. In other places, other sorts of mechanism are involved: behavioural habits as the direct cause of disease, for instance, or service use which affects the outcome of disease. Despite the attempt at the beginning to clarify the nature of a social cause, it is not always clear which link in the chain of cause is regarded as the ‘direct' one. Some discussion of, and discrimination between, different kinds and levels of cause would have added to the book's value.
Despite this, Cockerham's book remains an exciting and important text, scholarly but entirely accessible, which I would highly recommend as a sourcebook for students, and a stimulus for discussion for all those engaged in health research or practice.
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