Fundamental Causation

Modern Epidemiology focuses on proximate risk factors that can be controlled at the individual level, but tends to ignore the social conditions that are largely responsible for diseases. This has led to incomplete understanding and underestimation of the influence of social determinants on health. According to Link and Phelan (1995) the social determinants are the 'Fundamental causes' of diseases. The social factors that are linked to illness include race, socioeconomic status, gender and stress. A fundamental cause involves access to resources that help individuals avoid risks whereas the individual-level risk factors like poor diet, cholesterol, exercise and high blood pressure can be considered as the intervening mechanisms. In modern epidemiology the social factors, seen as the distal cause of mortality, are considered irrelevant after the intervening modifiable mechanisms are identified. However, this concept does not hold true because even after the proximate risk factors have been eliminated, socioeconomic inequalities in mortality remained undiminished (Rosen, 1979). Thus, even if the intervening mechanisms are modified or eradicated, an association between a fundamental cause and disease will re-emerge. A study by Berkman and Syme (1979) showed that when competing risk factors are controlled mortality risk doubled for those low on a social network index compared to those high on the index. Some studies have shown that job strain due to work load is more common in low status job and is associated with high BP and coronary heart diseases. Rosenfield's study (1989) reported that women have higher symptoms of depression and anxiety due to overload caused by work and family demands. It is important to search for factors that put people at risk of risks. Without a proper understanding of the factors that lead to risk, any intervention undertaken to reduce risks may prove