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Fundamental Causes Theory

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by Christopher Nielsen

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Society’s poor and less privileged members seem to always suffer more and die younger than its rich and privileged members. The Fundamental Causes Theory offers a holistic view of the underlying causes of society’s health inequalities. This is accomplished by investigating the primary factors that contribute to socioeconomic status (SES) and how those factors define the fundamental causes of disease (2). Fundamental Causes Theory explains how money, knowledge, power, and social connections are related to:

  • Disease outcomes (1).
  •  Exposure to health risks (1).
  •  Access to health related resources (1). 

The Fundamental Causes Theory provides insight about how access to a greater collection of resources enables people to avoid disease and death over a wide range of circumstances (1). The implication is that increased access to resources will result in better health (1). Consequently, inequalities in health and mortality will persist as long as resource inequalities exist (1). Below, Figure 1 shows the dynamic, interconnected, and multilevel aspect of the social environment exemplifying why an analysis of independent variables is shortsighted (5). To best appreciate population health, identification of its fundamental causes and their relationships is necessary.

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Figure 1. Social Environment (5).



The theory of fundamental causes can be traced back to 1985 when Lieberson developed the concept of basic causes (1). The concept of basic causes is critical for understanding the strong SES-mortality association, but it does not explain what is it about SES that allows for the association to remain despite the elimination of intervening mechanisms (4). In 1995, Link and Phelan consulted Lieberson’s concept of basic causes when they were struggling to understand why socioeconomic status and health are associated (2). Then, they composed the Fundamental Causes Theory to help explain the perpetual association between SES and health.


Applications to Global Health Planning and Practice:

Arguable the theory of fundamental causes is at the core of public health. Maintaining a public health focus of understanding the association of a fundamental cause’s relationship to health should help reduce the health disparities that continuously plague many countries (3). For example, claiming poverty is associated with poor health may be true, but without an understanding of why poverty is associated with poor health little can be done to change the association. Children born into poverty promulgate this association because these children must cope with exposures and experiences that can have profound health effects later in life. For example, these exposures and experiences include, but are not limited to: traumatic events and exposures to noxious substances such as lead or secondhand smoke. Public health policy that recognizes and acts on the associations of fundamental causes to public health is central in mitigating their effects. To put these associations in perspective, research suggests that approximately 245,000 deaths in the United States in 2000 were attributable to low education, 176,000 to racial segregation, 162,000 to low social support, 133,000 to individual-level poverty, 119,000 to income inequality, and 39,000 to area-level poverty (3). 


Constant innovation in medical science and technology has permitted many developed countries to enjoy a trend of increased life expectancy. However, mortality from deadly diseases and infections such as tuberculosis has been superseded by chronic diseases, including lung cancer and cardiovascular disease (2). Health risk factors such as sanitation have become less important as factors including smoking, blood pressure, and cholesterol gained importance (2). SES is not only linked to a higher prevalence of these chronic diseases, but also with a lack of resources to take advantage of the relevant medical innovation, diagnostic tools and treatments (2). The Fundamental Causes Theory explains why those with the most resources are best able to take advantage of medical advancements. Despite a push for universal health care, the most advantaged members of society tend to always have the best outcomes (2). If a nation wants to equitably improve the health of its citizens, it must not only focus on the individual aspects of medical advancements, but also on the fundamental causes and sociologic determinants of health (6).



Socioeconomic inequalities in health and mortality may remain due to difficulties gaining acceptance of the Fundamental Causes Theory. This may be a result of issues with empirically measuring the dynamic interconnectedness of SES. Furthermore, demonstrating the existence of socioeconomic inequalities in health over time does not necessarily provide support for the theory because human behavior is complex (1). Although health and a long life are desired by many people, others may prefer to partake in activities that stress the body. Behavior contrary to preserving the body can be easily observed in humans, exemplified by a Hunter S. Thompson quote: “Life should not be a journey to the grave with the intention of arriving safely in a pretty and well preserved body, but rather to skid in broadside in a cloud of smoke, thoroughly used up, totally worn out, and loudly proclaiming "Wow! What a Ride!” (7).

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(1) Phelan JC, Link BG, Tehranifar P. Social Conditions as Fundamental Causes of Health Inequalities Theory, Evidence, and Policy Implications. Journal of Health and Social Behavior. 2010 Nov 1;51(1 suppl):S28–40.


(2) CHANG VW, LAUDERDALE DS. Fundamental Cause Theory, Technological Innovation, and Health Disparities: The Case of Cholesterol in the Era of Statins. J Health Soc Behav. 2009 Sep;50(3):245–60.


(3)“On Mechanisms vs. Foundations | | Boston University.” School of Public Health. N.p., n.d. Web. 15 Dec. 2016.


(4) “Fundamental Sources of Health Inequalities.” RWJF. N.p., 1 Jan. 2004. Web. 18 Dec. 2016.


(5) Kaplan, George A. “Part III Summary.” Annals of the New York Academy of Sciences 896.1 (1999): 116–119. Wiley Online Library. Web.


(6) Link, Bruce G., and Jo Phelan. “Social Conditions As Fundamental Causes of Disease.” Journal of Health and Social Behavior (1995): 80–94. JSTOR. Web.


(7) “A Quote from The Proud Highway.” Goodreads. N.p., n.d. Web. 19 Dec. 2016.

DRAFT: This module has unpublished changes.