Ambulatory Talks‎ > ‎

Social Conditions

Facilitator:  Aaron Fox


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Social Conditions


At its most basic, social epidemiology is the study of the role of social factors in the development of disease, or put differently, the social determinants of health.  While medical schools have adopted a biopsychosocial approach to patient care in order to capture the full spectrum of an individual’s well being, this seminar is meant to complement this approach and ask the question, “what makes a healthy society?”  We will not have time to cover all the theory and methodology used by social epidemiologist, but hopefully this introduction will have you thinking broadly about the factors affecting your patients’ health. 


Reading: Wypijewski, J.  The secret sharer: sex, race, and denial in an American small town – man infects people with AIDS in Jamestown, New York.  Harper’s Magazine, July 1998.



  1. What risk factors did the young women in Jamestown have for contracting HIV?  Are they different than the traditional HIV associated risk factors?  Would these risk factors be different in the Bronx? Or in Uganda?
  2. Townspeople describe Jamestown as “a good place to live,” but the author seems to have a different impression.  What neighborhood factors are implicated in the outbreak of HIV and the town’s health in general?  How is this neighborhood effect mediated at the individual level?  How would you research these potential mechanisms of disease spread?
  3. What are some public health interventions that could have reduced the risk of HIV transmission in Jamestown?  What was proposed and would this have worked?    
  4. The author brings up the issue of race and gender in the context of HIV risk.  Does institutionalized racism put minorities at risk?  Are women uniquely at risk because of our society’s expected gender roles? 


Link BG and J Phelan.  Social Conditions as Fundamental Causes of Disease.  Journal of Health and Social Behavior.  1995 (extra issue): 80-94.



1.     The article mentions low socioeconomic status being associated with higher rates of infant mortality as one example of the link between social conditions and disease.  What other examples can you think of emphasizing this link?

2.     What do the authors mean by contextualizing risk factors?

3.     Consider the following case:

IH is a 59 yo African American female with hypertension and hyperlipidemia.  She also smokes and is overweight.  She presents to a health center in the South Bronx with substernal chest pain and has evidence of ischemia on EKG.  She is sent to the emergency department where she is treated for myocardial infarction


i. What is the context of Ms. H’s risk factors?  Is she at increased risk for any of these traditional risk factors?

ii. In treating these traditional risk factors, are there other risk factors for cardiovascular disease that would be missed?

iii. How might social conditions affect Ms. H’s treatment at the ED?

4.     The authors contend that health disparities persist over time when public health interventions fail to address fundamental causes of disease.  Why is this?  In what specific ways have interventions to address smoking preferentially benefited those of high socioeconomic status?

5.     On page 88, the authors predict that AIDS will contribute to SES differentials in mortality.  Since the publication of this article, has this been true?  Why?  Can you think of other emerging diseases or risk factors that contribute to this differential or will in the future?

6.     In clinical practice, we cannot affect most fundamental causes of disease.  Therefore, are we wasting our time?  How will you negotiate this dilemma in your career?

7.     The authors propose that broad policy initiatives relevant to fundamental causes should include a “health impact statement.”  In addressing the tax cuts of 2001 and 2003, what would a potential health impact statement have looked like?  There has been recent debate about universal health insurance coverage (with mandates or affordable individual policies).  Would this address a fundamental cause of disease?       


Suggested Readings:


Banks J et al.  Disease and Disadvantage in the United States and in England.  JAMA.

2006; 295: 2037-2045.


Barbeau EM, Krieger N, and MJ Soobader.  Working Class Matters: Socioeconomic

Disadvantage, Race/Ethnicity, Gender, and Smoking in NHIS 2000.  American

Journal of Public Health.  2004; 94: 269-278.


Cohen D et al.  “Broken Windows” and the Risk of Gonhorrhea.  American Journal of

Public Health.  2000; 90: 230-6.


Diez Roux AV et al.  Neighborhood of Residence and Incidence of Coronary Heart

Disease.  New England Journal of Medicine.  2001; 345: 99-106. 


Epstein H.  Ghetto Miasma: Enough to Make You Sick.  New York Times Magazine

October 12, 2003.


Ferrie JD, ed.  Work, Stress, and Health: The Whitehall II Study.  London:  Public and

Commercial Services Union, 2004.


Green AR et al.  Implicit Bias among Physicians and its Prediction of Thrombolysis

Decisions for Black and White Patients.  JGIM.  2007; 22: 1231-1238.


Kawachi et al.  Social Capital, Income Inequality, and Mortality.  American Journal of

Public Health.  1997; 87: 1491-1498.


Krieger N.  Why Epidemiologists Cannot Afford to Ignore Poverty.  Epidemiology

2007; 18: 659-663.


Marmot M.  Health in an Unequal World.  Lancet.  2006; 368: 2081-94.


McCollum AD et al.  Outcomes and Toxicities in African American and Caucasian

Patients in a Randomized Adjuvant Chemotherapy Trial for Colon Cancer. 

Journal of the National Cancer Institute.  2002; 94: 1160-1167. 


Putnam RD.  Bowling Alone: America’s Declining Social Capital.  Journal of Democracy.  1995; 6: 65-78.