EXTENDING THE “FUNDAMENTAL CAUSE”
THEORY TO EXPERIENCES OF RACISM
AMONG AMERICAN AND CARIBBEAN
PEOPLE OF AFRICAN DESCENT
Arthur L Whaley, PhD, DrPH
Jackson State University
Paper presented at the 3rd Annual Health Disparities Institute of the Caribbean
Exploratory NCMHD Research Center, St. Thomas, VI, October 21-22, 2010
Overview
 Review the fundamental cause theory
 Discuss the dynamics of race and social class in
health and mental health outcomes
 Present the perspective of, and the evidence for,
racism as a fundamental cause of health disparities
 Describe and use the National Survey of American
Life (NSAL) to test hypothesis that racism is a
fundamental cause of racial disparities in health
 Conclusion and implications
Fundamental-Cause Theory (FCT)
 Background
 SES differences in health or mental health outcomes persist or
increase with improvements in the health care delivery system
 Basic Tenets
 Resources (money, power, knowledge, prestige) can be used to
minimize risk and avoid emergent diseases
 Fundamental causes linked to multiple disease outcomes through
multiple mechanisms
 The association between fundamental cause and disease is
reproduced over time via replacement of intervening mechanisms
 Implications
 Fundamental causes cannot be eradicated through targeting
individual-level risk factors
Link, B.G., & Phelan, J. (1995), Social condition as a fundamental cause of disease.
Journal of Health and Social Behavior, Extra Issue, 80-94.
Research Support for FundamentalCause Theory
 National Longitudinal Mortality Study data revealed
that preventable causes of mortality more strongly
associated with SES than less preventable causes
(Phelan et al., 2004)
 The data from the Wisconsin Longitudinal Study and
Health and Retirement Study were used to show that
SES variables are associated with health disparities
even when controlling for IQ (Link et al., 2008)
Limitations of the Fundamental
Cause Theory
 Theory fails to consider cultural context in which
social conditions manifest.
 FCT cannot explain why ethnicity/race is
considered an individual-level risk factor.
 The theory also assumes a main effect for the
SES-disease relationship.
 FCT does not account for the dynamics of the
relationship for SES and race.
Dynamics of Race and Social Class in
Health and Mental Health
 Race differences often remain when SES is controlled in
health studies (Jackson et al., 2004; Whaley, 2003).
 Poverty concentration differs by race and may underlie
some of the main effects for race in health studies (see
Schulz et al., 2000; Wilson, 1987).
 It may be more accurate to consider the interaction
between race and SES, instead of simply the main effects
(Kessler & Neighbors, 1986)
 The interaction may result from differential exposures to
racism as an environmental toxin (Whaley, 2003)
Perspective on Racism as a Fundamental
Cause of Health Disparities
 White privilege contributes to better health outcomes
for European Americans with similar resources as
African Americans (Institute of Medicine, 2002).
 Racial disparities in health exist over time and place,
despite changes in intervening mechanisms (Whaley,
1998).
 Racism creates disparate effects on multiple health
and mental health outcomes (Institute of Medicine,
2002; Neighbors et al., 2002).
 Racism operates through multiple mechanisms to
create disparities in health and mental health
Evidence for Racism as a Fundamental
Cause of Health Disparities
 Research indicates that Black Americans are more
concerned than White Americans about their selfpresentation to ensure that they receive good health
care (Malat, van Ryn, & Purcell, 2006).
 Studies show that racial differences in various health
and mental health outcomes across the nation have
been persistent over decades.
 Racial differences in health and mental health
outcomes are manifestations of different mechanisms—
e.g., physician attitudes and behaviors (individual) and
residential segregation (structural).
Black-White Rate Ratios, Ages 25-44, for U.S.
All-Cause Mortality Adjusted for Income,
1978-1985
2.5
2
1.5
Unadjusted
Adjusted
1
0.5
0
Male
Female
Sorlie, P., & Rogot, E. (1992). Black-white mortality differences by family
income. Lancet, 340(8815), 346-350.
Perceived Discrimination, Economic
Resources and Health Outcomes among
African-Descended Individuals
 Qualitative and quantitative reviews of the literature
indicates that perceived discrimination adversely affects
mental and physical health (Williams, Neighbors, &
Jackson, 2003; Pascoe & Richman, 2009).
 Perceived discrimination is associated with an increase
in self-reported symptoms in African American women
(Keith et al., 2010; Schulz et al., 2005).
 Economic resources do not protect African Americans
from the effects of discrimination on health and mental
health (e.g., Schulz et al., 2005; Siefert et al., 2007)
Physicians’ Recommendation of Coronary
Artery Bypass Graft Surgery by Patients’
Race-Gender Group
40
35
30
25
Black
White
20
15
10
5
0
Male
Female
van Ryn, M., Burgess, D., Malat, J., & Griffin, J. (2006). Physicians' Perceptions of Patients' Social
and Behavioral Characteristics and Race Disparities in Treatment Recommendations for Men With
Coronary Artery Disease. American Journal of Public Health, 96(2), 351-357.
National Survey of American Life:
Overview
 National Survey of American Life is a
comprehensive and detailed study of mental
disorders and the mental health of Americans of
African descent.
 Complex sampling produced a representative
sample of 3,570 African Americans, 1,623
Caribbean Blacks, and 1,006 non-Hispanic Whites
 The questionnaire contains 1,535 items covering 17
domains and takes, on average, 2 hours and 20
minutes to complete
National Survey of American Life: Use to
Test Fundamental-Cause Theory
Independent Variables: Demographic variables (sex,
age, education, marital status, employment status,
household income), neighborhood quality,
psychological variables (self-esteem, perceived
lack of control, and perceived discrimination)
Dependent Variables: Global self-reports of physical
health and mental health.
Hypothesis: Perceived discrimination will be
positively associated with ratings of poor physical
and mental health for persons of African descent
National Survey of American Life:
Description of Continuous Variables
Variable
Items
Values Mean Alpha
Sample Item
Physical Health Rating
1
1-5
2.59
--
How would you rate your
physical health?
Mental Health Rating
1
1-5
2.17
--
How would you rate your
mental health?
Neighborhood Quality
8
1-8
2.00
.81
There is a medical clinic in
your neighborhood.
Self-Esteem
10
1-4
.77
I feel that I am a person of
worth.
Perceived Lack of
Control
10
1-10
3.38
.77
What happens in my life
depends on me.
Perceived
Discrimination
10
1-10
4.70
.89
Frequently treated with less
respect than others.
National Survey of American Life:
Results
General Linear Model – Physical and mental health
ratings regressed on demographic variables only,
and then second model adding psychological
variables. Separate models of African
Caribbeans, African Americans and European
Americans
Variables of Interest: Education, Income,
Neighborhood Quality, and Perceived
Discrimination
Demographic and Psychosocial Predictors of Global Self-Reported
Physical Health by Ethnic/Racial Group
Variables
African American
Wald F
African Caribbean
Wald F
European American
Wald F
Years of Education
3.113*
7.731**
3.781*
Marital Status
1.484
3.327
.107
Work Status
19.239**
7.704**
3.259
Sex
16.153**
8.208**
1.718
Age
37.460**
8.855**
1.847
1.832
1.515
21.262**
Rosenberg Self Esteem Scale
30.387**
2.552
11.159**
Perceived Lack of Control
18.833**
13.454**
17.236**
.956
.898
19.270**
4.839*
1.331
2.576
Household Income
Positive Neighborhood
Characteristics
Perceived Discrimination
* p<.05
** p<.01
Demographic and Psychosocial Predictors of Global Self-Reported
Mental Health by Ethnic/Racial Group
Variables
African American
Wald F
African Caribbean
Wald F
European American
Wald F
Years of Education
1.105
.671
.712
Marital Status
.571
1.917
3.112
Work Status
5.226**
3.123
.473
Sex
12.657**
2.131
5.892**
Age
13.201**
.931
3.673
.004
.257
.041
Rosenberg Self Esteem Scale
64.473**
17.406**
45.344**
Perceived Lack of Control
40.121**
4.214*
14.609**
1.441
.465
1.083
19.548**
2.059
.062
Household Income
Positive Neighborhood
Characteristics
Perceived Discrimination
* p<.05
** p<.01
Conclusions and Implications
 Perceived discrimination was significantly
associated with both physical and mental health
ratings of African Americans but not African
Caribbean or European American respondents.
 Interventions to increase patients’ self-advocacy
skills and reduce physicians’ bias need to be
implemented, especially for African Americans.
 Policies and legislation must address racial
disparities along with economic inequality to
eradicate fundamental causes of health and
mental health disparities.