January 23, 2022

the unifying theory of inequality

a city street viewed from a few stories up, with buildings, cars, and people
photo caption: a city street in Chicago as seen from a car on its El train track. how you access a city depends a great deal on how much money you have.

huge thanks to my friend John, who told me about this theory over a few (?) beers this summer. thanks man!


The month I graduated from college, I was exploring fun activities for my new “adult” life. That’s how one night I found myself playing adult kickball despite never having kicked a ball in my life. I slid hard into gravel, biked home in the rain, and cleaned the wound with a homemade bar of soap. Within a few days I had developed a staph infection. One leg soon swelled to twice the size of the other one.

I was weeks away from my insurance kicking in and I could no longer access the student health center for free. I scraped together the money to afford a clinic visit and some cheap antibiotics. Pretty soon I was soon fine again.  I haven’t forgotten that feeling of vulnerability. A single evening in a rented field could have cost me my life or my livelihood. I didn’t realize what I was risking at a time when I had no insurance and a $15/hour job. It could have been anything that felled me. The staph infection just got to me first.

It’s pretty easy to think of improving one’s health as a simple system of cause and effect. If you want to prevent diabetes, lose weight and eat right. If you want to avoid heart disease, control your blood pressure and cut down on red meat. Like many problems in the world today, these diseases are easier to solve if you’re rich than if you’re poor. My seeya often told me, “health makes wealth,” but the reverse is more accurate. Many of us can intuit a clear line between a person’s health and their socioeconomic status (SES).

Jo Phelan, Bruce Link, and Parisa Tehranifar wanted to dig into why a person’s SES had such an effect on their health. They noticed that throughout history, “society’s poorer and less privileged members live in worse health and die much younger than the rich and more privileged ones.” This is true even though many of the diseases of the nineteenth century don’t pose the same risk to our lives today. Diseases caused by unsafe and unsanitary living conditions are more or less a thing of the past. Yet people with low SES are dying of other diseases sooner than their wealthy neighbors. Fundamental Cause Theory argues that wealth and status can protect a person’s health no matter what they might face. And in turn, people with low SES will never have what they need to prevent every disease they meet.

the trap of poverty

The theory itself provokes many thoughts! Alicia R. Riley would later contribute needed depth to aspects of race and social mobility not in the original paper. But Fundamental Cause Theory also feels incomplete by itself. Fundamental Cause Theory appears to fall into the realm of too-obvious science. Like, of course money and clout will buy you better medicine. Why do we need a study about that? The simple answer is that science operates by building on the research that came before. Once we document something, we can do something about it.

That said, the message behind FCT is looming for me. For those of us committed to improving the health of our communities, FCT is bleak. It doesn’t matter how many mortality moles you whack. People with low economic standing will always suffer worse from something.

Thankfully, that isn’t always true. If I decided to give kickball a try again, at my age, level of wealth, and social status, my outcome would be different. I would likely drive to and from the field. I could go to urgent care the same night I slid in gravel. An accident like that would be painful, sure, but not deadly.

I turn back to Alicia R. Riley’s study because of how she reframes Fundamental Cause Theory (and health inequity in general). She suggests it’s less important to look at disease and mortality according to class. Instead, the fundamental causes of disease are more evident as systems of exposure. This reframing helps us see that disease is not inevitable. We have to think bigger.

consider the ecosystem

Fundamental Cause Theory reminds us that none of us live in a vacuum. Humans are complex living things. We don’t follow simple cause and effect. We know that our life circumstances can have wide-ranging impacts. If we can move further upstream from a problem, we could better address its true root causes.

reject fatalism

There’s so much in the world to feel defeated about. My favorite is climate change. I was an environmentalist in fifth grade. I once begged my mom to buy a box of tampons so I could get a complimentary copy of 50 Simple Things You Can Do to Save the Earth. Unfortunately, I was not successful at saving the earth.

Climate change doesn’t have an individual-level solution. We have to join together to effect global change. If we want to change the fundamental causes of disease, we have to work towards ending inequality. We have to stop allowing people to profit from basic human necessities. No matter how difficult it appears, we have to move forward. Oppressed people have no choice but to move forward and keep trying. We can’t sit around and hope for the best. We have to try to make our situations better, in whatever way we can.

keep building

Fundamental Cause Theory is a foundation, not a conclusion. FCT joins other acronyms like Social Determinants of Health to spotlight health inequality. We have to show people what’s wrong. Then we have to show it’s possible to change it. Then we have to work together to make it happen.

my name is josh martinez. i have always loved trying to understand systems, and the systems that built those systems. i spend a lot of time thinking about how to get there from here.

say hello: josh[at]bethefuture[dot]space