BRUCE LINK
University of California, Riverside 

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ACCORDING TO FUNDAMENTAL-CAUSE THEORY (e.g. Link and Phelan 1995; Phelan and Link 2015), health inequities originate in circumstances that favor people propitiously situated in socioeconomic and racial hierarchies. But large swaths of health-inequalities research turn the focus away from the actions of people with power and influence. Instead, attention is directed to the behaviors and circumstances of people who are disadvantaged with respect to these characteristics to ask what is wrong with “them.”  When this happens, attention is effectively diverted away from the actions of more advantaged individuals and groups, successfully providing them a pass with respect to absorbing any responsibility for inequities-producing action that may be theirs to own. Why might this happen?

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Our answer is that large and pervasive health inequalities pose a challenge for people who are advantaged with respect to their SES and racial and ethnic status. The challenge derives from the possibility that individuals advantageously situated both benefit from these inequities and are culpable in producing them. Shedding direct light on inequities-generating actions exposes these groups’ advantages to scrutiny and to the possibility of corrective efforts should they be deemed unfair (Brown 2008; Strega and Brown 2015). Challenged in these ways, “diversions” are actions that provide relief when they adeptly direct attention away from the self-supporting behaviors of the advantaged to the characteristics and circumstances of the disadvantaged. Put simply, a diversion constructs the source of the inequality in “them” (the disadvantaged) in their traits, their behaviors, their families, their communities, their cultural orientations, their genes, and their presumed inability to be resilient. Consequently, diversions occur when researchers turn attention away from the inequity-generating actions of more privileged groups allowing them to remain hidden and unchallenged.  

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What Diversions Divert From

 

According to fundamental-cause theory, health inequalities by socioeconomic status, race and ethnicity emerge when people deploy resources to ensure that advantaged health-related circumstances accrue to themselves and to those in their circle of caring. The action that creates inequalities is the action of those more propitiously situated with respect to SES-related resources and more advantageously located within racial hierarchies in the United States and around the globe (Link and Phelan 1995, Phelan, Link and Tehranifar 2010, Phelan and Link 2015). People use resources of knowledge, money, power, prestige and beneficial social connections to secure an advantage for themselves and/or their loved ones, whether it is to procure the best doctor, avoid environmental contaminants, or live in areas that are safe, clean, and replete with good options for nutritious food and healthy exercise. But despite the strong direction signs in these sociological theories, substantial bodies of health inequalities research pay little or no attention to the actions of the advantaged. 

 

Diversions in Health Inequities Research

 

• “Their problem” needs fixing. This diversion follows what seems to be a compelling logic: the worse health of people living in disadvantaged communities is attributable to problems in those communities. Research needs to identify what those problems are and help those affected fix them, whether it be to reduce violence, ensure access to safe drinking water, increase access to dental services, reduce the prevalence of vermin, or some other community-situated problem. Of course, problems like these are very real and need to be addressed. What is diversionary is an intense focus on a single problem without consideration of the source of multiple problems, how those problems developed and why they persist. Once it becomes “their problem,” one that exists on “their turf” then the diversionary message for more advantaged groups is that “it is not our fault, the problem is in their community.”

 

• If “they” could only be like “us.” Success and good health are postulated to accrue from intelligence, conscientiousness, perseverance, the ability to delay gratification and other such traits -- traits that more advantaged people often see as the source of their success and well-being. It follows that in order to address health inequities, these key traits need to be instilled in disadvantaged groups. Ideally, this would occur early in life when such traits are developing and might effectively be altered. If we could just boost intelligence, encourage conscientiousness, teach perseverance and increase the capacity to delay gratification, success and good health would follow for people from disadvantaged circumstances. The diversionary message rests in the identification of traits resident in individuals from disadvantaged groups with attention diverted away from the actions of more privileged groups.

 

• Bad Choices. Here the claim is that people from low SES origins have choices but make bad ones. They choose to eat poorly, exercise infrequently, drive without seatbelts, fail to follow through on medical advice, forgo screenings even if they are free, have their infants sleep on their stomachs, smoke cigarettes and binge drink. Directed toward “their” behavior, core features of diversions are realized in allowing the more advantageously situated to assert: “The worse health of the least well off is the result of their choices. It’s not my fault.”

 

• Genetic factors. Whether on their own or in concert with environmental conditions, genetic factors are enormously important for human health and need to be studied for that reason. But, substantial funds and elaborate programs of research have been mounted to address genetic factors as potential contributors to health inequities. While assessments of the accomplishments of these endeavors diverge (Kaufman et al. 2015, West et al. 2017), a successful turn of the explanatory lens from structural factors (i.e social inequalities) to individual (i.e. genetics) achieves a successful diversion. When interviewed about his article on genes and disparities by The Atlantic (Silverstein 2015), Kaufman put it like this, “If you show that this is a predisposition that is genetically determined—black people just have this gene, there’s nothing we can do about it, this is just nature—then society is completely absolved.” The search for the source of health inequities in genetic factors achieves a successful diversion – it’s not my fault, it’s nature’s fault.

 

Vulnerability & Resilience Among the “At-Risk.”

 

Despite theoretical exhortations to keep a sociological eye on structures of advantage, it is all too easy to leave them behind to ask, “Why do some people succumb while others seem to thrive?” When people are exposed to high rates of community violence, threats of deportation, police harassment, massive loss of blue-collar jobs, some of those exposed appear to do just fine, while others experience severe mental and physical health problems. What makes some people more resilient than others? It is an interesting intellectual issue again the question has become, “What is it about them?” Attention is diverted away from the actions of more advantaged or powerful groups.

 

Conclusion

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A principal fact motivating our consideration of diversions is that health inequities by race and socioeconomic status have remained prominent, even though national goals to reduce them have been repeatedly set over multiple decades. Despite the goal of Healthy People 2000 to reduce health inequalities and of Healthy People 2010 to eliminate them, health inequities have endured. This discrepancy between goals and outcomes may be due to the mistargeting of research to the wrong group. We argue that when diversions focus attention away from the self- promoting actions of privileged groups and to the characteristics or circumstances of underprivileged groups they contribute to the stalled progress in addressing health inequities. To the extent that diversionary research predominates, it creates a canon of work that blames marginalized groups and exculpates privileged groups. This canon shapes policy, influences interventions, and provides a sophisticated out for more privileged groups. Diversionary research creates an illusion that something is being done when, in fact, much of what transpires is misdirected thereby contributing to prominent enduring health inequities. 

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Bruce Link will speak at the Reverberations of Inequality Opening Conference, Panel 1: Health and Inequality, September 20,
9:00-10:40 am, 3501 Sansom Street. Click here to register.