Disease aetiology and materialist explanations of socioeconomic mortality differentials

The social structure can affect health by distributing exposure to environmental hazards and by conditioning behaviours which damage or promote health. The present paper concentrates on the former route, which the Black Report described as the structural or materialist type of explanation of health inequalities. The contribution of materialist factors is assessed by examining socioeconomic mortality differentials as a form of relative deprivation and by presenting evidence of the sensitivity of these differentials to multiple indicators of social position. A definition of materialist factors is developed which generates hypotheses about disease causation. The literature on the aetiology of disease is reviewed to estimate the proportion of all deaths attributable to the materialist factors so-defined. An apparent discrepancy is identified between the lesser importance attributed to materialist factors in the aetiological literature and that suggested by the evidence initially presented. This discrepancy, it is argued, may be partly explained by artefactual processes but also reflects the complexity of the mechanisms by which socioeconomic gradients in disease are produced. An understanding of the processes through which materialist factors combine and accumulate over the course of life is an important target for understanding disease aetiology as well as socioeconomic differences in health.