3.stigma As A Fundamental Cause of Health Inequality

Stigma as a Fundamental Cause of Health Inequality
Oxford Handbooks Online

Bruce G. Link, Jo C. Phelan, and Mark L. Hatzenbuehler
The Oxford Handbook of Stigma, Discrimination, and Health
Edited by Brenda Major, John F. Dovidio, and Bruce G. Link
Print Publication Date: Jan 2018 Subject: Psychology, Social Psychology, Health Psychology
Online Publication Date: Dec 2017 DOI: 10.1093/oxfordhb/9780190243470.013.4
Abstract and Keywords
Accumulating evidence shows that stigma has health-harming consequences that build
health disparities between those who are stigmatized and those who are not. However,
most research has considered one stigmatized status at a time as it affects (generally)
one outcome at a time. Moving from this singular focus to consider all forms of stigma as
they affect multiple outcomes suggests a large and pervasive effect of stigma on life
chances. This chapter considers whether stigma should be classified as a “fundamental
cause”—an especially pernicious social factor that remains persistently associated with
health inequalities over time. The chapter concludes by observing that if the stigma-as-a-
fundamental-cause idea is supported, it follows that reductive efforts to address
disparities via biomedical interventions will fail. Stigma stands as a factor that needs to
be addressed in its own right if health inequalities are to be addressed and population
health improved.
Keywords: fundamental causes, health disparities, stigma, stigma motives, social determinants of health, racism
and health
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The aim of this volume is to elucidate the many ways in which stigma affects physical
health. This chapter contributes to that theme by linking stigma to the social
determinants of health and by claiming that stigma should be considered a social
determinant of health, alongside education, housing, occupations, social relationships,
and access to quality medical care. Furthermore, we propose stigma as a “fundamental
cause” of health inequalities, a concept that has previously been applied to socioeconomic
status and racism. By fundamental cause, we mean an especially pernicious social factor
or circumstance that remains persistently associated with health inequalities over time
despite dramatic changes in diseases, risk factors, and health interventions. The
significance of identifying stigma as a fundamental cause is that policies and
interventions must address stigma itself rather than the mechanisms that link it to health.
Otherwise, stigma will continually produce health inequalities through the creation of
new mechanisms. We begin with our definition of stigma and the role that power plays in
it, followed by a discussion of stigma as a social determinant of health. We then explicate
the fundamental cause concept as it was originally applied to socioeconomic status and
later extended to racism. Finally, we argue and marshal evidence that stigma is a
fundamental cause of health inequities.
Power in the Definition of Stigma

We use a definition of stigma that broadly coheres with the definition used by other
authors of this volume, whether that definition is from Goffman (1963)—an “attribute that
is deeply discrediting” and that reduces the bearer “from a whole and usual person to a
tainted, discounted one” (p. 3)—or Crocker, Major, and Steele’s (1998) revision of that
definition as “a social identity that is devalued in a particular social context” (p. 505).
What we add is an emphasis on power, by which we mean a person’s ability to exercise
his or her will even against (p. 54) resistance from others (Weber, 1978). The definition is
taken from Link and Phelan (2001) and asserts that
stigma exists when the following interrelated components converge. In the first
component, people distinguish and label human differences. In the second,
dominant cultural beliefs link labeled persons to undesirable characteristics—to
negative stereotypes. In the third, labeled persons are placed in distinct
categories so as to accomplish some degree of separation of “us” from “them.” In
the fourth, labeled persons experience status loss and discrimination that lead to
unequal outcomes. Stigmatization is entirely contingent on access to social,
economic and political power that allows the identification of differentness, the
construction of stereotypes, the separation of labeled persons into distinct
categories and the full execution of disapproval, rejection, exclusion and
discrimination. Thus we apply the term stigma when elements of labeling,
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stereotyping, separation, status loss and discrimination co-occur in a power

situation that allows them to unfold. (p. 367)
The focus on power, when joined with the other components of the definition, allows us to
see that power is likely to be involved in the development of stigma. In particular, we
argue that people who are inclined to stigmatize others (stigmatizers) need power to
ensure that the human differences they choose to focus on are broadly identified in the
culture as differences to be reckoned with. They need power to ensure that the culture
recognizes and deeply accepts the stereotypes they connect to labeled differences.
Furthermore, stigmatizers need power to have the “us”/”them” categories they prefer be
identified as the categories that really matter on the social stage. Finally, stigmatizers
need broad institutional power in domains such as education, jobs, housing, and health
care to ensure that their categories, their stereotypes, and their preferences for deciding
who belongs have real consequential teeth for what matters for people’s life chances.
When one adopts this lens for understanding stigma, one sees that stigma is not an equal
opportunity adventure but, rather, one that is massively dependent on power. Not
everyone gets to choose which of all the possible human attributes become Goffman’s
(1963) deeply discredited ones. And although stigma is situationally dependent, occurring
in some contexts and not others, the range of situational contexts people encounter is
strongly influenced by power differences. White citizens who encounter a police officer
from a force heavily dominated by White officers are much less likely to encounter biases
than are Black citizens. Of course the opposite could occur—a White person could
encounter a Black police officer who harbors stereotypes about the dangerousness of
White people—but it is much less likely to actually happen. And so it is with stigmatized
circumstance after stigmatized circumstance—the chances of encountering situations in
which stigma is enacted are strongly affected by the power hierarchies extant in the
society at large.
Having drawn attention to power in stigma processes, it is important to observe that the
kind of power that is exercised goes beyond the obvious sort of power that we see in war,
police operations, dictatorships, judicial actions, or the passage and enactment of laws.
Often, it is a kind of power that takes shape in taken-for-granted cultural circumstances
that are not obvious to the casual observer. The concept of “White places” that make
minority group members feel unwelcome and out of place is for the most part invisible to
the average White person who is unaffected by them (Pinkett, Robinson, & Patterson,
2011). Indeed, if we examine stigma processes described in other chapters of this book,
we will note that in many instances (e.g., stereotype threat, aversive racism, and implicit
biases) the processes described are ones that are hidden from a casual observer’s view.
In keeping with these observations, Link and Phelan (2014) made a connection between
power as exerted in stigma processes, or “stigma power” as they called it, and the ideas
of the French sociologist Pierre Bourdieu concerning “symbolic power” (Bourdieu, 1987,
1990). According to Bourdieu, symbolic power is the capacity to impose on others a
legitimatized vision of the social world and the cleavages within that world, an assertion
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that corresponds closely to our focus (mentioned previously) on issues of who gets to
decide which human attributes are stigmatized, which stereotypes are applied and how
strongly, and which groups must operate as a “them” distinct from a dominant “us.” Thus,
stigma power is a form of Bourdieu’s more general concept of symbolic power. Support
for this very same contention regarding the importance of a legitimated vision of the
social world could be derived from social dominance theory in social psychology with its
focus on “legitimizing myths” (Sidanius & Pratto, 2011).
Stigma as a Social Determinant of Health

Having argued that power is central to stigma, we might expect an unequal society with
large power (p. 55) differentials to generate many stigmatized statuses with many
disadvantaged outcomes. However, the full extent of stigma as a significant source of
social inequalities in life chances such as housing, education, jobs, and the opportunity to
live a healthy life has generally been underrecognized. One reason is that most research
proceeds by examining the stigma associated with only one circumstance (e.g., AIDS,
mental illness, obesity, or sexual preference) and only one outcome (e.g., earnings, self-
esteem, housing, social interactions, or mental health status) at a time. Table 3.1 depicts
this approach, with each row representing a study that involves one stigmatizing
characteristic and one outcome marked by a single “X.” Using this approach, researchers
often find an effect of stigma on the selected outcome under consideration. However,
because many factors other than stigma also influence that outcome, stigma appears to
be just one factor among many. This can lead to the erroneous conclusion that stigma,
although it may contribute to social and health inequalities, has relatively modest effects
compared to other factors.
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Table 3.1 Apparently Modest Impact of Stigma When Studies Assess Only One Stigmatized Status and Only One Outcome at a Time
Outcome
Stigmatized Housing Educational Social Health Health Care Health

Status Attainment Relationships Behaviors
Mental illness X
Sexual minority X
Obesity X
HIV/AIDS X
Disability X
Minority race/ X
ethnicity
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A very different picture emerges when we adopt a broader view. Specifically, if we

leverage Link and Phelan’s (2001) definition or any other definition of stigma, and
consider the wide range and large number of circumstances that fit such definitions, the
prevalence of exposure to stigma across many stigmatized statuses is likely to be quite
high. In addition, stigma rarely affects just one domain of life chances but instead has
effects on many. Thus, as depicted in Table 3.2, the overall effect of stigma must be
considered to be all of the “X” ’s in the table and not just one. In an assessment of
precisely this issue, Hatzenbuehler, Phelan, and Link (2013) examined multiple
stigmatized statuses together with multiple stigma-related outcomes and found that
stigma disrupts multiple life domains for members of multiple stigmatized groups.
Specifically, the authors chose six stigmatized statuses/characteristics (mental illness,
minority sexual orientation, obesity, HIV/AIDS, disability, and minority race/ethnicity) that
were the focus of recent quantitative (i.e., meta-analytic) and qualitative reviews and
examined the range of outcomes with which these statuses/characteristics were
associated. The results were consistent with the multiple stigma–multiple outcome
conceptualization in two important ways. First, when considered together, the six
stigmatized conditions were found to affect more than half of the general population.
Second, the stigma associated with these conditions was found to be related to critically
important life domains, such as housing, employment or income, social relationships,
psychological or behavioral responses, health care access, and health.
The results of Hatzenbuehler et al.’s (2013) review highlighted two very important points
with respect to stigma as a source of life chances. First, when one studies the impact of a
particular stigma for a particular outcome, it is important to keep in mind that the
particular status under consideration can affect many outcomes, not just one. Thus, a full
accounting must consider the overall effect of a particular stigma on many outcomes.
Second, in studying a particular outcome, many stigmatized statuses may be involved in
determining that (p. 56) outcome. Thus, for example, it is not just stigma associated with
mental illness that influences who is unemployed but, rather, the stigma associated with a
host of stigmatized status, including obesity, HIV/AIDS, sexual orientation, disability, and
minority race/ethnic status. A full assessment of the impact of stigma on such an outcome
must therefore take into account that many stigmatizing circumstances may contribute to
that outcome and not just the one selected for a particular study.
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Table 3.2 Potentially Large Impact of Stigma When All Stigmatized Statuses and All Outcomes Are Considered
Outcome
Stigmatized Housing Educational Social Health Health Care Health

Status Attainment Relationships Behaviors
Mental illness X X X X X X
Sexual minority X X X X X X
Obesity X X X X X X
HIV/AIDS X X X X X X
Disability X X X X X X
Minority race/ X X X X X X
ethnicity
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Given the pervasiveness of stigma, its disruption of multiple life chances (e.g., resources,
social relationships, and coping behaviors), and its corrosive impact on the health of
populations, Hatzenbuehler et al. (2013) concluded that stigma should be considered
alongside the other major organizing concepts for research on social determinants of
health and other inequalities. In light of the current volume’s focus on stigma and health,
Hatzenbuehler et al.’s paper is important because it shows that stigma influences many of
the so-called social determinants of health. Thus, to the extent that stigma limits or
impairs social relationships, constrains housing choices, impedes access to education,
blocks job opportunities, imposes a barrier on the reception of quality health care, and
induces stress, it enables a broad band of social determinants of health (for citations
supportive of these possibilities, see Hatzenbuehler et al., 2013, Table 2). Evidence for
connections between these social determinants and multiple health outcomes has grown
substantially during the past several decades, and although controversy still remains in
some domains, the general conclusion that social conditions matter greatly for health has
gained substantial credibility. It follows that when stigma researchers identify
mechanisms linking stigma to such social determinants, they simultaneously provide
evidence bearing on the importance of stigma for health.
As previously mentioned, many of the domains that the Hatzenbuehler et al. (2013) paper
identifies as being affected by stigma—social relationships, education, jobs, housing, and
access to health care—have large literatures documenting health consequences. Reviews
of the evidence concerning such social determinants can be found in the sociological
literature in, for example, the Handbook of Medical Sociology (Bird, Conrad, Fremont, &
Timmermans, 2010) or in the epidemiological literature in, for example, Social
Epidemiology (Berkman, Kawachi, & Glymour, 2014). These two volumes seek to capture
the state of the evidence concerning the social determinants of health and thereby allow
us to underscore two critical points relevant to the approach taken here. First, the
comprehensive reviews these two volumes contain make the strong case that social
determinants do matter, sometimes greatly, for health outcomes, thereby supporting our
contention that stigma, which has been shown to influence these social factors, is also an
important social determinant of health. Second, although each of these texts contains a
chapter on race and ethnic prejudice/discrimination, neither one includes a chapter on
stigma more broadly, supporting our contention that stigma is underrecognized as a
social determinant of health.
Thus, one point of this chapter is that stigma influences many social determinants of
health and therefore should be considered a social determinant itself. But furthermore,
the multiplicity of (p. 57) mechanisms linking stigma with health is a hallmark of a
particularly potent and recalcitrant social determinant of health, which we have called a
fundamental cause.
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Fundamental Causes
The theory of “fundamental social causes” (Link & Phelan, 1995; Phelan, Link, &
Tehranifar, 2010) was first applied to socioeconomic status (SES). It starts with the
observation of social inequalities in morbidity and mortality by indicators of SES such as
education, occupation, income, and wealth. The standard trope used to understand and
address such disparities is to identify the modifiable intervening risk factors, address
those risk factors, and thereby address the broader health inequalities. However, a
prominent set of facts concerning the generality of the SES–health association across
places (Mackenbach et al., 2015) and times (Antonovsky, 1967) suggests that a different
understanding may be needed.
To exemplify what we mean, consider the strong association between SES and mortality
that was found in Rhode Island in 1865: People of greater means (“taxpayers”) were
much less likely to die compared to people of lesser means (“non-taxpayers”) (Chapin,
1924). The main causes of death at that time were cholera, tuberculosis, and small pox,
and the main SES-related risk factors were contaminated water, substandard housing
conditions, and poor sanitation. These intervening modifiable risk factors were addressed
with the development of modern sanitation systems, improved housing conditions, and
cleaner water systems. Moreover, vaccines and new medications ensured that people no
longer die of cholera, tuberculosis, and small pox in Rhode Island. The mechanisms that
intervened between SES and disease were blocked, but the association is resilient and
still very much evident in the current era. It is this persistence across time that Link and
Phelan (1995) aimed to explain with their theory of fundamental causes. They reasoned
that one cannot claim to understand why health inequalities exist if one cannot explain
why they persist under conditions that should eliminate or reduce them, and if one can
understand why they persist, this may provide clues to the more general problem of the
causes of health inequalities.
In order to account for the reproduction of SES gradients in different places and at
different times, Link and Phelan (1995) posit that SES-related resources of knowledge,
money, power, prestige, and beneficial social connections are “flexible resources” that
can be used in different places and at different times to garner a health advantage.
Consequently, fundamental causes can affect health even when the profiles of risk and
protective factors and diseases change radically. For example, if the problem is cholera in
the 19th century, a person with greater resources might be expected to be better able to
avoid areas where the disease is rampant, and one would expect that highly resourced
communities would be better able to prohibit entry of infected persons. If the problem is
heart disease in the current era, one would expect that a person with greater resources is
better able to maintain a heart-healthy lifestyle and get the best medical treatment
available. The flexible nature of the resources leads to the re-expression of SES gradients
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at different places and at different times. It is this re-expression that led Link and Phelan
to deem such causes “fundamental causes.”
Figure 3.1 depicts the theory by representing three historical periods. Within each
historical period, people possess varying levels of the flexible resources the theory
identifies—knowledge, money, power, prestige, and beneficial social connections. The
idea is that these resources are deployed individually and collectively to garner a health
advantage in terms of the risk factors and protective factors known to influence the
diseases extant at the time. The key point is that these risk and protective factors change
from period to period as knowledge and technology develop to address particular
diseases. Thus, in the example of Rhode Island in 1865, peoples’ levels of flexible
resources influenced exposure to substandard housing, contaminated water, and
inadequate sanitation, and these were major mechanisms (Figure 3.1, bold arrows)
creating health inequalities (Figure 3.1, historical period 1). As knowledge of these risk
factor mechanisms grew and approaches to addressing them were developed, their
importance in creating inequalities declined (Figure 3.1, historical period 2). By a third
historical period after the development of antibiotics and vaccines, some disease
mechanisms were almost completely blocked (Figure 3.1, dashed arrows), and people no
longer die of cholera, small pox, and tuberculosis in Rhode Island. However, as some
mechanisms linking flexible resources to disease declined, others came into existence. In
particular, as new knowledge and technology became available, its benefits were
maldistributed throughout the population, thereby creating new mechanisms linking
resources to health. (p. 58)
Ironically, perhaps, the

animating process in this
theory is progress in the
production of knowledge
and technology that
improves health. Examples
of knowledge are the
discovery that smoking is
harmful to health, that a
healthy diet and exercise
are important for health
Click to view larger
maintenance, and that
Figure 3.1 Multiple mediating mechanisms
reproduce social inequalities in health. taking an aspirin soon
after experiencing a heart
attack is beneficial to recovery. Examples of new technologies are medicines that control
blood pressure or reduce cholesterol, antiretroviral medications for HIV, and medical
procedures that dramatically reduce the impact of stroke if applied in a timely manner.
Consistent with the idea that people have learned something about how to address major
killers including heart disease, stroke, and, more recently, cancer and AIDS, age-adjusted
Page 10 of 27

death rates for such diseases have declined in recent years, in some instances
dramatically (Link, 2008; Phelan & Link, 2005).
The theory of fundamental causes engages this improvement to observe that the
distribution of the knowledge and technology that led to these advances has been uneven
(Link, 2008). People of higher SES have been more likely, individually and collectively, to
harness the benefits, thereby creating disparities. For example, evidence shows that
when new life-saving cancer screens were developed, a disparity in access to those
screens by SES indicators was evident in epidemiological data (Link, Northridge, Phelan,
& Ganz, 1998). Thus, from a health inequalities perspective, the development of the
screen and its subsequent maldistribution through the population created a new
mechanism linking SES to health. A review of the evidence regarding the theory can be
found in Phelan et al. (2010), and recent tests of some of its predictions are presented in
Rubin, Clouston, and Link (2014) and Mackenbach et al. (2015).
Previously, we provided evidence that stigma affects many social determinants of health,
such as education, occupation, housing, social relationships, and medical care. In the
context of fundamental cause theory, we can identify these as SES-related resources and
can state that one way in which stigma can have an important influence on health
outcomes is through its depletion of access to the flexible resources central to that theory.
If, for example, obesity stigma, incarceration stigma, or mental illness stigma limits
educational opportunities where knowledge might be procured, blocks access to good
jobs that might confer higher income and prestige, and constrains the formation of social
(p. 59) relationships that might provide beneficial connections, then members of
stigmatized groups would be expected to be less able to access the benefits of new
health-relevant knowledge and technology. The prediction would be for health disparities
between stigmatized and nonstigmatized groups to emerge or be exacerbated when new
health-relevant knowledge and technology becomes available and diffuses (unevenly)
through the population. To our knowledge, tests of this reasoning have not been
undertaken, leaving this idea as one that could be tested in future research. However, our
reasoning about stigma in relation to fundamental cause theory leads us beyond the
conclusion that stigma affects the flexible resources specified by that theory. Our interest
is in whether stigma can be considered a fundamental cause in its own right, and our
answer is that it can be.
Stigma as a Fundamental Cause of Health

Inequalities
We propose that stigma is a two-part fundamental cause of health inequalities. In the first
part, stigma is a fundamental cause of the flexible SES-related resources of knowledge,
money, power, prestige, and beneficial social connections, which in turn are a
fundamental cause of health inequalities (Hatzenbuehler et al., 2013). In the second part,
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stigma is a fundamental cause of health inequalities independent of SES-related

resources. To develop the argument supporting these claims, we draw on (1) work by
Phelan and Link (2015) that considers racism, arguably a prototype of stigma, as a
fundamental cause and (2) the line of argument presented previously and in
Hatzenbuehler et al. (2013) concerning the role of power in stigma, motives to keep
people down, in, or away, and a flexible and replaceable tool kit of mechanisms to achieve
such ends.
Racism as a Fundamental Cause of Health Inequalities
Phelan and Link (2015) took up the challenge of applying fundamental cause theory to a
cause other than SES. Specifically, they asked whether White racism could be considered
a fundamental cause of the inferior health experienced by Blacks. They note that like
health inequalities associated with SES, health inequalities by race exist across multiple
disease outcomes and are influenced by multiple risk factor mechanisms. Therefore,
descriptive facts suggest the possibility of a fundamental cause relationship, but what
Phelan and Link sought to address was whether the other characteristic features of a
fundamental cause are present in the association between racism and health.
Phelan and Link (2015) presented a two-step process that we extend beyond racism to
stigma more generally. In the first step, racism is a fundamental cause of SES-related
resources, which in turn are a fundamental cause of health outcomes. In the second step,
racism is a fundamental cause independent of SES-related risk factors. If we allow that
SES can be considered a fundamental cause of health inequalities, the two points
requiring further consideration are (1) whether racism is a fundamental cause of SES-
related resources and (2) whether racism is a fundamental cause of health inequalities
independent of those SES-related resources. With respect to the first issue, Phelan and
Link provide evidence that racism is associated with multiple SES-related outcomes
(educational attainment, housing, and jobs) through multiple mechanisms (redlining,
incarceration, interpersonal discrimination, etc.). Moreover, especially if one takes a
broad historical perspective, it is evident that the mechanisms of White racism have
changed from the institution of slavery to Jim Crow laws and Ku Klux Klan intimidation to
current-day incarceration policies and less obvious but still powerful social psychological
mechanisms such as aversive racism. Finally, in keeping with fundamental cause
reasoning, inequalities have persisted while mechanisms have changed. Educational
attainment, income, and wealth have increased over time for both Black and White
Americans, but racial gaps in median income (since 1948), wealth (since 1983), and
percentage with at least 4 years of college (since 1940) have remained relatively steady
or grown (McKernan, Ratcliffe, Steverle, & Zhang, 2013; US Census Bureau, 2016a,
2016b). Thus, the fundamental cause idea of replaceable mechanisms resulting in similar
outcomes across time appears to be consistent with a substantial body of evidence.
Page 12 of 27

With respect to the second issue concerning whether racism can be considered a
fundamental cause of health inequalities independent of SES, Phelan and Link (2015)
proceed by considering whether Blacks are disadvantaged relative to Whites with respect
to flexible resources that can be separated from SES. They conclude that with respect to
prestige (honor/deference), as evidenced by, for example, Whites’ explicit and implicit
attitudes, power as reflected in influence in interracial groups, and beneficial social
connections as influenced by racial segregation, Blacks experience decrements in flexible
resources separate from SES. In addition, (p. 60) in keeping with Amartya Sen’s (1999)
emphasis on freedom, Phelan and Link propose adding “freedom” to the list of flexible
resources to join knowledge, money, power, prestige, and beneficial social connections.
Whereas power—already on the list—refers to the ability to control others, freedom

involves the ability to control one’s own life circumstances. Also, freedom can be viewed
as a flexible resource. An obvious example helps make the point. A slave does not have
the freedom to avoid harm from his or her owner or overseer, to avoid harsh working
conditions, to relocate to escape infectious disease, or to control his or her access to
health care. In the current era, incarceration imposes a significant unfreedom (to use a
term introduced by Amartya Sen [1999]) that is maldistributed by race even with SES
controlled. Less extreme than slavery or incarceration, but nevertheless very real
examples of limits on freedom for Blacks, include official and unofficial harassment,
discrimination, and threat of harm that thwart Black Americans’ freedom of movement
and behavior, and also placing limitations on how one dresses and behaves and where one
walks, shops, eats, or drives (Feagin, 1991; Harris, 1999). Another highly consequential
unfreedom is discrimination in housing and employment, which thwarts Black Americans’
ability to live and work where they want (Pager, 2003; Turner & Ross, 2006). All these
sources of unfreedom hold controlling for SES.
Consistent with the idea that racism affects the distribution of flexible resources over and
above its influence on SES-related resources, most research shows that Blacks
experience worse health outcomes with SES controlled compared to Whites (Franks,
Muennig, Lubetkin, & Jia. 2006; Hayward, Miles, Crimmins, & Yang. 2000; House &
Williams, 2000; Hummer, 1996; Rogers, Hummer, & Nam, 2000; Sorlie, Backlund, &
Keller, 1995; for an exception, see Do, Frank, & Finch, 2012). In summary, Phelan and
Link (2015) conclude that the connection between race and health outcomes endures
largely because racism is a fundamental cause of racial differences in SES and because
SES is a fundamental cause of health inequalities but that racism also has a fundamental
association with health outcomes independent of SES.
This consideration of racism as a fundamental cause of health inequalities provides an

important building block for thinking about stigma more generally as a fundamental
cause of health inequalities.
Beyond Racism: Extending Fundamental Cause Theory to Other

Stigmatized Statuses
Page 13 of 27

Having developed the forgoing reasoning about SES and racism as fundamental causes of
health inequalities, we now explore a generalization of this thinking to other stigmatizing
circumstances. In doing so, we draw on previous work concerning motivations for
stigmatizing others (Phelan, Link, & Dovidio, 2008) and “stigma power” (Link & Phelan,
2014). These themes postulate that power is essential to stigma, that people have motives
in enacting stigma (keeping people down, in, or away), and that a flexible tool kit of
mechanisms exists to achieve desired ends.
One lesson learned in the extension of fundamental cause reasoning to racism is that the
key driver is different for racism as opposed to SES. Specifically, when SES is the
concern, the key driver of health disparities lies in an individual’s deployment of flexible
resources to influence his or her health outcomes. The action occurs when a person uses
flexible resources to situate him- or herself more propitiously with respect to health risks
and protections through individual action and contextual advantage. The implicit motive
is a desire to be healthy and to avoid pain and death. In racism, the key driver of health
disparities is the use of power in such a way as to constrain the chances of other people’s
opportunities for a prosperous and healthy life. The action lies in limiting the
opportunities of others in ways that have health consequences. But what are the
underlying motives that would lead us to predict that mechanisms would be replaced
such that if one mechanism failed another would be created? We need an explicit
consideration of the motives for such behavior.
Phelan et al. (2008) proposed three ends that people can attain through stigma-related
processes: (1) exploitation/domination, or keeping people down; (2) enforcement of social
norms, or keeping people in; and (3) avoidance of disease, or keeping people away.
Exploitation and Domination

Wealth, power, and high social status can be attained by a powerful group when that
group successfully dominates or exploits another. The path to domination and exploitation
is facilitated by stigma processes that create, legitimate, and perpetuate these
inequalities, with the group designated as the one to be kept down being deemed to be
inferior in terms of intelligence, character, competence, (p. 61) and the basic human
qualities of worthiness and value (Phelan et al., 2008). Classic examples are the racial
stigmatization of Blacks beginning in the era of slavery, the Europeans’ colonization of
countries throughout the world, and US Whites’ expropriation of the lands of American
Indians (Feagin, 2009).
Page 14 of 27

Enforcement of Social Norms

People construct systems of written and unwritten rules to govern everything from how
soldiers should fight wars to how people should line up at bus stops. Some degree of
investment in norms such as these develops as people come to count on them, leading
them to be upset when they are violated. Failure to comply with these norms is often cast
in terms of the flawed morality or character of the transgressor (Goffman, 1963), and
stigma processes are deployed as a corrective mechanism. Stigma is useful because it
imparts a stiff cost in the form of social disapproval that is intended to make subsequent
transgressions less likely. If the transgressor responds by conforming, he or she may be
allowed to rejoin the in-group, achieving what Braithwaite (1989) termed “reintegrative
shaming.” In this use of stigma, people are kept in by influencing the behavior of the
norm violator. However, this is not the only way stigma can be used to keep people in; the
people around the norm violator are also kept in by learning the boundaries of acceptable
behavior and by observing what happens to someone who goes beyond those boundaries
(Erikson, 1966).
Avoidance of Disease
Many illnesses and disabilities (e.g., psoriasis, dwarfism, and facial disfigurement) do not
seem to be stigmatized in order to exploit or dominate or in order to directly control
behavior and enforce norms. Kurzban and Leary (2001) provide another motivation for
stigmatization in these circumstances. They focus on evolutionary pressures to avoid
members of one’s species who may spread disease, noting that infection can lead to
“deviations from the organism’s normal (healthy) phenotype” (p. 197), such as
asymmetry, marks, lesions, and discoloration; coughing, sneezing, and excretion of fluids;
and behavioral anomalies due to damage to muscle-control systems. In this way, the
advantage of avoiding disease might have led to a distaste for deviations from the way
humans are supposed to look or carry themselves (Kurzban & Leary, 2001). In keeping
with these ideas, Park, Schaller, and Crandall (2007) considered the possibility that some
part of obesity stigma emerges from such psychological process (see also Van Leeuwen,
Hunt, & Park, 2015). Thus, a broad band of deviations might lead to a visceral response
of disgust and a strong desire to keep the person carrying such a deviation away.
Of course, these reasons for stigmatizing others are not mutually exclusive and can
operate in sequence or in concert. The key point is that whether it is to keep people
down, in, or away, there are motives or interests lying beneath the exercise of stigma. It
follows that people are likely to act to achieve outcomes consistent with those motives or
interests. Next, we briefly review four generic mechanisms that stigmatizers can use to
keep people down, in, or away.
Four Generic Mechanisms Provide a Flexible “Tool Kit” for Discrimination

Identifying and deeply understanding the mechanisms that connect stigma to physical
health is the central theme of this volume (see Chapter 1, this volume). As a consequence,
there is little need to review them in depth here because they are thoroughly addressed
Page 15 of 27

in several other chapters in this volume. At the same time, it is important for the line of
argument we develop to bring to mind the breadth of mechanisms through which people
can be kept down, in, or away.
Direct person-to-person discrimination is what people are most likely to think of when
they think of discrimination. In such direct discrimination, Person A discriminates against
Person B based on Person A’s prejudicial attitudes or stereotypes connected to a label
applied to Person B (Allport, 1954).
Discrimination that operates through the stigmatized individual occurs when ambient
stereotypes (e.g., dangerousness, incompetence, laziness, unpredictability, and
uncleanliness) and social psychological processes related to reactions to those
stereotypes (Link, Cullen, Struening, Shrout, & Dohrenwend, 1989; Link & Phelan, 2014;
Steele & Aronson, 1995) lead to disadvantaged outcomes for the targets of such
stereotypes.
Interactional discrimination emerges in the back-and-forth between individuals but does

not involve blatant and very obvious forms of discrimination (Phelan, Lucas, Ridgeway, &
Taylor, 2014; Sibicky & Dovidio, 1986). A classic example is the research conducted in the
so-called “expectations states” tradition in sociology that demonstrates that external
statuses (race, gender, and history of mental hospitalization) affect power and influence
in interactions (p. 62) between partners, even when the external status has no bearing on
the tasks performed in the experimental context (Lucas & Phelan, 2012).
Structural stigma (see Chapter 6, this volume) is defined as “societal-level conditions,

cultural norms, and institutional policies that constrain the opportunities, resources, and
well-being of the stigmatized” (Hatzenbuehler & Link, 2014, p. 2). Laws and policies that
disadvantage groups such as marriage bans for gays and lesbians or differential
sentencing for crack as opposed to powdered cocaine for racial and ethnic minorities are
examples of structural stigma. A policy or attitudinal context can directly disadvantage
people targeted by it, such as when a marriage ban directly restricts rights of some
people but not others. Policies or attitudinal contexts can also affect people indirectly,
such as when a strong negative evaluation of a particular stigmatized group
(undocumented immigrants in a border town) can make members of that group feel like
they do not truly belong and that they may be at risk if they engage in what other people
consider normal and expectable activities, such as driving a car, bringing a child to the
local school, or calling the police if one is the victim of a crime.
As previously mentioned, other chapters in this volume probe these mechanisms in much
more detail. What matters here is that there are multiple mechanisms through which
people’s interests in keeping others down, in, or away can be enacted. These mechanisms
can occur at the interpersonal level, they can act through the stigmatized person, they
can emerge in interactions, or they can be embedded in societal norms and structures.
And, of course, if one considers specific mechanisms, one recognizes that there is
substantial variation within these generic types. For example, there are all manner of
ways in which one person can make another feel less worthy and accepted, and there is
Page 16 of 27

an enormous variety of laws and policies that can be implemented (or fail to be
implemented) that lead to the disadvantage of stigmatized groups. Viewed in this way, the
mechanisms of stigma represent an extremely flexible tool kit that can be creatively
drawn upon by more powerful groups to ensure that their interests in keeping another
group down, in, or away are as successful as the power difference between them allows
(regarding the idea that relations between more and less powerful groups occur in a
system that can replace itself over time, see Sidanius & Pratto, 2011).
How Motivations to Stigmatize Coupled with a Flexible Tool Kit of

Discriminatory Practices Facilitate Fundamental Cause Relationships
Between Stigma and Health
The forgoing reasoning develops a theoretical basis for expecting a fundamental cause
relationship between stigma and health. Simply stated, if stigmatizers have strong
motives, the requisite power, and a flexible set of means, all of which persist over time,
we expect them to reliably achieve the ends they desire. Figure 3.2, like Figure 3.1,
portrays different historical periods with mechanisms that change across those periods. It
differs from Figure 3.1 in that it places the motives to stigmatize as the central factor that
produces the mechanisms that lead to health inequality. The core idea is that as long as
the motive to stigmatize is operative, new mechanisms will be developed to achieve
desired ends. A concrete example that appears to fit the model is the treatment of Black
people by White people in the United States. As previously mentioned, slavery was
followed by Jim Crow laws, Ku Klux Klan intimidation, and, most recently, unequal
exposure to mass incarceration. The fundamental cause hypothesis is that as long as the
motives to keep people down, in, or away remain strong, mechanisms will be replaced so
that such motives can be expressed.
When stigmatizers achieve aims of keeping people down, in, or away, they disadvantage
stigmatized groups via the two-step process described for racism as a fundamental cause.
In the first step, stigmatization depletes SES-related resources (knowledge, money,
power, prestige, and beneficial social connections). Then, according to fundamental cause
theory, these disadvantages produce health inequalities by blocking access to, and
inhibiting uptake of, new approaches to the prevention and cure of disease. Furthermore,
when stigmatization depletes flexible resources, it renders stigmatized groups more
vulnerable than others to untoward health consequences when tragedies (e.g., hurricanes
and economic downturns) strike. In the second step, stigmatization directly harms health
through a fundamental cause process that works independently of SES. Here, the
depletion of resources such as prestige, power, and freedom that fall outside the domain
of SES blocks access to health-enhancing measures and increases vulnerability for
stigmatized groups.
Perhaps the most obvious and compelling case for a fundamental cause explanation for
the reproduction of inequalities would come if we could see (p. 63) more powerful groups
creating and then implementing the most effective discriminatory mechanism possible:
Page 17 of 27

“Let’s try this. Whoops it’s not working, so let’s try that, and it might even work a little
better if we added this one other mechanism.” Sometimes this is all very obvious, and we
can see it happening in a historical record (e.g., the Nazi persecution and murder of Jews
and the institution and rationalization of Jim Crow laws). In other instances, it is much
more difficult to identify, either because the mechanisms are generally accepted as just
the way things are or because they are hidden in motives that are difficult to identify in
others or even in oneself. A White couple examining real estate might in a fleeting
instance use the proportion of Blacks in a neighborhood to judge neighborhood quality
and then choose to live in a “better” neighborhood that is more White, thereby
maintaining racial segregation even in an era that bans discrimination. Across a broad
band of stigmatized statuses, people can be made to feel they do not belong in a context,
do not fit the corporate image, are not the kind of student who belongs at a high-status
university, are not a person who should be dealing face-to-face with customers, are not
the kind of person who adopts a healthy lifestyle, or do not belong in this part of town or
in this area of the country (Covarrubias & Fryberg, 2015; Feagin, 1991; Johnson,
Richeson, & Finkel, 2011; Mendoza-Denton, Downey, Purdie, Davis, & Pietrzak, 2002;
Ostrove & Long, 2007; Stephens, Fryberg, Markus, Johnson, & Covarrubias, 2012). This
message of what has been aptly described as “belonging uncertainty” (Walton & Cohen,
2007) is powerful but communicated in a way that is often difficult to pinpoint (Bourdieu,
1987; Dovidio & Gaertner, 2004; Major & Crocker, 1993; Major, Feinstein, & Crocker,
1994; Pearson, Dovidio, & Gaertner, 2009). There are so many ways to make people feel
unwelcome that mechanism change in this obscure realm of rejection can be achieved
with ease.
Click to view larger

Figure 3.2 Multiple mediating mechanisms
reproduce disadvantage for stigmatized groups.
Page 18 of 27

Evidence and Predictions

In keeping with the intent of this volume’s emphasis on future research possibilities,
evidence for the theoretical conjectures set forth previously is incomplete. Hatzenbuehler
et al.’s (2013) review of reviews (described previously) provides evidence (p. 64)
consistent with the theory by showing (1) that multiple stigmatized statuses are related to
multiple life chances and (2) that this likely occurs because stigma affects the distribution
of many social determinants of health (housing, jobs, social networks, and access to
health care), thereby instantiating multiple health-relevant mechanisms. Next, we identify
several research agendas that might be pursued to test the theory and determine
whether it does in fact help us understand why health inequalities emerge and persist for
stigmatized groups.
Drawing on fundamental cause theory with respect to SES, Phelan, Link, Diez-Roux,
Kawachi, and Levin (2004) put forth the proposition that if the theory were true, then the
SES mortality gradient should be steeper for diseases for which death might be avoided
through prevention or cure (e.g., lung cancer, colon cancer, and heart disease) than for
diseases that the medical field is less adept at addressing (pancreatic cancer and brain
cancer). When people have relatively little knowledge as to how to prevent death from a
disease, flexible SES-related resources are of less use because there is no benefit they
can procure. However, when prevention (cancer screening and health behaviors) and
cure are achievable, people can use flexible resources to gain a health advantage. Results
from the US National Longitudinal Mortality Study generally support this theory (Phelan
et al., 2004), as have recent tests in multiple countries in Europe (Mackenbach et al.,
2015).
This testing strategy might be generalized to stigmatized groups, with the prediction
being that mortality inequalities for people with mental illnesses, people who have been
incarcerated, or people in sexual minority groups, for example, would be more
pronounced for causes of death that are preventable than for causes that are not. To our
knowledge, only one study has explored this possibility. Using morbidity data for the
years 2001–2011 from the Stockholm Public Health cohort, a representative general
population-based study in Stockholm, Sweden, Bränström, Hatzenbuehler, Pachankis, and
Link (2016) showed that there were no sexual orientation differences in morbidity due to
low-preventable diseases. In contrast, both gay/bisexual men and lesbian/bisexual women
showed higher prevalence of illness compared to heterosexuals for high-preventable
morbidity. This research provides some preliminary support for the fundamental cause
perspective as applied to sexual minorities and suggests the utility of pursuing this line of
work applied to other stigmatized groups.
In addition, in the area of stigma research, it would be possible to refine tests of

fundamental cause theory by using direct measures of stigma at the interpersonal or
structural level to predict variation within stigmatized groups. The prediction would be
that health inequalities between those more as opposed to less exposed to stigma/
Page 19 of 27

discrimination would be stronger for diseases for which death can be prevented than for
diseases for which death is less preventable. Such a test would be especially strong if the
exposure is ongoing or repeated frequently over time. An example of such a test could be
developed as an extension of an analysis by Chae et al. (2015). This study used rates of
Google searches for racist terms as a measure of the social climate of geographical areas
and found that age-adjusted mortality for Blacks was higher and inequalities were greater
in areas where rates of racist searches were high. The idea proposed here would be to
extend the test separating highly preventable causes of death from causes that are less
preventable. According to the theory, inequalities associated with racist contexts should
be higher for more, as opposed to less, preventable causes of death. This same kind of
analysis might be extended to other groups facing stigma/prejudice.
Fundamental cause theory predicts that when a newly found life-saving discovery
emerges (evidence that smoking is a cause of lung cancer, screening for cancer or
precancerous conditions, or antiretroviral drugs for HIV), people of high SES use flexible
resources to exploit new knowledge or procure the benefit more rapidly, thereby creating
an inequality in morbidity and mortality. Epidemiological trends support this prediction
for lung cancer (Rubin et al., 2014), colorectal cancer (Saldana-Ruiz, Clouston, Rubin,
Colen, & Link, 2013), HIV mortality (Rubin, Colen, & Link, 2010), and access to life-
saving cancer screening (Link et al., 1998), with SES disparities arising, rather than
diminishing, after new discoveries were made.
Extending fundamental cause theory to stigma would lead to the prediction that
stigmatized groups might be disadvantaged in the uptake of new discoveries and that we
might expect health inequalities to emerge or worsen when such discoveries are made.
For example, the discovery of the highly effective but expensive medicines for hepatitis C
might be expected to not only benefit wealthy people more than poorer people (because
of the cost) but also perhaps to be denied to stigmatized groups such as people addicted
to drugs (p. 65) or homeless people. In many states, Medicaid requirements demand that
people abstain from alcohol or illicit drugs for 1 year before hepatitis C treatment is made
available. Under circumstances such as these, we might expect disparities to grow as
stigmatized groups are excluded from life-saving treatments.
Fundamental cause theory specifies a replacement of mechanisms. When considering

SES as a fundamental cause, mechanisms are replaced when new beneficial knowledge
and technology is maldistributed. When one turns to stigma processes, it is the motives of
stigmatizers that lead to the selection of new mechanisms. As discussed previously,
Hatzenbuehler et al. (2013) provide examples of new mechanisms of racism and mental
illness stigma emerging as old ones are discarded. However, the idea of replaceable
stigma mechanisms remains just that, an idea—an idea that is consistent with some
observations but not yet thoroughly tested. Studying the history of the treatment of
multiple stigmatized groups to determine if new mechanisms emerge for keeping people
down, in, or away as old ones are discarded would add more evidence.
Page 20 of 27

The replacement of mechanisms might also be examined in experimental studies. Many

creative ideas along these lines might be conceived, but to give an example, we can
consider an experiment by Lucas and Phelan (2012) that showed fairly strong behavioral
social distance enacted to avoid a fictitious partner who participants were led to believe
had been hospitalized for mental illness. When given the binary choice to remain with the
same partner in a second phase of the study or pick the only other partner available,
participants were substantially more likely to pick the other partner if they were
randomly assigned to believe their initial partner had been hospitalized for mental illness.
One idea might be to block this mechanism of choice in a random half of the participants
who chose a different partner by informing them that a mistake had been made and that
really the only partner left was their initial partner. Then willingness to participate in the
second phase and/or actual attendance at the second session would be potential
outcomes. The logic from the point of view of the participant would be that if
investigators will not allow me to choose to stay away, then I will achieve the same aim by
dropping out or not showing up, providing support for the fundamental causes theory of
interchangeable mechanisms.
Conclusion
The overall theme of this volume is to elucidate the many ways in which stigma affects
physical health. This chapter contributes to that theme by linking stigma to the social
determinants of health and using fundamental cause theory to expand our conceptual
lens and make novel predictions about relations between stigma and physical health.
Thus, we claim, and many of the other chapters in this volume support the claim, that
stigma affects many of the social determinants of health, such as education, housing,
occupations, social relationships, and access to quality medical care. In fact, it is so
interconnected with these factors and so plausibly related to health through them that we
propose that going forward stigma be considered a social determinant of health along
with these other social determinants (Hatzenbuehler et al., 2013).
However, we also go beyond identifying stigma as an “upstream” factor with

“downstream” (health) consequences to claim stigma as a fundamental cause that tends
to reproduce associations between stigmatized statuses and life chances through
different mechanisms at different times and in different places. Although our assertion in
this regard coheres with enough existing evidence to allow us to make the assertion, it
has not been fully tested—a circumstance that spurred us to propose ways in which it
might be further tested in future work. If the idea survives such future testing, it says
something powerful about research such as that presented in this volume. When social
scientists study stigma, they simultaneously study factors that are integral to the social
shaping of population health. What they study cannot be forcefully addressed at the
biomedical level only, because as a fundamental cause, stigma will affect who does and
Page 21 of 27

who does not benefit from beneficial biomedical knowledge and technology. Stigma
stands as a factor that needs to be addressed in its own right as we seek to reduce health
inequalities and improve population health.
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Bruce G. Link
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Riverside, CA, USA
Jo C. Phelan
Jo C. Phelan, Mailman School of Public Health, Columbia University, New York, NY,
USA
Mark L. Hatzenbuehler
Mark L. Hatzenbuehler Mailman School of Public Health Columbia University New

York, NY, USA
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Abstract and Keywords

Subscriber: UWE Bristol Library; date: 18 September 2018

Power in the Definition of Stigma

Subscriber: UWE Bristol Library; date: 18 September 2018

stereotyping, separation, status loss and discrimination co-occur in a power

Subscriber: UWE Bristol Library; date: 18 September 2018

Stigma as a Social Determinant of Health

Subscriber: UWE Bristol Library; date: 18 September 2018

Stigmatized Housing Educational Social Health Health Care Health

Subscriber: UWE Bristol Library; date: 18 September 2018

A very different picture emerges when we adopt a broader view. Specifically, if we

Subscriber: UWE Bristol Library; date: 18 September 2018

Stigmatized Housing Educational Social Health Health Care Health

Subscriber: UWE Bristol Library; date: 18 September 2018

Subscriber: UWE Bristol Library; date: 18 September 2018

Subscriber: UWE Bristol Library; date: 18 September 2018

Ironically, perhaps, the

Subscriber: UWE Bristol Library; date: 18 September 2018

Stigma as a Fundamental Cause of Health

Subscriber: UWE Bristol Library; date: 18 September 2018

stigma is a fundamental cause of health inequalities independent of SES-related

Racism as a Fundamental Cause of Health Inequalities

Subscriber: UWE Bristol Library; date: 18 September 2018

Whereas power—already on the list—refers to the ability to control others, freedom

This consideration of racism as a fundamental cause of health inequalities provides an

Beyond Racism: Extending Fundamental Cause Theory to Other

Subscriber: UWE Bristol Library; date: 18 September 2018

Exploitation and Domination

Subscriber: UWE Bristol Library; date: 18 September 2018

Enforcement of Social Norms

Four Generic Mechanisms Provide a Flexible “Tool Kit” for Discrimination

Subscriber: UWE Bristol Library; date: 18 September 2018

Interactional discrimination emerges in the back-and-forth between individuals but does

Structural stigma (see Chapter 6, this volume) is defined as “societal-level conditions,

Subscriber: UWE Bristol Library; date: 18 September 2018

How Motivations to Stigmatize Coupled with a Flexible Tool Kit of

Subscriber: UWE Bristol Library; date: 18 September 2018

Click to view larger

Subscriber: UWE Bristol Library; date: 18 September 2018

Evidence and Predictions

In addition, in the area of stigma research, it would be possible to refine tests of

Subscriber: UWE Bristol Library; date: 18 September 2018

Fundamental cause theory specifies a replacement of mechanisms. When considering

Subscriber: UWE Bristol Library; date: 18 September 2018

The replacement of mechanisms might also be examined in experimental studies. Many

However, we also go beyond identifying stigma as an “upstream” factor with

Subscriber: UWE Bristol Library; date: 18 September 2018

Covarrubias, R., & Fryberg, S. A. (2015). The impact of self-relevant representations on

Subscriber: UWE Bristol Library; date: 18 September 2018

disparities in health. Social Science & Medicine, 74(9), 1385–1393. doi:10.1016/

Feagin, J. R. (1991). The continuing significance of race: Antiblack discrimination in

Goffman, E. (1963). Stigma: Notes on the management of spoiled identity. Englewood

Hummer, R. A. (1996). Black–White differences in health and mortality: A review and

Subscriber: UWE Bristol Library; date: 18 September 2018

Subscriber: UWE Bristol Library; date: 18 September 2018

Subscriber: UWE Bristol Library; date: 18 September 2018

Sen, A. (1999). Development as freedom. New York, NY: Knopf.