Proximate vs. Distal Causes: Lifelines & Socioeconomic Impact

Lifelines 1 In their 1995 article, “Social Conditions are Fundamental Causes of Disease,” Bruce Link and Jo Phelan note that proximate causes of disease have received much more attention than distal causes. Define proximate and distal causes and discuss the role of each in shaping the health outcomes of the patients Dr. Leana Wen encounters or treats in her work as an emergency room physician. What were the fundamental causes of disease in the patient stories? To what extent is Link & Phelan’s statement about proximate and distal causes of disease correct more than 25 years after their article was published? The 1995 article, by Bruce Link and Jo Phelan, “Social Conditions are Fundamental Causes of Disease”, introduces the idea that there are proximate and distal links to disease. They describe proximate risk factors as individual behavior based, like poor diet. Proximate risk factors are easier to control but don’t look at disease in a broader context, which is usually overlooked as a cause of disease. Distal risk factors are more difficult to control and look at the effects of socioeconomic status and it “contextualizes” risk factors meaning distal causes could influence proximate risk factors. In the book ,“Lifelines: A Doctor’s Journey in the Fight for Public Health”, by Dr. Leana Wen, we see distal and proximate causes that led to many preventable deaths if a patient’s socioeconomic status was better. Dr. Wen encountered many different types of diagnoses that might be due to individual behaviors causing physiological impacts in the body to develop illness, but socioeconomic effects must also be considered. In Dr.Wen’s prologue, she mentions that aside from prescribing medication for diabetes she recommends better eating habits for further prevention. Eating habits are crucial for preventing heart disease and diabetes but accessible and affordable food is not always a priority or an option for families. For this instance, Dr.Wen’s patient could only afford food from the corner store as it was cheap, but it only had fatty, processed food and no fruits or vegetables. Thus, the choice of the patient’s food is the proximate cause of disease. However, when the only source of food that is accessible and affordable is not necessarily the healthiest, a broader sociological factor is influencing health. Therefore, we see how distal factors, like food deserts, can influence proximate factors. Throughout the book, Dr.Wen emphasizes the importance and influence of public health and how there is a direct relationship between socioeconomic standing and good health. For instance, Dr.Wen had a patient who could barely breathe because her lungs were filled with fluid, but she was also on dialysis but missed her last three appointments because she couldn't afford a taxi and her son, who usually brings her to the clinic, had just been arrested. This demonstrates how her declining health is not necessarily because of individualistic behaviors, but rather the lack of transportation, which has exacerbated the degree of her illness. Having no transportation is the distal, broader, cause of illness as missed appointments are detrimental for health. However, her socioeconomic status (SES) is the fundamental cause of her disease, as due to it she could not afford a taxi to the clinic or pay her bills. Therefore, her SES provides more ways for distal causes to arise which then influence proximate causes. Link and Phelan’s statement about proximate causes receiving more attention than distal causes still applies after 25 years of publishing the article. For instance, Dr. Wen describes a situation where she had pediatric patients with asthma who come for treatment only to come again the next week. The likely proximate cause of asthma is an air pollutant causing irritation which physicians can treat. However, the Lifelines 1 distal causes, like poor living conditions, are not addressed or solved in treatment plans. Moreover, the proximate causes, like exposure to allergens and mold spores have received lots of attention as it is treatable and recognized as an irritant to asthma. However, the broader reason, like house conditions, are not considered much, causing recurring visits to the hospital. Treating direct causes will not fix the underlying reason, which are the distal causes such as houses with mold. However, behind the distal causes is the fundamental cause of disease, which is socioeconomic status (SES). Within Lifelines, there is a theme that patients with lower SES have more distal causes of disease which result in proximate causes. Moreover, proximate causes are still what receive more attention because they are more identifiable but are not permanent resolutions to illness. Causes of illness can be categorized into proximate and distal causes. As described by Link&Phelan’s article in 1995, distal causes are broader, overlooked causes of illness, while proximate risk factors are more individualistic and direct. However, the connection between disease and distal causes is through proximate causes, as distal causes can influence proximate causes. However, the fundamental cause of illness is SES because it influences how feasible it is for individuals to avoid disease, through precautions. We see this phenomena in the book Lifelines: A Doctor’s Journey in the Fight for Public Health, by Dr. Leana Wen, as she describes scenarios where SES is the underlying theme as it affects living conditions, food accessibility, and other distal causes which affect proximate risk factors. Thus, the link between poverty and illness still exists, with Link&Phelan’s statement about proximate and distal causes still being true, but SES being the root cause.