Thirty years on: reflecting on Fundamental Cause Theory and its implications for action

In September, the Glasgow Centre for Population Health and the University of Glasgow were delighted to host Professors Bruce Link and Jo Phelan – founders of Fundamental Cause Theory (FCT) – on the 30th anniversary of their seminal contribution to understanding health inequalities. Their visit presented a valuable opportunity to reflect on why, despite decades of research, health inequalities still persist across time and place.

Fundamental Cause Theory challenges us to look beyond individualised causes of poor health, such as lifestyle and health behaviours, and instead recognise that disadvantages are systemic, and are embedded in our political, economic and social structures. These structures shape people’s access to ‘flexible resources’, such as money, power, and social connections, which enable some groups to protect and promote their health, whilst others are left behind. Crucially, the theory exposes the mechanisms by which health inequalities are reproduced over time; diseases change, risk factors change, protective resources change, yet health inequalities persist. Unequal access to flexible resources, maintained and exacerbated through the weaponisation of stigma, racism, and other forms of discrimination, are central to explaining this persistence.

Fundamental Cause Theory has reframed how we understand health inequalities, but translating it into meaningful action remains a challenge, particularly within an economic system designed to prioritises profit over people. This workshop brought together academics, policymakers and practitioners to explore what action might look like on an individual and community level: how can we move from simply recognising fundamental causes, towards developing policies that mitigate, resist or undo the processes that perpetuate inequality?

This blog presents a new framework aimed at those who hold the levers to change, to ensure they are not exacerbating the problem of health inequalities, and are instead taking meaningful steps towards challenging and reducing them. It will reflect on key discussions from the seminar workshop, which explored ways to bring FCT’s insights to life in shaping fairer and healthier policies for Scotland.

The key discussion points set out by our presenters

We began the day with Bruce Link setting out the key tenets of FCT and the kinds of action that might minimise health inequalities as we continue to pursue the goal of eliminating them. Gerry McCartney then provided a convincing, evidence-based argument for the ways in which policy (specifically austerity policies) are heavily implicated in driving health inequality and, at the same time, for a notable lack of engagement with this evidence by many public health agencies and think tanks. Together these presentations suggested a bias against evidence that specifically investigates causes of a political nature. Using the example of stigma and how it creates barriers for vulnerable groups in their use of health services (those who are ‘missing’), David Baruffati moved the discussion onto the importance of recognising how fundamental causes shape people’s lived experiences via media discourses, policy-making and service delivery. Finally, Mhairi Mackenzie built on the previous presentations to ask ‘what FCT means for action on health inequalities in the here and now.’ She presented a framework which categorised action using Geronimus’ typology of Undo/Resist/Mitigate/Exacerbate (2002) and which seeks to prompt researchers, planners and practitioners to ask how practices and policies can be strengthened to mitigate rather than exacerbate inequalities, how they might help push back against health damaging policies and, how they might actively work to undo fundamental causes of health inequalities.

Figure 1 - Undo/Resist/Mitigate/Exacerbate: A Framework for Dialogue and Prioritisation (Mackenzie et al. 2025)

Workshop: Mobilising people and resources to mitigate and undo health inequalities in the Scottish context

With these presentations fresh in mind, the attendees were split into groups, each comprising a mix of policymakers, practitioners and academics. Drawing on the framework outlined above, participants engaged in frank discussion focused on the extent to which their own organisational policies, or those set out in Scotland’s Population Health Framework were likely to exacerbate, mitigate, resist or undo health inequalities. Their reflections demonstrated the value of engagement with the framework and highlighted both challenges and ways forward.

Discussion across most groups acknowledged the challenging political and economic environment, significantly challenging openness and/or capacity for policy change seeking to tackle health inequalities at their root causes. The  framework was identified as a useful tool for guiding collaborative thinking amongst stakeholders. It offered a coherent means to bring together a sustained focus on the  ultimate goal of undoing the fundamental causes of health inequalities with a need, in the current political and economic climate, to identify and prioritise policies and actions that mitigate health inequalities without inadvertently making them worse. The framework also helpfully provides a strategic focus on bridging these two elements of ‘undoing’ and ‘mitigating’ by mobilising people and resources towards challenging and reversing health inequalities. Some existing actions and initiatives were identified, including community wealth building, which were viewed to have potential to meaningfully contribute to this endeavour. Groups discussed that it would be helpful to have more worked examples of the framework in action.

For researchers, a key theme in discussions groups centred on the ineffective translation of research findings into policy, again highlighting the view that policy is often driven more by political considerations than by evidence. Some signalled a need for researchers and funders to move beyond the assumption that the production of research evidence, however compelling, was enough to encourage those with power to move towards ‘undoing’ health inequalities. More effective translation of research into policy requires more deliberate and effective exertion of influence on political decision-making, with clearer communications of ideas, theory and evidence beyond academia, and, deeper and more meaningful engagement with communities and the public. In moving towards resisting and undoing health inequalities, workshop participants emphasised the importance of greater activism, calling on researchers, practitioners and those in positions of relative privilege and power to actively engage and support efforts for change – recognising throughout history that activism has been a powerful  driver of social change.

The insights shared across these discussions will shape and inform the development of a forthcoming paper, where the final version of the  framework will be published. We thank all those who took part in the seminar and look forward to future collaborations in developing and putting the central ideas into practice.

 Please contact Mhairi Mackenzie for further information: mhairi.mackenzie@glasgow.ac.uk 

References

Clouston, S.A.P., Link, B. (2021). A Retrospective on Fundamental Cause Theory: State of the Literature and Goals for the Future. Annual Review of Sociology.

Geronimus A. T. (2000). To mitigate, resist, or undo: Addressing structural influences on the health of urban populations. American Journal of Public Health, 90(6), 867–872. 10.2105/ajph.90.6.867

Link BG, Phelan J. (1995). Social conditions as fundamental causes of disease. J Health Soc Behav; Spec No:80-94. PMID: 7560851. https://pubmed.ncbi.nlm.nih.gov/7560851/

Mackenzie M., Baruffati, D., McCartney, G., Pearce, J., Walsh, D. (in preparation). Health inequalities and a sliding scale of mitigation.

Scottish Government. Scotland’s population health framework 2025 - 2035. Edinburgh: Scottish Government; 2023.  https://www.gov.scot/publications/scotlands-population-health-framework/

Walsh, D., and McCartney, G. (2025). Social Murder? Austerity and Life Expectancy in the UK. Policy Press.