UNIT
3
Study Session 1: Impact of Economic Capital on Health.
Study Session 2: Psycho-social Pathways.
Study Session 3: Cultural Capital.
Study Session 4: Social Capital.
By the end of this unit, you should be able to:

Outline the role economic capital plays in health.
 Outline Wilkinson´s hypothesis on income inequality and health.
 Describe the possible psycho-social mechanisms by which the social context impacts on health.
 Discuss the concept of cultural capital.
 Discuss the concept of social capital.
 Outline how social capital has been used to explain health outcomes.
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This session will provide you with an overview of the evidence linking economic capital, and more specifically income and wealth, to health outcomes. It will then outline the recent evidence that, above a certain threshold of per capita income, inequalities in income may matter more than absolute income for health outcomes in a population.
1 Learning outcomes of this session
2
3
Readings
Evidence of the link between income and health
4 The Wilkinson Hypothesis
There are four readings in this session, and four tasks.
By the end of this session, you should be able to:
 Understand the link between income and health.

Outline the Wilkinson Hypothesis.
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You will be referred to the following readings in the course of this session.
Author/s Reference details
Wagstaff, A., Bustreo, F.,
Bryce, J., Claeson, M. &
WHO-World Bank Child
Health and Poverty
Working Group
(2004). Child Health: Reaching the Poor. American
Journal of Public Health , 94 (5): 726-736.
Szreter, S. & Woolcock,
M.
Wilkinson, R.
Kaplan, G. A., Pamuk,
R.E., Lynch J. W.,
Cohen, R. D. & Balfour,
J. L.
(2002). Health by association? Social Capital, Social
Theory and the Political Economy of Public Health . Von
H ügel Institute Working Paper: 1-36.
(Jan 1992). Income Distribution and Life Expectancy.
British Medical Journal, 304 (6820): 165-168.
(April 1996). Inequality in Income and Mortality in the
United States: Analysis of Mortality and Potential
Pathways. British Medical Journal, 312 (7037): 999-1003.
Szreter, S. (1999). Rapid economic growth and ‘the four Ds’ of disruption, deprivation, disease and death: public health lessons from nineteenth century Britain for twenty-first century China? Tropic Medicine and International Health ,
4 (2): 146-152.
Although economic capital is not always an insurance against bad health, its opposite
- inadequate resources, for the individual, for the family or for institutions dedicated to the protection of health - pose a threat, which materialises in a multitude of ways.
READING
Wagstaff, A., Bustreo, F., Bryce, J., Claeson, M. & WHO-World Bank Child Health and
Poverty Working Group. (2004). Child Health: Reaching the Poor. American Journal of
Public Health , 94 (5): 726-736.
Szreter, S. & Woolcock, M.
(2002). Health by association? Social Capital, Social Theory and the Political Economy of Public Health . Von H ügel Institute Working Paper: 1-36.
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TASK 1 – Explore how income impacts on health
After studying the reading, answer this question:
In what ways did income and wealth impact upon health in the case described in the reading?
FEEDBACK
The impact of income on health is one of the most studied issues in Public Health, and findings are similar across history and societies. In the reading, the study shows that both social class and culture were important factors. This explains the levels of infant mortality with its heavy burden of infectious diseases, limited resources and different patterns of breast-feeding, in different social groups and geographical areas.
Among adults in the pre-industrial society, mortality was almost always higher in the poorest parts of the population than in the more wealthy groups. History gives many examples of the detrimental effects of drought and famine combined with an increased migration of poor people looking for work and food, leading to the spread of epidemics. As we are well aware, today’s world is still not free from starvation and under-nutrition owing to lack of economic capital and basic resources.
Once the medical agents in Western Europe could serve the population with good preventive advice during the 19th century, two factors contributed (for a period) to the increasing mortality differences between rich and poor. First of all, the rich lived in larger and healthier housing, and they could quickly afford the new technology giving access to clean water, sewerage, water toilets and other hygienic devices. Economic capital gave a quicker and qualitatively better health service, a factor that became more and more important when medical technology found new ways to care and cure. The wealthy and educated could also buy and read the new literature about a healthy way of feeding and caring for infants and children, probably one of the reasons for the decline of infant and child mortality, which started earlier in the middle class than in the poorer parts of the population.
Even societies that have reached a relatively high level of health are vulnerable to profound economic changes that affect parts of their populations negatively. This is illustrated by the economic crisis emerging in the communist part of Europe during the 1970s, combined with a stagnation of the mortality decline, compared with
Western Europe. This process has culminated in countries such as Russia during the dramatic re-organisation of the economy, with rising rates of unemployment, shrinking real wages and rising figures of mortality during the 1990s. At the same time, mortality differences by income, class and education have increased to the disadvantage of vulnerable parts of the population.
Poverty and inequality also cause health problems in developing countries. The lack of private and collective economic capital which could decrease the burden of disease is demonstrated by, for instance, the insufficient supply of vaccine and cures for old and new infectious diseases, notably HIV/AIDS, but also malaria, cholera, tuberculosis and other curable or preventable diseases. Except for the appearance
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of tuberculosis and similar problems in economically and socially marginalised urban sub-populations, these diseases are no longer a major problem in rich countries.
A low level of income inequality is positively correlated with health, when the groups that are compared are all provided with enough income and wealth to get the necessary material resources to protect their health. This less obvious phenomenon has puzzled health researchers for a long time, but we may have come a step closer to its solution when new theories are tested. “Better poor and happy than rich and unhappy” may be true in some cases, but it can also be said that “Better rich and happy than poor and unhappy” is a proven fact. Income and economic capital is, in many societies, a sign of success for the wealthy. One hypothesis is that economic capital is correlated with emotional welfare and a better mobilisation of the psychological defence against disease and illness.
This idea, that it is more than just absolute income that is important for health, has received greater attention recently with the apparent finding that life expectancy does not seem to gain much after a certain minimum per capita. After this threshold, it seems to matter more how the income is distributed rather than the total income. This has been postulated by Wilkinson.
READING
Wilkinson, R. (Jan 1992). Income Distribution and Life Expectancy. British Medical Journal,
304 (6820): 165-168.
TASK 2 – Explain the threshold of impact of absolute income on health
Read Wilkinson (1992). a) After what level of income does absolute income per capita cease to make a difference to mortality? b) What could be other explanations of this finding?
FEEDBACK
It is possible that this finding is a result of the differences in measuring income and mortality across different countries. It would therefore be better to measure the relationship between income inequality and mortality within countries.
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READING
Kaplan, G. A., Pamuk, R. E., Lynch J. W., Cohen, R. D. & Balfour, J. L. (April 1996).
Inequality in Income and Mortality in the United States: Analysis of Mortality and Potential
Pathways. British Medical Journal, 312 (7037): 999-1003.
TASK 3 – How income inequality affects health
Read Kaplan et al (1996). a) How do these results relate to the findings comparing countries? b) What could be the pathways whereby income inequality leads to worse health?
FEEDBACK
This study and others seem to support the cross-national studies in demonstrating a link between income distribution and health, even after issues such as confounding, choices of indicators and ecological fallacy have been taken into account.
Let us assume for the moment that it is true that above a certain threshold in per capita income, the difference in health is no longer caused by absolute lack of income, but by differences in the distribution of the income. In other words, if we compare societies that have similar incomes per capita, we find that in those societies where the income is more evenly distributed (such as modern day Sweden or Norway), the life expectancy is far greater than societies where the income is not as evenly distributed (such as the United Kingdom or the United States). The question then arises: How does living in a society with an unequal distribution of income and wealth impact on your health?
READING
Szreter, S. (1999). Rapid economic growth and ‘the four Ds’ of disruption, deprivation, disease and death: public health lessons from nineteenth century Britain for twenty-first century China? Tropic Medicine and International Health , 4 (2): 146-152.
TASK 4 – How income inequality affects health
Read Szreter (1999).
How might economic growth and increasing inequalities lead to worse health?
Make a summary of the main points mentioned in the reading.
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FEEDBACK
Three possible mechanisms have been suggested to explain this finding:
1. Disparities in income result in poor health through direct psychological pathways and/or
2. Income disparities disrupt the social fabric and lead to disinvestment in “social capital” and/or
3. The income and wealth of many is still insufficient to ensure optimal health and welfare even in the most developed countries.
In the next session, we will examine each of these explanations in turn.
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This session will provide you with an overview of the evidence linking social and economic conditions with biological effects, and then ultimately with health outcomes.
This is a relatively new field, but with improvements in laboratory and measurement techniques it is developing fast.
1
2
3
Learning outcomes of this session
Readings
The association between social and economic conditions, psychological wellbeing and health
Possible biological links between psycho-social factors and health 4
5 References
There are four readings, and two tasks in this session.
By the end of this session, you should be able to:
 Review the association between social and economic conditions,
psychological well-being and health.
 Identify possible biological links between psycho-social factors and health.
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You will be referred to the following readings in the course of this session.
Author/s Reference details
Marmot M et al. (1997). Contribution of Job Control and Other Risk Factors to
Social Variations in Coronary Heart Disease Incidence. Lancet,
350: 235-9.
Kristenson, M et al.
(2001). Risk Factors for Coronary Heart Disease in Different
Socioeconomic Groups of Lithuania and Sweden - The
LiVicordia Study. Scandinavian Journal of Public Health, 29:
140-150.
Wilkinson R.
Marmot, M.
(1996). Ch 2 - Health Becomes a Social Science. In R.
Wilkinson. (ed). Unhealthy Societies: The Afflictions of
Inequality.
London: Routledge: 13-28.
(1999). Social Determinants of Disease. In M. Marmot & R. G.
Wilkinson. Social Determinants of Health.
Oxford University
Press: 12-13.
It has been found in numerous developed countries that self-rated health - measured by surveys where people estimated their health in different dimensions - is a good indicator of the general health status, and a good predictor for an individual’s future health. The positive correlation found in many studies between the strength of social networks, and self-rated health, has stimulated a discussion concerning the explanation for this phenomenon. It has, with good arguments, been said that social networks provide support, but the exact mechanisms whereby they become good for health has been harder to detect and describe in a simple way. The fact that weak or non-existing social networks are correlated with a wide variety of diseases and health problems has led to the conclusion that the correlation must exist due to a mediating factor which has an impact on all these complaints.
Stimulated by Aaron Antonovsky’s theory about the connection between good health and what he calls “sense of coherence” (1979), further research has found a positive correlation between social networks, self-rated health and the respo ndent’s answers concerning their physical and psychological vitality, feelings of being able to handle the work situation, getting positive feedback at work, and generally in life, high selfesteem, trust in other persons, positive hopes for the future and other answers indicating psychological well-being. On the other hand, chronic fatigue, passiveness, not feeling in control and not receiving feedback at work, being suspicious about
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other people’s intentions, frustration, low self-esteem, pessimism and hopelessness, are correlated with low self-declared health, sometimes even with conditions diagnosed as depression. These negative patterns can be found both among persons in high positions who feel that the expectations of themselves and others are exceeding their capacities, and by persons in low-paid, monotonous jobs with little control over their working conditions. Social stress has become a common word for these types of negative psycho-social experiences.
A clue to the possibility that psychological factors have an important impact on health outcomes has come from the work of Michael Marmot and others on the differences in health of British civil servants.
READING
Marmot, M. et al. (1997). Contribution of Job Control and Other Risk Factors to Social
Variations in Coronary Heart Disease Incidence. Lancet, 350: 235-9.
TASK 1 – Summarise some psychological factors that affect health
Read Marmot M et al (1997) and summarise the findings of this study.
FEEDBACK
This study seems to suggest that amongst English public servants, even after controlling for differences in other risk factors such as smoking, blood pressure, cholesterol etc, the hierarchical position within the administrative body was positively correlated with health, illustrating the effects of a variable which is more related to status and feeling of control at work than to the monthly salary.
Epidemiologists have started to measure the relationship between some of these psychosocial factors and the incidence of noncommunicable diseases, in particular comparing Eastern and Western Europe. Below is an example of such a study.
READING
Kristenson, M et al. (2001). Risk Factors for Coronary Heart Disease in Different
Socioeconomic Groups of Lithuania and Sweden - The LiVicordia Study. Scandinavian
Journal of Public Health, 29: 140-150.
On a larger scale, Richard Wilkinson used an index of income inequality (the range of income distribution in the population) for different countries, showing that life expectancy was lower than expected (according to their Gross National Product per capita) in countries where income distribution and income inequality was high. In
Wilkinson’s opinion, the reason was that inequalities create negative psycho-social effects, even among the wealthy classes in that society. His results have been questioned by other scholars who refer to the methodological problems of defining a
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relationship between two variables without access to individual data for both variables. You will come back to this issue in the next unit.
READING
Wilkinson R. (1996). Ch 2 - Health Becomes a Social Science. In R. Wilkinson. (ed).
Unhealthy Societies: The Afflictions of Inequality.
London: Routledge: 13-28.
TASK 2 – Social and political factors and their impact on health
Read Wilkinson (1996) and make notes on the social and political factors that have an impact on health.
It is not only conditions at work that are correlated with negative feelings. Studies in former communist Europe after the fall of the Berlin Wall in 1989 have given the same results, plus the respondents’ feeling of the pressure of unemployment. The respondents also express a pessimistic view of government’s ability to promote better times through supporting the welfare system or keeping a strict public budget in an economy in tough competition on the global market. Their pessimism extends to both the political system of the past and the new regime. Coupled with a dramatic rise in crime, these factors result in frustration and pessimism caused by forces people feel are outside their influence. Today’s Russia and other former communist states have been described as socially stressed societies .
4
The idea of psycho-social factors being responsible for the differences in mortality has been taken further by both epidemiologists and animal researchers. Biomedical research has recently become interested in this intriguing connection between social stress, psycho-social reactions and biological responses, which even leads to serious physiological health problems. It is well known that depression affects the immune system negatively, thereby increasing the risk of infections and probably also the risk of diabetes and cancer. Stress has been associated with gastro-intestinal problems, stroke and different types of cardiovascular diseases among adults.
One of the present theories about stress and cardiovascular disease is that several endocrinal processes are involved, one of them being increases in cortisol, a hormone activated during experiences of stress. Cortisol is a necessary substance that helps us to cope with stressing situations. Normally its level will go down when the stress is over, but if stress becomes chronic, the level stays high, and the defence systems against stress no longer function the way they should under normal circumstances. That, in its turn, undermines the capacity to meet problematic events in the future. The first sign of a dysfunction may be aggressiveness due to frustration,
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but in the end, vital exhaustion, passiveness and depression emerge; this theory that has been supported by recent studies.
The biological link is one more piece of information, and this provides us with a reasonable explanation of why there is a connection between social networks, psycho-social reactions and health risks on a wide scale. The documented risks of stress and depression - drug abuse, alcoholism, frustrated aggressiveness or passive ignorance of normal care of one’s own person - increase the number of health problems, many of which have been attributed to lifestyles.
Some of this work is summarised in the following reading by Marmot (1999) which you should now read.
READING
Marmot, M. (1999). Social Determinants of Disease. In M. Marmot & R. G. Wilkinson. Social
Determinants of Health.
Oxford University Press: 12-13.
In summary, economic capital is important for health. However there has been a strong case put forward that suggests that in more developed economies, in which citizens have attained a certain minimum income to provide them with the basic food, education and shelter, inequalities in income matter more. The pathways in which this works is not clear, but there is a suggestion that it is related to psycho-social effects. Central to this is the idea that in more unequal societies, there is a breakdown of social cohesion and what has been called social capital . It is to these concepts that we now turn.
Antonovsky, A. (1979). Health, Stress and Coping . San Francisco: Jossey-Bass.
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This session will provide you with an overview of the concept of cultural capital first developed by the French sociologist, Pierre Bourdieu.
1 Learning outcomes of this session
2 Readings
3 Different forms of capital
There is one reading and one task in this session.
By the end of this session, you should be able to:

Outline the different forms of capital.
 Describe the concept of cultural capital.
You will be referred to the following reading in the course of this session.
Author/s Reference details
Bourdieu, P. (1985). The Forms of Capital. In John G. Richardson. (ed). Handbook of Theory and Research for the Sociology of Education.
N.Y:
Greenwood: 241-258.
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The French sociologist and philosopher, Pierre Bourdieu, dedicated a large part of his research to the concept of symbolic capital . He has been credited with the foresight to introduce the concept of different forms of capital that interact with the traditional forms of capital - such as physical, economic and human. In the following reading he presents the different forms of capital.
READING
Bourdieu, P. (1985). The Forms of Capital. In John G. Richardson. (ed). Handbook of Theory and Research for the Sociology of Education.
N.Y: Greenwood: 241-258.
TASK 1 – The relationship between economic and cultural capital
Read Bourdieu (1985).
What is the relationship between economic and cultural capital?
Cultural capital consists of knowledge , even what may be called knowledge by doing or tacit knowledge, which is provided by upbringing and life experiences. It is knowledge of how things are or work in practice in the dominant perceptions of people around you. It is strongly associated with the self-appointed elite, who usually consider themselves the people that matter in a specific context. It also entails knowing and having the competence to behave in a manner that lets one be accepted in a certain culture, social group, or local society. Hence, cultural capital can be anything from knowing how to solve a mathematical problem to saying the right thing at a dinner table, or to wearing the right dress for the right moment (if that is what is important to becoming one of the elite).
Bourdieu was not specifically discussing the relation between health and cultural capital or the more obvious advantages of knowledge such as how to feed a child properl y or having access to the best available information on how to protect one’s own health. His major interest was how cultural capital ( embodied knowledge ) - acquired by upbringing and by formal education ( institutionalised knowledge ) - opens the doors to the right circles, to the right work, to influence and prestige. Cultural capital was therefore, for Bourdieu, a social resource which invested its owners with power. Having studied how cultural capital played a role in a North African population, he applied his findings to his own country, especially to how the elite reproduces its capital through the generations, and dominates the power structures of society. His definition describes a resource attributable both to a group and a single individual within the group.
Economic capital can be used to get cultural capital, but economic wealth does not necessarily lead it. Bourdieu describes the sophisticated manners and taste of the old noblesse (nobility), which it directed towards what it considered to be sublime , for instance in arts and literature. Ownership of a piece of art or a collection of books is
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therefore not just invested with a price on a commercial market, but also with a symbolic value, providing the owner with distinction . He contrasts this lifestyle with the more materialistic tastes and insignia of the newly rich, who often demonstrate their status by lavish lifestyles, big houses and luxury cars. This can also be seen in the taste for different sports between economic classes: for instance in England, the upper classes are dedicated to cricket, while tennis and golf have gradually become middle class activities; football, once an activity for the upper classes, is now a popular sport amongst the working class.
Even the perception of the ideal body can vary in different groups: for example the notion of the slim French intellectual , compared to the muscular body of a working class young man. Historically, the ideal of the body has changed back and forth. If you visit a well equipped art museum - or take a quick trip through some pages on the Internet - it is possible to see, for instance, the contrast between the European medieval paintings of dressed, slender virgins compared to the portraits of well-fed persons during the 17th and early 18th century Baroque period. At that time, body mass was a sign of wealth, further underlined by the appearance of the more moderate statures of peasants and workers on folklore paintings from the same period. Skipping 250 years up to today, the female stars on TV and posters give you a feeling of hard starvation before reaching their bodily ideals, while the male models are a bit more well-fed and provided with a moderate mass of muscles. If they are white, they will usually also have acquired a certain light brown tan, probably from time-efficient visits to the solarium. Supported by the medicalisation (identification as a medical problem) of overweight, “obesity” and similar less neutral words have acquired a cultural stigma related to certain groups, who are seen as ignorant or at least insufficiently educated.
What we are seeing is that what is seen as good taste can “migrate” over time between social groups. Smoking cigarettes provides another example from Europe and the United States: having been a habit of “distinguished” modern upper and middle class men (and later also women) during the interwar period, it spread to other social groups who had previously mostly smoked pipes or used snuff; this transition process was encouraged by the media and commercial interests.
Nowadays, mostly because of the medical dangers described in Public Health campaigns, smoking has become relatively rare among the educated and looked upon as a stigma of the less educated, in stressful, low-paid jobs, for instance working class women.
Jazz is another example: initially it was seen as a banal and depraved form of music by the social establishment. However, in the 1950s, when rock-and-roll and other forms of popular music became the dominant culture of the young and the general public, jazz acquired a sublime identity, and was consumed by a small group of intellectuals. Thereby, its content also changed, becoming a less accessible art for musicians and consumers. In a similar way, traditional folk music was looked down upon while it was mainstream popular culture, but became an estimated part of the cultural heritage for the few connoisseurs when it lost its grip to pop music.
This form of cultural migration is part of the process of constantly shaping and reshaping the content of cultural capital in the same way as science changes its ideas and explanations over time. It contributes to the making of social insiders with
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“distinction” (the word used by Bourdieu to describe cultural and social segregation).
Although cultural capital is to a great extent reproduced by “breeding” and formal education, it is also created by the sub-conscious adaptation to the lifestyles and norms of the group to which one belongs and with which one identifies. It contributes to feelings of what is right and wrong, an element of belonging and safety. But it can also be a tool for the preservation of social privileges, domination, segregation or social exclusion of outsiders.
These effects are not in any way the goals of French politics and law, which is, on the contrary, based on the traditions of “liberty, equality and brotherhood”, but arise through the elite character of the school system and other subtle mechanisms that keep them alive. A drastic example of formal “distinction” was of course found in apartheid South Africa, when de facto segregation was written into laws. In contexts like these, educational and linguistic segregation is an effective way to keep groups apart, and to conserve the in-bred reproduction of political, economic and social elites. In the cultural arena, this was symbolised by the Bantu Education system, one of the sparks that ignited active resistance against the apartheid system.
Cultural capital is not, as we have seen, shaped by an individual in a vacuum. It is provided by formal institutions and family, but also by other informal groups or networks from the cradle to the grave of each individual: voluntary associations, churches, trade unions, political parties, social clubs, neighbours, friends, colleagues at work, and other networks. This explains why cultural capital is so closely linked to what has been called social capital , Bourdieu’s second major concept. Cultural capital opens the doors to different networks and different networks cherish and foster different forms of cultural capital. Social capital is in brief a product of the individual’s connections to the different networks to which she belongs. She is born into certain networks; others will be opened (and sometimes closed again) later in life.
Social capital is described in the next session.
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2
3
4
An important advance in the understanding of how societal factors impact on health has been the development of the concept of social capital. This session will provide you with an overview of the evidence that has led some commentators to identify social capital as an important factor in good health.
1 Learning outcomes of this session
Readings
Evidence suggesting a link between social capital and health
Social capital
5 Social capital and Public Health
There are seven readings and two tasks in this session.
By the end of this session, you should be able to:
 Review two case studies suggesting a link between social cohesion and health.
 Define the different kinds of social capital.
 Review the evidence of the link between social capital and Public Health.
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2 READINGS
You will be referred to the following readings in the course of this session.
Author/s Reference details
Wilkinson, R.
Berkman, L. &
Syme, S. L.
Ch 6 - A Small Town in the USA, Wartime Britain, Eastern Europe and
Japan & Ch 7 - An Anthropology of Social Cohesion. In Unhealthy
Societies: The afflictions of inequality: 113-117 & 137-139.
(1979). Social Networks, Host Resistance and Mortality: a Nine Year
Follow Up Study of Alameda County Residents. American Journal of
Epidemiology, 109:186-204.
Cassel, J. (1995). The Contribution of the Social Environment to Host Resistance.
American Journal of Epidemiology, 141 (9): 798-814.
Macinko, J. &
Starfield, B.
Portes, A.
(2001). The Utility of Social Capital in Research on Health
Determinants. Milbank Quarterly, 7 (3): 387-427.
(1998). Social capital: Its origins and application in modern sociology .
Annual Review of Sociology, 24: 9-15.
Kawachi, I.,
Kennedy, B.,
Lochner, K. &
Prothrow-Smith, D.
(Sept 1997). Social Capital, Income Inequality and Mortality. American
Journal of Public Health, 87 (9):1491-1498.
Rose, R.
(2000). How Much Does Social Capital Add to Individual Health? A
Survey Study of Russia. Social Science and Medicine, 51: 1422-1435.
The Nobel prize winning economist Amartya Sen has pointed out that paradoxically the infant mortality rate and other objective measures of health in Britain improved significantly during the 1940s when she was at war. A similar finding was observed in a small town called Roseto in the United States that had much lower rates of cardiovascular disease than neighbouring towns, even though the inhabitants had the same levels of risk factors (blood pressure, smoking, obesity etc). In the next reading
Richard Wilkinson describes these two cases and suggests some explanations.
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READING
Wilkinson, R. Ch 6 - A Small Town in the USA, Wartime Britain, Eastern Europe and Japan &
Ch 7 - An Anthropology of Social Cohesion. In Unhealthy Societies: The afflictions of inequality: 113-117 & 137-139.
Various studies that have measured individual participation in networks and groups, and mortality rates have provided further evidence of the importance of social cohesion and participation in networks. One example is the following study from
Alameda County in California by Berkman & Syme (1979). Read this article, and the one by Cassel (1995) after reading the requirements of Task 1.
READINGS
Berkman, L. & Syme, S. L. (1979). Social Networks, Host Resistance and Mortality: a Nine
Year Follow Up Study of Alameda County Residents. American Journal of Epidemiology,
109:186-204.
Cassel, J. (1995). The Contribution of the Social Environment to Host Resistance. American
Journal of Epidemiology, 141 (9): 798-814.
TASK 1 – Social environment and social cohesion
Read Berkman & Syme (1979) and Cassel (1995). a) How do the findings from this study link to the article by Cassel on the role of social environment and host resistance? b) Does the lack of social cohesion in societies with high income inequality perhaps explain the Wilkinson Hypothesis?
We have already seen how public health researchers are linking poor health outcomes in many societies, not with absolute levels of income, but with relative differences in income. One pathway is that unequal societies create increased psycho-social stress in individuals. But it is not clear how this works. In other words, how do unequal societies produce psycho-social stress in individuals?
The two readings above are suggesting that the social cohesiveness and networks that people have is the link.
This is where the concept of social cohesion and social capital come into the picture.
There seems to be good reason to believe that social cohesion plays a role in protecting participants from excess mortality. In trying to more clearly measure social cohesion, epidemiologists have turned to a concept that has been widely used by criminologists and educational sociologists - social capital.
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In trying to explain the components of a community or society that has high levels of social cohesion, the concept of social capital has been introduced.
READING
Macinko, J. & Starfield, B. (2001). The Utility of Social Capital in Research on Health
Determinants. Milbank Quarterly, 79 (3): 387-427.
TASK 2
Read Macinko & Starfield (2001). a) Write a definition of the two different kinds of social capital.
Social capital is in brief a product of the individual’s connections to the different networks to which she belongs: she is born into certain networks, others will be opened (and sometimes closed again) later in life.
Like other forms of capital, social capital needs time and work - in other words, investment. To enter a network may need the previous acquisition of cultural capital through education or “breeding” (a joint process by the individual and her kin). To stay in the network means time invested in social activities with other members of the network, and other acts of confirmation and rituals of belonging and loyalty, defined by Bourdieu as “symbolic gifts”, for instance voluntary work, unpaid advice and help to members. Even a material gift may be exchanged, but its true value is not only - or primarily - measured in money, but in its symbolic value .
As we have already seen, social networks can prov ide a feeling of “belonging” (as opposed to isolation), identity, security and therefore also more self-confidence.
Normally, the more work that is invested in social capital, the more is the value of the network for the individual, while she is at the same time increasing the accumulated social capital of the network itself. Shared cultural capital, homogenous norms and beliefs tend to strengthen the network and contribute to mutual trust between its members, a valuable asset when needed. Therefore the network or one of its members can help in business transactions, in an occupational career or in times of trouble.
Although both cultural and social capitals need investment, they do not necessarily diminish when used. Economic capital can sometimes be more easily cashed in , but it will shrink at the same time and it can disappear because of a wrong investment.
There are also certain things - true friendship and altruism - that economic capital may not always be able to buy, but which can be a product of social capital. In some societies, money cannot secure a high position in business or public administration, while social capital may tip the balance in a favourable direction. Social (and cultural) capital is therefore a sustainable asset for individuals and society. However, that does not mean that it cannot be hurt, eroded and disappear for an individual, for a
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social group or for a whole society, when the social fabric develops in a negative way.
Social scientists have used the concept of social capital to explain a wide variety of social phenomena from educational performance, to criminality to Public Health.
The next reading summarises some of the ways it has been used in sociological research. Read Portes (1998).
READING
Portes, A. (1998). Social capital: Its origins and application in modern sociology . Annual
Review of Sociology, 24: 9-15.
A number of health researchers are now examining the relationship between levels of social capital and Public Health. Below is one of the first examples of such a study.
READING
Kawachi, I., Kennedy, B., Lochner, K. & Prothrow-Smith, D. (Sept 1997). Social Capital,
Income Inequality and Mortality. American Journal of Public Health, 87 (9):1491-1498.
TASK 3 –
Read Kawachi, Kennedy, Lochner & Prothrow-Smith (1997). a) What are the measures of social capital that are used? b) What relationship do the authors find between measures of social capital and income inequality? c) What relationship do they find between the measures of social capital and mortality?
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FEEDBACK
Questions relating to social trust, perceived lack of fairness, perceived helpfulness of others and group membership were used as measures of social capital. Yes there was a strong inverse relationship between these measures of social capital and income inequality. The more unequal the distribution of income the less social capital was present.
There was also a strong inverse relationship between the measures of social capital and mortality. Decreases in measures of social capital are associated with increases in mortality. Furthermore, this relationship did not change much when income inequality was controlled for, suggesting that income inequality impacts social capital, which in turn impacts on mortality.
This study was further supported by analysis of measures of social capital at a state level in the United States from a large general social survey where it was also possible to control for individual level confounders such as smoking, overweight, housing, etc. A person living in a state with low levels of social capital was at more risk of poor self-rated health (which has been found to correlate closely with actual health in this population) than a person living in a state with high levels of social capital even after adjusting for individual confounders (adjusted OR 1.41) (Kawachi et al, 1999).
Some researchers have now started to apply this concept to measure whether the recent increases in mortality in Russia are related to changes in social capital. Read
Rose (2000) and consider this assertion.
READING
Rose, R. (2000). How Much Does Social Capital Add to Individual Health? A Survey Study of
Russia. Social Science and Medicine, 51: 1422-1435.
Kawachi at al have outlined three possible mechanisms that might link social capital to health: by influencing health related behaviours; by influencing access to services and amenities and by affecting psycho-social pathways.
1) Health related behaviours may be influenced in neighbourhoods with high social capital, by allowing the more rapid diffusion of health information or increasing the likelihood that more healthy norms are adapted, (i.e. physical activity) and by exerting social control over deviant health related behaviour, (i.e. drug abuse).
2) Socially cohesive neighbourhoods are more successful at protecting local services from the effects of budget cuts and collectively creating extra services and amenities. Knowing people who work for local bureaucracies is also a feature of communities and individuals with high levels of social capital and this can quite often facilitate access to services (especially health services).
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3) More cohesive communities could lead to greater levels of trust in each other, and hence increases in self-esteem and mutual respect. As you have already seen in the previous unit, this could have biological importance.
However, some researchers are beginning to question the pathways that link income inequalities, social capital and health. We now turn to these critiques in the final unit of this module.
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