Individuals tend to be healthier the higher they are on the income ladder. But nations with a higher GDP/capita are not necessarily healthier nations. A relationship has been found, however, between income inequality and population health status. Some of the literature that seeks to interpret these findings is reviewed. Some suggest equality may affect health through its impact on social cohesion or social capital. There are various mechanisms or dynamics through which different types of social capital might have an impact on health. Social capital may contribute directly to health or may result in policies that are more supportive of healthy outcomes.
IF THERE IS ONE canonical fact in population health research it is that social status and health are strongly related: in virtually every Western nation there is a relationship between the social status of individuals, variously measured, and a wide variety of health indicators. Epidemiological studies have generally measured socio-economic status (SES) in terms of income, educational attainment and occupational prestige scores. They have found relationships between SES and such health indicators as the incidence of cancer, heart or cardiovascular disease, hypertension, degree of obesity and morbidity and mortality in general.[ 1 ]
Income and health
The simplest explanations for the relationships generally describe purchasing power (from income), knowledge power (from education) and employment power (from prestige and control) as resources that elevate or sustain health status. Unfortunately, however, SES has been incorporated into many empirical epidemiological studies with little explicit theorizing about society and the social hierarchies within it to which SES may correspond. Is SES an indicator of where an individual stands on a single static social hierarchy or is it instead a rough indicator of membership in a sociologically defined social class engaged in relations with other classes? Adler et al. conclude that “[s]ocial class is among the strongest known predictors of illness and health and yet is, paradoxically, a variable about which very little is known.”[ 2 ] A growing interest in the concept “social capital” coincides with serious attention being paid to theoretical conceptions of the nature of social relations and society by population health researchers.
At the individual level, the relationship between income and health within Western nations seems to be curvilinear, almost logarithmic in shape, such that we cannot determine a poverty threshold below which health is threatened and above which health is randomly distributed or solely influenced by factors unrelated to income. Instead, the relationship seems to produce a smooth (but weakening) gradient wherein people are healthier the higher they are on the income ladder. The income and health relationship is not recreated across countries, however. Richard Wilkinson has demonstrated that, among OECD countries and given a certain degree of societal wealth, nations with a higher GDP/capita are not necessarily healthier nations.[ 3 ] If the purchasing power of income explains the relationship between income and health among individuals then this finding across countries is not intuitively obvious, since presumably the average citizen of a wealthier society has greater purchasing power, and thence better health, than does the average citizen of a poorer one.
A relationship among communities (or societies) that focuses on community-level attributes rather than on characteristics of individuals, as Wilkinson’s does among OECD countries, is called an ecological relationship. We would predict that the individual-level relationship between income and health would translate naturally into an ecological relationship between societal wealth and the health of populations. This may not be the case.
In the “relative hypothesis” psycho-social mechanisms have been proffered to explain why an individual’s income affects his/her health and may serve to elucidate the (non) relationship described by Wilkinson. A psycho-social interpretation might argue that the material resources procured by income are not the primary mechanisms by which income affects health: what matters are peoples’ perceptions of themselves and their standing relative to others. If people compare themselves to their in-country peers, and suffer poorer health when they fall short in the comparison, then it does indeed make sense that income and health are related within but not between nations. What counts are comparisons among peers, and one’s peers reside in one’s own country. This form of an individual-level relationship between income and health would not necessarily translate into an ecological relationship between wealth and population health because of its focus on relative rather than absolute income.
Another explanation focuses on risky behaviour. We might argue that cultures of “acceptable” activities congregate within income classes. If smoking, sedentary activities and poor diet choices, for example, are more prevalent within poorer classes than within wealthier ones, then the individual-level, income-health relationship may reflect the influences of these activities on health status. A distribution of (non-) healthful behaviours may contribute to health inequalities, and if such behaviours manifest themselves similarly within countries, an ecological relationship between societal wealth and health need not surface.
The debate on the nature and strength of the wealth and health relationship has not neared resolution within population health discourse. For those pursuing a neo-materialist interpretation of the structure of society and pathways to health, the purchasing power of wealth and/or the distribution of risk behaviours matter. In support of the neo-materialist position, John Lynch and his colleagues have presented further evidence that wealth is related to health among an expanded data-set of 33 Western countries.[ 4 ] In return, Wilkinson has argued that the choice of countries for inclusion in analysis matters: among the 21 richest countries in 1995 the relationship between wealth and health is actually negative; among the 23 countries with the highest life expectancy the relationship is non-existent.[ 5 ]
Income inequality and health
Societal wealth does not predict much, if any, mortality among the wealthy nations of the industrialized Western world. Wilkinson noted, however, among the nine nations of the Luxembourg Income Study, that income inequality, measured by determining the percentage of overall wealth owned by the poorest 70 percent of the populace, is strongly related to population health status.[ 6 ] Several studies have found that this and other measures of income inequality are related to various health indicators within nations as well. For example, the relationship between income inequality and health is strong among the American states,[ 7 ] and among American metropolitan areas.[ 8 ]
In Canada, by contrast, Ross et al. failed to find statistically significant relationships between income inequality and health among Canadian provinces and again among Canadian metropolitan areas.[ 9 ] This may be because Canada does not have enough variability in inequality among provinces or cities for a relationship to manifest itself at these levels. There may be a threshold effect as well: the Canadian provinces/cities are more equal than nearly every American state/city and may have maximized the health benefits accrued from income equality. On the other hand, while I did not find a relationship between average household income and mortality rates among 30 health districts in Saskatchewan, I did find a nearly significant relationship between a crude measure of income inequality and the mortality rate.[ 10 ] This is somewhat surprising since we would expect income inequality to be less relevant for health, and less variable, at smaller levels of geopolitical aggregation, yet the populations of these health districts are quite small (ranging in size from about 11,000 to 220,000 people).
Why would a place with a relatively equal distribution of incomes have healthier people? Lynch and Kaplan proffer several types of explanations.[ 11 ] First, the individual-level relationship between income and health may “create” this ecological relationship (even though it may not contribute to the ecological relationship between wealth and health). Judge et al. and Gravelle note that because the individual-level relationship between income and health is curvilinear, should a given society with a given income distribution be transformed into a more equal one the poorer peoples’ health would improve more than the richer peoples’ health would deteriorate.[ 12 ] As a result the average level of population health would improve.
Wolfson et al. modelled this possibility among the American states and found that the individual-level relationship between income and health mathematically predicts a weaker ecological relationship between income inequality and health than has been noted empirically.[ 13 ] A multilevel exercise by Fiscella and Franks among American communities determined that the ecological relationship was non-significant after controlling for individual household income.[ 14 ] In contrast, Kennedy et al. found a modest empirical relationship between income inequality and self-rated health status among American states after controlling for individual income.[ 15 ] There is some, but not incontrovertible, evidence, therefore, that the ecological relationship between income inequality and health is more than simply a reflection of the relationship between income and health among individuals.
Second, “an inequitable income distribution may have direct consequences on peoples’ perceptions of their social environment that influence their health.”[ 16 ] Wilkinson in particular has advocated explanations of this sort.[ 17 ] This argument, similar to the relative hypothesis delineated above, might go as follows. A society with a wide distribution in incomes is one with a pronounced status order. People in all levels of the order are cognizant of one another (e.g., via direct interaction or communications media). Those falling short in psycho-social comparisons with others will feel this shortcoming quite strongly, given the width of the gap, and consequently will suffer poorer health than will the “losers” of comparisons in more equal places. Ill health might develop through the damaging emotions caused by such relative deprivation, emotions such as anxiety and arousal, feelings of inferiority and low self-esteem, shame and embarrassment, and recognition of the need to compete to acquire resources that cannot be gained by any other means.
This line of explanation, like the relative hypothesis, is attractive because it moves directly from income inequality, a characteristic of a collective, to emotion, meaning or perception and thence to physical health, dramatically illustrating how income inequality can “get under the skin,” as Leonard Syme would say. It is not certain that this form of explanation necessarily represents an alternative explanation, however. If ill health-inducing emotions are distributed along a status order that corresponds with the hierarchy of incomes then the argument proffered by Judge et al. and Gravelle may apply here as well. If such emotions are distributed throughout an unequal society in a less predictable or different fashion, then this form of explanation provides additional insight into the income inequality and health relationship.
Third, it has been noted that income inequality can only be applied to populations and not to individuals and can only be defined in relational terms.[ 18 ] This ecological aspect of social structure might influence health indirectly through other ecological processes, e.g., “an inequitable income distribution may be associated with a set of social processes and policies that systematically underinvest in human, physical, health and social infrastructure, and this underinvestment may have health consequences.”[ 19 ] Lynch and Kaplan suggest that “areas that tolerate high income inequality are also less likely to support the human, physical, cultural, civic and health resources in that area.” Unequal places may have more violent crime.[ 20 ] These background factors may “create a context of community infrastructure through policies that affect education, public health services, transportation, occupational health regulations, availability of healthy food, zoning laws, pollution, housing, etc.”[ 21 ] Such contextual explanations look to collective or ecological aspects of societies that are associated with income inequality: individual-level “outcomes” such as health status and their ecological counterparts such as population health status are much further down the explanatory line. Enter social cohesion, posited as one particularly important contextual means by which income inequality adversely affects population health.
Social cohesion, social capital and health: preliminary work
Wilkinson and Lynch and Kaplan propose that societies with a high degree of income inequality are also ones with low social cohesion, and that one of the ways in which income inequality affects health is through the presence or absence of this social resource.[ 22 ] Wilkinson describes social cohesion as the social nature of public life, “dominated by peoples” involvement in the social, ethical and human life of the society, rather than being abandoned to market values and transactions. People come together to pursue and contribute to broader, shared social purposes.” Lynch and Kaplan describe social capital, a concept often linked with social cohesion in population health discourse, as “the stock of investments, resources and networks that produce social cohesion, trust and a willingness to engage in community activities.” Supposedly, then, something about social spaces with some kinds of participation and trust facilitates or produces good health.
Wilkinson notes that it is particularly difficult to determine causality in this instance. “Although a narrower income distribution leads to a more egalitarian social ethic … [i]f a more egalitarian social ethos were to develop exogenously, for reasons unrelated to income distribution, it is implausible that such a society would tolerate great material inequalities without making efforts to reduce them.” A cohesive community should be understood in direct relation to its degree of social inequality, according to Wilkinson, such that cohesion and inequality are opposite principles of social organization. Increased social equality corresponds with co-operative and supportive social relations, and such relations, about “mutuality, reciprocity, sharing, and a recognition that the needs of others are needs for us”[ 23 ] are hypothesized to have a profound effect on health.
Ichiro Kawachi, Bruce Kennedy and their colleagues have done empirical tests of the income inequality, social cohesion and health hypothesis among the American states. Social capital, measured via three trust questions and one “participation in secondary associations” question, aggregated to the level of the state, was strongly related to both income inequality and mortality.[ 24 ] They conclude that social capital does indeed mediate the relationship between the other two: greater inequality leads to decreased participation in the public space and to greater mistrust, both of which then influence health. They have since shown that the same measure of social capital is also related to aggregated self-rated health status, even after controlling for individual-level proximal causes of health.[ 25 ]Ellaway and Macintyre found a similar result among post code sectors in western Scotland[ 26 ] while I found a nearly significant relationship between a crude measure of social capital, incorporating measures of participation in secondary associations and voting activity, and mortality rates among Saskatchewan’s health districts.[ 27 ] In contrast with the Kawachi et al. finding among the American states, however, my measures for social capital and income inequality were not significantly related to one another. Although the Kawachi et al. interpretation of “what causes what” may be (and has been) contested, the empirical results are stimulating, especially given the simplicity of the sometimes crude and opportunistic measures of social capital. What are they measuring?
Describing social capital
Pierre Bourdieu defined social capital as “the aggregate of the actual or potential resources which are linked to possession of a durable network of more or less institutionalized relationships of mutual acquaintance and recognition — or in other words to membership of a group.”[ 28 ]Membership in a social group provides personal resources that may be currently active (actual) or appropriable at a later time or in a new circumstance (potential). “Trust between members of a network ‘oils the wheels’ of social and economic exchange, reducing transaction costs, allowing group members to draw on favours, circulate privileged information, and gain better access to opportunities.”[ 29 ] Measures of the amount of participation in and/or number of clubs and secondary associations[ 30 ] can be interpreted as attempts to evaluate the prevalence of such networks of mutual acquaintance in a given community.
James Coleman’s description of social capital has been particularly influential.
- [S]ocial capital is defined by its function. It is not a single entity but a variety of different entities, with two elements in common: they all consist of some aspect of social structures, and they facilitate certain actions of actors — whether persons or corporate actors — within the structure. Like other forms of capital, social capital is productive, making possible the achievement of certain ends that in its absence would not be possible… [S]ocial capital is not completely fungible but may be specific to certain activities… [It] inheres in the structure of relations between actors and among actors.[ 31 ]
Thus social capital achieves; it facilitates ends. While Bourdieu’s definition implicitly describes social capital as a resource that facilitates ends for an individual, Coleman’s definition remains open to ends benefiting a social group. This variety of ends appears somewhat analogous to Putnam’s distinction (in this volume) between private and public returns. Both definitions imply that social capital is not a single “something.” A full description of a Coleman-esque social capital should identify the relevant social structure and the attributes of this structure that, through simple or complicated means that may incorporate social action, facilitate specified ends for specified individuals or groups. Such a description of social capital does not distinguish what social capital is from what social capital does, a distinction that Woolcock (in this volume) deems essential, but subsequent empirical and theoretical work may find that certain attributes of social structure do indeed work to achieve a multitude of ends, thereby allowing us to separate analytically these attributes from their effects.
There are multiple forms of social capital. A given network of mutual acquaintance with long-term obligations and trust is not necessarily one with deeply held norms pertaining to a common good, nor need it be a network that facilitates the flow of certain kinds of information. (These are three forms of social capital described by Coleman.) It follows, then, that such multiple social capitals can work to achieve various ends. Thus, for example, social capital has been thought to promote economic growth and development[ 32 ] and the performance of political institutions,[ 33 ] as well as the health of populations.
Figure 1 is a visual rendering of a society’s social structure that may help to clarify various social capitals and their “effects.” This rendering of social structure, a network of social relations and the attendant ideas/beliefs articulated by and within such relations, distinguishes deep structure from the interconnected political, economic and civil spheres and distinguishes these from shallow social structure. Social structure transcends any one person’s conception of it but is constantly reproduced in every-day interaction, i.e., reconstituted and reaffirmed in mind, action, communication and interaction. Each object in the picture is intrinsically social, therefore, a pattern of social actions, relations and meanings, both the condition and outcome of action.
I am concerned here with the influence of social relations in one sphere upon social relations within another, certainly, but also with arguing that social relations in general are multifaceted, enact multiple dimensions of social structure simultaneously and, ultimately, are all pertinent for population health. Those aspects of social relations pertaining to deep structure and to the economic and political spheres that produce (ill-) health have received substantial attention from medical sociologists; social relations in the civil space pertain to the social capital and health discourse in particular and represent a relatively untapped arena of inquiry. The definition of a given social structure will also determine the range of possible reasons why such attributes of social structure produce health inequalities: neighbourhoods may vary from one another in only a few dimensions while entire societies likely vary along many of the dimensions depicted in Figure 1.
Power is the differential capacity to command resources and gives rise to structured, asymmetric relations of domination and subordination among social actors. Class relations and other embedded power imbalances (by gender, sexual orientation, age, race or ethnicity, language, geographic location and/or religion, for example), if pronounced, probably belong to the deepest structures of society. They influence many aspects of the social structure but are not explicitly recognized by actors in most interactions. Deeply held norms about the “right” and “good” usually remain unrecognised as well, examples of which might include the nature of God in one society or the truth of scientific findings in another. To my mind, then, deep structure contains both realistic/materialistic (e.g., embedded power relations or control over resources) and ideational aspects (e.g., strongly held shared norms and beliefs) blended in some kind of synthetic ontology. Although it is difficult to prove that any one aspect of social structure “causes” another, I would argue that the shape of deep structure strongly influences the shapes taken by the other elements in the image. Thus aspects of deep structure will influence activity and the distribution of material resources in the economic sphere. They will influence control of human resources and/or people within the political sphere, including the state and such substructures as the judiciary, civil service, police and military. They will also influence activity within the civil sphere, including relations with close friends and neighbours, so-called strong or bonding relationships; relations with more distant friends, associates and colleagues, so-called weak or bridging relationships; civic activities linking the individual and the state, so-called linking relationships; and those secondary or voluntary associations that are not directly financed or maintained by the state.
Muntaner and Lynch argue that class relations (and politics too) should be incorporated into the income inequality-social cohesion-health discourse.[ 34 ] Scambler and Higgs argue that class should be considered as a phenomenon in its own right: the proper objects of study for sociologists interested in the social determinants of health are “beneath-the-surface relations, in the present context crucially including those of class, perceivable and examinable only through their effects.”[ 35 ]David Coburn’s proposition that the degree of adherence to neo-liberal tenets in a society will influence both the distribution of wealth and social cohesion (and especially trust) describes how the deepest structures of society shape the civil, political and economic spheres.[ 36 ] According to Coburn, a deeply embedded belief in the ability of markets to allocate resources properly will influence the nature of social relations in the civil space and the distribution of resources in the economic sphere, in part via its dance with class relations and through its influence on the nature of the welfare state. According to these perspectives, then, aspects of deep structure shape social relations in many spheres of patterned interaction.
Most conceptions of social capital focus on attributes of civil society. They explore participation in networks based within that nebulous place between the family and the state, excluding the economic sphere, and focus on trust among members of such networks and the collaborative actions they enact. Questions asked of individuals assessing “trust in most people” pertain to the nature of social relations throughout all of social structure and may or may not serve to measure trust in other members of civil networks in particular. As such, trust in “most people” is better conceived as a product of a civil society-based social capital than a component of such a social capital. The work by Robert Putnam and his colleagues among the regions of Italy pertains to relationships among the civil, economic and political spheres. Thus the prevalence of voluntaristic activities such as participation in soccer clubs or church choirs and civic activities such as voting or reading a local newspaper (in the civil sphere) may be related to one or all of the performance of political institutions, socio-economic modernity and income inequality. Knack and Keefer argue that actions such as participation in secondary associations and prescriptions such as adherence to civic norms and duties may influence economic development.[ 37 ] Woolcock explicitly incorporates the nature of the state and state-citizen relations into his conception of social capital and its correlates.[ 38 ] The empirical and theoretical insights provided by these researchers reinforce my belief, articulated by Coburn, that “the economy, the state and civil society are, in fact, inextricably interrelated.”[ 39 ]
I have depicted shallow structures as aspects of the social structure that rest upon deep structure and the interrelated economic, political and civil spheres, influencing these others somewhat but more properly reflecting more deeply embedded social relations. Many aspects of social structure reproduced in interaction are often consciously articulated: e.g., culture (art, music, television, movies), education, media communications and moral standards referring to beauty and taste. These aspects of social structure may also serve to promote health-producing actions and thence good or ill health, i.e., social capital. It makes sense to me, however, to limit the social capital concept to the civil sphere since most aspects of social structure could be otherwise deemed a health-producing social capital of sorts. We could argue that co-operative class relations facilitate co-operative relations between workers and supervisors in the workplace and thence better health for all of those participating in the labour market, or that deeply held beliefs concerning the rightness of neo-liberal tenets facilitate the ends of a dominant ethnic group and thence good health for that group (but poor health for others). These might be called “social capital,” aspects of social structure that facilitate certain actions and achieve certain ends (i.e., population health) for certain groups. The concept loses analytical meaning in such instances, however, by potentially encompassing all of social relations. The nature of social relations in the civil space, the extent to which they are embedded in social relations pertaining to other aspects of social structure and the ends they can facilitate for groups and individuals delimit a manageable conception of social capital.
Social capitals and health: multiple possibilities
Why might social capital within the civil space influence the health of people? Like the individual- and ecological-level relationships described above, we can analytically distinguish between the contextual and compositional effects of social capital on health. Contextual effects, or instrumental benefits, refer to social capital-relevant aspects of social structure that influence the population health of groups through indirect means. Compositional effects, or intrinsic benefits that result from contributing to social capital, refer to the direct influences of participation in multiplex networks, or adherence to prescriptive norms, for example, on the health of the participants themselves, simply by virtue of participating or adhering.
Compositional effects: The actions and ideals that individuals engage in or express which serve to contribute to the store of a given social capital might be health-inducing in and of themselves. This explanation is analogous to the arguments described above wherein the income inequality and health or wealth and health relationships simply or partially reflect the individual-level income and health one. Thus Wilkinson suggests that friendship patterns “can reflect, on the one hand, people’s social ease and confidence, or, on the other, the extent to which social contact provokes anxiety, negative social comparisons, feelings of inadequacy and angst.”[ 40 ] There is a broad literature on the effects of various kinds of social support and social relationships on health,[ 41 ] and patterns of mutual acquaintance in a social capital context may serve to sustain health along these lines. Knowledge of the resources inherent in one’s networks may promote a sense of mastery or personal control and reduce stress. Baum et al. show evidence that participation in the civic space is related to mental health status (and physical health status too, but less strongly) in Australia.[ 42 ] On the other hand, Ellaway and Macintyre did not find individual-level relationships between participation in a local association and self-rated health status in Scotland while I describe few relationships between participation in various kinds of secondary associations and self-rated health status among individuals in eight of Saskatchewan’s health districts.[ 43 ] These constitute only a few of the individual-level actions and perceptions that might contribute to a social capital in the civil space, however.
Contextual factors: To the degree that large-scale bureaucratic institutions are embedded within the non-political and non-economic social world, social capital within the civil space may influence the performance of political institutions in particular, demonstrated theoretically and empirically by Putnam et al. and Rice and Sumberg.[ 44 ] With Lomas, I have also speculated about means by which social capitals may affect the governing performance of regional health authorities specifically, although an empirical test of the relationship in Saskatchewan did not support the hypothesis.[ 45 ]
Other characteristics of political institutions which might also be influenced by social relations in the civil space, such as adherence to welfare-state principles, are especially pertinent to health. Kawachi and Berkman argue that American states with low levels of interpersonal trust (a consequence of some social capitals?) are less likely to invest in human security and provide generous safety nets.[ 46 ] Interpersonal trust supposedly accompanies more egalitarian patterns of political participation that often result in the passage of policies which ensure the security of all its members, policies perhaps pertaining to education, transportation, pollution, child welfare and zoning laws. Social capitals may influence access to services and amenities, since socially cohesive communities may be more successful at uniting to ensure that budget cuts do not affect health and social services. A state that seeks to redress social inequality in general may serve to reduce income inequality through welfare measures, thereby potentially improving the population’s health by the means, both materialistic and psycho-social, suggested above. To my mind this constitutes the more plausible line of causality among social capitals in the civil space, income inequality and population health status: not that income inequality threatens the nature of social relations so much as the distribution of income reflects, in part, the nature of social relations in the civil and political spheres and the deeper parts of social structure.
Social relations in the civil space may also influence economic development and growth, the concern of many of the papers in this volume. Suffice it to say that to the degree that additional wealth aggregated to the level of the community contributes to health (debated above) the influence of civil space social relations upon the economic sphere will have implications for population health. To the degree that social relations within the civil sphere affect deep structure, social capitals may mitigate class, racial, ethnic, gendered, religious and other power imbalances. Networks of mutual acquaintance spanning these potential chasms may introduce people to perspectives different from their own and produce a spirit of tolerance, thereby lessening the magnitude of influence embedded relations have upon social relations in general and health inequalities along racial lines, for example, in particular.
At any of the macro, meso and micro levels, some forms of social capital may influence health-related behaviours by promoting diffusion of health-related information (i.e., via the information channels described by Coleman), thus increasing the likelihood that healthy norms of behaviour are adopted, or by exerting social control (i.e., via the effective sanctions also described by Coleman) over deviant health-related behaviour. They may mitigate against the incidence of crime, juvenile delinquency and access to firearms within communities. With respect to psycho-social determinants of health, participation in co-operative networks that venture far into the civil space may produce social trust.[ 47 ] Lavis and Stoddart provide evidence from the World Values Survey that the expression of trust is related to self-rated health status in Canada at the individual level,[ 48 ] although I found that multiple forms of social and political trust were unrelated to self-rated health status in Saskatchewan. Kawachi et al. provide evidence that trust and health may be related at the ecological level, although this does not imply that individually held trust necessarily produces health for that individual.[ 49 ] Putnam has shown (in this volume) that community-level social capital seems to influence degree of happiness.
Compositional aspects of a civil space-oriented social capital may be a determinant of health, certainly, but do not in my opinion constitute the most important contributions of social capital theory to population health research. Individual-level relationships have been explored in depth by social epidemiologists and others over the years; contextual effects are less well understood, and more difficult to model, than are compositional ones, and thereby represent a promising area for exploration and conceptualization. A final caveat: I have described potential influences on health of social capitals located within the civil space but do not claim that civil society necessarily provides the most potent influence of the social structure on health. The interrelatedness of the three spheres with deep social structure implies that population health researchers should always set civil society within the larger socio-politico-economic context. At this time it appears that theories focusing on consensus are popular with governments and policy makers, perhaps due to the rapid and overwhelming pace of change in modern societies, as are theories that support smaller government by emphasizing the role of civil society. In my opinion, theories of the social determinants of health that seek to be comprehensive should additionally encompass deeply embedded conflict and inequality and the roles of state and economy for producing good health for populations.
Social capital is the new kid on the block when it comes to exploring the social determinants of the health and well-being of Canadians, evidenced by a plethora of new research studies in Canada that implicitly or explicitly seek to explore social capitals and their effects. Just to name a few, the NRE project based at Concordia University is currently exploring processes of inclusion and exclusion among Canadian rural communities while the Equality/Security/Community project, based at UBC and concerned with describing the distribution of well-being in Canada, is focusing on economic, political and social determinants of public policies and their outcomes. Two studies based at the University of British Columbia, the Resilient Communities project and the Sawmills project, are exploring social capital and both economic resiliency and population health among coastal communities in British Columbia. Similar relationships are being investigated among these coastal communities and among a larger regional and national sample of communities by researchers from the Equality, Security and Community project and the Georgia Basin Futures project at UBC. The Left Out project, based at the universities of Alberta and Toronto, is exploring issues of exclusion and belonging as they pertain to social cohesion and health in Edmonton and Toronto while the Deconstructing the Local Determinants of Health project at McMaster university is exploring social capital as one of the determinants of the health of residents in Hamilton neighbourhoods. Results from these and other investigations should shed light on many of the issues raised in this paper and increase our understanding of the social determinants of the health of Canadians.
* Gerry Veenstra is an assistant professor in the Department of Anthropology and Sociology and a faculty member of the Centre for Health Services and Policy Research at the University of British Columbia.
1. See N. Adler, T. Boyce, M. Chesney, S. Cohen, S. Folkman, R. Kahn and S. Syme, “Socioeconomic status and health: the challenge of the gradient,” American Psychologist, Vol. 49 (1994), pp.15-24; and O. Fein, “The influence of social class on health status: American and British research on health inequalities,” Journal of General Internal Medicine, Vol. 10 (1995), pp. 577-586.
2. Adler et al. (1994), op cit.
3. R. Wilkinson, Unhealthy Societies: The Afflictions of Inequality (London: Routledge, 1996).
4. J. Lynch, P. Due, C. Muntaner and G. Davey Smith, “Social capital — Is it a good investment strategy for public health?” Journal of Epidemiology and Community Health, Vol. 54 (2000), pp. 404-408.
5. R. Wilkinson, “Inequality and the social environment: a reply to Lynch et al.,” Journal of Epidemiology and Community Health, Vol. 54 (2000), pp. 411-413.
6. Wilkinson (1996), op cit.
7. B. Kennedy, I. Kawachi and D. Prothrow-Stith, “Income distribution and mortality: cross sectional ecological study of the Robin Hood index in the United States,” British Medical Journal, Vol. 312 (1996), pp. 1004-1007; and G. Kaplan, E. Pamuk, J. Lynch, R. Cohen and J. Balfour, “Inequality in income and mortality in the United States: analysis of mortality and potential pathways,” British Medical Journal, Vol. 312 (1996), pp. 999-1003.
8. J. Lynch, G. Kaplan, E. Pamuk, R. Cohen, K. Heck, J. Balfour and I. Yen, “Income inequality and mortality in metropolitan areas of the United States,” American Journal of Public Health, Vol. 88 (1998), pp. 1074-1079.
9. N. Ross, M. Wolfson, J. Dunn, J. Berthelot, G. Kaplan and J. Lynch, “Relation between income inequality and mortality in Canada and in the United States: cross sectional assessment using census data and vital statistics,” British Medical Journal, Vol. 320 (2000), pp. 898-902.
10. G. Veenstra, “Social capital and health (plus wealth, income inequality and regional health governance): an ecological analysis,” submitted to Social Science and Medicine (2000).
11. J. Lynch and G. Kaplan, “Understanding how inequality in the distribution of income affects health,” Journal of Health Psychology, Vol. 2 (1997), pp. 297-314.
12. K. Judge, J. Mulligan and M. Benzeval, “Income inequality and population health,” Social Science and Medicine, Vol. 46 (1998), pp. 567-579; and H. Gravelle, “How much of the relation between population mortality and unequal distribution of income is a statistical artifact?” British Medical Journal, Vol. 316 (1998), pp. 382-385.
13. M. Wolfson, G. Kaplan, J. Lynch, N. Ross and E. Backlund, “The relationship between income inequality and mortality: an empirical demonstration,” British Medical Journal, Vol. 319 (1999), pp. 953-957.
14. K. Fiscella and P. Franks, “Poverty or income inequality as predictor of mortality: longitudinal cohort study,” British Medical Journal, Vol. 314 (1997), pp. 1724-1728.
15. B. Kennedy, I. Kawachi, R. Glass and D. Prothrow-Stith, “Income distribution, socioeconomic status, and self rated health in the United States: multilevel analysis,” British Medical Journal, Vol. 317 (1998), pp. 917-921.
16. Lynch and Kaplan (1997), op cit..
17. R. Wilkinson, “Income inequality, social cohesion, and health: clarifying the theory — a reply to Muntaner and Lynch,” International Journal of Health Services, Vol. 29 (1999), pp. 525-543; 2000, op cit.
18. C. Muntaner and J. Lynch, “Income inequality, social cohesion, and class relations: a critique of Wilkinson’s neo-Durkheimian research program,” International Journal of Health Services, Vol. 29 (1999), pp. 59-81.
19. Lynch and Kaplan (1997), op cit.
20. B. Kennedy, I. Kawachi, D. Prothrow-Stith, K. Lochner and V. Gupta, “Social capital, income inequality, and firearm violent crime,” Social Science and Medicine, Vol. 47 (1998), pp. 7-17; and I. Kawachi, B. Kennedy and R. Wilkinson, “Crime: social disorganization and relative deprivation,” Social Science and Medicine, Vol. 48 (1999), pp. 719-731.
21. Lynch (2000), op cit.
22. Wilkinson (1996), op cit.; Lynch and Kaplan (1997), op cit.
23. Wilkinson (1999), op cit.
24. I. Kawachi, B. Kennedy, K. Lochner and D. Prothrow-Stith, “Social capital, income inequality, and mortality,” American Journal of Public Health, Vol. 87 (1997), pp. 1491-1498.
25. I. Kawachi, B. Kennedy and R. Glass, “Social capital and self-rated health: a contextual analysis,” American Journal of Public Health, Vol. 89 (1999), pp. 1187-1193.
26. A. Ellaway and S. Macintyre, “Social capital and self-rated health: support for a contextual mechanism,” American Journal of Public Health, Vol. 90 (2000), p. 988.
27. Veenstra, “Social capital and health…,” op cit.
28. P. Bourdieu, “The forms of capital,” in J. Richardson, Handbook of theory and research for the sociology of education (New York: Macmillan, 1986).
29. P. Hawe and A. Shiell, “Social capital and health promotion: a review,” Social Science and Medicine, Vol. 51 (2000), pp. 871-885.
30. R. Putnam, R. Leonardi and R. Nanetti, Making Democracy Work: Civic Traditions in Modern Italy (Princeton, New Jersey: Princeton University Press, 1993); Kawachi et al. (1997), op cit.; and S. Knack and P. Keefer, “Does social capital have an economic payoff? A cross-country investigation,” Quarterly Journal of Economics, Vol. 112 (1997), pp. 1251-1288; and Veenstra, “Social capital and health…,” op cit.
31. J. Coleman, “Social capital in the creation of human capital,” American Journal of Sociology, Vol. 94 (1988), pp. S95-S120.
32. J. Helliwell and R. Putnam, “Economic growth and social capital in Italy,” Eastern Economic Journal, Vol. 21 (1995), pp. 295-307; and Knack and Keefer (1997), op cit.; and J. Temple, “Initial conditions, social capital and growth in Africa,” Journal of African Economies, Vol. 7 (1998), pp. 309-347; Woolcock, op cit..
33. Putnam et al. (1993), op cit.; T. Rice and A. Sumberg, “Civic culture and government performance in the American states,” Publius, Vol. 27 (1997), pp. 99-114; and G. Veenstra and J. Lomas, “Home is where the governing is: social capital and regional health governance,” Health and Place, Vol. 5 (1999), pp. 1-12.
34. Muntaner and Lynch (1999), op cit.
35. G. Scambler and P. Higgs, “Stratification, class and health: class relations and health inequalities in high modernity,” Sociology, Vol. 33 (1999), pp. 275-296.
36. D. Coburn, “Income inequality, social cohesion and the health status of populations: the role of neo-liberalism,” Social Science and Medicine, Vol. 51 (2000), pp. 135-146.
37. Knack and Keefer (1997), op cit.
38. Woolcock (1998), op cit.
39. Coburn, op cit.
40. Wilkinson (1999), op cit.
41. J. House, K. Landis and D. Umberson, “Social relationships and health,” Science, Vol. 241 (2000), pp. 540-545.
42. F. Baum, R. Bush, C. Modra, C. Murray, E. Cox, K. Alexander and R. Potter, “Epidemiology of participation: an Australian community study,” Journal of Epidemiology and Community Health, Vol. 44 (2000), pp. 414-423.
43. G. Veenstra, “Social capital, SES and health: an individual-level analysis,” Social Science and Medicinem, Vol. 50 (2000), pp. 619-629.
44. Putnam et al. (1993), op cit., and Rice and Sumberg (1997), op cit.
45. Veenstra and Lomas (1999), op cit.; Veenstra, “Social capital and health…,” op cit.
46. I. Kawachi and L. Berkman, “Social cohesion, social capital and health,” in L. Berkman and I. Kawachi (eds.), Social Epidemiology (New York: Oxford University Press, 2000).
47. J. Brehm and W. Rahn, “Individual-level evidence for the causes and consequences of social capital,” American Journal of Political Science, Vol. 41 (1997), pp. 999-1023.
48. J. Lavis and G. Stoddart, “Social cohesion and