Americans now understand that their health is at risk if they
smoke, overeat, and fail to exercise. But a growing body of evidence
suggests that public health also depends on a less widely understood
influencesocial cohesion. And while many Americans have stopped
smoking, gone on diets, and put on jogging shoes, American society
has become, if anything, less cohesive.
Consider what happened in Roseto, a small Italian-American community
in eastern Pennsylvania. During the 1950s, when the town first
caught the attention of medical researchers Stewart Wolf and J.G.
Bruhn, Roseto posed something of a mystery. Death rates in the
small town of about 1,600 people were substantially lower than
in neighboring communities. In particular, the rate of heart attacks
was about 40 percent lower than expected and could not be explained
by the prevalence of factors known to increase the risk of the
disease. Citizens of Roseto smoked at the same rate as neighboring
towns, they were just as overweight and sedentary, and their diet
consisted of about the same amount of animal fat. But the one
feature that stood out was the close-knit relations among residents
in the community. The town had been originally settled by immigrants
during the 1880s, who all came from the same village in rural
Italy. The researchers noticed the social cohesiveness and ethos
of egalitarianism that characterized the community:
Proper behavior by those Rosetans who have achieved material wealth
or occupational prestige requires attention to the delicate balance
between ostentation and reserve, ambition and restraint, modesty
and dignity. . . . The local priest emphasized that when preoccupation
with earning money exceeded the unmarked boundary it became a
basis for social rejection. . . . Rosetan culture thus provided
a set of checks and balances to ensure that neither success nor
failure got out of hand. . . . During the first five years of
our study it was difficult to distinguish, on the basis of dress
or behavior, the wealthy from the impecunious in Roseto. . . .
Despite the affluence of many, there was no atmosphere of "keeping
up with the Joneses" in Roseto.
But as young people began to move away to seek jobs in neighboring
towns and the community entered the mainstream of American life,
the social taboos against conspicuous consumption began to weaken,
as did the community bonds that once maintained the town's egalitarian
values. About a decade into the study, the researchers noted:
For many years the more affluent Rosetans restrained their inclination
toward material indulgence and maintained in their town the image
of a relatively classless society. When a few began to display
their wealth, however, many others followed. By 1965 families
had begun to join country clubs, drive expensive automobiles,
take luxury cruises, and make flights to Las Vegas.
The unforeseen consequence of improved material well-being and,
probably more important, rising socioeconomic disparities was
that the incidence of heart attack in Roseto caught up with neighboring
towns within a span of a decade.
The notion that social cohesion is related to the health of a
population is hardly new. One hundred years ago, Emile Durkheim
demonstrated that suicide rates were higher among populations
that were less cohesive. In 1979, after a nine-year study of 6,928
adults living in Alameda County, California, epidemiologists Lisa
Berkman and S. Leonard Syme reported that people with few social
ties were two to three times more likely to die of all causes
than were those with more extensive contacts. This relationship
persisted even after controlling for such characteristics as age
and health practices, including cigarette smoking, drinking, exercise,
and the use of medical services. The basic findings of the Alameda
County Study have since been confirmed in more than a half dozen
epidemiological studies in different communities.
These findings have ominous implications if the political scientist
Robert Putnam is right that social capital is declining in America
[see "The Strange Disappearance of Civic America," TAP,
Winter 1996]. Putnam's memorable metaphor for this change is bowling
league membership, which has declined while bowling overall has
increased. By social capital Putnam means the invisible glue that
holds society togetherthe social networks, norms, and trust that
enable groups of individuals to cooperate in pursuing shared objectives.
On the basis of research in Italy and elsewhere, Putnam argues
that social capital is a major contributing factor in economic
growth [see "The Prosperous Community: Social Capital and
Public Life," TAP, Spring 1993]. In fact, as the public
health research shows, the harm from weakening social cohesion
may not only be civic and economicit may also be physical.
IT DOES HURT TO BE ALONE
To explore this question, we set out to test the relationship
between social capital and public health at the state level. In
fact, there are quite marked geographical variations in civic
trust and association membership across the United States, and
when these indicators of social capital are arrayed against regional
differences in mortality and morbidity, the resulting correlations
are striking. The chart "Social Capital and Mortality Rates"
(below) shows the relationship between the level of civic trust
and the age-adjusted rate of death from all causes for the 39
states for which data were available in the National Opinion Research
Center's General Social Surveys. The lower the trust between citizensas
indicated by the proportion of respondents in each state who believed
that "most people cannot be trusted"the higher is the
average mortality rate.
A similar relationship with mortality prevails for the per capita
membership of state residents in voluntary associations. These
relationships between social cohesion and mortality hold among
both whites and African Americans, as well as among men and women,
and they persist after statistical adjustment for state variations
in median household income and proportion of households living
below the federal poverty threshold.
The figure below, "Social Trust and Quality of Life,"
displays the correlation between level of civic trust and a measure
of self-reported well-being. The National Center for Chronic Disease
Prevention and Health Promotion employed the Behavioral Risk Factor
Surveillance System (BRFSS) to ascertain the proportion of residents
in each state reporting that their health was only fair or poor
as opposed to good or excellent. (The BRFSS is a representative,
random telephone survey that sampled more than 350,000 community-dwelling
American adults between 1993 and 1996.) Again, there is a striking
correlation between social capital and quality of life.
But does "bowling alone" really increase the likelihood
that you'll get sick? Putnam's reference to the decline in bowling
leagues evinced skepticism from some critics. Katha Pollitt, for
example, pointed out that the popularity of bowling leagues emerged
from a particular period in American blue-collar culture that
permitted husbands plenty of boys' nights out (think of the memorable
first glimpses of Marlon Brando in A Streetcar Named Desire).
Other critics have pointed out that declining bowling league memberships
may be offset by increased participation of other kinds, such
as coaching and playing in youth soccer leagues.
Nonetheless, bowling league membership turns out to correlate
rather well with who lives or dies (see "Bowling League Membership
and Mortality," below). To paraphrase John Donne, no man
or woman is an island entire of itselftherefore we should never
send to ask for whom the ball rolls.
INEQUALITY AND PUBLIC HEALTH
Another feature of a society that may influence both its cohesiveness
and its members' health is the level of economic inequality. In
many countries, notably America, income and wealth are becoming
more concentrated. According to a Census Bureau report released
last year, the share of total income going to the top fifth of
American households increased from 40.5 percent to 46.9 percent
between 1968 and 1994. By contrast, the shares of the bottom 80
percent either declined or stagnated. The biggest income gains
went to the top 5 percent of households, whose share of the economic
pie increased from 16.6 percent to 21 percent. In 1994, the average
income among the top 5 percent of households was more than 19
times that of the bottom 20 percent.
Might this polarization of incomes be loosening the social cement?
In a forthcoming article in the American Journal of Public
Health, we argue that this is the case. "Income Inequality
(Robin Hood Index) and Social Trust" (below) shows the rising
trend in income inequality plotted against the steady decline
in civic trust, as tracked by the General Social Surveys. The
measure of income inequality we used is the Robin Hood Index,
which equals the proportion of aggregate income that would have
to be redistributed from households with disproportionate earnings
to those earning less, if incomes were to be level. The higher
the Robin Hood Index, the bigger the income gap. As "Income
Inequality and Social Trust" shows, the larger the income
gap, the lower is citizens' trust in each other. Nearly identical
results are obtained when we plot income disparity against per
capita participation in voluntary associations.
Comparing public health and income distribution across countries
lends further credence to the notion that income distribution
plays a greater role in the quality of public health than more
traditional indices do. In his recent book, Unhealthy Societies:
The Afflictions of Inequality, economic historian Richard
Wilkinson argues forcefully that the life expectancy in developed
countries cannot be explained by differences in their absolute
standard of living as measured, for example, by per capita income.
Rather, a population's health depends more on the level of economic
The United States, despite having one of the highest living standards
in the world (the real gross domestic product [GDP] per capita
was $24,680 in 1993), has a lower life expectancy (76.1 years
in 1993) than less affluent but more egalitarian countries like
the Netherlands (GDP, $17,340; life expectancy, 77.5 years); Israel
(GDP, $15,130; life expectancy, 76.6 years); or Spain (GDP, $13,660;
life expectancy, 77.7 years). In fact, societies with the smallest
income differences between rich and poor, such as Sweden and Japan,
tend to enjoy the highest life expectancy (78.3 and 79.6 years,
respectively). An egalitarian distribution of wealth and income
seems to imply a more cohesive, harmonious society. The quality
of social relations, Wilkinson concludes, is the prime determinant
of a country's human welfare and quality of life.
What does this imply for our future quality of life in this country?
Is what has been happening to American society simply a case of
Roseto writ large? Two studies published simultaneously in the
April 20, 1996, issue of the British Medical Journal, including
one we conducted, found that differences in income distribution
across the 50 states were highly correlated with mortality rates,
including deaths from heart disease, homicides, and infant mortality.
To be sure, overall life expectancy in the United States has been
steadily improving due to advances in medical treatment and the
prevention of disease through lifestyle changes. But mortality
might have declined more if income inequality had not risen. Our
model suggests that for every percent increase in income inequality,
the overall death rate is 2 to 3 percent higher than it needed
to have been. By any definition, this is an important public health
In recent years, unfortunately, government policy has tended to
reinforce growing inequality, which is unsurprising in view of
the disproportionate political weight that the well-off carry
[see Sidney Verba, Kay Lehman Schlozman, and Henry E. Brady, "The
Big Tilt: Participatory Inequality in America," TAP,
May-June 1997]. The danger is a self-perpetuating cycle of growing
income inequality, growing political inequality, and diminishing
social capital. And because health too is at stake, it is no exaggeration
to say that breaking that cycle will affect the body politic in
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