Understanding Changes in Societies going through Social Transition

Introduction

This unit will attempt to deepen your understanding of the concept of social capital and how it could be used in public health. It will do this by, firstly, identifying some of the weaknesses in Wilkinson’s explanation of the relationship between income inequality and health. This in turn leads to a more critical look at how social capital has been used to explain mortality changes. The work of some epidemiologists suggests that poverty and deprivation still remain very important even in developed countries. If this is the case, then it is important to understand the global context that is shaping social capital, resource allocation and public health responses in our 3 case studies. Finally, this unit will end with an outline of your assignment task which tries to engage you in putting these concepts together to analyse an important contemporary public health problem.

There are four study sessions in this unit.

Study session 1: Critique of Wilkinson Hypothesis

Study session 2: Critique of social capital

Study session 3: Impact of globalisation

Study session 4 Assignment

Intended Learning Outcomes
By the end of this Unit you should be able to:
•Outline the critique of the Wilkinson hypothesis and the use of social capital.
•Outline the critique of the concept and measurement of social capital.
•Describe a possible synthesis of the concepts into a conceptual framework to explain changes in health in societies undergoing social transition.
•Understand what is expected from you for the assignment.

Unit 4 - Session 1

Critique of Wilkinson Hypothesis

Introduction

In this session you will interact with more recent studies that reassess the relationship between income inequality, psycho-social pathways and health outcomes, and will encounter arguments from those who feel that the emphasis upon psycho-social pathways has been overplayed.

Contents of this session

1.Learning outcomes of this session

2.Readings

3.Evidence of the link between income inequality and health

4.A neo-materialist explanation?

Timing

There are four tasks in this session, and four readings.

1LEARNING OUTCOMES OF THIS SESSION

By the end of this session you should be able to:
  • Identify some possible weaknesses in studies linking income inequality and health.
  • Outline an alternative ‘neo-materialistic’ explanation for the relationship between health and income.

2.READINGS

Author/s /
Reference details
Lynch J, Davey Smith G, Hillemeier M, Shaw M et al. / (2001). Income Inequality, the Psychosocial Environment and Health: Comparisons of Wealthy Nations. Lancet, 358:194-200.
Osler, M., Prescott, E., Gronbaek, M. et al. / (2002). Income Inequality, Individual Income and Mortality in Danish Adults. British Medical Journal, 324:23-25.
Shibuya, K., Hashimoto, H., Yano, E. / (2002). Individual Income, Income Distribution and Self Rated Health in Japan. British Medical Journal, 324:16-19.
Lynch, J., Davey Smith, G., Kaplan, G. & House, J. S. / (2000). Income Inequality and Mortality: Importance to Health of Individual Income, Psycho-social Environment and Material Conditions. British Medical Journal, 320:1200-1204.

3EVIDENCE OF THE LINK BETWEEN INCOME INEQUALITY AND HEALTH

The relationship between income inequality and mortality as postulated by, among others, Wilkinson, has been seriously questioned by many other researchers who argue that Wilkinson and others have only looked at selected countries and have not taken into account individual incomes. Firstly we will look at a study that contradicts the relationship that Wilkinson found between income and health when comparing between countries.

TASK 1 – Revise Wilkinson hypothesis

Remind yourself of Wilkinson’s hypothesis (Unit 3, Session 1).

Task 2 is based on the next reading.

READING

Lynch, J., Davey Smith, G., Hillemeier, M., Shaw, M. et al. (2001). Income Inequality, the Psychosocial Environment and Health: Comparisons of Wealthy Nations. Lancet, 358:194-200.

TASK 2 – Extract information from text

a)How do the authors explain the difference between the results of this study and the findings of Wilkinson?

FEEDBACK

The authors argue that because Wilkinson only selected a few countries that seem to fit with his hypothesis he was able to show the inverse relationship between income inequalities and mortality. By including all the wealthy countries this association – between income inequality and health – is no longer found. Subsequent research, e.g. Ross et al. (2000), has indicated that the aggregate or ecological relationship of income inequality to health is quite variable across different types of aggregate units such as nations, states, SMSA's or census tracts or samples thereof, as well as across historical periods, and different model specifications in terms of temporality (cross-sectional versus longitudinal) and other independent variables (e.g., controls for mean income and/or education, racial composition, etc.). This is not surprising as aggregate or ecological correlations in small to modest-sized samples of ten to fifty or so units are often quite unstable in these ways.

To get around this, as we mentioned in the previous unit, we need to look within countries and to take into account individual income. The early studies from the United States suggested that even after controlling for individual level income, the level of income inequality for the area still had an impact on mortality. However, more recent studies are finding the opposite. Here is an example of two such studies.

READING

Osler, M., Prescott, E., Gronbaek, M. et al. (2002). Income Inequality, Individual Income and Mortality in Danish Adults. British Medical Journal, 324:23-25.

Shibuya, K., Hashimoto, H., Yano, E. (2002). Individual Income, Income Distribution and Self Rated Health in Japan. British Medical Journal, 324:16-19.

TASK 3 – Develop an argument about the relative importance of individual income and income inequality on mortality

From the readings,

a)What conclusions do you draw about the importance of individual income versus income inequality on mortality?

FEEDBACK

Most analyses of aggregate or ecological relationships of income inequality and health, at least by proponents of the impact of inequality on health, tend to ignore the fact that by far the most potent economic determinant of health is individual income. This is why the observed effect of income inequality on health is often diminished or eliminated by controls for mean levels of income. More importantly, the observed effect of income inequality is quite small relative to the effect of individual income in multilevel analyses, which are really the appropriate designs for determining the effect of income inequality. Further, the diminishing return of income for health, coupled with some biological ceiling on levels of attainable health, albeit a ceiling that may rise slightly over time, suggests that the impact of income on health is due not to the relative deprivation that inheres in any income distribution but rather to the absolute conditions of life that characterize the broad lower range (e.g., median and below) of the populations of even prosperous societies like the United States.

4A NEO-MATERIALISTIC EXPLANATION?

The realisation that individual income still plays such an important role in determining health outcomes is causing researchers to re-assess the importance of psycho-social factors, in favour of more material factors. One example of this is found in the following article.

READING

Lynch, J., Davey Smith, G., Kaplan, G. & House, J. S. (2000). Income Inequality and Mortality: Importance to Health of Individual Income, Psycho-social Environment and Material Conditions. British Medical Journal, 320:1200-1204.

Now complete the task based on this reading.

TASK 4 – Identify argument of the author

a)Do you agree with the argument put forward by the authors? Why, or why not?

FEEDBACK

Lynch et al argue that almost all behavioural, environmental, or psychosocial risk factors for health (including risky health behaviours, psycho-social, and physical stressors, lack of social relationships and support, environmental hazards, and health-damaging psychological states or traits) become more prevalent with decreasing income or other forms of socio-economic status and resources such as education, occupation or wealth. These conditions of life, along with remaining inequalities in medical care, which are all powerfully influenced by income and other aspects of socio-economic status, can largely explain why income is so strongly linked to health, without recourse to notions of relative deprivation or lack of social trust or cohesion.

This raises questions about the usefulness of the concept of cultural and social capital. This is the issue to which we turn in the next session.

Unit 4 - Session 2

Critique of Social Capital

Introduction

This session takes the critique of Lynch et al further by questioning the use of the concept of social capital. It will put forward the argument that the very broad definition and use of social capital as an explanatory variable reduces its usefulness at best and at worst, allows it to be used to justify conservative policies.

Contents

1.Learning outcomes of this session

2.Readings

3.Measuring social capital

4.Is the concept of social capital still useful for public health?

5.Summary

Timing

There are four readings in this session.

1LEARNING OUTCOMES OF THIS SESSION

By the end of this session you will be able to:
  • Identify weaknesses in the definition and use of the term social capital.
  • Outline ways in which the concept of social capital could be more useful in explaining changes in health.

2READINGS

Author/s /
Reference details
Macinko, J. & Starfield, B. / (2001). The Utility of Social Capital in Research on Health Determinants. Milbank Quarterly, 79 (3): 387-427.
Kunitz, S. J. / (2001). Ch 8 - Accounts of Social Capital: The Mixed Health Effects of Personal Communities and Voluntary Groups. In D.A. Leon & G. Walt. Poverty Inequality and Health. New York: Oxford University Press: 159-174.
Muntaner, C. & Lynch, J. / (1999). Income Inequality, Social Cohesion and Class Relations. International Journal of Health Services, 1: 67-73.
Pearce, N. & Smith, G. D. / (Jan 2003). Is Social Capital the Key to Inequalities in Health? American Journal of Public Health, 93 (1): 122-129.

3MEASURING SOCIAL CAPITAL

The use of the idea of social capital has come under attack from a number of sources. Firstly, there is concern that the way it is measured has not been standardised or rigorously validated. This is highlighted in the following reading.

READING

Macinko, J. & Starfield, B. (2001). The Utility of Social Capital in Research on Health Determinants. Milbank Quarterly, 79 (3): 387-427.

These technical concerns around measurement are in turn linked to deeper concerns about the theoretical base and use of the concept of social capital.

Read about these concerns in the reading by Kunitz.

READING

Kunitz, S. J. (2001). Ch 8 - Accounts of Social Capital: The Mixed Health Effects of Personal Communities and Voluntary Groups. In D.A. Leon & G. Walt. Poverty Inequality and Health. USA: Oxford University Press: 159-174.

A more radical critique of the traditional use of social capital to explain the impact of income inequalities has also emerged. This critique emphasises the importance of power, politics and economics. In the next reading, Muntaner and colleagues illustrate how this ill defined concept of social cohesion, and hence social capital, can lead to a measurement bias and ultimately to conservative conclusions.

READING

Muntaner, C. & Lynch, J. (1999). Income Inequality, Social Cohesion and Class Relations. International Journal of Health Services, 1: 67-73.

4.IS THE CONCEPT OF SOCIAL CAPITAL STILL USEFUL FOR PUBLIC HEALTH?

In summary, there has been a backlash against the focus on social capital as equivalent to social networks and support enjoyed by individuals, and that may buffer them against the stresses of everyday living. The debate is neatly summarised in this next reading by Pearce.

READING

Pearce, N. & Smith, G. D. (Jan 2003). Is Social Capital the Key to Inequalities in Health? American Journal of Public Health, 93 (1): 122-129.

Even though the traditional way of thinking about social capital is downplayed, Pearce does not dismiss the concept altogether. Instead, he suggests that the economic and political factors need to be considered as well. So there is a need to expand the concept of social capital.

The American political scientist Robert Putnam, who is credited with the recent explosion of interest in social capital, has examined local communities and social networks, and their impact on effective political life and a healthy milieu for economic progress. Putnam made his first enquiry in Italian local communities. He interpreted the results as a proof that social networks and social capital furthered trust and a general willingness to do business and collaborate in matters of importance for the local society. Finding this evidence, he made a similar analysis of the United States, claiming that social capital – primarily measured as participation in different types of voluntary associations and clubs – had diminished during the last decades of the twentieth century, hurting the trust between the citizens. Instead of doing it together with a group of friends, the American had started to bowl alone. Because of this, political participation in local affairs was weaker. Comparing different places in the US he also found proofs, based on his own figures and other results, that trust, political participation and even health was positively correlated with the degree of social networking and social capital – in communities and among individuals. However, he underplays the role of the state in nurturing civil society and increasing social capital.

Putnam’s roots in a liberal society with an interest in efficient governance and an efficient economic system is part of the context that may explain his critique of social-democratic political systems. His opinion has been challenged by Bo Rothstein, a Swedish political scientist and supporter of the welfare state. Rothstein used the same measurements and methods as Putnam did, and found that while social capital had declined in the United States, it had actually increased in social democratic Sweden in the last decades. Rothstein’s conclusion was that social capital can be enhanced by an active state, although its exact forms change over time. This standpoint has also been taken by other scholars, for instance by Michael Woolcock and Stephen Kunitz.

Putnam distinguished between two forms of social capital.

Bonding capital

The first form of social capital is ‘bonding social capital’, characteristic of socially and culturally homogenous groups where the network’s first objective was to strengthen the group’s identities and interests.

The early modern artisans’ guilds in Europe can be said to be a typical example of bonding social capital, trying to preserve their interests and excluding others from their privileges. Bourdieu’s cultural and social capitals can mostly be seen as representations of the ‘bonding’ types.

Bridging capital

There is, however, according to Putnam, another type of networks, which create ‘bridging social capital’. These networks consist of less homogenous groups with limited objectives and lesser attachment to specific values. Citizens in a local community taking care of the playground of their children, a bridge club or a sports club are all examples of this type of network. Their bridging nature consists of bringing people together, increasing the feelings of mutual belonging to the greater society and creating an atmosphere of open-mindedness to other groups, values and ways of living. These networks do not even have to be locally based; they can also be national associations. Bridging social capital is essential for political participation, community trust and economic progress.

Putnam was in principle aware of the fact that all types of networks and social capital may not be good for the society as a whole or even for the group that constitutes the network. However, when all “good” capital is summed up in society, he thought that its positive effects outweigh the negative ones.

The English historian Simon Szreter carried the critique of Putnam further in a theoretical discussion about the role of different types of social capital and its empirical application on the American history as interpreted by Putnam in his book about the ‘lonely bowler’ and in the debate following upon its publication.

Simon Szreter does not deny the value of the distinction between ‘bonding’ and ‘bridging’ social capital. He is, however, giving more weight to the potential negative effects of bonding capital. There are numerous examples of Szreter’s standpoint, such as the Ku Klux Klan and other organizations aiming at goals of exclusion, even taking action against the parts of the population they do not like. Criminal gangs of youngsters can be described as networks trying to create bonding capital, lacking any other form of capital that gives them self-esteem. The problem is of course that their activities are hardly to the benefit of society and it can be questioned whether their lifestyles are even good for themselves in a longer time perspective. Besides, with these extreme examples Bourdieu’s uncovering of the reproduction of power through informal elite bonds may still be valid for many societies, including the United States. Szreter is also less optimistic about the potential effects of social networks in creating bridging social capital, especially if class differences are taken into consideration.

While Putnam’s good society consists mainly of informal networks within local communities, giving little room for the formal political bodies in the creation of social capital, Szreter claims that the decline of social capital in the United States is primarily a product of the lack of will and initiative from the side of the state and the lack of power among other movements to create ‘linking social capital’, such as it had been during the era of active local engagement in community reforms during the early part of the 20th century, Franklin D. Roosevelt’s ‘New Deal’ in the 1930’s and during the political activities against racism and poverty during the Kennedy-Johnson era in the 1960’s. A ‘hands-off’ policy followed in Washington, giving room for strong groups to act without restrictions, lobbying at state and federal levels for the interests of big companies, the rifles association and other influential pressure groups. The result is egoistic individualism and a lack of interest in the less privileged citizens.

In Szreter’s view, politics and public authorities at all levels can participate in linking social capital – giving more of that resource to those who need it most. It also means that in order to be truly beneficial for the whole society, even informal networks and voluntary associations need not just represent limited self-interest, but also act according to an ideology of equality and compassion with fellow citizens of different kinds. In previous American history, Szreter finds examples of these types of networks/associations, sometimes starting as interest groups but developing into linking-type instruments for social capital. Hence, according to Szreter and others, politics and public and private institutions can play a role to create – or undermine – social capital for those who need it, but ideology will be an important part of the process. Even the public ‘discourse’, i.e. the ways media and politicians present a situation, its roots, implications and possible solutions, contributes to the shaping of social capital – which type, how, for what and for whom. Daniel Fox, president of the Milbank Memorial Fund, an endowed philanthropic foundation that works with policy makers in the public and private sectors to improve health policy, claims that in the contemporary United States there is no effective political support for proposals to reduce disparities in income by redistributing wealth, but that there is considerable support for reducing illness and suffering that result from individuals having inadequate resources. The explanation for the absence and presence of such support can be found in political culture and how it shapes day-to-day politics.