Discuss the concept of social capital as an explanatory factor accounting for health inequalities.

What problems are there using this concept and how useful do you find it in understanding inequalities in health?
In recent years, there has been an increasing acceptance that the determinants of health are complex, and cannot be reduced either to socio-economic, biological or genetic factors. Now, it has been rather widely acknowledged that socio-economic factors are major determinants of health. Probably in reaction to the predominance of neo-liberal economic considerations, we witnessed now a growing emphasis on social determinants1. The concept of social capital has recently been introduced as a possible explanation for findings with respect to inequalities in health and in particular for the relationship between income inequality and health 2.This new interest in social capital provides an opportunity for the policy makers to advance social agendas, but at the same time challenges them because it requires a better understanding on how health, income inequalities and social capital interact. Social capital is a key concept in the recognition of interconnections between social and economic outcomes, but it is a complex concept, which means that much of the discussions is about definition and measurement issues. Social capital has become rather fashionable, and there has been a wealth of literature on health and social capital, yet the concept is vague and needs some refinement in order to understand health inequalities and eventually provides some guidance to decision makers. What is social capital? Although social capital has a long history in sociology (it may have started when E. Durckeim, in 1901, identified a relationship between the rate of suicide and the level of social integration), the three influential schools of thought related to social capital were respectively led by Putnam, Bourdieu and Coleman. It is not clear who developed the first explicit definition of social capital. Robert Putnam conceived social capital as a community level resource3 and defined it as features of social organisation such as networks, norms and social trust that facilitate co-ordination and co-operation for mutual benefit4.The French sociologist, Pierre Bourdieu, put an emphasis on social capital as the sum of resources, actual or virtual, that accrue individuals as a result of their membership of networks5. Coleman, eventually, mainly wrote on the link between social capital and the education process, and thus the role of the family. There is no general agreement on the definition of social capital,

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but there are three main issues which might be relevant to health. The first is the distinction between an individual or a collective level of definition of social capital6, i.e. social capital is a resource which facilitates ends for individual or for a social group. However, collective social capital cannot be simply the sum of individual social capital. If social capital is a resource available through social networks, the resources that some individuals claim come at the expense of others. Secondly, these definitions do not really differentiate what social capital is from what social capital does7, or what are the sources and the consequences of social capital. To confuse the sources of social capital with the benefits derived from them leads to circular reasoning because the presence of social capital is often inferred from the assets that an individual or group acquires. Thirdly, social capital is almost always understood as a concept, which can only have positive effects without considering its possible negative implications. Considerations of the measurement of social capital inevitably reflect the conceptual debates about social capital itself. Macinko et al8 have reviewed the different indicators of social capital. The labelling of apparently the same criteria varies extensively from one study to another (e.g. social trust, mistrust, civic trust, interpersonal trust). A second problem arises because of the lack of consensus on the level of aggregation at which social capital measures should be assessed (individual, community, state). Most of the studies have been quantitative and have used proxies, when trying to measure a per capita membership in voluntary groups and levels of inter-personal trust. Concepts such as trust, community or networks are rather difficult to quantify. Some of the more recent work on social capital explicitly recognised the difficulties in measuring social capital as a single explanatory variable. Kawachi, in particular suggested that because of the methodological problems in measuring social capital, conclusions about the role of social capital should be interpreted with caution9. Interestingly, the World Bank has launched an initiative and funded a number of social capital projects which will help to define and measure social capital with a range of quantitative and qualitative approach. Health inequalities and social capital Since the publication of the Black Report (1980) on Britains health inequalities, research on the socio-economic determinants of health has received a greater interest. Recent studies have shown that better health outcomes seem to be correlated not only with the average income but sometimes more strongly with the distribution of income within society. While there is still

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some debate about the strength of the relation between inequitable distribution of incomes and health10, this new evidence requires further investigation. How income distribution may influence the health of the population and how social capital may interact? Scientists have given different explanations, but the debate is mainly around the two following sets of explanation. On one hand, Lynch et al posited that an inequitable income distribution may have direct consequences on peoples perception of their social environment that influence their health11. Wilkinson suggested the same kind of ideas12, i.e. ill health might be the consequences of the negative emotions such as anxiety, stress, low self-esteem, But on the other hand, Lynch et al eventually suggested in the same article that an inequitable income distribution may be associated with a set of social processes and policies that systematically under invest in human, physical, health and social infrastructure and this underinvestment may have health consequences. In sum, are health inequalities and income inequalities the consequences of the same macro-policies or are they causally linked? Enter social cohesion or social capital as one means by which income inequality may adversely affect health. It is important to bear in mind that the social capital concept has been borrowed from other disciplines rather than being developed specifically for the health field. It has been first thought to promote economic growth, development and the performance of political institutions. Interestingly, Putnam himself said that health should not be considered as an outcome of social capital13. Nevertheless the social capital hypothesis is supported by evidence that indicators of social capital, such as trust, belonging to and volunteering for community organisations are strongly related to mortality rates. For Wilkinson, the social cohesion is indicative of psychosocial factors that are closely associated with health14, and he put forward evidence that social status may affect health outcomes from work done on nonhuman primates. Kawachi et al published in 1997 a study carried out in 39 states in the United States. They conclude, apparently without any shadow of a doubt that income inequality leads to increased mortality via disinvestment in social capital15. Wilkinson and Lynch agree that societies with a higher degree of income inequality are also the ones with low social cohesion and that the presence or the absence of this social resource may affect the health of the population16. The issue is still the causality between the different factors, the evidence of associations between measures of social capital and health outcomes does not establish that these associations are causal. If communities with a higher level of participation and social trust are healthier, it does not necessarily mean that the level of health is a consequence of the level of social cohesion. Pearce also suggests that evidence regarding social trust and health is confined to particular countries17, such as the United States and he quotes a counter-example
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taken from a cross-national study by Lynch18 et al. They found that measures of social capital were only weakly and inconsistently associated with cause-specific mortality and that greater distrust was actually associated with lower coronary heart disease. We may assume that on a personal level, social support and social cohesion may have a positive influence on health, on the basis of the explanations given by Wilkinson for the link between unequal income and ill health. But on a macro level, there are different ways in which social capital may have an impact on health. First, social capital may influence the performance of political institutions (i.e. to increase their responsiveness to the populations needs). In particular, social capital may influence access to health services since a more cohesive community may be more successful at getting closer services (i.e. outreach programmes). Second, social capital may help to promote health behaviours through the channels provided by the existing networks. For Muntaner and Lynch, the Wilkinsons model implies that social cohesion rather than political change is a major determinant of population health. They worried that the emphasis put on the psychosocial factors may lead policymakers to try to improve social cohesion while ignoring others factors such as absolute and relative income or the delivery of health services19. Interestingly, the different interpretations of social capital eventually lead social scientists into a theoretical debate on the different schools of sociology , i.e. Wilkinson with a neo-Durckeimian model versus Muntaner and Lynch with a neo-Marxist model and thus into a political debate about the role of the state. Indeed, the Wilkinsons model does not take into consideration the social mechanisms that might determine the social cohesion. About the implied positive effects of social capital, Muntaner and Lynch drew our attention to the fact that relation between social cohesion and health is more likely to follow an inverted U shape. On one extreme, no participation produces social isolation and it is likely to have negative impact on health. On the other extreme, societies with a high level of cohesion may not be as healthy as expected. They quote a research carried out on the AIDS epidemic in the United States20, where the subjective experience of integration into social networks among men at risk for AIDS was associated with distress rather than with its reduction, as the social integration hypothesis would predict21. The term of social capital has been widely criticised because the concept has been stretched and modified to cover a wide range of relationships at different levels. Because of the problems of definition and measurement of social capital, I think the public health utility of

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this concept may have been exaggerated. Nevertheless a better understanding of the complexity of social capital and how social capital is related to health inequalities is necessary and the concept should be refined. To explore more in depth the mechanisms by which social capital might influence health, there is a need to agree to a theoretical framework and possible measurements, because the two set of explanations provided respectively by Wilkinson and Lynch are difficult to compare or test against competing hypotheses. Potential confounders such as class or gender need to be investigated more systematically. It should not divert us from a better understanding on how social inequalities occur, if not, it will be too easy to place the burden of reducing inequalities in health on the community and its capacity to be cohesive. Indeed, the consequence of an emphasis on the necessity for communities to be socially cohesive makes community eventually responsible for their health. It is may be more essential to understand how macro-policies shape our societies, i.e. the level of trust between citizens, but also the level of trust in our institutions. Sharing the view of F. Baum, I think it is important not to be carried away by some romantic view of community, more social capital is not necessarily an unmitigated good22. It is also worth noticing that all the research studies trying to understand the range of determinants have tended to focus their attention on a narrow definition of health, i.e. absence of disease or injury.

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Baum F. Social Capital: Is it good for your health? Issues for a public health agenda. J Epidemiol Community Health 1999;53:195-196. 2 Pearce N. Is Social Capital the key to inequalities in health? American Journal of Public Health. January 2003. 93(1):122129. 3 Baum F, Ziersch A. Social Capital. J Epidemiol Community Health 2003;57:320-323 4 Putnam R. Bowling alone: Americas declining social capital. Journal of Democracy. 1995;6:65-78. 5 Baum F, Ziersch A. Social Capital. J Epidemiol Community Health 2003;57:320-323 6 Macinko J, Starfield B. The utility of social capital in research on health determinants. Milbank Q. 2001;79(3):387-427. 7 Veenstra G. Social Capital and Health. Isuma. 2001;1(2):72-81. 8 Macinko J, Starfield B. The utility of social capital in research on health determinants. Milbank Q. 2001;79(3)::387-427. 9 Kawachi I, Berkman L. Social cohesion, social capital and health. Social Epidemiology. New York. NY Oxford University Press: 2000: 174-190 10 Judge K, Mulligan JA, Benzeval M. Income inequality and population health. Soc Sci Med 1998;46:567-79. 11 Lynch J, Kaplan G. Understanding how inequality in the distribution of income affects health. Journal of Health Psychology. 1997;2:297-314. 12 Wilkinson R. Income inequality, social cohesion, and health: clarifying the theory- a reply to Muntaner and Lynch. International Journal of Health Services. 1999;29:525-543 13 Putnam RD, Making democracy work. Princeton. NJ: Princeton University Press. 1993. 14 Wilkinson R. Income inequality, social cohesion, and health: clarifying the theory- a reply to Muntaner and Lynch. International Journal of Health Services. 1999;29:525-543 15 Kawachi I, Kennedy B, Lochner K, Prothrow-Stith. Social Capital, income inequality and mortality. American Journal of Public Health. 1997. 87:1491-1498.. 16 Veenstra G. Social Capital and Health. Isuma. 2001;1(2):72-81. 17 Pearce N. Is Social Capital the key to inequalities in health? American Journal of Public Health. January 2003. 93(1):122129 18 Lynch J, Davey Smith G, Hillemeyer M, Shaw M, Raghunathan T, Kaplan G. Income Inequality, the psychosocial environment, and health comparisons of wealthy nations. Lancet. 2001;358:194-200. 19 Muntaner C, Lynch J. Income inequality, social cohesion, and class relations: a critique of Wilkinsons neo-Durckeimian research program. International Journal of Health Services. 1999;29:59-81 20 OBrien K, et al. Social relationships of men at risk for AIDS. Soc Sci Med.1993.36: 1161-1167. 21 Muntaner C, Lynch J. Income inequality, social cohesion, and class relations: a critique of Wilkinsons neo-Durckeimian research program. International Journal of Health Services. 1999;29:59-81 22 Lynch J, Due P, Muntaner C, Davey Smith G. Social Capital-Is it a good investment strategy for public health?. J Epidemiol Community Health 2000;54:404-408.