Social capital and health
Stephen J Kunitz
Department of Community and Preventive Medicine, University of Rochester School of Medicine
and Dentistry, Rochester, New York, USA
Social capital refers to bonds between individuals, both in intimate relationships
(primary groups) and in voluntary associations (secondary groups) that make it
possible for individuals and groups to achieve a variety of goals. Such bonds have
also been claimed to have health promoting effects. In this chapter, I review a
variety of empirical studies at both levels of analysis and suggest that the results
are mixed, much depending upon the context in which such relationships occur.
Introduction
Social epidemiologists have long been interested in the ways in which
social organization and disorganization influence the health of populations.
A recent manifestation is the concept of social capital, which the American
sociologist James Coleman defined as follows:
This is a revised version of
the following chapter:
Kunitz SJ. Accounts of
social capital. In:
Leon DA and Walt E (eds),
Poverty, Inequality and
Health: An International
Perspective.
Oxford: Oxford University
Press, 2001. Reproduced
by permission of Oxford
University Press.
Correspondence to:
Stephen J. Kunitz, M.D.,
Ph.D., Department of
Community and
Preventive Medicine, Box
644, University of
Rochester Medical Center,
601 Elmwood Avenue,
Rochester, NY 14642, USA.
E-mail:Stephen_Kunitz@
urmc.rochester.edu
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. Like physical capital and human capital, social capital is not completely
fungible but may be specific to certain activities. A given form of social capital
that is valuable in facilitating certain actions may be useless or even harmful
for others (p. S98)1.
Coleman went on to say that, “Unlike other forms of capital, social capital
inheres in the structure of relations between actors and among actors. It
is not lodged either in the actors themselves or in physical implements of
production.”
As Coleman’s definition suggests, social capital is used at two levels of
analysis, primary and secondary groups. Primary groups are comprised
of family, friends and neighbours and are often thought of as forming
networks, or personal communities2. Secondary groups include voluntary
associations such as fraternal lodges and civic organizations.
At the primary group level, there have been countless studies of the
way social integration and social and emotional support affect both
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Cultures of health, cultures of illness
morbidity and mortality. At the secondary group level there have also been
many studies arguing that membership in voluntary associations increases
trust in one’s neighbours and that civic participation has beneficial consequences for the health of the entire community. Robert Putnam, one of the
leading authorities on this type of social capital, writes “Social capital refers
to features of social organization such as networks, norms, and social trust
that facilitate coordination and cooperation for mutual benefit” (p. 67)3.
This type of social capital originates in membership in voluntary associations, and in dense networks of such organizations in any community,
because it is in such settings that people learn to trust, to reciprocate and to
act in concert to demand public services and good government (p. 182)4.
It is fair to say that there has been great enthusiasm for the beneficial
health consequences of social capital, at both the primary and secondary
group level. In this chapter, however, I should like to argue that the data are
mixed. As with other forms of capital, its consequences may be negative
as well as positive.
Social capital and civic participation
I begin with a brief description of Alexis de Tocqueville’s observations
made during a famous trip to America in 1831–32. Tocqueville was not
only an astute and prescient observer, but his comments on the significance of voluntary associations in American life and on the involvement
of Americans in civic affairs have been an inspiration for many contemporary advocates of the benefits of social capital. He observed that the
men who initially settled the South were adventurers who came without
families in search of wealth. They were followed by “a more moral and
orderly race of men” who were, however, “nowise above the level of the
inferior classes in England.” And of course the introduction of slavery
exercised a “prodigious . . . influence on the character, the laws, and all
the future prospects of the South” (pp. 16–8)5.
These settlers compared unfavourably with those who settled the North,
who “belonged to the more independent classes of their native country.”
They were “neither rich nor poor.” All were educated and in proportion
to their number possessed “a greater mass of intelligence than is to be
found in any European nation of our own time.” They were sober, moral,
family men who were accompanied by their wives and children. They were,
he continued, Puritans, and “Puritanism was not merely a religious doctrine, but it corresponded in many points with the most absolute democratic
and republican theories” (pp. 16–9)5.
Other observers noted that southerners had come from the Celtic fringe
of the British Isles and brought with them an entirely different culture than
the Puritans. It was a culture that was kin-based, and that emphasized the
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importance of family and personal honour, the spoken over the written
word, agrarian over business values, and leisure over enterprise (p. 268)6.
Many of these cultural differences persisted as Northerners and Southerners pushed westward. People from New England tended to remain in
the northern tier of states, whereas southerners moved along the southern
tier into the American Southwest. One preacher contrasted the Yankee
settlers in Ohio who, “in the strong exercise of social inclination,
expressing itself in habits of neighborhood, [formed] villages, and live[d]
in them, . . . to that sequestered and isolated condition, which a Kentuckian,
under the name of ‘range,’ considers as one of the desirable circumstance
of existence” (pp. 268–9)6.
Reflecting the cultural differences between North and South were the
political differences observed by Tocqueville. He wrote:
Townships and a local activity exist in every State; but in no part of the
confederation is a township to be met with precisely similar to those of New
England. The more we descend towards the South, the less active does the
business of the township or parish become; the number of magistrates, of
functions, and of rights decreases; the population exercises a less immediate
influence on affairs; town-meetings are less frequent, and the subjects of
debate less numerous. The power of the elected magistrate is augmented, and
that of the elector diminished, whilst the public spirit of the local communities
is less awakened and less influential (pp. 77–8)5.
Complicating the story even further is the legacy of slavery, of which
Tocqueville himself was well aware. Stanley Engerman, Stephen Haber
and Kenneth Sokoloff have compared the economies of various countries in
the Western Hemisphere and have argued that factor endowments—land,
climate, indigenous populations—shaped the subsequent growth of
institutions and the degree of inequality in each country7. Countries in
which conditions had made slavery economically advantageous became far
more unequal than those in which small-holdings were relatively equally
distributed within the population. Elites in highly unequal countries established institutions that reinforced the early inequality and persist into the
present. For example, less is spent on education in such countries because
the children of the elite have been educated in private schools; financial
institutions and easy credit have not been widely available; and the franchise has not been inclusive. And what is the case at the national level, say
between Latin America on the one hand and the United States and Canada
on the other, is also true, though to a lesser degree, when the American
South is compared to other regions of the United States. That is, the institutional legacy of slavery in the American South has been low educational
attainment, high income inequality, and until recently lack of access to the
polls when compared to the North, the Midwest, and the West.
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All of these differences in the civic cultures and institutions implanted
in the North and South continue to make a difference right down to the
present. Many studies indicate that the South has the lowest levels of
social capital (measured as membership in voluntary associations, and in
trust of one’s neighbours), the lowest levels of education, the highest levels
of income inequality, and the highest levels of homicide and of overall
mortality of all the regions of the USA8–13.
At the state level, therefore, the advantage seems to be to the North,
where social capital is higher and mortality lower than in the South. At
the metropolitan level, however, a paradox emerges. A study of the impact
of racial segregation on mortality in metropolitan regions indicated that,
even adjusting for latitude and longitude, segregation was associated
with an increase in deaths among African-Americans but not among
whites14. But it was also observed that the most racially segregated metropolitan regions were in the Northeast and Upper Midwest, the very
areas in which the civic culture that so impressed Tocqueville had taken
deepest root. The two are not unrelated.
These cities were America’s industrial heartland, and the relatively
unskilled jobs available in their factories and mills provided economic
opportunities for vast numbers of immigrants. In the 19th century, cities
in the Northeast grew by annexation. They were able to acquire territory
at the fringes and incorporate them within a larger city. This was to everyone’s advantage. People in the annexed territory were glad to have city
services such as water, sewers, paved roads, and trolley lines, and the
city acquired an expanding tax base15.
In the late 19th and early 20th centuries, however, as immigrants from
Eastern and Southern Europe, and African-Americans from the deep
South began flooding these cities, the older inhabitants moved to the
suburbs and began erecting barriers that would prohibit annexation
without their consent, including exclusionary zoning and amendments
to state constitutions. They drew on the tradition of local community
government to protect their economic, ethnic and racial exclusivity. As a
result, these cities became the most racially segregated in the country, as
well as the least elastic. That is, they are cities that have failed to expand
their geographic boundaries to capture suburban growth16. Consequently, the metropolitan areas of which they are a part are divided into
many different jurisdictions with their own taxing authorities and
school systems. The effect has been to create relatively affluent suburbs
and poverty-stricken inner cities, populated disproportionately by poor
African-Americans. And in the inner cities access to services and jobs is
diminished and mortality and morbidity from many different causes are
elevated.
The same period that saw the emergence of exclusionary zoning and
independent suburbs is also celebrated as the ‘golden age of fraternalism’
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by believers in the efficacy of social capital and American associationalism
(when as many of the affairs of society as possible are managed by
voluntary and democratically self-governing associations). The burgeoning
of fraternal associations in the late 19th century was to a very large
degree fuelled by the immigration of people from many different
cultures, for mutual aid associations based upon religion and ethnicity
were a way to provide burial benefits and sickness insurance to
newcomers who would otherwise have been unprotected. They were
also among the vehicles by which native-born white Americans could
shelter themselves from contact with immigrants. In their ethnic and
religious exclusivity, they helped perpetuate and exacerbate cleavages
among groups, and they also became an important force resisting the
first attempts to create compulsory state sponsored health insurance in
the first two decades of the 20th century17,18.
Fraternal organizations, while an answer to one set of serious problems, helped to create obstacles to the provision of universally accessible health care for all Americans. They were not, of course, the only
sort of voluntary association to grow during the period between the
Civil War and World War I. Settlement houses, playground and parks
associations, and hundreds of other organizations devoted to civic
improvement and environmental protection emerged at the same time,
and with very different goals than the fraternal organizations19. That is
precisely the point. The civic culture and rich associational life that
have so impressed observers of late 19th and early 20th century America had mixed results. One result was to strangle solutions to problems
never anticipated when the colonies were established or when fraternal
organizations arose as the answer to the problems of recently arrived
immigrants.
Thus when Robert Putnam suggests, “[A]s a rough rule of thumb, if you
belong to no groups but decide to join one, you cut your risk of dying
over the next year in half. If you smoke and belong to no groups, it’s a
toss-up statistically whether you should stop smoking or start joining,”
he is using clever rhetoric but giving bad advice (p. 331)20. This suggests
confusion between relative risk and attributable risk. More importantly,
though, the mixed and uncertain consequences of group membership
and social networks, and the unequivocal ill-effects of smoking mean
that the decision is not a toss-up, either statistically or for an individual
smoker, and it is irresponsible to suggest otherwise.
To recognize the complex nature of civic culture and secondary
associations requires more than ecological correlations of measures of
trust and mortality. It requires that we think about the history and
culture of specific peoples and places21. We see something similar
when we turn to a consideration of primary groups and personal
communities.
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Social capital and primary groups
Just as social capital is fast becoming a paradigm with which to explain
inequalities in health at the societal level, so in the form of social support
and integration has it become important in studies of the health of
individuals22–34. And as in studies at the societal level, so too at the individual level are there results that should encourage a more nuanced way
of thinking about the processes at work.
The studies of social support and integration (i.e. involvement with
friends, kin and neighbours) on the one hand and subsequent mortality
on the other have generally shown that when support is high, the risk of
mortality tends to be reduced, even after controlling for various measures
of health status. The effects are particularly strong for white males. They
are much weaker or non-existent for women and for non-whites, including
African-Americans35, Japanese-Americans36 and Navajo Indians37, primarily
in rural populations. One commentator has suggested that such anomalies
“have to do with the extent to which women and blacks are deeply integrated into stable, rural communities . . . Under such circumstances, if
these groups routinely obtain large doses of social support, specific measures tapping frequency of contact and size of network may be less differentiating than in less well-integrated communities. Furthermore, these
sources of support may be so much a part of the normal daily lives of
these people that they commonly go unnoticed and, as a result, are
underreported in surveys of this sort. In urban areas, where people are more
mobile, their awareness of sources of support and frequency of contact
may be heightened”38.
It may well be that the differences are simply the result of methodological
difficulties, and that the instruments that have been used to measure
integration and support are too blunt to dissect subtle distinctions
among populations where support is generally high. On the other hand,
the notion that these anomalous results may be explained by the pervasiveness of social support rather than by its absence assumes that which must
be demonstrated. It may be that there are true differences in the structure,
meaning and functioning of social networks in different populations and
settings. For example, in a study in one southern community it was
found that African-Americans had lower levels of support than whites39,
rather than higher levels as suggested in the previous quotation. Moreover,
whereas family networks have been shown to be important sources of
support among African-Americans, the conflictual and non-supportive
side of such networks has also been noted (pp. 262–3)40.
Furthermore in a variety of studies, women are found to report higher use
of support than men, but they are also more likely than men to provide support. “Thus, women may be more likely to be exposed to negative social
outcomes regarding both themselves and others than is true for men.
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Women with larger networks may be more involved in dealing with the
stresses of others and thus experience more stress than women with
smaller networks or than men” (p. 553)41. Indeed, studies of “care-taker
stress” consistently show that people who care for disabled kin are more
susceptible to a variety of illnesses than people who do not42–46. More
generally, “negative aspects of close relationships [have] adverse effects”
on various aspects of health functioning of men and especially of women47.
Finally, living in poverty, living in a rural area, or living in a poor
country means that informal social networks and primary groups are
called upon to provide a broader range of services than they are in settings where the availability of, and access to, formal services are greater
(pp. 583–4)48. Without an infrastructure of functioning public health
services, widely accessible health care, public schools, a legal justice system,
and other formal institutions, the establishment and maintenance of personal networks are a matter of survival49. But social networks may also
impose heavy burdens, for example when reciprocity is required by other
members, when gossip and other forms of coercion are used to control
behaviour, or when no social services are available to ease the burdens of
family care-givers. Kinship and friendship networks are not unambiguously
supportive and may exact very high costs.
Not only are different contexts associated with differences in the services
provided by personal networks, but the structure of networks is different
as well. In general, “studies in several Western countries show that close
relatives, especially parents, continue to be of central importance in personal networks. There are, however, differences between rural and urban
populations and between social strata in the importance of extended kin
compared to friends and acquaintances. In larger cities as well as in middle
classes, relations with extended kin become looser, whereas those with
friends and acquaintances gain in importance” (p. 104)50,51.
In addition, network structure has profound consequences, even among
social strata in the same society. For example, in secure settings such as
those in which the middle and upper classes in developed countries live,
loose networks based upon friendship are particularly well suited to
obtaining jobs as well as needed services from a broad array of formal
organizations52. In contrast, dense networks in urban ghettos in the
United States isolate people from information about the availability of
jobs and services elsewhere in the city53.
Some of the complexities of the associations between social context
and the structure, function and effectiveness of social networks are suggested by the results of several studies among Navajo Indians in the
American Southwest. Indian reservations like the Navajo’s are generally
very rural and characterized by high rates of poverty and unemployment.
Traditionally extended families have been both a common as well as the
ideal form of social organization and in many instances still are because they
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are adaptive to the prevailing unstable economic conditions (pp. 243–5)54,
(pp. 53–4)55. This pattern is changing substantially, however, as people
move to towns on and off the reservation.
In a study of social integration and subsequent mortality among Navajo
men and women 65 years of age and above, my colleagues and I found
that only marital status was significantly associated with an increased
risk of death, and only among men over the age of 75. No other measures
of isolation or integration were significant56. This was because, in the
Navajo context, social integration meant that the family had to carry a
heavy burden. For instance, a significant number of our elderly informants
lived with adult children with physical or psychological disabilities for
whom no institutional or day care services were available, and for whom
the elderly parent was a major source of financial and other support.
Rates of depression were significantly higher among these respondents than
among people without such burdensome responsibilities.
We also observed in the 1970s that among women of childbearing age,
use of contraception was more likely by those who were not living with
their kin than among those who were, even adjusting for parity and education. This was because in a generally pronatalist setting, women of
childbearing age who lived in extended family arrangements were subjected to intense social pressure, and sometimes physical coercion, from
their mothers and husbands not to use contraception, whereas those living
neolocally (i.e. in independent nuclear households newly created at
marriage) were more autonomous and able to exercise choice57.
But the freedom associated with neolocality and nuclear families is a
mixed blessing. Young people who grew up in extended families learned
to use alcohol in settings that emphasized responsibilities to kin and
therefore shaped their careers as drinkers. Whereas heavy drinking often
led to serious difficulties, it was generally outgrown before catastrophe
occurred58. However, as the livestock economy has declined, people
have left rural areas and residence within extended families and moved
to reservation towns where they live in nuclear households, near unrelated neighbours, and attend school with non-relatives. In these new settings, the cross-generational fabric has been torn and a youth culture has
emerged which, at the extremes, is characterized by gangs, violence and
highly risky drinking59,60. As a result, the homicide rate has tripled since
the 1960s. Thus the same freedom from kin that has increased the likelihood
of contraceptive use has also resulted in the creation of social networks
that encourage destructive and self-destructive behaviour.
These brief examples have been meant to suggest some of the ways in
which the larger context may influence the structure, functions and effectiveness of social networks, and how these may in turn influence various
dimensions of peoples’ health and use of services. That is to say, social
relations are not always supportive and may be damaging, particularly
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when poverty, unemployment, insecurity and inadequate infrastructure
of formal organizations are prevalent. Under such conditions, people have
little choice in those upon whom they must depend, and the consequences
of enforced dependence on kinsmen may be quite mixed, for they may
be oppressive as well as supportive, a hindrance as much as a help. This
is unlike the situation of the well-to-do in developed countries, where a
good deal of freedom may be exercised in the choice of network members,
where networks are looser, and where in any event the need for support
from informal sources is less than in many other parts of the world. It is
this sort of complexity that explains why social relations which are often
assumed to be a form of social capital and of positive value may be of
little value or actually harmful.
Conclusion
Some of the most important themes running through the social thought
of the past almost two centuries—community, alienation, authority—have
represented attempts to come to terms with the consequences of two
revolutions, the democratic revolution in France and the Industrial
Revolution which began in England61. For some, like Herbert Spenser
and William Graham Sumner, the freeing of individuals from the bonds
of community and kin, the evolution of nuclear families, and the emergence of laissez-faire capitalism were at once welcome and inevitable62,63.
Others were at least ambivalent if not hostile. A widely shared view of
thinkers as different as Engels and Marx (p. 324)64 and Tocqueville was
that the two revolutions had destroyed aristocratic institutions and local
communities which had mediated between individuals and the state.
The result was mass society, alienation and overwhelmingly powerful
central governments with no intermediating institutions between them
and their citizens. Social capital shares in this tradition, for the answer
to the individualism, atomism and alienation of contemporary society—
civic cultures woven together by networks of voluntary associations—is
not so different from the answers given by many of our 19th century
intellectual ancestors.
Thus when Tocqueville went to America, it was to study the most
democratic nation of his day. What he found, especially in New England,
was municipal governments that were just the sort of intermediating
institutions whose absence he feared would lead to despotism in postrevolutionary France. He thought other forms of association could also
serve the same function as aristocracy had before the revolution. He wrote:
An association for political, commercial, or manufacturing purposes, or even
for those of science and literature, is a powerful and enlightened member of
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the community, which cannot be disposed of at pleasure, or oppressed without
remonstrance: and which, by defending its own rights against encroachments
of the government, saves the common liberties of the country (pp. 387–8)65.
The famous late 19th century French sociologist, Emile Durkheim,
whose name and study of suicide are cited and recited like a mantra in
many articles in the field of social epidemiology, made similar observations. The two forms of suicide that he thought were most important in
his time were egoistic and anomic. The egoistic type was the result of
loss of cohesion, particularly in religious society (pp. 169, 209)66. That
is why he claimed that rates among Protestants were higher than among
Catholics. Anomic suicide was the result of loss of restraint, prompted
by the growth of industrial society (pp. 254–5)66. Rates and patterns of
suicide were, he argued, just one instance of “the whole of our historical
development,” the “chief characteristic [of which] is to have swept
cleanly away all the older forms of social organization.” He continued,
“The great change brought about by the French Revolution was precisely
to carry this leveling to a point hitherto unknown . . . Only one collective
form survived the tempest: the State . . . [I]ndividuals are no longer subject to any other collective control but the State, so it is the sole organized collectivity” (pp. 388–9)66. He used the same metaphor of mass
society used by many of his contemporaries: “Individuals,” he said,
“tumble over one another like so many liquid molecules” (pp. 388–9)66.
We have inherited the world of Tocqueville and Durkheim, but precisely
because their insights are so powerful and their writing so persuasive, we
run the risk of allowing them to over-determine how we understand
ours. Durkheim’s study of suicide, for instance, has been so influential
and is so frequently cited, but not because his analyses were valid.
Indeed, they probably were not67,68. It is influential because he addressed
concerns that we share and provided answers to which we resonate. The
same is true of our response to Tocqueville.
But our world is different from theirs. Local governments may involve
their citizens in civic life, as Tocqueville suggested, but they may also
promote exclusivity and protect citizens from integration into larger
regional structures that may be widely beneficial. Associations “for political, commercial, or manufacturing purposes” may protect their own
interests, as Tocqueville and Durkheim both suggested, but in the process
may be harmful to the health and well-being of the public. This is amply
demonstrated by the opposition of the tobacco industry trade association
to limitations on cigarette advertising and sales, and by the destruction
of President Clinton’s plan for health care reform by a coalition of voluntary associations including the National Rifle Association, the Christian
Coalition, the National Federation of Independent Businesses and the
Health Insurance Association of America69.
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Churches may be the most integrative institutions in Hispanic and
African-American communities, but their deep conservatism prevented
them from acting early in the AIDS crisis and contributed to its
severity70. And kinship and friendship networks may provide support to
their members but may also exact high costs, resulting in resentment and
stress as well as delinquency and criminal behaviour. Social capital may
be valuable in facilitating certain actions, as James Coleman wrote, but
“may be useless or even harmful for others (p. S98)”1.
The quest for community has been a recurring theme in social and political thought. Certainly in the United States, perhaps the most individualistic of nations, it has been significant from the 19th century to the present
in the form of utopian communities and encounter and support groups.
Such communities generally represent a withdrawal from civil society
rather than engagement with it, and for this reason, the new republican
theorists distance themselves from communitarianism. Nonetheless,
they share common concerns and insights. Most importantly, both abjure
laissez-faire individualism in favour of the beneficial effects of association.
I have argued that whatever other benefits may derive from association—
and I believe them to be both real and significant—improved health is not
invariably one of them, for primary and secondary group ties may bind us
together, but they may also imprison and divide us.
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