How much does the decline of communities explain about America's health problems? A new survey shows how few people feel closely connected with their neighbors.
Suburbanites, as compared to urban and rural dwellers, are most certain of their access to community resources. They also care least about their neighbors. As such, their safe, affordable housing in unpolluted environments, with nearby health centers and plentiful recreation space, are good because they benefit them individually; that their fellow suburbanites benefit as well is almost incidental.
It's not just them. Strong communities made up of neighbors that care for, and about, one another are low on the list of health concerns of most Americans.
In a survey conducted for The Atlantic in conjunction with GlaxoSmithKline, a representative sample of 1,000 Americans revealed that our priorities for building healthy communities are inextricable from our reliance on institutions. The results of various questions show that many of us tend to put the responsibility for our community's' health in the hands of doctors and hospitals, whom we expect to be regularly available, in-person. Overall, participants ranked regular access to doctors and dentists (82 percent said it was "very important") second only to clean air and water (87 percent) as community resources that are important to their health.
There's good reason for fixing health care to be a priority in the U.S., but a burgeoning school of thought suggests that access to care can turn out to matter less, in terms of overall health, than we're apt to assume. "There are broader contextual factors in communities that are definitely driving health outcomes more" than access to care, said Jason Purnell, PhD, MPH, an assistant professor at Washington University's Brown School. "That understanding seemed to have been missing from the survey results." The World Health Organization insists, "To a large extent, factors such as where we live, the state of our environment, genetics, our income and education level, and our relationships with friends and family all have considerable impacts on health, whereas the more commonly considered factors such as access and use of health care services often have less of an impact."
"The health care system caters to people who are already ill," said Purnell. "There's a mismatch between the structure of the health care system and what's actually killing people." Population health, he added, is better served by prevention measures and by attention the factors, like place, that impact well-being.
As Steven Woolf wrote in Journal of the American Medical Association in 2009, "To focus on health care comes naturally to physicians, who work largely in this area, and it resonates with the public and their leaders, who view medicine as the front line in the war of disease." But "health is much more than health care," he continues, and "whereas health policy gives some attention to public health issues, it deals little with the social context of life, which exerts profound influence on health."
In our survey, high-income Americans placed least responsibility in the hands of the health care system, but they also took a highly individualistic approach to health. In fact, there was a direct correlation between increased income and decreased feelings of being closely connected with one's neighbors. While 40 percent of people earning less than $50K per year said that the health of the people in their community mattered to them "a great deal," only 27 percent of people in the highest income bracket felt the same.
Americans, regardless of socioeconomic status, are less healthy -- in terms of diseases, injuries, and behaviors -- than the populations of 16 other high-income nations, according to a report released last month.
The panel behind the study, of which Woolf happened to be the chair, was unable to identify one cause that, more than any other, accounted for Americans' striking shortcomings. But Woolf, in presenting their findings, highlighted as one explanation our cultural celebration of independence that discourages government intervention. Or, as co-author Paula Braverman put it, "Is it Americans' rugged individualism and the sense that the most important thing is the individual's freedom, and that's so much more important than doing what's right for society?"
The panel recognized the vast deficiencies in U.S. health services. But as they also pointed out in the report, "Social participation and integration in the immediate social environment (e.g. school, work, neighborhood) appear to be important to both mental and physical health. What also seems important is the stability of social connections, such as the composition and stability of households and the existence of stable and supportive local social environments or neighborhoods in which to live and work."
Not surprisingly, upper-income, white, and suburban Americans are the most likely to think they have a great deal of access to community resources. Meanwhile, low-income, minority, and urban Americans, who find these resources to be less readily available, are more likely to see them as important. But the one resource that the wealthiest Americans lacked just as much as the poorest was "kind, supportive neighbors": Only 33 to 35 percent of people in each bracket told us they had "a great deal" of that.
Could this de-emphasis on community living be part of what's plaguing America? An ambitious attempt to measure the effect of a neighborhood on individuals' health is Robert Sampson's Great American City, the result of a 15-year investigation into what he terms the "neighborhood effect," and which encompasses everything from the conditions of the streets to how likely a lost, stamped letter is to be placed in the mail.