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.
One of Sampson's key concepts is "collective efficacy," which he defines as "social cohesion among neighbors combined with their willingness to intervene of behalf of the common good." He showed how this dynamic can mitigate disadvantage to reduce violence and improve communities. Other research has demonstrated how the principles of collective efficacy can be harnessed as a way of increasing community members' ability to work together to address health issues, thus driving an intervention that comes from within, instead of from the government or health care system. Neighborhoods high in collective efficacy, it has also been suggested, have a lower prevalence of depression, obesity, and overall mortality, along with other public health measures.
Collective efficacy is not, Sampson has emphasized, "the outmoded assumption that neighborhoods are characterized by dense, intimate, emotional bonds." He would therefore insist that it really isn't important whether or not Americans have kind, supportive neighbors, as long as they share the belief that they are capable of taking action to achieve a desired community-wide effect, and are, as a rule, actively engaged residents of their community.
But collective efficacy does emphasize the common good, and requires an environment in which individuals feel connected to one another. It requires, it would seem, concern for the health of one's neighbors along with one's own health. Moreover, it appears to require the recognition that our health is tied to that of our neighbors -- something that was overlooked by most participants in the survey.
That this can be so sometimes manifests itself in ways difficult to measure by conventional means. In what was perhaps the strangest manifestation of how health spreads through community ties, national attention this time last year was captured by the mysterious spread of Tourettes-like symptoms in the working-class town of Le Roy, New York. What appeared to be an epidemic of collective hysteria left 18 high-school girls, one boy, and one 36-year-old woman with uncontrollable tics.
Despite calling upon experts of all sorts, from school officials to doctors and psychiatrists to environmental activist Erin Brokovitch, the community was unable to figure out what was causing the alarming symptoms. This only fueled the residents' panic, as Susan Dominus argued in a feature for The New York Times Magazine. Describing the implications of the mystery on Le Roy, she writes:
The sickness of the girls seemed to ripple out to affect the health of the whole community, which suddenly found itself an object of fascination and fear and mistrust. Five basketball games were canceled when parents of players in neighboring counties voted not to let their children travel to Le Roy. Belluscio has a friend who is worried that her real estate sale is falling through, a common tale in recent weeks, and local businesses were complaining that commerce was down, because people had fears about the water, not to mention an aversion to the media vans up and down Main Street. "It's emotionally exhausting to people who love this community," said Lorie Longhany, chairwoman of the Genesee County Democratic Committee. "Without laying any blame on any of these families -- they're going through their private hell with this. But it's not private hell, it's public hell. It's almost like a depression has just settled over Le Roy.
Granted, this was an extreme case. But seven in ten Americans, our survey found, do not believe that they are less likely to be healthy if their neighbors are less healthy. That's a feeling shared across all income and economic groups. What happened in Le Roy is perhaps just a more obvious manifestation of what goes on in subtler ways in towns and neighborhoods across the country. It's evidence, in its own, twitchy way, of how the smallest of lifestyle and social factors can have an unforeseen impact on mental and physical health, and of how change can be driven by neighbors learning to recognize their collective well-being as a valuable resource.
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