Adapted from Chapter 2 of Trendbenders by Darvin Ayre, Gruffie Clough, and Tyler Norris

Cultures that are more sophisticated in practicing capitalism in a societal context will be the ones that will have the high-quality populations and dominate in the next century.

J. Fraser Mustard, M.D.

The United States is living proof that investing in more and better medical care does not lead to a healthier society. Our deep, well-founded faith in medical science and technology has yielded some of the world's finest facilities and medical professionals. Yet, by many measures, Americans are in poor health compared to other democratic nations with market economies.

Consider this: while no nation outspends the U.S. in health care at more than $1 trillion annually, the U.S. ranks 20th of 29 countries in the Organization for Economic Cooperation and Development (OECD) for male life expectancy. What's more, the infant mortality rate in the U.S. is higher than 22 of the 29 OECD countries. In 1996 the U.S. spent 14.2 percent of its gross domestic product on health care, compared with the next closest country, Germany, at 10.5 percent.

Our health care system is well endowed with facilities and technical expertise geared to treating disease and delivering medical technology. Hospitals account for fully one-third of the $1 trillion health care tab. But preventing disease and maintaining wellness are low priorities, while 45 million Americans have neither health insurance nor regular access to primary care or preventative services. Accordingly, this country may be a great place to get very sick, but not to be well.

Clearly, the return on investment in medical care is diminishing, but why? Even if every citizen had access to state-of-the-art medical facilities under the care of high-quality health professionals, the nation's health status would not improve as much as if the underlying causes of poor health were addressed directly and actively. Those underlying causes of poor health include poverty, stress, powerlessness and a lack of social support. A growing body of evidence shows that health is in large part a product of social environment, income and lifestyle and behavioral choices.

The seemingly soft side of public health-being neighborly, feeling like one belongs-is emerging as the true underpinning of physical health. The heart (feelings) and mind (science) are coming together to inform the art and science of community building, which has been the focus of the authors' work in communities for years. The implications for leaders and decision-makers-for all of society- are profound. No community can afford to ignore this evidence.

"Socio-economic status is the predictor of health," according to Nancy Adler of the Center for Health and Community at the University of California at San Francisco (UCSF). Surprisingly, that predictive power holds true even for those who are relatively well off. A study conducted in England of civil servants,17 all of whom were considered middle-class citizens with access to national health care, revealed that those at the top enjoyed longer and healthier lives than those even one rank below them. This social gradient has been observed in studies of other populations as well. Those at the bottom of the ladder in terms of job status (measured by income and control over one's work) have a higher incidence of illness, absence and premature death than those at the top rung.

Lifestyle and behavior, genetics, and socio-economic conditions are much more potent determinants of health than access to and quality of medical care. Social status, income, sense of control over life circumstances and work, support networks, education and self-esteem are additional factors that make the real difference the health of a community.

The Real Causes of Death

Another way of looking at the health of a population is to examine the causes of death. Until recently, researchers compiling such statistics did not look much beyond what was written on the death certificate, for example, heart disease, cancer or stroke. However, a number of external factors can contribute to the incidence of disease. Two pre-eminent health leaders, J. Michael McGinnis (now with the Robert Wood Johnson Foundation) and William H. Foege (now with the Bill and Melinda Gates Foundation), set out to learn the causes behind the causes of death. Their findings, reported in the Journal of the American Medical Association, suggest the most prominent identifiable contributors to death among U.S. residents are: tobacco, diet and activity patterns, alcohol, microbial agents, toxic agents, firearms, sexual behavior, motor vehicles and illicit use of drugs.

About half of all deaths that occurred in 1990 could be attributed to those behavioral factors and thus could be considered to be premature deaths, likely preceded by a diminished quality of life. The chart below summarizes the findings.

Actual Causes of Death in the United States in 1990

CauseEstimated No.
of Deaths*
Percentage of
Total Deaths
Diet/activity patterns300,00014
Microbial agents90,0004
Toxic agents60,0003
Sexual behavior30,0001
Motor vehicles25,0001
Illicit use of drugs20,000<1

*Composite approximation drawn from studies that use different approaches to derive estimates, ranging from actual counts (e.g., firearms) to population attributable risk calculations (e.g., tobacco). Numbers over 100,000 rounded to the nearest 100,000; over 50,000, rounded to the nearest 10,000; below 50,000, rounded to the nearest 5,000.

The federal Centers for Disease Control and Prevention estimate that only 5 percent of the total annual health care cost is spent on prevention, even though half of the factors that contribute to death include behavioral choices that might be changed through education and a supportive environment.

Most public policy is still aligned with the notion that medical advancements and health care systems hold the key to better health. But in the field of public health, that viewpoint is giving way to one that recognizes the social determinants of health. The Center for Society and Health at Harvard University, the Center for Health and Community at UCSF, and the Canadian Institute for Advanced Research are among the institutions that are devoted to the scientific study of the social and economic aspects of health. Researchers at these institutions and others are beginning to quantify what we have long known intuitively: that health is more than the absence of disease.

Harvard's Center for Society and Health conducts research on the social determinants of health and communicates research findings and their implications for health and policy. Lisa Berkman, director of the center and chair of the Department of Health and Social Behavior at Harvard, says, "We think of the determinants as generally falling within four areas: One is social stratification, and this includes conditions related to social class or socioeconomic status. The second area involves social networks, by which we mean the importance of community, social integration, and the maintenance of close personal relationships. The third subject area includes the ways that race and ethnicity affect health-not race as a biological factor, but in how it relates to social conditions of individuals in our society. The last grouping of factors are those that are characteristics of work and work/family relationships."

"In addition to the social determinants, we're interested in investigating behaviors and the ways that they're embedded in social contexts. Behaviors like alcohol consumption, smoking, eating, and physical activity are embedded in a larger social structure that makes changing those behaviors difficult without addressing the social context in which those behaviors occur," she adds.

The Social Determinants of Health

The evidence for the social determinants of health is mounting, but not well disseminated beyond the research community. The World Health Organization (WHO) is a leader in the effort to present the research in clear, understandable terms for a wider audience. WHO defines six guiding tenets for the new public health paradigm as follows:

  1. Health is not merely the absence of disease or disability.
  2. Health problems are defined at the policy level.
  3. Health is a social issue.
  4. Improving health status requires a long-term focus on policy development.
  5. Improving health status requires a primary focus on changing basic conditions.
  6. Improving health status requires involving natural leaders in the process of change.

Empirical evidence shows that inhabitants of strong communities enjoy better health than those who live in areas with less interaction and support within the community. Researchers in 1997 found that mortality differences between states can be attributed to differences in social capital. For instance, states with higher levels of civic engagement (such as participation in voluntary groups and associations) have lower overall mortality rates and lower rates of mortality from heart disease and malignant neo-plasms.

Significant differences in levels of health can be found not only between states, but even from county to county, city to city, and neighborhood to neighborhood. Again, the evidence points to community capacity, or strong community, as a key influence on health. A 1997 study in Chicago found that women living in environments with more cooperative social networks were less likely to have low-weight births. Another Chicago study established that a significant portion of between-neighborhood differences in homicide rate and crime could be attributed to variances in social cohesion, trust and willingness to intervene on behalf of the common good.

What the Research Tells Us

The following is a brief synopsis of research findings concerning the social determinants of health from The Solid Facts: The Social Determinants of Health and Why are Some People Healthy and Others Not? The Determinants of Health of Populations.

What the Research Says About.

...Social and Economic Circumstances. Poor social and economic circumstances have a negative impact on health throughout life. Those at the bottom of the pecking order usually run twice the risk of serious illness and premature death of those at the top. Across the entire social and economic spectrum, a continuous gradient exists. This means that a member of middle management is likely to have poorer health than his or her supervisor, but is apt to be healthier than those who report to him or her.

...Early Life. Neuroscience research shows that prenatal and early childhood care make a big difference in how a child will fare in school and make the transition into adolescence. The foundations of adult health are laid in prenatal and early childhood. Poor social and economic circumstances present the greatest threat to a child's growth, raising the lifetime risk of poor physical health, as well as reduced cognitive and emotional functioning. Juvenile delinquency is high among youths who did not receive optimal nurturing, stimulation and nutrition in their pre-school years. Researchers are beginning to understand how social determinants affect the body through biological pathways. Significant brain development occurs from birth to age six. How the brain develops affects a person's ability to cope, deal with stress-ultimately the capacity to fully participate as a productive citizen-for the rest of his or her life. Policy Implications: Invest in better parental education and early childhood programs, plus stronger support networks and services for single parents in particular.

...Social Support. Friendships, good social relations and supportive networks improve health. Individuals with less emotional support are more prone to depression, run a higher risk of complications during pregnancy and are more likely to be disabled by chronic disease. Robert Putnam's study of communities in Italy found that high levels of social cohesion in the community were associated with low rates of coronary heart disease. When social cohesion declined, heart disease increased. Living in poverty makes a person more vulnerable to social exclusion, which is associated with physical and mental health problems. "Marginalization and isolation are components of inequity," says Angela Blackwell, director of Policy Link and a leader in the healthy communities movement. Or, put another way, more egalitarian societies tend to have higher standards of health. Policy Implications: Invest in health care and social services for disadvantaged populations, reduce income gaps and promote community building and social cohesion.

...Work. Stress in the workplace increases the risk of disease. Health suffers when people have low control or authority over work-related decisions, and when they do not have the opportunity to use their skills fully. Jobs that are demanding but offer low control over the work put workers at high risk for health problems. By contrast, those who hold demanding jobs but have a high degree of control run a lower risk for health problems. Job security is another important factor in health. Even the threat of a job loss can lead to chronic stress and negative health effects. Policy Implications: Encourage employers to involve employees in decision making and provide opportunities for development.

...Addiction. The use of alcohol, drugs and tobacco is an important factor in health inequalities. The economic cost to society from alcohol and drug abuse was an estimated $275 billion in 1995. Alcohol and drug abuse disorders are strongly correlated with health consequences and effects on the health care system, criminal behavior, job loss, financial destitution and subsequent reliance on society's safety nets. Parental alcohol and drug abuse is fueling a massive increase in the number of battered and neglected children. From 1986 to 1997, the number of abused and neglected children rose from 1.4 million to 3 million, an increase of 114 percent, or eight times the 14 percent increase in the children's population. Policy Implications: address social factors that lead to substance abuse.

...Transportation. Over-reliance on cars has a number of detrimental effects on health and community well being. Reducing car dependency can bring about four healthy benefits for community members: more exercise, more social contact, fewer fatal accidents and less air pollution. Policy Implications: Invest in public transportation, stop sprawl, provide bike paths and bus lanes.

The Community's Challenge in Improving Health

The premise of healthy communities work is that relationship building is the antidote for the negatives associated with the social determinants of health. Because the evidence for the social determinants of health is growing, it calls for new perspectives in apportioning public resources. Until this research comes into play in public policy discussions, there will be a heavy price to pay in terms of both direct health care costs and in the well being of citizens. However, our social systems, from governments, organizations and industry to neighborhoods and families, are not yet able or ready to respond appropriately. Despite what is known about the high costs of intervening only at the crisis stage (that is, in the emergency room or the court room), our systems are not set up to address the social determinants of health in a preventative way. Instead, our institutions and organizations are geared to address the symptoms of social ills one by one in what has been called the "silo approach."

Society's reliance on medical solutions to repair the damages of unhealthy lifestyles and behaviors, coupled with rapidly rising health care costs, may well be the undoing of our nation's economic vitality. By 2008, national health expenditures are predicted to total $2.2 trillion, over 16 percent of the gross domestic product. This escalation will place a severe handicap on our competitive stance in the global economy, given that so many nations not only spend less but enjoy better health. Substantive changes in community health and our economic stability require working much further "upstream" of the instance when individuals seek professional health care.

It is essential to re-think health care policies, now that we know medical technology has its limits. Changes in the social environment show the most promise for improving the health of the total population. Marc Renaud, a sociologist and chair of the Quebec Council on Social Research, asserts that some of the resources currently being invested in the detection and care of illness are better spent stimulating social and economic growth, providing education and setting up strategies to counteract poverty, crime and drug abuse.

The Costs of Downstreaming

The "downstream" approach to social problems, characterized by an under-emphasis on preventative measures, is firmly entrenched in our society. We are willing to pay dearly for medical care to treat illness, but are rather reluctant to invest in preventing illness. A look at our criminal justice system offers perhaps the most compelling evidence for the need to rethink our approach to social problems. Decision makers are far more likely to opt for building more prisons than to address the root causes of crime. We spend $.5 trillion per year in crime management and the number of prisoners is growing fast. The number of inmates in state and federal prisons tripled from 1980 to 1994, to about one million, according to the Bureau of Justice Statistics. Minorities are disproportionately represented in prisons and jails. In 1993, 51 percent of inmates were black and 14 percent were Hispanic. More prisoners are women or elderly, and have drug problems, AIDS or other chronic health conditions. Most inmates are parents, and most of those parents have children under the age of 18. These statistics are astounding, but even more so in light of the fact that there is no statistical correlation between incarceration and lowering crime.

Another disturbing trend is evident in the under-funding and endangerment of public education. In 1970, expenditures on health care and on education in the United States were equivalent, but by 1990, the health care tab was double the amount spent on education. If spending priorities were realigned based on evidence of the social determinants of health, bigger up front investments in education would almost certainly result in reductions in health care and criminal justice costs over the long term.

The good news is that research in neuroscience about the importance of early childhood development is igniting an interest in examining long-held policy assumptions. For example, after learning about the importance of brain stimulation for infants and toddlers, the governor of Georgia recently decreed that every newborn in the state is to receive a tape of classical music. This measure, while largely symbolic, sends an important message about the importance of pursuing public-policy decisions that actively promote the well being of citizens can and should be pursued, alongside the more traditional approach of protecting public welfare through such means as law enforcement and intervening when families are unable to provide adequate care.

Health is not an intervention. Health stems from wholeness and relationship. The words health and whole share the same root. Transportation, jobs, education, arts, culture, recreation, enjoyment, companionship and faith are among the factors that conspire to create health. The advent of behavioral medicine in the late 1970s developed out of the acknowledgement of the complex mind/body/spirit model of health and illness. Harvard Medical School's Dr. Herbert Benson, a pioneer of research in the mind/body health connection, has shown linkages between faith and health, including the ability of spiritual tools to lower blood pressure and other symptoms of stress. Those with strong faith or spiritual practices are less likely to fall ill and when they do, they recover more quickly than others.

Two rapidly growing maladies of our time, depression and stress, are diseases of our culture. They are caused in large part by alienation; by the poor quality of or lack of relationships and connections. They are ameliorated by the ways we address the disintegration of our communities and workplaces and families. People who report stress have health care costs that are 46.4 percent higher than those who do not report feeling stressed, and those with depression have annual health care tabs that are 70.2 percent higher than those without depression. Depression affects 19 million Americans each year, and costs the U.S. $44 billion per year in lost productivity, according to a National Foundation for Brain Research survey of human resource professionals.

To the extent that citizens create and strengthen community, they improve the ability to ameliorate the individual issues (or symptoms) of social ills. We become healthier as we reintegrate old-fashioned values of fellowship and neighborliness into our lives. In communities we learn the behavior and attitudes that determine life-long health and economic vitality. We learn how to be on time, to be productive and ready to work. In community we learn empathy, self-control, the value of persistence. All the "soft" but important and meaningful things take place within communities: caring and love and stimulating the hearts and minds of infants and children.

The scientific evidence for the social determinants of health supports the need for building strong, healthy communities. The lifestyle and behavioral changes necessary to have a significant, positive impact on public health will only take place in the context of widespread community action and cooperation. If applied to policy-making and investment decisions, the research has the potential to improve significantly the health and well being of all sectors of society.

Two key questions embody the central challenge for the future of healthy communities.

  • How can we work in communities to create priorities on the factors identified by researchers as social determinants of health?
  • How can we educate policymakers and decision makers about the importance of the social determinants of health, so that investment choices maximize health promotion?

These questions represent both the challenges and the opportunities for citizen leaders of today and in the future.