Ecological Level Influences The Importance of Place in Population Health

Social characteristics of individuals are closely related to health. Among the most important findings to emerge from public health research over recent years is the extent to which characteristics of areas exert independent effects on health. This ecological4 approach has been rediscovered and is now embedded in a multilevel framework. The major idea is that characteristics of places—neighborhoods, schools, work sites, and even nations— carry with them health risks for the individuals who live in those environments. The health risk conferred by these places is above and beyond the risk that individuals carry with them. Thus, we might view characteristics of physical environments (e.g., parks and buildings) as well as social environments (e.g., levels of inequality and civic trust) as truly properties of places, not individuals. In this section, the committee reviews evidence related to two aspects of places—economic inequality and social capital— that are assessed at an ecological level to examine their effects on health. These findings are relatively new and undoubtedly will be refined with further research. Economic inequality may exert an effect on health in addition to the effect of individual income on health. Such an effect may be particularly robust for people in the United States who are at the lower ends of the distribution.

The United States is among the richest countries in the world, yet it is also one of the most (and increasingly) unequal in terms of the distribution of its wealth as measured by a wide and growing gap between the best-off and the worst-off quintiles (Weinberg, 1996; Jencks, 2002) (see Box 2-2). At a national level, the hypothesis linking income inequalities and health would predict that two countries with the same average income but different income distributions would experience different patterns of mortality, with the country with the more even distribution having a longer life expectancy overall. Cross-national studies initially supported an association between income equality and population longevity, but more recent research, which includes newer and more accurate data for more countries, suggests that the area-level effects of inequality across nations may not hold over time (Lynch et al., 2001; Gravelle et al., 2002; Rodgers, 2002). Recent studies have shown the cross-national correlation between economic inequality and mortality to be very weak or virtually nonexistent (Kunst et al., 1998). Furthermore, in several countries (Canada, for example), inequalities at the level of provinces or neighborhoods within cities often have been found to be not significant in terms of health status. In the United

4 "Ecological" refers to the ecology or the combined characteristics (e.g., the social and economic characteristics) of places.

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