Abstract
Mikael Rostila has delved into the quagmire of meanings, effects, and pathways of social capital on health outcomes. He aims to understand the role of social capital as both an individual and a collective factor in health inequalities. Employing the sociological construct of social capital, Rostila seeks to understand its uses and misuses, its centrality in cross-disciplinary debates, and its confusions as it travels across disciplines. He wades through the multiple meanings and interpretations of social capital to arrive at a well-reasoned model in Chapter Four. The author positions social capital as a social determinant of health in his major thesis and explicitly states that social capital “could also influence or be influenced by the social and political environment in a society, area or welfare regime, and then influence health indirectly” (p. 61). An impressive and rigorous analysis of the European Social Survey data is employed to examine associations between social capital and health inequalities across different welfare regimes in 15 countries (2002–2010). Separate analyses are conducted to study levels of social capital and health in 26 countries in 2008, and ethnic immigration, health inequalities, and homophily in Sweden (Swedish Level of Living Surveys 1968, 1981, 1991, and 2010).
The findings on the ways that social capital, defined as formal and informal contact, social trust, and access to social resources, is associated with five welfare regimes—social democratic, conservative-corporatist, liberal, Mediterranean, and post-socialist—inform and extend contemporary theoretical paradigms on the social determinants of health. The initial chapters provide an overview of the databases. Each chapter has a detailed description of data sources employed and analytic methods used, and a methodological appendix is included. A distracting feature of the book is a repetitive chorus regarding reversed causality and data limitations, which undermines the innovation and theoretical strength of the work.
In Social Capital and Health Inequality in European Welfare States, Rostila accurately identifies two important levels of social capital at the individual and structural level. He cogently illustrates that these two levels are connected and designates this linkage as a resource-based theoretical definition of social capital that operates in the larger structural context as an exchange of both material and nonmaterial resources. He cautions that failure to measure the structural context often leaves an incomplete picture of the process of benefits of social capital to individuals. Rostila deepens his exploration of the differential effects of social capital on population health by examining variations in social capital by occupation, education, and immigrant/migrant status. His analyses confirm the centrality of these sociodemographic identifiers in offering insight on the role of inequity, or unequal distribution of resources, on health inequalities. The topic of how government welfare programs or political generosity impact social capital and eventually health is a salient and provocative conversation in the current national discourse on health equity globally and nationally in the United States.
Building on social capital theorists (e.g., Bourdieu, Coleman, and Putnam), the author delves into the topic of health inequalities, which have been subject to much public policy debate, excessive inquiry, and critique, but often without taking into account critical social determinants of health such as political generosity, educational level, and access to resources. Rostila has taken on a topic that is controversial, but only to the extent that it holds strong promise for powerful explanatory solutions to health disparity/inequality issues that can be explained by inequity. The data provide a compelling rationale for extending our theorizing models in investigations of health inequalities. A few of his principal findings are:
Neo-material conditions, psychosocial experiences of inequality, and lifestyle behaviors all in combination contribute to health inequalities (p. 9).
Comprehensive, universal welfare states of the social democratic model that provide benefits to all individuals in a political system do not “crowd out” but rather stimulate social capital and produce lower levels of income inequality and poverty (p. 85).
Education is an important dimension of social stratification and, later in life, access to social class position and income. It is linked with individual health (p. 91). Large inequalities in social capital between educational groups exist in European welfare regimes. These vary by regime and help to explain health inequalities (p. 109).
Consequences of a liberal regime and means-tested assistance (United Kingdom and United States) include high levels of income inequality, higher levels of poverty, and low levels of decommodification. Poverty compromises trust (pp. 114–115).
The major contribution of this book is its ability to bring together a widely diverse body of knowledge that spans decades and the work of interdisciplinary scholars across multiple countries. The accumulated evidence provides a significant and compelling direction for understanding pathways that are both directly and indirectly associated with health inequalities; for example, the facts that poverty undermines social trust and underinvestment compromises health. It convincingly argues that the political ideology of a government or welfare regime influences the generosity of the government in promoting income equality and social capital and, in turn, the health and mental well-being of its population.
Despite a rich application of social theory to health inequality, I observed potentially “dangerous” points that could result in misinterpretations. For example, I take issue with the framing of the “dark side” of social capital, or ethnic homophily defined as network closure and high levels of segregation (p. 181). Rostila proposes that excess risk exists among migrants, who tend to associate with one another. The risk is observed in higher mortality rates among migrants than natives. Multiple explanations can account for this excess mortality among migrants, including psychosocial factors such as depression due to loss, downward mobility, and low social support, or what is referred to as diseases of adaptation in epidemiology. It can also be linked partly with exclusionary practices of the host society due to migrants’ low socioeconomic position that closes off access to the opportunity structure. Although the author attempts to separate the more privileged migrant classes from the laboring classes, the latter are the most likely to experience the dark side of limited access to social networks. Thus, I caution that the construct can be misconstrued so as to blame the “victims of dark social capital” for their plight rather than exploring other social, political, and psychosocial factors.
In addition, two areas where the author treads unknown territory include his mention of the Hispanic paradox, whereby low SES (socio-economic status) in some studies does not predict early mortality for Hispanic immigrants, while his study in Sweden does predict premature death. How these areas are related remains undeveloped in the book but invites an intriguing cross-national comparison study. The other area is the mention of genetic explanations, which seem irrelevant to the topic. However, the fledgling field of epigenetics is making inroads on how health inequality is associated with adaptation to new environments and their impact on physiological systems. Although the book does not describe the effects of social capital domains on biological pathways, these findings confirm the importance of continued research on biomarkers, psychosocial processes, material resources, and the contributions of equity in the production and maintenance of health.
In sum, although at times one gets lost in multiple disciplinary perspectives in this dense text, the book is an important read for anyone who cares about the population health of global and U.S. citizens. Rostila introduces important areas for future research on the role of education, racial and ethnic homophily as a social determinant of health, and structural institutional context (government policy) in understanding the health of populations within a nation. This book sets a solid blueprint for evidence-based interdisciplinary approaches to the study of population health in the United States. Perhaps it will compel a shift in U.S. health discourse toward asking different research questions about why health differences exist between rich and poor and moving away from individual-centered models. This book encourages us to embrace a more interdisciplinary (social, political, and psychological) lens and common-sense approach to research on health inequality. New research findings can lead to public policies to reduce poverty and decrease income inequalities with the national goal to improve the health of the American people as a whole.