Social capital and the third way in public health

The construct of social capital has recently captured the interest of researchers in social epidemiology and public health. We review current hypotheses on the social capital and health link, and examine the empirical evidence available as well as its implications for health policy. With regard to theory, we contend that the construct as currently employed in the public health literature, lacks depth compared to its uses in social science. In addition, social capital presents itself as an alternative to materialist structural inequalities (class, gender and race) by bringing to the forefront of social epidemiology an appealing common sense idealist social psychology to which everyone can relate (e.g., good relations with your community are good for your health). The use of social capital invokes a romanticized view of communities without social con ict (e.g., Neo – Tocquevillian nineteenth century associationalism) and favours an idealist psychology over a psychology connected to both material resources and social structure. We argue that the evidence on social capital as a determinant of better health is still scant or ambiguous – depending on the definition that is used. Even if conŽ rmed, social capital hypotheses call for social determinants beyond the proximal realm of social psychology. We also maintain that social capital is used in public health as an alternative to both state-centred economic redistribution (e.g., living wage, full employment, and universal health insurance) and party politics (e.g., gaining control of the executive branch of the government). Social capital represents a ‘privatization’ of both economics and politics. Such uses of social capital mirror recent Third Way policies in Germany, UK and US. If Third Way policies end up losing support in Europe, its prominence there might be short lived. In the USA, where the working class is less likely to in uence social policy, interest in social capital could be longer lived or, alternatively, could drift in the academic limbo like other psychosocial constructs which at one point were heralded as the next ‘big idea’. Within the last few years, we have witnessed the rapid appearance of the concept of social capital in public health discourse. Before 1995, there was only one reference to the term ‘social capital’ in the Medline database and that was in regard to so-called Critical Public Health,Vol. 10, No. 2, 2000 Critical Public Health ISSN 0958-1596 print/ISSN 1469-3682 online © 2000 Taylor & Francis Ltd http://www.tandf.co.uk/journals Correspondence to: Carles Muntaner, Room 655c, UMB, 655 West Lombard Street, Baltimore, MD 21201-1579, USA. Tel: +1 (410) 706 0889; Fax: +1 (410) 706 0253; e-mail: Muntaner@son. umaryland.edu ‘family social capital’ and its effect on educational and occupational aspirations (Marjoribanks, 1991). Though the basic ideas encapsulated in the current use of social capital can be traced to the origins of classical sociology and political science, the appearance of the term itself in the mid 1990’s was largely stimulated by Robert Putnam’s work on civic participation and its effect on local governance (Putnam et al., 1993).He popularized this thesis by discussing the decline of social capital using the metaphor that America was ‘Bowling alone’ (Putnam, 1995a) – a powerful image that propelled Putnam to an audience with President Clinton to discuss the fraying of the social fabric in America. Since then, the concept of social capital has also appeared in other fields such as sociology (Portes, 1998) and development economics (Grootaert, 1997; Ostrom, 1999). In these Ž elds, there has been a good deal of debate about the definition, operationalization, and the theoretical and practical utility of the concept for improving human welfare, especially in regard to alleviating poverty and stimulating economic growth in less industrialized countries (Collier, 1998; Knack & Keefer, 1997). In fact, the World Bank sponsors a website devoted exclusively to the topic of social capital, where information is exchanged and issues actively debated. Despite all this activity, one of the leading scholars in this Ž eld, Michael Woolcock, has argued that the concept of social capital ‘. . . risks trying to explain too much with too little’ (Woolcock, 1998, p. 155). He says that the term social capital is being ‘. . . adopted indiscriminately, adapted uncritically, and applied imprecisely’ (Woolcock, 1998, p. 196). Social capital and its use in public health We believe Woolcock’s critique is especially true for many of the ways that the term social capital has been used in relation to health. To date there has been very little systematic theoretical, empirical, or practical appraisal of the concept in the public health literature, although more critical accounts are beginning to appear. (Muntaner & Lynch, 1999a; Muntaner et al., 1999; Lynch et al., 2000; Hayes & Dunn, 2000 unpublished observations; Hawe & Shiell, 2000). Nevertheless, the term has slipped effortlessly into the public health lexicon as if there was a clear, shared understanding of its meaning and its relevance for improving public health. The term social capital and its close cousin, social cohesion, have been used as multi-purpose descriptors for all types and levels of connections among individuals, within families, friendship networks,businesses and communities (Wilkinson,1996; Aneshensel & Sucoff, 1996; Kawachi & Kennedy, 1997; Kawachi et al., 1997a, b; Fullilove, 1998; Baum, 1997, 1999; Kennedy et al., 1999). In addition, it has been the subject of theme conferences (11th National Health Promotion Conference, Perth,Australia) and government sponsored discussion papers (Jenson, 1998; Lavis & Stoddart,1999); it has been the topic of million dollar calls for research proposals funded by the Centers for Disease Control in the US, and on the basis of highly dubious comparisons between observational studies and clinical trials of such things as anti-thrombolytic therapy, it has even been proposed as an important avenue of public health intervention. Lomas has argued that ‘interventions to increase social 108 C. 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