Commentary: Comments on the diversity in associations between community social capital and health

The paper on ‘The diversity of associations between community social capital and health’ raises two issues that I should like to address briefly. 1 The first has to do with the definition of social capital used by the authors. With the exception of one question—‘to what extent are you involved in the livability of your neighborhood?’—none gets at the phenomenon of civic participation that is central to Putnam’s concept of social capital (http://www.bowlingalone.com/data. htm.). Indeed, almost half the indicators that go into his composite measure of social capital have to do with the pervasiveness of voluntary associations. Nor do any of the measures deal directly with trust, which is another key part of his concept. On the other hand, several of the items in Putnam’s Index of Social Capital have to do with informal sociability (e.g. amount of time spent visiting with friends), which is more nearly akin to the items in the inventory used by van Hooijdonk and colleagues. Despite the differences from the measure of social capital that Putnam has created, there is an intuitive sense that the authors are measuring something meaningful with these questions. That something may be a sense of cohesion or community, which may or may not be associated with civic mindedness, but which is conceptually close to what many writers seem to be getting at when they invoke social capital as somehow causally associated with mortality. This sense of community refers to the local neighbourhood, which is consistent with much that has been written about social capital, but it ignores the larger political and institutional context, which is also consistent with much of the literature. This consistency is important and in a sense unfortunate, because the larger context may in fact be an important part of the story. This brings me to the second issue I should like to address. Not all the associations between social capital and all-cause and cause-specific mortality are significant; for those that are significant and in the expected direction, the associations are weak; and at least one—deaths due to cerebrovascular disease—is significant but not in the expected direction. They are elevated in neighbourhoods with high social capital compared with those with low social capital. It may be that neighbourhoods are not the appropriate units of analysis, or that the measure of social capital is inadequate. Neither of these possibilities seems to me to be a satisfactory explanation of the insignificant, weak or inconsistent results. It seems to me, rather, that social capital does not matter, or does not matter very much, in The Netherlands, a small, relatively homogeneous and generous welfare state with universal entitlement to health and other benefits and services. Social capital may be relevant to health in settings that are largely devoid of universally available services, in places where personal networks must be mobilized to obtain services of all sorts. For example, in preliminary analyses of the association between Putnam’s Comprehensive Index of Social Capital and age adjusted mortality (http://wonder.cdc. gov/mortsql.html.) among the 48 contiguous US states (Table 1 and Figure 1), it is clear that the association is significant only in the southern states, those with what has been called a traditionalistic political culture, compared with the moralistic and/or individualistic