Disaster and disease vs. social cohesion

January 11, 2013 at 10:59 AM Leave a comment

What do death rates during a summer heat wave in Chicago have to do with health care reform?


In the January 7 issue of the New Yorker, Eric Klinenberg has a fascinating article about the resilience of communities to disaster.  This was especially timely in the wake of Hurricane Sandy, and in fact part of his article visits people trying to recover from its damage on Long Island.  Dr. Klinenberg has been studying community responses to disaster for a couple of decades, most notably the heat wave during the summer of 1995 in Chicago.  During that disaster, 739 people died.  Analysis of the patterns by neighborhood found things you might expect.  The poor died disproportionately to the better off.  But there were some poor neighborhoods that had death rates that were lower than in the more affluent neighborhoods on Chicago’s North Side.  Two neighborhoods on the poor and predominantly African-American South Side had mortality rates an order of magnitude different from each other.  What does he make of this latter finding?


In response to disaster, communities have at least two categories of response: physical infrastructure and social infrastructure, he explains.  Many communities around the world have gotten good at dealing with the kind of flooding we saw from storm surge during Sandy.  They have installed dikes and seawalls, waterproofed utility lines, etc.  A mass effort to install air conditioning in every apartment in Chicago would have been such a response.  (Having air conditioning apparently reduced one’s odds of dying by 80%.)


Instead because Chicago now knows about neighborhood specific mortalities under these conditions, in hot periods they escalate welfare checks to the people they know are vulnerable there.  Klinenberg thinks these high mortality rates are reflective of low social cohesion, and that the low mortality neighborhoods (the ones that don’t differ much in geography, income, or race from the higher mortality ones) have high social cohesion.  There, people know who their vulnerable neighbors are on their block, and in their apartment building.  They know this because they have lived there for years, and know when their neighbors usually shop for groceries, or visit the hair salon.  The differences are not related to physical infrastructure; they are related to social infrastructure.


Put simply, lack of social cohesion kills.


So what if disaster response (or lack thereof) isn’t the only way poor social cohesion kills?  What if the same factors also predict medical mortality?  Re-admission rates to the hospital?  Medication adherence? 


What if building more hospitals, ambulances, and emergency rooms amounts to a physical infrastructure response to problems that are much more amenable to social infrastructure improvement?  As hospital beds continue to proliferate while demand is falling, are we just building more seawalls behind seawalls because we only know how to finance building seawalls, and have no clue how to finance building sustainable neighborhood associations?             


These questions I believe will become more and more prominent in our dialogue on progressing our American system for health optimization.  The health care delivery system seems to be mostly a physical infrastructure solution, and an unsustainably expensive one.  Developing a health optimization system seems to me to lead inevitably to a social infrastructure development system.  No matter how good they are, it seems unlikely that professional repairmen will ever substitute for a neighbor knowing the signs you’re not well, and being willing to do something about it. 

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