It takes a village to promote good health

A Jerusalem academic workshop on social capital and health produces some interesting conclusions.

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November 13, 2016 09:48
PROF. DOV CHERNICHOVSKY

PROF. DOV CHERNICHOVSKY. (photo credit: JUDY SIEGEL-ITZKOVICH)

 
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The idea of “social capital” goes back to the early 19th century, when French diplomat and historian Alexis de Tocqueville – who traveled widely in the US – noted that Americans frequently met to discuss a variety of political, economic and other matters, creating high levels of civic participation and involvement and a healthy democracy.

In recent decades, academics in the social sciences have latched onto the term. It has been defined by some as “a form of economic and cultural capital in which social networks are central, transactions are marked by reciprocity, trust and cooperation, and market agents produce goods and services not mainly for themselves but for a common good.”

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Others have called it the “influences of family and community on individuals’ obligations, expectations and information channels, or beneficial characteristics of relationships, groups, networks and social norms by individuals and community, such as trust, honesty, volunteerism, sociability and engagement in community affairs... that can improve the efficiency of society.”

High-falutin terms. It could be explained more simply by Hillary Clinton’s book title It Takes a Village...

Jerusalem’s Taub Center for Social Studies Policy in Israel held a workshop this month on “The Global Network on Social Capital and Health” at the Menachem Begin Cultural Center. The independent, non-partisan research institute invited 60 experts in the field to speak and listen to studies on social capital in the field of health, and all the seats in the hall were filled.

“We place a clear, undistorted mirror before Israel’s policymakers, reflecting the good as well as the bad in Israeli society,” according to Suzanne Patt Benvenisti, managing director of the Taub Center, whose executive director is economics Prof. Avi Weiss.

Prof. Dov Chernichovsky, an emeritus professor in health economics and policy at Ben-Gurion University in Beersheba and current chairman of Taub’s health policy program, initiated and chaired the workshop.



PROF. JONATHAN Halevy, director-general of Jerusalem’s Shaare Zedek Medical Center for the last 29 years, voluntary chairman of the Health Basket Advisory Committee for the fourth time and a fellow in Taub’s health policy program, described how social capital in health played out at his hospital.

“President Reuven Rivlin recently described Israel as being comprised of four ‘tribes.’ They are secular Jews; traditional and modern Orthodox Jews; ultra-Orthodox [haredi] Jews; and Arabs. Each of the tribes are in the process of balancing out to a quarter of the population,” Halevy recalled. “Israel is divided among Jews and Arabs. We Israelis want to wipe out inequality, but nevertheless, the Arabs do not enjoy full equality. We must learn to live together. If not, there is danger to the country.”

In this aspect of the health community, “Shaare Zedek is no different than other hospitals, except that our [Jewish] founders in Germany said the hospital would be run according to Halacha [Jewish law].”

While 38% of Jerusalemites are Arabs and the rest of the population is divided among the three types of Jews, “we have fewer Arabs in our patient population, as there are a number of Arab hospitals in the capital,” Halevy noted.

Yet inequality “does not apply to health.” The Hadassah Medical Organization’s two hospitals, with a total of 1,000 beds, and Shaare Zedek and its Bikur Cholim Hospital affiliate, also with 1,000 beds, have “equality between Jews and Arabs. Doctors and other medical professionals at my hospital are chosen for senior positions according to their professional achievements.”

He gave the example of Dr. Maher Deeb, a senior cardiothoracic surgeon, who lives in Beit Jala in the Palestinian Authority. “During the last intifada, due to roadblocks, he couldn’t cross the road and spend 15 minutes driving to work. So we rented an apartment for him for a while in west Jerusalem. When a young woman tourist from the US was shot and bled profusely, Deeb resected her lung and saved her life. She invited him to attend her wedding in Chicago. It was surreal.”

Halevy asserted that after so many years of running Shaare Zedek, “I say there is no discrimination in Israeli hospitals. They are havens for peace.”

His hospital has the largest pediatric dialysis unit in the country; it takes care of children with kidney failure, who come in for five to six hours a day, three times a week. Due to consanguinity (inbreeding or marriage of first cousins due to customs), bad genes – some of them related to kidney diseases – kidney failure is much more prevalent in the Arab population; 70% of the children treated in the unit are Israeli Arabs. As most ultra-Orthodox women do not want to undergo prenatal tests so as not to have an abortion, some suffer from defective genes, including those involving defective kidneys. “So if you go into the unit, you will see two main social groups – Arabs and haredim – sitting together, speaking Hebrew,Yiddish and English or Arabic and English and warmly communicating with each other. This brings people together.”

Halevy explained that he had been offered many positions over the years – from other hospitals, a mayoral candidate or a university president, but he never agreed to leave Shaare Zedek because “the social structure of the city is so fascinating. One has to find ways to suit among various customs and approaches of the tribes, and we face ethical dilemmas that didn’t exist in previous generations.”

An interesting footnote on social capital and health at his hospital is that by instruction from its founders in 1902, the hospital director must stop by at the beds of all (Jewish) patients, together with the hospital rabbi and department head, on the day or two before Yom Kippur and ask if they intend to fast. If their medical condition makes not eating or drinking for 25 hours risky, they do their utmost to discourage would-be fasters.

“This is the highlight of my work, getting to meet every patient and discuss his or her case. There is no religious coercion. We get to know each other. Arabs are exempt from fasting for Yom Kippur, of course, but we do the same before their Ramadan fast.”

PROF. LORENZO Rocco, an empirical economist at the University of Padova visiting Israel for the first time, gave various definitions of social capital. Whatever the technical choice, he said that social capital in society can be measured according to generalized trust, the number of friends, the amount of time spent with family and friends, if one is a member of formal or information organizations, voting turnout, voluntary activities and even blood and organ donations.

“Social capital generally has a positive effect on individual health, better governance and better political institutions. It makes it possible to deliver health care more efficiently, increasing the political weight of a community. A more cohesive society is attentive to common well-being and avoids opportunistic behaviors leading to pollution, unhealthy waste disposal and unhealthy work environments. So social capital helps shield people against stress and uncertainty and favors cooperation and the formation of social nets,” said Rocco. “It even encourages the enforcement of health-enhancing norms, helps cut smoking and risky sexual behaviors.”

UNIVERSITY OF Haifa public health researcher Dr. Maya Simantov looked into the influence of religiosity and living in haredi communities and the rate of home accidents. Religiosity, she stressed, is a “proxy for social capital and predicts childhood injuries in religious and Orthodox families.” She did not differentiate between modern Orthodox and haredim in her presentation of research on 527 children up to age six, but admitted in the question-and-answer session that this was what she had meant. Studying the town of Elad, which is almost totally haredi, she noted that the rate of child injury was higher among residents than that of haredi children living in mostly secular cities and compared to children in secular families.

Families living in unsafe outdoor environments was responsible for higher child injury. Even though religiosity creates a strong type of social capital, she concluded, environment may be more important than the actual community in which the family lives. The types and frequency of child accidents differs significantly among secular, modern Orthodox and haredi families and Arab families due to different types of social capital, environments, religious practices, socioeconomic levels and education.

WONDERING WHETHER people with more social capital had a lower risk of being overweight or obese, Hebrew University public health epidemiologist and dietitian Dr. Vered Kaufman-Shriqui studied a population in Toronto, looking at variables that included the number of fast-food restaurants in their neighborhoods. She found that while marital status was not significant, gender and racial background (especially in whites vs. Asians) were. Women living in neighborhoods with higher social cohesion did have lower odds of being overweight or obese than those living in neighborhoods with less social cohesion; women living in poor neighborhoods were more likely to be too heavy than those who were socially deprived. However, social cohesion was not significantly associated with body-mass indices of men.

THE BABY boom generation, in which tens of millions of post-World War II American children were born between 1946 and 1964, is due to pass away in the next few decades. Prof. Eric Nauenberg, a health policy expert at the University of Toronto, investigated the possibility that the steady rise of elderly in North America would take a downturn when the next generation reaches old age.

“Nobody has examined this in detail,” he said, even though the trends will have an important impact on government, budgets and decision-making. But now, as the oldest baby boomers have become septuagenarians, the interest among planners on their dependency on social and health services has grown.

It has been suggested that the share of seniors in the North American population will eventually decrease if fertility rates are low and immigration rates are stable. Nauenberg found that after the Baby Boom era, there will be a plateau in the numbers of elderly, not a decline, and it will remain stable for some time.

“People are healthier and living longer, and this will continue. Immigrants to the US are today increasingly dominating the American population, and in Canada, too, more of the elderly will be immigrants,” he said. In addition, those with developmental disabilities such as Down syndrome and physical are, due to improvement in medicine, increasingly living into their senior years.”

ROCCO also studied the effects on the mental health of grandparents of taking care of their grandchildren because parents are too busy.

“Family is a big player in social capital.” Surprisingly to Israeli listeners, he found that European grandparents have a greater tendency to suffer depression as a result of being “drafted” to babysit for grandchildren of a variety of ages.

“There are good reasons to think that if you spend time taking care of your children and then grandchildren, you are mentally and physically active. But if you do this every day, many hours a day, it may be stressful and too much, and you might not be able to take care of your own health.

“Grandparents naturally love their grandchildren and looking after them can give them additional opportunities for physical activity and to be mentally active. But if it’s too much, grandparents may be paying a price in their health, whether physically or mentally,” Rocco said.

He studied grandparents aged 50 to 75 in 12 countries – not including Israel – who were assessed on whether and how often they babysat for grandchildren. There was the problem of self-selection, as not all grandparents provide care, and those that are asked to do so are probably in better mental and physical shape than those who are not asked to babysit.

Nevertheless, “we find that childcare does cause some depression in grandparents, especially if they have to do it for many hours,” Rocco concluded. Ten hours of babysitting per month increases the probability of depression in grandparents by 3% for females and 5.5% for males. In any case, if you take care of grandchildren, he pointed out, the elderly can easily expect their grown children to take care of them when they become dependent when aging.

As most Israelis would guess, as this tiny country is very child-oriented, with families located close to each other, the results here are very different than in Europe. Prof. Ariela Lowenstein, a senior University of Haifa gerontologist, investigated the question without looking at the number of hours grandparents spent babysitting.

“We found that taking care of grandchildren had a positive impact on the grandparents’ mental health. It can be tiring taking care of young children, but that doesn’t make them depressed.”

Vive la différence.

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