People in cities are healthier than they think

From a talk by Professor Julian Le Grand, the Professor of Social Policy at London School of Economics to the Millennium Festival of Medicine

I was approached about a year ago to give this talk on health and the city. Since then I have been able to unearth some puzzles. The first puzzle arises from the 1998 Health Survey for England. Taking a representative sample of around 20,000 people, it asks a variety of questions on a wide range of topics, including self-reported health, use of health services and standard demographic and socio-economic factors such as income, occupation and family structure. Also, each year it addresses a specific topic, such as the prevalence of a particular disease. In 1998 it concentrated on cardiovascular disease.

I was approached about a year ago to give this talk on health and the city. Since then I have been able to unearth some puzzles. The first puzzle arises from the 1998 Health Survey for England. Taking a representative sample of around 20,000 people, it asks a variety of questions on a wide range of topics, including self-reported health, use of health services and standard demographic and socio-economic factors such as income, occupation and family structure. Also, each year it addresses a specific topic, such as the prevalence of a particular disease. In 1998 it concentrated on cardiovascular disease.

The proportion of adults who reported their health as being good or very good in rural areas was 78 per cent for men and 77 per cent for women, much higher than in urban areas which showed 70 per cent for men and 69 per cent for women. So far, not very surprising; most people, I suspect, believe that cities - crowded, dirty and polluted - are unhealthier places to live than the countryside - empty, wholesome and clean.

However, the results for the prevalence of cardiovascular disease [CVD] - perhaps a more objective measure - give a rather different picture. It is apparent that rural CVD is higher than urban. This suggests that those in urban areas feel in worse health than those in rural and suburban areas, but are actually in better health. And that is the puzzle: if it is true, why are the inhabitants of cities getting better but feeling worse than their countryside counterparts?

Let me draw your attention to a different survey, called Health in England 1998. This survey interviewed 5,816 adults randomly selected from households that were themselves randomly selected. As well as asking questions relating to self-reported health and limiting, long-standing illness, it asked questions relating to personal support and "social capital".

Social capital seems to be an individual's sense of wellbeing - directly related to the extent of social support he or she possesses and the extent of his or her civic engagement.

The survey found that, among conventional socio-economic factors, age, household income, economic activity and housing tenure were all important factors associated with self-reported health. However, they also found that some of the indicators of social capital, including satisfaction with control over life and neighbourhood, were positively linked to being healthy.

So what does this suggest about our various puzzles? One explanation for the relatively poor levels of health reported in cities (as distinct from the actual levels of health) could be because of a relative absence of social capital in urban areas.

So where does this leave us in considering health and the city? First, we must be careful about mythologies. City-dwellers often have an image of the country as peopled by apple-cheeked cottagers, not wealthy in material goods but rich in areas where it counts, such as their health. In fact, this seems quite wrong: rural areas seem actually to be wealthier in terms of material goods but not necessarily better off in terms of actual health.

But they do report better health. And this raises a puzzle about the factors affecting self-reported health; could there be factors associated with urban living that depress self-reported health relative to actual health?

Although we have no data to make direct comparisons, I have suggested that there may be such factors, and that they could be associated with the rather ill-defined notion of social capital. Certainly the evidence suggests that the lack of some forms of social capital are closely associated with a low self-assessment of health; and it seems plausible to suppose that the relevant forms of social capital - such as those associated with a sense of community - are more likely to be found in the country than in cities. This is an area ripe for future research.