Social Narratives and Population Health

A couple of weeks back, the New England Journal of Medicine (NEJM) published our perspective article on how social narratives impact health. The core of our argument is that social narratives interact with how we understand the world. When they don’t align, your health suffers. 

I started discussing the idea with my eventual co-authors, Atheen Venkataramani and Tony Iton, in October 2023. Atheen and Tony come from different but merging worlds. Atheen is a physician and researcher. He runs the Opportunity for Health lab at the University of Pennsylvania. Him and his team are looking at how economic opportunity shapes health. Their work is empirical; there’s lots of data collection and number crunching. 

Tony is the former Chief Strategy Officer of The California Endowment, a health foundation. Also a physician, he led a team that turned an observation – that people without a sense of control over their lives have worse health – into an intervention. The foundation supported 14 low-income communities in California to gain control over their lives by building their power and influence with political and institutional leaders. They had considerable success. 

I approached Atheen after NEJM published his previous article on the link between hope and health. It was published around the time that affirmative action was being debated in the US. What Atheen showed was that affirmative action makes the targeted people feel hopeful and that can improve their health by making them less likely to engage in adverse health-related behaviors (such as smoking and alcohol use) and more likely to engage in future-oriented behaviors (such as school attendance and academic effort). 

At the time, Tony and I had recently published our article on the link between community power and health. As with Atheen’s article, it was very behavioral. It got into the processes involved in building community power and how that might be used to affect structural change. However, all three of us knew that before the behavioral there was something else going on, something more psychological. We set about trying to understand and describe this. 

After months of reading, where we got to – and what our article covers – is that we understand the world through ‘mental models’. They tell us how the world works, what is valued, and what our place in society is. From this understanding, we derive beliefs and expectations, our sense of belonging, and an appreciation of our status in society. All three of these influence how much stress we feel, which, in turns, influences our mental and physical health. 

Social narratives are the aggregation of the stories that our ‘out there’ in society. They’re the things we accept as the norm without anyone explicitly sitting us down and explaining them to us. Two classic examples are ‘rugged individualism’ – the narrative that we’re personally responsible for what happens to us – and ‘deservingness’ – the narrative that we get what we deserve based on the work we put in. 

For people living in disadvantaged neighborhoods neither of those narratives make sense. While being rugged, taking responsibility, and working hard will always be good things, it’s not as though they can overcome poor housing, polluted neighborhoods, bad schools and poor health care. For people enduring such conditions, those social narratives are incongruous. At best, they might leave someone confused. At worst, it breeds cynicism and stress. 

In the policy work I’m doing with the Future Governance Forum in the UK I am seeing this cynicism analyzed and discussed endlessly in the think tank community. I’m glad it’s happening but it doesn’t feel like rocket science. Governments are forever talking up their achievements but people know the reality when they walk through their neighborhoods. From that cynicism comes a gritty reality – people simply don’t feel respected. 

I could, of course, go from here to talk about how many are choosing to revolt by backing politicians that offer easy answers. I won’t. Because what matters to me is health. When you know you’re not valued and respected, when the social narratives bear little resemblance to how the world really works, the only conclusion is that you don’t belong and you should not hope for anything good from the society you live in. 

Call it despair, call it hopelessness, call it futurelessness. Lots of us have been dancing around these issues for some time. With some luck, our article will help to make solid something that, for some, has been fluffy. I don’t think describing a biological pathway is any kind of silver bullet. But perhaps it can remind us that we are our stories and our stories are ours. 

And it’s up to use to decide if they’re to be salutogenic or pathogenic. 

Pritpal S Tamber

The image below the title is by Jonathan McHugh / Ikon Images