Social vulnerability, health outcomes and the American Nations

In a new study in the American Journal of Medicine, Nationhood Lab’s Colin Woodard and his collaborators find evidence for the lasting social and physical health effects of 17th to 19th century settlement patterns on the North American continent

Credit: John Liberty/Motivf for Nationhood Lab. Related version published in American Journal of Medicine

By Colin Woodard

Regional cultures with a history of underinvesting in social services and public goods have the least resilience to external shocks like natural disasters, disease outbreaks, or catastrophic accidents like chemical spills.

For a new study in the American Journal of Medicine, I joined my public health research collaborators, Ross Arena of the University of Illinois-Chicago and Nico Pronk, president of the Minneapolis-based HealthPartners Institute, to examine U.S. social vulnerability patterns and their relationship to previously documented patterns of unhealthy lifestyle behaviors and a range of health indices. Once again we found geographical patterns that closely align with the centuries-old colonization patterns identified in my American Nations model from the book of the same name.

We used the Centers for Disease Control’s Social Vulnerability Index, a tool that employs 16 census variables to determine each U.S. county’s likely resiliency in the face of an external disaster, to identify the relative SVI of each of the American Nations. Factors used by the CDC include household socioeconomic indicators, household types and characteristics, access to transportation, the presence of racial minorities and non-English speakers.

The results, shown in the figure below, follow what the American Nations model might predict. Regions with a long historic track record of low taxes, weak regulations, and light investment in social programs and public goods — Deep South, Far West, El Norte (by dint of external control), Spanish Caribbean and Greater Appalachia — have poor SVI scores, as does the First Nation section of Alaska. Yankeedom, a region with a long tradition of communitarian public investment, has the best SVI score (7.5), which is 25% better than that of El Norte (10). Another communitarian region, the Midlands, came in at 7.6, and Left Coast just behind that at 7.8.

Credit: John Liberty/Motivf for Nationhood Lab. Related version published in American Journal of Medicine

Two other communitarian regions didn’t do nearly as well on the SVI index — New Netherland (Greater New York City) and Greater Polynesia (Hawaii) — though they both excel in most health metrics. In New Netherland’s case this is likely due to having extremely high housing and population density (3430 per square mile) — both treated negatively by the CDC’s index — and being unaffordable to many people living there. Greater Polynesia is probably dinged for some of the same reasons on account of most of more than two-thirds of its people living on Oahu, which has a population density of 1704 persons per square mile (about 20 percent higher than New Jersey, the most crowded state.) Tidewater, a region in the process of a rapid transformation from conservative bastion to liberal stronghold, is in the middle of the pack.

County-level SVI patterns match very closely to the 17th to 19th century colonization patterns indicated by the American Nations borders, but with two major exceptions. Notice the sections of Greater Appalachia that belong to states where the Midlands and Yankeedom can form a governing coalition — Pennsylvania, Ohio, and Illinois — have markedly better SVI scores that those that do not. A similar dynamic partly explains the wide schism between the northeastern and southwestern halves of the Far West, as Midland or Yankee-Midland blocs long shaped the policy environments of the Dakotas and Nebraska. Also note how well Utah — settled by the highly-communitarian Mormon exodus — does.

“Clear and statistically significant heterogeneity in social vulnerability is apparent across distinct regions in the US using the American Nations model,” lead author Arena, head of UIC’s physical therapy department, told Elsevier’s communications team for a press release they put out Dec. 18. “Akin to the previously described ‘stroke belt, there is evidence of a ‘social vulnerability belt’ sweeping across a large portion of the southern US region. Northern and western Alaska are also areas of concern.”

Our American Journal of Medicine study went on to compare these SVI patterns with county-level data on physical inactivity prevalence, a key cause of a variety of health problems we wrote about earlier this year. The data showed that the distribution overlaps considerably, but not perfectly. Compare the map above with this figure from our earlier work, first published in Progress in Cardiovascular Disease.

Credit: John Liberty/Motivf for Nationhood Lab.

Notice the two communitarian regions that received fairly poor SVI scores, New Netherland and Greater Polynesia, have pretty good inactivity numbers (measured in percent of people reporting having no leisure time activity). El Norte also performs quite well, while the geographic splits within Greater Appalachia and the Far West nearly vanish. The southern regions — Deep South, Greater Appalachia, Spanish Caribbean and New France — perform the worst, save for the First Nation section of Alaska.

In the paper we found that, nationally, the statistical correlation coefficient between SVI and inactivity was significant 0.59. (We also found the correlation to presence of racial minorities was very weak.) We found a similar figure (0.55) for the southern regions and First Nation, but a weaker correlation (0.39) for the other American Nations.

Inactivity is an important metric because it has been shown to be closely correlated to obesity, diabetes, healthspan and life expectancy.

“Our findings indicate social vulnerability and deep-seated characteristics of the United States’ distinct regions are likely influencing physical activity decisions,” Arena told Esevier. “These factors should be considered when designing physical activity health promotion campaigns and tailoring individual counseling. We need to figure out how to help specific communities and individuals make behavior changes. What tools do they need? What messaging will resonate with them? It’s time to apply a precision medicine approach to healthy living medicine.”

This research is part of a collaboration between Woodard, Pronk, Arena and other researchers investigating how early settlement patterns and the resultant regional cultures can explain and help solve various public health problems. In the past seven months it has produced ten academic papers that have been published or accepted at peer-review journals, including pieces we’ve shared here at Nationhood Lab on disabilities, and obesity, diabetes and physical inactivity. There’s plenty more to come.

Thanks to Nationhood Lab’s partners at Motivf, where John Liberty produced the maps you see here.

— Colin Woodard is director of Nationhood Lab at Salve Regina University’s Pell Center for International Relations and Public Policy.