Education And Debate

Socioeconomic determinants of health: Community marginalisation and the diffusion of disease and disorder in the United States

BMJ 1997; 314 doi: (Published 03 May 1997) Cite this as: BMJ 1997;314:1341
  1. Rodrick Wallacea, research scientist,
  2. Deborah Wallaceb, president
  1. a New York Psychiatric Institute, New York, NY 10032, USA
  2. b Public Interest, Scientific Consulting Service Inc, New York, NY 10027, USA
  1. Correspondence to: Dr R Wallace PISCS Inc, 549 W 123 St, Suite 16F, New York, NY 10027, USA.


    This article describes the cascading diffusion of “inner city problems” of disease and disorder in the United States–from the huge marginalised inner city communities of the largest municipalities, first along national travel routes to smaller cities, and then from central cities into surrounding more affluent suburbs–following the pattern of the daily journey to work. Public policies and economic practices which increase marginalisation act to damage the “weak ties” of the community social networks which bind central city neighbourhoods into functioning units. Spreading disease and disorder can be interpreted as indices of the resulting social disintegration, which is driven by policy. This “failure of containment” in the United States should serve as a warning for cities in Europe against reducing the municipal and other services that they provide to “unpopular” subpopulations.

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