The Education – Health Link: A Powerful Tool Paula Braveman, MD, MPH Professor of Family & Community Medicine Director, Center on Social Disparities in Health University of California, San Francisco George Washington University September 9, 2009 April 19, 2019 © 2008 Robert Wood Johnson Foundation. All rights reserved.

More health care spending but less health than in many other countries 4/19/2019 More health care spending but less health than in many other countries Life Expectancy – 2004 Infant Mortality - 2002 Japan LE = 82.1 Switzerland Iceland Italy Australia Sweden France Spain Canada Norway New Zealand Austria Germany Netherlands Greece Luxembourg Finland Belgium Ireland United Kingdom Portugal Korea Denmark United States LE = 77.8 Czech Republic Mexico Poland Slovak Republic Hungary Turkey Iceland IMR = 2.3 Finland Japan Sweden Norway Austria Czech Republic France Spain Germany Belgium Denmark Italy Australia Netherlands Portugal Switzerland Greece Ireland Luxembourg Untied Kingdom Korea Canada New Zealand United States IMR = 7.0 Hungary Poland Slovak Republic Mexico Turkey OECD data

Clues? Scarlet fever death rate in children <15: England & Wales 4/19/2019 Clues? Scarlet fever death rate in children <15: England & Wales Slide 1: I want to pose a Q to you? How can it be that the US is the wealthiest country in the world AND spends more on medical care –overall and per person– than anyone else, yet we consistently rank at or near the bottom among industrialized countries on key measures of health? Could this slide give us some clues? Sulpha drugs Penicillin © 2008 Robert Wood Johnson Foundation. All rights reserved. April 19, 2019 Thomas McKeown, 1974

More education, longer life † 4/19/2019 More education, longer life † And now could these next slides add a few clues? Huge disparities within US, by income, by education, not explained by race Note gradient but the dramatically larger risks for the poor and near-poor Source: National Longitudinal Mortality Study, 1988-1998. † This chart describes the number of years that adults in different education groups can expect to live beyond age 25. For example, a 25-year-old man with only a high-school diploma can expect to live 50.6 more years and reach an age of 75.6 years. Center on Social Disparities in Health, University of CA, San Francisco © 2008 Robert Wood Johnson Foundation. All rights reserved. April 19, 2019

More educated mothers: less infant mortality 4/19/2019 More educated mothers: less infant mortality Source: Matthews TJ, MacDorman MF. Infant Mortality Statistics from the 2004 Period Linked Birth/Infant Death Dataset. National Vital Statistics Reports, vol 55 no 15. Hyattsville, MD: National Center for Health Statistics, 2007. Center on Social Disparities in Health, University of CA, San Francisco © 2008 Robert Wood Johnson Foundation. All rights reserved. April 19, 2019

More educated parents: less illness among children† Source: National Health Interview Survey, 2001-2005. † Based on parental assessment and measured as poor, fair, good, very good or excellent. * Age-adjusted. Center on Social Disparities in Health, University of CA, San Francisco © 2008 Robert Wood Johnson Foundation. All rights reserved. April 19, 2019

4/19/2019 Racial/ethnic differences are important but do not explain the education disparities: e.g., adult health status† In each racial/ethnic group, we see a gradient. Differences between poor and highest-income group are most dramatic, with the near-poor next But we see health differences even among different “middle-income” groups Source: Behavioral Risk Factor Surveillance System Survey Data, 2005-2007. † Based on self-report and measured as poor, fair, good, very good or excellent. * Age-adjusted. Center on Social Disparities in Health, University of CA, San Francisco © 2008 Robert Wood Johnson Foundation. All rights reserved. April 19, 2019

© 2008 Robert Wood Johnson Foundation. All rights reserved. April 19, 2019

How could education affect health? 4/19/2019 How could education affect health? Educational attainment Nutrition Exercise Drugs & alcohol Health/disease management HEALTH Health knowledge, literacy & behaviors Working conditions Exposure to hazards Control / demand imbalance Stress HEALTH Educational attainment Work-related resources Health insurance Sick leave Retirement benefits Other benefits Work Income Housing Neighborhood environment Nutrition Stress Work-related factors Health-related behaviors Stress Sense of control HEALTH Educational attainment Social standing Social & economic resources Stress HEALTH Social & economic resources Health-related behaviors Family stability Stress Social support 9

One of the inter-related pathways Nutrition Exercise Drugs & alcohol Health & disease management Educational attainment HEALTH Health knowledge, literacy & behaviors © 2008 Robert Wood Johnson Foundation. All rights reserved. April 19, 2019

Another (inter-related) pathway Educational attainment Work Exposure to hazards Control / demand imbalance Stress HEALTH Working conditions Health insurance Sick leave Retirement benefits Other benefits Work-related resources Housing Neighborhood environment Nutrition Stress Income

And more (inter-related) pathways Work-related factors Health-related behaviors Stress HEALTH Sense of control Educational attainment Social standing Social & economic resources Stress Social & economic resources Health-related behaviors Family stability Stress Social support © 2008 Robert Wood Johnson Foundation. All rights reserved. April 19, 2019

Finding solutions: Understanding the importance of social factors Policies to promote child and youth development and education, infancy through college Policies to promote economic development and reduce poverty & racial segregation Policies to promote healthier homes, neighborhoods, schools and workplaces Economic & Social Opportunities and Resources Living & Working Conditions in Homes and Communities Medical Care Personal Behavior HEALTH Robert Wood Johnson Foundation Commission to Build a Healthier America www.commissiononhealth.org © 2008 Robert Wood Johnson Foundation. All rights reserved. April 19, 2019

The Education-Health Link Education and health are strongly linked Through multiple inter-related pathways, e.g., by determining income, working conditions, and health-related behaviors Advocates for education can use this as a powerful tool to augment the strength of their case Use it! Array of resources at national, state, and local level on www.commissiononhealth.org © 2008 Robert Wood Johnson Foundation. All rights reserved. April 19, 2019

Resources at www.commissiononhealth.org Array of reports and tools, including information at state and county levels, designed to be useful to decision-makers State-by-State Chartbooks on Child Health and on Adult Health Overcoming Obstacles to Health, February 2008. Overview of key issues and literature on the social determinants of health. Race and Socioeconomic Factors Affect Opportunities for Better Health, March 2009. Overview and synthesis of literature on how race and socioeconomic factors jointly influence health Education Matters for Health, September 2009 Education and Health Calculator