1. 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.

2. 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
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

3. 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

4. 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,
† 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

5. 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

6. More educated parents: less illness among children†
Source: National Health Interview Survey,
† 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

7. 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,
† 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

8. © 2008 Robert Wood Johnson Foundation. All rights reserved.
April 19, 2019

9. 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

10. 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

11. 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

12. 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

13. 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
© 2008 Robert Wood Johnson Foundation. All rights reserved.
April 19, 2019

14. 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
© 2008 Robert Wood Johnson Foundation. All rights reserved.
April 19, 2019

15. 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