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6
Social Factors
C
hapters 4 and 5 examined the role of health systems and health
behaviors in explaining the U.S. health disadvantage, but health is
also deeply influenced by “social determinants,” such as income and
wealth, education, occupation, and experiences based on racial or ethnic
identification. These factors have been shown to contribute to large health
disparities in the United States and other countries and should be consid-
ered in efforts to explain disparities in health among countries. Although
the science of the social determinants of health is still evolving, a growing
body of biological, epidemiological, and social science research has revealed
pervasive and strong links between a range of social factors that shape liv-
ing and working conditions and a wide array of health outcomes. A rapidly
accumulating literature also is elucidating the biological processes that may
account for these health effects (Adler and Stewart, 2010; Braveman et al.,
2011b; Commission on the Social Determinants of Health, 2008).
Following widespread convention, we use the term “social” to refer
to economic as well as psychosocial factors. Access to, and the quality of,
medical care are clearly influenced by social policies, such as the legislation
creating Medicare and Medicaid in 1965 and the Affordable Care Act in
2010. Generally, however, and in this report, the terms “social factors” and
“social determinants of health” refer to factors outside the domain of public
health and health care, which are covered in Chapter 4.
As discussed above, the terms “upstream” and “downstream” are often
used to denote relative positions of a given health determinant on plausible
causal chains. Upstream factors are closer to the fundamental cause and
often farther (“distal”) from the observed health outcome; downstream
161
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162 U.S. HEALTH IN INTERNATIONAL PERSPECTIVE
(“proximate”) factors are closer to the ends of causal chains. Upstream
social factors that have repeatedly been linked with important health out-
comes in many populations include income, accumulated wealth, educa-
tional attainment, and experiences based on racial or ethnic identification.
Downstream factors (which may be shaped by upstream factors) include
unhealthy diets, lack of exercise, and smoking. Features of neighborhoods
and work environments may be thought of as midstream.
This chapter focuses on the social factors that current knowledge sug-
gests may contribute significantly to the U.S. health disadvantage and that
can be compared across high-income countries: income and poverty, income
inequality, education, employment, social mobility, household composition,
and experiences based on racial or ethnic identification (Galea et al., 2011;
Link and Phelan, 1995; Marmot, 2005).
The chapter focuses primarily on social characteristics of individuals,
families, and populations. The potential role of the social environment —
such as features of housing, transportation, and neighborhoods—in con-
tributing to the U.S. health disadvantage is the focus of Chapter 7.
As in other chapters, the panel posed three questions:
• Do social factors matter to health?
• Are adverse social factors more prevalent in the United States than
in other high-income countries?
• Do differences in social factors explain the U.S. health disadvantage?
Before turning to these questions, however, we offer an important
comment on evidence and the role of social factors on health. Docu-
menting causality and testing the effectiveness of interventions for social
factors is inherently challenging (Braveman et al., 2011b; Kawachi et
al., 2010). The time intervals between exposures to social factors and a
health outcome—such as the psychosocial consequences of poverty—may
be quite long (Braveman et al., 2010a; Galobardes et al., 2008; Rychetnik
et al., 2002). Exposures may occur during childhood, gestation, or even
during the childhood of one’s parents (Hertzman, 1999; Kuh et al., 2002;
Melchior et al., 2007; Turrell et al., 2007). Furthermore, the causal path-
ways from fundamental social causes to health outcomes are often com-
plex, with opportunities for effect modification at multiple steps along the
way (Braveman et al., 2010a). Relationships are also not unidirectional:
cross-sectional associations do not clarify the role of reverse causality, as
when poor health limits education or income. Adverse health and socio-
economic circumstances can also negatively affect household stability,
family composition, and social support. Because it would be both dif-
ficult, if not unethical, to test these hypotheses in randomized controlled
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SOCIAL FACTORS 163
trials,1 researchers use a variety of other methods, including multivariate
modeling, instrumental variables, quasi-experimental designs, Bayesian
approaches to inference, natural experiments, and “connecting-the-dots”
between disparate bodies of knowledge (Braveman et al., 2010a; Dow et
al., 2010; Kelly et al., 2006).
Another challenge in analyzing social factors in a cross-national context
is that a given factor may have different health implications depending on
local circumstances. Standards of living vary across countries, as do social
safety nets and other programs designed to alleviate poverty, unemploy-
ment, and homelessness. We therefore approach this topic aware of these
important caveats and limitations.
QUESTION 1:
DO SOCIAL FACTORS MATTER TO HEALTH?
Recent reviews have documented links between social factors and
health, elucidated plausible causal pathways, and discussed the strength of
evidence for causality (Adler and Rehkopf, 2008; Adler and Stewart, 2010;
Braveman et al., 2010a, 2011b; Commission on the Social Determinants
of Health, 2008; Kawachi et al., 2010). As shown in Box 6-1, among the
broad types of social factors with strong and pervasive links to a wide
array of important health outcomes are income (Mackenbach et al., 2005;
Muennig et al., 2010; Woolf et al., 2010), accumulated wealth (Pollack
et al., 2007), educational attainment (Elo and Preston, 1996; Jemal et al.,
2008a; Woolf et al., 2007), occupational characteristics (An et al., 2011),
and social inequality based on racial or ethnic group (Bleich et al., 2012;
Marmot, 2005; Williams and Collins, 2001; Williams and Mohammed,
2009). In this section, we briefly summarize this literature.
Income and Wealth
Extensive evidence documents the association between income and
mortality. Unhealthy behaviors, such as smoking, tend to be more prevalent
among low-income groups. Income or wealth enables one to afford a nutri-
1
The premise that randomized controlled trials are the “gold standard” for establishing
causal relationships has put the accumulation of knowledge about the social determinants of
health at a distinct disadvantage. It is increasingly recognized that scientifically valid studies
of social factors that can answer important questions must draw on a wide variety of well-
implemented research designs (Anderson and McQueen, 2009; Black, 1996; Glasgow et al.,
2006; McQueen, 2009; Petticrew and Roberts, 2003; Victora et al., 2004).
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164 U.S. HEALTH IN INTERNATIONAL PERSPECTIVE
BOX 6-1
Social Factors That Affect Health Outcomes
Upstream social factors—Laws, policies, and underlying values that
shape the following:
• Income and wealth
• Education
• Employment
• Household composition
• Experiences based on race or ethnic group
• Social mobility
• Stressful experiences related to any of the above
• Income inequality
Midstream social factors—Factors that are strongly influenced by
up tream factors and that are likely to affect health:
s
• Housing
• Transportation
• Other conditions in homes, schools, workplaces, neighborhoods,
and communities, including conditions that produce stress and fam-
ily disruption (e.g., parenting skills, parenting stress, leisure time,
quality of schooling, physical and psychosocial working conditions)
tious diet (Treuhaft and Karpyn, 2010), to buy or rent healthy housing2 in a
healthy neighborhood (Shaw, 2004), and to engage in regular exercise (e.g.,
through gym membership or living where it is safe and pleasant to exercise
outdoors). However, careful analysis of longitudinal data has revealed that
the association between adverse economic conditions and mortality persists
even after adjusting for unhealthy behaviors (Lantz et al., 2010), suggest-
ing that economic stresses may also affect health through other pathways.
Access to employment, educational opportunities, and medical care can be
constrained by one’s income, particularly in the absence of adequate public
transportation (Gordon-Larsen et al., 2006). Exposure to poverty during
childhood may have particularly strong and enduring effects on health
across the entire life course (Cohen et al., 2010; Pollitt et al., 2005). Mate-
rial hardship is strongly related to family strife and disruption (Braveman et
2
Healthy housing refers to domiciles that are free of health and safety threats, such as lead,
which can affect children’s cognitive function, and free of excessive dust, mites, and mold,
which can provoke and exacerbate respiratory disease (Lanphear et al., 2001).
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SOCIAL FACTORS 165
al., 2010a; Evans et al., 2012). Accumulated wealth can buffer the adverse
effects of temporary periods of lower income.
Income Inequality
Income inequality in a society has repeatedly been shown to be inversely
associated with good health, but there is controversy about the health effects
of relative income inequality apart from the effects of absolute poverty or
economic hardship (Subramanian and Kawachi, 2004). Some experts view
relative inequality as a factor with independent effects, which may touch
the whole population, perhaps by undermining social cohesion (see Chap-
ter 7) (Daniels et al., 2000; Pickett and Wilkinson, 2009, 2010; Wilkinson
and Pickett, 2007, 2009). Other research, however, challenges the premise
that relative economic inequality exerts an independent effect apart from
its association with absolute levels of material deprivation (Beckfield, 2004;
Deaton and Lubotsky, 2009; Lynch et al., 2001, 2004a, 2004b). The appar-
ent association between economic inequality and poor health could reflect
other more fundamental factors that shape both economic inequality and
health, such as a society’s lack of social solidarity. There is, however, consen-
sus about the adverse health implications of absolute material deprivation.3
Education
Education and health are strongly interrelated. In 2006, the life expec-
tancy of 25-year-old American men without a high school diploma was
9.3 years shorter than those with a bachelor’s degree or higher education;
the corresponding disparity for women was 8.6 years (National Center for
Health Statistics, 2012).4 Education is generally a prerequisite for desir-
able employment and associated income and other resources (e.g., medical
insurance, pensions, sick leave). Early childhood experiences and education
shape early childhood development, which in turn influences school readi-
ness and, ultimately, educational attainment. Education can confer knowl-
edge, problem-solving skills, and a sense of control over life circumstances.
These psychosocial factors have been strongly tied to healthy behaviors
(Dunn, 2010; Pampel et al., 2010; Umberson et al., 2008) and, in some
3
Debates about the role of relative economic inequality isolated from the effects of absolute
deprivation have generally been confined to academic settings. In most contexts, economic
inequality is assumed to refer to absolute economic adversity for substantial segments of a
population alongside extreme wealth for others. High levels of relative inequality and absolute
hardship/poverty coexist in the United States and many other nations.
4 some research, the association between education and unhealthy behaviors and mortal-
In
ity loses significance after controlling for confounding variables, notably income (Lantz et
al., 2010).
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166 U.S. HEALTH IN INTERNATIONAL PERSPECTIVE
cases, more directly to health outcomes (Matthews et al., 2010; Pudrovska
et al., 2005). For example, across countries, education and smoking rates
are inversely related (Garrett et al., 2011; National Center for Health Statis-
tics, 2012; Pampel and Denney, 2011), and parental education is associated
with the health behaviors of children.5 Other evidence also supports causal
connections between education and health outcomes (Fonsenca and Zheng,
2011; Lleras-Muney, 2005), but the two may also have common anteced-
ents. Hopelessness and powerlessness, for example, may contribute both
to unhealthy behaviors and to educational and occupational setbacks, and
they may link more directly to poor health through plausible physiologic
mechanisms (Boehm and Kubzansky, 2012; Downey and Van Willigen,
2005; Goodman et al., 2009; Marmot et al., 1997; Matthews et al., 2010;
Pudrovska et al., 2005; Seeman et al., 2010).
Employment
Employment shapes health in diverse ways, in part by determining
employment opportunities and income (World Economic Forum, 2011).
Low-skilled and low-status employment is more likely to involve exposure
to physical hazards, such as toxic chemicals (e.g., pesticides, cleaning sol-
vents), and to occupational injuries. Job loss, unemployment, and economic
contraction have been linked with ill health and higher mortality because of
psychosocial as well as economic consequences (Bartley and Owen, 1996;
McLeod et al., 2012; Paxson and Schady, 2005; Strully, 2009; Sullivan and
von Wachter, 2009), although the evidence is not conclusive (Catalano et
al., 2011). (See Chapter 7 for additional evidence on the health and injury
risks associated with the work environment.)
Social Status
Income, wealth, education, and employment all have implications for
prestige and acceptance in society, and hence may affect health through
psychosocial pathways involved in perceived position in a social hierar-
chy. Lower perceived social status has been associated with adverse health
outcomes in some studies even after considering objective measures of
resources and social status (Singh-Manoux et al., 2003, 2005).
5
In 2007-2010, in U.S. households in which the head of household had less than a high
school education, 24 percent of boys and 22 percent of girls were obese. In households where
the head had a bachelor’s degree or higher, the corresponding figures were 11 percent for boys
and 7 percent for girls (National Center for Health Statistics, 2012).
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SOCIAL FACTORS 167
Household Composition
Household composition, which is strongly related to income and educa-
tion, can influence social factors that in turn influence health.6 For example,
children in low-income single-parent households experience higher rates of
poverty, food insecurity, unstable housing, and other adverse living condi-
tions (Center on Human Needs, 2012a). Poverty puts strains on families
and creates a greater risk of single-parent households (Center on Human
Needs, 2012a; DeNavas-Walt et al., 2011).
Low-income households are often the setting for adolescent childbear-
ing, which is more common in the United States than in other high-income
countries (see Chapter 2). Adolescent motherhood affects two generations,
children and mothers. Adolescent mothers are less likely than other ado-
lescents to complete their education, and they have more restricted labor
market opportunities and more disadvantaged family and household envi-
ronments (Ashcraft and Lang, 2006; Hoffman and Maynard, 2008). Their
children face a greater risk of poor child care, weak maternal attachments,
poverty, and other adverse conditions (Baldwin and Cain, 1980; Card,
1981). The female children of adolescent mothers are also at increased
risk of becoming adolescent mothers themselves, thus perpetuating adverse
conditions over two generations (Kahn and Anderson, 1992).
Racial and Ethnic Factors
In many countries, a variety of health outcomes vary markedly by race
and ethnicity (Agency for Healthcare Research and Quality, 2011; Com-
mission on Social Determinants of Health, 2008). These health disparities
often mirror large differences in income, wealth, education, occupation,
and neighborhood conditions among people of different races and ethnici-
ties, differences that reflect a historical legacy of discrimination (Acevedo-
Garcia et al., 2008; Bleich et al., 2012; Cullen et al., 2012; Williams, 1999;
illiams and Collins, 1995, 2001).7 For example, in the United States,
W
blacks with the same level of education as whites have lower incomes, as
well as markedly lower levels of accumulated wealth even at the same level
of income (Braveman et al., 2005; Kawachi et al., 2005). Living in a society
with a high degree of racial inequality may harm the health of society at
large—not only of those who experience disadvantage—in the same ways
6
As noted above, the reverse is also true: illness can influence household composition and
stability, as well as education and income opportunities.
7 is now widely recognized that racial and ethnic groupings are primarily social, not bio-
It
logical, constructs, and that genetic differences probably make a small contribution to racial
or ethnic health disparities (American Anthropological Association, 1998; McCann-Mortimer
et al., 2004; Winker, 2004).
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168 U.S. HEALTH IN INTERNATIONAL PERSPECTIVE
that some researchers have argued that relative economic inequality may be
detrimental to society at large, for example, by undermining social cohesion
and trust (Wilkinson and Pickett, 2009) or by affecting individuals’ sense
of their relative social standing (Marmot, 2006). Unfortunately, as noted
below, data are lacking to compare degrees of racial inequality across high-
income countries.
In the United States, racial and ethnic groups that have historically
experienced discrimination,8 including blacks, Native Americans, and His-
panics, may suffer ill health effects from these experiences. The health
effects may result both from material deprivation and other conditions that
directly damage health and from physiologic mechanisms involved in reac-
tions to stress. Such stress, which has been linked with smoking (Purnell
et al., 2012) and hypertension (Sims et al., 2012), can result not only from
overtly discriminatory experiences but also from a pervasive vigilance about
whether harmful incidents will occur to themselves or their families (Krieger
et al., 2011; Nuru-Jeter et al., 2009). A relative difference in social standing
or a sense of social exclusion for any reason may induce stress and influence
one’s sense of self-worth or control, which may in turn influence subsequent
economic success, health-related behaviors, and health outcomes (Dunn,
2010; Umberson et al., 2008).
Migration
Migration and associated experiences and cultural traditions have been
shown to influence health and health behaviors. Almost 14 percent of
the U.S. population in 2008 was born outside the United States (OECD,
2011e). Although some immigrants are at higher risk of certain infectious
diseases, most recent immigrants to the United States generally have favor-
able health profiles compared with the native-born population.
Stress
Psychological distress that arises from any of the above social fac-
tors, including from social rejection or exclusion associated with racial or
ethnic identification, may lead to worse health through physiologic mecha-
nisms involved in stress (Matthews et al., 2010; McEwen and Gianaros,
2010). Those mechanisms include the effects of stress on the hypothalamic-
pituitary-adrenal (HPA) axis, the sympathetic nervous system, and immune
8
This legacy has been perpetuated by deeply rooted societal structures, even in the absence of
conscious intent to discriminate. This form of unintentional discrimination is often referred to
as structural or institutional racism, deeply rooted ways in which opportunity is differentially
structured along racial or ethnic lines (Smedley, 2012).
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SOCIAL FACTORS 169
and inflammatory phenomena (Danese et al., 2007; Halfon and Hochstein,
2002; McEwen and Gianaros, 2010; Shonkoff et al., 2009). These effects
are thought to induce end organ damage and cardiovascular disease
(Barker, 1998; McEwen and Gianaros, 2010). While life-long stress leads
to accumulated damage, early exposure to stress can affect sensitive bio-
logical processes, such as brain development, and thereby permanently dis-
rupt stress responses later in life (Gluckman and Hanson, 2006; Shonkoff
et al., 2009).
A Life-Course Perspective
Research increasingly confirms that health is shaped by social factors
that individuals have faced across their entire life courses, not just current
or recent experiences. Social disadvantages—and the health consequences
associated with them—may accumulate across an individual’s lifetime and
span multiple generations, making the unfavorable odds increasingly dif-
ficult to overcome (Goodman et al., 2011).
Social disadvantage can therefore play an important contributory role
to the development of chronic diseases and other conditions that threaten
the health and life expectancy of adults age 50 and older, but they can also
foster the health problems of early life, including many of the conditions
discussed in Chapters 1 and 2. For example, the educational attainment and
cognitive skills of today’s youth could influence the behaviors that contrib-
ute to infant and child mortality due to rates of accidents and homicides;
adolescent births and sexually transmitted infection; HIV/AIDS; and drug-
related mortality.
Chronic material hardship or stressful events in childhood may also
manifest their effects in mid- or even late adulthood (Cohen et al., 2010;
Goodman et al., 2011). Chronic social or economic hardship during child-
hood has been linked with morbidity and mortality due to cardiovascular
disease, diabetes, and other chronic diseases in adulthood (Hertzman, 1999;
Kuh et al., 2002; Lawlor et al., 2005; Melchior et al., 2007; Turrell et al.,
2007). There is evidence of health consequences from experiences during
critical or sensitive periods (e.g., in early childhood and puberty), as well as
from the cumulative effects of experiences over an individual’s life course
(Murray et al., 2011; National Research Council and Institute of Medicine,
2000; Viner, 2012; World Bank, 2007). Over and above the influence of
any particular event, the number of such events and the number of domains
affected by social disadvantage can determine the health damage associated
with poverty (Evans and Kim, 2010; Sexton and Linder, 2011).
Inheritance is a major route of transmission for wealth and its associ-
ated advantages. Low social mobility—that is, the low likelihood that a
person born to low-income or poorly educated parents will achieve higher
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170 U.S. HEALTH IN INTERNATIONAL PERSPECTIVE
income or education levels as an adult—could exacerbate the health effects
of adverse social conditions by leading to the accumulation of social dis-
advantage across generations, thereby producing greater poverty or other
consequences that compromise health (Case et al., 2005). Downward social
mobility has repeatedly been linked with adverse health outcomes (Case
and Paxson, 2010, 2011; Currie and Widom, 2010; Delaney and Smith,
2012). Lack of upward mobility in a society could exacerbate economic and
social inequality and could plausibly affect health through a range of path-
ways, including by shaping optimism (Boehm and Kubzansky, 2012) and
health-related behaviors (Dehlendorf et al., 2010; McDade et al., 2011) and
possibly by undermining feelings of social solidarity (Pickett and Wilkinson,
2010; Wilkinson and Pickett, 2009).
Epigenetic Effects
Social factors—or their consequences in social and physical environments—
may also influence health by interacting with a person’s genotype in ways
that can trigger or suppress the phenotypic expression of deleterious (or
favorable) genes that may be related to obesity, heart and lung disease,
diabetes, and cancer. A deleterious gene in one’s DNA may not be harm-
ful in the absence of certain triggers that “turn on” gene expression and
cause cancers to develop. These modifications in gene expression, which are
thought to occur through molecular processes (such as histone modification
and DNA methylation) can be inherited and affect the health of offspring.
“Epigenetics” refers to the transfer, from one generation to the next, of gene
expression patterns that do not rely explicitly on differences in the DNA
code (Gluckman and Hanson, 2006; Institute of Medicine, 2006b; Sandoval
and Esteller, 2012). Social and environmental factors may therefore influ-
ence biological outcomes through their effects on gene expression.
QUESTION 2:
ARE ADVERSE SOCIAL FACTORS MORE PREVALENT IN THE
UNITED STATES THAN IN OTHER HIGH-INCOME COUNTRIES?
Cross-country comparisons of social factors can be difficult because of
differences in measurement, as well as the meaning of a given factor in dif-
ferent settings. Readily comparable cross-national data are not available on
all relevant factors. For example, racial and ethnic disparities are important
to health, but data are lacking to compare the United States with peer coun-
tries in terms of the magnitudes of racial and ethnic health disparities. Data
are available, however, to examine health disparities by income, education,
and other socioeconomic determinants. The comparative data produced
by the OECD are widely considered to be the best available and are the
principal source of cross-national comparisons presented here.
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SOCIAL FACTORS 171
In aggregate, socioeconomic conditions—income and wealth—in the
United States are at or above average for high-income countries. Both the
size of the U.S. economy and median household income in the United States
are among the highest in the world. As of 2007, the United States ranked
second in the OECD (after Luxembourg) in annual household income9
(OECD, 2011e) and seventh in gross domestic product per capita (World
Bank, 2012a). However, the United States ranks poorly on the equitable
distribution of economic resources, with relatively high levels of poverty
and income inequality.
Poverty
The relative poverty rate,10 defined as the proportion of the population
with low incomes relative to the median income, has been higher in the
United States than in other high-income countries since at least 1980 (Lux-
embourg Income Study, 2012). Historically, the U.S. poverty rate declined
from very high levels in the 1940s to low levels in the late 1970s (Danziger
and Gottschalk, 1986): the rate (based on total household income) fell from
40.5 percent in 1949 to 22.1 percent in 1959, 14.4 percent in 1969, and
13.1 percent in 1979 (Ross et al., 1987). During these same decades, many
European countries instituted social welfare reforms that were designed to
promote social equity and alleviate economic distress (see Chapter 8), low-
ering the rates of poverty in many of these countries (Brady, 2005). The gap
between the levels of income inequality in the United States and other rich
democracies began to widen in the 1970s-1980s, possibly because of the
adoption of more conservative economic policies in the United States and
a retrenchment in public assistance programs (Card and Freedman, 1993;
Danziger and Gottschalk, 1995; Hanratty and Blank, 1990).
Absolute poverty is a basis for comparing incomes across countries
against a common benchmark (such as a given level of income in U.S. dol-
lars). Analyses that have used a common data set to compare countries in
terms of absolute poverty find that other countries seem to have higher rates
9
Household income is defined by the OECD as annual median equivalized household dispos-
able income: gross household income after deduction of direct taxes and payment of social
security contributions and excluding in-kind services provided to households by governments
and private entities, consumption taxes, and imputed income flows due to home ownership
(OECD, 2011e).
10 Relative poverty is defined by the OECD as the percentage of people living with less than
50 percent of median equivalized household income. “People are classified as poor when their
equivalized household income is less than half of the median prevailing in each country. The
use of a relative income-threshold means that richer countries have the higher poverty thresh-
olds. Higher poverty thresholds in richer countries capture the notion that avoiding poverty
means an ability to access the goods and services that are regarded as customary or the norm
in any given county” (OECD, 2011e, p. 68). See above discussion of absolute poverty as an
alternate measure.
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SOCIAL FACTORS 181
Canada 56.1
Japan 55.7
Norway 46.8
United Kingdom 44.9
Australia 44.8
Denmark 44.8
France 43.1
Sweden 42.3
United States 41.0
Netherlands 40.1
Switzerland 40.0
Finland 39.3
Spain 38.2
Germany 26.7
Portugal 23.3
Austria 21.0
Italy 20.1
0 10 20 30 40 50 60
Percentage of PopulaƟon with TerƟary EducaƟon
FIGURE 6-6 Percentage of adults aged 25-34 with a tertiary education in 17 peer
countries, 2009. Fig6-6.eps
NOTE: Tertiary education corresponds to International Standard Classification of
Education (ISCED) classifications 5A and 5B, equivalent to a 2-year or 4-year col-
lege education in the United States.
SOURCE: Data from OECD (2011a, Table A1.3a).
who were educated many years ago, educational performance in the past
decade, as reported above, may be less relevant to current health outcomes
than the quality of education in prior decades. Hanushek and colleagues
(2008) compiled data for 50 countries from 1964 to 2003 by standardizing
the results of 12 PISA tests and other international mathematics and science
assessments. In the 1960s and 1970s, U.S. students had lower scores than
those in 13 countries (including 9 of the peer countries examined in Part I).
The United States was outranked by 18 countries in the 1980s (including 10
peer countries), by 20 countries in the 1990s (including 9 peer countries),
and by 23 countries in the 2000s (including 10 peer countries). By the
2000s, Finland and nonpeer countries such as Korea, Taiwan, and Japan
were the top performers (Hanushek et al., 2008).
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182 U.S. HEALTH IN INTERNATIONAL PERSPECTIVE
TABLE 6-1 Comparative Ranking of 15-Year-Old Students in High-
Income Countries, 2006
Rank Reading Science Mathematics
1 Finland Finland Finland
2 Canada Canada Netherlands
3 Australia Japan Switzerland
4 Sweden Australia Canada
5 Netherlands Netherlands Japan
6 Switzerland Germany Australia
7 Japan United Kingdom Denmark
8 United Kingdom Switzerland Austria
9 Germany Austria Germany
10 Denmark Sweden Sweden
11 Austria Denmark France
12 France France United Kingdom
13 Norway United States Norway
14 Portugal Spain Spain
15 Italy Norway United States
16 Spain Italy Portugal
17 United States Portugal Italy
NOTES: Actual scores for United States vs. OECD average were as follows: Reading (est. 460
vs. 495), Science (489 vs. 500), and Mathematics (474 vs. 498). According to the OECD’s
website, the U.S. reading data that were originally displayed in bar charts were “subsequently
removed from the PISA publications for technical reasons.” In the 2009 PISA, the U.S. reading
score was 487, lower than all but three peer countries.
SOURCE: Data from OECD (2012n).
Employment
The recession-related decline in employment between 2007 and 2009
was more abrupt in the United States than in many countries (OECD,
2011e), but unemployment rates in the United States have traditionally
not exceeded those of other high-income countries since the 1980s (Nickell
et al., 2005; U.S. Census Bureau, 2012).23 The United States had notably
high unemployment rates in the 1960s and the mid-1970s, rates that were
23
TheUnited States has one of the lowest levels of employment for college graduates
(OECD, 2011a).
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SOCIAL FACTORS 183
higher than those in Australia, Canada, France, Italy, Japan, Sweden, the
United Kingdom, and West Germany (U.S. Census Bureau, 1970, 1980).24
Social Mobility
Multiple studies have demonstrated that the United States has less
social mobility than other countries (Blanden et al., 2005; Corak, 2004;
Isaacs et al., 2008; Solon, 2002). A report by the Brookings Institution
(Isaacs et al., 2008, p. 40) noted:
Men born into the poorest fifth of families in the United States in 1958
had a higher likelihood of ending up in the bottom fifth of the earnings
distribution than did males similarly positioned in five Northern European
countries—42 percent in the United States, compared to 25 to 30 percent
in the other countries.
In contrast, in the United States now, “only 8 percent make the ‘rags to
riches’ climb from bottom to top rung in one generation, while 11 to 14
percent do so in other countries” (Isaacs et al., 2008, p. 40). A 2011 follow-
up study reported that one-third of Americans who grew up in the middle
class fall below that category as adults (Acs, 2011).
A 2010 OECD report found that nine other OECD countries out-
ranked the United States on the link between individuals’ and their parents’
earnings, an accepted measure of economic mobility (OECD, 2010a). A
2005 report from Warwick University concluded that the United States
has a particularly “high likelihood [compared with Nordic countries, and
a higher likelihood than the United Kingdom] that sons of the poorest
fathers will remain in the lowest earnings quintile . . . [and a] . . . very low
likelihood that sons of the highest earners will show [long-term] downward
. . . mobility” (Jäntti et al., 2005, p. 27). Another study concluded that
“Intergenerational [economic] mobility in the United States is lower than in
France, Germany, Sweden, Canada, Finland, Norway, and Denmark; only
the United Kingdom had a lower rate of mobility than the United States”
(Hertz, 2006, p. i).25
Homelessness
Data are limited to compare housing instability in the United States and
other high-income nations. A telephone survey in Belgium, Germany, Italy,
24
Data are lacking to compare the occupational health and safety of workers in the United
States and other high-income countries.
25
Blacks in the United States have less economic mobility than whites (Blanden et al., 2005;
Hertz, 2006).
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184 U.S. HEALTH IN INTERNATIONAL PERSPECTIVE
the United Kingdom, and the United States found that the United Kingdom
(7.7 percent) and the United States (6.2 percent) had higher lifetime rates of
literal homelessness than did the other countries (Toro et al., 2007).
Incarceration
The United States has the highest incarceration rate among afflu-
ent countries—approximately 750 of every 100,000 U.S. citizens are in
prison—and the rate has been increasing over time (Glaze, 2011; Pew Cen-
ter on the States, 2008). Between 1987 and 2007, year-end prison counts
in the United States nearly tripled from 585,084 to 1,596,127 (Pew Center
on the States, 2008). And within the United States, the rate of ever having
gone to prison among males was more than six times higher among blacks
than whites (Bonczar, 2003). The U.S. Department of Justice estimates that
if incarceration rates remain unchanged, 6.6 percent of U.S. residents (and
32.2 percent of black males) born in 2001 will go to prison at some point
in their lifetime (Bonczar, 2003).
Household Composition
Between 1940 and 2000, the percentage of U.S. children born to unmar-
ried women increased from approximately 4 percent to almost 35 percent
(U.S. Census Bureau, 2003). By 2008, 30 percent of U.S. households with
children were headed by a single parent. The corresponding percentages
in comparable countries—including Canada, Japan, Denmark, France,
Germany, Ireland, Netherlands, Sweden, and the United Kingdom—also
increased during these decades, but none had the high percentage of the
United States. In 2007, 39.7 percent of live births in the United States
were to unmarried women, although some other countries (including Den-
mark, France, and Sweden) reported even higher rates (U.S. Census Bureau,
2011). A study that compared the United States with 16 other countries
(including 9 of the peer countries examined in Part I) found that children
born in the United States can expect to live more years with parents apart,
with a single mother, without a mother, or in a maternal stepfamily than
children in other countries (Heuveline et al., 2003). Single-parent house-
holds have a greater need for some social services, such as day care, which
are less available in the United States.
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SOCIAL FACTORS 185
Summary
The United States differs from other high-income countries in several
social domains that relate to health outcomes26:
• The United States has the second highest median household income
in the OECD but the fourth highest (among all OECD countries
and the highest among peer countries) level of income inequality,
the latter having increased in the United States since 1968.
• Since the 1980s, the United States has had among the highest rates
of overall poverty and child poverty of all rich nations and many
less affluent countries.
• The United States ranks high in average years of schooling and edu-
cational attainment, but other countries (including many emerging
economies) have been improving educational performance more
rapidly, and U.S. adults aged 25-34 now have mediocre rates for
completing secondary and tertiary education.
• U.S. preschool enrollment is lower than in most high-income
countries.
• Although U.S. grade school students score well relative to children
in other countries, by age 15 U.S. students have average or below-
average scores on mathematics, science, and reading.
• The United States has low levels of social mobility relative to other
high-income countries.
• The United States has the highest rate of incarceration among high-
income countries.
• The United States has the highest rate of households with children
headed by a single parent.
QUESTION 3:
DO DIFFERENCES IN SOCIAL FACTORS EXPLAIN THE
U.S. HEALTH DISADVANTAGE?
It is highly plausible—although not proven—that the social conditions
discussed above have contributed to the U.S. health disadvantage relative
26
Racial and ethnic disparities are an important domain that affects health outcomes
(Agency for Healthcare Research and Quality, 2011). However, for reasons noted above, no-
tably the lack of comparable evidence, this summary does not include differences among the
United States and other countries in the magnitude of racial or ethnic disparities. It focuses on
socioeconomic differences, for which data are more readily available, but the panel is acutely
aware of the important additional role of race and ethnicity in the health profile of all high-
income countries. We also note that the implications of the listed conditions can differ substan-
tially across countries because of differences in social programs and the strength of safety nets.
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186 U.S. HEALTH IN INTERNATIONAL PERSPECTIVE
to other high-income countries. In particular, overall poverty and child
poverty are especially plausible explanations for the pervasive U.S. health
disadvantage across multiple causes of illness, unhealthy behaviors, and
mortality during the first three or possibly four decades of life. Both have
been markedly higher in the United States than in almost all other high-
income countries during the years when people now in their 20s, 30s, or
early 40s were born, growing up, or entering young adulthood. Conditions
for children and young people during that period could have shaped risks
for low birth weight and infant mortality among the babies born to that
cohort, as well as risks for virtually all of the health conditions on which
the United States has a disadvantage during the first three or four decades
of life. Adult poverty during the past three to four decades may even
explain some of the health disadvantage observed among older U.S. adults,
but these effects might be less dramatic than those for younger age groups.
Chapters 1 and 2 documented that the U.S. health disadvantage is not
confined to minorities or those with low incomes or low educational levels
but exists at all socioeconomic levels and for non-Hispanic whites. The high
rates of poverty and child poverty in the United States would not explain
the persistence of the problem in these advantaged groups, although it is
possible that social inequality itself contributes to or reflects conditions that
affect the entire population.
Similarly, it is plausible that racial inequality in the United States
compounds the societywide effects of economic inequality with which it is
intertwined, but empirical cross-national data on this dimension of social
inequality are unavailable. The large incarcerated population in the United
States suggests a profound degree of multidimensional social disadvantage
that affects many people—not only prisoners themselves but also their
families and communities (Wildeman and Western, 2010). Racially dispro-
portionate incarceration rates in the United States are probably reflections
of multiple societal problems and are a likely contributor to the health risks
associated with poverty and to social immobility.
Although the United States has a proportionally larger foreign-born
population than the OECD average (OECD, 2011e), the large immigrant
population does not explain the U.S. health disadvantage because of the
“immigrant paradox,” the tendency of first-generation immigrants to have
better health than the native-born population. This phenomenon is chiefly
manifested in the United States as the so-called Hispanic paradox, in which
Hispanic Americans tend to have better health outcomes than people born
in the United States, especially within 10 years of immigration (Markides
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SOCIAL FACTORS 187
and Eschbach, 2005). The phenomenon has also been documented among
black immigrants from Africa and the Caribbean (Collins et al., 2002).27
Differences in child care and preschool education in the United States
could have broad effects that reach beyond disadvantaged groups. Strong
evidence demonstrates that high-quality child care and early childhood
development programs (from infancy through age 5) lead to higher educa-
tional attainment, income, and employment rates in adulthood, and lower
rates of criminal behavior. Although the benefits of preschool education
are greater for poor children than others, they have been demonstrated
among children of diverse socioeconomic backgrounds; and the benefits
are themselves strong predictors of subsequent health (Karoly et al., 2005;
National Research Council and Institute of Medicine, 2000; Rolnick and
Grunewald, 2003).
The mixed but overall mediocre—and in some cases very low—com-
parative standing of the United States on educational attainment and mea-
sures of educational achievement in secondary and tertiary education may
contribute to the U.S. health disadvantage. The educational attainment and
cognitive skills of today’s young adults could, for example, influence the
behaviors that can contribute to infant and child mortality due to accidents
and homicides; adolescent births and sexually transmitted infections; HIV/
AIDS incidence and mortality; and drug-related mortality. That the United
States once led the world on educational attainment and has a highly
educated cohort of older adults, however, makes education a less likely
contributor to the health disadvantages currently observed among older
Americans. They were educated many decades ago, when their counterparts
in other high-income countries did not, as a group, hold an educational
advantage.
Inequalities in life expectancy and all-cause death rates among Ameri-
cans with different levels of education and income have been increasing for
decades (Dow and Rehkopf, 2010; Jemal et al., 2008b; Meara et al., 2008;
Pappas et al., 1993), and this gradient may be steeper in the United States
than in other high-income countries. In an examination of mortality rates
by educational attainment among adults aged 30-74, mortality rates among
white men were higher in the United States than in England and Wales,
France, Norway, Sweden, and Switzerland, but the excess mortality was
more pronounced in lower than in higher educational groups (Avendano
et al., 2010). For example, although mortality among U.S. men was 30
percent higher than among Swedish men, it was 24 percent higher among
men with a tertiary or higher education, but 55 percent higher among men
27
The panel did not examine evidence regarding whether or not some of the specific health
disadvantages observed in the United States (e.g., certain communicable diseases and injuries)
are more common among immigrants.
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188 U.S. HEALTH IN INTERNATIONAL PERSPECTIVE
with a lower secondary education or less. The authors concluded that
part of the excess mortality among U.S. men is due to larger inequalities
in mortality by educational levels in the United States than those in some
European countries.
A variety of hypotheses could explain this pattern, among them that
prosperity in the United States may be more deeply tied to higher educa-
tion (Cutler et al., 2011). The consequences of inadequate educational
attainment may differ by country, depending on the educational creden-
tials required for desirable jobs, economic security, and other material and
psychosocial benefits gained through employment. In comparison with
the United States, only Poland, Portugal, Spain, and Turkey have similarly
low rates (approximately 20 percent or less) of skilled employment among
employed persons who lack tertiary schooling, indicating the larger socio-
economic consequences in the United States of not having a tertiary educa-
tion (OECD, 2009b).
The health benefits associated with education might be stronger in
the United States than in other countries. A recent study reported that life
expectancy among people with less than 12 years of education decreased in
the United States between 1990 and 2008, at the same time that it increased
among people with 12 or more years of education (Olshansky et al., 2012).
Underscoring the importance of education, the study also found that blacks
and Hispanic Americans with 16 or more years of education lived 7.5 years
and 13.6 years longer, respectively, than whites with less than 12 years of
education, although racial and ethnic disparities persisted at all levels of
education. The study noted that “[t]he same highly educated black men and
women who live longer than less educated whites still live about 4.2 years
less than comparably educated whites” (p. 1,806).
More so than in other countries, there appears to be a stronger link
in the United States between parental education and children’s economic,
educational, and socioemotional outcomes (Ermisch et al., 2012). Medio-
cre performance on education could be a result of disadvantaged home
environments, such as a lack of parental stimulation of children’s cognitive
development, or other disadvantages that could accompany child poverty
(Ermisch et al., 2012). Compared with disadvantaged students in many
high-income countries, those in the United States appear to have less “resil-
ience” and to show greater deficiencies in reading (OECD, 2011a). Their
disadvantage also could be exacerbated by deficiencies in health during
childhood and young adulthood (Fletcher and Richards, 2012).
Another factor that could compound the effects of low income and
education is the comparatively weak social safety net (i.e., fewer publicly
funded transfers and services) in the United States (Avendano and Kawachi,
2011). A weaker safety net may exacerbate the detrimental health effects of
poverty, unemployment, and economic insecurity (Bartley et al., 1997; Dow
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SOCIAL FACTORS 189
and Rehkopf, 2010). The health effects of unemployment may be buffered,
for example, by programs that provide job training and counseling, medi-
cal care, and income and housing supports for the unemployed (Bartley
and Owen, 1996). In one recent study, prospective data from the United
States and Germany covering 1984 to 2005 showed that unemployment
was associated with higher mortality in the United States but not in Ger-
many. This relationship was only evident among low- and medium-skilled
workers, prompting this analysis by the authors (McLeod et al., 2012, pp.
1,544-1,555):
In the American cohort there was no relationship between unemployment
and mortality for the high-skilled. It appears that individuals with a high
level of education may be best suited to take advantage of the more flexible
labor markets within the United States. The high-skilled were also more
likely to receive benefits, when unemployed, than were those of lower
skill levels. These individuals may also have other resources (e.g., savings,
familial resources, and social or business contacts from educational or
professional organizations) to draw upon that would buffer the effect of
unemployment on health. . . . In Germany, the unemployed medium-skilled
had the lowest relative risk of dying. This is the strongest evidence that
institutional environment can affect the relationship between unemploy-
ment and health as institutional protection is targeted toward medium
(and vocationally) skilled workers in Germany.
The health consequences of low income may be mitigated by other
resources that help individuals and families meet their basic needs (Anand
and Ravallion, 1993), such as free or subsidized food, medical care, child
care, elder care, education, housing, public transportation, recreational
services (e.g., parks, supervised activities for children), and other social pro-
tections. A study of 18 countries documented that social security transfers
and public health spending significantly reduce poverty levels (Brady, 2005).
As with other social factors, child poverty could potentially have more
severe adverse health consequences in the United States than in other
affluent nations. Greater public investments in child and family supports—
including child care, early childhood development, and preschool programs
(see Chapter 8)—appear to help alleviate the effects of child poverty in
other countries. For example, in a study that compared Sweden and the
United States in the 1980s, the authors found that child poverty rates did
not differ substantially when measured by household income before social
transfers and taxes (Jäntti and Danziger, 1994, p. 50):
After counting income from both the market and the welfare state, 12.8%
of children in the United States and 2.1% of children in Sweden were dis-
posable income-poor. The difference in disposable income poverty rates
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190 U.S. HEALTH IN INTERNATIONAL PERSPECTIVE
between children living in two-parent and single-mother families was 32.5
percentage points in the United States, but virtually nil in Sweden. Over
the mid-1980s, child poverty increased by almost one-third in the United
States (from 9.6% to 12.8%), while it fell slightly in Sweden (from 2.6%
to 2.1%).
The relatively weak social safety net in the United States is a potential
explanation not only of a health disadvantage among low-income children
and a contributor to low social mobility, but also of the health disadvan-
tages observed among children in all income groups. Stronger safety nets
could, at least in theory, lessen the stress and anxiety associated with a
potential loss of income or the high costs of medical care, child care, and
education (Bartley et al, 1997).28
Safety net programs, the quality of schools, and economic conditions in
the United States are shaped in part by public policies, such as the relatively
low public spending on services for families and young children compared
with other high-income countries. The role of public policies in shaping
social conditions is discussed further in Chapter 8.
CONCLUSIONS
Part I of this report documents that life expectancy and other health
outcomes (e.g., infant mortality) in the United States began to lose pace
with other high-income countries in the late 1970s, a trend that has contin-
ued to the present. During this same time, as this chapter notes, there has
also been a potentially important co-occurrence of worsening social condi-
tions in the United States, notably a rise in income inequality, poverty, child
poverty, single-parent households, divorce, and incarceration—all more
pronounced than in other rich nations—and the loss of the U.S. leadership
position in education. Like the U.S. health disadvantage, many of these
social problems began to differentiate the United States from other rich
nations in the late 1970s and 1980s.
Whether these co-occurring social trends, individually or in combina-
tion, were causally related to the increasing U.S. health disadvantage is
still unclear. Answering this question requires a careful examination of
historical data to make relevant cross-national comparisons on a range of
social conditions over several decades. The cross-country rankings on social
indicators discussed in this chapter reflect relatively recent data (since the
28
The role of safety net programs and their interplay with other societal factors is undoubt-
edly complex, however. As discussed further in Chapter 8, European studies have shown
that although stronger safety nets are consistently associated with better aggregate health in
countries, they do not necessarily correlate with the size of health inequalities within European
countries (Kunst et al., 1998; Mackenbach et al., 1997, 2008).
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SOCIAL FACTORS 191
1980s), but as noted throughout this report, current health outcomes may
have been influenced significantly by social conditions experienced much
earlier, particularly for children in the post–World War II era. To under-
stand the current U.S. health disadvantage, it would be important to exam-
ine cross-nationally the trajectories of social factors, including programs,
services, and spending, that were in place four to six decades before the
relevant health outcomes appeared.
Whether the worsening social conditions in the United States and its
growing health disadvantage are causally interrelated, their co-occurrence
during the same time span in recent U.S. history certainly warrants further
scrutiny. As documented in this and the next chapter, there have been dra-
matic changes in the social fabric of the United States; see in particular the
discussion of social capital in Chapter 7. These unsettling trends present a
potentially important explanation for the U.S. health disadvantage and are
shaped by a range of more deeply rooted societal and structural factors. An
examination of these underlying causes can shed light on why the United
States appears to be losing ground in so many domains: not only health,
but also education, economic equality, and child well-being.
Chapter 7 explores the role of the physical and social environment
as an explanatory factor. Chapter 8 explores the important role of life-
styles, cultural attributes, public policies, spending priorities, and values as
contributors to the patterns observed in this report. These societal factors
cannot be ignored when trying to understand either the U.S. health disad-
vantage or the unfavorable social and economic circumstances reported in
this chapter.
