To provide a foundation for the discussions, Steven Woolf of Virginia Commonwealth University’s Center on Society and Health gave a brief overview of why educational success matters for health. The discussion that followed was moderated by Joshua Sharfstein, Johns Hopkins Bloomberg School of Public Health. (Highlights of this session are presented in Box 2-1.)
Woolf outlined five domains from the report U.S. Health in International Perspective: Shorter Lives, Poorer Health (NRC and IOM, 2013) that are important to shaping health outcomes. These include health care and public health (which, he noted, account for only 10–20 percent of health outcomes); individual behaviors; the physical and social environment; social and economic factors (including education); and public policies and spending, which shape the other four domains (see Figure 2-1). Differences in health outcomes are related to differences in how people and communities experience each of these domains. Key factors impacting health outcomes include
1 Unless otherwise noted, as in the case of the question and answer/discussion period, this chapter represents the rapporteur’s synopsis of the presentation delivered by Steven Woolf of Virginia Commonwealth University and the statements have not been endorsed or verified by the National Academies of Sciences, Engineering, and Medicine.
- education and income (e.g., families with limited incomes cannot live in healthy neighborhoods);
- quality of housing (e.g., exposure to allergens that cause asthma, overcrowding);
- quality of food that is accessible to residents (convenient availability of fresh, nutritious foods versus unhealthy options);
- the built environment (e.g., opportunities for residents to safely exercise, walk, cycle, or play outside);
- proximity to highways, factories, and other sources of exposure to pollutants and toxic agents;
- access to primary care providers and quality hospitals;
- access to affordable and reliable public transit (for travel to jobs, health and child care, social services, etc.); and
- residential segregation or other features that isolate communities and stifle economic growth.
Education, income, and wealth are among the most powerful predictors of health outcomes, Woolf said.
In the United States, the risk of dying from any cause (all-cause mortality) is directly related to educational attainment. Woolf described this relationship as a gradient: for both men and women, the more years of education an individual has, the lower the risk of death (Ross et al., 2012). Similarly, people who have less educational attainment more frequently self-report fair or poor health (Schiller et al., 2012). This association (between higher education and better health) is demonstrable across a range of different health outcomes, Woolf said, and he shared prevalence data by education for coronary heart disease, stroke, lung diseases, diabetes, kidney disease, and others (Schiller et al., 2012).
There is a tendency in U.S. society to assume that health is primarily the result of health care, Woolf observed, but he said the assumption is incorrect. Analyzing data from Kaiser Permanente in Northern California, Woolf and colleagues found that the educational attainment–health outcome gradient persists even among patients in this integrated health system, whose members have equivalent access to health care. Factors outside of the health care system contribute to the differences in health outcomes by educational attainment.
Tremendous amounts of money are dedicated to health care in the United States, he said, but the importance of the social determinants of health, including education, is not always fully appreciated. He shared data that suggest that for every life saved by medical advances, seven
lives would be saved if all adults had the mortality rate of people with some college education (Woolf et al., 2007).
Recognizing that patients who have less educational attainment are at greater risk for chronic diseases is important for clinicians, Woolf said, but there are also broader implications of this association for decision makers outside of the health sector, such as employers. A greater percentage of individuals with less educational attainment have difficulties with physical functioning—from walking, climbing steps, or handling small objects to lifting, carrying, or pushing large or heavy objects (Schiller et al., 2012). An educated workforce is more capable of physically functioning in blue-collar jobs. In addition to higher productivity, a more educated employee population will experience lower health care costs, less absenteeism, and more presenteeism.2
In a knowledge economy, it is difficult to separate the impact of education from that of income and wealth, Woolf said. People who have more education are more likely to obtain high-earning jobs and thus to have higher incomes and greater wealth. As with the education–health gradient, higher levels of income are associated with better health across a wide range of both physical and mental health outcomes (Schiller et al., 2012). Woolf added that people with less educational attainment are more dramatically impacted by societal trends. For example, although life expectancy in industrialized countries has been increasing for the past century, U.S. life expectancy has decreased in recent years, and this trend has been more pronounced among adults who have not graduated from high school (Olshansky et al., 2012). The factors behind this trend are complex. Woolf cited the work of Case and Deaton, who have drawn attention to the problem of “deaths of despair”: death rates from drug overdoses, alcoholism, and suicides have increased significantly since the 1990s. Case and Deaton showed that this increase was concentrated among middle-aged whites, especially among Americans with less educational attainment (Case and Deaton, 2017).
Education can produce better health through multiple pathways (see Figure 2-2). For example, those who have more education have the ability to access more economic resources, such as better-paying jobs with health insurance benefits. Having those resources, in turn, allows them to live in healthier neighborhoods and avoid a range of health hazards, from
2 “Presenteeism” in this sense means the state of being present, as opposed to being present at work but not productive.
crime to air pollution. In what is called reverse causality, health can also influence educational outcomes. For example, proper management of conditions such as attention-deficit/hyperactivity disorder or asthma can improve a child’s academic success.
This education–health relationship is highly influenced by contextual factors, Woolf emphasized. Contextual factors are the conditions throughout a person’s life that can affect both education and health. These contextual factors, including both experiences and place, may often be the root cause of the correlation between education and health. For example, chronic stress and trauma are examples of contextual factors that can affect a child’s health trajectory and success in school. Research has shown that adverse childhood experiences can influence health throughout life, leading to higher risks of depression, substance abuse, and chronic diseases later in life (Felitti et al., 1998). Place—the conditions in communities where people live—can also shape both health outcomes and educational outcomes. For example, life expectancy in Chicago varies as much as 20 years by census tract, with much lower life expectancies in Southside Chicago and similar areas. Maps reveal that the areas that tend to have lower life expectancy are also areas where educational attainment is the lowest.
In closing, Woolf noted that many efforts are under way to draw a connection between the community and a child’s experience in school.
As examples, he mentioned the Whole School, Whole Community, Whole Child model3 that the Centers for Disease Control and Prevention developed and the Together for Healthy and Successful Schools Initiative being undertaken by Washington University in St. Louis.4
Strength and Appreciation of the Data
Moderator Sharfstein asked about the extent to which the data on the importance of education for health are appreciated by health care leaders. Woolf responded that there has historically been a lack of awareness in the health care community about the importance of the social determinants of health. In recent years, however, health care systems have become more attentive to these issues, driven in part by health care reform. The Patient Protection and Affordable Care Act and other health reforms that
mandate efforts to improve population health outcomes and lower the use of health care services have emphasized the importance of addressing the social determinants of health. Although health care systems have been focusing on addressing factors such as unstable housing and food security, there is increasing interest in investing in education, including not only education for children but also skills training for adults to compete for better jobs.
The issue of correlation versus causation was raised by a participant relative to the data on the association between education and health. Woolf acknowledged the problem, noting that more prospective studies are needed to demonstrate that improvements in education will improve health outcomes. “Just giving out diplomas doesn’t save lives,” he said. That said, although arguments could be made about the magnitude of the impact, the concept that improving education will improve health outcomes has been well established by numerous examples worldwide. Woolf referred to a National Research Council (NRC) and Institute of Medicine (IOM) study comparing the health of Americans to that of people in other high-income countries (NRC and IOM, 2013). The NRC and IOM committee found that life expectancy and other health outcomes in the United States were inferior to those in other high-income countries, across many different health metrics. A systematic examination of potential causes revealed differences compared to other countries across all five domains that shape health. Among these, education was a key factor: after World War II, Americans were the most educated people in the world, he said, but educational outcomes in the United States have not kept pace with progress in other high-income countries or even in some developing economies, such as South Korea. These countries have outperformed the United States in terms of their ability to educate young people and prepare them for successful careers.
Another key difference is that many other high-income countries invest more (per capita or as a proportion of their total spending) in social services, education, and other factors that improve health. From a policy perspective, Woolf said, the United States needs to shift its priorities as a way not only to improve health outcomes but also to strengthen its economic competitiveness with these other countries. If the U.S. workforce is less healthy than workers in other countries, the nation’s ability to challenge the economic performance of other countries is at risk if those kinds of investments are not made, he said.
Education and Health Inequities
Health inequities are a key health challenge in the United States, Sharfstein noted. He asked about the impact of educational challenges in
producing serious health inequities by race, location, or other key factors. The five domains that shape health outcomes also drive health inequities, Woolf responded. There are other factors that influence health inequities (e.g., the biological effects of experiencing racial discrimination and trauma), but racial and ethnic disparities in health are often mirrored by dramatic differences in educational outcomes, he said. For a variety of reasons (including racism), African Americans have, on average, a lower rate of graduation from high school and less success in obtaining 4-year degrees than white Americans. In marginalized communities, escaping the multigenerational cycle of poverty often depends on the ability of young people to get a good education. Woolf reiterated that education is important in shaping not only health outcomes but economic opportunity and social mobility. Investments are needed to address the gaps in education that often exist to a greater degree in marginalized populations, both to improve health outcomes and to end the negative economic cycle that has historically trapped these communities in a state of persistent disadvantage.
Sanne Magnan of the HealthPartners Research Institute asked whether young people are still being encouraged to pursue higher education the way they were after World War II and whether, given the expense of a college education, there should be more investment in craft, trade, and vocational education. Woolf agreed that a strong interest in higher education was evident after World War II, as exemplified by the GI Bill. He felt that although today’s world places a fair amount of pressure on high school students to perform well and try to get into the best schools, there are barriers to accessing a college education that prior generations did not face. He agreed that a 4-year degree was not the only way to break the cycle of poverty, adding that there is a great market demand for people who are trained in the trades and an underinvestment in vocational schools and community colleges.
Sally Kraft from Dartmouth-Hitchcock inquired about the existence of any research on whether innovative ways of delivering education at lower cost (e.g., open online courses) have the same impact on increasing educational attainment and the associated health and income outcomes. Woolf replied that although the question was a good one, he was not familiar with research on that topic.