The late 20th century brought landmark public health movements to the United States, like the control of tobacco, and medical breakthroughs in the treatment of heart disease and cancer. Life expectancy surged overall, but today the lower educated are still stuck in a different era.
From a new paper in Health Affairs (behind a paywall): “We found that in 2008 US adult men and women with fewer than twelve years of education had life expectancies not much better than those of all adults in the 1950s and 1960s. When race and education are combined, the disparity is even more striking.”
Here’s a graphic showing the breakdown of life expectancy at birth just for white females. Notice three things. First, the current gap between most and least educated women is more than 10 years. Second, the gap actually widened by several years between 1990 and 2008. Third, the gap widened mainly because of a reduction in life expectancy at the bottom, rather than faster gains at the top.
This is truly sobering. I previously blogged about a paper showing that health behaviors do not explain the growing mortality gradient between less and more-educated Americans, but I did not put the scale of the problem in context.
These powerful educational differences are the primary driver of growing disparities between whites and African Americans. Because a similar gradient exists among African Americans, and the college graduation rate is so much lower among African Americans, they are falling behind white Americans.
How does education confer positive health benefits? The authors consider at least two compatible theories:
“Education exerts its direct beneficial effects on health through the adoption of healthier lifestyles, better ability to cope with stress, and more effective management of chronic diseases. However, the indirect effects of education through access to more privileged social position, better-paying jobs, and higher income are also profound. The absence of education and its related socioeconomic status benefits exert their direct harmful effects throughout the relatively shorter lives of those in less fortunate social positions (especially whites). This is one important reason why efforts to modify behavioral risk factors alone are not likely to have a major impact on disparities in longevity.”
Perhaps. But before we give up on the idea that modifying behavioral risk factors will not make a significant dent in mortality, we need to get a better handle on how much we can improve life expectancy by chipping away at the main exposures that afflict the lower educated groups. With smoking, it was a comprehensive campaign to change the image of smoking and increase education about the risks of tobacco use. With obesity and the diseases of sedentary lifestyle, we are still in the phase of developing interventions and changing the messaging around unhealthy eating. Some behavioral interventions will work, many will not, but it remains to be seen how much reduction in mortality can come from pairing more dietary education with a fundamentally different food delivery system.
The authors also single out increasing educational attainment, which happened steadily through the 1990s, especially for African Americans. That goal is now more imperiled than ever before due to cuts to funding for higher education and tight state budgets. Evidence like this study – showing that educational attainment is a driver of life expectancy needs to be injected more forcefully into conversations about cutting educational spending. For reasons that we are still trying to piece together, more school means that people live longer and healthier.