Key Sources

Question 1

Jensen and Miller, 2007

Answer 1

Socioeconomic determinants of health inequalities within countries:
o Food culture

Giffen behavior = a situation in which consumers respond to an increase in the price of a good by demanding more of it

Subsidizing the prices of dietary staples for extremely poor households in two provinces of China, found strong evidence of Giffen behavior for rice in Hunan, and weaker evidence for wheat in Gansu

The data provide new insight into the consumption behavior of the poor, who act as though maximizing utility subject to subsistence concerns, with both demand and calorie elasticities depending significantly, and non-linearly, on the severity of their poverty

Understanding this heterogeneity is important for the effective design of welfare programs for the poor

Question 2

Inequalities in Health: Report of a Research Working Group (1980) (‘Black report’)

Answer 2

The working group on inequalities in health, chaired by Sir Douglas Black, had been commissioned in 1977 by the Labour government to investigate the variation in health outcomes across social classes and consider the causes and policy implications

1. Artefact – argument that way in which data was being measured over time had changed (REJECTED as an explanation for health inequalities)
2. Genetics – people in poorer sociological conditions more likely to marry others in poorer sociological conditions (REJECTED)
3. Social selection – those with health conditions may end up in lower paying jobs (not found to be a main driver of socioeconomic health inequalities)
4. Healthcare – access (plausible?)
5. Behavior – diet, etc. (plausible?)
6. Material deprivation – experience of being poor (found to be primary driver of health inequalities)

The report found inequalities in access to health services, particularly preventative services, with low rates of uptake by the working classes

The group’s recommendations focused on increased government intervention and spending in community health and primary care, but also on broader social policy such as increasing child benefit, improving housing and agreeing minimum working conditions with unions

Question 3

Michael Marmot, 2004

Answer 3

‘Health and longevity are intimately related to [relative] position in the social hierarchy’

Relative position in the social hierarchy, rather than absolute wealth, is what matters in determining health inequalities

Question 4

Captain John Graunt

Answer 4

Started publishing causes of death in London in the 15th century

Used socio-epidemiological tools to demonstrate that people die of different things, and at differing rates

Question 5

‘Lives on the Line’

Answer 5

Shows life expectancies in London by tube station—health inequalities evident even within a city

Question 6

Grossman, 1972

Answer 6

Suggests that education may result in increased productivity in activities associated with the ‘production of health,’ raising the benefits of health inputs such as doctor visits and therefore making an individual more efficient in producing health

Question 7

Cutler and Lleras-Muney, 2010; Rosenzweig and Schulz, 1981

Answer 7

Propose that education serves to affect health-relevant behaviors such as drinking, smoking, dietary choices, and adherence to safety precautions, perhaps by directly teaching what is healthy, or by producing educated people who are better able to both obtain and critically evaluate health information, as is suggested by Kenkel, 1991, Nayga, 2000, and de Walque, 2007

Question 8

Kenkel, 1991; Nayga, 2000; de Walque, 2007

Answer 8

Suggest that education affects health-relevant behaviors by producing educated people who are better able to both obtain and critically evaluate health information

Question 9

Lochner, 2012; Oreopoulos and Salvanes, 2011

Answer 9

Postulate other channels through which education can affect health outcomes, such as by raising income and therefore facilitating the purchase of healthier foods, as well as residence in healthier environments and acquisition of better health insurance
o Oreopoulos and Salvanes also argue that schooling improves trust and social interaction

Question 10

Becker and Mulligan, 1997; Fuchs, 1982

Answer 10

Hypothesize that education might improve health and health behaviors by positively affecting certain psychological predispositions, such as sense of control and time preferences

Question 11

Gathmann, Jürges, and Reinhold, 2015: overview

Answer 11

In an effort to establish the existence of a causal relationship between education and health, as well as to reconcile the divergent results found in much of the previous literature, Gathmann, Jürges, and Reinhold (2015) conduct a multi-country analysis, examining 18 compulsory schooling reforms implemented in European countries over the course of the twentieth century to estimate the average effect of compulsory schooling on mortality

In doing so, they compare various time periods and countries using harmonized data, rather than relying upon the different data sources and mortality measures frequently utilized by preceding studies

This analysis illuminates whether compulsory schooling reforms have a comparable effect on mortality rates across a range of diverse settings and countries, ultimately granting a better understanding of whether the treatment effects of these reforms are systematically associated with the characteristics of a given country

Question 12

Gathmann, Jürges, and Reinhold: conclusions (1)

Answer 12

The first key takeaway from the multi-country analysis described in the paper is that, throughout the 20th century, compulsory education reforms carried a stronger effect on health among men than women, with the authors finding that, on average, a lengthening of compulsory schooling resulted in small reductions in mortality among men, but finding no significant reductions in mortality for women

Though the risk of dying between the ages of 18 and 38—the 20-year mortality rate—is reduced by 2.9% for men, with similar effects found for 30- to 50-year mortality, women’s mortality is not affected by the schooling reforms at any age

Various explanatory mechanisms for these asymmetrical effects are explored:
o The authors ultimately find that the disparities CANNOT be attributed to gendered differences in compliance with the new schooling laws, since, on average, the reforms have increased years in school by roughly the same amount for both genders: 0.501 for men and 0.541 for women
o Moreover, they find NO SUBSTANTIATION for the plausible explanation that the health benefits of compulsory schooling are realized through labor market participation, such as via higher earnings or higher occupational status, the idea being that lower rates of female participation in the labor market may account for the negligible effects of (especially earlier) reforms on female mortality
o Though the authors do not possess the data necessary to test this theorized relationship empirically, they suggest that the differential effect could potentially be the consequence of gender-specific occupational choices, with men traditionally overrepresented in blue-collar jobs, and therefore exposed in greater numbers to occupational health hazards (through greater educational attainment, a proportion of these men may have been able to acquire less dangerous white-collar jobs)

Question 13

Gathmann, Jürges, and Reinhold: conclusions (2)

Answer 13

The second key finding of the study is that early twentieth century reforms are altogether more effective in reducing mortality than later reforms

The authors write, “Across alternative specifications, the effects on male mortality are larger if the education reform is implemented prior to 1930. On average, these reforms reduce male mortality between the ages 18 and 38 by 6.4%. In contrast, reforms implemented after 1970 reduce male mortality between the ages 18 and 38 by just 1.2%”

One proposed explanation for this pattern is that the earlier reforms increase the average school leaving age by more years than the later reforms:
o The authors do find that mortality reductions (indicated by an odds ratio smaller than one) are positively correlated with the effect of a given compulsory schooling reform on educational attainment, although THIS CORRELATION EXISTS TO A MUCH LESSER EXTENT FOR WOMEN

The authors recognize the possibility that reductions in mortality could be greater for the early reforms because compulsory schooling proves particularly effective when baseline educational attainment is low:
o However, they ultimately DISMISS THIS HYPOTHESIS, finding that the relationship between the minimum schooling requirements in place immediately before a reform and the estimate of the reform effects on mortality is very weak for men, and essentially nonexistent for women

The paper further postulates that if average income levels are low and/or poverty rates are high, additional compulsory education might beget higher income, and therefore potentially facilitate more health-improving investments:
o Using data on GDP per capita in the years around the reform as a proxy for average income, the authors find that reductions in mortality among men are slightly larger in countries with lower GDP per capita, but THERE IS NO EQUIVALENT RELATIONSHIP FOR WOMEN
o These results are in keeping with evidence from a Swedish compulsory schooling reform study that demonstrated stronger mortality reductions for men who came from more disadvantaged socioeconomic backgrounds (Meghir et al., 2012)

Question 14

Gathmann, Jürges, and Reinhold, 2015: in sum

Answer 14

The evidence collected by the authors “strongly suggests that conflicting results reported in the previous literature [on the causal effects of formal education on health outcomes] are not a coincidence but rather a systematic feature of different reform settings”

Question 15

Sen

Answer 15

Theories about the origins of health inequalities:
Capabilities
o Not necessarily interested in the set of outcomes people experience, but rather in their possibilities or capabilities
- Retaining the sense of individuality/preferences
o Things like status matter—an individual’s capacities/capabilities are shaped by how society views them
o What it means to have a ‘good life’ is contingent upon the country/society in which an individual is embedded

Question 16

Piketty

Answer 16

Income inequality and health: mechanisms
o Share of growth: In countries with larger income inequality, the wealthier receive a greater share of economic growth than the poor

Question 17

Kimberlé Williams Crenshaw

Answer 17

Intersectionality:
o Multiplicity
o E.g., position of black women within an institutional setting diminished on two accounts – black, women
o Institutional context important here

Question 18

Thomas Shapiro, “Toxic Inequality”

Answer 18

Discrimination and health: Poverty
o Structural racism –> dispossession, economic exclusion –> poverty
o Inherited/accumulated wealth
- Intergenerational inequality

Question 19

Matthew, Rodrigue, and Reeves, 2016; Reeves and Matthew, 2016

Answer 19

Black babies remain more than twice as likely as their white counterparts to die within the first year of life, even when adjusting for maternal education and income level; in fact, as reported by the Centers for Disease Control and Prevention, a black woman in the United States with an advanced/professional degree faces a higher probability of losing her infant than does a white woman who possesses an eighth-grade education or less

Question 20

Creanga et al., 2017

Answer 20

Maternal mortality also disproportionately affects black women, perhaps to an even greater extent than infant mortality—between the years 2011 and 2013, pregnancy-related mortality ratios for non-Hispanic black women in the U.S. exceeded those of non-Hispanic white women by a factor of 3.4, with similar trends evident in the period 2006-2010

Question 21

David and Collins, 2007

Answer 21

Representative of the consensus forged by the field at large in recent years, David and Collins conclude that “[o]verall patterns of racial disparities in mortality and secular changes in rates of prematurity as well as birth-weight patterns in infants of African immigrant populations contradict the genetic theory of race and point toward social mechanisms”

Perhaps the rival explanation most commonly offered for the disproportionately high rates of infant and maternal mortality witnessed among African Americans invokes alleged differences in genetic predispositions to various health-related conditions, with one’s race effectively treated as “a proxy for geographic ancestry and genetics”

Should we proceed under the assumption that genes and ancestry are primarily responsible for disparities in birth outcomes, then would we expect birthweight patterns of African immigrants to the United States to be comparable to those of native-born black Americans—this is not the case:
o Comparing the birth-weights of US-born white women, US-born black women, and African-born black women over a period of 15 years, David and Collins (2007) find that “[t]he overall birth-weight distributions for infants of US-born White women and African-born women were almost identical, with US-born Black women’s infants comprising a distinctly different population, weighing hundreds of grams less”
o Thus, David determined “there was something about growing up black in the United States and then bearing a child that was associated with lower birth weight” (as cited in Chatterjee and Davis, 2017, para. 24)

Question 22

Levy and Sidel, 2006

Answer 22

Social injustice = “the denial or violation of economic, sociocultural, political, civil, or human rights of specific populations or groups in the society based on the perception of their inferiority by those with more power or influence”
o Insofar as public health is concerned, Levy and Sidel define inequity—injustice—as occurring in the presence of “systematic disparities in health (or in the major social determinants of health) between social groups that have different levels of underlying social advantage or disadvantage—that is, different positions in a social hierarchy”

If genetic composition did in fact prove to be the driving force behind racial variations in infant and maternal outcomes, then any claim of social injustice would become much more tenuous, since no “denial or violation of economic, sociocultural, political, civil, or human rights” would be occurring, and there would arguably exist no “systematic disparities in health…between social groups”, at least insofar as we understand ‘systematic’ to refer to the operations of social institutions

Question 23

Collins and David, 1990

Answer 23

The last decade of the twentieth century saw the publication of studies that challenged or directly contradicted the risk factors traditionally thought responsible for the worsened neonatal outcomes of black babies relative to their white counterparts; namely, poverty and lack of education
o Researchers found that even middle-class, educated black women carried a higher relative risk of giving birth to smaller, premature babies who were less likely to survive, a finding which served to cast significant doubt upon the commonly accepted theory that greater risk of poverty, combined with reduced likelihood of having completed education before bearing children, can account for much of the considerably higher rates of mortality among infants born to black women

Question 24

Collins et al., 2004; Mustillo et al., 2004

Answer 24

The last decade of the twentieth century saw the publication of studies that challenged or directly contradicted the risk factors traditionally thought responsible for the worsened neonatal outcomes of black babies relative to their white counterparts; namely, poverty and lack of education
o Continued research into the potential causes of the relatively poor pregnancy outcomes experienced by this group eventually gave rise to a new dominant narrative—that cumulative exposure to racism and racial discrimination throughout the course of a black woman’s lifetime represents an independent risk factor for preterm delivery and low birthweight, which in turn increases the probability of infant mortality by a large margin

Question 25

Geronimus et al., 2010

Answer 25

Research suggests that stress-induced “weathering” may actually cause accelerated aging in black women at the molecular level, which, given that maternal age serves as a significant risk factor for a variety of potentially fatal complications associated with pregnancy (e.g., pre-eclampsia and gestational hypertension), means black women likely experience the physical toll of high-risk pregnancies at an earlier age than do white women

Question 26

Howell et al., 2015

Answer 26

Systemic racism also pervades the physical environments in which black women are likely to give birth, with the enduring realities of past segregation policies still evident in the poor maternal mortality outcomes of high black-serving hospitals

Question 27

Woods, 2009

Answer 27

Structural adjustment programs were initiated to ensure LMICs could repay their loans:
o	Liberalization (trade + tariffs)
o	Deregulation (making markets more ‘business friendly’)
o	Privatization (resources + sectors)
o	Stabilization (fiscal and monetary policy to ensure debts could be repaid, keep inflation low)

Question 28

Kentikelenis, 2017

Answer 28

From structural adjustment programmes to health consequences: causal pathways

Health (‘direct effects’ pathway)
o Cuts to spending
- Typically, reductions in staff, treatment/services
o Workforce
- Fear that public sector wage freezes may encourage doctors to leave lower-income countries for high-income countries

Health (‘indirect effects’ pathway)
o Mediated by macroeconomic and institutional reforms
o International financial institutions frequently encourage currency devaluation as one piece of their broader stabilization policies, increasing import prices, and therefore limiting the accessibility of medicines and equipment entering a country (Breman and Shelton, 2006)
o If tariffs and customs are removed as part of a trade liberalization strategy, then trade tax revenues will, at least temporarily, reduce accordingly, further jeopardizing the money available to fund healthcare expenditures (Baunsgaard and Keen, 2010)
o Privatization
- Prioritizes profit

Can affect social determinants of health (see: Wilkinson and Marmot, 2003)
o ‘Social determinants of health’ = macro-level factors
o Deregulation –> environmental effects
- Deregulation of industry—a component of structural adjustment programmes meant to increase the extent to which countries are ‘friendly’ to business—can induce negative environmental externalities, which carry plausible implications for the health of a population, especially insofar as one considers issues such as water cleanliness and general sanitation (Shandra et al., 2008, 2011)
o Tariffs (–> indirect taxes)
o Introduction of ‘user fees’ for various goods/services (e.g., fewer children seem to utilize early childhood education services)

Question 29

Breman and Shelton, 2006

Answer 29

Health (‘indirect effects’ pathway)
o International financial institutions frequently encourage currency devaluation as one piece of their broader stabilization policies, increasing import prices, and therefore limiting the accessibility of medicines and equipment entering a country

Question 30

Baunsgaard and Keen, 2010

Answer 30

Health (‘indirect effects’ pathway)
o If tariffs and customs are removed as part of a trade liberalization strategy, then trade tax revenues will, at least temporarily, reduce accordingly, further jeopardizing the money available to fund healthcare expenditures

Question 31

Wilkinson and Marmot, 2003

Answer 31

‘Social determinants of health’ = macro-level factors

“The causes of the causes—the social conditions that give rise to high risk of non-communicable disease” (Marmot, 2005):

1. The social gradient
2. Stress
3. Early life
4. Social exclusion
5. Work
6. Unemployment
7. Social support
8. Addiction
9. Food
10. Transport

Question 32

Shandra et al., 2008, 2011

Answer 32

Structural adjustment programmes can affect social determinants of health
o ‘Social determinants of health’ = macro-level factors
o Deregulation –> environmental effects
- Deregulation of industry—a component of structural adjustment programs meant to increase the extent to which countries are ‘friendly’ to business—can induce negative environmental externalities, which carry plausible implications for the health of a population, especially insofar as one considers issues such as water cleanliness and general sanitation

Question 33

Holland, 1986

Answer 33

Addresses the issue of the counterfactual in what he terms the Fundamental Problem of Causal Inference, which states that “[i]t is impossible to observe the value of Yt(u) [treatment] and Yc(u) [control] on the same unit and, therefore, it is impossible to observe the effect of t on u”

Question 34

Robert Anderson (chief of mortality statistics with the National Center for Health Statistics)

Answer 34

The US has lower life expectancy than other high-income countries
o “[Robert] Anderson [chief of mortality statistics with the National Center for Health Statistics] said the latest data suggest this mortality trend is heavily influenced by the ongoing drug epidemic and a rising rate of suicides nationwide”

Question 35

House et al., 2010

Answer 35

‘The Health Effects of Social and Economic Policy: The Promise and Challenge for Research and Policy’

o “…despite the marked growth in spending over the past fifty years, the U.S. has fallen from being amongst the top in life expectancy and infant mortality to ranking at or near the bottom among developed nations. Of the thirty nations in the OECD, only Mexico, Turkey, and three former Soviet bloc countries consistently rank below the U.S. on such indicators”

o “Most political and policy analysis related to health in the United States focuses on medical-care and insurance. Little attention is paid to levels of population health beyond the worry that spending constraints may adversely affect it. The concentration of policy discussion on medical services however, ignores historical facts about the causes of major changes in the overall health of populations”

o “The idea that a country could achieve better population health without explicitly increasing health care spending may seem paradoxical, but only if we assume that health care is the major determinant of health. As dramatic and consequential as medical care is for individual cases, much evidence suggests that such care is not, and probably never has been, the major determinant of overall levels of population health”

o “RATHER, economic, social, psychological, behavioral and environmental factors are more likely the major determinants of population health”

o “The exact nonmedical factors responsible for the great historical rise in life expectancy [between the mid-eighteenth and mid-nineteenth centuries, and accelerating in the first half of the twentieth century] are impossible to identify retrospectively, but general socioeconomic development—most notably improvements in nutrition, sanitation, housing and clothing, and general conditions of life, certainly played a central role”

o “It is increasingly hard to justify not considering potential health impacts of policy change given the range and size of potential health outcomes that flow from all policy, including policies that are seemingly unrelated to health”

o “Non-health related policies may have positive consequences for health that are equally or more important than the outcomes they were originally designed to produce. Thus, health effects can be central factors in decisions concerning changes in policy seemingly unrelated to health”

o “Health research and policy in the United States should shift towards models recently adopted in Canada, Sweden and the broader European Union that consider and evaluate the health impact of all policy, not just health policy”

o “Social and economic policy can present alternatives to increased health care spending for maintaining and improving health. By considering the health impacts of public and private policies not directly related to health care as mechanisms for promoting health and preventing or alleviating disease, the cost-effectiveness of non-health policies can also be greatly enhanced”

o “Six key policy areas with potentially sizable effects on health are addressed [in ‘Making Americans Healthier: Social and Economic Policy as Health Policy’]: education policy, income-support policy, civil-rights policy, macroeconomic and employment policy, welfare policy, and housing and neighborhood policy”

Question 36

Cutler, Rosen, and Vijan, 2006

Answer 36

Data suggests a low to near-zero correlation between health care expenditures and levels of population health across wealthier OECD nations, and shows declining rates of return to health from growing health care expenditures over time in the United States

Question 37

Bunker, Frazier, and Mosteller, 1994

Answer 37

Estimated that only about five years of the almost thirty-year increase in United States life expectancy over the twentieth century were due to preventive or therapeutic medical practice

Question 38

Kannel, 1971; Aronowitz, 1998

Answer 38

The rise of chronic diseases produced a major shift in the epidemiologic conception of and search for their causes—a shift from identifying a single necessary, proximate causal agent to identifying multiple contingent causal forces or risk factors
o None of these risk factors are necessary to produce disease, but each interacts with others, increasing the likelihood of developing major chronic diseases and the pathogenic physiology underlying them

Question 39

Cannon, 1932; Selye, 1956

Answer 39

Showed that perturbations in the relation between organisms and their psychosocial, as well as their physical, chemical, and biological environments led to physiological symptoms in the form of, for example, heightened heart rate or blood pressure
o These are perhaps best known collectively under Selye’s rubric of stress

These symptoms in turn could lead to physical disease and even death

Question 40

Taylor, Repetti, and Seeman, 1997

Answer 40

Showed how a broad range of socioeconomic and psychosocial factors could “get under the skin” and produce physical illness

Question 41

Marmot, Kogevinas, and Elston, 1987; Pappas et al., 1993; Wilkinson, 1996; Kaplan and Lynch, 1997; House and Williams, 2000

Answer 41

Perhaps the most striking and important development in social epidemiology over the last quarter century has been the discovery (or rediscovery) of large, persistent and even increasing disparities in health by socioeconomic status and race-ethnicity

Question 42

Marmot, Bobak, and Smith, 1995; Lynch et al., 1996; House and Williams, 2000

Answer 42

Socioeconomic position shapes people’s experience of, and exposure to, almost all risk factors for poor health

Question 43

‘Downstream’ approach to researching determinants of health

Answer 43

Current research on the psychosocial, biomedical, and environmental determinants of health has moved in two directions:
1) The more common approach might be referred to as ‘downstream,’ that is, seeking to understand the mechanisms through which psychosocial risk factors affect health. This approach tends to lead to a biomedical approach to mitigating the health impact of social or economic risk factors—for example, finding a pharmacological treatment for stress

Question 44

‘Upstream’ approach to researching determinants of health

Answer 44

Current research on the psychosocial, biomedical, and environmental determinants of health has moved in two directions:
2) An ‘upstream’ approach seeks to understand the broader aspects of social life that shape exposure to such psychosocial or environmental risk factors. Many public policies strongly impact health because they strongly impact the socioeconomic, psychosocial, and/or environmental determinants of health

Question 45

Negative Income Tax and MDRC welfare-reform evaluations

Answer 45

Though some well known—and highly regarded—social experiments have been conducted, they have typically been implemented with a focus on specific outcomes relative to the income maintenance and/or welfare-reform debate

Question 46

Irwin and Scali, 2005

Answer 46

We now routinely evaluate the environmental impact of programs and policies not explicitly environmental in nature

Question 47

Raphael and Bryant, 2006; Navarro, 2007

Answer 47

Models recently advocated and adopted in Canada, Sweden and the broader European Union consistently consider evaluating the impact of all policy—not just health policy—on health outcomes

Question 48

WHO definition of health inequalities

Answer 48

“Health inequalities are differences in health status or in the distribution of health resources between different population groups, arising from the social conditions in which people born, grow, live, work, and age”

Question 49

From education to health: Family formation (Chicoine, 2012)

Answer 49

Investigates the relationship between women’s education and fertility in the Kenyan context, finding that a policy change lengthening primary school by one year led to an increase in education, a delay in marriage, and reduced fertility beginning at the age of 20

Question 50

From education to health: Race as confounder (Olshansky et al., 2012)

Answer 50

Other factors can drive the relationship between education and health:
o Race → Education → Health
- E.g.: African-Americans with the highest levels of educational attainment (16+ years) have worse health than other racial groups with the same level of education (Olshansky et al., 2012)

Question 51

From education to health: Family background/genetics as confounder (Lundborg et al. 2016)

Answer 51

Other factors can drive the relationship between education and health:
o Family background/genetics → Education → Health
- E.g.: Twin studies have provided some evidence that differences in education have no impact on health (Lundborg et al., 2016)

Question 52

Cutler et al., 2011

Answer 52

Health behaviors are not fully explained by differences in education and health

Question 53

Avendano and Kawachi, 2014

Answer 53

The United States has poorer health and shorter life expectancy than do other high-income countries

The US health disadvantage begins at birth, extends across the life course, and is more pervasive for Americans living in the US South and Midwest

Differences in health care, individual behavior, socioeconomic inequalities, and the physical environment are all likely to contribute to the explanation, yet they offer only a partial account of the pervasiveness of the US health disadvantage across the life course and for many different outcomes

Avendano and Kawachi hypothesize that much of the US health disadvantage is due to variations in nonmedical determinants of health, some of which result from dramatic differences in public policies across the United States and other OECD countries

Ample evidence indicates that social policies and programs affecting Americans across the entire life course are less comprehensive in the United States than in other OECD countries
o This includes policies affecting outcomes in early childhood (through less-comprehensive early education and child care programs), at early adulthood and middle age (through more unequal access to high-quality education and less-comprehensive employment-protection and support programs), and at older ages (through less-comprehensive housing and income-transfer programs affecting older individuals)

Although the impact of many of these policies on social outcomes is well documented, the extent to which they influence health and contribute to differences in longevity among high-income countries is yet to be established

Disentangling the role of public policies is crucial to unravel why the most prosperous economy in the second half of the twentieth century continues to lag behind other high-income countries in life expectancy

Question 54

Avendano et al., 2009

Answer 54

Suggest that, in addition to poor life expectancy (compared to other industrialized nations), Americans also experience higher rates of disease, injury and health-damaging behaviors than men and women in other high-income countries

Older Americans report a higher prevalence of heart disease, stroke, hypertension, diabetes, obesity, lung disease and limitations with basic instrumental activities of daily living (IADL) than their European counterparts at ages 50 and above. Similar patterns have been reported for ages 50–74

Income support programmes in Europe are far more comprehensive than those in the US, which may contribute to the poorer health of Americans

Question 55

Ho, 2013

Answer 55

The fact that mortality at relatively young ages accounts for much of the US life expectancy disadvantage was highlighted in a recent analysis examining mortality under age 50 across countries

Results from this study indicate that mortality differences below age 50 account for two thirds of the gap in life expectancy at birth between men in the US and an average of 17 other OECD countries, and 40% of this difference among women. These findings underscore the point that the US life expectancy disadvantage originates at early age and extends across the life-course

Recent evidence indicates that the major causes of death contributing to years of life lost below age 50 between the US and an average of 17 other OECD countries among women were non-communicable diseases, perinatal conditions, transport injuries and non-transport injuries

Among men, homicide mortality was the largest contributor, followed by transport injuries, non-transport injuries and perinatal conditions

Mortality rates from infectious diseases; complications of pregnancy, childbirth and the puerperium; and conditions originating in the perinatal period are higher in the US than in nearly all other OECD countries

Interestingly, the fatality rate per 100 million vehicle kilometers travelled is similar in the US and a set of other 15 high-income countries, but the annual number of kilometers driven in the US far exceeds that in other countries
o IN OTHER WORDS, Americans die more from car crashes because they drive more

Question 56

Krug et al., 1998

Answer 56

Homicide mortality has consistently been higher in the US for several decades, which is consistent with prior evidence of substantially higher US rates of fire-arm related deaths

Question 57

National Research Council and Institute of Medicine, 2013

Answer 57

A recent review shows that Americans have also higher prevalence of preterm births and poor maternal health; adolescent pregnancy and sexually transmitted infections; and overweight, obesity and diabetes during childhood and mid-age

The built physical environment in most of the US provides limited opportunities for physical activity with few alternatives other than driving. The reliance of Americans on automobiles as their primary mode of transport is well documented

Question 58

Banks, Marmot et al., 2006

Answer 58

Differences between the US and Europe are also evident for biologically assessed outcomes such as blood pressure, blood cholesterol, fasting glucose levels and C-reactive protein

Both insured and uninsured Americans experience poorer health than their European counterparts, suggesting that health insurance might not be the only/main explanation for the US health disadvantage

While it is true that poor and black Americans are at increased health disadvantage, studies suggest that also white, middle class Americans have poorer health than their European counterparts
o	For example, a widely cited cross-national comparison of the health of American and English people found that Americans in the top third of the income distribution (97% of whom already have access to health insurance) had rates of hypertension and diabetes comparable to those in the bottom third of income earners in England. The comparison was all the more striking because it was restricted to whites in both countries

Nevertheless, the largest share of the American health disadvantage is likely to be borne by the poor and least educated, who have much higher rates of disease and death than their counterparts in Europe

Question 59

Wilmoth et al., 2010

Answer 59

Earlier reports indicate that even in the healthiest US regions, female life expectancy lags behind that in the least healthy regions of countries such as Japan and France

Among men, most divisions in the south and Midwest perform poorly compared to most other OECD countries, while the Pacific and New England divisions have relatively low mortality. Both men and women in the East South Central US divisions have the highest rates

Question 60

Avendano and Kawachi, 2014: Proposed explanations for the US health disadvantage

Answer 60

BROAD MECHANISM
o SPECIFIC FACTORS

Medical care and public health
o Access to health care insurance

Individual behaviors
o	Tobacco use
o	Obesity
o	Diet
o	Physical inactivity
o	Alcohol and other substance use
o	Sexual practices
o	Violence (especially firearm suicide and homicide)
o	Automobile reliance

Social/demographic factors
o Socioeconomic inequality and poverty

Physical environmental factors
o Racial disparities and residential segregation
o Social integration and social interactions
o Built environment (urban design, transport infrastructure, land use mix, urban planning and design)
o Food environment

Question 61

OECD Health Data, 2013

Answer 61

The US spends more on healthcare than any other OECD country

Data suggest that the US has one of the highest total caloric intake and the highest sugar intake among all OECD countries

The US also ranks high in total fat intake and total protein intake, while vegetable and fruit consumption in the US is similar to that in several other OECD countries

Question 62

Bezruchka, 2012

Answer 62

Medical care is often proposed as an explanation for the US health disadvantage

Question 63

Harris et al., 2002

Answer 63

Overall, health care provides at best a partial explanation for the US health disadvantage
o For example, excess deaths from violent causes (homicides, suicides, accidents) are hardly due to lack of health care; indeed, if it were not for advances in emergency medical care, it is estimated that thousands of more homicides would be recorded in the United States each year

Question 64

Coleman et al., 2008

Answer 64

US survival rates for several chronic conditions contributing to the US health disadvantage, such as heart disease, ischemic stroke and cancer, might be better in the US than in other high-income countries, suggesting that care for these conditions might not be worse in the US than in other OECD countries

Question 65

Macinko, Starfield and Shi, 2003

Answer 65

Linked the weaker primary health care system in the US to higher premature mortality

Question 66

National Academy of Science Panel, 2010, 2011

Answer 66

A recent report released by the National Academy of Sciences (NAS) concluded that smoking was likely the most important factor explaining the lag in US life expectancy at older age, particularly among women

While the US enjoys currently lower smoking prevalence than most other high-income countries, the smoking epidemic started earlier and reached a higher pick in the US than in other countries, particularly among women

Due to the long lag between smoking and lung cancer, current mortality reflects smoking trends two to three decades earlier. A recent study concluded that smoking explained two fifths of the difference in male life expectancy between the US and other high-income countries, and over three quarters of the difference in female life expectancy

Question 67

Hallal, 2012; Steptoe and Wikman, 2010

Answer 67

A poor diet, in combination with relatively low levels of physical activity, may explain the high US obesity rates

Question 68

Avendano and Glymour, 2008

Answer 68

Cohort studies suggest that even after adjusting for obesity and other risk factors, differences in morbidity across countries remain

Question 69

Ezzati et al., 2008

Answer 69

The US is characterized by pronounced racial, ethnic and socioeconomic disparities in health, which may contribute to the overall US health disadvantage
o For example, although life expectancy for the United States as a whole improved during the past three decades, life expectancy was stagnant or declining between 1983–1999 for women in 963 out of 2,068 counties, and 59 counties for men

Question 70

Williams and Collins, 2001

Answer 70

Argue that the persistent residential segregation of African Americans shapes their educational opportunities and labor market success, and contributes to their unequal exposures to environmental pollutants, violence, and other health threats

Question 71

Singh and Kogan, 2007

Answer 71

The role of socioeconomic status may be particularly salient for mortality under age 50
o For example, US mortality from homicide is nine times higher among young men in the bottom decile of socioeconomic deprivation compared to young men in the affluent top decile
o Strikingly, US girls in the bottom decile are fourteen times more likely to die from HIV/AIDS than their counterparts in the top affluent decile
o Similar differences by socioeconomic deprivation exist in childhood mortality

Question 72

Banks et al., 2010

Answer 72

A recent paper concluded that social participation and integration did not explain the US health disadvantage relative to other European countries

Question 73

French et al., 2001

Answer 73

There is an extensive literature on the relationship between the built environment and health-related behavior, but there are no systematic investigations of the contribution of the built environment to the US health disadvantage

Question 74

Avendano and Kawachi, 2014: Public policies that may contribute to differences in health and life expectancy between the US and other high-income countries

Answer 74

PUBLIC POLICY DOMAIN
o SPECIFIC PROGRAMMES

Childcare and early childhood education policies
o Policies determining the availability, cost, and quality of childcare and early childhood education programs

Education policies
o The share of public vs. private education systems
o Compulsory schooling laws
o Spending and distribution of resources for education
o Access to higher education

Labor and employment protection policies
o	Labor laws that affect job security, work conditions, working hours, worker's benefits and work flexibility
o	Parental leave
o	Minimum wage laws
o	Trade union membership laws
o	Work incentives and worker's compensation
o	Retirement policies
o	Unemployment insurance policy
o	Active labor market programmes

Income support and family and children support policies
o Child poverty alleviation and income tax credits
o Family allowance programmes
o Child support maintenance systems
o Child-related leave

Housing policies
o Incentives for homeownership
o Access to public housing
o Policies to improve housing conditions

Income inequality
o Tax and redistribution policies

Question 75

Education at a Glance 2012, OECD

Answer 75

The typical starting age for early childhood education in the US is four years, compared to three years or younger in 21 other OECD countries

While 84% of children in the OECD attend public or Government-funded private institutions, only 55% of early childhood pupils in the US attend public schools

Question 76

OECD Family Database, 2013

Answer 76

While regulations in most of Europe require that a qualified teacher delivers a formal curriculum, this is less well regulated in the US

As a percentage of GDP, the US spends far less on childcare support for families than almost any other OECD country

Programmes to support working parents are also substantially less comprehensive in the US:
o In 2011–2012, the duration of fully-paid maternity and parental leave was 45 weeks in France, 46 weeks in Sweden, and 21 weeks in the Netherlands, compared to none in the United States

Question 77

Heymann et al., 2013; Keating and Simonton, 2008

Answer 77

Early childhood interventions appear to bring important health benefits, especially among disadvantaged children

Studies indicate that early education programmes do not only improve educational outcomes but also lead to higher immunizations and height-for-age, and reduce child mortality at ages five to nine

Question 78

OECD, 2011

Answer 78

While the US spends more on public school education than most other OECD countries, American students perform around or below the OECD average

There are moreover substantial disparities in the quality of public schooling (e.g. reflected by student-teacher ratios) across communities in the United States, which are partly driven by residential segregation and the financing of the public school system by local property taxes

Question 79

OECD Stat., 2013

Answer 79

While educational attainment is relatively high in the US, inequalities in spending may lead to substantial disinvestment among socially disadvantaged groups most at risk of poor health

Question 80

Glymour et al., 2008; Banks and Mazzonna, 2012

Answer 80

Evidence from across the US and Europe suggests that education policies such as compulsory schooling laws have had long-run effects on health and mortality

Question 81

Dynarski, 2003

Answer 81

Other policies, such as education grant aid programmes, have increased schooling completion and college attendance

Question 82

OECD Benefits and Wages: Statistics, 2012

Answer 82

The US stands out for its weaker employment protection laws (euphemistically referred to as ‘labor flexibility’) compared to other OECD countries:
o US workers face comparatively high risks of job displacement, as employers bear relatively low costs associated with collective dismissals or contract termination

In addition, social policies to protect workers who become ill or displaced, as well as maternity leave policies, are modest in the US in comparison to most European countries

Income support programmes in Europe are far more comprehensive than those in the US, which may contribute to the poorer health of Americans

Many European countries offer generous cash housing benefits for rental accommodation for families in need

Question 83

Rogerson, 2006; Brunello et al., 2008; Ho, 2013; Transportation Research Board, 2010

Answer 83

A potential hypothesis is that as a result of US labor and employment protection policies, Americans work longer hours, spend less time cooking and eating meals at home, drive more as opposed to investing time in healthy transportation alternatives, and in general spend less time in non-market activities that might be conductive of health

Question 84

Rossin, 2011; Ruhm, 2000

Answer 84

Extending weeks of job-protected paid maternity leave significantly decreases infant mortality rates and improves child health, with the large effects on post-neonatal mortality

Question 85

Chatterji and Markowitz, 2012; Ruhm, 2011

Answer 85

Longer maternity leave may also improve maternal mental health around the post-partum weeks and increase mothers’ labor market attachment, leading to lung-run benefits for mothers and children

Question 86

Coe and Zamarro, 2011

Answer 86

Statutory retirement age laws may also influence health and mortality

Question 87

Gangl, 2004; Gangl, 2006

Answer 87

Less is known about the health impact of unemployment insurance and other employment protection laws
o However, the negative effects of unemployment on workers’ subsequent earnings are mitigated through generous unemployment benefit systems or strict labor market regulation

Question 88

OECD Income distribution: Poverty, 2013

Answer 88

In 2010, 21% of children in the United States lived in poverty, compared with 11% in France, 10% in the United Kingdom, and 8% in Sweden

Question 89

OECD Tax and Benefits, 2013

Answer 89

These differences in poverty rates and educational deprivation partly reflect the fact that cash minimum-income benefits are considerably lower in the US than in most other OECD countries

There is no US Federal programme for housing assistance, with only some states delivering programmes targeted to very low income households

European countries have more progressive tax systems and are designed to protect the poor to a larger extent than the US. As a result, not only are social policy programmes more comprehensive in Europe, but income and wealth inequalities are also smaller than in the US

Question 90

Strully et al., 2010

Answer 90

Expansions of the Earned Income Tax Credit may have led to increased birth weight and reduced maternal smoking

Question 91

Almond et al., 2011

Answer 91

Pregnancies exposed to the Food Stamps program had better birth outcomes than pregnancies unexposed, particularly among African American mothers

Question 92

Herd et al., 2008

Answer 92

Income transfer programmes may also improve the health of older Americans
o For example, an increase in state maximum Supplemental Security Income benefits was shown to reduce disability among older Americans

Question 93

Alesina et al., 2001; OECD Benefits and Wages: Statistics, 2012; Avendano et al., 2009; Avendano et al., 2010

Answer 93

Comparable income support programmes in Europe are far more comprehensive than those in the US, which may contribute to the poorer health of Americans

Question 94

Banks et al., 2003

Answer 94

Compared to US adults, British adults move into homeownership at younger ages, and a larger fraction of their wealth is concentrated in housing, while American hold a larger fraction in financial assets

Policies promoting homeownership in some European countries may have contributed to these differences:
o For example, the ‘right-to-buy’ scheme, introduced in 1980, granted UK households living in government housing for a minimum duration the right to buy their home with large discounts, which may have contributed to their larger housing wealth compared to US households

Question 95

Leventhal and Dupéré, 2011; Sanbonmatsu et al., 2012

Answer 95

Results from the Moving to Opportunity (MTO) project, a randomized experiment in which families in poor neighborhoods were offered vouchers and assistance to move to ‘low poverty’ neighborhoods, showed improvements in mental health, behavior and educational achievements for young girls and adults (albeit it may have led to poorer outcomes among boys)

Question 96

Jacob et al., 2013

Answer 96

A recent study in Chicago showed similar benefits to mental health, behavior and educational achievements of a programme randomly offering housing vouchers on female child mortality

Question 97

Howden-Chapman et al., 2007; Jackson et al., 2011

Answer 97

Recent trials and policy evaluations suggest that improvements in housing conditions, such as insulation and ventilation, effectively reduce hospitalizations and improve child health outcomes

Question 98

Dalstra et al., 2006; Ellaway and Macintyre, 1998; Filakti and Fox, 1995; Laaksonen et al., 2008

Answer 98

Homeowner occupiers have better health and lower mortality than renters, although whether this is due to selection or actual health benefits of homeownership is yet unknown

Question 99

Wolff, 1996; Wolff, 1998

Answer 99

European countries have more progressive tax systems and are designed to protect the poor to a larger extent than the US. As a result, not only are social policy programmes more comprehensive in Europe, but income and wealth inequalities are also smaller than in the US

Question 100

Granados, 2013; Mackenbach, 2002

Answer 100

A potential hypothesis is that Americans have poorer health because they have larger income and wealth inequalities

HOWEVER, evidence on the causal impact of income inequality on population health across high-income countries is as yet inconclusive

Question 101

Torre and Myrskylä, 2013

Answer 101

On the other hand, there is some suggestion that income inequality may have a causal effect on causes of death contributing to excess US mortality below age 50:
o A recent study using panel data from 21 developed countries found that income inequality increases mortality up to age 15 for females, and up to age 50 for males

Question 102

Avendano and Kawachi, 2014: CONCLUSIONS

Answer 102

The evidence discussed above suggests that public policies on early childhood, education, employment, income support, housing and income redistribution might influence health and mortality

A separate line of evidence suggests that these programmes are less comprehensive in the US than in most European countries

Somewhat surprisingly, however, there is as yet no literature linking these two phenomena to estimate to what extent public policies are causally linked to the US mortality disadvantage
o One potential reason for this is the fact that most policy evaluation studies focus on local programmes targeted to sub-populations within a specific country, while less is known about the impact of national public policies on population health and mortality