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Inequality in education, income, and occupation exacerbates the gaps between the health "haves" and "have-nots."
ABSTRACT: Socioeconomic status (SES) underlies three major determinants of health: health care, environmental exposure, and health behavior. In addition, chronic stress associated with lower SES may also increase morbidity and mortality. Reducing SES disparities in health will require policy initiatives addressing the components of socioeconomic status (income, education, and occupation) as well as the pathways by which these affect health. Lessons for U.S. policy approaches are taken from the Acheson Commission in England, which was charged with reducing health disparities in that country.
SOCIOECONOMIC STATUS, whether assessed by income, education, or occupation, is linked to a wide range of health problems, including low birthweight, cardiovascular disease, hypertension, arthritis, diabetes, and cancer.1 Lower socioeconomic status is associated with higher mortality, and the greatest disparities occur in middle adulthood (ages 45-65).2
J. Michael McGinnis and William Foege have provided an incisive analysis of the "actual causes" of death in which they estimated the number of U.S. deaths caused by factors such as tobacco, diet and lack of activity, and toxic agents.3 They noted the mismatch between the importance of these factors and allocation of health care resources, with most resources going to treat diseases and relatively few to modifying the predisposing factors. To modify these risk factors, one needs to look even further upstream to consider their "actual determinants." Socioeconomic status is a key underlying factor. In this paper we examine multiple pathways through which it can influence health, and we consider the implications of these pathways for policy.
While socioeconomic status is clearly linked to morbidity and mortality, the mechanisms responsible for the association are not well understood. Identifying these mechanisms provides more options for policy remedies. Given the pervasive effects of socioeconomic status, no single policy, or even one domain of policy, can eliminate health disparities. The Acheson Commission in the United Kingdom, which was charged with providing policy suggestions for reducing health disparities in that country, made thirtynine recommendations, organized around key populations (such as children, older people, and ethnic minorities) and domains (such as income and tax benefits, education, and employment).4 If a U.S. equivalent of the Acheson Commission were convened, what policies should it consider...