Social factors such as low education, racial segregation and inadequate social support are responsible for more premature American deaths each year than heart attacks, stroke and lung cancer, according to a provocative new study by researchers at New York’s Columbia University and the University of Michigan in Ann Arbor.
Since heart disease, cancer and stroke are 1-2-3 in terms of premature deaths in this country, you’d think this study, published last week in the American Journal of Public Health, would have made some kind of media splash. Or gotten the attention of politicians looking for ways to cut health-care costs.
But it got very little coverage. Nor, as far as I know, was the study brought up in any political speech.
Perhaps that’s because we find it easier these days to blame individuals for their health problems than to put any responsibility on broader social factors.
I spoke on Wednesday about the study with Dr. Jasjit Ahluwalia, executive director for the Center for Health Equity at the University of Minnesota. He was not involved with the research.
“This should be a wake-up call to the country,” he told me.
Going further upstream
It’s been almost 20 years since another provocative study looked “upstream” from the pathophysiological causes of premature deaths (things like high blood pressure and unfavorable cholesterol) and found that the leading contributors to those deaths — the sources of that high blood pressure and bad cholesterol — were most often lifestyle factors, especially smoking, unhealthful food choices, inactivity and alcohol. A decade later another team of researchers essentially confirmed that list, although they found that obesity-related factors (poor diet and physical activity) might soon overtake smoking as the leading cause of preventable deaths.
But this new study went even further upstream and investigated the links between social factors and premature death. In other words, these researchers did not just stop at, say, tobacco as a health risk. They asked instead, what causes some people to use tobacco?
The answer led them to six social factors: low education, racial segregation, low social support, individual-level poverty, income inequality and area-level poverty.
“Without being dramatic, people in the field know this and talk about this,” said Ahluwalia. “But this is a manuscript that comes up with numbers.”
And the numbers, which the researchers estimated by systematically analyzing 47 other studies published between 1980 and 2007, are striking. They found that in the year 2000 approximately 245,000 premature deaths were attributable to low education, 178,000 to racial segregation, 162,000 to low social support, 133,000 to individual level poverty, 119,000 to income inequality, and 39,000 to area-level poverty.
And we’re not just talking about people dying prematurely after the age of 65. When poverty and low education were combined, the risk of death was greater for individuals aged 25 to 64 than for those 65 and older.
“Social causes can be linked to death as readily as can pathophysiological and behavioral causes,” the researchers concluded.
Indeed, the number of deaths attributed to low education is comparable to those caused by heart attacks (192,898). Those attributed to racial segregation are comparable to those from stroke (167,661). And those attributed to low social support are similar to deaths from lung cancer (155,521).
Numbers might be higher today
“I think there’s a lot of truth to this data,” said Ahluwalia. It’s unlikely the numbers in the study are exact, he added, but “they are not out of the realm of reality.”
In fact, Ahluwalia added, the numbers would probably be higher if the estimates were based on today’s statistics. The income inequality gap, for example, has climbed since 2000, “so if those numbers are up, the [study’s] numbers would be up, too,” he said.
One of the study’s limitations is that social risk factors often overlap. Individuals who live in poverty are also likely to have dropped out of high school, for example, and to have fewer social support systems in place.
But the same can be said for behavioral factors. Individuals who make unhealthful food choices are also more likely to be physically inactive and smokers.
Political fallout
Ahluwalia calls the study “a bold attempt” to understand the broader causes of mortality in the United States. He also agrees with its authors’ call for public-health officials to take a more expansive policy approach to improving health — an approach that addresses social factors as well as individual responsibility.
That call to action has political ramifications, of course. Conservatives like to point to poor lifestyle choices by individuals as the key cause of health problems, said Ahluwalia, while liberals tend to blame society.
“The thing is, it’s both,” he said.
But given the deafening silence this study has received — and the current calls for government cutbacks to many social safety nets — addressing the social-factor aspect of that equation seems unlikely to happen anytime soon.
