For more information, contact:
Jon Gardner, Health Affairs, 301-656-7401, ext. 230

Tuesday, March 12, 2002



Special Issue Explores Nonmedical Factors In Depth

The percentage of women with diabetes who have not completed high school is more than twice the percentage who have, the Centers for Disease Control and Prevention reported in February. Women with diabetes are twice as likely to live in households with annual incomes below $25,000 a year than in households above that level. In general, death rates from chronic disease among high school graduates are less than half what they are among non-graduates.

In many estimates, socioeconomic, behavioral, and environmental factors far outweigh access to medical services in explaining variations in population health. But there is little agreement among researchers about how these factors work. Even more controversial are the policy questions raised by nonmedical determinants of health The March/April issue of the policy journal Health Affairs features fifteen articles by a distinguished lineup of scholars, who tackle "the policy implications of the gradient," or the tendency for health status to decline with income, from a variety of angles. The papers include objective analysis of what we know about the "powerful yet mysterious" mechanisms by which nonmedical factors influence health status; theoretical discussion of how far redistributive strategies - and other policy options - might go toward reducing disparities; detailed treatments of the economics of tobacco, alcohol, and illegal drug regulation; and other papers on the effects of obesity, parenting issues, and tobacco advertising.

Health and Wealth

"Poorer people die younger and are sicker than richer people," Princeton University's Angus Deaton writes in the volume's opening paper. But the question of whether health policy should therefore focus on equalizing incomes remains complex because of the intervening effects of other factors such as behavior, education and social "rank"; and the reciprocal influence of health on income. "The existence of the gradient strengthens the case for income redistribution," Deaton concludes, but an exclusive focus on inequality "would not be sound policy."

The British epidemiologist Sir Michael Marmot draws on a large body of research in the United Kingdom for his discussion of nuances in the relation between health and wealth. "Once education is included in the model, the effect of income on mortality is markedly reduced," Marmot notes. Status and social support systems also matter. "Important as money might be, we need to go beyond absolute measures of income to understand the relation between social position and health." Both of these papers are available free to the public on the journal's Web site,


David Mechanic, of Rutgers University, finds similarly that abundant evidence of a correlation between disparities in health and wealth does not yield clear-cut policy implications. "Initiatives intended to improve population health also may increase disparities," Mechanic finds, citing large reductions in black infant mortality in the U.S. after 1950 that nevertheless did not close the gap with whites. Poor countries with relatively healthy populations display an "emphasis on educational attainment; empowerment of women; and well-organized primary medical care," he points out.

Nancy Adler and Katherine Newman, of the University of California at San Francisco and Harvard, respectively, map the relevant components of socioeconomic status (SES) - education, income, and occupation - and explain how SES interacts with factors such as environment and behavior to influence health status. Policymakers need to recognize the multiple pathways created by these interactions and tailor interventions accordingly with multiple approaches.

Policymaking, Regulation and Economics

Michael McGinnis and colleagues at the R.W. Johnson Foundation tour the wide universe of health determinants - genetics, social status, environment, behavior, and access to care - and outline the complex challenge of selecting interventions within realistic resource constraints. The difficulties include assessing the effectiveness of measures taken and assigning political accountability for the choices. Leadership, incentives, and research emerge as critical factors.

Nicole Lurie of RAND examines the policy options in greater detail and suggests a robust agenda. Leadership from CDC, the Surgeon General's office and other federal agencies will set the pace. Cooperation between disparate government departments is essential, and federal agencies can exert leverage by "management of the informational environment." Obstacles, as well as opportunities, are considered. Additional perspectives are offered by John Lavis and Leonard Syme and colleagues.

Three papers explore the economic dimension of policymaking in some of the most developed and familiar areas of nonmedical but health-related legislation and regulation - tobacco, alcohol, and illegal drug use. Authors include Philip Cook, Jonathan Gruber, Michael Grossman, and Frank Chaloupka.

An interview with outgoing CDC director Jeffery Koplan rounds out the volume, along with shorter papers on "Parental Behavior and Child Health," "The Effects of Obesity, Smoking, and Problem Drinking on Chronic Medical Problems and Health Care Costs," and "Youth Targeting by Tobacco Manufacturers: Magazine Advertising Since the Master Settlement Agreement."

Health Affairs, published by Project HOPE, is a bimonthly multidisciplinary journal devoted to publishing the leading edge in health policy thought and research. Copies of the March/April 2002 issue will be provided free to interested members of the press. To obtain a copy, or to get an advance copy of this article, contact Jon Gardner at Health Affairs, 301/656-7401, ext. 230, or via email, All articles from the March/April issue are available to subscribers on the journal's Web site, The special issue was published with the generous support of the Robert Wood Johnson Foundation.


©2002 Project HOPE–The People-to-People Health Foundation, Inc.