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Ichiro Kawachi, MD, PhD

Monica Wang, ScD, MS

Harvard School of Public Health


PH201x: Health and Society
Socioeconomic Status (SES)
Magazine Die Gartenlaube, Titanic Sinking,
http://commons.wikimedia.org/wiki/File:St%C3%B6wer_Titanic.jpg, PD
Titanic casualties
Total on Board: 2,201
Lifeboat Capacity: 1,178
Total Deaths: 1,490
Dead
68%
Saved
32%
Chart created by Dr. Kawachi
Titanic survivors
Class Saved Total
First 203 325
Second 118 285
Third 178 706
Crew 212 885
Titanic survivors
62.5
41.4
25.2
24
0
20
40
60
80
First Second Third Crew
Class
P
e
r
c
e
n
t

S
a
v
e
d

Chart created by Dr. Kawachi
Why was there a social class gradient
in mortality on the Titanic?
Lord Mersey
John Bigham, 1st Viscount Mersey (1840-1929), Barclay Bros. http://en.wikipedia.org/wiki/File:1stViscountMersey.jpg, PD
Why was there a social class gradient in
mortality on the Titanic?
Confounding by age and sex of
passengers in different sections of the
boat.
Age, sex
Class Survival
Mortality on board Titanic, by gender
and class
Class
Men Women/Children
First
67.4% 2.7%
Second
91.7% 11.2%
Third
83.8% 57.8%
Why was there a social class gradient
in mortality on the Titanic?
1. Confounding by age and sex of passengers in different sections of
the boat.
2. Upper class people were physically more fit, or quicker to respond
to instructions of the crew.
3. Discrimination against 3
rd
class passengers / Preferential treatment
of 1
st
class passengers.
4. Structural differences in access to life-saving resources (lifeboats).
Cutaway diagram of RMS Titanic, http://commons.wikimedia.org/wiki/File:Titanic_cutaway_diagram.png, PD
Evidence of SES gradients in health in
contemporary society
! Income
! Educational attainment
! Occupation
Relative risks of all-cause mortality by household
income level: U.S. panel study of income dynamics
3.03
2.49
2
1.45
1.36
1
0
0.5
1
1.5
2
2.5
3
3.5
<15,000 -20,000 -30,000 -50,000 -70,000 >70,000
R
e
l
a
t
i
v
e

r
i
s
k

Household income (1993 $)
Source: McDonough et al. 1997
Chronic disease mortality among US adults aged 25-64
by education level
0
100
200
300
400
500
600
Men Women
D
e
a
t
h
s

p
e
r

1
0
0
,
0
0
0

< 12 yrs
12 yrs
13+ yrs
Education
Source: Health, United States, SES and Health Chartbook 1998
Chronic disease mortality among US adults aged 25-64
by education level
0
100
200
300
400
500
600
Men Women
D
e
a
t
h
s

p
e
r

1
0
0
,
0
0
0

< 12 yrs
12 yrs
13+ yrs
Education
Source: Health, United States, SES and Health Chartbook 1998
!" $%&" '()"* (+, *-*'$.
Mortality gradient by occupational class in the
British Whitehall Study
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
Admin Prof/Exec Clerical Other
R
R

o
f

m
o
r
t
a
l
i
t
y
Marmot, MG et al. (1978). "Employment grade and coronary heart disease in British civil servants". Journal of
Epidemiology and Community Health 32 (4): 244–249. doi:10.1136/jech.32.4.244
Two types of threat to causal inference
• Reverse Causation
• Confounding (omitted variable bias)
Reverse Causation:
Bad health compromises educational attainment, not the other
way round
Education Health
Reverse Causation:
Bad health compromises educational attainment, not the other
way round
Education Health
It is often asserted that education is less susceptible to
reverse causation (compared to income & occupation)
• Most people have completed their schooling
by the time they develop chronic disease
• If you get sick, you can’t lose education (in
the way that you can lose income or your
job)
• But is that strictly accurate?

Evidence from 1958 British Birth Cohort (National
Child Development Study, NCDS)
• Chronic health conditions during childhood do appear to have an
adverse impact on educational attainment (Case, Fertig & Pason, 2005)

• Even after taking into account household and parental characteristics,
each chronic condition reported at age 7 leads to on average 0.3 fewer
subjects passed on General Certificate of Education O-level
examinations at age sixteen
• In short, chronic conditions during childhood – e.g. diabetes, ADHD, or
mental health problems – result in children missing school
In summary !
• Reverse causation is real!
• Though not every instance of SES
gradients reflects this bias
The relationship between SES and health is reciprocal
and dynamic across the life course
Adler et al. Reaching for a Healthier Life, The John D. and Catherine T. MacArthur Foundation Research Network on
Socioeconomic Status and Health. http://www.macses.ucsf.edu/downloads/reaching_for_a_healthier_life.pdf
Two types of threat to causal inference
• Reverse Causation
• Confounding (omitted variable bias)
Confounding
Association between SES & health is spurious,
and reflects the influence of omitted “third”
variables.
SES
Health
?
Sidebar
(A bit of Epi review)
Carrying matches in
your pocket
Lung cancer
Relative risk = 2.0
Should we advise people to stop carrying
matches around?
Sidebar
(A bit of Epi review)
Carrying matches in
your pocket
Lung cancer
Relative risk = 2.0
smoking
How would you demonstrate that the association is
confounded by cigarette smoking?
Association between carrying matches &
lung cancer stratified by smoking status
!"#$%&' )#*+'"#$%&'
Relative risk of lung
cancer among
match-carriers vs.
non-carriers


Association between carrying matches &
lung cancer stratified by smoking status
!"#$%&' )#*+'"#$%&'
Relative risk of lung
cancer among
match-carriers vs.
non-carriers

1.00
Association between carrying matches &
lung cancer stratified by smoking status
!"#$%&' )#*+'"#$%&'
Relative risk of lung
cancer among
match-carriers vs.
non-carriers

1.00

1.00
Is it necessary to adjust for “carrying matches” when
studying the association of smoking with lung cancer?
Lung cancer
Carrying matches
Relative risk = 20
Smoking
Is it necessary to adjust for “carrying matches” when
studying the association of smoking with lung cancer?
Lung cancer
Carrying matches
Relative risk = 20
Smoking
Moving beyond observational data
Identification Strategies to Assess Causality

! Randomized controlled trials
! Quasi-experiments
Randomized controlled trials of schooling
• Extremely sparse due to low feasibility and
ethical concerns
• Two trials studied intensive preschool
interventions

a. High/Scope Perry Pre-school Program
b. Abecedarian Program
Perry Program
• Intensive pre-school program in
Ypsilanti, MI (1962-7)

Perry Program
• Intensive pre-school program in
Ypsilanti, MI (1962-7)
• Enrolled N=123 disadvantaged
black children, age 3-4 years

Perry Program
• Intensive pre-school program in
Ypsilanti, MI (1962-7)
• Enrolled N=123 disadvantaged
black children, age 3-4 years
• Treatment: Daily dose of 2.5 hr
instruction by teachers with
Masters degree on weekday
mornings, plus weekly 90-min
home visit by teacher

Perry Program
• Intensive pre-school program in
Ypsilanti, MI (1962-7)
• Enrolled N=123 disadvantaged
black children, age 3-4 years
• Treatment: Daily dose of 2.5 hr
instruction by teachers with
Masters degree on weekday
mornings, plus weekly 90-min
home visit by teacher
• Duration: 30 wk/yr for 2 years
• Follow-up through age 40
Perry Program
• Intensive pre-school program in
Ypsilanti, MI (1962-7)
• Enrolled N=123 disadvantaged
black children, age 3-4 years
• Treatment: Daily dose of 2.5 hr
instruction by teachers with
Masters degree on weekday
mornings, plus weekly 90-min
home visit by teacher
• Duration: 30 wk/yr for 2 years
• Follow-up through age 40
Abecedarian Program
• Intensive pre-school program in
Chapel Hill, NC (1972-7)
Perry Program
• Intensive pre-school program in
Ypsilanti, MI (1962-7)
• Enrolled N=123 disadvantaged
black children, age 3-4 years
• Treatment: Daily dose of 2.5 hr
instruction by teachers with
Masters degree on weekday
mornings, plus weekly 90-min
home visit by teacher
• Duration: 30 wk/yr for 2 years
• Follow-up through age 40
Abecedarian Program
• Intensive pre-school program in
Chapel Hill, NC (1972-7)
• Enrolled N=111 disadvantaged
black children, age 4 months

Perry Program
• Intensive pre-school program in
Ypsilanti, MI (1962-7)
• Enrolled N=123 disadvantaged
black children, age 3-4 years
• Treatment: Daily dose of 2.5 hr
instruction by teachers with
Masters degree on weekday
mornings, plus weekly 90-min
home visit by teacher
• Duration: 30 wk/yr for 2 years
• Follow-up through age 40
Abecedarian Program
• Intensive pre-school program in
Chapel Hill, NC (1972-7)
• Enrolled N=111 disadvantaged
black children, age 4 months

• Treatment: 8 hrs/day, 5 days/wk
academic enrichment program
for first 5 years. Additional
activities from grade 1-3
Perry Program
• Intensive pre-school program in
Ypsilanti, MI (1962-7)
• Enrolled N=123 disadvantaged
black children, age 3-4 years
• Treatment: Daily dose of 2.5 hr
instruction by teachers with
Masters degree on weekday
mornings, plus weekly 90-min
home visit by teacher
• Duration: 30 wk/yr for 2 years
• Follow-up through age 40
Abecedarian Program
• Intensive pre-school program in
Chapel Hill, NC (1972-7)
• Enrolled N=111 disadvantaged
black children, age 4 months
• Treatment: 8 hrs/day, 5 days/wk
academic enrichment program
for first 5 years. Additional
activities from grade 1-3

• Duration: 50 wk/yr for 8 years
• Follow-up through age 21
High/Scope Perry trial outcomes at age
27
Data from: http://www.highscope.org/content.asp?ContentId=219
Intervention
Control
Abecedarian program outcomes at age
21
Intervention
Control
Data from: http://abc.fpg.unc.edu/
WHY IS EARLY EDUCATION
IMPORTANT FOR HEALTH?
What did Mischel find?
• Experimenter left room for up to 15 mins
• Almost no child lasted 15 mins
• More than a quarter caved within 2 mins

• Average child lasted 6 mins
• Another 25 percent lasted more than 10 mins
Does marshmallow test predict
anything of consequence?

Maybe the kids who skipped breakfast on
the morning of the experiment had low blood
glucose and were more likely to ring the
bell!

Predicting adolescent cognitive and self-regulatory competencies
from preschool delay of gratification: identifying diagnostic
conditions
• Re-contacted subsample of original kids
(N=185) when they were 16-18 years old
• Parental questions inquiring about
adolescent’s coping styles and SAT scores
Shoda et al. (1990). Developmental Psychology, 26(6): 978-986.
Correlations between delay time on
marshmallow test & adolescent outcomes
Pow llkely ls your chlld Lo yleld Lo LempLauon? -.30***
Pow capable ls your chlld of exhlblung self-conLrol when frusLraLed? .40**
!,- .%&/01 .42*
!,- 230*45046% .37**
Shoda et al. (1990). Developmental Psychology, 26(6): 978-986.
Correlations between delay time on
marshmallow test & adolescent outcomes
Pow llkely ls your chlld Lo yleld Lo LempLauon? -.30***
Pow capable ls your chlld of exhlblung self-conLrol when frusLraLed? .40**
!,- .%&/01 .42*
!,- 230*45046% .37**
*4-year old klds who walLed 3 mlns. longer scored on average 300 polnLs
hlgher on SA1s ln hlgh school (171 polnLs hlgher on quanuLauve & 126
polnLs hlgher on verbal).
Shoda et al. (1990). Developmental Psychology, 26(6): 978-986.
Broader implication
• Early education teaches children to be more patient (executive
function)
• Self regulation promotes healthier lifestyles in adulthood
Larly Lducauon Þrevenuve behavlor
Wlllpower
Quasi-Experiments
Life is short; most of us will not get around to
doing experiments on social determinants.

If we can’t directly manipulate the exposure, we
can resort to-
• Instrumental variables
• Natural experiments
Instrumental variables
• Find a variable (Z) that causes variation in x, but has no direct effect
on outcome y
• i.e. find exogenous source of variation (like a coin toss)
x y
u
Z
Can we find an instrument for education?
Education Risk of mortality
IQ, genes,
personality,
etc.
Z
Can we find an instrument for education?
Educational
attainment
Risk of mortality
IQ, genes,
personality,
etc.
Compulsory schooling laws in the state of
one’s birth
Compulsory schooling laws (CSLs) as
instruments for education
• In the U.S., the number of years a child must spend in school
is determined by state law
• Requirements have historically varied between states, and
states changed their CSLs repeatedly during the first half of
the 20th century
• States extended mandatory schooling by: a) lowering the age
at which children had to begin school, or b) raising the age at
which they could drop out or get a work permit
• Hence, we can treat CSLs as “natural policy experiments”

Source: Lleras-Muney A (2005). “The Relationship between Education and Adult Mortality in the U.S.” Rev Econ Stud, vol. 72.
2 Stage least squares (2SLS)
edictors Pr Other X
ˆ
k
! + " ! + ! =
1 0
! + " + " + " =
1 0
edictors Pr Other X
ˆ
Y
k
Findings
• IV estimates of education on mortality suggest strong protective
effect
• Each additional year of schooling lowers 5-year mortality rates by
between 3.6 to 5 percent
1
• Recent analyses using similar approach also suggest causal effect
of education on improved cognitive functioning at older ages
2

1.
Lleras-Muney (2005).
2.
Glymour, Kawachi, Robins & Berkman (2008) JECH, 62(2):532-437
Explanations for the
association between schooling and health
1. Non causal:
– Reverse causation
– Confounding by IQ or other measure of ability
– Less time spent in hazardous jobs (“warehousing”)
0
100
200
300
400
500
600
Men Women
D
e
a
t
h
s

p
e
r

1
0
0
,
0
0
0

< 12 yrs
12 yrs
13+ yrs
Source: Health, United States, SES and Health Chartbook 1998
Explanations for the
association between schooling and health
2. Causal – cognitive mechanisms:
– Acquisition of knowledge
– Health literacy

Explanations for the
association between schooling and health
2. Causal – cognitive mechanisms:
– Acquisition of knowledge
– Health literacy

3. Causal – non-cognitive mechanisms:
– Self-regulation: patience, ability to plan for the future
– Executive functioning
Explanations for the
association between schooling and health
4. Indirect mechanisms:
– Schooling and credentials as gateways to safer jobs, higher
income

5. Other:
– Higher prestige/status in community
– More social connections (“social capital”)
– Improved future prospects leads to greater incentive to invest
in health
If we accept that schooling matters,
where should we invest?
• Knudsen et al. (2006). Economic, neurobiological,
and behavioral perspectives on building America’s
future workforce. PNAS, 103(27): 10155-10162.

“There is a striking convergence of four core
concepts that have emerged from decades of
mutually independent research in economics,
neuroscience, and developmental psychology!”
[ ]
Core concept #1
[From neuroscience]

• Skill development and brain maturation are
hierarchical processes in which higher-level
functions depend on (and build on) lower
level functions.
• Skills beget skills.
Core concept #2
[From developmental psychology]

• Early experiences have a uniquely powerful
influence on the development of cognitive and
social skills and on brain architecture.
• There are developmentally sensitive periods for
optimal learning, e.g. language acquisition.
Knudsen et al. (2006). Economic, neurobiological, and behavioral perspectives on building America’s future workforce. PNAS, 103(27): 10155-10162.
• 8owl or rlce
• 8owl of llce
Knudsen et al. (2006). Economic, neurobiological, and behavioral perspectives on building America’s future workforce. PNAS, 103(27): 10155-10162.
Core concept #3
[from economics]

• Early intervention lowers the cost of later
investment.
• Later remediation efforts are less effective – e.g.
adult literacy services, prisoner rehabilitation programs
& education programs for disadvantaged adults yield
lower economic returns than early intervention.
Knudsen et al. (2006). Economic, neurobiological, and behavioral perspectives on building America’s future workforce. PNAS, 103(27): 10155-10162.
Core concept #4
• Everything is not all over by age 4!
• Early interventions are sustained best when
they are followed by continued high quality
learning experiences.
• Early investments must be followed by later
investments to recoup maximum value.
Conclusion
• The most cost effective strategy for education is
investing in the social and cognitive environments
of children who are disadvantaged, beginning as
early in life as possible.
• [The estimated rate of return per dollar of cost in the
Perry Program is > 17%, i.e. far higher than the standard
rate of return on stock market equity].