>[I think it was only this Fall Doug was remarking that there was a paucity
>of research on this subject. But now there seems to be an explosion, at
>least in the professional journals. And their conclusions are remarkably
>strong compared to what went before according to this NYT survey.]
>Michael
>For Good Health, It Helps to Be Rich and Important
>
>By ERICA GOODE
> D octors usually evaluate patients' vulnerability to serious
> disease by inquiring about risk factors like cigarette smoking,
> obesity, hypertension and high cholesterol.
>
> But they might be better off asking how much money those patients
> make, how many years they spent in school and where they stand
> relative to others in their offices and communities.
> _________________________________________________________________
>
> Trying to explain why illness diminishes with a rise in social class.
> _________________________________________________________________
>
> Scientists have known for decades that poverty translates into
> higher rates of illness and mortality. But an explosion of research
> is demonstrating that social class -- as measured not just by
> income but also by education and other markers of relative status
> -- is one of the most powerful predictors of health, more powerful
> than genetics, exposure to carcinogens, even smoking.
>
> What matters is not simply whether a person is rich or poor,
> college educated or not. Rather, risk for a wide variety of
> illnesses, including cardiovascular disease, diabetes, arthritis,
> infant mortality, many infectious diseases and some types of
> cancer, varies with relative wealth or poverty: the higher the rung
> on the socioeconomic ladder, the lower the risk. And this
> relationship holds even at the upper reaches of society, where it
> might seem that an abundance of resources would even things out.
>
> Social class is an uncomfortable subject for many Americans. "I
> think there has been a resistance to thinking about social
> stratification in our society," said Dr. Nancy Adler, professor of
> medical psychology at the University of California at San Francisco
> and director of the John T. and Catherine D. MacArthur Foundation
> Research Network on Socioeconomic Status and Health. Instead,
> researchers traditionally have focused on health differences
> between rich and poor, or blacks and whites (unaware, in many
> cases, that race often served as a proxy for socioeconomic status,
> since blacks are disproportionately represented in lower income
> brackets).
>
> But the notion that a mid-level executive with a three-bedroom,
> split-level in Scarsdale might somehow be more vulnerable to
> illness than his boss in the five-bedroom colonial a few blocks
> away seems to have finally captured scientists' attention.
>
> In the past five years, 193 papers addressing aspects of
> socioeconomic status and health have appeared in scientific
> journals -- twice the number in the previous five-year period. The
> National Institutes of Health last year declared research on
> disparities in health related to social class or minority status
> one of its highest priorities, said Dr. Norman Anderson, associate
> director of the N.I.H. And a recent conference in Bethesda, Md., on
> the topic, sponsored by the New York Academy of Sciences and the
> MacArthur Foundation network, drew more than 250 participants from
> a wide variety of disciplines.
>
> Executive Privilege Includes Longevity
> A study following 18,133 male civil servants over 25 years shows that
> the grade of employment was a strong predictor of mortality,
> especially before retirement.
> [060199hth-socioeconomic-status.1.gif]
> The New York Times
>
> Source: M. G. Marmot and Martin J. Shipley.
> _________________________________________________________________
>
> What first compelled researchers interest was a now-classic study,
> begun in the late 1960's, of men in the British civil service. The
> Whitehall study, directed by Dr. Michael Marmot, director of the
> International Center for Health and Society at University College
> London, tracked mortality rates over 10 years for 17,530 male civil
> service employees.
>
> When the data were analyzed, the researchers were astonished to
> discover that mortality rates varied continuously and precisely
> with the men's civil service grade: the higher the classification,
> the lower the rates of death, regardless of cause.
>
> This finding was as perplexing as it was intriguing. The men all
> had jobs, and equal access to health care under Britain's national
> health system. But mortality rates for men in the lowest civil
> service classification, the researchers found, were three times
> higher than those for men in the highest grade. And a 25-year
> follow-up of the Whitehall subjects, some results of which were
> published in 1996, found the social class gradient persisted well
> past retirement, even among men into their late 80's.
>
> Subsequent studies demonstrated a similar relationship between
> socioeconomic status and mortality in the United States and Canada.
>
> What could account for such startling findings? One plausible
> explanation was that lower-ranked men might engage in more risky
> behaviors, like smoking.
>
> But the same health disparity from pay grade to pay grade that was
> evident in smokers held for nonsmokers, too. And all coronary risk
> factors combined, the researchers found, accounted for only a third
> of the differences between grades.
>
> Stress, or other aspects of psychological life that can have an
> impact on a person's vulnerability to disease, the Whitehall group
> reasoned, might also play a role in the results. Prolonged exposure
> to stress, researchers have found, can lead to abnormalities in
> immune function and glucose metabolism, and destroy brain cells
> involved in memory. And studies show that the lower one's social
> status, the more stressed people feel, and the more stressful
> events they encounter in their lives.
>
> Dr. Sheldon Cohen, professor of psychology at Carnegie Mellon
> University in Pittsburgh, has demonstrated a link between social
> status and vulnerability to infectious disease in male macaque
> monkeys. In a study carried out in conjunction with primate
> researchers at Wake Forest University School of Medicine, Dr. Cohen
> found that males at the lower end of the dominance hierarchy were
> more susceptible to a cold virus than dominant males.
>
> Dr. Cohen and his colleagues at Carnegie Mellon then replicated
> those findings in humans. Subjects in the study were asked to rate
> their relative standing in their community on a social status
> ladder, then were exposed to mild respiratory virus. People who
> ranked themselves low on the ladder were more likely to become
> infected with the virus than those who ranked themselves higher up
> on the ladder.
>
> In another study, the researchers found that people who had been
> unemployed for one month or more under highly stressful conditions
> were 3.8 times more susceptible to a virus than people who were not
> experiencing a significant stressful situation.
>
> At least in primates, the interaction of stress with social class
> and illness, however, depends both on the nature of the stress and
> the context in which it occurs, as demonstrated in a series of
> studies by Dr. Jay R. Kaplan, a professor of pathology and
> anthropology at Wake Forest.
>
> In a crowded situation where resources are scarce, for example,
> male monkeys at the lowest end of the dominance hierarchy, who must
> scramble hardest to survive, are likely to feel the most stress.
> And in studies of primates in the wild, researchers find that
> subordinate animals show higher levels of stress hormones.
>
> But when Dr. Kaplan and his colleagues fed male monkeys a "luxury"
> diet, high in fat and cholesterol, and moved them each month for
> two years into a new group of strange males, it was the dominant
> animals, forced to reassert their position continually, who
> suffered the most stress. Under such conditions, Dr. Kaplan finds,
> dominant males show a hypervigilant response, and have higher rates
> of coronary artery disease than subordinates.
>
> For humans and primates, a sense of control over life events is
> intimately related to stress. And control seems to have been one
> factor at work in the Whitehall study.
>
> In 1985, Dr. Marmot and his colleagues launched Whitehall II, a
> second large-scale study, which included civil servants of both
> sexes and which collected more detailed information on the
> participants.
>
> As part of the study, employees were asked to rate the amount of
> control they felt over their jobs. Managers also rated the amount
> of control employees had. Job control, the researchers found,
> varied inversely with employment grade: the higher the grade, the
> more control. And the less control employees had, as defined either
> by their own or managers' ratings, the higher the employees' risk
> of developing coronary disease. Job control, in fact, accounted for
> about half the gradient in deaths from pay grade to pay grade.
>
> To some extent, people's ability to withstand stress, and the ways
> in which they interpret and respond to life events, are shaped by
> early life, the product of what one social scientist, Dr. Clyde
> Hertzman of the University of British Columbia, calls "the long arm
> of childhood." Genetics play a role, as does nutrition. (In the
> Whitehall study, height -- which varies with social class -- was
> used as a rough indicator of childhood influences on development,
> and accounted for a small portion of the association between
> mortality and employment grade.) And scientists have found that
> early life experiences -- abuse and neglect, for example -- can
> alter brain development and influence responses to stressful
> events.
>
> Any discussion of socioeconomic status in the United States of
> necessity involves a discussion of race, since the two are entwined
> in complex, sometimes inextricable, ways. Proportionally, far more
> African-Americans live in poverty than whites: 28.4 percent of
> blacks fell below the poverty line in 1996, compared with 11.2
> percent of whites, according to Government data.
>
> Death rates for African-Americans from all causes are 1.6 times
> higher than for white Americans, Dr. David R. Williams of the
> University of Michigan's Institute for Social Research, said at the
> Bethesda conference.
>
> Life expectancy for blacks and whites also varies. At age 45, a
> white man can expect to live five years longer than an
> African-American man, and white women can expect to live 3.7 years
> longer than their black counterparts.
>
> If socioeconomic status is taken into account, health differences
> between blacks and whites decrease substantially: Black men in the
> highest income brackets, for example, have a life expectancy 7.4
> years longer than black men in the lowest brackets, Dr. Williams
> said. White men at top income levels live 6.6 years longer than
> their lowest-income counterparts.
>
> But race and to some extent sex still have an impact on health that
> is independent of social class. The gap in infant mortality rates
> between blacks and whites, for example, actually increases with
> higher social status. And being black or female discounts some of
> the advantages afforded by education: white men accrue health
> advantages with every additional year of schooling they receive.
> But black men and women, though they also show gains, show them
> only through high school, according to an analysis of Federal data
> by Dr. Adler and Dr. Burton Singer of Princeton University's Office
> of Population Research. White women, the researchers found,
> continue to gain in health status through college, but unlike white
> men, do not receive the gains in health bestowed by post-graduate
> education.
>
> Social exclusion, residential segregation and other expressions of
> institutional racism magnify the impact of socioeconomic status.
> Several studies, for example, have shown higher adult and infant
> mortality rates for people living in segregated areas.
>
> For both blacks and whites, living in a neighborhood where social
> bonds have eroded may have negative effects on health. Dr. Robert
> Putnam of Harvard University coined the term "social capital" to
> describe the elements that contribute to social cohesion.
>
> Dr. Ichiro Kawachi, director of the Harvard Center for Society and
> Health, has explored one aspect of social capital -- interpersonal
> trust -- and its relationship to national and community rates of
> illness and death.
>
> Dr. Kawachi and his colleagues correlated mortality rates in states
> with the percentage of state residents who agreed with the
> statement, "Most people would try to take advantage of you if they
> got the chance." Death rates, Dr. Kawachi reported at the Bethesda
> conference, were strongly linked to level of social trust, with the
> most mistrustful ratings clustering in southern and northeastern
> states. Another study, of Chicago neighborhoods, yielded similar
> findings: neighborhoods in which more residents agreed with the
> statement "Neighbors can be trusted" had lower mortality rates.
>
> Why are neighborhoods or states with higher levels of trust
> healthier? Dr. Kawachi suggests that in neighborhoods where social
> trust is high, negative health behaviors -- smoking and alcohol
> consumption, for example -- might be discouraged through community
> pressure.
>
> Residents in high trust neighborhoods may also share more
> resources, be more willing to help one another out and offer one
> another more emotional support. "It is speculation," Dr. Kawachi
> said, "but probably these little things add up to quite important
> health differences."
>
> Even so, the relationship between social class and health is
> unlikely to be entirely explained by social capital, or by any
> other single dimension of life experience. Said Dr. Adler, "There
> isn't going to be a single explanation or an easy solution, but
> we've started mapping out some of the places where we can
> intervene."
> _________________________________________________________________
>
> Copyright 1999 The New York Times Company
>