>>[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
>>