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Smoking or Schools: Which is More Important to Your Health?

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(Raul Lieberwirth: Flickr)
Sorry, cigarettes are still terrible for you, but can a good school system lead to better health? (Raul Lieberwirth: Flickr)

Too often, we confuse health with health care. Health care comes from a doctor or hospital. But health comes from many places we don't normally think of as health at all -- things like good schools, safe neighborhoods and access to a variety of jobs. In other words, if you live in places without those things, you have a lower likelihood of enjoying good health.

Today, a new study from researchers at Stanford's School of Medicine confirms that health disparities across the country have more to do with social factors than the color of your skin or where you live. In fact, the researchers say that some of these social factors even outweigh -- gasp -- the effect of cigarette smoking. (More on that later).

The study, Geographic and Racial Variation in Premature Mortality in the US, looked at counties across the United States and the likelihood of people living to age 70. Lead author Dr. Mark Cullen says this measure is a good alternative to looking at life expectancy, because it shifts attention to events that occur earlier in life. In particular, researchers found that educational opportunities, distribution of income and a mix of jobs accounted for better health outcomes across the population of a county. These "social determinants of health" as public health professionals call them, also explain health disparities between African-Americans and caucasians. "In most parts of the country," Cullen says, "if African-Americans had the same advantages that their white counterparts had, almost ALL of the racial disparity would go away."

The study is national in scope. Here in California, Cullen says that people who live along the coast up to about Mendocino enjoy the best health statistics. But head east to the Central Valley and the health outcomes are much worse.

"It's not surprising," Cullen says, "the dominant theme there is these are regions of relatively lower socioeconomic status, relatively lower levels of educational attainment. We're not talking about individuals here, we're talking about populations at the county level."


Cullen stresses that all policy avenues lead back to health. "ALL policy is health policy," he says, "which is to say that every time at the state level or the county level or the federal level, there's a debate about expenditures on housing or job training or education, those frankly are health debates. One of the biggest consequences of either cutting out programs or strengthening programs are the health consequences to the population. You don't see them in a day or a week, you see them over decades."

One person who sees policy outcomes up close is KQED's Community Correspondent Xan West. She writes for KQED's blog ouRXperience from her neighborhood of West Oakland, which is primarily African-American, low income and high crime. Responding to questions about today's study, she described not only West Oakland's lack of jobs and school closures, but also its run down playgrounds.

"You see a lot of decrepit and broken down play structures, that kids would hurt themselves on," she told me. "Neighborhoods are not safe for kids to be outside in West Oakland. It effects how much being outside, being a kid, being able to play is important to childhood, as well as .. important to obesity, important to hypertension. You see heightened rates of obesity in West Oakland and other inner city places and part of that is the inability of people to go outside and play."

Dr. Anthony Iton, now at The California Endowment, served for six years as Health Officer of Alameda County. While there, he published research about Alameda County's social determinants of health. He called today's report a "great study." Like Cullen, he countered the idea that simply being African-American doomed someone to poorer health. "That is one of the great misperceptions," he told me. People need to understand "the difference between race and racism. Race doesn't matter, racism does matter because it constrains people's access to ... high educational attainment, high income, high employment."

And finally, what of cigarettes? By no means is anyone suggesting smoking is good for you, but Cullen's research showed the power of these social determinants of health. "Some counties have higher rates of smoking," he explained. "Some counties have higher rates of obesity. But it was dwarfed by the social environment that was already measured. In fact, when you added it into the equation, it added very little. Now that's not to say that being obese or smoking is individually a good thing. But it turns out when you look at large swaths of the population, that the underlying factor of education and wealth and occupation and so forth dominate."

Editor's Note: The California Endowment is a funder of KQED.

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