Often lost in the debate about health disparities in the United States is an analysis of differences in health and longevity among women. While the majority of Americans enjoyed an unprecedented growth in life expectancy for most of the 20th century, in recent years it has become clear that many American women will have life spans shorter than those of their mothers.
“Studies have documented this reversal since the mid-1980s,” explains Jennifer Karas Montez, PhD, a sociologist and a 2011-2013 Robert Wood Johnson Foundation (RWJF) Health & Society Scholar at Harvard University. Even more alarming, Montez adds, is the fact that “when compared to women around the world, American women have lost a tremendous amount of ground. In the early 1980s, life expectancy of U.S. women ranked 14th in the world, but in the 2005 to 2010 data, we’d fallen to 41st place.”
Working with mentor Lisa Berkman, PhD, co-director of the Health & Society Scholars program at Harvard and director of the Harvard Center for Population and Development Studies, Montez is investigating the issues behind the life expectancy decline. “As a Health & Society Scholar, I’ve had the opportunity to explore this topic with colleagues in ways that would not have otherwise been possible,” Montez says.
“Our approach is different because we’re focusing on factors that are upstream in the causal chain, such as employment and work-family conflict, to identify the root causes. We’re also working closely with researchers in Europe to learn whether social policies such as family leave and child care that are more common in Europe than the United States help explain the declining position of U.S. women at all education levels.”
The Women at Risk
While decades of research have focused primarily on health disparities in African American women, current studies reveal that the factors that may reduce life expectancy now have a larger impact on some groups of White women. “To give you an idea about the size of the decline, a 2008 study by Ellen Meara, PhD, found that during the 1990s, life expectancy of women with 0-12 years of education declined by 0.9 years among White women and by 0.2 years among Black women,” Montez says.
In addition, a recent National Research Council report, “Explaining Divergent Levels of Longevity in High-Income Countries,” revealed that U.S. women report worse health than women in other high-income countries such as England, Canada, Australia and Japan on numerous indicators such as heart disease, stroke, diabetes, and functional limitations. “However, it’s unclear how much of the gap is due to better diagnoses of health conditions in the United States,” Montez adds.
The trends for men are less clear. Some studies find that life expectancy increased for all men, just more for men who are better educated, but other studies find trends similar to those found in women. Montez and her colleagues are using data from the National Health Interview Survey Linked Mortality file to examine the trends in more detail.
The New Meaning of Poverty
At first glance, the declining life expectancy in American women appears to be caused by unhealthy behaviors long associated with lower levels of education. Montez and other researchers have documented high and increasing rates of tobacco use, for example, among women in this group (smoking has dropped in higher education groups). One recent study found that smoking may account for as much as 25 percent of the education-mortality gap. Another survey documented high and increasing rates of accidental poisoning for low-income White women, primarily from overdoses of prescription and other drugs. This fact may be linked to the recent findings of RWJF Clinical Scholar Stephen W. Patrick, MD, MPH. His research estimated that a baby was born experiencing withdrawal from opiates nearly every hour. The dramatic increase Neonatal Abstinence Syndrome (NAS) took place between 2000 and 2009. The infants were also more likely to have been born to mothers on Medicaid.
Reviewing the data with the eyes of someone sensitive to the powerful, downstream effects of low levels of education, Montez says, “these issues are most likely symptoms brought on by overarching social conditions. That’s why we are looking upstream at labor force participation for this group, stress and childhood conditions.”
To begin with, Montez notes, “to a great degree, women with low levels of education have really been shut out of the workforce, especially in recent years. We often hear about the dramatic increases in women’s labor force participation, but these women haven’t followed that trend. Based on estimates from the Current Population Survey, full-time employment of U.S. women without a high school diploma is currently at levels similar to the late 1960s.”
The increasing wealth gap between Americans with high levels of education and those with lower levels has also changed what it means to be a child growing up in America. “Studies have shown that childhood conditions are diverging, based on parents’ education levels. Parents in the top bracket can spend more time, money and other resources on their children and their educational opportunities,” Montez says.
Difficult childhoods may also be followed by adult lives that offer less cohesiveness and comfort than in the past. Rates of single motherhood have increased greatly for women, while rates of marriage—a contributor to better health—have dropped fastest among women with lower levels of education, regardless of whether they have children.
Advances in medicine that should also help to alleviate some education-income-related health disparities by providing a better quality of care for all, may actually be making matters worse. Groups with higher levels of education and income are far more likely to have health insurance and access to increasingly expensive, cutting-edge medical technologies, therefore widening the gap between the groups.
The cumulative effect of this quiet storm of social factors may be greatly increased “levels of stress in this group,” Montez says.
As the racial differences in the rates of life expectancy decline among the women, Montez explains, “we need a better understanding of the longevity consequences of low education across racial and ethnic groups.”
“To really understand the changes in behaviors and the other things at play here, we need to look further back in the causal chain at what life is like for these women from the time they are very young,” Montez says. “We must also remember that the focus should not just be on women with low levels of education, because American women at all educational levels are doing worse, in terms of life expectancy, than women with similar education levels in other high-income countries.” Montez’s new research on the topic will be published in early 2013.