RWJF Commentary Regarding Social Factors' Influence on Variations in Health and Life Expectancy

The following is a commentary by Risa Lavizzo-Mourey, M.D., M.B.A., RWJF president and CEO, released following the latest WHO report, Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health.

A new report from the World Health Organization finds what may seem to be the obvious: social factors such as poverty and education are to blame for huge variations in health and life expectancy around the globe. So, no big deal. Right? Every society has its haves and have-nots, particularly those in the developing world.

But here is something that is a very big deal: the extent to which this global reality is hitting us at home here in the United States. Consider this: People who live at one end of the Washington, D.C., metro system’s Red Line in suburban Maryland live more than nine years longer on average than those who live in downtown D.C., near Union Station. The distance between them is only 30 miles.

In this country, you are twice as likely to be obese if you haven’t gone to college, and your baby is more likely to die if you only have a high school education. In fact, according to government reports, the United States ranks 42 in the world in infant mortality. Our ranking is comparable to Croatia, Lithuania and Taiwan, and far behind other industrialized nations such as Sweden, France, Japan and Germany.

Social differences in health are not just a matter of the rich versus the poor. Research shows that there is a gradient to health disparities: The very wealthy live longer and healthier than the moderately wealthy, who do better than the upper middle-class and so on down the line.

The WHO has found these health differences in countries all over the world. Here in the United States, the Robert Wood Johnson Foundation Commission to Build a Healthier America—led by former White House advisors Mark McClellan and Alice Rivlin—has found the same.

We’ve learned that there is much more to good health than health care. Where and how people live, learn, work and play have more impact on their health than medical care. The United States spends more than $2 trillion a year on health care—one-sixth of our economy—and yet our health is not what it should or could be.

We are so focused on “fixing” poor health with medical care that we fail to recognize the often toxic relationship between how we live our lives and our economic, social and physical environments. Sir Michael Marmot, a prominent researcher and chairman of the WHO Commission on the Social Determinants of Health, explains: “People need the opportunity, the possibility, to take control over their lives—but the conditions need to be right to allow them to do that.”

The United States prides itself on being the land of opportunity, and yet we do not all have the same opportunity to be healthy. It starts at birth. Obstacles children encounter early in life create a negative chain of events that is difficult to break and may transcend generations. Poor education leads to limited job options, which leads to low income, which leads to living in poor neighborhoods, which leads to poor housing, which leads to poor health.

As children grow up, social disparities in health can become a matter of life or death. For example, higher rates of death from heart disease are often seen in communities where fewer adults have a college education. In fact, the prevalence of heart disease is nearly 50 percent higher among poor adults than among adults in the highest income group.

The RWJF Commission is searching outside the health care sector, including at the local level and in the private sector, for workable, evidence-based innovations that can improve health. Solutions must come from all levels, all sectors; from government, from business, from the nonprofit sector.

A recent study on ROI from Trust for America’s Health shows that a small investment in community prevention programs can produce substantial savings in overall health care costs. Researchers found that an annual investment of $10 per person in community programs to increase physical activity, improve nutrition and prevent smoking could save the country more than $16 billion within five years. This is a return of $5.60 for every $1 invested. Projected savings include $5 billion for Medicare; $1.9 billion for Medicaid; and $9 billion for private payers.

We believe that investing in early childhood development is one of the most important steps toward improving the health of all Americans. It is clear that early childhood development can affect educational attainment, which is linked to lower rates of heart disease, stroke, hypertension, diabetes, obesity, smoking, drug use and depression. Take an idea like the Nurse-Family Partnership, which provides home visits to first time, low-income mothers and their families beginning in pregnancy. Among its many beneficial effects: Children of these women are nearly 60 percent less likely to be arrested and almost 50 percent less likely to be abused, neglected or injured. There’s a financial return here too. A study conducted by RAND estimated the return on investment at $5.70 per dollar spent on the program. This means that for every dollar spent on the program over $5 in other societal costs are averted or other value is gained.

These results beg the question: What if all women in poverty and their babies had access to a program like this?

And let’s not stop there. Let’s think about how to maximize America’s position in an increasingly competitive world. What would happen if all children ate three healthy meals a day? What would happen to health if everyone completed high school and postsecondary education? What would happen to health if everyone lived in a safer neighborhood? We must ask these questions, even knowing that the answers we seek are not perfectly attainable, because we can’t, in good conscience, write off the future health of millions of Americans at birth nor can we afford the economic consequences of having a population with declining health status relative to our world competitors.

As the WHO report shows, and as ongoing RWJF Commission fact-finding demonstrates, the evidence is in, and now is the time to move forward. We must link education and other social policies to health, or pay the piper with illness and premature death that make no sense at all in a society as bountiful as ours.

Risa Lavizzo-Mourey, M.D., M.B.A.
President and CEO
Robert Wood Johnson Foundation


The Robert Wood Johnson Foundation focuses on the pressing health and health care issues facing our country. As the nation's largest philanthropy devoted exclusively to improving the health and health care of all Americans, the Foundation works with a diverse group of organizations and individuals to identify solutions and achieve comprehensive, meaningful and timely change. For more than 35 years, the Foundation has brought experience, commitment, and a rigorous, balanced approach to the problems that affect the health and health care of those it serves. When it comes to helping Americans lead healthier lives and get the care they need, the Foundation expects to make a difference in your lifetime.