摘要：Objectives. We assessed the relationship between distribution of education and health indicators in a large urban area to determine if distribution of education may be a determinant of population health. Methods. We studied the association between distribution of education, measured with the education Gini coefficient, and rates of 8 health indicators in 59 neighborhoods in New York City. Results. In separate adjusted ecological models, neighborhoods with more poorly distributed education had better population health indicators that might plausibly be associated with short-term changes in the social environment (e.g., homicide and infant mortality rate); there was no association between education distribution and health indicators more likely to be associated with long-term accumulation of social and behavioral stressors (e.g., cardiovascular disease and chronic lung disease mortality rates). These findings were robust to measures of income and to adjustment for several potential confounders (e.g., gender and race/ethnicity). Conclusions. The presence in a neighborhood of highly educated people may be salutary for all residents, independent of the potentially deleterious consequences of income maldistribution. Income and education are often considered “fundamental” determinants of health and primary indicators of socioeconomic status. 1 – 3 The relationships between income and health and between education and health are well established; people who are wealthier and people who are better educated live longer and suffer less morbidity during their lifetimes. 4 – 6 In the past 2 decades, a substantial body of work also has assessed the relationship between unequal distribution of income (frequently referred to in the public health literature as “income inequality”) and population health. 7 – 10 The evidence in the field remains controversial, but recent systematic reviews of the literature suggest that while there is little consistent evidence of a cross-national relationship between income distribution and health, there may be a relationship in the United States between income maldistribution and indicators of poor health at the state, city, and neighborhood levels. 9 , 10 At the group level, the relation between distribution of education and population health may be different from that between distribution of income and population health. 11 , 12 The presence in a community of people with a wide range of incomes has been hypothesized to generate interpersonal stress and concentrate resources among those with more wealth; in contrast, the presence of people with a wide range of educational attainment may be accompanied by positive (“spillover”) benefits generated by the actions of those of high educational attainment. 13 For example, a health care facility may provide services and information at the level demanded by its most educated patients, which would then benefit all who use the facility. Similarly, more educated people may have access to individuals in power and may, for example, successfully lobby against undesirable projects such as construction of waste disposal facilities. Such improvements in health determinants, while driven by individuals at higher education levels, will then be available to all other residents of a particular area as long as the improved resources are not prohibitively expensive. Therefore, it is plausible that a small group of more highly educated individuals may contribute to improvements in the shared facilities and resources of a given area. These shared facilities and resources, in turn, barring significant financial barriers, may contribute to improved well-being among all the area’s residents. These benefits may be particularly important in the context of health indicators, such as homicide and infant mortality rates, that are likely to be affected by short-term changes in the social environment. Therefore, distribution of education may be an important determinant of population health, and it may play a role different from that of income distribution. Although all US residents have access to education at the primary and secondary school levels, there are wide ranges in educational attainment. 14 Substantial educational disparities exist between various racial/ethnic and socioeconomic groups in the United States, 15 – 17 and it has been argued that these disparities may contribute to racial/ethnic inequalities in health. 18 However, we are not aware of previous work in which the role of area-level education distribution has been explicitly assessed as a potential determinant of health. We examined the relations between education distribution, income distribution, and specific health indicators in New York City neighborhoods. We hypothesized that neighborhoods with wider education distributions would fare better in terms of population health indicators that may be sensitive to short-term changes in the social environment (homicide, infant mortality, low birthweight, late or no prenatal care) after neighborhood educational levels, income levels, and income distribution had been taken into account. We also hypothesized that there would be no association between education distribution and health indicators that are more likely to reflect biological factors or cumulative social stressors over the long term (mortality resulting from cardiovascular disease, chronic lower respiratory disease, chronic liver disease and cirrhosis, and cerebrovascular disease).
