摘要：Objectives. Social determinants of health, such as inadequate education, contribute greatly to mortality rates. We examined whether correcting the social conditions that account for excess deaths among individuals with inadequate education might save more lives than medical advances (e.g., new drugs and devices). Methods. Using US vital statistics data for 1996 through 2002, we applied indirect standardization techniques to estimate the maximum number of averted deaths attributable to medical advances and the number of deaths that would have been averted if mortality rates among adults with lesser education had been the same as those among college-educated adults. Results. Medical advances averted a maximum of 178193 deaths during the study period. Correcting disparities in education-associated mortality rates would have saved 1369335 lives during the same period, a ratio of 8:1. Conclusions. Higher mortality rates among individuals with inadequate education reflect a complex causal pathway and the influence of confounding variables. Formidable efforts at social change would be necessary to eliminate disparities, but the changes would save more lives than would society’s current heavy investment in medical advances. Spending large sums of money on such advances at the expense of social change may be jeopardizing public health. The past century’s progress in medicine and public health has reduced morbidity and lengthened life expectancy, but the pace of progress has been modest. For more than 100 years, the national death rate has declined at a rate that has remained remarkably constant (1% per year), with the exception of the conspicuous spike during the 1917–1918 influenza pandemic (Figure 1 ▶ ). Neither the public health advances of the early 20th century nor the medical technological advances in more recent times have done much to change the modest downward slope. Open in a separate window FIGURE 1— Age-adjusted mortality rates in the United States: 1900–2003. Note. Data were derived from the National Center for Health Statistics; specific database sources are available as an online supplement to this article. In the past few decades there have been heavy investments in technological advances. Both industry and government have spent billions of dollars per year on the development of new drugs and devices. The failure of these efforts to enhance the rate of decline in mortality rates, however, raises questions about the prudence of carrying this investment priority into the new century. A potentially more effective alternative might be to continue technological advancements but to invest more substantively in areas outside of medical innovation that can do more to avert deaths and enhance health. We demonstrated in a previous analysis that equity of mortality rates among African Americans and Whites would have resulted in 5 times as many lives being saved during 1991 through 2000 as those saved by medical advances. 1 Minority groups have higher mortality rates for multiple reasons, notably adverse social conditions such as inadequate access to health care, educational disparities, and poverty. 2 – 4 People of low socioeconomic status have higher mortality rates and poorer health status than does the general population. 5 , 6 Addressing these social determinants of health might do more to save lives than the incremental advancements in the technology of care that consume the bulk of societal investments in health. 6 , 7 We explored this possibility by examining death rates among adults with inadequate education, a group known to have excess mortality rates. Mortality rates among adults with a high school education and those with less than a high school education (inadequate education) are 2.3 and 2.7 times higher, respectively, than rates among those with at least some college education. 8 Education empowers individuals with knowledge to make better personal health choices and with higher earnings to obtain access to quality health care. The link between education and mortality is confounded by its association with other factors that also affect health outcomes (e.g., early life experiences, race and ethnicity, community and environmental conditions). We used education-associated excess mortality as a proxy for this web of sociological, economic, and biological variables. We recognize that this excess mortality will not be fully eliminated by education alone but rather by ameliorating the combination of related sociological factors, education among them, that account for the health of the educated. Our aim was to quantify the potential benefit from such an enterprise and to contrast it with the lives saved by our current investment in medical advances.
