A Surprising Secret to a Long Life: Stay in School

Gina Kolata, New York Times, Jan 3, 2007

James Smith, a health economist at the RAND 
Corporation, has heard a variety of hypotheses 
about what it takes to live a long life ­ money, 
lack of stress, a loving family, lots of friends. But he has been a skeptic.

Yes, he says, it is clear that on average some 
groups in every society live longer than others. 
The rich live longer than the poor, whites live 
longer than blacks in the United States. 
Longevity, in general, is not evenly distributed 
in the population. But what, he asks, is cause 
and what is effect? And how can they be disentangled?

He is venturing, of course, into one of the 
prevailing mysteries of aging, the persistent 
differences seen in the life spans of large 
groups. In every country, there is an average 
life span for the nation as a whole and there are 
average life spans for different subsets, based 
on race, geography, education and even churchgoing.

But the questions for researchers like Dr. Smith 
are why? And what really matters?

The answers, he and others say, have been a 
surprise. The one social factor that researchers 
agree is consistently linked to longer lives in 
every country where it has been studied is 
education. It is more important than race; it 
obliterates any effects of income.

Year after year, in study after study, says 
Richard Hodes, director of the National Institute 
on Aging, education “keeps coming up.”

And, health economists say, those factors that 
are popularly believed to be crucial ­ money and 
health insurance, for example, pale in comparison.

Dr. Smith explains: “Giving people more Social 
Security income, or less for that matter, will 
not really affect people’s health. It is a good 
thing to do for other reasons but not for health.”

Health insurance, too, he says, “is vastly overrated in the policy debate.”

Instead, Dr. Smith and others say, what may make 
the biggest difference is keeping young people in 
school. A few extra years of school is associated 
with extra years of life and vastly improved health decades later, in old age.

It is not the only factor, of course.

There is smoking, which sharply curtails life 
span. There is a connection between having a 
network of friends and family and living a long 
and healthy life. And there is evidence that 
people with more powerful jobs and, presumably, 
with more control over their work lives, are healthier and longer lived.

But there is little dispute about the primacy of education.

“If you were to ask me what affects health and 
longevity,” says Michael Grossman, a health 
economist at the City University of New York, “I 
would put education at the top of my list.”

Graduate Student Finds Answer

The first rigorous effort to decide whether 
education really changes people so they live 
longer began in a most inauspicious way.

It was 1999 and a Columbia University graduate 
student, Adriana Lleras-Muney, was casting about 
for a topic for her doctoral dissertation in 
economics. She found an idea in a paper published 
in 1969. Three economists noted the correlation 
between education and health and gave some 
advice: If you want to improve health, you will 
get more return by investing in education than by investing in medical care.

It had been an inflammatory statement, Dr. 
Lleras-Muney says. And for good reason. It could 
only be true if education in and of itself caused good health.

But there were at least two other possibilities.

Maybe sick children did not go to school, or 
dropped out early because they were ill. Or maybe 
education was a proxy for wealth, and it was 
wealth that led to health. It could be that 
richer parents who gave their children 
everything, including better nutrition, better 
medical care and a better education, had children 
who, by virtue of being wealthy, lived longer.

How, she asked herself, could she sort out causes 
and effects? It was the chicken-and-egg problem that plagues such research.

The answer came one day when Dr. Lleras-Muney was 
reading another economics paper. It indicated 
that about 100 years ago, different states 
started passing laws forcing children to go to 
school for longer periods. She knew what to do.

“The idea was, when a state changed compulsory 
schooling from, say, six years to seven years, 
would the people who were forced to go to school 
for six years live as long as the people the next 
year who had to go for seven years,” Dr. Lleras-Muney asked.

All she would have to do was to go back and find 
the laws in the different states and then use 
data from the census to find out how long people 
lived before and after the law in each state was changed.

“I was very excited for about three seconds,” she 
says. Then she realized how onerous it could be 
to comb through the state archives.

But when her analysis was finished, Dr. 
Lleras-Muney says, “I was surprised, I was really 
surprised.” It turned out that life expectancy at 
age 35 was extended by as much as one and a half 
years simply by going to school for one extra year.

Her prize-winning paper appeared in Review of 
Economic Studies. And she ended up with a job as 
an assistant professor at Princeton. Now, others 
papers have appeared, examining the effects of 
changed laws on compulsory education in Sweden, 
Denmark, England and Wales. In every country, 
compelling children to spend a longer time in school led to better health.

“You might think that forcing someone to go to 
school who does not want to be there may not be 
the same thing as going to school because you 
want to,” Dr. Lleras-Muney said. “That did not seem to be the case.”

Not everyone was convinced.

Victor Fuchs, a health economist at Stanford, 
points out that it is not clear how or why 
education would lead to a longer life.

And, he said, there are other mysteries. For 
example, women increased their years of schooling 
more than men have in recent decades. But men are 
catching up with women in their life spans.

And it might be expected that after a certain 
point, more years of school would not add to a 
person’s life span. That, however, is not what 
the data shows. The education effect never wanes. 
But most researchers say they are swayed by Dr. 
Lleras-Muney’s work and the studies in other 
countries. That, though, leaves the question of 
why the education effect occurs.

Dr. Lleras-Muney and others point to one 
plausible explanation ­ as a group, less educated 
people are less able to plan for the future and 
to delay gratification. If true, that may, for 
example, explain the differences in smoking rates 
between more educated people and less educated ones.

Smokers are at least twice as likely to die at 
any age as people who never smoked, says Samuel 
Preston, a demographer at the University of 
Pennsylvania. And not only are poorly educated 
people more likely to smoke but, he says, 
“everybody knows that smoking can be deadly,” and 
that includes the poorly educated.

But education, Dr. Smith at RAND finds, may 
somehow teach people to delay gratification. For 
example, he reported that in one large federal 
study of middle-aged people, those with less 
education were less able to think ahead.

“Most of adherence is unpleasant,” Dr. Smith 
says. “You have to be willing to do something 
that is not pleasant now and you have to stay 
with it and think about the future.”

He deplores the dictums to live in the moment or 
to live for today. That advice, Dr. Smith says, 
is “the worst thing for your health.”

An Observation on the Street

In the late 1970’s, Lisa Berkman, now a professor 
of public policy at the Harvard School of Public 
Health, took a part-time job at a San Francisco 
health care center. It drew people from Chinatown 
and the city’s Italian neighborhood, North Beach, 
as well as from the Tenderloin district, a poor 
area where homeless people lived on the streets 
and mentally ill people roamed. And she noticed something striking.

“In Chinatown and North Beach, there were these 
tightly bound social networks,” Dr. Berkman 
recalls. “You saw old people with young people. 
In the Tenderloin, people were just sort of 
dumped. People were really isolated and did not 
have ways of figuring out how to make things work.”

A few years later, she was haunted by that 
observation. She had entered graduate school and 
was studying Seventh-day Adventists when she 
began to wonder whether the standard explanation 
for their longer lives ­ a healthy, vegetarian diet ­ was enough.

“They were at decreased risk from many, many 
diseases, even ones where diet was not 
implicated,” Dr. Berkman says. And, she adds, “it 
seemed they simply had a slower rate of aging.”

Seventh-day Adventists, like the people in 
Chinatown and North Beach, had “incredibly 
cohesive social networks,” Dr. Berkman notes. Could that be the clue?

Thirty years later, studies have borne out her hunch.

The risks of being socially isolated are 
“phenomenal,” Dr. Berkman says, associated with 
twofold to fivefold increases in mortality rates. 
And the correlations emerged in study after study 
and in country after country.

Yet, Dr. Berkman adds, there was that perennial 
question: Did social isolation shorten lives or 
were people isolated because they were sick and 
frail and at great risk of death?

She knows that sometimes ill health leads to 
social isolation. But, Dr. Berkman says, the more 
she investigated, the more evidence she found 
that social isolation might also lead to poor 
health and a shorter life by, for example, 
increasing stress and making it harder to get assistance when ill.

But researchers also warn that their findings 
that education and, to a lesser degree, social 
networks, may directly affect health do not 
necessarily mean that other hypotheses would also 
hold up. The cautionary tale, health economists 
say, is the story of the link between health and wealth.

Over and over again, studies show that health is 
linked to wealth. It even matters where a person lives.

For example, in a new analysis of Medicare 
beneficiaries, Stephanie Raymond and Kristen 
Bronner of Dartmouth College find that the lowest 
death rates are in the wealthiest places. So in 
San Francisco, with a per capita income of 
$57,496, just 4.16 percent of Medicare 
beneficiaries die each year. But in Tuscaloosa, 
Ala, whose per capita income is $24,257, the 
annual death rate was 5.97 percent.

Race was not a large factor.

“If you control for where people live, the 
disparities between black and white mortality 
rates become much smaller,” said Jonathan 
Skinner, a Dartmouth health economist.

An obvious explanation is that wealth buys 
health. And it seems plausible. Poorer people, at 
least in the United States, are less likely to 
have health insurance or access to medications.

But Dr. Fuchs says, then why don’t differences 
between rich and poor shrink in countries where everyone has health care?

“All you have to do is look at the experience of 
countries like England that have had health 
insurance for more than 40 years,” he says. 
“There is no diminution in the class 
differentials. It’s been the same in Sweden. It’s true everywhere.”

In fact, Dr. Smith says, the wealth-health 
connection, at least among adults, goes in the 
wrong direction. It is not that lower incomes 
lead to poor health so much as that poor health 
leads to lower incomes, he found.

A Skewing of the Numbers

Sick people tend to have modest out-of-pocket 
medical expenses, but often are unable to work or unable to work full time.

The result can be a drastic and precipitous and 
long-lasting drop in income. As the ranks of 
middle- and upper-income populations become 
depleted of people who are ill, there is a 
skewing of the data so healthy people are disproportionately richer.

That effect emerged when Dr. Smith analyzed data 
from the National Institute on Aging’s National 
Health and Retirement Survey, a national sample 
of 7,600 American households with at least one person aged 51 to 61.

If someone developed cancer, heart disease or 
lung disease ­ which will affect about a fifth of 
people aged 51 to 61 over the next eight years ­ 
the household’s income declined by an average of 
more than $37,000. And its assets ­ its wealth ­ 
fell by $49,000 over the ensuing eight years, 
even though out-of-pocket medical expenses were just $4,000.

Dr. Smith also asked whether getting richer made 
people healthier, an effect that could translate 
into a longer life. It does not, he concluded 
after studying the large increases in income 
during the stock market surge of the 1990s.

“I find almost no role of financial anything in 
the onset of disease,” Dr. Smith says. “That’s an 
almost throw-you-out-of-the-room thing,” he 
confesses, but the data, he and other economists insist, is consistent.

Income, says Dr. Preston, “is so heavily influenced by health itself.”

Much More Than Genes and Luck

As director of the National Institute on Aging, 
Dr. Hodes often speaks to policy makers, giving 
briefings on the latest scientific findings. But, 
he and others say, all too often there is a disconnect.

There are some important findings: Health and 
nutrition early in life, even prenatally, can 
affect health in middle and old age and can affect how long people live.

For the most part, genes have little effect on 
life spans. Controlling heart disease risk 
factors, like smoking, cholesterol, blood 
pressure and diabetes, pays off in a more 
vigorous old age and a longer life. And it seems 
increasingly likely that education plays a major role in health and life spans.

And then there is the question of what to do. It 
might seem logical to act now, pouring money into 
education or child health, for example.

But scientists often say they would like good 
evidence beforehand that a program that sounds 
like it would make a difference, like keeping 
students in school longer, really works. And if 
the goal is longer and healthier lives, is that 
the most cost-effective way to spend public money?

There are just so many questions remaining, says 
Richard Suzman, a program director at the 
National Institute on Aging. Even studies showing 
that, for many people, the die may be cast early 
in life, do not reveal how best to make changes.

“We have only a vague idea of when and where 
early experience links to old age or when and 
where to intervene,” Dr. Suzman says.

“When it comes to changing things,” says Dr. 
Skinner, the Dartmouth economist, “we are in uncharted territory.” 

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