Differences In Life Expectancy Due To Race And Educational Differences Are Widening, And Many May Not Catch Up

Trends in Educational Inequalities in Drug Poisoning Mortality: United States, 1994-2010

OBJECTIVES

We estimated trends in drug poisoning death rates by educational attainment and investigated educational inequalities in drug poisoning mortality by race, gender, and region.

METHODS

We linked drug poisoning death counts from the National Vital Statistics System to population denominators from the Current Population Survey to estimate drug poisoning rates by gender, race, region, and educational attainment (less than high school degree, high school degree, some college, college degree) from 1994 to 2010.

RESULTS

There were 372,485 drug poisoning deaths. Education-related inequalities increased during the study among all demographic groups and varied by region. Absolute increases in educational inequalities were higher among Whites than Blacks and men than women. The age-adjusted rate difference between White men with less than a high school degree increased from 8.7 per 100,000 in 1994 to 27.4 in 2010 (change = 18.7). Among Black men, the corresponding increases were 11.7 and 18.3, respectively (change = 6.6).

CONCLUSIONS

We found strong educational patterning in drug poisoning rates, chiefly by region and race. Rates are highest and increasing the fastest among groups with less education.

Mortality Attributable to Low Levels of Education in the United States

BACKGROUND

Educational disparities in U.S. adult mortality are large and have widened across birth cohorts. We consider three policy relevant scenarios and estimate the mortality attributable to: (1) individuals having less than a high school degree rather than a high school degree, (2) individuals having some college rather than a baccalaureate degree, and (3) individuals having anything less than a baccalaureate degree rather than a baccalaureate degree, using educational disparities specific to the 1925, 1935, and 1945 cohorts.

METHODS

We use the National Health Interview Survey data (1986-2004) linked to prospective mortality through 2006 (N=1,008,949), and discrete-time survival models, to estimate education- and cohort-specific mortality rates. We use those mortality rates and data on the 2010 U.S. population from the American Community Survey, to calculate annual attributable mortality estimates.

RESULTS

If adults aged 25-85 in the 2010 U.S. population experienced the educational disparities in mortality observed in the 1945 cohort, 145,243 deaths could be attributed to individuals having less than a high school degree rather than a high school degree, 110,068 deaths could be attributed to individuals having some college rather than a baccalaureate degree, and 554,525 deaths could be attributed to individuals having anything less than a baccalaureate degree rather than a baccalaureate degree. Widening educational disparities between the 1925 and 1945 cohorts result in a doubling of attributable mortality. Mortality attributable to having less than a high school degree is proportionally similar among women and men and among non-Hispanic blacks and whites, and is greater for cardiovascular disease than for cancer.

CONCLUSIONS

Mortality attributable to low education is comparable in magnitude to mortality attributable to individuals being current rather than former smokers. Existing research suggests that a substantial part of the association between education and mortality is causal. Thus, policies that increase education could significantly reduce adult mortality.

Inequalities in health: definitions, concepts, and theories

Individuals from different backgrounds, social groups, and countries enjoy different levels of health. This article defines and distinguishes between unavoidable health inequalities and unjust and preventable health inequities. We describe the dimensions along which health inequalities are commonly examined, including across the global population, between countries or states, and within geographies, by socially relevant groupings such as race/ethnicity, gender, education, caste, income, occupation, and more. Different theories attempt to explain group-level differences in health, including psychosocial, material deprivation, health behavior, environmental, and selection explanations. Concepts of relative versus absolute; dose-response versus threshold; composition versus context; place versus space; the life course perspective on health; causal pathways to health; conditional health effects; and group-level versus individual differences are vital in understanding health inequalities. We close by reflecting on what conditions make health inequalities unjust, and to consider the merits of policies that prioritize the elimination of health disparities versus those that focus on raising the overall standard of health in a population.

The past, present, and future of cancer incidence in the United States: 1975 through 2020

BACKGROUND

The overall age-standardized cancer incidence rate continues to decline whereas the number of cases diagnosed each year increases. Predicting cancer incidence can help to anticipate future resource needs, evaluate primary prevention strategies, and inform research.

METHODS

Surveillance, Epidemiology, and End Results data were used to estimate the number of cancers (all sites) resulting from changes in population risk, age, and size. The authors projected to 2020 nationwide age-standardized incidence rates and cases (including the top 23 cancers).

RESULTS

Since 1975, incident cases increased among white individuals, primarily caused by an aging white population, and among black individuals, primarily caused by an increasing black population. Between 2010 and 2020, it is expected that overall incidence rates (proxy for risk) will decrease slightly among black men and stabilize in other groups. By 2020, the authors predict annual cancer cases (all races, all sites) to increase among men by 24.1% (-3.2% risk and 27.3% age/growth) to >1 million cases, and by 20.6% among women (1.2% risk and 19.4% age/growth) to >900,000 cases. The largest increases are expected for melanoma (white individuals); cancers of the prostate, kidney, liver, and urinary bladder in males; and the lung, breast, uterus, and thyroid in females.

CONCLUSIONS

Overall, the authors predict cancer incidence rates/risk to stabilize for the majority of the population; however, they expect the number of cancer cases to increase by >20%. A greater emphasis on primary prevention and early detection is needed to counter the effect of an aging and growing population on the burden of cancer.

Economic downturns and suicide mortality in the USA, 1980-2010: observational study

BACKGROUND

Several studies have suggested strong associations between economic downturns and suicide mortality, but are at risk of bias due to unmeasured confounding. The rationale for our study was to provide more robust evidence by using a quasi-experimental design.

METHODS

We analysed 955,561 suicides occurring in the USA from 1980 to 2010 and used a broad index of economic activity in each US state to measure economic conditions. We used a quasi-experimental, fixed-effects design and we also assessed whether the effects were heterogeneous by demographic group and during periods of official recession.

RESULTS

After accounting for secular trends, seasonality and unmeasured fixed characteristics of states, we found that an economic downturn similar in magnitude to the 2007 Great Recession increased suicide mortality by 0.14 deaths per 100,000 population [95% confidence interval (CI) 0.00, 0.28] or around 350 deaths. Effects were stronger for men (0.28, 95% CI 0.07, 0.49) than women and for those with less than 12 years of education (1.22 95% CI 0.83, 1.60) compared with more than 12 years of education. The overall effect did not differ for recessionary (0.11, 95% CI -0.02, 0.25) vs non-recessionary periods (0.15, 95% CI 0.01, 0.29). The main study limitation is the potential for misclassified death certificates and we cannot definitively rule out unmeasured confounding.

CONCLUSIONS

We found limited evidence of a strong, population-wide detrimental effect of economic downturns on suicide mortality. The overall effect hides considerable heterogeneity by gender, socioeconomic position and time period.

Trends in U.S. life expectancy gradients: the role of changing educational composition

BACKGROUND

I examined age patterns and the role of shifting educational distributions in driving trends in educational gradients in life expectancy among non-Hispanic Whites between 1991 and 2005.

METHODS

Data were from the 1986-2004 National Health Interview Survey with mortality follow-up through 2006. Life expectancies were computed by sex, period and education. Age decompositions of life expectancy gradients and composition-adjusted life expectancies were computed to account for age patterns and shifting educational distributions.

RESULTS

Life expectancy at age 25 among White men increased for all education groups, decreased among the least-educated White women and increased among White women with college degrees. Much of the decline in measured life expectancy for White women with less than a high school education comes from the 85+ age group. Educational gradients in life expectancy widened for White men and women. One-third of the gradient is due to ages below 50. Approximately 26% (0.7 years) and 87% (0.8 years) of the widening of the gradient in life expectancy between ages 25 and 85 for White women and men is attributable to shifting education distributions. Over half of the decline in temporary life expectancy among the least-educated White women is due to compositional change.

CONCLUSIONS

Life expectancy has increased among White men for all education groups and has decreased among White women with less than a high school education, though not to the extent reported in previous studies. The fact that a large proportion of the change in education-specific life expectancy among women is due to the 85+ age group suggests changes in institutionalization may be affecting estimates. Much of the change in education-specific life expectancy and the growth in the educational gradient in life expectancy is due to the shifting distribution of individuals across education categories.

Postmenopausal Motherhood Reloaded: Advanced Age and In Vitro Derived Gametes

In this paper we look at the implications of an emerging technology for the case in favor of, or against, postmenopausal motherhood. Technologies such as in vitro derived gametes (sperm and eggs derived from nonreproductive cells) have the potential to influence the ways in which reproductive medicine is practiced, and are already bringing new dimensions to debates in this area. We explain what in vitro derived gametes are and how their development may impact on the case of postmenopausal motherhood. We briefly review some of the concerns that postmenopausal motherhood has raised-and the implications that the successful development, and use in reproduction, of artificial gametes might have for such concerns. The concerns addressed include arguments from nature, risks and efficacy, reduced energy of the mother, and maternal life expectancy. We also consider whether the use of in vitro derived gametes to facilitate postmenopausal motherhood would contribute to reinforcing a narrow, geneticized account of reproduction and a pro-reproductive culture that encourages women to produce genetically related offspring at all costs.

Racial/ethnic disparities in midlife depressive symptoms: The role of cumulative disadvantage across the life course

This study examines the role of cumulative disadvantage mechanisms across the life course in the production of racial and ethnic disparities in depressive symptoms at midlife, including the early life exposure to health risk factors, the persistent exposure to health risk factors, and varying mental health returns to health risk factors across racial and ethnic groups. Using data from the over-40 health module of the National Longitudinal Study of Youth (NLSY) 1979 cohort, this study uses regression decomposition techniques to attend to differences in the composition of health risk factors across racial and ethnic groups, differences by race and ethnicity in the association between depressive symptoms and health risk factors, and how these differences combine within racial and ethnic groups to produce group-specific levels of--and disparities in--depressive symptoms at midlife. While the results vary depending on the groups being compared across race/ethnicity and gender, the study documents how racial and ethnic mental health disparities at midlife stem from life course processes of cumulative disadvantage through both unequal distribution and unequal associations across racial and ethnic groups.

Trends in education gradients of 'preventable' mortality: a test of fundamental cause theory

Fundamental cause theory explains persisting associations between socioeconomic status and mortality in terms of personal resources such as knowledge, money, power, prestige, and social connections, as well as disparate social contexts related to these resources. We review evidence concerning fundamental cause theory and test three central claims using the National Health Interview Survey Linked Mortality Files 1986-2004. We then examine cohort-based variation in the associations between a fundamental social cause of disease, educational attainment, and mortality rates from heart disease, other "preventable" causes of death, and less preventable causes of death. We further explore race/ethnic and gender variation in these associations. Overall, findings are consistent with nearly all features of fundamental cause theory. Results show, first, larger education gradients in mortality risk for causes of death that are under greater human control than for less preventable causes of death, and, second, that these gradients grew more rapidly across successive cohorts than gradients for less preventable causes. Results also show that relative sizes and cohort-based changes in the education gradients vary substantially by race/ethnicity and gender.

Prosper and Live Long: Productive Life Span Tracks Increasing Overall Life Span Over Historical Time among Privileged Worker Groups

Life expectancy has increased continuously for at least 150 years, due at least in part to improving life conditions for the majority of the population. A substantial part of this historical increase is due to decreases in early life mortality. In this article, we analyze the longevity of four privileged sets of adults who have avoided childhood mortality and lived a life more similar to the modern middle class. Our analysis is focused on writers and musicians from the 17th through the 21st centuries. We show that their average age at death increased only slightly between 1600 and 1900, but in the 20th century increased at around 2 years/decade. We suggest that this confirms that modern life span extension is driven by delay of death in older life rather than avoidance of premature death. We also show that productive life span, as measured by writing and composition outputs, has increased in parallel with overall life span in these groups. Increase in age of death is confirmed in a group of the minor British aristocracy and in members of the US Congress from 1800 to 2010. We conclude that both life span and productive life span are increasing in the 20th and early 21st century, and that the modern prolongation of life is the extension of productive life and is not the addition of years of disabling illness to the end of life.

On the decomposition of life expectancy and limits to life

Life expectancy is a measure of how long people are expected to live and is widely used as a measure of human development. Variations in the measure reflect not only the process of ageing but also the impacts of such events as epidemics, wars, and economic recessions. Since 1950, the influence of these events in the most developed countries has waned and life expectancy continues to lengthen unabated. As a result, it has become more difficult to forecast long-run trends accurately, or identify possible upper limits. We present new methods for comparing past improvements in life expectancy and also future prospects, using data from five developed, low-mortality countries. We consider life expectancy in 10-year age intervals rather than over the remaining lifetime, and show how natural limits to life expectancy can be used to extrapolate trends. We discuss the implications and compare our approach with other commonly used methods.

Coming unmoored: disproportionate increases in obesity prevalence among young, disadvantaged white women

OBJECTIVES

Since the 1980s, older, low-educated White women experienced an unprecedented decrease in life expectancy. We investigated whether a similar phenomenon was evident among younger women for obesity.

METHODS

Using the National Health and Nutrition Examination Survey, age-adjusted changes were estimated in the prevalence of overall and abdominal obesity (BMI ≥ 30 kg/m(2) , waist circumference > 88 cm) between 1988-1994 and 2003-2010 among non-Hispanic White women aged 25-44 years, stratified by educational attainment (<high school (HS), HS, some college, college degree). To address bias from secular increases in educational attainment, White women's changes in obesity prevalence were compared to changes among similarly educated Black women.

RESULTS

Relative increases in overall obesity were disproportionately larger for low-educated (<HS) compared to college-educated White women: 12.3 (95% CI: 3.1, 21.5) percentage points (ppts). For overall and abdominal obesity, general trends indicated dissimilar racial differences by educational attainment. For instance, overall obesity increased more in Blacks than Whites among college-educated (9.9 ppts) but not low-educated (-2.5 ppts) women.

CONCLUSIONS

Contemporary young, low-educated White women showed indications of disproportionate worsening of overall obesity prevalence compared to more educated White and similarly educated Black women. Low education levels are more powerful indicators of obesity risk among contemporary White women than 30 years ago.

Changes in child mortality over time across the wealth gradient in less-developed countries

BACKGROUND

It is unknown whether inequalities in under-5 mortality by wealth in low- and middle-income countries (LMICs) are growing or declining.

METHODS

All Demographic and Health Surveys conducted between 2002 and 2012 were used to measure under-5 mortality trends in 3 wealth tertiles. Two approaches were used to estimate changes in under-5 mortality: within-survey changes from all 54 countries, and between-survey changes for 29 countries with repeated survey waves. The principal outcome measures include annual decline in mortality, and the ratio of mortality between the poorest and least-poor wealth tertiles.

RESULTS

Mortality information in 85 surveys from 929 224 households and 1 267 167 women living in 54 countries was used. In the subset of 29 countries with repeat surveys, mortality declined annually by 4.36, 3.36, and 2.06 deaths per 1000 live births among the poorest, middle, and least-poor tertiles, respectively (P = .031 for difference). The mortality ratio declined from 1.68 to 1.48 during the study period (P = .006 for trend). In the complete set of 85 surveys, the mortality ratio declined in 64 surveys (from 2.11 to 1.55), and increased in 21 surveys (from 1.58 to 1.88). Multivariate analyses suggest that convergence was associated with good governance (P ≤ .03 for 4 governance indicators: government effectiveness, rule of law, regulatory quality, and control of corruption).

CONCLUSIONS

Overall, under-5 mortality in low- and middle-income countries has decreased faster among the poorest compared with the least poor between 1995 and 2012, but progress in some countries has lagged, especially with poor governance.

Long-term trends in adult mortality for U.S. Blacks and Whites: an examination of period- and cohort-based changes

Black-white differences in U.S. adult mortality have narrowed over the past five decades, but whether this narrowing unfolded on a period or cohort basis is unclear. The distinction has important implications for understanding the socioeconomic, public health, lifestyle, and medical mechanisms responsible for this narrowing. We use data from 1959 to 2009 and age-period-cohort (APC) models to examine period- and cohort-based changes in adult mortality for U.S. blacks and whites. We do so for all-cause mortality among persons aged 15-74 as well as for several underlying causes of death more pertinent for specific age groups. We find clear patterns of cohort-based reductions in mortality for both black men and women and white men and women. Recent cohort-based reductions in heart disease, stroke, lung cancer, female breast cancer, and other cancer mortality have been substantial and, save for breast cancer, have been especially pronounced for blacks. Period-based changes have also occurred and are especially pronounced for some causes of death. Period-based reductions in blacks' and whites' heart disease and stroke mortality are particularly impressive, as are recent period-based reductions in young men's and women's mortality from infectious diseases and homicide. These recent period changes are more pronounced among blacks. The substantial cohort-based trends in chronic disease mortality and recent period-based reductions for some causes of death suggest a continuing slow closure of the black-white mortality gap. However, we also uncover troubling signs of recent cohort-based increases in heart disease mortality for both blacks and whites.

Educational attainment and life expectancy: a perspective from the NIH Office of Behavioral and Social Sciences Research

The NIH Office of Behavioral and Social Sciences Research (OBSSR) furthers the mission of the NIH by stimulating behavioral and social sciences research throughout NIH and integrating these areas of research more fully into the NIH health research enterprise, thereby improving our understanding, treatment, and prevention of disease. OBSSR accomplishes this mission through several strategic priorities: (1) supporting the next generation of basic behavioral and social sciences research, (2) facilitating interdisciplinary research, (3) promoting a multi-level systems perspective of health and behavior, and (4) encouraging a problem-focused perspective on population health.

Intervening in ageing to prevent the diseases of ageing

Increases in human lifespan worldwide have revealed that advancing age is the predominant risk factor for major life-threatening diseases. Recent work has shown that ageing in diverse animals, including humans, is malleable to specific types of genetic mutation, diet, and drugs that can extend lifespan and improve health during ageing. These findings point to the prospect of broad-spectrum preventive medicine for the diseases of ageing based on intervention in relevant aspects of the ageing process itself.

Behavior change and reducing health disparities

The mission of the National Institutes of Health,"... is science in pursuit of fundamental knowledge about the nature and behavior of living systems and the application of that knowledge to enhance health, lengthen life, and reduce illness and disability". A wide range of factors contribute to longer life and to less illness. Although estimates vary, most analyses suggest that only about 10% of the variation in health outcome is attributable to medical care. Further, medical care is most effective in addressing and preventing infectious disease and acute illnesses. Recent large randomized clinical trials often fail to demonstrate that medical care lengthens life expectancy. International comparisons suggest that life expectancy in the United States is increasing, but the rate of increase is falling behind that of other wealthy countries. Strategies for improving health outcomes include better dissemination and implementation of proven evidence-based interventions. Further, reduction of services that use resources but do not offer health benefits must be considered. The final section of this paper reviews evidence relevant to factors outside the health care system that may enhance life expectancy and reduce illness and the disability. The relationship between educational attainment and life expectancy is used as a case example. The potential of behavioral and social interventions for increasing life expectancy may be orders of magnitude greater than traditional medial interventions. However, considerably more research is necessary in order to provide persuasive evidence for the benefits of these programs.

Recognizing global disparities in health and in health transitions in the 21st century: what can nurses do?

PURPOSE

To examine changes in patterns of health and disease in global context between rich countries (USA, Korea, South Africa) and poor countries (Cambodia, Malawi) by using the framework of epidemiology theory developed by Orman (1971, 2005), and to raise awareness of global health disparities thereby prompting actions to reduce such disparities.

FINDINGS

1) Life expectancy has increased across all selected countries except South Africa; 2) Korea and the USA have substantially lower mortality rates than other countries; 3) Infant and maternal mortality are still high in the poor countries; 4) The major cause of mortality in the poor countries is still communicable disease with evidence of the onset of non-communicable disease; and 5) The health transition theory provides a description and explanation of the differences in progress in economic development between countries but fails to explain differences in health status within and between countries.

CONCLUSIONS

Life expectancy and mortality are enormously different among the five selected countries. This excessive health disparity is primarily due to the higher risk of communicable diseases in low-income countries. Social determinants of health are mainly responsible for the health disparities observed within and between countries.

CLINICAL RELEVANCE

Future health care development and global research priorities will not be the same for all countries because the pattern of health transitions in the developing countries is not the same as the developed countries. Actions to reduce global health disparities need to recognize the conditions and social context in which persons live. An effective strategic approach to global health equality should develop a shared system of values, priorities, and delivery infrastructures with the populations who are targeted, aligning delivery within the local social contexts.

Trends in Work-Family Context among U.S. Women by Education Level, 1976 to 2011

This study compares trends in work-family context by education level from 1976 to 2011 among U.S. women. The major aim is to assess whether differences in work-family context by education level widened, narrowed, or persisted. We used data from the 1976-2011 March Current Population Surveys on women aged 25-64 (n=1,597,914). We compare trends in four work-family forms by education level within three race/ethnic groups. The work-family forms reflect combinations of marital and employment status among women with children at home. Trends in the four work-family forms exhibited substantial heterogeneity by education and race/ethnicity. Educational differences in the work-family forms widened mainly among white women. Compared with more-educated peers, white women without a high school credential became increasingly less likely to be married, to be employed, to have children at home, and to combine these roles. In contrast, educational differences in the work-family forms generally narrowed among black women and were directionally mixed among Hispanic women. Only one form-unmarried and employed with children at home-became more strongly linked to a woman's education level within all three race/ethnic groups. This form carries an elevated risk of work-family conflict and its prevalence increased moderately during the 35-year period. Taken together, the trends underscore recent calls to elevate work-family policy on the national agenda.

Educational Attainment and Life Expectancy

National objectives for health concentrate on improving life expectancy and enhancing health-related quality of life. Although U.S. life expectancy has seen significant extensions over the last century, the rate of increase has been falling behind other wealthy countries, and these trends have been worsening over the last 30 years. In addition, the United States spends considerably more on health care in comparison with major trading competitors. Most policy approaches for enhancing health focus on increasing expenditures for medical care. Yet, medical care explains only about 10% of the variance in health outcomes, whereas behavioral and social factors outside of health care explain nearly 50%. Evidence suggests that educational attainment may be one of the strongest correlates of life expectancy. As a baseline, cancer screening and optimizing established risk factors for premature death typically extend life expectancy by less than 1 year. In contrast, remediating the health disparity associated with low educational attainment might enhance life expectancy by up to a decade. Amassing persuasive evidence on the health benefits of interventions to improve educational attainment will be challenging. To address this issue, a robust program of systematic research is needed.

Divergence in age patterns of mortality change drives international divergence in lifespan inequality

In the past six decades, lifespan inequality has varied greatly within and among countries even while life expectancy has continued to increase. How and why does mortality change generate this diversity? We derive a precise link between changes in age-specific mortality and lifespan inequality, measured as the variance of age at death. Key to this relationship is a young-old threshold age, below and above which mortality decline respectively decreases and increases lifespan inequality. First, we show for Sweden that shifts in the threshold's location have modified the correlation between changes in life expectancy and lifespan inequality over the last two centuries. Second, we analyze the post-World War II (WWII) trajectories of lifespan inequality in a set of developed countries-Japan, Canada, and the United States-where thresholds centered on retirement age. Our method reveals how divergence in the age pattern of mortality change drives international divergence in lifespan inequality. Most strikingly, early in the 1980s, mortality increases in young U.S. males led to a continuation of high lifespan inequality in the United States; in Canada, however, the decline of inequality continued. In general, our wider international comparisons show that mortality change varied most at young working ages after WWII, particularly for males. We conclude that if mortality continues to stagnate at young ages yet declines steadily at old ages, increases in lifespan inequality will become a common feature of future demographic change.

Are Differences in Disability-Free Life Expectancy by Gender, Race, and Education Widening at Older Ages?

To examine change from 1991 to 2001 in disability-free life expectancy in the age range 60-90 by gender, race, and education in the United States. Mortality is estimated over two 10-year follow-up periods for persons in the National Health Interview Surveys of 1986/1987 and 1996/1997. Vital status is ascertained through the National Death Index. Disability prevalence is estimated from the National Health and Nutrition Examination Surveys of 1988-1994 and 1999-2002. Disability is defined as ability to perform four activities of daily living without difficulty. Disability-free life expectancy increased only among white men. Disabled life expectancy increased for all groups-black and white men and women. Racial differences in disability-free life expectancy widened among men; gender differences were reduced among whites. Expansion of socioeconomic differentials in disability-free life at older ages occurred among white men and women and black women. The 1990s was a period where the increased years of life between ages 60 and 90 were concentrated in disabled years for most population groups.

Neuroenhancing public health

One of the most fascinating issues in the emerging field of neuroethics is pharmaceutical cognitive enhancement (CE). The three main ethical concerns around CE were identified in a Nature commentary in 2008 as safety, coercion and fairness; debate has largely focused on the potential to help those who are cognitively disabled, and on the issue of 'cosmetic neurology', where people enhance not because of a medical need, but because they want to (as many as 25% of US students already use nootropic cognitive enhancers such as ritalin). However, the potential for CE to improve public health has been neglected. This paper examines the prospect of improving health outcomes through CE among sections of the population where health inequalities are particularly pronounced. I term this enhancement of the public's health through CE 'neuroenhancing health'. It holds great promise, but raises several ethical issues. This paper provides an outline of these issues and related philosophical problems. These include the potential effectiveness of CE in reducing health inequalities; issues concerning autonomy and free will; whether moral enhancement might be more effective than CE in reducing health inequalities; and the problem of how to provide such CE, including the issue of whether to provide targeted or universal coverage.

Racial differences in the prevalence of severe aortic stenosis

BACKGROUND

In an era of expanded treatment options for severe aortic stenosis, it is important to understand risk factors for the condition. It has been suggested that severe aortic stenosis is less common in African Americans, but there are limited data from large studies.

METHODS AND RESULTS

The Synthetic Derivative at Vanderbilt University Medical Center, a database of over 2.1 million de-identified patient records, was used to identify individuals who had undergone echocardiography. The association of race with severe aortic stenosis was examined using multivariable logistic regression analyses adjusting for conventional risk factors. Of the 272 429 eligible patients (mean age 45 years, 44% male) with echocardiography, 14% were African American and 82% were Caucasian. Severe aortic stenosis was identified in 106 (0.29%) African-American patients and 2030 (0.91%) Caucasian patients (crude OR 0.32, 95% CI [0.26, 0.38]). This difference persisted in multivariable-adjusted analyses (OR 0.41 [0.33, 0.50], P<0.0001). African-American individuals were also less likely to have severe aortic stenosis due to degenerative calcific disease (adjusted OR 0.47 [0.36, 0.61]) or congenitally bicuspid valve (crude OR 0.13 [0.02, 0.80], adjusted OR dependent on age). Referral bias against those with severe valvular disease was assessed by comparing the prevalence of severe mitral regurgitation in Caucasians and African Americans and no difference was found.

CONCLUSIONS

These findings suggest that African Americans are at significantly lower risk of developing severe aortic stenosis than Caucasians.

The Growing Gap in Life Expectancy: Using the Future Elderly Model to Estimate Implications for Social Security and Medicare

Mortality gradients by education and income have been rising in the United States and elsewhere. However, their impact on Social Security progressivity has received relatively little attention, and the impact on Medicare has received effectively none. This paper uses the Future Elderly Model to estimate the effects of increased mortality gaps on the progressivity of Social Security and Medicare for those born between 1928 and 1990. It finds significant reductions in progressivity of both programs if current mortality trends persist and noticeable effects on total program costs. The effects are large enough to warrant more attention from both policy-makers and researchers.

The influence of health disparities on targeting cancer prevention efforts

Despite the advances in cancer medicine and the resultant 20% decline in cancer death rates for Americans since 1991, there remain distinct cancer health disparities among African Americans, Hispanics, Native Americans, and the those living in poverty. Minorities and the poor continue to bear the disproportionate burden of cancer, especially in terms of stage at diagnosis, incidence, and mortality. Cancer health disparities are persistent reminders that state-of-the-art cancer prevention, diagnosis, and treatment are not equally effective for and accessible to all Americans. The cancer prevention model must take into account the phenotype of accelerated aging associated with health disparities as well as the important interplay of biological and sociocultural factors that lead to disparate health outcomes. The building blocks of this prevention model will include interdisciplinary prevention modalities that encourage partnerships across medical and nonmedical entities, community-based participatory research, development of ethnically and racially diverse research cohorts, and full actualization of the prevention benefits outlined in the 2010 Patient Protection and Affordable Care Act. However, the most essential facet should be a thoughtful integration of cancer prevention and screening into prevention, screening, and disease management activities for hypertension and diabetes mellitus because these chronic medical illnesses have a substantial prevalence in populations at risk for cancer disparities and cause considerable comorbidity and likely complicate effective treatment and contribute to disproportionate cancer death rates.

Cross race comparisons between SES health gradients among African-American and white women at mid-life

This study explored how multiple indicators of socioeconomic status (SES) inform understanding of race differences in the magnitude of health gains associated with higher SES. The study sample, 1268 African-American women and 2066 white women, was drawn from the National Longitudinal Surveys of Youth 1979. The outcome was the Physical Components Summary from the SF-12 assessed at age 40. Ordinary least squares regressions using education, income and net worth fully interacted with race were conducted. Single measure gradients tended to be steeper for whites than African-Americans, partly because "sheepskin" effects of high school and college graduation were higher for whites and low income and low net worth whites had worse health than comparable African-Americans. Conditioning on multiple measures of SES eliminated race disparities in health benefits of education and net worth, but not income. A discussion of current public policies that affect race disparities in levels of education, income and net wealth is provided.

Widening rural-urban disparities in life expectancy, U.S., 1969-2009

BACKGROUND

There is limited research on rural-urban disparities in U.S. life expectancy.

PURPOSE

This study examined trends in rural-urban disparities in life expectancy at birth in the U.S. between 1969 and 2009.

METHODS

The 1969-2009 U.S. county-level mortality data linked to a rural-urban continuum measure were analyzed. Life expectancies were calculated by age, gender, and race for 3-year time periods between 1969 and 2004 and for 2005-2009 using standard life-table methodology. Differences in life expectancy were decomposed by age and cause of death.

RESULTS

Life expectancy was inversely related to levels of rurality. In 2005-2009, those in large metropolitan areas had a life expectancy of 79.1 years, compared with 76.9 years in small urban towns and 76.7 years in rural areas. When stratified by gender, race, and income, life expectancy ranged from 67.7 years among poor black men in nonmetropolitan areas to 89.6 among poor Asian/Pacific Islander women in metropolitan areas. Rural-urban disparities widened over time. In 1969-1971, life expectancy was 0.4 years longer in metropolitan than in nonmetropolitan areas (70.9 vs 70.5 years). By 2005-2009, the life expectancy difference had increased to 2.0 years (78.8 vs 76.8 years). The rural poor and rural blacks currently experience survival probabilities that urban rich and urban whites enjoyed 4 decades earlier. Causes of death contributing most to the increasing rural-urban disparity and lower life expectancy in rural areas include heart disease, unintentional injuries, COPD, lung cancer, stroke, suicide, and diabetes.

CONCLUSIONS

Between 1969 and 2009, residents in metropolitan areas experienced larger gains in life expectancy than those in nonmetropolitan areas, contributing to the widening gap.

Relationship between pain and chronic illness among seriously ill older adults: expanding role for palliative social work

Confronting the issue of pain among chronically ill older adults merits serious attention in light of mounting evidence that pain in this population is often undertreated or not treated at all (Institute of Medicine, 2011 ). The relationship between pain and chronic illness among adults age 50 and over was examined in this study through the use of longitudinal data from the University of Michigan Health and Retirement Study, sponsored by the National Institute on Aging and the Social Security Administration. Findings suggested positive associations between pain and chronic disease, pain and multimorbidity, as well as an inverse association between pain and education. Policy implications for workforce development and public health are many, and amplification of palliative social work roles to relieve pain and suffering among seriously ill older adults at all stages of the chronic illness trajectory is needed.

Linking Cultural Competence to Functional Life Outcomes in Mental Health Care Settings

Minorities in the United States have well-documented health disparities. Cultural barriers and biases by health care providers may contribute to lower quality of services which may contribute to these disparities. However, evidence linking cultural competency and health outcomes is lacking. This study, part of an ongoing quality improvement effort, tested the mediation hypothesis that patients' perception of provider cultural competency indirectly influences patients' health outcomes through process of care. Data were from patient satisfaction surveys collected in seven mental health clinics (n=94 minority patients). Consistent with our hypothesis, patients' perception of clinicians' cultural competency was indirectly associated with patients' self-reported improvements in social interactions, improvements in performance at work or school, and improvements in managing life problems through the patients' experience of respect, trust, and communication with the clinician. These findings indicate that process of care characteristics during the clinical encounter influence patients' perceptions of clinicians' cultural competency and affect functional outcomes.

Trends in the educational gradient of mortality among US adults aged 45 to 84 years: bringing regional context into the explanation

OBJECTIVES

We investigated trends in the educational gradient of US adult mortality, which has increased at the national level since the mid-1980s, within US regions.

METHODS

We used data from the 1986-2006 National Health Interview Survey Linked Mortality File on non-Hispanic White and Black adults aged 45 to 84 years (n = 498,517). We examined trends in the gradient within 4 US regions by race-gender subgroup by using age-standardized death rates.

RESULTS

Trends in the gradient exhibited a few subtle regional differences. Among women, the gradient was often narrowest in the Northeast. The region's distinction grew over time mainly because low-educated women in the Northeast did not experience a significant increase in mortality like their counterparts in other regions (particularly for White women). Among White men, the gradient narrowed to a small degree in the West.

CONCLUSIONS

The subtle regional differences indicate that geographic context can accentuate or suppress trends in the gradient. Studies of smaller areas may provide insights into the specific contextual characteristics (e.g., state tax policies) that have shaped the trends, and thus help explain and reverse the widening mortality disparities among US adults.

Uneven futures of human lifespans: reckonings from Gompertz mortality rates, climate change, and air pollution

The past 200 years have enabled remarkable increases in human lifespans through improvements in the living environment that have nearly eliminated infections as a cause of death through improved hygiene, public health, medicine, and nutrition. We argue that the limit to lifespan may be approaching. Since 1997, no one has exceeded Jeanne Calment's record of 122.5 years, despite an exponential increase of centenarians. Moreover, the background mortality may be approaching a lower limit. We calculate from Gompertz coefficients that further increases in longevity to approach a life expectancy of 100 years in 21st century cohorts would require 50% slower mortality rate accelerations, which would be a fundamental change in the rate of human aging. Looking into the 21st century, we see further challenges to health and longevity from the continued burning of fossil fuels that contribute to air pollution as well as global warming. Besides increased heat waves to which elderly are vulnerable, global warming is anticipated to increase ozone levels and facilitate the spread of pathogens. We anticipate continuing socioeconomic disparities in life expectancy.

MPH education for the 21st century: motivation, rationale, and key principles for the new Columbia public health curriculum

Public health is at a watershed moment. The world's health needs are changing, and complex problems require interdisciplinary approaches and systems-based solutions. Our longer lives and changing environments necessitate life-course and structural approaches to prevention. This argues strongly for public health graduate education that adequately prepares trainees to tackle emerging challenges and to lead now and in the future. Nearly a century of scholarship and scientific advances may offer a blueprint for training the next generation of public health leaders. We articulate a case for change; discuss some of the foundational principles that should guide public health education; and discuss what such a change might look like building on prior scholarship, on the examples set by other disciplines, and on our own experience.

Making equity a value in value-based health care

Equity in health and health care in America continues to be a goal unmet. Certain demographic groups in the United States-including racial and ethnic minorities and individuals with lower socioeconomic status-have poorer health outcomes across a wide array of diseases, and have higher all-cause mortality. Yet despite growing understanding of how social-, structural-, and individual-level factors maintain and create inequities, solutions to reduce or eliminate them have been elusive. In this article, the authors envision how disparities-related provisions in the Affordable Care Act and other recent legislation could be linked with new value-based health care requirements and payment models to create incentives for narrowing health care disparities and move the nation toward equity.Specifically, the authors explore how recent legislative actions regarding payment reform, health information technology, community health needs assessments, and expanding health equity research could be woven together to build an evidence base for solutions to health care inequities. Although policy interventions at the clinical and payer levels alone will not eliminate disparities, given the significant role the social determinants of health play in the etiology and maintenance of inequity, such policies can allow the health care system to better identify and leverage community assets; provide high-quality, more equitable care; and demonstrate that equity is a value in health.

US trends in quality-adjusted life expectancy from 1987 to 2008: combining national surveys to more broadly track the health of the nation

OBJECTIVES

We used data from multiple national health surveys to systematically track the health of the US adult population.

METHODS

We estimated trends in quality-adjusted life expectancy (QALE) from 1987 to 2008 by using national mortality data combined with data on symptoms and impairments from the National Medical Expenditure Survey (1987), National Health Interview Survey (1987, 1994-1995, 1996), Medical Expenditure Panel Survey (1992, 1996, 2000-2008), National Nursing Home Survey (1985, 1995, and 1999), and Medicare Current Beneficiary Survey (1992, 1994-2008). We decomposed QALE into changes in life expectancy, impairments, symptoms, and smoking and body mass index.

RESULTS

Years of QALE increased overall and for all demographic groups-men, women, Whites, and Blacks-despite being slowed by increases in obesity and a rising prevalence of some symptoms and impairments. Overall QALE gains were large: 2.4 years at age 25 years and 1.7 years at age 65 years.

CONCLUSIONS

Understanding and consistently tracking the drivers of QALE change is central to informed policymaking. Harmonizing data from multiple national surveys is an important step in building this infrastructure.

How long must humans live?

Species are defined by biological criteria. This characterization, however, misses the most unique aspect of our species; namely, an ability to invent technologies that reduce mortality risks. Old animals are rare in nature, but survival to old age has become commonplace in humans. Science now asks how long can humans live, but we suggest a more appropriate question is: How long must humans live? Three lines of evidence are used to identify the biological equivalent of a warranty period for humans and why it exists. The effective end of reproduction, the age when the sex ratio is unity, and the acceleration of mortality reveal that approximately 50-55 years is sufficient time for our species to achieve its biological mandate-Darwinian fitness. Identifying this boundary is biomedically important because it represents a transition from expected health and vigor to a period when health and vigor become progressively harder to maintain.

Long-term use of opioids for complex chronic pain

Increased opioid prescribing for back pain and other chronic musculoskeletal pain conditions has been accompanied by dramatic increases in prescription-opioid addiction and fatal overdose. Opioid-related risks appear to increase with dose. Although short-term randomised trials of opioids for chronic pain have found modest analgesic benefits (a one-third reduction in pain intensity on average), the long-term safety and effectiveness of opioids for chronic musculoskeletal pain remains unknown. Given the lack of large, long-term randomised trials, recent epidemiologic data suggest the need for caution when considering long-term use of opioids to manage chronic musculoskeletal pain, particularly at higher dosage levels. Principles for achieving more selective and cautious use of opioids for chronic musculoskeletal pain are proposed.