BOOK REVIEW ESSAY Rediscovering The Social ...

At the Intersection of Health, Health Care and Policy Cite this article as: David Mechanic Essay: Rediscovering The Social Determinants Of Health Health Affairs, 19, no.3 (2000):269-276 doi: 10.1377/hlthaff.19.3.269

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B oo k R e v ie w Essa y Rediscovering The Social Determinants Of Health b y Da v i d M e c h a n i c

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ny ob s erv a n t per s on understands that one’s position in life and the adversities associated with poverty, ignorance, and powerlessness erode health and shorten life. By the middle of the nineteenth century there were already careful, detailed inquiries in England, France, Germany, and the United States on how the conditions of the poor cut life short. Edwin Chadwick, in his report on sanitary conditions in England, noted that in London’s Bethnal Green mechanics, servants, and laborers and their families died at an average age of sixteen, whereas gentlemen and professionals died at an average age of forty-five.1 John Griscom, a physician at the New York Hospital, noted in a comparable investigation of the laboring population of New York in 1845, “The rich…live in larger houses, with freer ventilation, and upon food better adapted to support health and life. Their means of obtaining greater comforts and more luxuries, are to them, though perhaps unconsciously, the very reason of their prolonged lives.”2 Thousands of studies since then have confirmed and elaborated such observations. Almost every outcome conceivable—from fetal wastage and perinatal mortality, infant mortality, developmental problems, disability, distress, and longevity—has been found to be associated with social position. There has been a recent outpouring of publications on the topic. I focus here on a British inquiry on inequalities in health and four collections of papers and essays published in the United

Kingdom, the United States, and Canada, but my larger goal is to explore the importance of social class and other social determinants of health and to suggest ways of improving health. 3 In both England and the United States growing inequalities amid economic growth have helped to redirect attention to the issue. The election of Britain’s Blair government especially focused interest on possible remedial efforts as part of New Labour’s agenda. The Acheson report, commissioned by the secretary of state for health, made thirty-nine principal recommendations to alleviate poverty and reduce inequalities. While generally following the 1980 Black report, which was repressed by the Thatcher government, the newer report is vague in specification of underlying strategies and priorities.4 The recommendations involve income redistribution through increased benefits and pensions, which are concrete but politically difficult, and many other programs whose costs and effectiveness are unclear. The other four volumes also abound with recommendations on reducing inequalities through policy changes in almost every sector, from child care and nutrition to employment and transportation. Beyond the moral questions concerning the persistence of poverty in an environment of plenty, such recommendations have relevance for the development of human capital for an increasingly complex global economy; for the maintenance of safe

David Mechanic is the René Dubos University Professor of Behavioral Sciences and director of the Institute for Health, Health Care Policy, and Aging Research at Rutgers University. His research and writing deal with social aspects of health and health care, with a particular emphasis on patient perspectives. H E A L T H A F F A I R S ~ M a y / J u n e 2 0 0 0 Downloaded from content.healthaffairs.org by Health Affairs on July 22, 2011 © 2000 Project HOPE–The People-to-People Health Foundation, Inc.

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and livable communities; and for future de- effects into a single SES measure, although mands on health care, social welfare, and with powerful statistical approaches it is criminal justice systems. more reasonable to analyze components indiThe U.K. National Health Service (NHS), vidually to assess their independent as well as the most strictly rationed Western health their cumulative effects. care system, and the United States, with the Most epidemiological studies on social dehighest health expenditures, are both trou- terminants seek to elucidate the specific pathbled by potential future health demand, as are ways through which SES functions. By identipolicymakers in most other nations. They be- fying such mediating factors as knowledge, lieve (probably mistakenly) that healthy health habits and behavior, diet and nutrition, populations will make fewer demands for ex- occupational and housing hazards, control pensive medical and other inover one’s work and one’s life, terventions, and they exhort social supports, coping capaci“There is a social their constituencies to practies, and the like, they seek to gradient in the tice more health-promoting explain the relationship and relationship behaviors. The mental leap beinform social interventions. between SES and tween such conventional ideas The assumption is that if the health that and appreciation that different pathways are completely and transcends any social structures produce varycorrectly described, the health ing health outcomes is a sigdisadvantages of those who plausible concept nificant shift in paradigm. Alare less privileged will be exof poverty, though not a new idea, it is not plained, and this will enable deprivation, one that policymakers easily more well-designed, targeted ignorance, or embrace. interventions. powerlessness.” The social determinants of A different view, nicely rephealth that typically make up resented in the work of Bruce this field of study are social class, sex, age, Link and Jo Phelan, is that SES is a fundamenrace, and ethnicity. In this essay I focus mainly tal cause of health outcomes that cannot be on social class but note that there is a rich and explained simply by enumerating the various growing literature indicating that social risk factors such as substance abuse or poor stratification has significant health effects be- health practices associated with both SES and yond social class. health outcomes.6 They draw on a long tradition that derives from the classic study of suiConcepts Of Social Class cide published in 1897 by French sociologist The concept of social class is intended to Emile Durkheim.7 In his study Durkheim characterize how groupings of persons organ- amassed many data to show that varying suiized in hierarchical arrangements relate to cide rates could not be explained by individone another in terms of social standing, ual propensities such as depression, often asauthority, and power and influence.5 Its more sociated with suicide, but was more the simple proxy—socioeconomic status (SES)— product of the organizational relationships characterizes most empirical research, how- and belief systems of communities. Thus, ever. Typically, it is measured by education, Durkheim illustrated how suicide rates were income, occupation, and sometimes residen- higher in more highly integrated societies tial location. These measures are highly asso- such as Japan, where suicide reflected norms ciated but commonly explain different com- about loyalty to the group and expiating ponents of the relationship between SES and shame, and, alternatively, in societies where health, suggesting that each acts through norms were unclear or where religious syssomewhat different pathways. Investigators tems encouraged greater introspection about commonly build indices that combine these the meaning of life. H E A L T H

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Link and his colleagues, using data on the SES link to health during various historical periods, show that while the prevalences of different risk factors have changed over time, the associations between SES and health outcomes remain and often even increase.8 They argue that those who are more socially advantaged fare better in all historical periods, regardless of the then-prevalent risk factors, because their privileged positions provide the social arrangements, skills, information, and tools to capitalize on the most advanced knowledge and practices that facilitate health. Thus, they are first to take advantage of new protections, preventive screening opportunities, and behavior changes. Information and health opportunities eventually filter out to others, but by the time the benefits are implemented, privileged persons are using their knowledge, access, power, and financial resources to take advantage of newly emerging health opportunities.

Two Lines Of Study New vigor in studies of SES and health, and social determinants more generally, come from two lines of study that motivate the four new volumes published in 1999. The first provides increasing evidence that there is a social gradient in this important relationship between SES and health that transcends any plausible concept of poverty, deprivation, ignorance, or powerlessness. Indeed, increments of additional social advantage, even at the highest levels, in some of these studies appear to confer additional health advantage. The second comes from a variety of international comparative studies as well as national studies in several countries that suggest that inequality itself, independent of level of economic well-being, results in decrements in population health. n The SES health gradient. Michael Marmot and his colleagues at University College London have been involved for many years in the Whitehall Studies of British Civil Servants. 9 These ambitious studies of officebased workers at a range of civil service grades seek to explain why there continues to

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be a monotonic decrease in mortality and improved health with increased status. Even the lowest grades of the civil service are not poor in an absolute sense, and this population has stable employment, is relatively homogeneous, and is exposed to comparable environmental conditions. Thus, we might reasonably expect relatively little variation, particularly at the higher levels, but the gradient remains, although smaller at higher grades. Control for risk factors reduces differences but only partially explains the status gradient. Much of the earlier work on SES and health assumed a threshold effect, in which income and education would influence disease processes up to a point until disadvantages were overcome, and then the relationship would plateau at higher levels of advantage. In developing countries, for example, modest improvements in standards of living and education bring large health gains, while in developed countries further increases in income bring only small health improvements. Many data sets showed this plateau pattern at higher SES levels, and some continue to do so. Remarkably, however, in many instances the association with socioeconomic factors extends well into the middle and upper ranges of social advantage, suggesting a more complex picture of health determinants. Complications are compounded by historical studies and comparative observations around the world that indicate that relatively economically deprived populations such as some in India, Sri Lanka, and Costa Rica have good levels of health and relatively low mortality, while other populations that are more economically advantaged do poorly.10 In these cases, culture, education, and empowerment appear to play significant roles.11 n The inequality thesis. The second development in the study of SES and health is the provocative observation that independent of socioeconomic level, the amount of inequality itself in states, regions, or nations is associated with increased mortality and poorer health. This notion, first popularized in London by Richard Wilkinson, has caught the 2 0 0 0


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imagination of a number of researchers and policymakers. 12 The edited volume by Marmot and Wilkinson and that of Ichiro Kawachi, Bruce Kennedy, and Wilkinson bring together many of the important ideas and relevant research literature pertinent to this discussion.13 The fact of growing income and health inequalities in the United Kingdom and the United States, despite their strong economies over the past decade, adds interest to the purported relationship. Unlike the incontestible link of SES to health, the study of the effects of inequality on health involves more difficult methodological and data problems, lack of conceptual clarity about the definition of inequality, more vagueness about possible causes, and much speculative theorizing.14 The inequality hypothesis addresses relative differences among population aggregations and focuses on comparisons among countries or among U.S. metropolitan areas or states. Given the types of data typically used, the relationship may be artifactual in a statistical sense because of the larger effects of individual income on mortality among persons of low as compared with those of high income.15 A recent effort to test this notion suggests that the finding is only partly attributable to this artifact, but the failure to control for other relevant factors continues to cast suspicion on the causal importance of inequality.16 Various researchers working with individual data in multilevel analyses in contrast to ecological data, and others who have added additional controls to aggregate data to better take account of differences in income, education, time, and geographic effects, have not been able to confirm the contention of a strong inequality effect.17 These researchers are successful in replicating the inequality effect in their initial analyses, but it disappears or is much attenuated when appropriate controls are added. The premise of this new literature is that the effects of inequality on health are real and may have even greater importance than material deprivation itself. I strongly doubt this view, but, nevertheless, many interesting H E A L T H

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studies and ideas are offered. Wilkinson presents the inequality thesis most confidently and aggressively. He speculates that “greater income inequality is one of the major influences on the proportion of the population who find themselves in situations that deny them a sense of dignity, situations that increase the insecurity they feel about their personal worth and competence and that carry connotations of inferiority in which few can feel respected, valued, and confident.”18 The debate will continue, but the inequality effect is clearly not as large, pervasive, or consistent across outcome measures and data sets as proponents would have us believe. Proponents often compare the United States or the United Kingdom with countries such as Japan, Norway, or Sweden, which have more equal income distributions, greater longevity, and better health. These countries, however, are more homogenous and have more of a common culture than Britain or the United States has, and it is impossible to say what is cause and what is effect. Aggregate studies of inequality cannot distinguish between per capita SES effects and inequality effects. Wilkinson argues, however, that the differences found in these studies cannot be attributed to either material living conditions or culture. Citing George Kaplan’s work on U.S. state and metropolitan area patterns of inequalities and health outcomes, Wilkinson argues that in the fifty states “cultural differences are smaller and people shop at many of the same chain stores selling the same range of goods throughout the country.”19 Readers can decide for themselves how convinced they are by this assertion of homogeneity among states. Differing views on such issues are more than arcane arguments among scholars, because the nature of interventions and their likely success will depend on how inequality is conceived. Proponents of the inequality thesis have not always been clear about its meaning. It is one thing to have a society in which the rich become richer and the poor, poorer and quite another to have a society in which all rise in income but the more privileged rise more, inN u m b e r

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creasing the income gap. Wilkinson believes, and Kawachi and Kennedy seem to concur, that growing inequalities are harmful to health even when the poor are better off, because it is a person’s relative income that affects his or her health. It is unlikely that relative deprivation, however important, has the explanatory power suggested. Wilkinson dismisses studies that do not support his thesis because the geographic units studied were too small and hence, too homogeneous. 20 He believes that one would only expect to see relative deprivation and inequality effects among larger areas with wider income heterogeneity. But if there is a lesson to be learned from the literature on relative deprivation, it is that we compare ourselves and judge equity in relationship to others like ourselves. As much as Wilkinson is offended by increases in the compensation of top U.S. executives, it has nothing to do with how most of us make judgments about ourselves.

Religion And Health There is a curious omission in all of these volumes. While the editors are prepared to speculatively generalize from Rhesus and Cynomolgus monkeys and wild baboons to inequality in human societies, they scarcely mention the impact of religion and religious participation on health. I have no special brief for religion, but I suggest that the evidence in this area is probably more persuasive than the literature on inequality.21 Both areas share many of the same methodological challenges such as selection biases, unmeasured variables, and the lack of robustness across measures and analyses, but both also offer intriguing insights. It is even more curious that in arguments that focus on social capital, one of the most formative institutions for its development is hardly worth a mention. The scientific literature on religion and health is growing and is increasingly sophisticated. There is indication that participation in religious activities, and perhaps even some kinds of spirituality, are linked to better health outcomes. At one level, this is obvious, since some religious groups explicitly dis-

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courage smoking and the use of alcohol and drugs, and religious participation often gives people a community providing instrumental and social support. But the effects probably transcend these pathways. Mormons, for example, clearly benefit from not smoking and drinking, but the Mormon community also teaches the importance of family, parenthood, and relationships and strongly encourages education and skills and mastery of the environment. 22 It has been argued that religion is not a true determinant of health because its effects are explainable through pathways such as a sense of belonging and social support.23 But this is exactly what social capital is presumed to do—establish possible pathways to health and well-being.

Social Status And Development Work on SES is based on the assumption that it is a proxy for many life conditions affecting the health and welfare of populations and acts through a multitude of causal pathways. SES is already influential in perinatal and early life, and its effects are also intergenerational. Thus, the early and adolescent development of future mothers will affect the birthweight and other characteristics of their infants. An infant’s size at birth is predictive of later hypertension, coronary heart disease, and diabetes. Height at age seven (a proxy for childhood health and growth), associated with SES, predicts unemployment risk better than adult height.24 Health outcomes for children depend not only on how poor they are at any point in time but on the extent of their poverty over time.25 Populations are always sorting and resorting themselves, or being sorted through environmental or social influences. Thus, the social gradient is not solely a social product but is also a product of selection. Even in such processes as social support that are quintessentially social, children (and presumably adults as well) with different temperaments attract varying levels of support from their peers and adults. Similarly, socioeconomic level, social attainment, and one’s position in the social hierarchy of the civil service is not

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solely a social product. It is the culmination of an interaction between social advantage and personal characteristics such as temperament and capacity and how they interact and evolve during development, schooling, and socialization. The existing body of research shows that social privilege early in life is extraordinarily important but that individual capacities are as well.26 These interact from the start; privilege allows capacity to flourish by providing stimulating environments, social support, developmental opportunities, and much more. Differences are already pronounced by the time children begin their schooling. But in assessing health and disease data, we still should consider the extent to which limits in capacity, energy, and poor health affect work, earnings, and status positions in social structures as well as the reverse.27

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Work on social determinants is important for policymakers because it suggests possible interventions for reducing health disparities. The typical approach is to modify pathways leading to poor functioning and poor health through nurse home visiting programs for infants and mothers, parenting education, preschool childhood programs, well-organized child care, preventive health practices, substance abuse prevention, and changes in health behavior, among many others. Recent work, however, transcends these individual endeavors and seeks to encourage societal changes that directly change existing inequalities, for example, through redistribution of income and modifications of entitlements and tax structures. Some programs, such as Social Security and the Earned Income Tax Credit for the working poor, are highly effective in reducing poverty. In contrast, compressing the socioeconomic hierarchy will be less effective, even if the political minefields could be negotiated, than ensuring the essential requirements of a healthy life for everyone—including subsistence, housing, health insurance, and educational opportunity. There is much to do in building a strong safety net for those with the greatest need.

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Building Social Capital The discussion of health inequalities is increasingly focused on the idea of social capital, first elaborated on by the sociologist James Coleman, referring to the networks of community relationships that facilitate trust and motivate purposive action.28 Social capital derives from relationships among people, the norms they share, and the groups they develop to advance their mutual values and goals. It was social capital that so impressed Alexis de Tocqueville in his nineteenthcentury study of America’s democratic vitality, and it is America’s social capital that is now said to be eroding.29 Social capital helps members of communities to look after one another and to pursue agendas for social as well as individual good, but it is not obvious how new social capital can best be developed. Social capital evolves over generations, even centuries, of social and cultural development; it is not subject to quick fixes. Robert Putnam has become the social-capital guru for the inequality theorists, but they pay little attention to the implications of his historical analysis that the roots of civil community in southern and northern Italy go back for centuries. Putnam builds an index of traditions of civic involvement among Italian regions in 1860–1920, including such items as election turnout and membership in mutual aid societies. This index had a correlation of .93 with civic community measured in the 1970s and .86 with institutional performance measured for 1978–1985.30 The aspect of SES that offers potentially the largest opportunity for both human and social capital is schooling.31 Once one is beyond the deprivations of poverty, education is probably the most influential of the SES components on health and social development. Educated parents provide more stimulating cognitive environments for their children and activate potential during critical developmental periods. Schooling is important not only for the knowledge, skills, and personal gratifications it affords but also because good school structures provide the habits of mind, behavior, and cooperative participation that make N u m b e r

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adaptation more possible in highly structured, complex societies. Americans strongly value individual ingenuity and accomplishment, but they also agree that all children deserve equality at the starting point. As researchers at the Canadian Institute for Advanced Research suggest, early life and childhood deserve our strong focus because this is where much deprivation and inequality begin.32 Once begun, inequality is a cumulative process, with each added disadvantage leaving children further and further behind. The case is substantial for intensive programs for infants and children, as the Acheson report and other works make clear. The various volumes on equality abound with ideas for future research, but they provide limited bases for new social interventions. The notion that we improve health simply through compressing socioeconomic differences, however desirable, remains unproven. It is a fair inference from the literature that reducing material deprivations for the most vulnerable in the areas of housing, nutrition, subsistence, education, and health care will promote health, and this is a more promising target and one more likely to gain political acceptance. Several new efforts, including one under way at the Institute of Medicine, seek to identify good ideas from the social and behavioral sciences as a basis for new interventions. Implementation, from promise to demonstrating performance, continues as a major challenge. As in health care more generally, there is a large gap between establishing efficacy in highly controlled trials and demonstrating effectiveness in the larger world.

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u i l d i n g h u m a n c a p i t a l and com munities through education, mutual cooperation, social cohesion, social support, meaningful productive activity, and social responsibility are goals worthy of our best efforts, regardless of how they affect health. The selections in the volume edited by Alvin Tarlov and Robert St. Peter are especially concerned with efforts to develop social capital with a strong focus on the state of Kansas.33 Ensuring that every person has a H E A L T H

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decent minimum is part of building a civic culture. But we had best not be naïve about the many forces in play and the extreme difficulty of doing this. Here we have much to learn f rom history; the extraordinary continuity in institutional arrangements; and the unanticipated social, economic, and technological changes that often have a large impact on our lives. NOTES 1. E. Chadwick, Report on the Sanitary Condition of the Labouring Population of Great Britain (1842) (Edinburgh: Edinburgh University Press, 1965). 2. J.H. Griscom, The Sanitary Condition of the Laboring Population of New York: With Suggestions for Its Improvement (New York: Harper, 1845), 4. 3. D. Acheson, Independent Inquiry into Inequalities in Health (London: Stationery Office, 1998); M. Marmot and R.G. Wilkinson, eds., Social Determinants of Health (Oxford: Oxford University Press, 1999); D.P. Keating and C. Hertzman, eds., Developmental Health and the Wealth of Nations: Social, Biological, and Educational Dynamics (New York: Guilford Press, 1999); I. Kawachi, B.P. Kennedy, and R.G. Wilkinson, eds., The Society and Population Health Reader, Volume I: Income Inequality and Health (New York: New Press, 1999); and A.R. Tarlov and R.F. St. Peter, eds., The Society and Population Health Reader, Volume II: A State and Community Perspective (New York: New Press, 1999). 4. D. Black et al., Inequalities in Health: Report of a Research Working Group (London: Department of Health and Social Security, 1980); and D. Black et al., “Better Benefits for Health: Plan to Implement the Central Recommendation of the Acheson Report,” British Medical Journal 318, no. 7185 (1999): 724–727. 5. D. Mechanic, “Socioeconomic Status and Health: An Examination of Underlying Processes,” in Pathways to Health: The Role of Social Factors, ed. J.P. Bunker, S. Gomby, and B.H. Kehrer (Menlo Park, Calif.: Henry J. Kaiser Family Foundation, 1989), 9–26. 6. B.G. Link and J. Phelan, “Social Conditions as Fundamental Causes of Disease,” Journal of Health and Social Behavior (Extra Issue, 1995): 80–94. 7. E. Durkheim, Suicide: A Study in Sociology (1897), trans. J.A. Spaulding and G. Simpson (New York: Free Press, 1951). 8. B.G. Link et al., “Social Epidemiology and the Fundamental Cause Concept: On the Structuring of Effective Cancer Screens by Socioeconomic Status,” Milbank Quarterly 76, no. 3 (1998): 375–402. 9. See, for example, M.G. Marmot, M.J. Shipley, and G. Rose, “Inequalities in Death-Specific Explana-

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10. 11.

12. 13. 14.

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tions of a General Pattern,” Lancet 1, no. 8384 (1984): 1003–1006; and M.G. Marmot and M.J. Shipley, “Do Socioeconomic Differences in Mortality Persist after Retirement? Twenty-five Year Follow-up of Civil Servants from the First Whitehall Study,” British Medical Journal 313, no. 7066 (1996): 1177–1180. Also see Marmot and Wilkinson, eds., Social Determinants of Health. J.C. Caldwell, “Routes to Low Mortality in Poor Countries,” Population and Development Review 12, no. 2 (1986): 171–220. D. Mechanic, “Promoting Health: Implications for Modern and Developing Nations,” in Health and Social Change in International Perspective, ed. L.C. Chen et al. (Cambridge, Mass.: Harvard University Press, 1994), 471–489. R.G. Wilkinson, Unhealthy Societies: The Affliction of Inequality (London: Routledge, 1996). Marmot and Wilkinson, eds., Social Determinants of Health; and Kawachi et al., eds., The Society and Population Health Reader, Volume I. For papers on methodological and data problems, see Section 2 of The Society and Population Health Reader, Volume I. Perhaps the most extensive critique and a review of other critiques are found in two papers by Jennifer Mellor and Jeffrey Milyo in the Working Paper series of the Robert Wood Johnson Scholars in Health Policy Research program. These include “Income Inequality and Health Status in the United States: Evidence from the Current Population Survey” (February 1999); and “Re-Examining the Evidence of an Ecological Association between Income Inequality and Health” (October 1999). For a good discussion of some of the interpretive issues, see G.A. Kaplan et al., “Inequality in Income and Mortality in the United States: Analysis of Mortality and Potential Pathways,” British Medical Journal 312, no. 7037 (1996): 999–1003. The existence of such differential effects has led James House and David Williams (“Understanding and Reducing Socioeconomic and Racial/Ethnic Disparities in Health,” Institute of Medicine Conference on Capitalizing on Social Science and Behavioral Research to Improve the Public’s Health, Atlanta, Georgia, February 2000) to argue that our efforts to improve health should focus on the lower 40–60 percent of the socioeconomic distribution. See H. Gravelle, “How Much of the Relation between Population Mortality and Unequal Distribution of Income Is a Statistical Artefact?” in Kawachi et al., eds., The Society and Population Health Reader, Volume I, 99–104; M. Wolfson et al., “Relationship between Income Inequality and Mortality: Empirical Demonstration,” British Medical Journal 319, no. 7215 (1999): 953–955; and H. Gravelle, “Diminishing Returns to Aggregate Level Studies,” British Medical Journal 319, no. 7215

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(1999): 955–957. 17. See, for example, K. Fiscella and P. Franks, “Poverty or Income Inequality as Predictor of Mortality,” British Medical Journal 314, no. 7096 (1997): 1724–1728. 18. R.G. Wilkinson, “Putting the Picture Together: Prosperity, Redistribution, Health, and Welfare,” in Social Determinants of Health, 267. 19. Kaplan and colleagues’ papers are included in Kawachi et al., eds., The Society and Population Health Reader, Volume I; and Wilkinson, “Putting the Picture Together,” in Social Determinants of Health, 258. 20. R.G. Wilkinson, ”Social Relations, Hierarchy, and Health,” in The Society and Population Health Reader, Volume II, chap. 10. 21. R.A. Hummer et al., ”Religious Involvement and U.S. Adult Mortality,” Demography 36, no. 2 (1999): 273–285; and J.S. Levin, ”Religion and Health: Is There an Association, Is It Valid, Is It Causal?” Social Science and Medicine 38, no. 11 (1994): 1475–1482. 22. T.F. O’Dea, The Mormons (Chicago: University of Chicago Press, 1957). 23. R.P. Sloan, E. Bagiella, and T. Powell, ”Religion, Spirituality, and Medicine,” Lancet 353, no. 9153 (1999): 664–667. 24. D. Blane, “The Life Course, the Social Gradient, and Health,” in Social Determinants of Health, 67. 25. J. Brooks-Gunn, G.L. Duncan, and P.R. Britto, “Are Socioeconomic Gradients for Children Similar to Those for Adults? Achievement and Health of Children in the United States,” in Developmental Health and the Wealth of Nations, chap. 6. 26. L.S. Gottfredson, “Why g Matters: The Complexity of Everyday Life,” Intelligence 24, no. 1 (1997): 79–132. 27. J.P. Smith, “Healthy Bodies and Thick Wallets: The Dual Relation between Health and Economic Status,” Journal of Economic Perspectives 13, no. 2 (1999): 145–166. 28. J.S. Coleman, Foundations of Social Theory (Cambridge, Mass.: Harvard University Press, 1990), 300–321. 29. A. de Tocqueville, Democracy in America, trans. D. Lawrence, 2 volumes (1835–1839) (Garden City, N.Y.: Doubleday, 1969); and R. Putnam, ”Bowling Alone: America’s Declining Social Capital,” Journal of Democracy 6, no. 1 (1995): 65–78. 30. R. Putnam, Making Democracy Work: Civil Traditions in Modern Italy (Princeton, N.J.: Princeton University Press, 1993), 151. 31. D. Mechanic, “Socioeconomic Status and Health: An Examination of Underlying Processes,” in Pathways to Health, 3–26. 32. Keating and Hertzman, eds., Developmental Health and the Wealth of Nations. 33. Tarlov and St. Peter, eds., The Society and Population Health Reader, Volume II.

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