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Posts By Laudan Aron

Bio: Laudan Aron is a senior research associate in the Urban Institute's Labor, Human Services and Population center.

Eric Garner's death is about much more than a police choke hold

Author: Laudan Aron

| Posted: August 8th, 2014




Last week, the New York City Medical Examiner ruled that Eric Garner died on July 17 as a result of a choke hold by a police officer. In other words, Garner’s death was ruled a homicide, even though his health conditions—including asthma, heart disease, and obesity—were found to be “contributing factors.” The confrontation with police, which was caught on video by a bystander, and his death have captured the nation’s attention and sparked much outrage.

But Garner’s death is about much more than a police choke hold or police brutality, as critical as these are. As this tragic case unfolds, one can also see in Garner’s life many of the conditions contributing to our large and growing “US health disadvantage” and especially the role of social determinants. These are the social and physical environments that shape our behaviors and experiences from the day we are born, as well as the public policies that affect our family, community, and life circumstances. These are things beyond genetics, biology, medical care, or even the healthcare system that affect our health. Here are just a few examples (I’m sure there are many more) of how the social determinants of health mattered to Eric Garner.

Garner was as African American man, age 43, with a history of chronic health problems. His weight of 350 pounds and his other underlying health conditions are almost always mentioned in media and other reports describing his encounter with the police and his subsequent death. Chronic illnesses are the nation’s leading cause of death and disability; they affect 90 million Americans and absorb 75 percent of our health care dollars. They lead to premature and preventable death and cause lifelong disability and a much lower quality of life. Among people who are less educated, unable to work, or struggle to make ends meet, the rates and burdens of chronic illness are even greater.

Although his health was a contributing factor, Garner’s death was ruled a homicide. Homicide, along with other intentional injuries and violence generally, is a major social determinant of health. Among black men, it is a leading cause of death, reducing life expectancy by almost one year. Murder rates among black Americans are four times higher than the national average.

But Garner’s death was also linked to two other less obvious “upstream” social determinants of health – tobacco taxes and policing policies. On the day he died, police had suspected Garner of hawking illegal tax-free cigarettes, an offense he was charged with several times before. Cigarette taxes have been effective in reducing smoking, an important social determinant of health. But a recent study of low-income smokers in New York found that they spend nearly a quarter of their household incomes on cigarettes. At $4.25 a pack, New York’s cigarette tax rate is the highest in the country. These taxes place a very high burden on low-income households, whose members smoke at higher rates, experience higher levels of trauma and stress, and are less able to afford smoking cessation supports. Obviously no one is forced to sell untaxed cigarettes and the practice is illegal, but this tax policy coupled with the challenges of fighting nicotine addiction is one example of how policies can and do shape people’s lives and behaviors.

Finally, Garner’s death has been implicated in a policy known as “broken windows” policing: the idea that aggressive enforcement of minor offenses, such as peddling untaxed cigarettes, leads to safer and more orderly communities. The strategy was adopted in New York City decades ago, but it is unclear if it is what has led to reductions in violent crime because levels have fallen across the country. What is clear, however, is the impact this policy is having on the lives of many New Yorkers. As the New York Times editorial board explains:

The mayor and the commissioner should acknowledge the heavy price paid for heavy enforcement. Broken windows and its variants—“zero-tolerance,” “quality-of-life,” “stop-and-frisk” practices—have pointlessly burdened thousands of young people, most of them black and Hispanic, with criminal records. These policies have filled courts to bursting with first-time, minor offenders whose cases are often thrown out, though not before their lives are severely disrupted and their reputations blemished. They have caused thousands to lose their jobs, to be suspended from school, to be barred from housing or the military. They have ensnared immigrants who end up, through a federal fingerprinting program, being deported and losing everything.

It is striking how many social determinants of health are reflected in the life and death of one man. This case is still playing out for his family, his community, and the entire city of New York, and the nation is waiting for the justice system’s response to this tragedy. But one beneficial outcome would be our greater understanding and action on policies and practices that affect people’s health and life chances. Improving these for everyone, but especially for people like Eric Garner, is a worthy goal for us all.

Photo: Ellisha Flagg, sister of Eric Garner cries during a vigil demanding justice for Eric Garner, a Staten Island man who died while being arrested by New York City police, Tuesday, July 22, 2014, in New York. Demonstrators gathered at a park Tuesday, near where police attempted to arrest Garner, 43, on suspicion of selling untaxed cigarettes. (AP Photo/John Minchillo)

Filed under: Corrections, reentry, and community supervision, Crime and Justice, Cross-Center Initiatives, Disability and long-term care, Education and Training, Health and Health Policy, Health care spending, access, and utilization of care, Income and Wealth, Job Market and Labor Force, Neighborhood indicators, Neighborhoods, Cities, and Metros, New York, Policing and crime prevention, Social determinants of health, Social Determinants of Health, Victims of crime |Tags: , , , , , ,
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What really accounts for how long we'll live?

Author: Laudan Aron

| Posted: March 21st, 2014



Last Sunday, the New York Times business section featured a powerful and long overdue piece about the social determinants of health. In the article, Annie Lowrey compares two communities—Fairfax County in Northern Virginia and McDowell County in West Virginia—and shows how far apart they are on virtually every measure of economic and social well-being despite being separated by only 350 miles.

But, as Lowrey makes clear in the title of her story, “Income Gap, Meet the Longevity Gap,” profound differences also arise in terms of the health and survival of the people who live in these two communities. Residents of McDowell die about 20 years earlier than those in Fairfax. Many other measures of health (including rates of disability, obesity, and various types of chronic illness) are also far worse in McDowell.

The close relationship between income and health is well known and documented, both across place and time and among individuals, communities, and even nations. What has been less appreciated and understood—especially here in the United States—is the importance of other social determinants of health. These are the very issues that the New York Times piece highlights: things like employment, education, social services, food availability, and peace of mind.

As the article explains, “dollars in a bank have never added a day to anyone’s life…. Instead, those dollars are at work in a thousand daily-life decisions—about jobs, medical care, housing, food, exercise —with a cumulative effect on longevity.”

What may come as a surprise to many Americans, even to residents of Fairfax Country and readers of Annie Lowrey’s piece, is how unhealthy even the most advantaged Americans are relative to their counterparts in other wealthy democracies. While there are a host of reasons why this may be the case, social and economic conditions once again appear to be major factors. A National Research Council/ Institute of Medicine study panel (which I directed) examined the US health disadvantage relative to other high-income countries and found:

Although the income of Americans is higher on average than in other countries, the United States also has higher levels of poverty (especially child poverty) and income inequality and lower rates of social mobility. Other countries are outpacing the United States in the education of young people, which also affects health. And Americans benefit less from safety net programs that can buffer the negative health effects of poverty and other social disadvantages.

Over the next several months, the Urban Institute and the VCU Center on Society and Health will be taking a much closer look at the issue of income and health, as well as state-level variations in the social determinants of health. This work will be critical to supporting evidence-based health-promoting policies outside the formal healthcare system and to bringing a stronger understanding of “health in all policies” to many areas of public policy and the private sector. These are critical needs for communities such as McDowell County, and may even help places like Fairfax County too.

Illustration by Daniel Wolfe, Urban Institute.

Filed under: Economic Growth and Productivity, Health and Health Policy, Poverty, Vulnerability, and the Safety Net, Public health, Social determinants of health, VA, WV |Tags: , , , , ,

Women's Health: A key link to understanding the US health disadvantage?

Author: Laudan Aron

| Posted: January 3rd, 2014

Last week, Wonkblog asked some “interesting, important and influential thinkers” to name their favorite graph of 2013. It was a thrill to learn that Emily Oster, an associate professor of economics at the University of Chicago Booth School, picked a figure from a study that I directed at the National Research Council (NRC) and the Institute of Medicine (IOM).

The graph shows that the United States is slipping further and further behind other high-income countries (mostly those in Western Europe, along with Canada, Australia, and Japan) on life expectancy at birth. The NRC/IOM report looked at the health of Americans through a cross-national prism and showed how we are losing ground across the board: on virtually every measure of morbidity and mortality, at all ages up to age 75, among all races and ethnicities, at all socioeconomic levels, and among both men and women. This large and growing “US health disadvantage,” as the NRC/IOM report calls it, has attracted widespread attention—ranging from a New York Times editorial to a commentary by Rush Limbaugh—since the report was released in January 2013. My own editorial views were published a few months later in the New Scientist and Slate.

As I considered the chart that Oster picked, I wondered if she shouldn’t have picked a slightly different and even more eye-popping figure from our report (and it should be noted that both figures come from a prior related study that inspired our study). This figure shows the probability of women in high-income countries surviving to age 50. As with the Oster figure, the United States is shown in red and the other high-income countries are shown in grey:

Probability of survival to age 50 for females in 21 high-income countries, 1980-2006


The graph shows that US women are less likely to reach age 50 than women in other advanced countries. We are a true outlier in this case. A more recent analysis by scholars at the University of Wisconsin–Madison shows that in many places across the country, mortality among women is actually worsening. In the decade between 1992-96 and 2002-06, female mortality rates actually increased in 42.8 percent of US counties. Here is a map of those counties:

Change in female mortality rates from 1992–96 to 2002–06 in US counties


We really need to get a handle on what’s going on here. As the Urban Institute digs into the social determinants of health in an effort to better understand the US health disadvantage, a key part of this work will be exploring the many drivers of women’s health. Our preliminary analyses suggest that increases in mortality are especially pronounced among white women of reproductive age, not a group we generally think of as being disadvantaged. And finally, because women’s health (and survival) directly affects children and families, we will be looking at their well-being too.

Filed under: Health and Health Policy, Maternal and child health, Other, Public health, Social determinants of health |Tags: , , , , ,

Can strengthening the economy both reduce inequality and increase economic mobility?

Author: Laudan Aron

| Posted: December 19th, 2013



President Obama has joined many pundits (see, for instance, Ezra Klein) in a growing national discussion about how to tackle two important and worrying trends within the United States - growing income inequality and declining social mobility.

Yet these are not the same goals. In a recent discussion between EJ Dionne of the Washington Post and David Brooks of the New York Times, Brooks argued that

If you emphasize inequality, then you tend toward a redistributive set of policies. If you emphasize social mobility, then you emphasize human capital policies such as early childhood education and college grants and things like that…

[T]hey do point in slightly different directions. And if I were the Republicans, I would emphasize social mobility, giving people the tools to rise and compete rather than redistribution.

Dionne quickly pointed out that that inequality is often intertwined with limited social mobility, which then led to the real underlying question: are there policies that can make a difference on both fronts? Brooks argued that “the core of the inequality problem and the core of the mobility problem is a widening education premium… [And] giving people … the human capital tools to rise and compete is a lot better to me than to raise the tax rates and redistribute money downwards.”

My guess is that both Brooks and Dionne might very well agree that the following types of policies should rise to the top of the list of what we should do as a nation: high-quality childcare, early childhood education programs for young children, and early intervention and prevention (in the areas of health, education, and social services). And while we’re at it, we could make more level the playing field when it comes to K-12 public schools across the country – with respect to per-pupil funding, teacher quality, facilities, and after-school offerings. And let’s make sure our least-privileged young people have a fair shot at high-quality post-secondary education and career-focused training, including enhanced apprenticeship opportunities.

Those kinds of investments in human capital are not just palliative: they would lower poverty and improve the lives of millions of people today, all the while giving them the tools they need to climb the economic ladder. Equally important, they would reduce dependence on the social safety net, lowering future government spending.

But there’s another twist along this path—while Dionne acknowledges the costs of human capital investments and Brooks mentions higher tax rates, that’s not the only route.

In his forthcoming book tentatively titled “Dead Men Ruling,” my colleague Gene Steuerle shows that the government already spends over $50,000 per household each year, and this amount is growing significantly simply with economic growth. Social welfare spending comprises about $30,000, while households additionally benefit from other public goods. Even cross-national comparisons with other high-income countries reveal that our social welfare spending is quite generous, just behind Sweden when you include tax-based subsidies and private spending.

What distinguishes the United States from these other countries – countries that are beating on us on almost every measure of health, education, adult skills, and well-being – is how we spend that money. For instance, we spend a lot more on very high-cost healthcare (while historically leaving many without health insurance or access to care) and a lot less on children and families.

So here’s my take. With or without higher tax rates, we have the means now to employ a thoughtful human capital investment strategy to help stem both growing inequality and increasing economic immobility. We already have the way, now we need the will.

Illustration by Daniel Wolfe, Urban Institute.

Filed under: Economic Growth and Productivity, Income and Wealth, Inequality, Low-income working families, Poverty, Poverty, Vulnerability, and the Safety Net |Tags: , , , , , ,
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Americans are in poor health, but what’s really ailing us?

Author: Laudan Aron

| Posted: November 20th, 2013




This morning the US Senate’s Committee on Health, Education, Labor and Pensions (HELP) is holding a hearing called “Dying Young: Why Your Social and Economic Status May Be a Death Sentence in America.” Is there much evidence for this provocative and alarming title? Sadly, the answer is a decisive “yes.”

Earlier this year, I wrote about a study I recently directed for the National Academy of Sciences and the Institute of Medicine that documented a large and growing US “health disadvantage” relative to other high-income countries. This disadvantage shows up in higher rates of disease and injury from birth to age 75 for men and women, rich and poor, across all races and ethnicities. Study after study confirms that the health of Americans is suffering dramatically and even slipping, and that real solutions to this situation lie far outside the health care system and the Affordable Care Act (ACA), as important as these are.

The real drivers of health in modern America are the non-medical or social determinants of health. These are things such as education, income, and neighborhood conditions that shape so many of our individual choices and behaviors—including behaviors such as smoking, diet, exercise, and driving—but also broader local, state, and national policies that shape our social and economic circumstances in very powerful and fundamental ways.

Unfortunately, for many of these social determinants, the United States is doing very poorly. Recent work at the Urban Institute shows this through our work on long-term unemployment, widening wealth inequality, and insecurity in children’s lives. Even social mobility, a cherished American ideal, is increasingly limited.

Rather than wait for breakthroughs in biomedical research, we can start attending to the social determinants of health through sound social and economic policies. Many other countries are doing this as part of their “health in all policies” approaches, and today’s HELP committee hearing suggests that the United States may finally be heading in this direction too.

In the months ahead, Urban Institute researchers and affiliated scholars will be contributing to this knowledge base and highlighting public policy implicitions for the social determinants of health.

Illustration by Daniel Wolfe, Urban Institute

Filed under: Aging, Disability and long-term care, Health and Health Policy, Health care delivery and payment, Long-term care, Maternal and child health, Social determinants of health, Uninsured |Tags: , , ,
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Despite fifty years of improvements in infant mortality, large black-white gap remains unchanged

Author: Laudan Aron

| Posted: August 26th, 2013

[Negro Americans] must march from the cemeteries where our young and our newborns die three times sooner and our parents die seven years earlier. They must march from there to established health and welfare centers. – National Urban League Director Whitney Young, August 28, 1963

It is hard to believe that after half a century of social, scientific, and medical progress, these words by Whitney Young are as telling today as they were in 1963 when he spoke at the March on Washington for Jobs and Freedom. Today, as in the early 1960s, black infants are more than twice as likely as white infants to die within their first year of life.

Infant mortality has long been considered to be an important indicator of a nation’s health, and while it has fallen dramatically over the past five decades, there are still stark differences along socioeconomic, geographic, and especially racial lines. In 2009, the infant mortality rate was 12.4 infant deaths per 1,000 live births among blacks, compared to 5.3 among whites. Equally large and persistent differences by race are found for other birth outcomes – including stillbirths, preterm births, and low birth weight – and many of these contribute to the racial gap in infant mortality.


Many factors are known to affect birth outcomes – these include the mother’s age, education, health status, and behavior during pregnancy. But study after study show that these factors fail to explain large differences by race.

Highly educated white women who wait until their 20s and 30s to have a child have much better birth outcomes than highly educated black women of the same age. In fact, black mothers with college and even advanced degrees have a higher infant mortality rate than white mothers who have not finished high school.

Nor do genetics explain the difference. The birth weights of babies born in the US to African-born mothers are similar to those of babies born to white American mothers – and both are significantly higher than those born to black American women.

Researchers and others are still trying to solve this complex and worrying puzzle. They are expanding their inquiries by looking at women’s experiences across the course of their lives – including health early in life, in utero, and even in the prior generation – in an effort to understand what’s going on. They are also looking beyond individual level factors, to family and community conditions such as father involvement, reproductive social capital (how connected a pregnant woman feels to her to community), and community supports.

Finally, researchers are also looking more closely at how broader social and economic conditions, including racism, stress, and material hardship, shape the experiences and health of black women and their families. The evidence on the biology of disadvantage – how social and economic conditions affect our health and survival – is rapidly building and points to the need for radically different approaches to closing the black-white gap in birth outcomes.

Fifty years after the March on Washington, it is clear that we still have a long way to go before the life chances of a black newborn resemble those of a white newborn. We need to heed Whitney Young’s call to action now more than ever.

Graphic from Figure 2 of  "From Figure 2 of Infant Mortality in the United States, 1937-2007: Over Seven Decades of Progress and Disparities"

Filed under: Center on Labor, Human Services, and Population, Child welfare, Children, Children's health and development, Economic well-being, Economic well-being, Families, Health and Health Policy, Maternal and child health, National (US), Other, Parenting, Poverty, Vulnerability, and the Safety Net, Public health, Race, Ethnicity, and Gender, Racial and ethnic disparities, Social determinants of health |Tags: , , , ,

In the conversation about poverty: don't forget about deep and persistent poverty

Author: Laudan Aron and Margery Turner

| Posted: June 6th, 2013




About 15 percent of Americans are living in poverty and many more experience one or more spells of poverty over the course of a year. Thanks to Alan Berube and Elizabeth Kneebone’s new book, Confronting Suburban Poverty in America, people are talking about this bleak reality and what to do about it.

Over the past few months, the two of us have been focusing on an even more distressing reality: the 6.6 percent of Americans—more than 20 million adults and children—who live in deep poverty.

Deep poverty is commonly defined as having cash income below half the poverty line—in 2012, that’s less than $1,000 a month for a family of four. Other measures change this picture slightly, but even the Census Bureau’s new Supplemental Poverty Measure puts deep poverty at about 5 percent after factoring in cash transfers, tax credits, and tax liabilities, as well as major expenses like the cost of commuting to work, out-of-pocket medical costs, and child support payments.

People suffering from deep poverty are diverse and their circumstances defy simple characterizations. Their needs reflect multiple and often interacting disadvantages. They include single mothers and their children, people who are homeless or formerly incarcerated, disabled veterans, and people with serious mental illnesses. They include many immigrants. While people of color have among the highest levels of poverty, the poor and deeply poor are predominantly white. About half of those living in deep poverty are under age 25. Most deeply poor adults aren’t working.

Many people in deep poverty face significant personal challenges: disabilities and other major health problems, very low levels of education and work skills, criminal background histories, and limited social networks that can buffer them in hard times. Any of these challenges makes working difficult and research shows that combinations of multiple challenges make it especially hard for people to escape deep poverty. They also make it hard to provide a stable and nurturing environment for children.

Over the course of months and years, many people cycle in and out of poverty. A job loss, a divorce, a natural disaster, or time away from work to care for a newborn or tend to an ill family member can all push a family into poverty—even deep poverty—temporarily. Many of these families climb back out of poverty fairly quickly. Indeed, about half the people who fall into poverty are poor for less than a year, and about three-quarters are poor for less than four years.

But about a third of people who become poor in a given year will remain poor for half or more of the next 10 years. Persistent poverty year after year is very debilitating. Children raised in persistently poor families have far worse outcomes later in life than those who were poor for just a year or two.

Poverty is, by definition, a lack of income. But deep and persistent poverty reflects deficits that are much more profound. Addressing them requires intensive and sustained supports that span conventional policy and programmatic silos. The work requirements and other conditions imposed by many of today’s federal safety-net programs may make sense for people experiencing short spells of poverty, but they are clearly failing to meet the needs of people in deep and persistent poverty.

As the nation tackles poverty in the aftermath of the Great Recession—and develops strategies that reflect new economic and geographic realities—let’s remember people living in deep and persistent poverty. The portfolio of anti-poverty tools deployed in any community should include the intensive, multi-faceted, and long-lasting supports needed by individuals and families trapped in deep and persistent poverty.

Photograph by JOAKIM ESKILDSEN from "Below the Line: Portraits of American Poverty," photo-essay commissioned by Time magazine, November 2011, and forthcoming in Joakim Eskildsen and Natsha Del Toro, American Realities (Steidl). Used with permission.

Filed under: Adolescents and Youth, Children, Children's health and development, Economic well-being, Economic well-being, Poverty, Poverty, Vulnerability, and the Safety Net, Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF) |Tags: , , , , ,