Economic opportunity: a determinant of health?
Authors: Srinivasa Vittal Katikireddi
Journal: The Lancet Public Health (2016)

The economic circumstances into which an individual is born have been repeatedly shown to fundamentally shape health throughout their life. By contrast, surprisingly little research has been done into the inequality in an individual's opportunity to move out of those circumstances— particularly since these factors might be potentially modifiable. In The Lancet Public Health, Atheendar Venkataramani and colleagues1Venkataramani AS Brigell R O'Brien R Chatterjee P Kawachi I Tsai AC Economic opportunity, health behaviours, and health outcomes in the USA: a population-based cross-sectional study.Lancet Public Health. 2016; (published online Oct 3.)http://dx.doi.org/10.1016/S2468-2667(16)30005-6Google Scholar provide a major contribution to the field. The traditional focus taken within much of the social mobility and health literature has been the comparison of health outcomes between those who move upwards, downwards, or remain unchanged along some dimension of social stratification—often social class or education in the UK, or income within the USA. Instead, Venkataramani and colleagues ask whether living in an area with equitable levels of economic opportunity benefits health. Drawing on a newly available measure of inequality of opportunity, they find that counties in the USA with a higher intergenerational social mobility tend to experience better self-reported health outcomes (namely improved self-reported health, reduced smoking and HIV risk behaviours, but not body-mass index) than those with lower intergenerational social mobility. The authors conduct substantial additional analyses to check the robustness of their findings to alternative classifications of the exposure and adjustment for a range of confounders. However, as the authors acknowledge, their study represents the first step to establishing whether inequality of opportunity is a genuine determinant of population health. Moving beyond this observed association to establish causation will be a major challenge for social epidemiologists in the future. One potential avenue of further exploration is comparative research, either over time or across geographical locations. The magnitude of inequalities of opportunity in Europe has at times been controversial, but different European countries do seem to afford differing economic opportunities to their young people.2Breen R Jonsson JO Inequality of opportunity in comparative perspective: recent research on educational attainment and social mobility.Annu Rev Sociol. 2005; 31: 223-243Crossref Scopus (769) Google Scholar However, the most appropriate spatial scale at which an effect of inequality of opportunity operates remains unclear. Although this study considers US counties (which contain an average of approximately 100 000 people), whether the country level or an even more local level is most analytically appropriate is not known. Even more problematically, the most appropriate spatial scale might vary over time and place depending on the extent of the residential mobility of a population. Ultimately, comparison at a range of spatial scales is likely to be necessary. An alternative and increasingly appealing approach to address the causality question is to try to identify natural experiments, where a rapid change in inequality of opportunity could provide an opportunity to more directly study its causal effects. Economic recessions might provide one example, since people entering the labour market during a recession will often experience barriers to meeting their economic potential. Recessions themselves have been linked to a range of adverse effects on health, but not consistently so—context, and particularly the availability of active labour market policies to foster employment opportunities, seem to have a role.3Katikireddi SV Niedzwiedz CL Popham F Trends in population mental health before and after the 2008 recession: a repeat cross-sectional analysis of the 1991–2010 health surveys of England.BMJ Open. 2012; 2: e001790Crossref Scopus (134) Google Scholar, 4Stuckler D Basu S The body economic: why austerity kills. Basic Books, New York, NY2013Google Scholar, 5Stuckler D Basu S Suhrcke M Coutts A McKee M The public health effect of economic crises and alternative policy responses in Europe: an empirical analysis.Lancet. 2009; 374: 315-323Summary Full Text Full Text PDF PubMed Scopus (979) Google Scholar Venkataramani and colleagues' study suggests a potential mechanism through which recessionary effects might be realised and this in turn provides an opportunity to test their hypothesis. Establishing that inequality of opportunity exerts a causal effect on health will not necessarily guide policy makers as to the best actions for improving population health, but learning from natural policy experiments might help achieve that too. Another important and unanswered question is what the implications of this research are for health inequalities. There is broad agreement that the social determinants of health underlie health inequalities. However, more studies of upstream determinants on differential health outcomes across social groups are needed, with a particular focus on the intergenerational transmission on health inequalities.6Katikireddi SV Higgins M Smith KE Williams G Health inequalities: the need to move beyond bad behaviours.JECH. 2013; 67: 715-716Google Scholar Although intuitively increased social mobility might be expected to narrow health inequalities, this might not be the case.7Dibben C Popham F Are socio-economic groupings the most appropriate method for judging health equity between countries?.J Epidemiol Community Health. 2011; 65: 4-5Crossref PubMed Scopus (8) Google Scholar, 8Simons AMW Groffen DAI Bosma H Socio-economic inequalities in all-cause mortality in Europe: an exploration of the role of heightened social mobility.Eur J Public Health. 2013; 23: 1010-1012Crossref PubMed Scopus (9) Google Scholar If an individual's innate ability to attain income is also associated with health, more meritocratic societies might allow those with better health to preferentially move to more advantaged socioeconomic circumstances, thereby widening health inequalities. Understanding whether equality of opportunity results in improved population health but widens health inequalities remains a major gap for future research. Understanding inequality of opportunity has never been more urgent. Thomas Piketty, a French economist, has argued that wealth is becoming increasingly concentrated in the hands of the few and this is impeding the potential for social mobility amongst the many.9Piketty T Goldhammer A Capital in the Twenty-first Century. Harvard University Press, 2014Crossref Google Scholar If Piketty is correct in his calculations that inequality of opportunity will worsen, this latest study1Venkataramani AS Brigell R O'Brien R Chatterjee P Kawachi I Tsai AC Economic opportunity, health behaviours, and health outcomes in the USA: a population-based cross-sectional study.Lancet Public Health. 2016; (published online Oct 3.)http://dx.doi.org/10.1016/S2468-2667(16)30005-6Google Scholar suggests the potential implications for public health could be serious. Ensuring economic policy is cognisant of effects on health is likely to become increasingly necessary for public health in the future. SVK is funded by a NRS Scottish Senior Clinical Fellowship (SCAF/15/02), the Medical Research Council (MC_UU_12017/15), and the Chief Scientist's Office (SPHSU15). Economic opportunity, health behaviours, and health outcomes in the USA: a population-based cross-sectional studyEconomic opportunity is independently associated with self-reported health and health behaviours. Policies seeking to expand economic opportunities might have important spillover effects on health. Full-Text PDF Open Access