Of course there is a link between health and education. Everybody knows that! You might even say that it is too obvious to be worth discussing. End of article. Or is it?

Yes, indeed, we all know that health and education go hand in hand. But precisely how? Is it simply a matter of "You are educated, therefore you will enjoy better health"? Statistically, there is a lot of support for that proposition, but it is clearly not the whole story.

Collective health is not the same as individual health. You may be enjoying the benefits of a superb education, but your health may be poor. That is why we need to explore not just the link between education and health but also that between health education and patients' health. In other words, education does not stop at school or on graduation. Patients - persons who are ill - will benefit from health education, because it will help them and their families and carers to cope more successfully with their condition, its management and, if possible, their recovery and the prevention of recurrence. That, too, is a statement of the obvious, but few would claim that is it adequately reflected in the practice of health policy today.

Health status

To start with: first principles. How do we measure health status? Many methods can be used, and each implies a link with a variety of factors that will influence health. For example, the health status of different nations is often measured as 'Life expectation at birth'. Infantile mortality is generally highest in the poorest developing countries. It was also a prime factor in determining health status in the industrialised world in the 19th and early 20th centuries - a period when there was a wide gulf between rich and poor in both education and sanitation.

Here, we already have three pairs of influences on the health status of nations: poverty vs. wealth, illiteracy vs. education, and weak vs. strong public policy on sanitation [clean water, clean air]. Each of these has a powerful impact on health.

In the 21st century, ours is an ageing society. In keeping with the theme of this website (www.healthandage.com), it may be fitting to compare the health status of nations by examining Healthy Life Expectancy at age 60 (instead of the more commonly measured total life expectancy at birth). In other words, on average, how many additional healthy life-years can we expect once we have reached the age of 60, after deducting prospective "time spent in poor health" from total life expectancy? The World Health Organisation [WHO] has estimated this for the populations of 191 countries. Here is a league table of some leading industrialised and developing countries:

HEALTHY LIFE EXPECTANCY AT AGE 60 in 14 countries
[= estimated years of total life expectancy at age 60 less estimated time spent in poor health]

COUNTRY	WOMEN	MEN
Japan	20.7	17.1
Switzerland	19.4	16.9
France	19.1	16.1
Italy	18.2	15.5
Canada	17.9	15.3
Germany	17.7	15.0
United Kingdom	16.9	15.0
USA	16.6	14.9
Mexico	14.9	14.5
China	14.2	12.7
Brazil	13.0	9.4
Russia	12.7	8.5
South Africa	11.4	8.9
India	10.2	9.7

(Source: Extracted from Annex Table 1, World Health Report 2002, WHO, Geneva 2002)

Women not only live longer than men, but their healthy life expectancy at age 60 is generally about two-and-half to three years longer than that of men - though there are exceptions, for example in Mexico and India where the gender difference is only about six months.

Wealth clearly is a passport to health. The industrialised countries (top part of the table) all have longer healthy life expectancy at 60 than the poorer developing countries, though the difference between one of the richest (USA) and, for example, China is not as wide as the gulf in national wealth would suggest. Other factors are evidently at work. For example, the prospects of healthy longevity at age 60 in Japan may be genetic and also linked to Japanese nutrition, whereas the relatively mediocre average prospects of elderly Americans may be connected with inequality of access to the best medical care:

"A General Accounting Office report published in April 1999 found that 43% of all Medicare beneficiaries who are eligible for Medicare savings programs.... are not aware of these programs... or are intimidated by the application process. (this could be improved).... if the government were to launch an educational campaign to raise awareness of the interrelationship between Medicare and Medicaid among medical and social service professionals as well as among dually eligible beneficiaries."¹

In 2001 in the U.S., 36% of patients (of all ages) with below-average income "did not see doctor when sick" compared 15% of patients with above-average income. Similarly, 36% of below-average compared with 14% above-average patients "did not get recommended test or treatment".²

Here, both income levels and education in how to 'navigate' a complex health care system are involved in obtaining satisfactory access to care.

Link factors in health status and health care

This and other examples help us to identify some of the main factors influencing the health status of nations and of individuals:

1. Socio-economic status (wealth vs. poverty; education vs. illiteracy)
2. Exposure to disease (AIDS in sub-Saharan Africa is a catastrophic example)
3. Access to health insurance, health education, prevention and care (health policy)
4. Advances in technology for health improvement (surgery, medicines, diagnostics)
5. Genetic risk factors (how to handle them in the practice of medicine)
6. Lifestyle risk factors (diet, smoking, alcohol, clinical obesity, health 'behaviour')

In formulating health policy, these factors should never be viewed in isolation. They form an interrelated complex of opportunities and problems in improving health status.

Education enters into every one of these factors:

1. It improves socio-economic status
2. It helps to reduce exposure to disease
3. It plays a vital role in securing access to health care and disease prevention
4. It promotes appropriate use of advances in health technology
5. It is needed for medical genetics as our knowledge of the human genome grows
6. Education is essential in motivating and persuading us to adopt healthy lifestyles.

Health status and general education - the evidence

Among the more remarkable illustrations of the link between general education and health is what has been described as the 'Kerala Paradox'. Kerala (a state in south India) has health indices that are "far superior to the Indian national averages and approaching those of the developed countries"³. Yet Kerala is 'poor' by the standards of the industrialised world.

"Researchers have agreed that the main agent of change in Kerala health indicators is the education of girls. The literacy rates in the state for men and women are 94% and 86%, as against the national averages of 64% and 39%."³

Literacy has helped women to seek antenatal care, institutional birth delivery, and the immunisation of children - access to which, too, is higher in Kerala than in India generally.

Extensive studies have established direct links between general education and health status in the USA. An analysis of chronic disability among elderly black and non-black persons in 1999 revealed striking differences when linked to their years in education:

CHRONIC DISABILITY* AND LENGTH OF EDUCATION
Age Group 65-74, USA 1999

EDUCATION	% DISABLED Black	% DISABLED Non-black
Grade 0-8	15.5	16.1
Grade 9-12	12.4	9.0
Grade 13+	10.8	6.7

* more than 90 days impairment of 'activities and instrumental activities of daily living'
Source: Manton and Gu⁴

For higher age groups, disability rises but the percentage of chronically disabled still declines with length of education among persons aged 75 and above. With demographic ageing, the personal, social, financial and political implications of these findings will be of growing importance for long-term care of the elderly. Education prevents or postpones chronic disability and helps to avoid overloading systems of long-term care that are widely seen as inadequate in quality, unaffordable financially, or at risk of breaking down altogether.

The above analysis correlates higher education and reduced morbidity (expressed as disability). Another recent U.S. study links length of education with lower mortality from a wide range of diseases and concludes:

"When adjusted for age, sex and race, the number of potential life-years lost from all causes of death was 3.5 times as great for persons with less education than for persons with more education... (They) lost 12.8 and 3.6 life-years before 75 years of age per person, respectively, a difference of 9.2 years."⁵

Of the total number of life-years lost as a result of educational differences, 35% were attributed to cardiovascular (heart and circulatory) disease, 27% to cancers, 9% to infectious diseases, 5% to lung diseases other than cancer, 4% to diabetes, and 20% to all other diseases. The prominence of 'smoking-related diseases' was noted by the authors as the common factor among all six leading contributors to the educational disparity in mortality (i.e. from ischaemic heart disease, lung cancer, stroke, pneumonia, congestive heart failure and lung disease). They were responsible for no less than 40% of the overall educational disparity and will evidently benefit from being targeted by specific health education.

These two studies indicate clearly that, in a U.S. context, the length of general education alone significantly improves your chances of living longer as well as living better (without or with less chronic disability).

Education and 'psychological' aspects of health

So far, we have looked at objective analysis based on directly measurable criteria like the diagnosis of disease, the occurrence of death, or the observation of more than 90 days of impaired 'activities of daily life' (dressing, bathing, eating, walking, housework, shopping, preparing meals). Are the benefits of education limited to these? Or can they also help with the more subjective or psychological aspects of health?

Reports of Self-perception of health status reveal a very different state of affairs from the findings of objective analysis. The European Community Household Panel has reported on "Self-perception of a person's own health" with astonishing variations in how some of us think about our health status, especially among the older age groups.

SELF-PERCEPTION OF OWN HEALTH IN EUROPE, 1997
65+ years of age, % non-standardised

COUNTRY	'VERY GOOD or GOOD': WOMEN	'VERY GOOD or GOOD': MEN
United Kingdom	54.4	57.5
Ireland	53.5	62.3
Denmark	43.4	53.7
EUROPEAN UNION average	29.0	34.5
France	27.1	31.6
Spain	26.4	36.9
Greece	23.1	37.8
Italy	20.3	26.7
Germany	17.2	19.3
Portugal	5.1	12.8

Source: Eurostat Yearbook 2002⁶

Here the irrational element in "how I feel about my health" presents a totally different vision of Europe from the one that we deduce factually from official statistics.

In the first place, elderly women feel worse about their health throughout Europe than elderly men, especially in Ireland, Denmark, Spain and Greece - yet women live longer and their healthy life expectancy at 60 is higher than that of men. (see first table in this article). Secondly, self-perceptions of 'very good or good' health among elderly French men and women are below the European average (and at roughly half the British level). Yet French health care and education are generally regarded as among the best in the world, whereas serious defects in the corresponding British systems are widely acknowledged. The Portuguese present an absolutely desolate self-image of health among elderly citizens. Although Portugal and Greece have the lowest income per head of population in the European Union, their self-perceptions of health among elderly citizens differ dramatically. Finally and remarkably, the elderly in Germany - the European Union's richest member state with excellent health care - appear next to bottom in the self-perception table.

These self-perceptions defy logical analysis and seem instead to cry out for the psychiatrist's couch. Are elderly Germans confirmed hypochondriacs while their British counterparts are stoically content with a lower standard of health and care? Or could it be that Germans expect far better health at age 60+ than they get, while the British are pleasantly surprised when their modest expectations are surpassed? In her study of "Medicine and Culture", the American author Lynn Payer⁷ has commented that, in Germany, "patients seem unlikely to emerge from the doctor's office with the news that they are in good health". The fact that they may not even expect such news has been amusingly epitomised by a German author⁸ as the tendency for patients to ask their physician:

"Ich fühle mich so gesund, Herr Doktor, ist das normal?"
"I am feeling so well, doctor, is that normal?"

'The 'cultural' psychology of health care and being a patient remains speculative. Does that take us any further in terms of health policy and education?

A recent study has concluded that self-perceived 'low energy' states of health (like fatigue, psycho-somatic ailments, and general dissatisfaction with life) are not strongly influenced by educational attainment⁹ That does not imply that education is irrelevant. It merely suggests that appropriate forms of psychological health education need also to be developed to help counteract 'low energy' states that may well be connected with the growing societal phenomenon of stress. After all, stress is known to be a contributory cause of diseases for which a link with education has been clearly established in studies cited earlier in this article.

From general education to health education for the benefit of patients

The impact of health education on medical outcomes and patients' health status is not as well documented as that of general educational attainment. That is surprising and disappointing, because health education is a natural follow-on from general education. Yet it remains the Cinderella of medicine. In the mid-1990s, Switzerland - a rich country with one of the best health care systems in the world - devoted just 1.75% of its total health care expenditure to preventive health¹⁰ - an activity that is above all educational. By 1998, this had fallen to 1.6%¹¹.

There are a number of recent examples of studies that have shown how health education is needed and can help to achieve better health outcome for patients, especially in the management of chronic diseases:

Diabetes: A Canadian study of the experience of 30 family physicians recorded their view that "early educational interventions for patients with diabetes resulted in better outcomes. 'The better job you do right at the start of educating them, the longer the effect's going to last. If you just sort of gloss over at the start, they don't really take it seriously.'" Participants described ongoing educational intervention as "a cornerstone of diabetes care."¹²

Asthma: a French analysis of 1,475 asthma patients observed that 18% suffered from moderate-to-severe unstable asthma, and that 96% of these patients were being given inadequate treatment. They constituted "the clearest target for measures aiming at patient education and training of health professionals (in screening, evaluating and adapting treatment). Although this will probably involve higher costs initially, such action could eventually avoid the likely worsening of asthma and thus the associated additional expenditure."(¹³, author's translation)

Depression: An investigation by the UK Clinical Standards Advisory Group in 1998/9 concluded that, in primary care in the UK, "only 7 in 100 patients with clinical depression are effectively treated at present." The President of GAMIAN-Europe (Global Alliance of Mental Illness Advocacy Networks) considers that "What is needed is a comprehensive educational initiative to raise awareness of the prevalence of depression combined with better understanding of the illness and the promotion of good mental health. All stakeholders should be involved: physicians, psychiatrists, psychologists, pharmacists, patients, the press, politicians and the pharmaceutical industry.... There is, after all, no such thing as a vaccine against depression."¹⁴

Genomic medicine: A look into the future emphasises the need for "the development of genetic literacy" as an essential feature of health promotion and disease prevention: ".... no transformation that has prevention as its central outcome can occur without a collaboration between patient and provider that is rooted in the same assumptions about....the implications of genetic medicine for individuals, families and society. The construction of that collaboration is the true challenge of education in the genomic world"¹⁵

Educational involvement of all stakeholders in patients' health and outcomes is the crux. Health promotion, disease prevention, and medical treatment are complex matters with continually changing learning curves. Medical technology is advancing; financial pressures on health care systems are becoming more intensive; instant communication of new knowledge is now feasible via the Internet; patients are increasingly empowered and can educate one another in health affairs. These trends are here to stay.

Health is our most precious personal possession. That is not all. The influence of health and ill-health on the well-being of our ageing society will be critical in the political and economic environment of the 21st century. Without health in youth and middle age, society is ravaged, as the population crisis caused by "the apocalyptic scale of the AIDS epidemic in Africa"¹⁶ is demonstrating with tragic clarity.

Among the older age groups, healthy life expectancy after the age of 60 will become more and more important as society ages. Quite apart from its direct benefits to our personal quality of life, good health reduces the physical and economic dependency of elderly persons. It also makes national expenditure on patients in medical and long-term care more affordable. This will, however, be achieved only with determined and purposeful efforts to treat health education as an essential and lifelong part of general education.