Traumatic childhood experiences such as abuse, neglect and household dysfunction can have an impact on health as well as behavior and learning. Such experiences can include physical neglect and emotional abuse to family issues involving substance abuse or mental illness. According to the U.S. Centers for Disease Control and Prevention, ACEs have been linked to risky health behaviors, chronic health conditions and even early death, with the risk for such outcomes increasing with the number of adverse events a child experiences. While researchers are still studying the link between such events in childhood and health as an adult, ACEs are preventable.
The theory that the accumulated burden of chronic stress creates a common pathway to the onset and progression of many different diseases. Measures of allostatic load reflect how well or poorly the cardiovascular, metabolic, nervous, hormonal and immune systems are functioning, with higher scores indicating greater vulnerability to illness. Scores are based on readings of blood pressure, body mass index, kidney function, blood sugar, cholesterol, C-reactive protein and other tests.
Behavioral risk factors
Habits such as smoking, inactivity, poor diet, and drug or alcohol abuse change a person’s vulnerability to illness and account for some of the health differences between people of different social classes. But people in poorer communities also are likely to face more environmental hazards and more stressful living conditions while having fewer resources to deal with their effects.
The rate at which a population bears children, often broken down in data by race, age, marital status and other factors. Sometimes also referred to as the “fertility rate.”
Broken Windows effect
The so-called Broken Windows theory has led to initiatives that try to reduce violence by restoring deteriorating neighborhoods, removing or securely sealing abandoned buildings, and greening vacant lots. The idea is that abandoned places give cover to criminal activity and signal that no one is in control. Researchers have found significant associations between the risk of violent assault and the presence of abandoned buildings and vacant lots, even after controlling for demographic and socioeconomic characteristics of the neighborhoods. But it’s not yet clear if property restoration efforts are an effective way to reduce crime.
Bullying is defined by the U.S. Centers for Disease Control and Prevention as unwanted aggressive behavior such as hitting, tripping, name calling, teasing, spreading rumors or shunning. Although schools have historically served as the center for bullying, it has evolved outside those walls in the Internet age and social media in which a single act can be repeated and viewed endlessly. Such behaviors, according to the CDC, can lead to health problems such as injury, emotional distress, depression and sleep disorders. Vulnerable populations include lesbian, gay, bisexual and transgender (LGBT) youth as well as young people with developmental disabilities or health problems, and those living in poverty, according to a 2016 NAS report. Ethnicity can also be a factor in conjunction with a school’s racial and ethnic make-up, NAS concluded.
The willingness of neighbors to band together for the common good - their collective efficacy - is tightly linked to levels of neighborhood violence. The higher the collective efficacy, the lower the violence. The lack of collective efficacy may largely explain why people living in poor neighborhoods are more likely to be victims of violent crime. Collective efficacy requires a foundation of social cohesion, or trust and respect, among community residents, combined with their ability to share resources and respond to negative situations. A number of cities are testing ways to mobilize collective efficacy as a way to improve public health.
Comparative effectiveness research
Comparative effectiveness research goes by many names. Among them are “health technology assessment,” “patient-centered outcomes research,” and “cost-effective analysis.” As Valerie Virta, Ph.D., scientific editor, PubMed Health website, National Center for Biotechnology Information, National Library of Medicine, explained during her presentation to the 2018 AHCJ Comparative Effectiveness Research fellows, the bottom line is that the benefits and harms of healthcare strategies are being compared in the messy, real-world setting rather than in the more tightly controlled clinical trial scenario.
Unlike clinical trials, the real-world clinical setting essentially takes all comers, not excluded people for various factors such as other conditions, their sex or age or history of health problems. That means, said Virta, that comparative effectiveness studies should reflect a “comprehensive array” of how a given strategy will affect outcomes for different populations and subgroups of patients.
These studies can address everything from drugs to devices, technologies being rolled out with the goal of improving care, costs comparisons, diagnoses and other patient outcomes. These studies take what clinical trials show and use those findings as a start point rather than as an endpoint. In environmental assessments, researchers might begin evaluating the risks of a chemical in well-controlled lab experiments, but the real effects remain unclear until they evaluate these chemicals in the messy chaos of the natural world. In human studies, clinical studies are the sterile, controlled lab versions, while the clinical setting most of us know and experience is that uncontrolled, unpredictable real world.
If you’re interested in digging into some data about comparative effectiveness research, the U.S. National Library of Medicine maintains a searchable database and a huge list of resources for the enterprising reporter, covering everything from grant awards to related legislation to organizations who focus in this area.
Contextualized risk factors
Behavioral risk factors can be influenced by social, cultural, and economic forces. In some poor neighborhoods, for example, tobacco and liquor advertising is prominent, lack of safe or convenient parks discourages outdoor recreation and most of the food offered for sale is unhealthy.
Controllable risk factor
Along with uncontrollable factors, those that can be controlled also influence one’s overall risk for various diseases. Controllable risk factors, or lifestyle risk, can include exercise, diet, alcohol consumption, drug use and other behaviors. Such factors can play a role in conditions such as obesity, diabetes and some cancers, among others.
The ability of health care providers to deliver care and services that take into account the cultural needs of a diverse patient population. Language, health literacy, customs, beliefs, practices and communication are all key factors in providing such care.
Developmental origins of health and disease
From conception through infancy and early childhood, exposures to certain stresses can alter the trajectory of development in ways that increase vulnerability to disease in adulthood. Exposure to endocrine disruptor chemicals in the womb, for example, or a disadvantaged mother’s poor diet can modify an infant’s lifelong disease risk. These early life exposures may act in subtle ways. They don’t have to grossly disrupt development or directly trigger disease to make people more vulnerable to heart disease, weight gain and other health problems decades later. One way this happens is through epigenetic processes that change the activity of genes.
One in four adults in the United States eventually will experience disability. Disabilities can be visible or invisible, and they can affect all aspects of daily life, particularly factors associated with access to work, entertainment, home, and medical care. People with disabilities have disproportionally higher representation across negative social, health and access factors that are tied to health.
Preventive health efforts that focus on identifying high-risk individuals are bound to provide only short-term improvements because the unchanged conditions of the environment will continue to produce new high-risk people, allowing a cycle of poor health to persist. Eco-epidemiology refers to an expanded scope for the study of disease prevention that includes multiple levels of causation – including the social environment – acting over lifetimes. Advocates say this approach should yield widespread protection and enhanced health with less reliance on personal behavior change.
The disproportionate burden of pollution and other harmful environmental exposures falling mainly on disadvantaged neighborhoods and people with less wealth, social status, and influence.
Stressful experiences can change how genes function, an effect called “epigenetic” modification. Such changes may influence the susceptibility to chronic diseases. Epigenetic modification is not a mutation of the DNA sequence, rather it is a change in the regulatory systems that turn a gene on and off. Epigenetic changes in gene expression can be short-term or enduring, and some can be transmitted across generations.
A concept of health care that views patients’ families as integral to their care and incorporates them into their health and wellness. Often this is done through communication and information sharing but also by involving families in making decisions and other aspects of delivering medical care. Such care acknowledges “emotional, social, and developmental support are integral components of health care,” according to the American Academy of Pediatrics.
Federal poverty level
This U.S. government metric, updated annually, is used to help determine eligibility for certain federal programs, such as subsidies under the Affordable Care Act and Medicaid. Unlike the poverty statistics issued annually by the Census Bureau, the Federal Poverty Level is an administrative guidelines issued by the Department of Human Services. For 2015, the measure was $11,700 for an individual and $24,250 for a family of four, although Alaska and Hawaii have higher allowances.
Fidelity of health care delivery
Medical research and development spending goes overwhelmingly to developing new treatments, leaving comparatively little for improving the “fidelity” of medical services, that is, the extent to which health systems give patients appropriate tests and treatments when they are needed. (Only about half of adults in the U.S. receive all the recommended preventive care and screening tests, by one recent estimate). Neglecting the fidelity of health care to spend more on new drugs and devices may cost lives. For example, researchers found that the billions of dollars invested in developing anti-clotting drugs more potent than aspirin may have prevented fewer strokes than just making sure that all at-risk people took aspirin.
Specially-trained social workers are increasing being employed as so-called “financial navigators” to help patients sort through the funding of their health care . Their primary role is to help ensure that patients understand their insurance coverage and related options. Such navigators are often increasingly utilized in cancer care, which can involve expensive and lengthy treatments.
Urban neighborhoods and rural areas with few or no grocery stores selling fresh, affordable produce have earned the catchy nickname “food deserts.” The term seems to have originated in Scotland in the early 1990s, but quickly gained worldwide use among academics, policy makers, and advocates. There is a mountain of evidence showing that low-income and minority Americans are more likely to live in “food deserts.” But it’s not at all clear to what extent the lack of supermarkets and grocery stores contributes to obesity or other health outcomes.
Having some access to food but not all the time – and not enough of it to sustain one’s household – is a general way to think about insecurity when it comes to food. But what used to once be an umbrella term has in recent years been redefined to recognize the varying levels of what it means to have inconsistent access to something to eat. The U.S Department of Agriculture breaks it down four ways: Low food security, very low food security, marginal food security and high food security. At the “very low” end, people report “multiple indications of disrupted eating patterns and reduced food intake,” such as skipping meals or eating less than enough to feel full, while those with high security report no problems with adequate access to food. It is closely linked to poverty and other social determinants of health.
Food stamp cycle
Women who receive food stamps are more likely to be overweight and some researchers think it has to do with a feast-or-famine cycle. When food stamp benefits run out at the end of the month, mothers in food-insecure families may go hungry for several days to provide enough for children. When benefits are restored, these women may overeat. Overeating when palatable food is plentiful, followed by a short period of involuntary food restriction, followed by overeating, could be a pattern that results in gradual weight gain over time, but the evidence is largely circumstantial.
Generally defined as how one sees their gender and how they express and call themselves, whether it is male, female, neither of those or a combination. Children can generally identify their own gender as young as age two or three. Transgender individuals are those who identify as something other than their sex at birth. Agender, or non-binary, individuals identify with no particular gender.
People’s bodies succumb to the effects of aging at different rates, and environmental exposures seem to play a much bigger role than genes. (Only about one quarter of human longevity is heritable). George Martin, a physician-scientist at the University of Washington, coined the term ‘gerontogen’ for any environmental exposure or toxicant that accelerates aging. According to the theory, varying exposure to largely unknown gerontogens explains much of the non-genetic variation in the rates of human physiological aging.
A widely used measure of income inequality. Perfectly equal distribution would yield a value of 1 on the Gini index, while a value of 0 would indicate that one person commanded all of the income. The United States currently scores around 0.47. That’s 18 percent higher than in 1967, according to the U.S. Census Bureau. Sweden, Denmark and Norway, the wealthy countries with the most equal distribution of income, score around 0.25. South Africa and a few other African countries score higher than 0.63.
The choices and behaviors that people and their communities make can have a profound impact on individuals’ and community health. Health behaviors play a role in a range of health conditions and issues such as HIV/AIDS, smoking, obesity, pregnancy, communicable diseases and even early detection of cancer. Alcohol and drug use, injuries and medication adherence are also impacted by health behavior. At the community level, health behavior can be impacted by available resources and conditions such as access to green space or grocery stores. Tied closely with health promotion, researchers also focus on the role of advertising and media in impacting behaviors that can impact heath.
Differences in health status experienced by groups of people disadvantaged because of their race, ethnicity, religion, socioeconomic status, gender, age, mental health, physical disability, sexual orientation, geographic location, or other characteristics historically linked to discrimination or exclusion.
An ideal envisioned by public health experts in which all people can achieve their best health without being disadvantaged by various factors. The goal is for people to have the same and equal opportunities in order to reach their full health potential. However, social determinants such as economic, social or environmental issues can lead to differences that can create gaps among different groups of people, or health disparities.
Understanding health comes in many forms. On one level, it relates to one’s ability to access and understand information needed to make appropriate health decisions. At the same time, it also includes the ability of health providers and their institutions to provide accessible and meaningful information.
Health impact assessment (HIA)
A systematic assessment of the potential effects that a government program or project may have on the health of a population. HIAs are supposed to help policy makers avoid unintended harmful effects and take advantage of opportunities to promote health.
Health in all policies (HiAP)
This public health strategy emerged in Europe and is now gaining traction in the U.S. It calls upon political leaders and policy makers to explicitly consider the health impact of the priorities they set in education, taxes, recreation, transportation, housing, and other arenas beyond strictly defined health care or public health.
Healthy People 2020
Health People 2020 is a U.S. federal initiative to improve the nation’s health. Key for health care journalists, though, is its online data search offerings across topic areas, a trove of potential story ideas or data to inform a narrative.
People who are homeless face many health threats and are among the heaviest users of hospital services. Housing First is a public health strategy based on the idea that secure, affordable housing is a necessary first step to care effectively for people with chronic mental health and substance abuse problems who live on the streets. See also: Housing as health care
Learned stereotypes and prejudices that operate automatically and unconsciously when interacting with others. Also referred to as unconscious bias. When a person’s actions or decisions are at odds with their intentions this is implicit bias.
Also known as the wealth gap, the divide between the rich and the poor has come to broadly define income inequality. Such gaps are measured based on household disposable income, most notably by the Gini index, according to the Organisation for Economic Co-operation and Development. Sometimes called "economic inequality," the wealth gap can vary from county to county, state to state and even nation by nation, and offers an indication of how resources are spread in a society.
Index of disparity
Used in statistical analysis. The index is developed based on using the usual categories of social determinations such as education or income, but correcting them for population weights. How big each category is reflected in a graphic representation of the proportion of a population that is reflected in each ordered group within the category. An example of how such a graphic might look is here, taken from this paper, whose authors initially described this tool.
One of the key factors in the social determinant of health, decisions that a person makes and how they act can impact their risk factors, health status and disease outcomes. Examples of such behaviors include whether or not to use tobacco, have unprotected sex, abuse drugs or consume alcohol. One’s diet and physical activity levels are also considered individual behaviors as are some other public health measures such as hygiene and hand washing. Related to Behavioral risk factors and Health behaviors.
Sustained exposure to lead can cause long-term health problems, most notably neurological damage. While no level of lead in the blood is safe, the U.S. Centers for Disease Control and Prevention’s “advisory” level for concern is 10 µg/dL to 5 µg/dL for children and adults. Other U.S. agencies, however, have set their own level for acceptable lead levels – in the blood, air, food, water, soil and paint – that would trigger regulatory action. A known toxin, lead can impact brain development and cause behavioral problems, particularly among children. Its health impacts are cumulative.
The effects of social class on health are often measured by comparing life expectancy, the average number of years of life remaining at a given age, based on the current mortality rate for the population. For example, the average life expectancy at birth among African American men in the District of Columbia – 63 years – is 17 years less than that of white men in adjacent Montgomery County, Md.
Initiatives that set out to tackle health inequalities often pay lip service to the social determinants of health (quality education, safe neighborhoods, reliable employment). But public health officials tend to drift “downstream” to focus on individual behaviors (smoking, diet, alcohol, drugs) and to ignore the “upstream” drivers of these behaviors — the fundamental causes.
Feeling alone can have both psychological and physical impacts, from causing aggression or social anxiety to sleep loss, changes in the brain, and elevated stress hormones. Loneliness in modern society has grown to become a public health concern as isolation and changes on social and community structures change the way people live. Some studies also suggest there may be a genetic component to why being alone may weigh more on certain people.
Maternal mortality rate
The number of women who die each year per every 100,000 live births. To classify as maternal-related, the death must be linked to childbirth or the management of the birth. It cannot be due to an accident or another incidental cause. Estimates of the rate vary, but in the United States it ranges from 21 in 2010 (CIA World Factbook), 17.3 in 2013 (U.S. Centers for Disease Control and Prevention) and 14 in 2015 (World Bank). Some other analyses in peer-reviewed journals have estimated an even higher rate. There is also considerable fluctuation between U.S. states, and country-to-country. In 2015, Sierra Leone had the highest rate worldwide, while Greece, Poland, Finland and Iceland had the lowest rate, according to the World Bank.
Members of this generation of young adults include those born between 1992 and 2000. According to the U.S. Census Bureau, there were 83.1 million millennials in 2014, representing more than 25 percent of the U.S. population.
The manifestation of life events that are “extreme and unprecedented” that cross a moral line and can cause harm to individuals involved in the act. Similar to psychological trauma, moral injury can cause anxiety, anger, guilt and even self-harm, among other injuries. It can affect a range of workers from soldiers and police to journalists and emergency personnel. Experts have said while moral injury and post-traumatic stress disorder (PTSD) can overlap, moral injury involves some form of transgression, although more research is needed.
This up-and-coming field looks at how nutrients from food can impact how one’s individual genes are expressed. This field of study looks at how diets can impact disease as well as illness prevention. Scientists are also looking at how food and its nutrients can protect genes or damage them, a concepts known as “genome health.” Nutrigenomics’ role is being studied in relation to obesity and diabetes as well as maternal health, Crohn’s disease and other conditions.
A term used in the health assessment of an entire group of people. “Population” often refers to those in a certain geographic area or with the same characteristics, but it can also refer to those cared for by a particular health care provider or whose care is covered by the same insurer or other payer. Additionally, it could refer to primary care patients or another set of patients in the health care system. Although sometimes interchanged with the term public health, it invokes a broader connotation regarding efforts to promote health and prevent disease.
An alternative way to compare the health of different populations is to add up the potential years life lost (PYLL) due to premature death, defined by a standard cut-off age. If the standard age is defined as 70, a death at age 5 counts as 65 potential years of life lost, while a death at age 60 counts as 10 potential years of life lost.
Sometimes referred to as psychoendoneuroimmunology, psychoneuroimmunology (PNI) is the study of the interaction of the brain and the body. More specifically, it examines how physiological issues can impact one’s propensity for disease; how stress can weaken the immune system and cause illness is one example.
Although sometimes used interchangeably with the term population health, “public health” is increasingly used to reference a narrower set of actions linked to or taken by official government agencies and other organizations.
Higher social standing may help people build psychological resources, or a reserve capacity, to cope with stressors more resiliently so as to minimize damaging physiological responses.
The ability to recover or “bounce back” from difficult situations or challenging circumstances. Such capacity could be at an individual level or a collective one such as a local community. The power to respond to certain challenges such as stressors, crises or other conditions can play a role in both mental and physical health. It is also contributes to one’s overall well-being. Factors that could potentially influence resilience include social networks, adaptability and interventional actions, among others. However, resilience “is not a trait that people either have or do not have. It involves behaviors, thoughts and actions that can be learned and developed,” according to the American Psychological Association.
In general, “rural” refers to places outside of a city, or as HHS’s Health Resources and Services Administration puts it: “Whatever is not urban is considered rural.” But that leaves out areas such as the suburbs or mostly-rural counties with one city center. The federal government uses more than 15 different definitions for “rural,” according to the Rural Policy Research Institute. The U.S. Office of Management and Budget defines it as a county that does not have an urban core of 50,000 people, so it could include areas with some denser “micropolitan” areas. The U.S. Census Bureau, however, does not use county or other borders, and defines rural as any area that falls outside one with 50,000 or more people or one with a densely settled core of between 2,500 and 49,999 people. Whether an area is classified as rural can impact health policy, for example in determining eligibility for certain grants.
Health and longevity tend to decrease with poverty and social isolation, and increase with wealth and social status. This link between socioeconomic status and health, the SES-health gradient, persists even among people in the middle and upper ranges of social advantage, many studies have shown.
Sometimes confused with gender identity, sexual orientation refers to one’s attraction to other people based on their sex. Heterosexuals are those attracted to someone of the opposite sex. Homosexuals are attracted to someone of the same biological sex, although the term has fallen out of favor – gay or lesbian is the one now used by the AP Stylebook, although it is still used in some medical terminology. Bisexuals are those attracted to both male and females.
Unlike traditional wealth, social capital is a nod to the relationship connections in one’s life that cannot be given financial weight but that can be equally impactful. The collective value of social capital comes from the bonds of human networks that people create. Such a resource can help provide information, assistance and other benefits that do not carry a price tag but have distinct value. As modern society continues to shift, however, the notion of social capital is also evolving. “Today it would be hard to come up with a single definition that satisfied everyone,” according to researchers at the Organisation for Economic Co-operation and Development (OECD) .
Socioeconomic status (SES)
A person’s social class, or place in the hierarchy of power and self-determination can be quantified using measures of socioeconomic status. The typical measures are proxies such as years of education, income level, occupation, and sometimes residential location.
Social determinants of health
The conditions in which people are born, grow, live, work, and age are mostly responsible for health inequalities—the unfair and avoidable differences in health that divide populations. Economic and social disadvantage make people more vulnerable to illness, disability, suffering, and premature death. For convenience, researchers studying the social determinants of health tend to focus on a limited set of markers of social status, such as income, education, occupation, race or ethnicity, and neighborhood qualities (home ownership, property values, degree of segregation).
Social determinants of health (income, education, social class, etc.) are sometimes referred to as “structural determinants” by those who want to emphasize their primary role in shaping health inequalities. Structural determinants exert their effects through intermediary determinants such as housing and neighborhood quality, stressful living circumstances, access to care and support, and health behaviors.
Targeting with universalism
Providing programs and services in a way that they will be available to everyone, including (and maybe especially) targeting higher-risk or often-excluded populations.
Social disadvantage appears to accelerate aging at the cellular level as indicated by the length of telomeres, the protective sections of DNA at the tips of chromosomes that shorten with age. For example, children who experience chronic stress from a disadvantaged life have shorter telomeres than their advantaged peers, according to a recent study of 9-year-old African-American boys. Adults who completed less than a high school education had significantly shorter telomeres than those who graduated from college, in another study. The evidence is far from conclusive, however. Some investigators have found inconsistent correlations between telomere length and socioeconomic status.
A method of care or treatment that seeks to examine a person’s past history of trauma and focus on how it has impacted their behavior or health. This focus on past traumatic events is used in a range of fields, including medicine, education and criminal justice. While trauma-informed approach can be integrated into models used by physicians, therapists, counselor, judges, teachers and others, specific trauma intervention programs have also been created. Overall, assessing past trauma and how it has impacted a patient’s situation aims to help better address their needs and choose the best care.
Traumatic stress injury
Some military experts, psychiatrists and other advocates have been pushing for the renaming of post-traumatic stress disorder to post traumatic stress injury, or TSI, as a way to reduce stigma and increase treatment. Although the American Psychiatric Association did not adopt the term when it revised its mental illness manual in 2013, the term is still used among some veterans groups, clinicians and others who say it helps people seek care.
Uncontrollable risk factor
While there are some things people can do that can either increase or decrease their risk for disease, there are other factors that can have an impact but cannot be controlled. These include age, gender and race as well as other heredity factors that are part of one’s genetic make-up that show up in family history or DNA testing.
Medically underserved populations are those who lack access to health care services such as low-income people, the homeless or other subgroups who face barriers to care from economic, cultural, language or geographic challenges. Certain regions can also be underserved when an area faces a shortage of care providers. Also referred to by the federal government as Medically Underserved Areas and Populations (MUA/Ps).
The U.S. health care system is really more of a “sick care” system. Recognizing this, some health professionals have started trying to assess and improve the “upstream” social and environmental conditions that shape health outcomes. The movement gets its name from a parable about children being swept down a river. Rescuers make heroic efforts to save one child after another from drowning until finally it dawns on them to venture upstream to stop whoever is throwing the children in the river. The upstream movement is exemplified by HealthBegins, an online community founded by Dr. Rishi Manchanda, author of the book The Upstream Doctors; and the Canadian nonprofit Upstream, directed by Dr. Ryan Meili, a family physician in Saskatoon.
Cities in America have sprawled so much that researchers call them “metropolitan statistical areas,” or MSAs. Urban areas are less based on exact city boundaries and more on density to include a wide swath of surrounding suburbs. U.S. federal agencies define metropolitan areas as those with a “core” of more than 50,000 people. That could be a city, or a larger area covering several counties in a state. Specifically, the U.S. Census Bureau also recognizes urban “clusters” that include areas that have at least 2,500 but less than 50,000 people. The New York-Newark area is the nation’s most populated urban area, according to the 2010 Census, followed by the Los Angeles-Long Beach-Anaheim area, and the Chicago area.
Some evidence suggests that greater exposure to adverse social conditions and physical environments produces a chronic stress response that over time accelerates wear and tear on physiological systems. This “weathering” hypothesis has been proposed to explain why African American women who give birth in their twenties face greater risk of infant death than those who give birth as teenagers. The opposite is true for most other women in the United States, who face greater risk as teenagers.
Finding traditional health systems ineffective at addressing the social determinants of health, some communities are trying to establish public trust funds to help deliver preventive health and support. The Prevention and Wellness Trust Fund of Massachusettsis probably the most ambitious to date. The Trust has $60 million to spend over four years on grants to communities, health care providers, regional-planning agencies, employers and other entities. The money comes from a tax on insurers and an assessment on large hospital systems.
The Whitehall Study of British Civil Servants, started in 1967, famously showed that men in the lower employment grades were more likely to die prematurely than men in the higher grades. Whitehall II, launched in 1984, is tracking a larger group and includes women.