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date: 01 October 2022

# Rebooting Education: A Keystone to Ending Racial and Ethnic Minority Health Disparities

• William A. VegaWilliam A. VegaOffice of Research and Economic Development, Florida International University
•  and Esther J. CalzadaEsther J. CalzadaSteve Hicks School of Social Work, University of Texas at Austin

### Summary

Undermining educational attainment at any stage is a threat to life course health. A strong educational platform is required for adequate human development in the 21st century because it provides a foundation for lifelong knowledge, skills, and competencies that protect health. The importance of educational attainment for health has been acknowledged but remains understudied as an interdisciplinary issue. In US American society, unequal educational opportunity is a historical reality and is reflected in health disparities among African American and Latinx populations over the life span. Reform efforts have been initiated for decades, yet gains in educational attainment show limited progress and wide disparities in lifetime health persist. Educational attainment is a fundamental social determinant of health because it leverages higher income, improves the management of other social determinants of health, improves social skills, improves occupational life chances, and extends life expectancy. The reverse is also true. Low educational attainment that is intergenerational imperils human development by failing to prepare youth with the capabilities to overcome structural disadvantages and poverty, which themselves imperil development. African American and Latinx populations in the United States, who together represent nearly 100 million people and who will be the largest component of the majority-minority American population by the year 2046, confront a web of aversive social determinants, including poverty in de facto segregated communities, violence and trauma, toxic exposures, poorly compensated and often temporary employment, a lack of universal health insurance, racism, and sexism in their daily lives. Clearly, there are social, biologic, and psychological issues associated with the educational attainment and health gradient, and early childhood learning experiences represent a critically important opportunity for human potential by advancing cognitive performance, problem-solving ability, motivation to learn, and overall structural and functional brain development. Families from low educational attainment backgrounds experience the negative impacts of social determinants in their daily lives, and their children’s life chances are diminished by poorly funded schools with ineffective educational programs. Putative causes and potential responses to overcoming the historical problem of neglect have been identified, and there are promising efforts at educational system reform aiming to promote health with effective programs and comprehensive strategies that will close the gaps in educational attainment.

### Subjects

• Epidemiology
• Global Health
• Non-communicable Diseases
• Special Populations

The worst form of inequality is to try to make unequal things equal. —Aristotle

### Introduction

This article focuses on the contemporary associations between education and disparities in health and life chances in American society. The health and educational attainment gradient is rooted in a historical legacy of unequal educational opportunity (Braveman et al., 2011). It is critically important to understand how an individual’s place in the social structure is influenced by educational attainment, and equally important to understand how social stratification influences educational attainment and social determinants of health (Conti et al., 2010). The article examines interdisciplinary research about the importance for health of acquiring cognitive growth, social skills, and adequate educational attainment. It also examines the barriers to, and opportunities for, changes to educational systems, as well as the implications for African Americans and Latinx, who have been historically disadvantaged by American school systems (Kaplan et al., 2014).

The pathways between low educational attainment and population health are both direct and indirect, affecting the social determinants linked to lifestyle and disease risk factors (Goldmand & Smith, 2011). A social determinants and social stress analysis is presented supported by data about educational performance, and health-promoting programs for African Americans and Latinx1 students in American school systems.

The United States stands out among highly developed national economies as a case study of the extreme level of variation in school financing that privileges affluent neighborhoods and underinvests in low-income area school districts that are epicenters of health disparities, including behavioral health problems (Benabou, 1996; Raghupathi & Raghupathi, 2020). The focus of this article is African American and Latinx populations, who are the largest minority groups also disproportionately concentrated within the lowest educational attainment tiers of the United States. As of 2020, the African American population constituted about 12.4% of the total population, or 41.1 million people, and the Latinx population about 18.7%, or 62.1 million people. The 2019 poverty rate was 7.3% for Whites (non-Latino), 18.8% for African Americans, and 15.7% for Latinx (U.S. Census Bureau, 2020). The wealth of Latinx and African American households was estimated to be less than one fifth of that of White households (Maroto, 2016). This article examines why and how lower educational attainment affects large segments of African Americans and Latinx at risk for disparities in health and lowers their coping ability, including sense of personal control, to modify social determinants of health.

### Education as the Foundation of Social Determinants of Health

There are fundamental assumptions and social determinants for healthy development, derived from the public health framework of health equity, that are applicable to the education and health gradient, as described in Figure 1 (Braveman et al., 2011). Figure 1 identifies the three critical interconnected pathways in which educational attainment influences health. First and foremost, educational attainment affects health knowledge and literacy by improving an individual’s decision-making about their own health and the health of their families. Increased education is also linked to higher-paying employment, higher sense of control, and higher social status, defined as social rank in society, and reduced social stress.

This article examines how education influences downstream social determinants of health, and simultaneously how social determinants structure the quality of education received. The social determinants include place of residence, intergenerational poverty, substandard housing, food insufficiency, low healthcare access and quality, and systematic exposure to environmental toxins and violence. Operating as a web of connected risk factors, they affect personal health behaviors and population health outcomes (Oxman et al., 2009). This interconnection constitutes a formidable challenge for public health policy because it requires cross-sector coordination in assessing need, program design, readiness, and accountability. The issues are challenging for public health scholars and administrators to address (Mohajer & Earnest, 2010), and any impasse may be attributed to the issues’ sheer complexity, political convolutions, and the high risk of failure.

The article summarizes the empirical literature in support of the social determinants model, with a particular emphasis on two interrelated concepts: a life course approach to health, and the intergenerational nature of educational attainment and health risk or protective effects. Advantages in lifelong health commence early in life with strong educational preparation and are rooted in interactive social and environmental advantages resulting in health-promoting person-level experiences that are cumulative over the life span (Frieden, 2010; Miroski & Ross, 2005). Conversely, the personal capacity to reduce or eliminate the cumulative health burden of adverse social determinants by mid to late adulthood is limited in effectiveness and costly to remediate using medical interventions (Levine et al., 2019). In addition to experiencing worse health outcomes themselves, adults with limited educational attainment also have fewer resources to support education and health in their children.

#### Building a Foundation for Educational Attainment: Brain Development and Performance

Academic disparities emerge in early life (American Psychological Association, Presidential Task Force on Educational Disparities, 2012; Entwisle & Alexander, 1993). These findings align with a robust neuroscientific literature showing that learning opportunities in early childhood are necessary for the development of underlying neurological functions and structures that support lifelong learning (Duncan et al., 2012). One recent study used a trans-ethnic meta-analysis of genetic interactions between childhood socioeconomic factors and mother’s and father’s education level. There are statistically significant lower memory performance and greater memory declines in later adult life of children whose parents had lower educational attainment and chronic social stress exposure (Faul et al., 2021). Literacy by kindergarten is recognized by the American Academy of Pediatrics as “an essential component of primary care pediatric practice” (American Academy of Pediatrics, 2015). Yet African American and Latinx students display lower academic readiness skills in kindergarten and have lower state test scores starting in the third grade (Musu-Gillette et al., 2017).

According to the social determinants of health model, educational attainment impacts health via individual knowledge growth, literacy, and behaviors, in that they shape nutrition, exercise, substance use, and health/disease management (top box of Figure 1). To illustrate, we draw on the concept of “cognitive reserve,” a process supported by educational attainment that commences in early life and is associated with brain health across the life span (Manly et al., 2005). Cognitive reserve distinguishes and includes both passive advantages attributable to differences in brain structure, specifically cortical volume, and cognitive performance advantages attributable to superior synaptic region connectivity (Stern, 2002). Cognitive performance combines knowledge acquisition, performance level, and skills variously defined as literacy, verbal processing time, working memory, vocabulary, verbal fluency, world knowledge, word recall, and text recall, as well as early life mastery that affords lifelong advantages (Chen et al., 2019). Very low education is predictive of low cognitive reserve, and higher educational attainment beyond secondary school accentuates higher cognitive reserve (Rodriguez et al., 2018).

Perhaps the most consequential and consistent finding is a robust association between grade completed in school and lifetime cognitive performance, with implications for brain resilience against mental disorders and dementia (Lövden et al., 2020). However, individuals with fewer school grades completed, compared to individuals with more grades completed, will have lower cognitive performance at every stage of life. Cognitive performance increases with educational attainment level and benefits socioeconomic position, occupational attainment and complexity, and lived experience with additional competencies (Horvat et al., 2014; Richards et al., 2004). There is evidence, supported by magnetic resonance imaging research, of a positive association between brain volume and greater cognitive reserve (Rodriguez et al., 2021). Some of these studies have used large community samples, thus the evidence is very strong in support of reliable associations, albeit inconclusive regarding underlying brain mechanisms.

Brain performance is potentially modifiable. The human brain develops in stages, in concert with epigenetic changes having a very important role in development, and it has plasticity across the life span and is always replacing older neurons, albeit at declining numbers as people age into adulthood (Kolb & Gibb, 2011). Neurons can be created by intentional learning experiences (Fagiolini et al., 2009). The primacy of early educational support in preschool and primary school during the critical period of life when the foundation for neuronal capacity is established is obviously important, and an association between poverty and lower brain volume in children has been reported (Blair & Raver, 2016; National Research Council and Institute of Medicine Committee, 2000). Early childhood benefits from development of competencies such as reading and social skills, improves early life health, and is associated with higher school retention and life satisfaction in adolescence and beyond (Karcher et al., 2021; Le et al., 2013). In adulthood the benefits of higher quality education include higher income, intellectually stimulating employment, better health maintenance and physical functioning, less likelihood and later onset of disability, and lower risk of serious cognitive decline (Livingston et al., 2020; Vega et al., 2019).

#### Occupation, Income, Social Stress, and the Education–Health Gradient

Higher educational attainment and higher income are positively correlated and are fundamental social determinants of population health in the United States and of increased longevity (Link et al., 2008; Montez et al., 2012). Unemployment drops with every additional level of education attained in the United States, and it has been estimated that each year of additional education increases lifetime income by 11% (Braveman et al., 2011). In a rare quantitative estimation of the education–health gradient, Conti and colleagues (Conti et al., 2010) modeled the causal association of educational attainment with obesity, poor health, depression, exercise level, daily smoking, and lifetime cannabis use, as well as wages and full-time employment. The study used an adult panel in the United Kingdom who were followed from birth, assessed at age 10 years, and assessed again at age 30 years. Quantitative statistical modeling was used to provide estimates of discrete statistical associations of educational attainment, the “causal component,” and non-educational attainment factors, the “selection component,” with all health, wage, and full-time employment variables by sex. The conclusion was that higher educational attainment had strong causal associations that reduced health risk factors, with the exception of obesity in women. Educational attainment was causally associated with regular exercise, higher wages, and full-time employment, net of selection factors. The strength of associations varied by outcome category and sex. Cognitive development measured at age 10 years had strong effects on labor market status and health disparities at 30 years of age.

Turning to the role of employment in the social determinants of health model (middle box of Figure 1), key studies in social epidemiology and in behavioral psychology have provided important insights about how stress can develop from the experiences of daily living and ultimately become a risk factor for disease. Social stress theory emerged from one brief yet generative statement by Selye (1974): “Stress is the nonspecific response of the body to any demand made upon it, that is, the rate at which we live at any one moment.” Different forms of social stress can be useful and necessary; other types of stress exposures can have cumulative and long-range effects that degrade health and quality of life. An investigation of social stress and regulation of biologic subsystems was conducted by the British Civil Service. The investigation tracked workers in different levels of employment grade, examining the association of education, social status, and health outcomes. In the classic Whitehall studies, Whitehall II authors reported a consistent association between lower employment grade and a higher incidence of angina, ischemia, and symptoms of chronic bronchitis (Marmot et al., 1991). Two social behavioral pathways were associated with poor health outcomes and mortality: predisposing factors attributable to lower social status family background and the employment environment, both linked to intergenerational lower educational attainment.

Subjective (inferior) social status was also related to lower personal control and higher stress experienced by workers who were in the bottom job categories and who had heightened health risks (Cannon, 1929; Rahal et al., 2020; Somaini et al., 2011). It was postulated that systematic exposure to social stress related to lower social status, over time, could affect the hypothalamic-pituitary-adrenal (HPA) axis, which affects multiple metabolic subsystems, including cardiovascular, hormonal (endocrine), and immune systems (Iacono et al., 2018). Simply stated, low educational attainment and low social status, including belonging to discriminated subgroups, increases social stress and biological risk of disease (Institute of Medicine, 2006). Conversely, higher educational attainment and higher social status, operating through intermediary factors like lower job stress, increases perceived control and reduces disease risk.

#### Personal Control, Social Status, and the Education–Health Gradient

Critical stressful life experiences that occur during primary and secondary school years are correlated with health risks in later adulthood (Gil et al., 2004; Turner & Gil, 2002). Overall, the relevant literature provides compelling evidence that stress exposures, especially traumatic events, have multiple sources and pose greater long-term hazards for physical and mental health in lower education-income groups with fewer personal resources to buffer their impact (Aneshensel, 1992; Pearlin et al., 1981; Turner, 2010). Social stress and trauma will be greatest in populations that face marginalization and will foment pathways to poor health by weakening student commitment to learning and academic accomplishment (Levy et al., 2016).

A behavioral health risk model was proposed to explain a propensity to substance abuse and addictions among minority disadvantaged populations (Amaro et al., 2021) and illustrates the roles of personal control and social status as risk and protective factors (bottom box of Figure 1). From this perspective, low education shapes the perception that life’s adverse circumstances are difficult or impossible to modify, even as they serve as a consistent and generalized threat. The United States is an affluent nation, yet people with low education and income are disproportionately concentrated in urban environmental enclaves of social disorganization, violence, and physical neglect wherein African American and Latinx people are highly segregated (DeFina & Hannon, 2009). As reported by Amaro et al. (2021), both human and animal studies have found that subordinate social status is linked with social defeat stress (Larrieu et al., 2017), increased proinflammatory cytokines (Muscatell et al., 2016), and elevated cortisol (Sherman & Mehta, 2020). These processes endanger individual health and increase risk of substance use (Sinha, 2008). Ultimately, these experiences inhibit successful social role transitions in educational advancement, social relationships and employment, and economic upward mobility (Howe et al., 2017).

Lower educational attainment and social status in the United States is linked via multiple pathways to health threats, including: higher toxic exposures, occupational accidents, obesity, cardiovascular disease, diabetes, stroke, hearing loss, disability, lung cancer, liver and kidney failure, depression, substance dependence, slower recovery from illness, infectious disease mortality, poor vision, and, in older adults, earlier functional limitations in mobility, cognitive decline, and dementia (Chinn et al., 2021; Choi et al., 2011; Mirowski & Ross, 2017; Noonan et al., 2016; Vega et al., 2009; Velasco-Mondragon et al., 2016; Yancey, 2020). The well-documented association of lower education and lower social status, defined as lower relative social rank in society, with social stress, adversity, trauma, and health and disease risk is a major focus of current biopsychosocial health-equity research (Rasposa et al., 2014).

A review of human and animal studies noted that three key protective factors, which are strengthened by educational attainment in humans, are social integration, social support, and social status. These factors independently predicted life span, and early-life social adversity negatively affected later-life survival (Snyder-Mackler et al., 2020). Differences in developmental and life experiences emerge through cumulative exposures to underlying social determinants that affect academic success in early life, and ultimately affect personal control, health behaviors, financial sufficiency, work life, social stress, and life course health. These determinants can support or aversively affect, through stress-related pathways, general health status, immune function, behavioral health, inflammation, metabolic regulation, and brain health at different stages of the life span (Hankin et al., 2010; Miller et al., 2009; Pearlin & Radabaugh, 1976; Weiss et al., 2013).

#### Testing, Tracking, and Low-Quality Segregated Schooling: Health Implications

In the United States, the model for climbing the educational ladder of success is inherently stressful, and pressure to perform and succeed falls on a national population that varies greatly in background preparedness and personal resources. The educational hierarchy is supported by informal tracking systems of selection based on mass testing to determine who advances to higher educational and social ranks and who does not. In essence, the “meritocracy” approach was developed and justified as a rational model of natural selection using near universal performance tests to tap verbal and mathematical competencies at a highly refined level. The assumed objectivity of achievement tests was supported by a consensus of professionals (Au, 2013) and has afforded a method for sorting large populations of students differentially into pathways with quite different potential for achieving future academic advancement and socioeconomic status (Karp, 2006). Thus, after many decades of inequitable access to quality education, a very predictable result was attained: a socially ratified partitioning of access to higher education for specific groups throughout the 20th and 21st centuries.

Public schools in the United States are primarily governed at the state and local levels, such that a substantial majority of school funding comes from local tax revenue. The reliance on taxpayer income and property values results in significant variations in expenditure per pupil, and the implications are striking: a 25% difference in spending explains the “achievement gap” (i.e., the opportunity gap) between students categorized as poor and those categorized as nonpoor (Jackson et al., 2015). Across states, spending per pupil ranges from $7,478 (Utah) to$23,321 (New York), with an average expenditure of $12,624 (EducationData.org, 2021). In New York State, home to the largest K–12 student population in the country, expenditures vary up to$10,000 per individual student across school districts (New York State Education Department, 2020).

The disparities in spending have been shown to fluctuate with the racial composition of local neighborhoods. Using 15 years of national data across school districts, Sosina and Weathers (2019) showed that as segregation increased, expenditures per pupil decreased for African American and (to a lesser extent) Latinx students but remained the same for White students. In other words, the co-occurrence of low-performing schools, poverty, and education and health disparities by place of residence is reinforced by intensive de facto segregation (Parker & Stansfield, 2015).

The segregation of students of color in the U.S. education system has a long history both within and outside of federal, state, and local legal structures (MacDonald, 2013). Despite legislation and judicial decisions that integrated schools during the civil rights era (i.e., Brown v. Board of Education), segregation today is not only prevalent but increasing (Frankenberg et al., 2019; Fuller et al., 2019). White students attend schools with majority White student populations, and African American and Latinx students attend schools with majority students of color (Frankenberg et al., 2019). As of 2016, 18% of U.S. public schools served student populations with 90% to 100% students of color. In these “intensely segregated” schools, the majority of students live in poverty. In New York, 65% of African American students and 55% of Latinx students attend intensely segregated schools (Frankenberg et al., 2019). An analysis of New York City high schools showed that African American and Latinx students, and English language learners (ELL) in particular, had significantly less access to science, music, art, and advanced placement courses, and that their schools were significantly less likely to have libraries, science labs, and music rooms (New York City Independent Budget Office Education Research Team, 2013). A similar study of public schools in Virginia found that schools with the highest rates of student poverty were the most likely to underspend on instruction, including teacher salaries, professional development, and advanced placement coursework, and were the least likely to be accredited (Duncombe, 2017).

Segregated schools are large, overcrowded, and lacking in critical instructional resources, and their teachers are less experienced and less qualified and lack training in cultural and linguistic diversity (Eamon, 2005; Prince, 2002; Ray et al., 2006). As a result, teachers—who are overwhelmingly (80%) White and monolingual English speakers (New York State Education Department, 2020)—are often unfamiliar with the community norms of their students and are unprepared to follow asset-based pedagogy or to communicate effectively with families (Lopez, 2016; Siwatu et al., 2009). ELLs (16% of the K–12 population), particularly Spanish-speaking students (8% of the K–12 population; National Center for Education Statistics [NCES], 2018), are the student population most likely to be segregated.

Without English proficiency, ELLs must learn 50% more in each elementary school year in order to be on par academically with non-ELL students (Thomas & Collier, 2002). But without resources, few ELL students show grade-level proficiency in reading (8.6% are proficient) or math (14.3% are proficient). Spanish-speaking ELL students are at the greatest risk for underachievement; even relative to other ELLs, Spanish-speakers are the least likely to score in the proficient range on standardized math and reading tests, the least likely to become English proficient during the early childhood grades, and the most likely to be placed into special education services (Hemphill et al., 2011; Stiefel et al., 2003). Only 67% of Spanish-speaking ELLs graduate from high school within six years.

### Recognizing the Gaps in Academic Performance and Enhancing Control With Effective Reforms

A key assumption of social epidemiology is that disease is, in part, produced by aversive so21al determinants, environmental conditions, and daily interactions affecting the human body via systematic exposures that create vulnerability to specific pathologies (House, 2002). School is a setting where aversive experiences are very likely to be experienced by African Americans and Latinx students in three forms: fear for personal safety, unpreparedness to adequately compete academically, and the lack of coping resources needed to adequately respond to environmental threats. Figure 1 identifies the areas where students need to receive support to adequately compete and develop a sense of control. The personal capacity to mitigate threats is conditioned by societal contextual factors, especially social capital and material resources, and is negatively affected by experiences of marginalization based on race, ethnicity, and social class (Williams, 1998). Social stress for people with low education is reinforced by social marginality and is compounded by a cascade of additional threats to personal agency and control . A wealth of evidence documents how intersectional factors like racism and sexism introduce additional and potentially detrimental health risks (Ben et al., 2017; Homan, 2019; Reitsma et al., 2021; Yearby, 2020).

As shown in Figure 1, the role of educational attainment is to increase cognitive and social skills and to transmit knowledge, starting in childhood, in anticipation of social role requirements of adulthood. The less likely it is that schools are able to accomplish these essential tasks, the greater the likelihood that students will flounder, especially in the absence of strong family resources to support youthful personal development. It’s neither justifiable nor realistic to assume that schools can be, or should be, a sole source for helping children overcome the effects of material deprivation and social injustice and disorganization. There is an urgent need in childhood and early adolescence to close the gap in core competencies required for educational attainment. Failure to do so undermines the goal of preparation for successful role transitions into adulthood and contributes to continuing health disparities in African American and Latinx populations in the United States. Figure 2 presents illustrative morbidity data for selected disease indices comparing African Americans and Latinx to Whites in the United States. Strikingly, the recent Covid-19 epidemic had the highest infection and mortality rates in the African American and Latinx populations (Webb et al., 2020).

The education system in the United States was created to provide all students with a common and egalitarian educational experience rooted in the democratic ideal of universal literacy (Goldin & Katz, 1999; Labaree, 1997). In reality, though, the first schools were intended to educate White males, with the primary goal of reinforcing Christian values (Center on Education Policy, 2020). Subsequently, for most of the country’s history, public schools were primarily attended by Whites, and it was not until 1970 that the enrollment of students of color reached the same rate as that of Whites (Goldin & Katz, 1999). Today, the prekindergarten through grade 12 (PK–12) population is majority (54%) students of color, including 13.4 million Latinx, 7.2 million African Americans, and 5.4 million Indigenous, Asian, Pacific Islander, and biracial students (of 48.1 million students total; NCES, 2020). Not surprisingly, the diversification of the U.S. population has challenged the public education system. Students of color may hold cultural values, beliefs, and norms that diverge from those of the education system; they may not speak English as a first language; and they may face contextual stressors related to immigration, acculturation, discrimination, and racism that interfere with engagement and learning in school (Carter, 2018).

In the United States, 86% of students attending public high schools graduate within four years (based on 2018–2019 data), but completion varies significantly depending on student demographic background. The NCES has long documented these gaps in achievement, which consistently favor majority, White students (NCES, 2018). Students of color have lower achievement scores across grades, are less likely to complete high school and enter higher education, and are less likely to obtain a college degree (Musu-Gillette et al., 2017). By fourth grade, White and Asian/Pacific Islander students outperform Latinx, African American, and American Indian students in reading by 21 to 35 points; students in low-poverty schools outperform those in high-poverty schools by 34 points; and non-ELL students outperform ELL students by 33 points. These disparities persist through middle and high school, and by twelfth grade, the gap based on ELL status grows to nearly 50 points (Hussar et al., 2020).

The percentages of students in California who were recent high school graduates ranged from 96.6% of Asians, 87.9% of Whites, 82.5% of Latinx, to 76.9% of African Americans (Kids Data, 2020). Among all students in the United States who gained college admission between 18 and 24 years of age, the percentages of each ethnic group were 41% of Whites, 62% of Asians, 37% of African Americans, and 36% of Latinx (Irwin et al., 2021). Of those attending college, only 58% of Latinx and 57% of African American students graduate on time, compared to 83% of White students (based on 2008 data; Ansell, 2011). Of those who do not complete at least a high school level of education, 73% of African American adults and 84% of Latinx adults report suboptimal health, compared with 70% of pan-Asian and 69% of White adults (Egerter et al., 2009).

In New York City, the largest school system in the United States, differential patterns of academic achievement across racial/ethnic groups impact future educational accomplishments and labor market outcomes (New York City Independent Budget Office, 2017). Lower performance is associated with grade retention, school suspension rates, and rates of disability among African American and Latinx students. Gaps in performance in the third grade correlate with gaps in the eighth grade, but only for African American and Latinx students (New York City Independent Budget Office, 2017). Moreover, performance scores have been systematically associated with socioeconomic status and parental education, demonstrating the intergenerational association of income with educational inequality (New York City Independent Budget Office, 2017).

### Enhancing Health Through the Education System

As evidenced by the literature on social determinants of health, the critical question is not whether educational attainment is important for population health, because the unambiguous response is affirmative (Basch, 2011). The core issue for improving educational outcomes, as depicted in Figure 1 is identifying the pathways, supports, and impediments to promoting better health through educational attainment. In light of the glaring evidence of systemic problems disadvantaging African American, Latinx, and other students of color, a highly visible literature and policy dialog has evolved to explore potential remedies (Berliner, 2013), but despite efforts at reform, only meager improvements have been noted. In the United States, economic privilege continues to structure educational outcomes. Indeed, scholars and policymakers have come to recognize that what has historically been referred to as the achievement gap (i.e., emphasizing individual student academic skills) may be better understood as the opportunity gap (Carter, 2018). Research shows that the most academically successful students are also those who have access to the most resources (Lee & Burkam, 2002; Rumberger & Thomas, 2000), and by and large, the most well-resourced schools are attended by students who are White, English-speaking, and nonpoor (Noguera et al., 2015; Vasquez Heilig et al., 2012). Resource allocation can be understood, at least in part, in terms of historical and contemporary patterns of segregation that correspond to poor financing (Crosnoe et al., 2004; National Women’s Law Center [NWLC], 2009; Rowe & Perry, 2020).

#### Improving Health and Well-Being Programs in Schools

There is substantial literature examining the impacts of school-based programs on student health and well-being. In a review of the effectiveness of school-based health centers (SBHCs), Arenson and colleagues (2019) found evidence for the successful treatment of asthma, obesity, and other chronic health conditions through school-based services. In addition, students who accessed SBHCs were found to have lower rates of depression, suicidality, and teenage pregnancy; moreover, teens who were pregnant received better prenatal care. There is also evidence that SBHCs are associated with higher rates of attendance, lower rates of suspensions, and better grades.

Leroy et al. (2017) conducted a systematic review of the literature on the effects of school-based health services on chronic health conditions (asthma, food allergies, diabetes, seizures, poor oral health) in K–12 students. They found that the extant research has focused almost exclusively on the treatment and management of asthma. For students with asthma, access to school health services improved clinical symptoms, medication adherence, and school attendance. Impact on grades and test scores, however, was mixed.

A review of behavioral support programs in schools similarly found positive impacts on a range of mental health and education outcomes, including symptoms of post-traumatic stress disorder and depression, aggressive and disruptive behaviors, suspensions, and achievement scores (Kase et al., 2017). Atkins and colleagues (2006) compared their school-based mental health service model, known as the Links to Learning (L2L), in which mental health providers work directly with classroom teachers and parents to address mental health needs, to the clinic-based services for students living in high-poverty urban communities. They reported that L2L led to improved student behavior, in part because engagement and retention rates were higher. Overall, the literature, reflected in Figure 1, supports the notion that students benefit from a wide range of school-based health programs beginning in early development, and including parental participation, but such programs remain underfunded.

#### Promoting Health in Schools Through Self-Development Programs

The purview of public schools in the United States extends beyond academics to student health and well-being (Office of Elementary and Secondary Education, 2021). At the federal level, the Office of Safe and Drug-Free Schools oversees efforts to promote physical and mental health. Programming varies at the state and local levels but generally can be categorized as health education (sexual health, behavioral health, and substance use), physical activity and nutrition, and family engagement. Based on a 2016 school survey by the Centers for Disease Control (CDC) using data aggregated at the state level (N = 43 states), 89% of U.S. schools require students to take health education courses, and 87% require high-school students to take sexual health education. Physical activity is offered in 34% to 85% of schools during the school day, in 72% to 93% of schools through after-school programs, and in 35% to 87% of schools through sports programs. Physical education is more commonly required in elementary and middle school than in high school, yet as few as 10% of schools have a physical education class as part of their curriculum.

The CDC has also examined changes in school health policy and practices over time (CDC, 2016). Analyses showed that, with the exception of violence prevention, fewer schools required health prevention programs (e.g., programs addressing alcohol, tobacco, drugs, pregnancy, STD, HIV, and infectious disease) in 2016 relative to 2000. There was also an observed decrease in services for students who were already facing these health issues. In contrast, there was an increase in the number of schools that required physical education, tracking of student physical fitness (CDC, 2016), and the use of healthy food preparation guidelines. Healthy food guidelines have become more regulated, in line with federal meal programs. Data from 2016 showed that over 30 million school children relied on free and reduced-price breakfast and lunch at their schools (U.S. Department of Agriculture, 2019). Cullen and Chen (2017) found that children who eat meals at school get almost half of their daily caloric intake, including 41% of their vegetables and 77% of their dairy, through the federal meal program. This has prompted California to now offer universal meal programs for all public schools.

Health policies and practices are often overseen by school nurses. Nurses were originally positioned in schools in the early 1900s to address the problem of absenteeism, and they continue to focus on individual student health through direct care and case management. Having a school nurse is associated with reduced absenteeism for students with asthma, for example (Rodriguez et al., 2013; Telljohann et al., 2004). Over time, the role of school nurses has expanded to also include health policy and reform, with a focus on social determinants of health (National Association of School Nurses, 2016). Professional guidelines call for one nurse for every 750 students, and they prescribe that each school have at least one full time nurse to address health-related obstacles to educational attainment (U.S. Department of Health and Human Services, Healthy People 2010 (Group),(2000)). Presently, 82% of K–12 schools employ a school nurse (U.S. Department of Education, 2020); elementary schools, schools in urban and suburban areas, and wealthier schools are most likely to have a nurse on staff (Willgerodt et al., 2018). Many nurses work in more than one school and serve a large number of students; in Washington State, for example, school nurses serve an average of 1,173 students (Gratz et al., 2020). In California, only 12% of first graders and 20% of twelfth graders have access to a school nurse (Reback, 2018).

In some schools, student health and well-being are addressed through SBHCs that offer primary medical, behavioral health, and dental care. SBHCs may be on site (i.e., on campus), in nearby centers or mobile units, or remote (i.e., telehealth). According to a 2016–2017 national survey (Love et al., 2018), centers are most often staffed by nurse practitioners or physician’s assistants, but some (65%) have a physician, a behavioral health professional, and/or a specialist (e.g., dentist, nutritionist) on staff. The availability and focus of centers vary across location: most operate full-time (i.e., more than 31 hours per week; 75%), focus on middle- and high-school students (i.e., prioritize adolescents; 81%), and are open to the larger community (i.e., out-of-school youth, students from other schools, and family members; 62%). SBHCs typically serve schools that have a high percentage of students from low-income backgrounds, to give students regular access to medical care. In 2016, more than 6 million students, or approximately 12% of the K–12 population, in 48 states had access to SBHCs (Love et al., 2018).

Contemporary literature in American public health, behavioral health, and human biology links the interplay of social experiences and social determinants with the formation and staging of downstream disease risk factors and stress-linked pathways. This article aimed to capture how this nexus of factors is propelled by the intergenerational low education and low socioeconomic status that underlie health disparities. Educational attainment is not a singular cause of social inequality and disease; rather, educational attainment provides intellectual growth, competencies, and social skills, especially in early stages of development before the transition to early adulthood, as well as readiness to manage environmental demands successfully over the life span. Educational attainment prepares individuals psychologically and emotionally to manage the vicissitudes of personal life challenges, traumatic events, and social change. However, the ability of children to benefit from mass public education requires effective mitigation of multiple social disadvantages with appropriate supportive services that may involve assistive services beyond the physical realm of the school system. The trend of social stratification toward sustained higher levels of income inequality, unaffordable higher education, and declining rates of social mobility in the United States is reflected in large variations in operating budgets of highly segregated urban and suburban schools and ideological tension around equity of resources. If the mission of education includes advancing health, there is little doubt the United States has fallen woefully short.

The American system of education is premised on the notion of local control, but with overlapping authority within county, state, and national levels of government. Ideally, local control represents opportunities for tailoring programs and resources to local needs, thereby providing a basis for innovative design and program development anchored to place of implementation. In practice, school board meetings often devolve into arenas of confrontation, where stakeholders and school board members contest a wide range of issues with parents and other elected or public agency officials. Instead of methodically deliberating and reaching consensus about altering programs or introducing new ones, meetings devolve into lengthy struggles, often with a strong underlying political agenda. The sheer number of public agencies and school boards is a singular impediment to maintaining a momentum to action and to sustaining integrity of implementation and fidelity to policy and program development criteria recommended by federal and state agencies. For example, California has 1,037 school districts, and Los Angeles County alone has 88 school districts. Each of these school districts has an elected school board, separate school district administrators, and funding that reflects state and local community socioeconomic resource distribution.

The CDC, the Institute of Medicine, and the World Health Organization (WHO) uniformly support a social model of health that emphasizes health as a social issue that falls beyond the purview of medical systems. In the mid-1980s, the WHO launched its Health-Promoting Schools (HPS) initiative, calling on educators and policymakers to prioritize health promotion in the school setting. The innovation of HPS and other similar movements is not in relying on schools to address student health: primary and secondary schools already serve, de facto, to meet the health needs of their students because children simply cannot engage in learning if their basic needs go unmet (Green et al., 2013). Instead, HPS has value as an intentional and proactive blueprint for addressing student health systemically at a population level. Health-promoting schools are defined by six core features: healthy school policies, healthy physical school environments, healthy school social environments, health skills and education, links with parents and the school community, and access to school health services. To be successful, the HPS initiative requires government- and school-level commitments to make necessary investments in health-promoting goals and infrastructure.

This article focuses on how education, as a fundamental cause of population health, also structures opportunities for healthy living over the life course. There is an urgent need to provide high-quality education for all children and adolescents regardless of their demographic characteristics and social position. A limitation of this article is that most of the analysis presented is pertinent to the United States. Other affluent nations will have both commonalities with, and important differences from, the United States in social structure and health associations that could prove highly instructive regarding qualities of educational systems that are protective for health in the context of cultural diversity, social disadvantage, and health disparities.

### Notes

• 1. This article uses the racial-ethnic descriptor African Americans to refer to Blacks born in the United States and self-identified in public databases as such in the U.S. Census. Other much smaller population subgroups, including Afro-Caribbean people, recent African immigrants, and Blacks relocating from other nations to the United States, would not be expected to identify as African Americans. Albeit imperfect, the descriptor African American avoids double-counting of individuals who are self-identified as both Latinx and as Black. The use of the term Latinx is inclusive of all people of ancestry from Spanish-speaking nations of the Western Hemisphere and Puerto Rico residing in the United States. The distribution is primarily people with ancestry from Mexico (62%), Puerto Rico (9.6%), Cuba (3.9%), and El Salvador (3.8%), and smaller proportions from Central America, the Dominican Republic, and other South American nations.