New research from Dennis Raphael, professor in York University’s School of Health Policy & Management in the Faculty of Health, shows income – not education – plays the biggest role in health inequality.
For more than 20 years, Raphael has been a leading voice in the field of social determinants of health – a way of understanding how the conditions in which people live and work affect their well-being. He has focused especially on how health inequalities are rooted in social systems.
Raphael adds to his body of work with a new study, published in Community Health Equity Research & Policy, that explores a persistent divide in how researchers and policymakers understand the root causes of health inequality, ascribing it to either education or income. The study was co-authored with Avery Ervin, a third-year undergraduate student in the Health Studies program.
To better understand this divide, Raphael and Ervin reviewed 10 exemplary academic studies: five that treat education as the primary determinant of health, and five that focus on income. They examined how each perspective influences both the explanation of health outcomes and the proposed means of promoting health.
Their findings reveal a consistent trend. Studies emphasizing education tend to rely on individualistic, behavioural explanations for good or bad health – such as personal responsibility, decision-making or cognitive abilities.
The belief that education is a key driver of health inequality is often explained through several assumptions: that education leads to better jobs and income, which in turn provide greater access to health resources like nutritious food, safe housing and medical care; that people with more education are more likely to make healthier choices, such as avoiding smoking, exercising regularly and seeking preventive care; and that education empowers individuals to navigate the health system more effectively and advocate for their needs.
But Raphael and Ervin argue that this approach overlooks structural inequalities – and may unintentionally reinforce stigma and victim-blaming for those unable to achieve higher educational attainment. These structural inequalities – whether based in class, race or gender – not only shape educational attainment, but also determine whether such attainment becomes translated into better living and working conditions.
In contrast, other studies they reviewed focused on income highlighting systemic factors like poverty, job insecurity and poor working conditions. These studies also show housing and food insecurity as central to health outcomes and that public policies – such as ease of unionization, minimum wages and mandated benefits – and tax structures that favour the wealthy are behind these health threatening conditions. These studies show poor health not as a result of bad individual choices, but a consequence of unequal social conditions shaped by public policy.
“It is rather remarkable how research stressing education as a determinant of health sets parameters around what is doable or not doable as means of promoting health and avoiding illness by limiting focus to individuals and their attributes," says Raphael. "In contrast, those considering income look at how societal factors shape the distribution of the determinants of health and how such distributions can be made more equitable."
Raphael and Ervin suggest the widespread faith in education as a solution is shaped by the depoliticized nature of existing research, and the control over societal discourse by the wealthy and powerful. By avoiding harder questions – like who benefits from current systems – education-focused studies may reinforce the status quo and hinder progress.
While it’s possible to care about both education and income as factors that shape health, in practice, researchers and policymakers often emphasize one over the other. Raphael and Ervin call for a reframing of the conversation: it’s not just about encouraging better choices and developing individuals skills – it’s about ensuring people have real, fair choices to make in a society organized to promote health.
“Considering the evidence of deteriorating living and working conditions for many in Canada, we see the emphasis on promoting a more equitable distribution of income as the preferred means of promoting health for all Canadians," says Raphael.
Ultimately, Raphael and Ervin call for public health strategies that prioritize tackling income inequality, precarious work and unaffordable housing. They advocate for policy changes that go beyond expanding education and instead address the root causes of health gaps.