What would be the best thing we could do for our health? 

What could a government do to improve the health of the people in a country?  Campaign against smoking or drinking?  Encourage healthy eating and exercise?  Research: basic or applied?  You may be surprised by the answer.

But first an explanation of how these things are measured.  The discussion focusses on “quality-adjusted life-year gains per dollar invested”.  This means not only the number of years of life gained.  It also takes into account the quality of the years gained: five years of active and happy life are more desirable than five years on life support.  How these calculations are made can be pretty complicated; but the experts in these things have worked out ways and means that most of them can agree on.

This is the measure.  The answer to how much a health intervention is successful is measured in “quality-adjusted life-year gains per dollar invested”.  Knowing that, which intervention would you guess yields the greatest benefit for health?

It turns that the most gain to quality-adjusted life-years is gained from:

 reducing primary school class sizes.

This is the conclusion from Project STAR (Student Teacher Achievement Ratio).  Project STAR began in 1985 so it is a long-term study and is a large multi-school randomized trial.  These results are about as solid and reliable as you can get.  The figures are: a student graduating from high school after attending smaller-sized classes gains an average of 1.7 quality-adjusted life-years and generates a net $168,431 in lifetime revenue.  This is a US study, so the figures would be somewhat different in other countries.  However, the impact of this intervention is extraordinary and has huge implications for any of us in the industrialised countries.

According to one of the researchers (Peter A. Muennig, MD, MPH, assistant professor of Health Policy and Management at the Mailman School) the benefits of schooling are not only confined to small class sizes.  He says:

“Regardless of class size, the net effect of graduating from high school is roughly equivalent to taking 20 years of bad health off of your life.”

This research (and there is an increasing amount saying the same kind of things) means that it is the social determinants of health where we should be directing our attention.  To achieve this will mean a revolution in thinking about health (not focussing on sickness, seeing that health is social and not just individual) and remarkable political will (imagine a politician if you can closing a hospital – I can’t).  But this is the challenge.  If we really want to be healthier it is the social determinants of health where we should be concentrating our efforts.

The findings will be published in the November issue of the American Journal of Public Health.

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