Education: a neglected social determinant of health.

Education and health and wellbeing are intrinsically linked. The evidence behind the importance of education as a determinant of health is amongst the most compelling. Education is strongly associated with life expectancy, morbidity, health behaviours, and educational attainment plays an important role in health by shaping opportunities, employment, and income. In this issue of The Lancet Public Health, two research Articles emphasise the lifelong impact of education on health. The study by Yu-Tzu Wu and colleagues shows that differences in education and wealth established earlier in life were strongly associated with disparities in healthy ageing across a large, multi country cohort of older people. The study by Marty Parker and colleagues looked at healthy working life expectancy at age 50 years in England and reports inequalities by level of educational attainment and occupation.

Education shapes lives—it is key to lifting people out of poverty and reducing socioeconomic and political inequalities. Today—as the world is shaken by the COVID-19 pandemic and the long-overdue recognition of structural racism—the centrality of education and schools to societies has become much clearer.

In response to the COVID-19 pandemic, more than 80% of students worldwide have been affected by school closures, causing an unprecedented global interruption to education. The Children's Commissioner for England found that there were large disparities in the quantity and quality of remote schooling that children received, with more than 50% of students receiving no online lessons and around 10% of students spending less than 1 h per day on schoolwork. Besides providing an education, schools are important to young people's health and wellbeing as spaces for social and emotional development, physical exercise, safety, and a lifeline for those from poor, violent, or abusive households. In their Correspondence, Elizabeth Thomas and colleagues note that during the lockdown in the USA the incidence of child abuse and neglect is suspected to have increased, yet reporting in some states has fallen, probably reflecting the loss of monitoring via schools.

School closures for such a long period of time could have disastrous social and health consequences for children, and will probably exacerbate existing inequalities, widen the gap in educational attainment between pupils, and even undo previous progress. Girls in some countries might not return to school when pandemic restrictions are eased. As Annamaria Colao and colleagues note in their Correspondence: the COVID-19 crisis highlights that a school fulfils much more than an educational mission of knowledge acquisition and there is now an opportunity for rethinking the role of the school after COVID-19—an opportunity to redefine what type of school we want for the future.

The 2020 Global Education Monitoring (GEM) report, Inclusion and Education: all means all, released this month, is therefore not only timely but also crucial “to develop the education the world so desperately needs and to ensure that learning never stops”, as noted by UNESCO's director general Audrey Azoulay. The report takes stock of global progress, highlights deficiencies, and provides a roadmap to achieving the fourth Sustainable Development Goal (SDG) to ensure inclusive and equitable, quality education. In 2018, 258 million children were not enrolled in school. Exclusion from educational opportunities is evident in most countries, at varying levels: “…disadvantaged groups are kept out or pushed out of education systems by[…]exclusion from curricula, irrelevant learning objectives, stereotyping in textbooks, discrimination in resource allocation and assessments, tolerance of violence and neglect of needs”. The GEM report unambiguously calls on all education actors to widen their understanding of inclusive education to include all learners, no matter their identity, background, or ability and to put diversity at the core of education systems. The report calls for countries to concentrate on those being left behind and for inclusion in education—a particularly timely message in the midst of our current societal challenges.

Although the GEM report acknowledges that education policy should not be siloed into departments of education, but should be created through partnerships across government agencies, in view of the centrality of education in shaping healthy lives, there is a much broader opportunity here to also help in achieving health targets under SDG 3. Education is the most important modifiable social determinant of health. As we enter a post-COVID-19 era, there is an unprecedented opportunity to integrate SDGs 3 and 4, to achieve the interdependent goals of healthy, resilient, and fair societies.