Stark differences in China, but familiar methodological challenges remain
Education is a key component of social inequality and, in higher income countries, higher attainment is strongly linked to lower mortality risk.12 How does education associate with mortality risk in China, a country that has had substantial social change and now has a highly competitive education system? If such associations are found, are the underlying links causal?
In a linked study, Lu and colleagues (doi:10.1136/bmj‑2022‑073749) report on the educational inequalities in all cause and cardiovascular disease mortality rates in China and describe changes for successive generations born between 1940 and 1979. The study is remarkable in size, scope, and the profound social changes that they describe.3
Many of the study’s results mirror those seen in other large cohorts and reviews.456 In particular, the authors' central finding of stark inequalities in all cause and cardiovascular mortality by educational attainment are familiar. For example, participants in the oldest cohort who only had a primary school education had 83% (95% confidence interval 58% to 111%) higher risk of death than people who had an education level of college or above. The authors found that around 40% of the differences in mortality could be explained by measured socioeconomic, lifestyle, or metabolic factors. …