Nancy E. Adler, who linked wealth to health, dies at 77

Nancy E. Adler, a health psychologist whose work helped transform public understanding of the relationship between socioeconomic status and physical health, died Jan. 4 at her home in San Francisco. She was 77.

The cause was pancreatic cancer, said her husband, Arnold Milstein.

Dr. Adler was instrumental in documenting the powerful role that education, income, and self-perceived status in society play in predicting health and longevity.

Today the connection is well known; a truism among public health experts is that life expectancy is determined more by your zip code than your genetic code. But thirty years ago it was still an obscure idea.

“It is because of Nancy's decades of work and leadership that we now recognize socioeconomic status as one of the greatest and most consistent predictors of morbidity and mortality that we know,” said Elissa Epel, a health psychologist at the University of California, San Francisco. Francisco, and a mentee of Dr. Adler.

From 1997, Dr. Adler de MacArthur Foundation Research Network on Socioeconomic Status and Health, a group of health economists, epidemiologists, physicians, public health experts, psychologists, and sociologists who have studied the relationship between socioeconomic status and health. The group is credited with mainstreaming the concept of social determinants of health, along with their implications for healthcare and social policy.

“They looked at the question, 'How does inequality, poverty or stress get under your skin?'” said Claire Brindis, a public health and policy researcher at UCSF. “How does this affect your life? How many years are you going to live?”

Their work built on the Whitehall study, a survey of British civil servants beginning in 1967 that showed a strong link between social class and mortality. This finding pointed to factors beyond access to medical care or health insurance.

“What intrigued Nancy was that the relationship continued even into the upper echelons,” says Dr. Milstein, a leading health policy researcher. “If you had an extra year of training, or earned £200,000 instead of £190,000, the relationship would still exist.”

In 2000, Dr. developed Adler de MacArthur Ladder, a tool that asks people to indicate their perceived income, education, and socioeconomic status on the rungs of a ten-step ladder. It remains a reliable predictor of worsened health and premature illness, indicating that self-perception of status is a meaningful marker in itself.

In a 2007 report for the MacArthur Foundationshe wrote: “Premature death is more than twice as likely for middle-income Americans as for those at the top of the income ladder, and more than three times as likely for those at the bottom than for those at the top.”

Dr. Brindis said about Dr. Adler: “Once in a lifetime a scientist comes along and changes the way we see what is right in front of us.”

Nancy Elinor Adler was born on July 26, 1946 in Manhattan to Alan and Pauline (Bloomgarden) Adler. Her mother was a teacher, her father a clothing manufacturer and salesman. When Nancy was a young child, her family moved west and settled in Denver.

In high school, she was entranced by Nancy Drew, the fictional teenage detective, who became something of a role model. “I think I really impressed Nancy Drew and got really excited about the idea of ​​solving mysteries,” said Dr. Adler in one conversation at UCSF in 2015.

She attended Wellesley College. In her second year she met Dr. Milstein, then a junior at nearby Harvard, whose sister, Ann, also attended Wellesley.

“Ann invited me to meet a sweet girl from Denver who lives across the hall,” recalls Dr. Milstein, now a professor of medicine at Stanford University. “After introducing us, my sister told me this was the girl I was going to marry.”

Dr. Adler graduated in 1968 with a degree in psychology. She married Dr. Milstein in 1975.

In addition to her husband, she is survived by two daughters, Julia Adler-Milstein and Sarah Adler-Milstein; her brother, Richard Adler; and three grandchildren.

The research of Dr. Adler challenged prevailing views early on. In graduate school at Harvard, where she earned a Ph.D. in 1973 she interviewed women before and after they had an abortion for her dissertation.

“At the time, there was a lot of talk about how abortion amounted to a lifelong trauma for the woman,” says Dr. Harvey Fineberg, chairman of the Gordon and Betty Moore Foundation, a philanthropy based in Palo Alto, California, and a longtime friend of Dr. Adler was. “But Nancy discovered the exact opposite. She discovered that women saw it as an opportunity to reposition their lives.”

In 1972, Dr. Adler was hired as an assistant professor of psychology at the University of California, Santa Cruz. She moved to the university's San Francisco branch in 1977, where she became professor of medical psychology and vice chair of the departments of psychiatry and pediatrics. She retired in 2022.

At UCSF, she began a series of studies demonstrating the link between socioeconomic status and a spectrum of diseases, such as diabetes and cardiovascular disease. In 1979, she and two colleagues published a book there entitled 'Health Psychology', coining the term. She started the first graduate and postdoctoral programs in health psychology in the United States in the 1980s. Similar programs have since emerged around the world.

Ten years ago, buoyed by increasing attention to health disparities, Dr. Adler major hospitals are establishing programs to measure and address the social factors of personal health. Today, hospitals and clinics measure some of these routinely, and many have programs to mitigate them.