• health inequality
• intergenerational transmission
• children to parents

Health benefits associated with socioeconomic advantage have been widely documented across genders, life course, populations and cultures.1 Intergenerational transmission of income, social support and human capital in the family, and its association with health, is not a new phenomenon.2 3 The WHO Review of Social Determinants and the Health Divide in the WHO European Region 4 urged actions and policy to tackle intergenerational transmission of health inequality from parents and grandparents to children. A recent systematic review confirmed a positive downward ‘spillover’ effect of parents’ education on children’s health, as well as a positive upward ‘spillover’ effect of children’s education on parents’ health5; however, the upward direction of intergenerational transmission has been rarely investigated in studies of health inequalities.

The study published by Zhao et al 6 provides an interesting angle on the upward ‘spillover’ effect of children’s political status on their older parents’ physical health. This study benefits from the specific social context in contemporary China, where cadres are an advantaged stratum of the population, distinguished from others by their power and authority.7 The findings, suggesting that government cadres in the Chinese society bring social and economic advantages into their nuclear and extended family, are plausible, and it is likely that such benefits for cadre’s parents may indeed be substantially important. The political status therefore could operate as an important social determinant of health and a channel of intergenerational transmission of health inequality.

The conceptual framework of the WHO Commission on Social Determinants of Health8 provides a useful guidance on how each of the social determinant in different generations—parents and children—can be linked and intertwined. Current literature on upward health transfer (ie, from children’s socioeconomic position on parent’s health) focuses on two sets of effects—direct and indirect.9 10 Direct effects can take place because children with higher socioeconomic position (SEP) have better health, better access to information and greater economic resources to provide for older parents. Studies of indirect effects have, so far, been limited to influences of children’s SEP on healthier behaviours and lifestyles of their parents or on their enhanced social integration, as Zhao et al 6 proposed in their work. However, there may be other pathways of intergenerational transmission of socioeconomic advantage from children to parents, including psychosocial mechanisms. For example, government cadres in the Chinese society may raise their parents’ perceived social status (perceived by the parents themselves and by others), particularly among parents of high-ranking officials.

Zhao et al 6 proposed that the direct and indirect mechanisms only go one direction, namely from children to parents. This proposition, however, ignores the interplay of the SEP of both parents and their offspring, their health, and other intermediary determinants of health (eg, healthcare system, material circumstances, social support and cohesion, health behaviours, and biological and psychosocial risk factors).8

An important aspect of multiple generational transfers of health is the living arrangements of households. China is still a family-oriented society, although this has been eroded by the social and economic developments in recent years. It is not uncommon for multiple generations—grandparents, parents and grandchildren—to coreside or to live near each other. Such proximity enhances family ties and promotes mutual help and support between generations, and could improve the health of all family members. For households with older parents, coresiding with their children and/or grandchildren means that family members also share many environmental (not just genetic) factors that could influence their health, and this effect would not apply to those with different living arrangements.

More research will be needed to confirm the reported association. Cross-sectional studies are not well suited to disentangle the temporality of cause and effect and often suffer from reverse causation bias. While the authors suggest a causal relationship, it could well be that parents with higher SEP are healthier and this could make them more likely to have cadre children than parents with lower SEP. Additionally, testing the mediation in cross-sectional data could produce unreliable results, as cross-sectional approaches to mediation typically generate substantially biased estimates compared with longitudinal analyses.11 The direction of the bias is unknown, and the weak mediation of monetary transfer from children to the parents reported by Zhao et al 6 could be due to such bias.

Given the complexity of mechanisms and pathways involved in the upward intergenerational transmission of health inequality, a robust conceptual framework and longitudinal data are required to guide future research. Furthermore, it is likely that Chinese cadres are a heterogeneous group, with at least two distinct categories: the officials working in the huge party-state bureaucratic apparatus, and the political elite who enjoy more political power than the former.12 The ongoing anticorruption campaign in China, following stricter regulations on cadres, may offer a unique opportunity to conduct a natural experiment to assess the upward health transfer related to different types of cadre offspring.