Social Determinants of Health - World Health Organization...Social Context Social Stratification...

Social Determinants of HealthSocial Determinants of Health

Michael Marmot Michael Marmot

UCLUCL

Chair of CSDHChair of CSDH

PlenaryPlenary

IUHPE, VancouverIUHPE, Vancouver

11 June 200711 June 2007

MORTALITY OVER 25 YEARS ACCORDING TO LEVEL IN THE MORTALITY OVER 25 YEARS ACCORDING TO LEVEL IN THE OCCUPATIONAL HIERARCHY:WHITEHALL OCCUPATIONAL HIERARCHY:WHITEHALL

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

2

2.2

40-64yrs 65-69yrs 70-89yrs

Relative rate .

Admin Prof/Exec Clerical Other

(Marmot & Shipley, 1996)

% PROBABILITY OF DYING BETWEEN % PROBABILITY OF DYING BETWEEN

AGES 15 AND 60 (males)AGES 15 AND 60 (males)

8.28.2SWEDENSWEDEN

22.222.2PAKISTANPAKISTAN

22.622.6COLOMBIACOLOMBIA

23.223.2SRI LANKASRI LANKA

24.824.8BOLIVIABOLIVIA

48.548.5RUSSIARUSSIA

84.584.5LESOTHOLESOTHO

SOURCE: THE WORLD HEALTH REPORT 2006,WHO

OUTLINEOUTLINE

The ChallengeThe Challenge

Conceptual FrameworkConceptual Framework

ExplanationsExplanations

Linking poverty and the gradientLinking poverty and the gradient

Integrating knowledge for actionIntegrating knowledge for action

ONE APPROACH TO HEALTH ONE APPROACH TO HEALTH INEQUALITIES IN RICH AND POOR INEQUALITIES IN RICH AND POOR

COUNTRIESCOUNTRIES

OUTLINEOUTLINE







The simplified frameworkThe simplified framework

The causes of the causesThe causes of the causes

Average & Differential Health Impact

G L O B A L I S A T I O N

G OV ERNA NCE

for

H E A L T H

Social Context

Social StratificationDifferential access to ‘capital’ by e.g. education, class, sex, ethnicity

Differential Health Consequences

Differential Exposures & Vulnerabilities

ENVIRONMENTS:NaturalBuiltWorkHomeSchoolSocial

Healthcare

VULNERABILITIES:Material

PsychosocialBehavioural

Constitutional

OUTLINEOUTLINE






EXPLANATIONS:EXPLANATIONS:

–– ““ITIT’’S THE NATURAL ORDERS THE NATURAL ORDER””

TRENDS IN LIFE EXPECTANCYTRENDS IN LIFE EXPECTANCY

77.6

68.1

46.1

63.2

71.7

70.4

66.9

70.3

69

45.8

50.1

61.1

60.5

52.1

40 45 50 55 60 65 70 75 80

OECD

CEE and CIS

Sub-Saharan Africa

South Asia

Latin America and Caribbean

East Asia and Pacific

Arab States

2000-2005 1970-75

Human Development Report 2005

The widening trend in mortality by education in The widening trend in mortality by education in

Russia, 1989Russia, 1989--20012001

0.4

0.45

0.5

0.55

0.6

0.65

0.7

198919

9019

9119

9219

9319

9419

9519

9619

9719

9819

9920

0020

01

Calendar year

45 p 20

elementary university

45 p20 = probability of living to 65 yrs when aged 20 yrs

Source: Murphy et al, AJPH, 96, 1293-9, 2006

Vågerö, EriksonThe Lancet 1997

MEDICAL CARE?MEDICAL CARE?

BENEFITS FROM GOVERNMENT HEALTH SERVICE BENEFITS FROM GOVERNMENT HEALTH SERVICE

EXPENDITURE, AVERAGE FOR 21 COUNTRIESEXPENDITURE, AVERAGE FOR 21 COUNTRIES

0

2

4

6

8

10

12

14

16

Less Same More

Number of countries*

Source: Reaching the Poor, eds:Gwatkin,D.R. Wagstaff,A. Yazbeck A.S. The World Bank, 2005

*Number of countries where lowest quintile receives less, the sa*Number of countries where lowest quintile receives less, the same, or more me, or more

benefit compared with the highest income quintilebenefit compared with the highest income quintile

EXPENDITURE ON MEDICAL CARE EXPENDITURE ON MEDICAL CARE

PER CAPITA IN US AND UKPER CAPITA IN US AND UK

UNITED STATES: UNITED STATES:

–– US$ 5274US$ 5274

UNITED KINGDOM: UNITED KINGDOM:

–– US$ 2164 (adjusted for purchasing US$ 2164 (adjusted for purchasing

power)power)

(Human Development Report 2005)

HEALTH DIFFERENCES BETWEEN ENGLAND AND HEALTH DIFFERENCES BETWEEN ENGLAND AND

THE USTHE US

5555--64 year olds64 year olds

0

5

10

15

20

25

England US England US England US

Low income Middle income High Income

Heart disease Diabetes CancerSource: Banks, Marmot, Oldfield and Smith; JAMA 2006

% Prevalence

Probability at birth of surviving to Probability at birth of surviving to

age 65(selected countries)age 65(selected countries)

86.7 (36)86.7 (36)79.1 (33)79.1 (33)USAUSA1010

88.588.579.179.1ChileChile3737

86.286.280.080.0CubaCuba5252

89.489.483.6 83.6 UKUK1515

93.7 (1)93.7 (1)86 (2)86 (2)Hong KongHong Kong2222

93.3 (2)93.3 (2)85.7 (4)85.7 (4)JapanJapan1111

91.4 (5)91.4 (5)87.4 (1)87.4 (1)IcelandIceland22

Female (rank)Female (rank)Male (rank)Male (rank)CountryCountryHDI rankHDI rank

Human Development Report 2005

EXPLANATIONS:EXPLANATIONS:

POVERTY IN THE POOR COUNTRIESPOVERTY IN THE POOR COUNTRIES

&&

BAD BEHAVIOUR IN THE RICH?BAD BEHAVIOUR IN THE RICH?

(Source: Angus Deaton)

YES, BUTYES, BUT……

GDP PER CAPITA AND LIFE GDP PER CAPITA AND LIFE

EXPECTANCY: SELECTED COUNTRIESEXPECTANCY: SELECTED COUNTRIES

75.175.110,87410,874CHILECHILE

58.958.99,9029,902RUSSIARUSSIA

76.076.09,4819,481COSTA RICACOSTA RICA

71.771.74,3904,390SRI LANKASRI LANKA

LIFE LIFE

EXPECTANCY AT EXPECTANCY AT

BIRTH (MALES)BIRTH (MALES)

GDP PER GDP PER

CAPITA (PPP CAPITA (PPP

US$)US$)

Source: Human Development Report 2006


The simplified frameworkThe simplified framework

The causes of the causesThe causes of the causes

COMPARISON OF SMOKING PREVALENCE BETWEEN LOW COMPARISON OF SMOKING PREVALENCE BETWEEN LOW

AND HIGH SOCIOECONOMIC GROUPSAND HIGH SOCIOECONOMIC GROUPS

0

1

2

3

4

5

6

7

8

9

10

India

(Delhi)

China Brazil Cuba South

Africa

Hungary

SMOKING RATE RATIOBETWEEN LOW AND HIGH SOCIOECONOMIC GROUPS

Bobak et al in ‘Tobacco control in developing countries’ ed: Jha & Chaloupka, 2000

Technology transfer?Technology transfer?

Yes, butYes, but……

RICHER UNDERSTANDING OF POVERTYRICHER UNDERSTANDING OF POVERTY

OUTLINEOUTLINE



Inequalities within and between countriesInequalities within and between countries




EMPOWERMENTEMPOWERMENT

––MaterialMaterial

–– PsychosocialPsychosocial

–– PoliticalPolitical

0.8

1.3

1.8

2.3

2.8

High job control Intermediate job

control

Low job control

Rate

ratio

Adjusted age, sex, length of follow up

+ effort/reward imbalance

+ grade, coronary risk factors, negative affect

Bosma et al, 1998

SELF-REPORTED JOB CONTROL AND CHD

INCIDENCE WHITEHALL MEN AND WOMEN

OUTLINEOUTLINE



Inequalities within and between countriesInequalities within and between countries




Commission on Social Determinants of Commission on Social Determinants of

HealthHealth

2005 2005 --20082008

�� Launched Chile March 2005Launched Chile March 2005�� Interim Statement July 2007Interim Statement July 2007�� Final Report and Final Report and

recommendations midrecommendations mid--20082008

Set up by the World Health Organisation

www.who.int/social_determinants

Knowledge into action:Knowledge into action:

Create the social conditionsCreate the social conditions

for empowermentfor empowerment

-500

-400

-300

-200

-100

0

100

US $

billion

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Developing economies

E and S Asia

Western Asia

Latin America

Transition economies

Africa

Sub-Saharan Africa

HIPCs

Source: United Nations Dept. of Economic and Social Affairs, 2006. 2005 figures are pre-liminary. “Sub- Saharan Africa”excludes Nigeria, South Africa

Net financial flows, by region and all developing and Net financial flows, by region and all developing and

transition economies, 1993transition economies, 1993--20052005

(CSDH GKN)

reduced

capacity to

access markets

& resources reduced school

attendance,

learning capacity

less education

& employment

for women & girls

weakened immune

systems,

rising

chid mortality

impaired maternal

and infant health

risky survival

strategies,

spread of HIV/ADS,

malaria etc

unsustainable use of

natural resources

Adapted from: FAO: The State of Food Insecurity in the World 2005

Hunger &

malnutrition

lead to …

The Nutrition TransitionThe Nutrition Transition

WHO 2006

Impact of better education and nutrition for Impact of better education and nutrition for women on nutrition and health for families in women on nutrition and health for families in

Kerala, IndiaKerala, India

0 10 20 30 40 50 60

stunted children

infant mortality

underweight women

(BMI below 18.5)

women 15-49 with no

education

India as a whole Kerala

Better education and nutrition for women

Improved nutrition and health for families

National Family Health Survey,

India (NFHS-3: 2005-2006)

““The success of an economy and of a The success of an economy and of a

society cannot be separated from the lives society cannot be separated from the lives

that the members of the society are able to that the members of the society are able to leadlead…… we not only value living well and we not only value living well and

satisfactorily, but also appreciate having satisfactorily, but also appreciate having

control over our lives.control over our lives.””

Amartya Sen, Development as Freedom Amartya Sen, Development as Freedom (1999)(1999)

NUMBER OF MAZES SOLVED IN 15 MIN: NUMBER OF MAZES SOLVED IN 15 MIN:

INDIAN CHILDREN 11INDIAN CHILDREN 11--12 YEARS12 YEARS

3

3.5

4

4.5

5

5.5

6

6.5

High Caste Low Caste

Caste announced?NO YES

(Source: Hoff & Pandey, 2004)

MAKING A DIFFERENCE TO MAKING A DIFFERENCE TO

PEOPLEPEOPLE’’S LIVES: SEWA S LIVES: SEWA Vegetable sellers in Vegetable sellers in AhmedabadAhmedabad

Micro creditMicro credit

Vegetable wholesalers Vegetable wholesalers

Legal right to sell vegetables Legal right to sell vegetables

Child care provision Child care provision

Health care provision Health care provision

Housing Housing

PensionsPensions

Commission on Social Commission on Social

Determinants of HealthDeterminants of Health

Bringing people and organisations Bringing people and organisations

together to create a global movementtogether to create a global movement

www.who.int/social_determinants/en

A world where social justice is taken A world where social justice is taken

seriouslyseriously

“Rise up with me…against the organisation of misery.”

From: The Banner by Pablo Neruda

Social Determinants of Health - World Health Organization...Social Context Social Stratification...

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