Yawen Cheng, ScD Associate Professor Institute of Health Policy and Management, College of Public...

Yawen Cheng, ScD Associate Professor Institute of Health Policy and Management, College of Public Health, National Taiwan University Essentials of Global Health April 13, 2012 1 Unless noted, the course materials are licensed under Creative Commons Attribution- NonCommercial-ShareAlike 3,0 Taiwan (CC BY-NC-SA 3.0)Attribution- NonCommercial-ShareAlike 3,0 Taiwan

Why are public health researchers concerned about health inequalities and social determinants of health? A brief review of the development of public health sciences Existence and trends of health inequalities What are the causes? Explanations? Job stress problems as an example Causal explanations and the links to public policies Documentary Unnatural Causes: In Sickness and In Wealth (56 minutes) Discussion in group & preparation for the homework 2

Public health is the science and art of preventing disease, prolonging life, and promoting health through the organized efforts of society. Goal: biological, physical and mental well-being of all members of society. Core courses: biostatistics, epidemiology, health sciences 3 major branches Biomedical sciences Environmental and occupational health sciences Health policy and management 3

Before the 20th century Contagion Miasma theory Social production of health 4

5 1964 SG Report 1974 Lalonde Report 1978 Alma Ata Declaration 1986 Ottawa Charter 2005 WHO CSDH Traditional Public HealthNew Public Health Historical Evolution of Public Health 1883 Germany-SI 1948 UK-NHS 1961 Japan-NHI 1971 Canada-NHI 1989 Korea-NHI 1995 Taiwan-NHI 1911 Germany-RVO 2002 Thai-Mix 1848 UK-Public Health Act 1884 Kochs Postulates 1928 Penicillin Laissez-faireEfficiencyEquity in AccessCost Control 1948 WHO Tung-Liang Chiang Medical care systems Major health discourses

6 Edwin Chadwick (1800-1890) Report of the Poor Law Commission (1832) New Poor Law (1834) Report on the Sanitary Condition of the Laboring Population (1842) Public Health Act (1848) Sanitary idea - miasma theory Drainage system Central and local boards of health

7 Wikimedia German Federal Archive

In the 20th century Golden age of Germ theory (1900-1950) Modern epidemiology (after 1950) emphasize on biomedical science and life styles Emerging of social epidemiology (1990s~) emphasize on social determinants 8

9 Germ Theory of Disease proposes that microorganisms are the cause of many diseases. Koch's postulates, formulated in 1884, are four criteria designed to establish a causal relationship between a causative microbe and a disease.

10 Eugenic movement in the 1920s (1)birth control (2)marriage regulation (3)Sterilization (4)immigrant restriction Slogan liked:

11 In 1988, Lalonde received WHO Medal for his exceptional contribution to health policy; in 2002, he was selected by the Pan America Health Organization as one of eleven Public Health Heroes. (1974)

12 RESPIRATORY TB MORTALITY England & Wales, 1840-1970 McKeown thesis The role of medicine: dream, mirage, or nemesis? (London, 1976) The modern rise of population (New York: Academic Press, 1976) The origins of human disease (Great Britain: TJ Press Ltd, 1988) David Coetzee

Driving forces Long history of concept of social influence on health Social political changes widening social inequalities in health Changes in scientific knowledge on causality Psycho-medicine: Evidences of psychosocial stress on health; all disease and health status are influenced by psychosocial conditions Influences from other disciplines 13

What are the causes? Healthcare systems? Biomedical factors? Genetic factors? Life style? Environmental factors? Social factors? The spider of the causal web? 14

Interventions are closely linked to causal interpretation Medical Biological Behavioral Environmental Social, political, structural 15

Health indicators Life expectancy Mortality (death rate) Morbidity (disease rate) Disease survival Health-related quality of life Social factors Social class (Marxian), Social economic status (income, education, occupation), early life experiences Gender, sex Place, neighborhood and community Racial and ethnic groups Policy and social systems Politics, culture, trade, etc. 16

17 Pre-menstrual syndrome Diabetes Hypertension Ischaemia Cough with phlegm National Taiwan University Yawen Cheng Source: Marmot, Health inequalities among British civil servants: the WhitehallIIstudy, The Lancet Volume 337, Issue 8754, 8 June 1991, Pages 13871393

18 National Taiwan University Yawen Cheng Source: Marmot, Health inequalities among British civil servants: the WhitehallIIstudy, The Lancet Volume 337, Issue 8754, 8 June 1991, Pages 13871393

19 National Taiwan University Yawen Cheng Source: Marmot, Health inequalities among British civil servants: the WhitehallIIstudy, The Lancet Volume 337, Issue 8754, 8 June 1991, Pages 13871393

20 Cumulative Economic Hardship and Physical, Psychological, Cognitive and Social Functioning in Alameda County, 1994 (Lynch & Kaplan, NEJM 1997; 337: 1889-95) * Adjusted for age, sex, BMI, pack-years of smoking, alcohol intake, and physical activity National Taiwan University Yawen Cheng

21 Drever F, Whitehead M, Roden M

22 77.371.769.959.61991-1993 76.571.168.859.11988-1990 75.770.769.459.31984-1986 73.968.767.758.41978-1980 69.164.652.248.3 1964 47.742.713.59.8 1933 FMFM Han ChineseAborigines*Year * Average of plain and mountain aborigines National Taiwan University Yawen Cheng

23 Ethnic Group Male Female Taiwanese 73 79 Plain Aborigine 62 (-11) 72 (-7) Mountain Aborigine 58 (-15) 69 (-10) Life expectancy of aborigines and Han Chinese in Taiwan 2000 National Taiwan University Yawen Cheng

24 1976 1995 Tung-Liang Chiang National Taiwan University Tung-Liang Chiang

Social selection Social heritage Social drifting Social causation (exposure and resource) Material pathways environmental hazards, infection, poor diet, limited access to health care Psychosocial pathways Stress, negative emotions, learned helplessness, lower self-efficacy and self-esteem 25

26 Changes in Gini Coefficient: 1981~2008 National Taiwan University Yawen Cheng

27 World Map of Gini coefficient (2009)

Example 1:Job stress problems 28

Cases of karoshi (sudden death from overwork) occurred frequently in Taiwan in recent years; most cases were young or middle-aged men with cardiac or cerebrovascular causes of death These cases were from a wide range of occupations and socioeconomic groups, including truck drivers, engineers, physicians, trainees, managers, professors etc. Controversies over karoshi claims for workers compensation intensified, and there are growing public concerns and anxiety on work stress. 29

30 Labor Days March in Taipei (May 1, 2011) Main themes strengthen regulations on working hours strengthen regulations on outsourcing & dispatched work Improve OSH standards & labor inspection March in support of pro-labor regulations Taiwan Labor Front

Occupational health services Health monitoring, health promotion & education Workers Regulations Work place Monitoring of workplace hazards and risk assessment Compensation and rehabilitation Inspection Monitoring and reporting systems Of occupational injuries and diseases National Taiwan University Yawen Cheng

32 Data Source: IMD WORLD COMPETITIVENESS ONLINE 1995 - 2010 National Taiwan University Yawen Cheng

33 Graph made by Shiuan-Be Wu. Data source: (1) Huberman, M., Working Hours of the World Unite? New International Evidence of work time, 1870- 1913. The Journal of Economic History, 2004. 64(04): p. 964-1001; (2) OECD (http://stats.oecd.org/index.aspx);http://stats.oecd.org/index.aspx (3) US (http://www.bls.gov/cps/cps_aa2003.htm); (4) Japan (http://www.stat.go.jp/english/data/chouki/19.htm);http://www.bls.gov/cps/cps_aa2003.htmhttp://www.stat.go.jp/english/data/chouki/19.htm (5) Taiwan (Wu, 2011; Master thesis of the Institute of Health Policy and Management, NTU). F D N UK C US J Korea TW1 TW2 International comparison of average annual working hours in employees: 1870-2010 Shiuan-Be Wu

34 Model of Job Stress and Health Major stressors Demands (effort) quan., qual., emotional, sensory, etc. Job control authority, skill Social support supervisor,coworker Work rewards income, respect, esteem, fairness, security, support, etc. Role conflicts Shift work Management Hazardous exposure Job strain Stress- related illnesses Psychological: job dissatisfaction depression anxiety Physiological: somatic complaints hypertension hyperlipoidemia immune depression Behavioral: smoking drinking sleep problems Age, Sex, Education, Personality, Coping disability; accident; illness Other stressors Other social support National Taiwan University Yawen Cheng

Developed by Robert Karasek and Tores Theorell in 1970s Alienation as the main cause of job stress Emphasizing on job enrichment, democracy in the workplace, and social support Product of social democratic movement; political struggle to overcome powerlessness, de-skilling and alienation 35

36 Psychological demands Job control Low strain jobs High strain jobs Passive jobs Active jobs strain Active learning National Taiwan University Yawen Cheng

37 Skill discretion Decision authority Psychological demands Supervisor support Coworker support 1.Learn new things 2.No repetitive work 3.Require creativity 4.High skill level 5.Variety 6.Develop own abilities 1.Own decisions 2.Decision freedom 3.Lots of say 1.Work fast 2.Work hard 3.Excessive work 4.Not enough time 5.Conflicting demands 1.Supervisor concerned 2.Supervisor pays attention 3.Helpful supervisors 4.Supervisor good organizer 1.Coworker competent 2.Coworker interest in me 3.Coworker friendly 4.Coworkers helpful Job control National Taiwan University Yawen Cheng

40 Photographed by National Taiwan University, Yawen Cheng, May, 2010.

41 www.osh.govt.nz

42 Adjusted for age, sex, BMI, marital status, smoking, shift work, work hours, job insecurity, and work-place social support. SF-36 mental health score in relation to job control and demands - micro-electronic workers in Taiwan (n=1,078) National Taiwan University Yawen Cheng

43 Comparison of job demands and job control measured by Job Content Questionnaire for Men* * Sources: Karasek et al. 1998; Kawakami et al 2004; Cheng et al 2003; EU- JACE study, 2002. EU-North EU-Middle EU-South Japan (two companies) Taiwan Japan (JSTRESS) US(NMEC) Canada-Quebec Netherlands Canada- Quebec(W) National Taiwan University Yawen Cheng

44 Proportion of workers, % Source: The1977 Quality of Employment Survey and 1997 National Survey of the Changing Workforce in the US Source: European Foundation Surveys EUUS National Taiwan University Yawen Cheng

45 Changes in Job Demands (2001-2010) National Taiwan University Yawen Cheng

46 Changes in Job Control (2001-2010) National Taiwan University Yawen Cheng

47 Macro level Politics, policy, law, enforcement Deregulation Globalization Employer-labor power imbalance Economic factors Impacts of new technology Cultural factors Mezzo level Flexible labor Downsizing Outsourcing Contingent workers Multi-role workers Floating wage Profit-oriented performance evaluation Micro level Wage/benefit Workloads Job security Career prospect Skill utilization Skill development Influence Participation Social support Mutual trust Social integration Meaningfulness National Taiwan University Yawen Cheng

48 WHO

Choose one type of the health problems, and answer the following questions Occupational injuries or occupational diseases Coronary heart disease or hypertension Obesity Smoking Alcoholism In your country or region, is there health inequality of this health problem by social categories (e.g., education, occupational grade, income, gender, ethnicity, neighborhood) ? If so, what might be the cause (s)? What kinds of public policies do we need to reduce social inequalities of this health problem? What obstacles and opportunities may exist? 49

pag e WorkLicensing Author/ Source 4 Wikimedia commons Dbenzhuser http://commons.wikimedia.org/wiki/File:Black_Death.jpg 2012/06/02 visited 4 Wikimedia commons Marcantonio Raimondi http://commons.wikimedia.org/wiki/File:Il_Morbetto.jpg 2012/06/02 visited 5 This work is licensed by Tung-Liang Chiang for the use of Essentials of Global Health ONLY. The copyright belongs to the above mentioned creator(s) and GET does not have the authorization right. 6 Wikimedia commons Adam sk http://commons.wikimedia.org/wiki/File:SirEdwinChadwick.jp g 2012/06/02 visited 7 Wikimedia commons German Federal Archive http://commons.wikimedia.org/wiki/File:Bundesarchiv_Bild_18 3-R68588,_Otto_von_Bismarck.jpg 2012/06/02 visited

pageWorkLicensing Author/ Source 7 Wikimedia commons Chnodomar http://commons.wikimedia.org/wiki/File:Maerz1848_berli n.jpg 2012/06/02 visited 9 Wikimedia commons Tryphon http://commons.wikimedia.org/wiki/File:RobertKoch_crop ped.jpg 2012/06/02 visited 9 Wikimedia commons Nicolas Andry http://commons.wikimedia.org/wiki/File:Nicolas_Andry_il lustrations_of_microorganisms.jpg 2012/06/02 visited 10 Wikimedia commons Beao http://en.wikipedia.org/wiki/File:Eugenics_congress_logo.png 2012/06/02 visited 11 New Perspective on the Health of Canadian, A working document. by Minister of National health and Welfare Marc Lalonde http://www.amazon.com/gp/customer-media/product- gallery/B004D9IJVQ/ref=cm_ciu_pdp_images_0?ie=UTF8& index=0&isremote=0 This work is used subject to the fair use doctrine of Article 52, 65 Taiwan Copyright Act by GET. 2012/06/13 visited

pageWorkLicensing Author/ Source 12 This is from David Coetzee, Infectious Disease Epidemiology Unit University of Cape Town PPT. http://0rz.tw/FNcax This work is used subject to the fair use doctrine of Article 52, 65 Taiwan Copyright Act by GET. 17 National Taiwan University Yawen Cheng 18 National Taiwan University Yawen Cheng 19 National Taiwan University Yawen Cheng 20 National Taiwan University Yawen Cheng

pageWorkLicensing Author/ Source 21 This work is from : Drever F, Whitehead M, Roden M. Current patterns and trends in male mortality by social class (based on occupation). Popul Trends. 1996 Winter;(86):15-20. This work is used subject to the fair use doctrine of 52, 65 Taiwan Copyright Act by GET. 22 National Taiwan University Yawen Cheng 23 National Taiwan University Yawen Cheng 24 This work is licensed by Tung-Liang Chiang for the use of Essentials of Global Health ONLY. The copyright belongs to the above mentioned creator(s) and GET does not have the authorization right. 24 This work is licensed by Tung-Liang Chiang for the use of Essentials of Global Health ONLY. The copyright belongs to the above mentioned creator(s) and GET does not have the authorization right.

pageWorkLicensing Author/ Source 26 National Taiwan University Yawen Cheng 27 Wikimedia commons Hysohan http://commons.wikimedia.org/wiki/File:Gini_Coefficient_ World_CIA_Report_2009-1.png 2012/06/02 visited 30 This work is licensed by Taiwan Labor Front, for the use of Essentials of Global Health ONLY. The copyright belongs to the above mentioned creator(s) and GET does not have the authorization right. 30 This work is licensed by Taiwan Labor Front, for the use of Essentials of Global Health ONLY. The copyright belongs to the above mentioned creator(s) and GET does not have the authorization right. 30 This work is licensed by Taiwan Labor Front, for the use of Essentials of Global Health ONLY. The copyright belongs to the above mentioned creator(s) and GET does not have the authorization right.

pageWorkLicensing Author/ Source 31 National Taiwan University Yawen Cheng 32 National Taiwan University Yawen Cheng 33 This work is licensed by Shiuan-Be Wu, for the use of Essentials of Global Health ONLY. The copyright belongs to the above mentioned creator(s) and GET does not have the authorization right. 34 National Taiwan University Yawen Cheng 36 National Taiwan University Yawen Cheng

pageWorkLicensing Author/ Source 37 National Taiwan University Yawen Cheng 38 This work is from : Karasek, R. and T. Theorell (1990). Healthy Work - Stress, Productivity, and the Reconstruction of Working Life. New York, This work is used subject to the fair use doctrine of Article 52, 65 Taiwan Copyright Act by GET. 39 This work is from : Karasek, R. and T. Theorell (1990). Healthy Work - Stress, Productivity, and the Reconstruction of Working Life. New York, This work is used subject to the fair use doctrine of Article 52, 65 Taiwan Copyright Act by GET. 40 National Taiwan University Yawen Cheng, May 2010 40 National Taiwan University Yawen Cheng, May 2010

pag e WorkLicensing Author/ Source 41 http://www.osh.govt.nz/publications/booklets/stress- tools2008/models-stress.asphttp://www.osh.govt.nz/publications/booklets/stress- tools2008/models-stress.asp This work is used subject to their copyright page http://www.dol.govt.nz/common/copyright.asp 2012/8/14 visited 42 National Taiwan University Yawen Cheng 43 National Taiwan University Yawen Cheng 44 National Taiwan University Yawen Cheng 45 National Taiwan University Yawen Cheng

pageWorkLicensing Author/ Source 46 National Taiwan University Yawen Cheng 47 National Taiwan University Yawen Cheng 48 This work is from : WHO (2007). Employment conditions and health inequalities, Commission on Social Determinants of Health http://www.google.com.tw/url?sa=t&rct=j&q=&esrc=s&sour ce=web&cd=1&ved=0CFYQFjAA&url=http%3A%2F%2Fww w.who.int%2Fsocial_determinants%2Fresources%2Farticles %2Femconet_who_report.pdf&ei=LmsOUID1BezOmAWAxIG QDA&usg=AFQjCNHipIqKBRHupzEsR24mU8W5Wr51Pw&sig 2=0OGEphm_zc_nsULwRhzH7A This work is used subject to WHO copyright notice: http://www.who.int/about/copyright/zh/ http://www.who.int/about/copyright/zh/

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