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 ChallengeThe Challenge
Conceptual FrameworkConceptual Framework
ExplanationsExplanations
Linking poverty and the gradientLinking poverty and the gradient
Integrating knowledge for actionIntegrating knowledge for action
Social Determinants of HealthSocial Determinants of Health
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
The ChallengeThe Challenge
Conceptual FrameworkConceptual Framework
ExplanationsExplanations
Linking poverty and the gradientLinking poverty and the gradient
Integrating knowledge for actionIntegrating knowledge for action
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
Social Determinants of HealthSocial Determinants of Health
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
The ChallengeThe Challenge
Conceptual FrameworkConceptual Framework
Inequalities within and between countriesInequalities within and between countries
ExplanationsExplanations
Linking poverty and the gradientLinking poverty and the gradient
Integrating knowledge for actionIntegrating knowledge for action
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
The ChallengeThe Challenge
Conceptual FrameworkConceptual Framework
Inequalities within and between countriesInequalities within and between countries
ExplanationsExplanations
Linking poverty and the gradientLinking poverty and the gradient
Integrating knowledge for actionIntegrating knowledge for action
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
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