Consequences of the Economic Crisis for Social Determinants of Health

1. Consequences of the Economic Crisis for Social Determinants of Health Michael MarmotUCL Public Health Federations Istanbul 1st May 2009

2. Dramatic inequalities dominate global health • A social gradient in health exists in all countries and within cities

3. Social justice • Empowerment – material, psychosocial, political • Creating the conditions for people to take control of their lives

4. CSDH – Areas for Action Health Equity in all Policies Good Global Governance Fair Financing Early child development and education Healthy Places Fair Employment Social Protection Universal Health Care Market Responsibility Gender Equity Political empowerment – inclusion and voice

5. Unemployment Rates(selected OECD ) January 2008 – January 2009* *United Kingdom: November 07— November 08 Source: OECD.

6. Non-standard employment in the European Union (%) Parent-Thirion et al. (2007).

7. Vulnerable employment as share of total employment (%), 1997-2007 ILO GET 2009

8. Growth in Global Industrial Production andMerchandise Trade(Annualized three-month percent change) IMF World Economic Outlook Jan 2009

9. Global unemployment according to three scenarios Rise in unemployment from 5.7% in 2007 to between 6.1% and 7.1% in 2009 (between 18 million and 51 million people) Source: ILO, Trends Econometric Models, December 2008

10. Working poverty scenarios (USD 1.25) Working poor (less that $1.25 a day) predicted to rise to between 700 million & 800 million; Increase in 200 million in working poor in most pessimistic scenario Source: ILO, Trends Econometric Models, December 2008

11. ILO

12. Long-standing illness in 1991 and unemployment in 1971 and 1981 among men aged 15-40 in 1971 Bartley and Plews 2002

13. Mortality* of men aged 16-64 by social class and employment status at the 1981 census Employed in 1981 Unemployed in 1981 Standardised Mortality Rate I II IIIN IIIM IV V I II IIIN IIIM IV V Social class * adjusted for age and salary 1981 LS Cohort. *England & Wales: mortality 1981-92

14. Good work • Financial security • Social protection • Paid holiday • Social status • Personal development • Social relations • Self esteem • Protection from physical and psychosocial hazards

15. Global vulnerable employment according to three scenarios Source: ILO, Trends Econometric Models, December 2008

16. Prevalence of poor mental health in manual workers by type of contract: Spain % Artazcoz et al 2005

17. Mortality 1990-2001 for women on temporary contracts: Finland reference group women in permanent employment * adjusted for age and salary Kivimaki et al 2003; American Journal Epid 158:663-668

18. The Iso-strain concept of stress at work Socially isolated (no supportive co-workers or supervisors) High strain (High demands and low control)

19. ODDS RATIO* OF METABOLIC SYNDROME BY EXPOSURE TO ISO-STRAIN: WHITEHALL II PHASES 1 TO 5 Odds Ratio Exposure to Iso-strain *Adj. for age, employment, grade and health behaviours Chandola, Brunner & Marmot, BMJ, 2006

20. ODDS OF DEPRESSION BY CONTROL AT WORK & AT HOME WITHIN GRADE - WOMEN WHITEHALL II odds ratios High Medium Low EMPLOYMENT GRADE Griffin et al, Soc Sci Med, 2002

21. Prevalence of children’s mental disorders by family characteristics: GB 2004 % % (Source: Survey of the mental health of children and young people in Great Britain, ONS)

22. Not all business is declining… • McDonald's UK: 4,000 new jobs • extra two million customers a month compared to last year (Aug 2008) • McDonalds Europe: 240 new restaurants mostly in Spain, France, Italy, Russia and Poland • ‘consumers, particularly in Germany and Spain, favouring the cheapest menu items’ (Jan 09) Photo: R. Bell

23. Employment policy is health policy

24. Policy choices: ILO recommended policy measures Nov 2008 • wider coverage of unemployment benefits • re-skilling redundant workers • protecting pensions from devastating declines in financial markets; • public investment in infrastructure and housing, community infrastructure and green jobs; • support to small and medium enterprises; • social dialogue at enterprise, sectoral and national levels.

25. Unemployment benefits replace on average 40% of previous earnings – but there is huge variation within OECD Average of net replacement rates over a period of 60 months of unemployment in 2004, for four family types and two earnings levels in percentage – data are for 2004 Source: OECD 2007 SOCIETY AT A GLANCE

26. The Global Development Agenda?

27. CSDH – Areas for Action Health Equity in all Policies Good Global Governance Fair Financing Early child development and education Healthy Places Fair Employment Social Protection Universal Health Care Market Responsibility Gender Equity Political empowerment – inclusion and voice

28. Nancy Birdsall: developing countries will need $1 trillion over the next couple of years to pay for bank rescues, fiscal stimuli, and to maintain minimal social safety nets

29. MELADI NAGAR Before After Slide courtesy of Gujarat Mahila Housing SEWA Trust

30. Global slum upgrading • Cost estimate: less than US$ 100 billion. • Finance on shared basis, for instance by • international agencies and donors (45%), • national and local governments (45%), and • households themselves (10%), helped by micro-credit schemes.

31. A world where social justice is taken seriously www.who.int/social_determinants/en