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“WHY SOCIAL DETERMINANTS OF HEALTH? THE EVIDENCE” Commission on Social Determinants of Health Michael Marmot Fiocruz National School of Public Health June 27 th 2005 Basic needs Action as if people mattered Health as the driver ‘Causes of the causes’ Putting it into action

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why social determinants of health the evidence commission on social determinants of health

“WHY SOCIAL DETERMINANTS OF HEALTH? THE EVIDENCE”Commission on Social Determinants of Health

Michael Marmot

Fiocruz National School of Public Health

June 27th 2005

slide2
Basic needs

Action as if people mattered

Health as the driver

‘Causes of the causes’

Putting it into action

Presentation Outline

slide3
Basic needs

Action as if people mattered

Health as the driver

‘Causes of the causes’

Putting it into action

Presentation Outline

under 5 mortality rate per 1000 live births
UNDER 5 MORTALITY RATE PER 1000 LIVE BIRTHS

SOURCE: THE WORLD HEALTH REPORT 2004,WHO

probability of dying between ages 15 and 60 males
% PROBABILITY OF DYING BETWEEN AGES 15 AND 60 (males)

SOURCE: THE WORLD HEALTH REPORT 2004,WHO

slide10

INFANT MORTALITY IN BRAZIL, BY RACE AND MOTHER’S

EDUCATION, 1990

Source: Pinto da Cunha, E. M. G. (1997). Raça: aspecto esquecido da iniquidad em saúde no

Brasil. In Barata, R.B et al (editors) Equidade e Saúde. Abrasco Hucitec, São Paulo, Brazil.

slide11
There is a 33 year gap in male life expectancy between Asians in Westchester Co (LE 89) and American Indians in South Dakota (LE 56)
slide12
Travel from the Southeast of downtown Washington to Montgomery County Maryland. For each mile travelled life expectancy rises about a year and a half. There is a twenty year gap between poor blacks at one end of the journey (Male LE 57) and rich whites at the other (LE 76.7).
probability of survival from age 15 65 years among us blacks whites
Probability of Survival From Age 15-65 Years Among US Blacks & Whites

% probability of survival

US White Poor White US Black Poor Black

Males Males Males Males

Geronimus et al, NEJM 1996

the widening trend in mortality by education in russia 1989 2001
THE WIDENING TREND IN MORTALITY BY EDUCATION IN RUSSIA,1989-2001

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

Murphy, Bobak, Nicholson, Rose, and Marmot, 2005 under review

females le and hle at birth by deprivation deciles england 1994 99
FEMALES: LE AND HLE AT BIRTH BY DEPRIVATION DECILES, ENGLAND, 1994-99

Years of life

Affluent deprivation deciles Deprived

Source: Health Survey for England

Madhavi Bajekal, National Centre for Social Research

two types of success in reducing mortality
TWO TYPES OF SUCCESS IN REDUCING MORTALITY
  • Growth-mediated: if economic growth is widespread and participatory e.g. Hong Kong or S. Korea - poverty removal and public health.
  • Support led: Costa Rica, Kerala, Sri Lanka - enhanced quality of life through social services and education.

A.Sen: Innocenti Lecture, Florence 1995

gdp per capita and life expectancy selected countries
GDP PER CAPITA AND LIFE EXPECTANCY: SELECTED COUNTRIES

Source: Human Development Report 2004 and World Health Report 2004

human flourishing
HUMAN FLOURISHING

SOCIAL PARTICIPATION

AUTONOMY

HEALTH

slide23
Basic needs

Action as if people mattered

Health as the driver

‘Causes of the causes’

Putting it into action

Presentation Outline

the solid facts 10 messages
THE SOCIAL GRADIENT

STRESS

EARLY LIFE

SOCIAL EXCLUSION

WORK

UNEMPLOYMENT

SOCIAL SUPPORT

ADDICTION

FOOD

TRANSPORT

THE SOLID FACTS: 10 MESSAGES
slide26
Basic needs

Action as if people mattered

Health as the driver

‘Causes of the causes’

Putting it into action

Presentation Outline

chile social programmes for health
CHILE: Social programmes for health
  • Chile Solidario
  • Child development and well-being
  • Family-focussed primary health care
slide28
Basic needs

Action as if people mattered

Health as the driver

‘Causes of the causes’

Putting it into action

Presentation Outline

slide29

What good does it do to treat people's illnesses ...

then send them back to the conditions that made them sick?

early life
Early Life
  • The effects of early development last a life-time: a good start in life means supporting mothers and young children.
youth literacy scores 16 25 years and parents education
YOUTH LITERACY SCORES (16-25 YEARS) AND PARENTS’ EDUCATION

Literacy Scores

Sweden

Canada

US

Parents’ Education (years)

Willms 1999

addiction
Addiction
  • Individuals turn to alcohol, drugs and tobacco and suffer from their use. Use is influenced by the wider social setting.
comparison of smoking prevalence between low and high socioeconomic groups
COMPARISON OF SMOKING PREVALENCE BETWEEN LOW AND HIGH SOCIOECONOMIC GROUPS

SMOKING RATE RATIO

BETWEEN LOW AND HIGH

SOCIOECONOMIC GROUPS

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

slide34
Food
  • Healthy food is a political issue.
obesity patterns across the developing world
OBESITY PATTERNS ACROSS THE DEVELOPING WORLD

%

(Popkin, Development Policy Review, 2003)

transport
Transport
  • Healthy transport means reducing driving and encouraging more walking and cycling, backed up by better public transport.
more than a million people worldwide are killed in road crashes every year
More than a million people worldwide are killed in road crashes every year
  • Low and middle-income countries account for 86% of the world’s road deaths but have only 40% of the world’s motor vehicles.
slide40
“RELATIVE DEPRIVATION IN

THE SPACE OF INCOMES CAN

YIELD ABSOLUTE DEPRIVATION

IN THE SPACE OF CAPABILITIES”

Amartya Sen, Inequality Re-examined, 1992

action taken by european countries
Action taken by European Countries
  • taxation, tax credits
  • social welfare
    • old age pension
    • sickness/rehabilitation benefits
    • maternity/ child benefits
    • unemployment benefits
  • housing policy, housing benefits
  • labour markets
  • communities
  • care facilities

IK Crombie, et al., 2004

slide43

Economic

and social

security

Conditions in

childhood

and

adolescence

Healthier

working

life

Environments

and

products

Participation

in

society

Health

promoting

medical

care

SWEDISH PUBLIC HEALTH POLICY

Alcohol

drugs

tobacco

Eating

Safe food

Physical

activity

Sexual

health

Prevention

communicable

disease

early child development
Early Child Development

The effects of early development last a life-time: a good start in life requires supporting mothers and young children

effects of familias en accion in colombia
EFFECTS OF ‘FAMILIAS EN ACCION’ IN COLOMBIA
  • Improved nutritional status of children;
  • Increases in height and weight in young children (0-4 years);
  • 10% Reduction in numbers of children (0-4 years) with diarrhoea;
  • More children registered for growth and development check-ups
  • Increase in school enrolment of children (12 -17 years).
oportunidades program mexico
'Oportunidades' Program: Mexico

Aim: Improve health, education and nutrition levels in

poor households

Program design: health prevention including: health talks, antenatal and postnatal care, nutritional supplements to pregnant and lactating women

Coverage: 4.24 million poor families

2001 to April 2003coverage increased:

  • Number of pregnant women: 82,000 to 120,000
  • Number of antenatal care visits: 133,000 to 214,000
  • nutrition supplements for under–two yrs: 48,4000 to 72,7000
oportunidades program mexico47
"Oportunidades" Program (Mexico)

The Table shows the reduction in maternal and infant mortality in municipalities participating in the "Oportunidades" Program vis-a-vis those not participating in it

health systems
Health Systems

The organization of health systems fundamentally contributes to health outcomes

health systems49
Health Systems

Targeting health care system to local needs in Morogoro and Rufiji areas of Tanzania:

40% reduction in child mortality

food security
Food Security

Hunger is one of the most obvious manifestations of poverty and ill health

vulnerable group development program bangladesh
Vulnerable Group Development Program: Bangladesh
  • Aim: integrate food and nutrition security with development and income generation
  • Target population: ultra poor women
  • Program design: monthly allocation of wheat in exchange for participating in training (in literacy, numeracy, savings and nutrition)

(International Food Policy Research Institute, 2004)

progress can be achieved in short time periods
Progress can be achieved in short time periods

In 7 years

In 9 years

In 15 years

LIFE EXPECTANCY

POTABLE

WATER

PRIMARY SCHOOL ENROLLMENT

POVERTY

15m

56 yrs

33%

89%

48 yrs

18%

46%

7m

Sri Lanka

1946 - 53

South Africa

1994-2001

China

1990 - 99

Botswana

1970 - 85

slide53
Basic needs

Action as if people mattered

Health as the driver

‘Causes of the causes’

Putting it into action

Presentation Outline

slide54

Mutually reinforcing areas of work to achieve these outcomes

Leadership

Learning

Advocacy

Action

Communication/Exchange

the commissioners
The Commissioners
  • Fran Baum – Professor of Public Health, Flinders University, Australia
  • Giovanni Berlinguer – member of the European Parliament
  • Monique Begin – former Canadian Minister of National Health and Welfare
  • Mirai Chatterjee – Coordinator of Social Security for India’s Self-employed Women’s Association
  • Manuel Dayrit – Secretary of Health of the Philippines
  • Bill Foege – Emeritus Presidential DistinguishedProfessor of International Health, Emory University and Gates Fellow
  • Kiyoshi Kurokawa – President of the Science Council of Japan and the Pacific Science Association
  • Ricardo Lagos – President of Chile
the commissioners56
The Commissioners
  • Stephen Lewis – UN special envoy for HIV/AIDS in Africa
  • Seyed Marandi – Former Minister of Health in Iran
  • Michael Marmot (chair) – Director of International Centre for Health and Society, UCL
  • Charity Ngilu – Minister of Health, Kenya
  • Hoda Rashad – Director, Social Research Center of the American University in Cairo
  • David Satcher – President of Morehouse School of Medicne, former US Surgeon General
  • Amartya Sen – Nobel Laureate, Lamont Professor, University of Harvard
  • Anna Tibaijuka – Executive Director of UN-HABITAT
  • Denny Vagero – Professor of Medical Sociology, Director of Centre for Health Equity Studies, Stockholm.
what would success look like
What would success look like?
  • Knowledge, leadership and debate
  • Action
  • Institutional change
  • Policy change
social justice imperative
SOCIAL JUSTICE IMPERATIVE
  • HEALTH IS A MARKER OF HOW WELL POLICIES MEET HUMAN AND SOCIAL NEEDS
slide60

‘THE SUCCESS OF AN ECONOMY AND OF A SOCIETY CANNOT BE SEPARATED FROM THE LIVES THAT THE MEMBERS OF THE SOCIETY ARE ABLE TO LEAD…WE NOT ONLY VALUE LIVING WELL AND SATISFACTORILY, BUT ALSO APPRECIATE HAVING CONTROL OVER OUR OWN LIVES’Amartya Sen, Development as Freedom (1999)