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GLOBAL ACTION AND SOCIAL DETERMINANTS OF HEALTH Michael Marmot 11 th World Congress of Public Health Rio de Janeiro 2006 OUTLINE The Challenge Conceptual Framework Inequalities within and between countries Explanations Linking poverty and the gradient OUTLINE The Challenge

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global action and social determinants of health

GLOBAL ACTION AND SOCIAL DETERMINANTS OF HEALTH

Michael Marmot

11th World Congress of Public Health

Rio de Janeiro

2006

outline
OUTLINE
  • The Challenge
  • Conceptual Framework
  • Inequalities within and between countries
  • Explanations
  • Linking poverty and the gradient
outline3
OUTLINE
  • The Challenge
  • Conceptual Framework
  • Inequalities within and between countries
  • Explanations
  • Linking poverty and the gradient
outline5
OUTLINE
  • The Challenge
  • Conceptual Framework
  • Inequalities within and between countries
  • Explanations
  • Linking poverty and the gradient
simple view
“SIMPLE VIEW”

GROWTH

DEVELOPMENT

simple view8
“SIMPLE VIEW”

MATERIAL CIRCUMSTANCES

HEALTH

slide9

BEYOND GDP

  • AND INCOME POVERTY

DEVELOPMENT

GROWTH

DEVELOPMENT

EMPOWERMENT

slide10

2) BEYOND MATERIAL CIRCUMSTANCES

AND HEALTHCARE

HEALTH

MATERIAL CIRCUMSTANCES

HEALTH

EMPOWERMENT

more than an analogy
MORE THAN AN ANALOGY

GROWTH

DEVELOPMENT

HEALTH

EMPOWERMENT

outline12
OUTLINE
  • The Challenge
  • Conceptual Framework
  • Inequalities within and between countries
  • Explanations
  • Linking poverty and the gradient
mortality over 25 years according to level in the occupational hierarchy whitehall
MORTALITY OVER 25 YEARS ACCORDING TO LEVEL IN THE OCCUPATIONAL HIERARCHY:WHITEHALL

(Marmot & Shipley, 1996)

life expectancy in london borough of camden men
LIFE EXPECTANCY IN LONDON BOROUGH OF CAMDEN: MEN
  • Cycle from Hampstead in the north of Camden to UCL in the south. Travel from area where life expectancy for men is 81 years; within 30 min by bike life expectancy drops by eleven years to 70 years.
widening life expectancy
WIDENING LIFE EXPECTANCY

Source: ‘Let Glasgow Flourish’ Hanlon,P.,Walsh,D. & Whyte,B.,2006

slide18
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).
slide19
Oscar winning actors and actresses lived an astonishing 4 years longer than their co-stars and the actors nominated who did not win. (Redelmeier & Singh)
  • Winning the Oscar is like reducing your chance of dying from a heart attack from about average to zero.

Status Syndrome

men aged 64 in 1990 who died up to 1996 by education swedish national sample
MEN AGED 64 IN 1990 WHO DIED UP TO 1996 BY EDUCATION SWEDISH NATIONAL SAMPLE

Erikson 2001

life expectancy at birth
LIFE EXPECTANCY AT BIRTH

(*http://www.hreoc.gov.au, Social Justice Report 2005;**Human Development report 2005)

life expectancy and ethnicity in new zealand
LIFE EXPECTANCY AND ETHNICITY IN NEW ZEALAND

European

females

Pacific females

European males

Pacific males

Maori females

Maori males

(Tobias & Cheung, 2003)

under 5 mortality rates by socioeconomic quintile of household
UNDER 5 MORTALITY RATES BY SOCIOECONOMIC QUINTILE OF HOUSEHOLD

per 1000

Source: Gwatkin et al 2000

mortality and education south korea
MORTALITY* AND EDUCATION, SOUTH KOREA

*Mortality in Korean working population aged 20-64, 1993-1997, adjusted for age

(Source: Son et al. JECH 56:798, 2002)

outline29
OUTLINE
  • The Challenge
  • Conceptual Framework
  • Inequalities within and between countries
  • Explanations
  • Linking poverty and the gradient
slide30
EXPLANATIONS:
    • “IT’S THE NATURAL ORDER”
trends in life expectancy
TRENDS IN LIFE EXPECTANCY

Human Development Report 2005

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

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

slide33

Vågerö, Erikson

The Lancet 1997

slide34
EXPLANATIONS:

POVERTY IN THE POOR COUNTRIES

&

BAD BEHAVIOUR IN THE RICH?

ten tips for staying healthy
Ten Tips for Staying Healthy
  • Don't be poor. If you can, stop. If you can't, try not to be poor

for long.

  • Don't have poor parents.
  • Own a car.
  • Don't work in a stressful, low paid manual job.
  • Don't live in damp, low quality housing.
  • Be able to afford to go on a foreign holiday and sunbathe.
  • Practice not losing your job and don't become unemployed.
  • Take up all benefits you are entitled to, if you are unemployed, retired or sick or disabled.
  • Don't live next to a busy major road or near a polluting factory.
  • Learn how to fill in the complex housing benefit/ asylum application forms before you become homeless and destitute.

Dave Gordon, 1999

infant mortality 1000 live births
INFANT MORTALITY/1000 LIVE BIRTHS

(*http://www.hreoc.gov.au, Social Justice Report 2005;**Human Development Report 2005)

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

Source: Human Development Report 2005 and World Health Report 2005

global pattern of disease
Global pattern of disease

communicable

Non-communicable

injury

WHO 2005

projected increase in elderly population over 65 2000 2030 selected countries
PROJECTED INCREASE IN ELDERLY POPULATION (OVER 65): 2000-2030, SELECTED COUNTRIES

% increase

US Census Bureau, 2001

slide45
PEOPLE IN PROFESSIONAL AND MANAGERIAL CLASSES REACH THE SAME LEVEL OF DISABILITY AS THOSE IN ROUTINE AND MANUAL CLASSES ABOUT 15 YEARS EARLIER.

ENGLISH LONGITUDINAL STUDY OF AGEING

outline46
OUTLINE
  • The Challenge
  • Conceptual Framework
  • Inequalities within and between countries
  • Explanations
  • Linking poverty and the gradient
slide47

2) BEYOND MATERIAL CIRCUMSTANCES

AND HEALTHCARE

HEALTH

MATERIAL CIRCUMSTANCES

HEALTH

EMPOWERMENT

slide48
EMPOWERMENT
    • INDIVIDUAL CONTROL (EFFICACY)
    • COLLECTIVE CONTROL (EFFICACY)
slide51

SOCIOECONOMIC

STATUS

CONTROL

BELIEFS

CLASSICAL RISK

FACTORS

HEART DISEASE

Source: Bosma et al. Soc Sci Med 60 (2005) 737

heart disease ses and control beliefs men and women aged 57 years
HEART DISEASE, SES, AND CONTROL BELIEFS (men and women aged 57 years +

Hazard ratio

Model 1: Sex and age-adjusted

Model 2: + classical risk factors

Model 3:+ control beliefs

Bosma et al. Soc Sci Med 60 (2005) 737

the iso strain concept of stress at work
The Iso-strain concept of stress at work
  • Socially isolated
    • (no supportive co-workers or supervisors)
  • High strain
    • (High demands and low control)
odds ratio of metabolic syndrome by exposure to iso strain whitehall ii phases 1 to 5
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

benefits from government health service expenditure average for 21 countries
BENEFITS FROM GOVERNMENT HEALTH SERVICE EXPENDITURE, AVERAGE FOR 21 COUNTRIES

Number of countries*

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

benefit compared with the highest income quintile

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

expenditure on medical care per capita in us and uk
EXPENDITURE ON MEDICAL CARE PER CAPITA IN US AND UK
  • UNITED STATES:
    • US$ 5274
  • UNITED KINGDOM:
    • US$ 2164 (adjusted for purchasing power)

(Human Development Report 2005)

differences in self reported health between england and the us 55 64 year olds
DIFFERENCES IN SELF REPORTED HEALTH BETWEEN ENGLAND AND THE US55-64 year olds

Heart disease

Diabetes

Cancer

Source: Banks, Marmot, Oldfield and Smith; JAMA 2006

slide59

COMMISSION ON SOCIAL DETERMINANTS OF HEALTH

  • Set up by the World Health Organization
  • Launched in Santiago, Chile, March 2005
commission on social determinants of health
Commission on Social Determinants of Health
  • improving health and health equity through action on the socially determined causes of health inequities
slide61
Commissioners
  • Knowledge networks
  • Civil society
  • Country action
  • Global initiative
  • WHO