“why social determinants of health? the evidence” commission on social determinants of health
DESCRIPTION
“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. - PowerPoint PPT PresentationTRANSCRIPT
““WHY SOCIAL DETERMINANTS WHY SOCIAL DETERMINANTS
OF HEALTH? THE EVIDENCE”OF HEALTH? THE EVIDENCE” Commission on Social Commission on Social Determinants of HealthDeterminants of Health
Michael MarmotMichael Marmot
Fiocruz National School of Public Health
June 27th 2005
Basic needsBasic needs
Action as if people matteredAction as if people mattered
Health as the driverHealth as the driver
‘‘Causes of the causes’Causes of the causes’
Putting it into actionPutting it into action
Presentation Outline
Basic needsBasic needs
Action as if people matteredAction as if people mattered
Health as the driverHealth as the driver
‘‘Causes of the causes’Causes of the causes’
Putting it into actionPutting it into action
Presentation Outline
INEQUALITIES BETWEEN INEQUALITIES BETWEEN COUNTRIESCOUNTRIES
UNDER 5 MORTALITY RATE PER UNDER 5 MORTALITY RATE PER 1000 LIVE BIRTHS1000 LIVE BIRTHS
SIERRA LEONESIERRA LEONE 316316
BOLIVIABOLIVIA 8080
KYRGYZSTANKYRGYZSTAN 6363
SRI LANKASRI LANKA 2020
ICELANDICELAND 33
SOURCE: THE WORLD HEALTH REPORT 2004,WHO
% PROBABILITY OF DYING BETWEEN % PROBABILITY OF DYING BETWEEN AGES 15 AND 60 (males)AGES 15 AND 60 (males)
LESOTHOLESOTHO 90.290.2
RUSSIARUSSIA 46.946.9
BOLIVIABOLIVIA 2626
SRI LANKASRI LANKA 23.823.8
COLOMBIACOLOMBIA 23.623.6
PAKISTANPAKISTAN 22.722.7
SWEDENSWEDEN 8.38.3
SOURCE: THE WORLD HEALTH REPORT 2004,WHO
ADULT MORTALITY: THE DOUBLE ADULT MORTALITY: THE DOUBLE BURDEN OF DISEASEBURDEN OF DISEASE
(WHO, 2003)
Life expectancy and GDP in $US (PPP) in 2002
LELEat birthat birth GDPGDP
JapanJapan 81.581.5 26,94026,940
SwedenSweden 8080 26,05026,050
SpainSpain 79.279.2 21,46021,460
SwitzerlandSwitzerland 79.179.1 30,01030,010
FranceFrance 78.978.9 26,92026,920
GreeceGreece 78.278.2 18,72018,720
UKUK 78.178.1 26,15026,150
Costa RicaCosta Rica 7878 8,8408,840
USUS 7777 35,75035,750
CubaCuba 76.776.7 5,2595,259
INEQUALITIES WITHIN INEQUALITIES WITHIN COUNTRIESCOUNTRIES
INFANT MORTALITY IN BRAZIL, BY RACE AND MOTHER’SEDUCATION, 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.
There is a 33 year gap in male life There is a 33 year gap in male life expectancy between Asians in expectancy between Asians in Westchester Co (LE 89) and Westchester Co (LE 89) and American Indians in South Dakota American Indians in South Dakota (LE 56)(LE 56)
Travel from the Southeast of Travel from the Southeast of downtown Washington to Montgomery downtown Washington to Montgomery County Maryland. For each mile County Maryland. For each mile travelled life expectancy rises about a travelled life expectancy rises about a year and a half. There is a twenty year year and a half. There is a twenty year gap between poor blacks at one end gap between poor blacks at one end of the journey (Male LE 57) and rich of the journey (Male LE 57) and rich whites at the other (LE 76.7)whites at the other (LE 76.7)..
Probability of Survival From Age 15-65 Probability of Survival From Age 15-65 Years Among US Blacks & WhitesYears Among US Blacks & Whites
20
30
40
50
60
70
80
% p
roba
bili
ty o
f su
rviv
al
Geronimus et al, NEJM 1996
US White Poor White US Black Poor BlackMales Males Males Males
GROWING INEQUALITIESGROWING INEQUALITIES
THE WIDENING TREND IN MORTALITY BY EDUCATION IN RUSSIA,1989-2001
0.4
0.45
0.5
0.55
0.6
0.65
0.7
Calendar year
45 p
20
elementary university
45 p20 = probability of living to 65 yrs when aged 20 yrs
Murphy, Bobak, Nicholson, Rose, and Marmot, 2005 under review
QUALITY OF LIFEQUALITY OF LIFE
FEMALES: LE AND HLE AT BIRTH BY FEMALES: LE AND HLE AT BIRTH BY DEPRIVATION DECILES, ENGLAND, 1994-99DEPRIVATION DECILES, ENGLAND, 1994-99
68 67 66 65 62 60 59 58 56 52
13 14 15 16 18 20 21 21 2326
3035404550556065707580
1 2 3 4 5 6 7 8 9 10
HLE not-HLE
Affluent deprivation deciles Deprived
Years of life
Source: Health Survey for EnglandMadhavi Bajekal, National Centre for Social Research
HEALTH AS A MEASURE OF HEALTH AS A MEASURE OF ‘SOCIAL SUCCESS’‘SOCIAL SUCCESS’
TWO TYPES OF SUCCESS TWO TYPES OF SUCCESS IN REDUCING MORTALITYIN REDUCING MORTALITYGrowth-mediated: if economic growth is Growth-mediated: if economic growth is widespread and participatory e.g. Hong widespread and participatory e.g. Hong Kong or S. Korea - poverty removal and Kong or S. Korea - poverty removal and public health.public health.
Support led: Costa Rica, Kerala, Sri Lanka Support led: Costa Rica, Kerala, Sri Lanka - enhanced quality of life through social - enhanced quality of life through social services and education.services and education.
A.Sen: Innocenti Lecture, Florence 1995
GDP PER CAPITA AND LIFE GDP PER CAPITA AND LIFE EXPECTANCY: SELECTED COUNTRIESEXPECTANCY: SELECTED COUNTRIES
GDP PER GDP PER CAPITA (PPP CAPITA (PPP US$)US$)
LIFE LIFE EXPECTANCY AT EXPECTANCY AT BIRTH (MALES)BIRTH (MALES)
SRI LANKASRI LANKA 3,5703,570 67.267.2
COSTA RICACOSTA RICA 8,8408,840 74.874.8
RUSSIARUSSIA 8,2308,230 58.358.3
CHILECHILE 9,8209,820 73.473.4
Source: Human Development Report 2004 and World Health Report 2004
HUMAN FLOURISHINGHUMAN FLOURISHING
AUTONOMY SOCIAL PARTICIPATION
HEALTH
Published by Holt2004
Basic needsBasic needs
Action as if people matteredAction as if people mattered
Health as the driverHealth as the driver
‘‘Causes of the causes’Causes of the causes’
Putting it into actionPutting it into action
Presentation Outline
THE SOLID FACTS: THE SOLID FACTS: 10 MESSAGES10 MESSAGES
THE SOCIAL THE SOCIAL GRADIENTGRADIENT
STRESSSTRESS
EARLY LIFEEARLY LIFE
SOCIAL EXCLUSIONSOCIAL EXCLUSION
WORKWORK
UNEMPLOYMENTUNEMPLOYMENT
SOCIAL SUPPORTSOCIAL SUPPORT
ADDICTIONADDICTION
FOODFOOD
TRANSPORTTRANSPORT
Basic needsBasic needs
Action as if people matteredAction as if people mattered
Health as the driverHealth as the driver
‘‘Causes of the causes’Causes of the causes’
Putting it into actionPutting it into action
Presentation Outline
CHILE: Social programmes for CHILE: Social programmes for healthhealth
Chile SolidarioChile Solidario
Child development and well-beingChild development and well-being
Family-focussed primary health careFamily-focussed primary health care
Basic needsBasic needs
Action as if people matteredAction as if people mattered
Health as the driverHealth as the driver
‘‘Causes of the causes’Causes of the causes’
Putting it into actionPutting it into action
Presentation Outline
then send them back to the conditions that made them
sick?
What good does it do to treat people's What good does it do to treat people's illnesses ...illnesses ...
Early LifeEarly Life
The effects of early The effects of early development last a life-time: a development last a life-time: a good start in life means good start in life means supporting mothers and young supporting mothers and young children.children.
YOUTH LITERACY SCORES (16-YOUTH LITERACY SCORES (16-25 YEARS) AND PARENTS’ 25 YEARS) AND PARENTS’
EDUCATIONEDUCATION
-1.5
-1
-0.5
0
0.5
1
1.5
6 7 8 9 10 11 12 13 14 15 16 17 19
Sweden
Canada
US
Parents’ Education (years)
Literacy Scores
Willms 1999
AddictionAddiction
Individuals turn to alcohol, Individuals turn to alcohol, drugs and tobacco and suffer drugs and tobacco and suffer from their use. Use is from their use. Use is influenced by the wider social influenced by the wider social setting.setting.
COMPARISON OF SMOKING PREVALENCE BETWEEN LOW COMPARISON OF SMOKING PREVALENCE BETWEEN LOW AND HIGH SOCIOECONOMIC GROUPSAND HIGH SOCIOECONOMIC GROUPS
01
23
45
67
89
10
India(Delhi)
China Brazil Cuba SouthAfrica
Hungary
SMOKING RATE RATIOBETWEEN LOW AND HIGHSOCIOECONOMIC GROUPS
Bobak et al in ‘Tobacco control in developing countries’ ed: Jha & Chaloupka, 2000
Food Food
Healthy food is a political Healthy food is a political issue.issue.
OBESITY PATTERNS ACROSS OBESITY PATTERNS ACROSS THE DEVELOPING WORLDTHE DEVELOPING WORLD
35.2 32.1 26.636 37.9
19.4 26.7
24.4
6.4 12.412.4
32.1
6
31.8
01020304050607080
Mexicomales
Brazilmales
Brazilfemales
Egyptmales
Egyptfemales
S. Africamales
S. Africafemales
25<BMI<30 BMI>30
(Popkin, Development Policy Review, 2003)
%
TransportTransport
Healthy transport means Healthy transport means reducing driving and reducing driving and encouraging more walking and encouraging more walking and cycling, backed up by better cycling, backed up by better public transport.public transport.
More than a million people More than a million people worldwide are killed in road crashes worldwide are killed in road crashes
every yearevery year
Low and middle-Low and middle-income countries income countries account for 86% of account for 86% of the world’s road the world’s road deaths but have only deaths but have only 40% of the world’s 40% of the world’s motor vehicles.motor vehicles.
INCOME?INCOME?
Kerala and other Indian states compared.Infant Infant mortalitymortality/1000 /1000 birthsbirths
Female Female literacy literacy (%)(%)
Females Females married married <18<18
Villages Villages with with medical medical facilitiesfacilities
IncomeIncome($1985)($1985)
KeralaKerala 1717 6666 33 9696 11441144
GujaratGujarat 7272 3131 44 2828 16011601
Tamil Tamil NaduNadu
5959 3636 99 3333 13831383
Madyha PMadyha P 111111 1515 3131 66 11051105
RajasthanRajasthan 8484 1111 3535 1717 11421142
““RELATIVE DEPRIVATIONRELATIVE DEPRIVATION IN IN
THE SPACE OF THE SPACE OF INCOMESINCOMES CAN CAN
YIELD YIELD ABSOLUTEABSOLUTE DEPRIVATION DEPRIVATION
IN THE SPACE OF IN THE SPACE OF CAPABILITIESCAPABILITIES””
Amartya Sen, Inequality Re-examined, 1992Amartya Sen, Inequality Re-examined, 1992
LEADERSHIP IS NEEDED TO MAKE A LEADERSHIP IS NEEDED TO MAKE A DIFFERENCEDIFFERENCE
Action taken by European Action taken by European CountriesCountries
taxation, tax creditstaxation, tax credits social welfaresocial welfare– old age pensionold age pension– sickness/rehabilitation benefitssickness/rehabilitation benefits– maternity/ child benefitsmaternity/ child benefits– unemployment benefits unemployment benefits housing policy, housing benefits housing policy, housing benefits labour marketslabour markets communitiescommunities care facilitiescare facilities
IK Crombie, et al., 2004
Participationin
society
Economicand socialsecurity
Conditions inchildhood
and adolescence
Healthierworking
life
Environmentsand
products
Health promoting medical
care
Prevention communicable
disease
Sexualhealth
Physical activity
EatingSafe food
Alcoholdrugs
tobacco
SWEDISH PUBLIC HEALTH POLICY
Early Child DevelopmentEarly Child Development
The effects of early The effects of early development last a life-time: a development last a life-time: a
good start in life requires good start in life requires supporting mothers and young supporting mothers and young
childrenchildren
EFFECTS OF ‘FAMILIAS EN EFFECTS OF ‘FAMILIAS EN ACCION’ IN COLOMBIAACCION’ IN COLOMBIA
Improved nutritional status of children;Improved nutritional status of children;Increases in height and weight in Increases in height and weight in young children (0-4 years);young children (0-4 years);10% Reduction in numbers of children 10% Reduction in numbers of children (0-4 years) with diarrhoea;(0-4 years) with diarrhoea;More children registered for More children registered for growth and development check-upsgrowth and development check-upsIncrease in school enrolment of Increase in school enrolment of children (12 -17 years). children (12 -17 years).
'Oportunidades' Program: Mexico'Oportunidades' Program: Mexico
AimAim:: Improve health, education and nutrition levels in Improve health, education and nutrition levels in poor householdspoor households
Program designProgram design: health prevention including: health talks, : health prevention including: health talks, antenatal and postnatal care, nutritional supplements to antenatal and postnatal care, nutritional supplements to pregnant and lactating womenpregnant and lactating women
CoverageCoverage: 4.24 million poor families: 4.24 million poor families2001 to April 20032001 to April 2003 coverage increased:coverage increased:
Number of pregnant women: 82,000 to 120,000Number of pregnant women: 82,000 to 120,000Number of antenatal care visits: 133,000 to 214,000Number of antenatal care visits: 133,000 to 214,000nutrition supplements for under–two yrs: 48,4000 to 72,7000nutrition supplements for under–two yrs: 48,4000 to 72,7000
"Oportunidades" Program (Mexico)"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
Level of Level of povertypoverty
Differential reduction Differential reduction in Maternal mortalityin Maternal mortality
Differential reduction Differential reduction in Infant mortalityin Infant mortality
Very LowVery Low -1%-1% -2%-2%
LowLow -6%-6% -1%-1%
AverageAverage -24%-24% 1%1%
HighHigh -9%-9% -1%-1%
Very HighVery High -32%-32% -8%-8%
National National AverageAverage -11%-11% -2%-2%
Health SystemsHealth Systems
The organization of health systems The organization of health systems fundamentally contributes to fundamentally contributes to
health outcomeshealth outcomes
Health SystemsHealth SystemsTargeting health care system to local needs in Morogoro and Rufiji areas of Tanzania:
40% reduction in child mortality
Food SecurityFood Security
Hunger is one of the most Hunger is one of the most obvious manifestations of obvious manifestations of
poverty and ill healthpoverty and ill health
Vulnerable Group Development Vulnerable Group Development Program: BangladeshProgram: Bangladesh
AimAim: integrate food and nutrition : integrate food and nutrition security with development and income security with development and income generationgeneration
Target populationTarget population: ultra poor women: ultra poor women
Program designProgram design: monthly allocation of : monthly allocation of wheat in exchange for participating in wheat in exchange for participating in training (in literacy, numeracy, savings training (in literacy, numeracy, savings and nutrition)and nutrition)
(International Food Policy Research Institute, 2004)
Progress can be achieved in Progress can be achieved in short time periodsshort time periods
LIFE EXPECTANCY
56 yrs
48 yrs
Sri Lanka1946 - 53
South Africa1994-2001
In 7 years
POVERTY
33%
18%
China1990 - 99
PRIMARY SCHOOL ENROLLMENT
89%
46%
Botswana1970 - 85
In 9 years In 15 years
POTABLEWATER
15m
7m
Basic needsBasic needs
Action as if people matteredAction as if people mattered
Health as the driverHealth as the driver
‘‘Causes of the causes’Causes of the causes’
Putting it into actionPutting it into action
Presentation Outline
AdvocacyAdvocacy LearningLearningActionAction
Mutually reinforcing areas of work to achieve these outcomes
Communication/ExchangeCommunication/Exchange
LeadershipLeadership
The CommissionersThe Commissioners
Fran Baum – Professor of Public Health, Flinders University, Fran Baum – Professor of Public Health, Flinders University, AustraliaAustraliaGiovanni Berlinguer – member of the European ParliamentGiovanni Berlinguer – member of the European ParliamentMonique Begin – former Canadian Minister of National Health Monique Begin – former Canadian Minister of National Health and Welfareand WelfareMirai Chatterjee – Coordinator of Social Security for India’s Mirai Chatterjee – Coordinator of Social Security for India’s Self-employed Women’s AssociationSelf-employed Women’s AssociationManuel Dayrit – Secretary of Health of the PhilippinesManuel Dayrit – Secretary of Health of the PhilippinesBill Foege – Emeritus Presidential DistinguishedProfessor of Bill Foege – Emeritus Presidential DistinguishedProfessor of International Health, Emory University and Gates Fellow International Health, Emory University and Gates Fellow Kiyoshi Kurokawa – President of the Science Council of Kiyoshi Kurokawa – President of the Science Council of Japan and the Pacific Science AssociationJapan and the Pacific Science AssociationRicardo Lagos – President of Chile Ricardo Lagos – President of Chile
The Commissioners The Commissioners
Stephen Lewis – UN special envoy for HIV/AIDS in AfricaStephen Lewis – UN special envoy for HIV/AIDS in AfricaSeyed Marandi – Former Minister of Health in IranSeyed Marandi – Former Minister of Health in IranMichael Marmot (chair) – Director of International Centre Michael Marmot (chair) – Director of International Centre for Health and Society, UCL for Health and Society, UCL Charity Ngilu – Minister of Health, KenyaCharity Ngilu – Minister of Health, KenyaHoda Rashad – Director, Social Research Center of the Hoda Rashad – Director, Social Research Center of the American University in CairoAmerican University in CairoDavid Satcher – President of Morehouse School of David Satcher – President of Morehouse School of Medicne, former US Surgeon GeneralMedicne, former US Surgeon GeneralAmartya Sen – Nobel Laureate, Lamont Professor, Amartya Sen – Nobel Laureate, Lamont Professor, University of HarvardUniversity of HarvardAnna Tibaijuka – Executive Director of UN-HABITATAnna Tibaijuka – Executive Director of UN-HABITATDenny Vagero – Professor of Medical Sociology, Director Denny Vagero – Professor of Medical Sociology, Director of Centre for Health Equity Studies, Stockholm.of Centre for Health Equity Studies, Stockholm.
Financing Social
Programmes
Diseases of Public
Health Impt
Early childDevelopment + education
Women + Gender
inequities
UrbanSettingsSocial
Exclusion
Employmentconditions
Globalization
Health systems
Measurement
Building Health & Health Equity
KNOWLEDGE NETWORK THEMES
What would success look like?What would success look like?
Knowledge, leadership and debateKnowledge, leadership and debate
ActionAction
Institutional changeInstitutional change
Policy changePolicy change
SOCIAL JUSTICE IMPERATIVESOCIAL JUSTICE IMPERATIVE
HEALTH IS A MARKER OF HOW WELL HEALTH IS A MARKER OF HOW WELL POLICIES MEET HUMAN AND SOCIAL POLICIES MEET HUMAN AND SOCIAL NEEDSNEEDS
‘‘THE SUCCESS OF AN ECONOMY AND THE SUCCESS OF AN ECONOMY AND OF A SOCIETY CANNOT BE SEPARATED OF A SOCIETY CANNOT BE SEPARATED FROM THE LIVES THAT THE MEMBERS FROM THE LIVES THAT THE MEMBERS OF THE SOCIETY ARE ABLE TO LEAD…OF THE SOCIETY ARE ABLE TO LEAD…WE NOT ONLY VALUE LIVING WELL AND WE NOT ONLY VALUE LIVING WELL AND
SATISFACTORILY, BUT ALSO SATISFACTORILY, BUT ALSO APPRECIATE HAVING CONTROL OVER APPRECIATE HAVING CONTROL OVER
OUR OWN LIVES’OUR OWN LIVES’
Amartya Sen, Development as Freedom Amartya Sen, Development as Freedom (1999)(1999)