Healthy CitiesHealth for All

SOCIALDETERMINANTS

OF HEALTH

InternationalCentre

Health andSociety

EUR/ICP/CHVD 03 09 011998

By the year 2000, all settings of social life and activity,such as the city, school, workplace, neighbourhoodand home, should provide greater opportunities forpromoting health.

Abstract

Policy and action for health need to be geared towardsaddressing the social determinants of health in orderto attack the causes of ill health before they can leadto problems. This is a challenging task for bothdecision-makers and public health actors andadvocates. The scientific evidence on socialdeterminants is strong but is discussed mainly byresearchers. This booklet is part of a WHO RegionalOffice for Europe campaign to present the evidence onsocial determinants in a clear and understandableform. The booklet identifies the broad implications forpolicy in ten selected areas. The campaign is meant tobroaden awareness, stimulate debate and promoteaction.

© World Health OrganizationAll rights in this document are reserved by the WHO Regional Officefor Europe. The document may nevertheless be freely reviewed,abstracted, reproduced or translated into any other language (butnot for sale or for use in conjunction with commercial purposes)provided that full acknowledgement is given to the source. For theuse of the WHO emblem, permission must be sought from the WHORegional Office. Any translation should include the words: Thetranslator of this document is responsible for the accuracy of thetranslation. The Regional Office would appreciate receiving threecopies of any translation. Any views expressed by named authors aresolely the responsibility of those authors.

Keywords

PUBLIC HEALTHSOCIOECONOMIC FACTORSSOCIAL ENVIRONMENTSOCIAL SUPPORTHEALTH BEHAVIORHEALTH PROMOTIONHEALTHY CITIESEUROPE

HFA Policy on Europe: Target 14SETTINGS FOR HEALTH PROMOTION

ISBN 92–890–1287–0

SOCIALDETERMINANTS

OF HEALTH

Edited by Richard Wilkinson and Michael Marmot

Dr Mel BartleyUniversity College London,United Kingdom

Dr David BlaneCharing Cross and WestminsterMedical School, London,United Kingdom

Dr Eric BrunnerUniversity College London,United Kingdom

Dr Danny DorlingGeography Department,Bristol University,United Kingdom

Ms Jane FerrieUniversity College London,United Kingdom

Dr Martin JarvisImperial Cancer Research FundHealth Behaviour Unit,University College London,United Kingdom

Professor Michael MarmotUniversity College London,United Kingdom

Contributors

Professor Mark McCarthyUniversity College London,United Kingdom

Dr Mary ShawGeography Department,Bristol University,United Kingdom

Professor Aubrey SheihamUniversity College London,United Kingdom

Dr Stephen StansfeldUniversity College London,United Kingdom

Professor Mike WadsworthMedical Research CouncilNational Survey ofHealth and Development,University College London,United Kingdom

Professor Richard WilkinsonUniversity of Sussex, Brighton,and University College London,United Kingdom

Contributors 2

Foreword 4

Preface 5

Introduction 6

1. The social gradient 8

2. Stress 10

3. Early life 12

4. Social exclusion 14

5. Work 16

6. Unemployment 18

7. Social support 20

8. Addiction 22

9. Food 24

10. Transport 26

Contents

A call to decision-makers and public healthprofessionals to address the social determinantsof health should rest on clear evidence. Mostpeople have an intuitive understanding of thepositive and negative effects of living andworking conditions on their health. Althoughthere is no shortage of legitimizing evidence, thedebate on the social determinants of healthcontinues to be limited mainly to academic fora.The recent history of public health can showmany examples of inexcusable inaction, evenwhen the facts are unequivocal, as in the case oftobacco. It is disturbing that the tobacco industryfinally admitted that smoking is addictive only ayear ago. The lack of sufficient action againsttobacco was often blamed on the lack of boldlypresented evidence.

Recognizing the health impact of economic andsocial policies and conditions could have far-reaching implications for the way society makesdecisions about development, and it couldchallenge the values and principles on whichinstitutions are built and progress is measured.The good news is that decision-makers at alllevels increasingly recognize the need to invest inhealth and sustainable development. To do this,they need clear facts as much as they needstrategic guidance and policy tools. Nobodyexpects science to be black or white, but it mustbe accessible, creating opportunities for debateand informed decision-making.

At the WHO Regional Office for Europe, theCentre for Urban Health, in close partnership withthe Communication and Public Affairs and the

new European Health Communication Network,have, has embarked on a campaign to promoteawareness, debate and action on the socialdeterminants of health. The campaign aims atreaching the widest possible audiences of publichealth advocates and professionals, communityactivists and decision-makers. The campaign willdevelop and employ materials that are attractiveand easy to read and translate. A principal vehiclefor the promotion of the campaign throughoutthe European Region will be the networks of theWHO Healthy Cities project. The timing of thiseffort is excellent, as it coincides with thelaunching of the renewed strategy health for allfor the twenty-first century, the launching ofphase III (1998–2002) of the Healthy Cities projectand the increasing commitment of a number ofcities to local Agenda 21.

The backbone of the campaign is the provision ofup-to-date information on the key areas of socialdeterminants, in a concise, clear and authoritativeform. This was achieved through closepartnership between WHO and the InternationalCentre for Health and Society, University CollegeLondon, United Kingdom. I should like to expressmy gratitude to Professor Michael Marmot andProfessor Richard Wilkinson, who coordinated thepreparation and edited the materials for thisbooklet. The drafting process consisted of a seriesof brainstorming sessions and consultations. Ishould like to thank all the members of thescientific team who contributed to this excellentpiece of work. I am convinced that the bookletwill be a valuable tool for understanding anddealing with social determinants.

FOREWORD

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Translating scientific evidence into policy andaction is always a complex process. It isparticularly difficult when the implications foraction may change the way we think aboutpolicies that affect health. Governments anddecision-makers have taken over half ageneration to recognize and begin to addresssocial inequalities in health.

Today, scientific knowledge on the socialdeterminants of health is accumulating quickly.The need to direct our efforts there has becomeincreasingly clear. This means “up-streaming”public health, spreading awareness of andpromoting debate on social determinants.

The International Centre for Health and Society iscommitted to research on the social determinantsof health and translating research findings into aform that is useful to policy-makers and thepublic. This WHO campaign is a most welcomeopportunity to contribute to the challenging taskof promoting healthy public policies.

Sir Donald AchesonChairman, International Centre forHealth and SocietyUniversity College London

A special word of thanks is due to Dr JillFarrington, WHO consultant and focal point forthe social determinants campaign, for her creativeideas and valuable editorial input and for ensuringgood communications with the Centre. Manythanks are due to Ms Patricia Crowley,administrator the International Centre for Healthand Society, for the efficient and effective wayshe monitored all the stages of the preparation ofthe scientific papers. Finally, a word of thanks toMary Stewart Burgher, who edited the text of thebooklet on a short deadline.

Dr Agis TsourosHead, Centre for Urban HealthWHO Regional Office for Europe

PREFACE

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Even in the richest countries, the better off liveseveral years longer and have fewer illnesses thanthe poor. These differences in health are animportant social injustice, and reflect some of the

INTRODUCTION

most powerful influences on health in themodern world. People's lifestyles and theconditions in which they live and work stronglyinfluence their health and longevity.

People's lifestyles and the conditions in which they live and work strongly influence their health.

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Medical care can prolong survival after someserious diseases, but the social and economicconditions that affect whether people become illare more important for health gains in thepopulation as a whole. Poor conditions lead topoorer health. An unhealthy materialenvironment and unhealthy behaviour have directharmful effects, but the worries and insecuritiesof daily life and the lack of supportiveenvironments also have an influence.

This booklet discusses ten different butinterrelated aspects of the social determinants ofhealth. They explain:

1. the need for policies to prevent peoplefrom falling into long-termdisadvantage;

2. how the social and psychologicalenvironment affects health;

3. the importance of ensuring a goodenvironment in early childhood;

4. the impact of work on health;5. the problems of unemployment and job

insecurity;6. the role of friendship and social

cohesion;7. the dangers of social exclusion;8. the effects of alcohol and other drugs;9. the need to ensure access to supplies of

healthy food for everyone; and10. the need for healthier transport

systems.

Together the messages provide the keys to higherstandards of population health in the developedindustrial countries of Europe. These messagesare intended to point out how social andeconomic factors at all levels in society affectindividual decisions and health itself. Each personis responsible for ensuring that he or she eats ahealthy diet, gets enough exercise and avoidssmoking and excessive drinking. Nevertheless, wenow know the importance to health of social andeconomic circumstances that are often beyondindividual control. The booklet is thereforeintended to ensure that policy – at all levels ingovernment, public and private institutions,workplaces and the community – takes properaccount of the wider responsibility for creatingopportunities for health. The booklet thereforeprovides information on the social and economicenvironment that is conducive to higher standardsof health in the population.

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People’s social and economiccircumstances strongly affect theirhealth throughout life, so health policymust be linked to the social andeconomic determinants of health.

The evidencePoor social and economic circumstances affecthealth throughout life. People further down thesocial ladder usually run at least twice the risk ofserious illness and premature death of those nearthe top. Between the top and bottom, healthstandards show a continuous social gradient, soeven junior office staff tend to suffer much moredisease and earlier death than more senior staff.

Most diseases and causes of death are morecommon lower down the social hierarchy. Thesocial gradient in health reflects materialdisadvantage and the effects of insecurity, anxietyand lack of social integration.

Disadvantage has many forms and may beabsolute or relative. It can include: having fewfamily assets, having a poorer education duringadolescence, becoming stuck in a dead-end job orhaving insecure employment, living in poorhousing and trying to bring up a family in difficultcircumstances. These disadvantages tend toconcentrate among the same people, and theireffects on health are cumulative. The longerpeople live in stressful economic and socialcircumstances, the greater the physiological wearand tear they suffer, and the less likely they are toenjoy a healthy old age.

BARTLEY, M. ET AL. Healthand the life course: why safetynets matter. British medicaljournal, 314: 1194–1196(1997).

BLANE, D. ET AL. Diseaseetiology and materialistexplanations ofsocioeconomic mortalitydifferentials. European journalof public health, 7: 385–391(1997).

DAVEY SMITH, G. ET AL.Lifetime socioeconomicposition and mortality:prospective observationalstudy. British medical journal,314: 547–552 (1997).

THE SOCIAL GRADIENT

Policy implicationsLife contains a series of critical transitions:emotional and material changes in earlychildhood, the move from primary to secondaryeducation, starting work, leaving home andstarting a family, changing jobs and facingpossible redundancy, and eventually retirement.Each of these changes can affect health bypushing people onto a more or less advantagedpath.

People who have been disadvantaged in the pastare at the greatest risk in each transition. Thismeans that welfare policies need to provide not

MONTGOMERY, S. ET AL.Health and social precursorsof unemployment in youngmen in Britain. Journal ofepidemiology and communityhealth, 50: 415–422 (1996).

WUNCH, G. ET AL.Socioeconomic differences inmortality: a life courseapproach. European journalof population, 12: 167–185(1996).

KEY SOURCES

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only safety nets but also springboards to offsetearlier disadvantage.

Good health involves reducing levels ofeducational failure, the amount of job insecurityand the scale of income differences in society. Weneed to ensure that fewer people fall and that

Poor social and economic circumstances affect health throughout life.

they fall less far. Policies for education,employment and housing affect health standards.Societies that enable all their citizens to play a fulland useful role in the social, economic andcultural life of their society will be healthier thanthose where people face insecurity, exclusion anddeprivation.

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Stress harms health.

The evidenceSocial and psychological circumstances can causelong-term stress. Continuing anxiety, insecurity,low self-esteem, social isolation and lack ofcontrol over work and home life have powerfuleffects on health. Such psychosocial risks

accumulate during life and increase the chancesof poor mental health and premature death. Longperiods of anxiety and insecurity and the lack ofsupportive friendships are damaging in whateverarea of life they arise.

How do these psychosocial factors affect physicalhealth? In emergencies, the stress response

STRESS

Lack of control over work and home can have powerful effects on health.

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KEY SOURCES

BRUNNER, E.J. Stress and thebiology of inequality. Britishmedical journal, 314: 1472–1476 (1997).

KARASEK, R.A. & THEORELL,T. Healthy work: stress,productivity and thereconstruction of working life.New York, Basic Books, 1990.

MARMOT, M.G. Does stresscause heart attacks?Postgraduate medical journal,62: 683–686. (1986)

MARMOT, M.G. ET AL.Contribution of job controland other risk factors to socialvariations in coronary heartdisease. Lancet, 350: 235–239 (1997).

SAPOLSKY, R.M. & MOTT, G.E.Social subordinance in wildbaboons is associated withsuppressed high densitylipoprotein-cholesterolconcentrations: the possiblerole of chronic social stress.Endocrinology, 121: 1605–1610 (1987).

SHIVELY, C.A. & CLARKSON,T.B. Social status and coronaryartery atherosclerosis infemale monkeys.Arteriosclerosis thrombosis,14: 721–726 (1994).

activates a cascade of stress hormones that affectthe cardiovascular and immune systems. Ourhormones and nervous system prepare us to dealwith an immediate physical threat by raising theheart rate, diverting blood to muscles andincreasing anxiety and alertness. Nevertheless,turning on the biological stress response toooften and for too long is likely to carry multiplecosts to health. These include depression,increased susceptibility to infection, diabetes, anda harmful pattern of cholesterol and fats in theblood, high blood pressure and the attendantrisks of heart attack and stroke.

Humans and various non-human primates studiedin the wild and in captivity have similarmechanisms for dealing with psychosocial stress.Studies of primates show that subordinateanimals are more likely than socially dominantanimals to suffer from clogged blood vessels andother changes in their metabolism. In humans,such changes are linked to a higher risk ofcardiovascular disease. The lower people are inthe social hierarchy of industrialized countries, themore common these health problems become.

Policy implicationsA medical response to the biological changes thatcome with stress might be to try to control themwith drugs. But attention should be focusedupstream, on tackling the causes of ill health.

In schools, businesses and other institutions, thequality of the social environment and materialsecurity are often as important to health as thephysical environment. Institutions that can give

people a sense of belonging and of being valuedare likely to be healthier places than those inwhich people feel excluded, disregarded andused.

Governments should recognize that welfareprogrammes need to address both psychosocialand material needs: both are sources of anxietyand insecurity. In particular, governments shouldsupport families with young children, encouragecommunity activity, combat social isolation,reduce material and financial insecurity, andpromote coping skills in education andrehabilitation.

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The effects of early development last alife-time; a good start in life meanssupporting mothers and young children.

The evidenceImportant foundations of adult health are laid inprenatal life and early childhood. Slow growthand a lack of emotional support during thisperiod raise the life-time risk of poor physicalhealth and reduce physical, cognitive andemotional functioning in adulthood. Poor social

and economic circumstances present the greatestthreat to a child’s growth, and launch the child ona low social and educational trajectory.

Acting through poor or inappropriatenourishment of the mother and throughsmoking, parental poverty can reduce prenataland infant development. Slow early growth isassociated with reduced cardiovascular,respiratory, kidney and pancreatic functioning inadulthood. Parents’ smoking impedes the child’s

EARLY LIFE

Important foundations of adult health are laid in early childhood.

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KEY SOURCES

BARKER, D.J.P. Mothers, babiesand disease in later life.London, BMJ Publishing Group,1994.

BARKER, W. ET AL. Childprotection: the impact of thechild development programme.Bristol, Early ChildhoodDevelopment Unit, Universityof Bristol, 1992.

HERTZMAN, C. & WIENS, M.Child development and long-term outcomes: a populationhealth perspective andsummary of successfulinterventions. Social scienceand medicine, 43: 1083 (1996)

KUH, D. & BEN-SHLOMO, Y. Alife course approach to chronicdisease epidemiology. Oxford,Oxford University Press, 1997.

ROBINS, L. & RUTTER, M., ED.Straight and deviouspathways from childhood toadulthood. Cambridge,Cambridge University Press,1990.

TAGER, I.B. ET AL.Longitudinal study of theeffects of maternal smokingon pulmonary function inchildren. New England journalof medicine, 309: 699 (1983).

SCHWEINHART, L.J. ET AL.Significant benefits: the High/Scope Perry Preschool Studythrough age 27. Ypsilanti, TheHigh Scope Press, 1993.

respiratory development; this decreasesrespiratory functioning and thus increasesvulnerability in the adult.

Poor nutrition and physical developmentadversely affect the child’s cognitivedevelopment. In addition, the mental exhaustionand depression associated with poverty reducethe parents’ stimulation of the child, and candisrupt emotional attachment.

Parental poverty starts a chain of social risk. Itbegins in childhood with reduced readiness for

and acceptance of school, goes on to poorbehaviour and attainment at school, and leads toa raised risk of unemployment, perceived socialmarginality and to low-status, low-control jobs inadult life. This pattern of poor education andemployment damages health and, ultimately,cognitive functioning in old age.

Policy implicationsNew action is needed to foster health anddevelopment early in life, particularly amongpeople in poor social and economiccircumstances. Policy should aim to:

1. reduce parents' smoking;2. increase parents' knowledge of health and

understanding of children's emotional needs;3. introduce pre-school programmes not only to

improve reading and stimulate cognitivedevelopment but also to reduce behaviourproblems in childhood and promoteeducational attainment, occupational chancesand healthy behaviour in adulthood;

4. involve parents in such pre-school programmesto reinforce their educational effects andreduce child abuse;

5. ensure that mothers have adequate social andeconomic resources; and

6. increase opportunities for educationalattainment at all ages, since education isassociated with raised health awareness andimproved self-care.

Investment in these policies would greatly benefitthe health and working capacity of the futureadult population.

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Social exclusion creates misery and costslives.

The evidenceProcesses of social exclusion and the extent ofrelative deprivation in a society have a majorimpact on health and premature death. The harmto health comes not only from materialdeprivation but also from the social andpsychological problems of living in poverty.

Poverty, unemployment and homelessness haveincreased in many countries, including some ofthe richest. In some countries, as much as onequarter of the total population – and a higherproportion of children – live in relative poverty(defined by the European Union as less than halfthe national average income). Relative poverty, aswell as absolute poverty, leads to worse healthand increased risks of premature death. Peoplewho have lived most of their lives in poverty sufferparticularly bad health.

Migrants from other countries, ethnic minoritygroups, guest workers and refugees areparticularly vulnerable to social exclusion, andtheir children are likely to be at special risk. Theyare sometimes excluded from citizenship andoften from opportunities for work and education.The racism, discrimination and hostility that theyoften face may harm their health.

In addition, communities are likely to marginalizeand reject people who are ill, disabled oremotionally vulnerable, such as former residentsof children’s homes, prisons and psychiatric

SOCIAL EXCLUSION

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KEY SOURCEShospitals. Those with physical or mental healthproblems often have difficulty gaining anadequate education or earning a living. Disabledchildren are most likely to live in poverty.Stigmatizing conditions such as mental illness,physical disability or diseases such as AIDS makesmatters worse. People living on the streets, whomay suffer a combination of these problems,suffer the highest rates of premature death.

Societies that pursue more egalitarian policiesoften have faster rates of economic growth andhigher standards of health.

Implications for policyA variety of actions at a number of different levelsis needed to tackle the health effects of socialexclusion. These include the following.

1. Legislation can help protect the rights ofmigrants and minority groups, and preventdiscrimination.

2. Public health interventions should removebarriers to access to health care, social servicesand affordable housing.

3. Income support, adequate national minimumwages and educational and employmentpolicies are needed to reduce social exclusion.

4. Income and wealth should be redistributed toreduce material inequalities and the scale ofrelative poverty; more egalitarian societies tendto have higher standards of health.

POWER, C. Health andsocial inequality in Europe.British medical journal,309: 1153–1160 (1994).

SIEM, H. Migration andhealth - the internationalperspective. SchweizerischeRundschau fur MedizinPraxis, 86(19): 788–793(1997).

WALKER, R. Poverty andsocial exclusion in Europe.In: Walker, A. & Walker, C.,ed. Britain divided: thegrowth of social exclusionin the 1980s and 1990s.London, Child PovertyAction Group, 1997.

WILKINSON, R.G.Unhealthy societies: theafflictions of inequality.London, Routledge, 1996.

VAN DOORSLAER E. ET AL.Income-related inequalitiesin health: someinternational comparisons.Journal of healtheconomics, 16: 93–112(1997).

People living on the streetssuffer the highest rates ofpremature death.

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Stress in the workplace increases therisk of disease.

The evidenceEvidence shows that stress at work plays animportant role in contributing to the largedifferences in health, sickness absence andpremature death that are related to social status.

Several workplace studies in Europe show thathealth suffers when people have little opportunityto use their skills, and low authority overdecisions.

Having little control over one’s work is particularlystrongly related to an increased risk of low backpain, sickness absence and cardiovascular disease.

WORK

Jobs with both high demand and low control carry special risk.

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KEY SOURCES

These risks have been found to be independent ofthe psychological characteristics of the peoplestudied. In short, they seem to be related to thework environment.

Studies have also examined the role of demandsat work. Some show an interaction betweendemands and control. Jobs with both highdemand and low control carry special risk. Someevidence indicates that social support in theworkplace may reduce this effect.

Further, receiving inadequate rewards for theeffort put into work has been found to be

BOSMA, H. ET AL. Low jobcontrol and risk of coronaryheart disease in Whitehall II(prospective cohort) study.British medical journal, 314:558–565 (1997).

JOHNSON, J.V. Conceptualand methodologicaldevelopments in occupationalstress research inoccupational stress research:an introduction to state-of-the-art reviews. Journal ofoccupational healthpsychology, 1: 6–8 (1996).

KARASEK, R.A. & THEORELL, T.Healthy work: stress,productivity and thereconstruction of working life.New York, Basic Books, 1990.

associated with increased cardiovascular risk.Rewards can take the forms of money, status andself-esteem. Current changes in the labour marketmay change the opportunity structure, and make itharder for people to get appropriate rewards.

These results suggest that the psychosocialenvironment at work is an important contributor tothe social gradient in ill health.

Policy implications1. There is no trade-off between health and

productivity at work. A virtuous circle can beestablished: improved conditions of work willlead to a healthier work force; this will lead toimproved productivity, and hence to theopportunity to create a still healthier moreproductive workplace.

2. Appropriate involvement in decision-making islikely to benefit employees at all levels of anorganization.

3. Redesigning practices in offices and otherworkplaces – to enable employees to have morecontrol, greater variety and more opportunitiesfor development at work –benefits health.

4. Work that does not provide appropriate rewards– in terms of money, self-esteem and status –damages health.

5. To reduce the burden of musculoskeletaldisorders, workplaces must be appropriateergonomically as well as in the organization ofwork.

SIEGRIST, J. Adverse healtheffects of high-effort/low-reward conditions. Journal ofoccupational healthpsychology, 1: 27–41(1996).

THEORELL, T. & KARASEK,R.A. Current issues relating topsychosocial job strain andcardiovascular diseaseresearch. Journal ofoccupational healthpsychology, 1: 9–26 (1996).

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KEY SOURCES

Job security increases health, wellbeingand job satisfaction.

The evidenceUnemployment puts health at risk, and the risk ishigher in regions where unemployment iswidespread. Evidence from a number of countriesshows that, even after allowing for other factors,unemployed people and their families suffer asubstantially increased risk of premature death.The health effects of unemployment are linked toboth its psychological consequences and financialproblems, especially debt.

The effects start when people first feel their jobsare threatened, even before they actually becomeunemployed. This shows that anxiety aboutinsecurity is also detrimental to health. Jobinsecurity has been shown to increase effects onmental health (particularly anxiety anddepression), self-reported ill health, heart diseaseand risk factors for heart disease. Becauseunsatisfactory or insecure jobs can be as harmfulas unemployment, merely having a job cannotprotect physical or mental health. Job quality isimportant.

During the 1990s, changes in the economies andlabour markets of industrialized countries haveincreased feelings of job insecurity. As jobinsecurity continues, it acts as a chronic stressorwhose effects increase with the length ofexposure; it increases sickness absence and healthservice use.

Policy implicationsPolicy should have three goals:

• preventing unemployment and job insecurity;• reducing the hardship suffered by the

unemployed; and• restoring people to secure jobs.

Government management of the economy, toreduce the highs and lows of the business cycle,can make an important contribution to jobsecurity and the reduction of unemployment.Limitations on working hours may also be

UNEMPLOYMENT

BEALE, N. & NETHERCOTT, S.Job-loss and family morbidity:a study of a factory closure.Journal of the Royal Collegeof General Practitioners, 35:510–514 (1985).

BETHUNE, A. Unemploymentand mortality. In: Drever, F. &Whitehead, M., ed. Healthinequalities. London, H.M.Stationery Office, 1997.

BURCHELL, B. The effects oflabour market position, jobinsecurity, and unemploymenton psychological health. In:Gallie, D. et al., ed. Socialchange and the experience ofunemployment. Oxford,Oxford University Press, 1994,pp. 188–212.

FERRIE, J. ET AL., ED. Labourmarket changes and jobinsecurity: a challenge forsocial welfare and healthpromotion. Copenhagen,WHO Regional Office forEurope (in press) (WHORegional Publications,European Series, No. 81).

IVERSEN, L. ET AL.Unemployment and mortalityin Denmark. British medicaljournal, 295: 879–884(1987).

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beneficial, if they are pursued alongside jobsecurity and satisfaction.

To equip people for the work available, highstandards of education and good retraining

Unemployed people and their families suffer a much higher risk of premature death.

schemes are important. For those out of work,unemployment benefits set at a higher proportionof wages are likely to have a protective effect.Further, credit unions may be beneficial byreducing debts and increasing social networks.

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Friendship, good social relations andstrong supportive networks improvehealth at home, at work and in thecommunity.

The evidenceSocial support and good social relations make animportant contribution to health. Social supporthelps give people the emotional and practical

SOCIAL SUPPORT

Belonging to a social network makes people feel cared for.

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KEY SOURCES

BERKMAN, L.F. & SYME, S.L.Social networks, hostresistance and mortality: anine year follow-up ofAlameda County residents.American journal ofepidemiology, 109: 186–204(1979).

KAPLAN, G.A. ET AL. Socialconnections and mortalityfrom all causes and fromcardiovascular disease:prospective evidence fromeastern Finland. Americanjournal of epidemiology, 128:370–380 (1988).

Access to emotional and practical social supportvaries by social and economic status. Poverty cancontribute to social exclusion and isolation.

Social cohesion – the existence of mutual trustand respect in the community and wider society –helps to protect people and their health. Societieswith high levels of income inequality tend to haveless social cohesion, more violent crime andhigher death rates. One study of a communitywith high levels of social cohesion showed lowrates of coronary heart disease, which increasedwhen social cohesion in the community declined.

Policy implicationsExperimental studies suggest that good socialrelations can reduce the physical response tostress. Interventions in high-risk groups haveshown that providing social support improvesoutcome after heart attacks, longevity in peoplewith some types of cancer and pregnancyoutcome in vulnerable groups of women.

In the community, reducing income inequalitiesand social exclusion can lead to greater socialcohesiveness and better health in the population.Improving the social environment in schools, theworkplace and the community in general will helppeople feel valued and supported in more areasof their lives and will contribute to their health,especially mental health. In all areas of personaland institutional life, practices should be avoidedthat cast others as socially inferior or less valuable;they are divisive.

resources they need. Belonging to a socialnetwork of communication and mutualobligation makes people feel cared for, loved,esteemed and valued. This has a powerfulprotective effect on health.

Support operates on the levels of both theindividual and the society. Social isolation andexclusion are associated with increased rates ofpremature death and poorer chances of survivalafter a heart attack. People who get lessemotional social support from others are morelikely to experience less wellbeing, moredepression, a greater risk of pregnancycomplications and higher levels of disability fromchronic diseases. In addition, the bad aspects ofclose relationships can lead to poor mental andphysical health.

KAWACHI, I. ET AL. Aprospective study of socialnetworks in relation to totalmortality and cardiovasculardisease in men in the USA.Journal of epidemiology andcommunity health, 50(3):245–251 (1996).

OXMAN, T.E. ET AL. Socialsupport and depressivesymptoms in the elderly.American journal ofepidemiology, 135: 356–368(1992).

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Individuals turn to alcohol, drugs andtobacco and suffer from their use, butuse is influenced by the wider socialsetting.

The evidenceDrug use is both a response to social breakdownand an important factor in worsening theresulting inequalities in health. It offers users a

ADDICTION

People turn to alcohol, drugs and tobacco to numb the pain of harsh economic and social conditions.

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KEY SOURCES

MAKELA, P. ET AL.Contribution of deathsrelated to alcohol use ofsocioeconomic variation inmortality: register basedfollow up study. Britishmedical journal, 315 : 211–216 (1997).

MARKOV, K.V. ET AL.Incidence of alcohol drinkingand the structure of causes ofdeath in men 40-54 years ofage. SovetskoeZdravookhranenie, 4: 8–15(1990).

MARSH, A. & MCKAY, S. Poorsmokers. London, PolicyStudies Institute, 1994.

MELTZER, H. ET AL. Economicactivity and social functioningof adults with psychiatricdisorders. London, H.M.Stationery Office, 1996 (OPCSSurveys of PsychiatricMorbidity in Great Britain,Report 3).

RYAN, M. Alcoholism andrising mortality in the RussianFederation. British medicaljournal, 310: 646–648 (1995).

mirage of escape from adversity and stress, butonly makes their problems worse.

Alcohol dependence, illicit drug use and cigarettesmoking are all closely associated with markers ofsocial and economic disadvantage. In the RussianFederation, for example, the past decade hasbeen a time of great social upheaval. Deathslinked to alcohol use – from accidents, violence,poisoning, injury and suicide – have risen sharply.Alcohol dependence and violent death areassociated in other countries too.

The causal pathway probably runs both ways.People turn to alcohol to numb the pain of harsheconomic and social conditions, and alcoholdependence leads to downward social mobility.The irony is that, apart from a temporary releasefrom reality, alcohol intensifies the factors that ledto its use in the first place.

The same is true of tobacco. Social deprivation –as measured by any indicator: poor housing, lowincome, lone parenthood, unemployment orhomelessness – is associated with high rates ofsmoking and very low rates of quitting. Smokingis a major drain on poor people’s incomes and ahuge cause of ill health and premature death. Butnicotine offers no real relief from stress orimprovement in mood.

Policy implicationsWork to deal with drug problems needs not onlyto support and treat people who have developedaddictive patterns of use but also to address thepatterns of social deprivation in which the

problems are rooted. Policies need to regulateavailability through pricing and licensing, forinstance, to inform people about less harmfulforms of use, to use health education to reducerecruitment of young people and to provideeffective treatment services for addicts.

None of these will succeed if the social factorsthat breed drug use are left unchanged. Trying toshift the whole responsibility on to the user is aclearly inadequate response. This blames thevictim, rather than addressing the complexities ofthe social circumstances that generate drug use.Effective drug policy must therefore be supportedby the broad framework of social and economicpolicy.

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Healthy food is a political issue.

The evidenceA good diet and adequate food supply are centralfor promoting health and wellbeing. The shortageof food and lack of variety cause malnutrition anddeficiency diseases. Excess intake (also a form ofmalnutrition) contributes to cardiovasculardiseases, diabetes, cancer, degenerative eyediseases, obesity and dental caries. Food povertyexists side by side with food plenty. The importantpublic health issue is the availability and cost ofhealthy, nutritious food. Access to good,affordable food makes more difference to whatpeople eat than health education.

Industrialization brought with it theepidemiological transition from infectious tochronic diseases – particularly heart disease,stroke and cancer. This was associated with anutritional transition, when diets changed tooverconsumption of energy-dense fats andsugars, producing more obesity. At the sametime, obesity became more common among thepoor than the rich.

World food trade is now big business. TheGeneral Agreement on Tariffs and Trade and theCommon Agricultural Policy of the EuropeanUnion allow global market forces to shape thefood supply. International committees such asCodex Alimentarius, which determine foodquality and safety standards, lack public healthrepresentatives, and food industry interests arestrong.

Social and economic conditions result in a socialgradient in diet quality that contributes to healthinequalities. The main dietary difference between

AVERY, N. ET AL. Crackingthe Codex. An analysis ofwho sets world foodstandards. London, NationalFood Alliance, 1993.

COMMITTEE ON MEDICALASPECTS OF FOOD POLICY.Nutritional aspects ofcardiovascular disease.London, H.M. StationeryOffice, 1994.

Diet, nutrition, and theprevention of chronicdiseases. Geneva, WorldHealth Organization, 1990(WHO Technical ReportSeries, No. 797).

STALLONE, D.D. ET AL.Dietary assessment inWhitehall II: the influence ofreporting bias on apparentsocioeconomic variation innutrient intake. Europeanjournal of clinical nutrition,51: 815–825 (1997).

WORLD CANCERRESEARCH FUND. Food,nutrition and the preventionof cancer: a globalperspective. Washington,DC, American Institute forCancer Research, 1997.

FOOD

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social classes is the source of nutrients. The poorsubstitute cheaper processed foods for freshfood. High fat intakes often occur in all social

groups. People on low incomes, such as youngfamilies, elderly people and the unemployed, areleast able to eat well.

Dietary goals to prevent chronic diseasesemphasize eating more fresh vegetables, fruits andpulses (legumes) and more minimally processedstarchy foods, but less animal fat, refined sugarsand salt. More than 100 expert committees haveagreed on these dietary goals.

Policy implicationsLocal, national and international governmentagencies, nongovernmental organizations and thefood industry should ensure:

1. the availability of high-quality, fresh food to all,regardless of their circumstances;

2. democratic decision-making and accountabilityin all food regulation matters, with participationby all stakeholders, including consumers;

3. support for sustainable agriculture and foodproduction methods that conserve naturalresources and the environment;

4. the protection of locally produced foods fromthe inroads of the global food trade;

5. a stronger food culture for health, fosteringpeople’s knowledge of food and nutrition,cooking skills and the social value of preparingfood and eating together;

6. the availability of useful information about food,diet and health; and

7. the use of scientifically based nutrient referencevalues and food-based dietary guidelines tofacilitate the development and implementationof policies on food and nutrition.tion

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Healthy transport means reducingdriving and encouraging more walkingand cycling, backed up by better publictransport.

The evidenceCycling, walking and the use of public transportpromote health in four ways. They provideexercise, reduce fatal accidents, increase socialcontact and reduce air pollution.

Because mechanization has reduced the exerciseinvolved in jobs and house work, people need tofind new ways of building exercise into their lives.This can be done by reducing the reliance on cars,increasing walking and cycling and expandingpublic transport. Regular exercise protects againstheart disease and, by limiting obesity, reduces theonset of diabetes. It promotes a sense ofwellbeing and protects older people fromdepression.

Reducing road traffic would reduce the toll ofroad deaths and serious accidents. Althoughaccidents involving cars injure cyclists andpedestrians, those involving cyclists injurerelatively few people. Well planned urbanenvironments, which separate cyclists andpedestrians from car traffic, increase the safety ofcycling and walking.

More cycling and walking, plus greater use ofpublic transport, would stimulate socialinteraction on the streets, where cars haveinsulated people from each other. Road trafficseparates communities and divides one side of

the street from the other. Fewer pedestrians meanthat streets cease to be social spaces, so thatisolated pedestrians often fear attack. Further,suburbs that depend on cars for access isolatepeople without cars, particularly the young andold. Social isolation and lack of communityinteraction are strongly associated with poorerhealth.

Reduced road traffic means decreasing harmfulpollution from exhaust. Walking and cycling makeminimal use of non-renewable fuels and do notlead to global warming. They do not createdisease from air pollution, make little noise andare preferable for the ecologically compact citiesof the future. Bicycles, which can bemanufactured locally, have a good “ecologicalfootprint” – in contrast to cars.

Policy implicationsDespite their health-damaging effects, journeysby car are rising rapidly in all European countries,while journeys by foot or bicycle are falling.National and local public policies must reversethese trends. Yet transport lobbies have strongvested interests. Many industries – oil, rubber,road building, car manufacturing, sales andrepairs, and advertising – benefit from the use ofcars. Just as the twentieth century has seen a startmade on reducing addiction to tobacco, alcoholand drugs, so the twenty-first century must see areduction in people’s dependence on cars.

Roads should give precedence to cycling andwalking for short journeys, especially in towns.Public transport should be improved for longer

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journeys, with regular and frequent connectionsfor rural areas. Incentives need to be changed;this means, for example, reducing state subsidiesfor road building, increasing financial support forpublic transport, creating tax disincentives for thebusiness use of cars and increasing the costs andpenalties of parking. Changes in land use are alsoneeded, such as: converting road space into greenspaces, removing car parking spaces, dedicatingroads to the use of pedestrians and cyclists,increasing bus and cycle lanes, and stopping thegrowth of low-density suburbs and out-of-townsupermarkets, which increase the use of cars.Increasingly, the evidence suggests that buildingmore roads encourages more car use, while trafficrestrictions may, contrary to expectations, reducecongestion.

DAVIES, A. Road transportand health. London, BritishMedical Association, 1997.

ELKIN, T. ET AL. Reviving thecity: towards sustainableurban development. London,Friends of the Earth, 1991.

On the state of health in theEuropean Union. Brussels,Commission of the EuropeanCommunities, 1996.

PRICE, C. & TSOUROS, A., ed.Our cities, our future. Policiesand action plans for healthand sustainable development.Copenhagen, WHO RegionalOffice for Europe, 1996(document).

Traffic impact of highwaycapacity reductions. Summaryreport. London, MVA andESRC Transport Studies Unit,University College, Universityof London, 1998.

oads should give precedence to cycling.

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Member States

Albania,Andorra,Armenia,Austria,Azerbaijan,Belarus,Belgium,Bosnia and Herzegovina,Bulgaria,Croatia,Czech Republic,Denmark,Estonia,Finland,France,Georgia,Germany,Greece,Hungary,Iceland,Ireland,Israel,Italy,Kazakstan,Kyrgyzstan,Latvia,Lithuania,Luxembourg,Malta,Monaco,Netherlands,Norway,Poland,Portugal,Republic of Moldova,Romania,Russian Federation,San Marino,Slovakia,Slovenia,Spain,Sweden,Switzerland,Tajikistan,The Former Yugoslav Republic

of Macedonia,Turkey,Turkmenistan,Ukraine,United Kingdom,Uzbekistan,Yugoslavia

The WHO Regional Officefor Europe

The World Health Organization(WHO) is a specialized agencyof the United Nations createdin 1948 with primaryresponsibility for internationalhealth matters and publichealth. The WHO RegionalOffice for Europe is one ofsix regional offices throughoutthe world, each with its ownprogramme geared to theparticular health conditionsof the countries it serves.

Centre for Urban HealthWorld Health OrganizationRegional Office for EuropeScherfigsvej 8,DK-2100 Copenhagen Ø,DenmarkTelephone +45 39 17 12 24http://www.who.dk/tech/hcp/index.htm