““ADDRESSING SOCIAL ADDRESSING SOCIAL DETERMINANTS OF HEALTHDETERMINANTS OF HEALTH””

Commission on Social Commission on Social Determinants of HealthDeterminants of Health

Michael MarmotMichael Marmot

WHO SEARODelhi

15th September 2005

Health is not only (primarily?) a Health is not only (primarily?) a matter of medical carematter of medical careSocial and political circumstances Social and political circumstances affect life and wellaffect life and well--being and, hence, being and, hence, healthhealthTherefore all policies should be Therefore all policies should be framed with regard to their effect on framed with regard to their effect on health and health inequity.health and health inequity.Major unsolved problems of Major unsolved problems of inequalities in health among and inequalities in health among and within countries.within countries.

Policy ApproachPolicy Approach

Early life development and educationEarly life development and education–– Including comprehensive primary careIncluding comprehensive primary carePeople of working agePeople of working age–– Working and living conditionsWorking and living conditionsEconomic and social conditions of older Economic and social conditions of older peoplepeople

“…WANT IS ONE ONLY OF FIVE GIANTS ON THE ROAD OF RECONSTRUCTION AND IN SOMEWAYS THE EASIEST TO ATTACK.THE OTHERS ARE DISEASE, IGNORANCE, SQUALOR ANDIDLENESS.”

Beveridge Report

WANT

SQUALORDISEASE

IGNORANCE

IDLENESS

“Winning it (freedom from want) needscourage and faith and a sense of nationalunity: courage to face facts and difficulties…;faith…in the ideals of fair play and freedom;a sense of national unity overriding theinterests of any class or section.”

Beveridge Report p.172

Presentation Outline Basic needsBasic needsAction as if people matteredAction as if people matteredHealth as the driverHealth as the driver‘‘Causes of the causesCauses of the causes’’Putting it into actionPutting it into action

Presentation Outline Basic needsBasic needsAction as if people matteredAction as if people matteredHealth as the driverHealth as the driver‘‘Causes of the causesCauses of the causes’’Putting it into actionPutting it into action

GIVING PEOPLE THE POSSIBILITY TO GIVING PEOPLE THE POSSIBILITY TO LEAD LIVES THAT THEY HAVE LEAD LIVES THAT THEY HAVE REASON TO VALUEREASON TO VALUE

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 90.290.2RUSSIARUSSIA 46.946.9BOLIVIABOLIVIA 2626SRI LANKASRI LANKA 23.823.8COLOMBIACOLOMBIA 23.623.6PAKISTANPAKISTAN 22.722.7SWEDENSWEDEN 8.38.3

SOURCE: THE WORLD HEALTH REPORT 2004,WHO

OBESITY PATTERNS ACROSS OBESITY PATTERNS ACROSS THE DEVELOPING WORLDTHE DEVELOPING WORLD

35.2 32.1 26.6 36 37.919.4 26.7

24.46.4 12.4

12.432.1

6

31.8

01020304050607080

Mexicomales

Brazilmales

Brazilfemales

Egyptmales

Egyptfemales

S. Africamales

S. Africafemales

25<BMI<30 BMI>30

%

(Popkin, Development Policy Review, 2003)

THE PREVALENCE OF DIABETES AND THE PREVALENCE OF DIABETES AND CARDIOVASCULAR DISEASE IS RISING CARDIOVASCULAR DISEASE IS RISING EXPONENTIALLY IN DEVELOPING EXPONENTIALLY IN DEVELOPING COUNTRIESCOUNTRIES

INDIA INDIA -- DIABETESDIABETES

Prevalence of diabetes: Prevalence of diabetes: 2000: 32 million2000: 32 millionProjected prevalence of diabetes: Projected prevalence of diabetes: 2030: 79 million2030: 79 million

Source: WHO

INDIA INDIA –– ISCHAEMIC HEART ISCHAEMIC HEART DISEASEDISEASE

PREVALENCE PREVALENCE RATE/1000RATE/1000

URBANURBAN RURALRURAL

6464 2525

Prevalence rate: 37 per 1000

Source: Indian Council of Medical Research, Assessment of Burden ofNon-communicable Disease, 2004

INEQUALITIES WITHIN INEQUALITIES WITHIN COUNTRIESCOUNTRIES

UNDER 5 MORTALITY RATES BY UNDER 5 MORTALITY RATES BY SOCIOECONOMIC QUINTILE OF HOUSEHOLDSOCIOECONOMIC QUINTILE OF HOUSEHOLD

0

50

100

150

200

Indonesia Brazil India Kenya

Poorest fifth 2nd poorest fifth Middle fifth2nd richest fifth Richest fifth

Under 5 mortalityper 1000

Victora et al 2003

Travel from the Southeast of Travel from the Southeast of downtown Washington to downtown Washington to Montgomery County Maryland. For Montgomery County Maryland. For each mile travelled life expectancy each mile travelled life expectancy rises about a year and a half. There is rises about a year and a half. There is a twenty year gap between poor a twenty year gap between poor blacks at one end of the journey blacks at one end of the journey (Male LE 57) and rich whites at the (Male LE 57) and rich whites at the other (LE 76.7)other (LE 76.7)..

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

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

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

HEALTH AS A MEASURE HEALTH AS A MEASURE OF OF ‘‘SOCIAL SUCCESSSOCIAL SUCCESS’’

TWO TYPES OF SUCCESS TWO TYPES OF SUCCESS IN REDUCING MORTALITYIN REDUCING MORTALITYGrowthGrowth--mediated: if economic growth is mediated: if economic growth is widespread and participatory e.g. Hong widespread and participatory e.g. Hong Kong or S. Korea Kong or S. Korea -- poverty removal and 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

Life expectancy and GDP in $US (PPP) in 2002

LELEat birthat birth GDPGDP

JapanJapan 81.581.5 26,94026,940SwedenSweden 8080 26,05026,050SpainSpain 79.279.2 21,46021,460SwitzerlandSwitzerland 79.179.1 30,01030,010FranceFrance 78.978.9 26,92026,920GreeceGreece 78.278.2 18,72018,720UKUK 78.178.1 26,15026,150Costa RicaCosta Rica 7878 8,8408,840USUS 7777 35,75035,750CubaCuba 76.776.7 5,2595,259

DEVELOPMENT AS DEVELOPMENT AS EMPOWERMENTEMPOWERMENT

Presentation Outline Basic needsBasic needsAction as if people matteredAction as if people matteredHealth as the driverHealth as the driver‘‘Causes of the causesCauses of the causes’’Putting it into actionPutting it into action

THE SOLID FACTS: THE SOLID FACTS: 10 MESSAGES10 MESSAGES

THE SOCIAL THE SOCIAL GRADIENTGRADIENTSTRESSSTRESSEARLY LIFEEARLY LIFESOCIAL SOCIAL EXCLUSIONEXCLUSIONWORK

UNEMPLOYMENTUNEMPLOYMENTSOCIAL SUPPORTSOCIAL SUPPORTADDICTIONADDICTIONFOODFOODTRANSPORTTRANSPORT

WORK

CHILE: Social CHILE: Social programmesprogrammes for for healthhealth

Chile Chile SolidarioSolidario

Child development and wellChild development and well--beingbeing

FamilyFamily--focussed primary health carefocussed primary health care

Presentation Outline Basic needsBasic needsAction as if people matteredAction as if people matteredHealth as the driverHealth as the driver‘‘Causes of the causesCauses of the causes’’Putting it into actionPutting it into action

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

then send them back to the conditions that made them

sick?

Presentation Outline Basic needsBasic needsAction as if people matteredAction as if people matteredHealth as the driverHealth as the driver‘‘Causes of the causesCauses of the causes’’Putting it into actionPutting it into action

COMPARISON OF SMOKING PREVALENCE BETWEEN HIGH COMPARISON OF SMOKING PREVALENCE BETWEEN HIGH AND LOW SOCIOECONOMIC GROUPSAND LOW SOCIOECONOMIC GROUPS

0123456789

10

India(Delhi)

China Brazil Cuba SouthAfrica

Hungary

SMOKING RATE RATIOBETWEEN LOW AND HIGH SOCIOECONOMIC GROUPS

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

Presentation Outline Basic needsBasic needsAction as if people matteredAction as if people matteredHealth as the driverHealth as the driver‘‘Causes of the causesCauses of the causes’’Putting it into actionPutting it into action

Mutually reinforcing areas of work to achieve these outcomes

AdvocacyAdvocacyLearningLearningActionAction

Communication/ExchangeCommunication/Exchange

LeadershipLeadership

ACTIONACTION

GLOBAL GLOBAL COUNTRIESCOUNTRIESREGIONSREGIONSCIVIL SOCIETYCIVIL SOCIETYPEOPLEPEOPLEWORLD HEALTH ORGANIZATIONWORLD HEALTH ORGANIZATION

Diseases of Public

Health Impt

Early ChildDevelopment+ education

Women + Gender

Inequities

Urban Settings

Social 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

‘‘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 OF THE SOCIETY ARE ABLE TO LEADLEAD……WE NOT ONLY VALUE LIVING WE NOT ONLY VALUE LIVING

WELL AND SATISFACTORILY, BUT ALSO WELL AND SATISFACTORILY, BUT ALSO APPRECIATE HAVING CONTROL OVER APPRECIATE HAVING CONTROL OVER

OUR OWN LIVESOUR OWN LIVES’’

Amartya Sen, Development as Freedom Amartya Sen, Development as Freedom (1999)(1999)