““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)