Transcript Name the Author I

“WHY SOCIAL DETERMINANTS
OF HEALTH? THE EVIDENCE”
Commission on Social
Determinants of Health
Michael Marmot
Fiocruz National School
of Public Health
June 27th 2005
Presentation Outline
Basic needs
Action as if people mattered
Health as the driver
‘Causes of the causes’
Putting it into action
Presentation Outline
Basic needs
Action as if people mattered
Health as the driver
‘Causes of the causes’
Putting it into action
INEQUALITIES BETWEEN
COUNTRIES
UNDER 5 MORTALITY RATE PER
1000 LIVE BIRTHS
SIERRA LEONE
316
BOLIVIA
80
KYRGYZSTAN
63
SRI LANKA
20
ICELAND
3
SOURCE: THE WORLD HEALTH REPORT 2004,WHO
% PROBABILITY OF DYING BETWEEN
AGES 15 AND 60 (males)
LESOTHO
90.2
RUSSIA
46.9
BOLIVIA
26
SRI LANKA
23.8
COLOMBIA
23.6
PAKISTAN
22.7
SWEDEN
8.3
SOURCE: THE WORLD HEALTH REPORT 2004,WHO
ADULT MORTALITY: THE DOUBLE
BURDEN OF DISEASE
(WHO, 2003)
Life expectancy and GDP in $US (PPP) in 2002
Japan
Sweden
Spain
Switzerland
France
Greece
UK
Costa Rica
US
Cuba
LE
at birth
81.5
80
79.2
79.1
78.9
78.2
78.1
78
77
76.7
GDP
26,940
26,050
21,460
30,010
26,920
18,720
26,150
8,840
35,750
5,259
INEQUALITIES WITHIN
COUNTRIES
INFANT MORTALITY IN BRAZIL, BY RACE AND MOTHER’S
EDUCATION, 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
expectancy between Asians in
Westchester Co (LE 89) and
American Indians in South Dakota
(LE 56)
Travel from the Southeast of
downtown Washington to
Montgomery County Maryland. For
each mile travelled life expectancy
rises about a year and a half. There is
a twenty year gap between poor
blacks at one end of the journey
(Male LE 57) and rich whites at the
other (LE 76.7).
Probability of Survival From Age 15-65
Years Among US Blacks & Whites
% probability of survival
80
70
60
50
40
30
20
US White Poor White US Black Poor Black
Males
Males
Males
Males
Geronimus et al, NEJM 1996
GROWING INEQUALITIES
THE WIDENING TREND IN MORTALITY BY
EDUCATION IN RUSSIA,1989-2001
elementary
university
0.7
45 p 20
0.65
0.6
0.55
0.5
0.45
19
89
19
90
19
91
19
92
19
93
19
94
19
95
19
96
19
97
19
98
19
99
20
00
20
01
0.4
Calendar year
45 p20 = probability of living to 65 yrs when aged 20 yrs
Murphy, Bobak, Nicholson, Rose, and Marmot, 2005 under review
QUALITY OF LIFE
FEMALES: LE AND HLE AT BIRTH BY
DEPRIVATION DECILES, ENGLAND, 1994-99
HLE
Years of life
80
75
70
65
60
55
50
45
40
35
30
13
68
1
14
67
2
15
66
3
16
65
4
18
62
5
not-HLE
20
60
6
21
21
23
59
58
56
52
7
8
9
10
Affluent deprivation deciles Deprived
Source: Health Survey for England
Madhavi Bajekal, National Centre for Social Research
26
HEALTH AS A MEASURE OF
‘SOCIAL SUCCESS’
TWO TYPES OF SUCCESS
IN REDUCING MORTALITY
Growth-mediated: if economic growth is
widespread and participatory e.g. Hong
Kong or S. Korea - poverty removal and
public health.
Support led: Costa Rica, Kerala, Sri Lanka
- enhanced quality of life through social
services and education.
A.Sen: Innocenti Lecture, Florence 1995
GDP PER CAPITA AND LIFE
EXPECTANCY: SELECTED COUNTRIES
SRI LANKA
GDP PER
CAPITA (PPP
US$)
3,570
LIFE
EXPECTANCY AT
BIRTH (MALES)
67.2
COSTA RICA
8,840
74.8
RUSSIA
8,230
58.3
CHILE
9,820
73.4
Source: Human Development Report 2004 and World Health Report 2004
HUMAN FLOURISHING
AUTONOMY
SOCIAL
PARTICIPATION
HEALTH
Published by Holt
2004
Presentation Outline
Basic needs
Action as if people mattered
Health as the driver
‘Causes of the causes’
Putting it into action
THE SOLID FACTS:
10 MESSAGES
THE SOCIAL
GRADIENT
STRESS
EARLY LIFE
SOCIAL
EXCLUSION
WORK
UNEMPLOYMENT
SOCIAL SUPPORT
ADDICTION
FOOD
TRANSPORT
Presentation Outline
Basic needs
Action as if people mattered
Health as the driver
‘Causes of the causes’
Putting it into action
CHILE: Social programmes for
health
Chile Solidario
Child development and well-being
Family-focussed primary health care
Presentation Outline
Basic needs
Action as if people mattered
Health as the driver
‘Causes of the causes’
Putting it into action
What good does it do to treat people's
illnesses ...
then send them back
to the conditions
that made them
sick?
Early Life
The effects of early
development last a life-time: a
good start in life means
supporting mothers and young
children.
YOUTH LITERACY SCORES (1625 YEARS) AND PARENTS’
Literacy Scores
EDUCATION
1.5
1
Sweden
0.5
0
Canada
-0.5
US
-1
-1.5
6
7
8
9
10
11
12 13
14
15
Parents’ Education (years)
16 17
19
Willms 1999
Addiction
Individuals turn to alcohol,
drugs and tobacco and suffer
from their use. Use is
influenced by the wider social
setting.
COMPARISON OF SMOKING PREVALENCE BETWEEN LOW
AND HIGH SOCIOECONOMIC GROUPS
SMOKING RATE RATIO
BETWEEN LOW AND HIGH
SOCIOECONOMIC GROUPS
10
9
8
7
6
5
4
3
2
1
0
India
(Delhi)
China
Brazil
Cuba
South
Africa
Hungary
Bobak et al in ‘Tobacco control in developing countries’ ed: Jha & Chaloupka, 2000
Food
Healthy food is a political
issue.
%
80
70
60
50
40
30
20
10
0
OBESITY PATTERNS ACROSS
THE DEVELOPING WORLD
32.1
24.4
6.4
35.2
Mexico
males
31.8
12.4
12.4
32.1
26.6
Brazil
males
Brazil
females
36
37.9
6
19.4
Egypt
males
25<BMI<30
26.7
Egypt S. Africa S. Africa
females males females
BMI>30
(Popkin, Development Policy Review, 2003)
Transport
Healthy transport means
reducing driving and
encouraging more walking and
cycling, backed up by better
public transport.
More than a million people
worldwide are killed in road crashes
every year
Low and middleincome countries
account for 86% of
the world’s road
deaths but have only
40% of the world’s
motor vehicles.
INCOME?
Kerala and other Indian states compared.
Infant
Female Females
mortality literacy married
/1000
(%)
<18
births
Villages Income
with
($1985)
medical
facilities
Kerala
Gujarat
Tamil
Nadu
17
72
59
66
31
36
3
4
9
96
28
33
1144
1601
1383
Madyha P
111
15
31
6
1105
Rajasthan
84
11
35
17
1142
“RELATIVE DEPRIVATION IN
THE SPACE OF INCOMES CAN
YIELD ABSOLUTE DEPRIVATION
IN THE SPACE OF CAPABILITIES”
Amartya Sen, Inequality Re-examined, 1992
LEADERSHIP IS NEEDED TO MAKE A
DIFFERENCE
Action taken by European
Countries
taxation, tax credits
social welfare
– old age pension
– sickness/rehabilitation benefits
– maternity/ child benefits
– unemployment benefits
housing policy, housing benefits
labour markets
communities
care facilities
IK Crombie, et al., 2004
Economic Conditions in Healthier Environments
childhood
and social
working
and
and
security
life
products
Participation
adolescence
in
society
Health
SWEDISH PUBLIC HEALTH POLICY
promoting
medical
care
Alcohol
drugs
Eating
tobacco
Prevention
Physical
Sexual
Safe food
activity
health communicable
disease
Early Child Development
The effects of early
development last a life-time: a
good start in life requires
supporting mothers and young
children
EFFECTS OF ‘FAMILIAS EN
ACCION’ IN COLOMBIA
Improved nutritional status of children;
Increases in height and weight in
young children (0-4 years);
10% Reduction in numbers of children
(0-4 years) with diarrhoea;
More children registered for
growth and development check-ups
Increase in school enrolment of
children (12 -17 years).
'Oportunidades' Program: Mexico
Aim: Improve health, education and nutrition levels in
poor households
Program design: health prevention including: health talks,
antenatal and postnatal care, nutritional supplements to
pregnant and lactating women
Coverage: 4.24 million poor families
2001 to April 2003 coverage increased:
Number of pregnant women: 82,000 to 120,000
Number of antenatal care visits: 133,000 to 214,000
nutrition supplements for under–two yrs: 48,4000 to 72,7000
"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
poverty
Differential reduction Differential reduction
in Maternal mortality
in Infant mortality
Very Low
-1%
-2%
Low
-6%
-1%
Average
-24%
1%
High
-9%
-1%
Very High
-32%
-8%
National
Average
-11%
-2%
Health Systems
The organization of health systems
fundamentally contributes to
health outcomes
Health Systems
Targeting health care system to local needs in Morogoro and Rufiji areas of
Tanzania:
40% reduction in child mortality
Food Security
Hunger is one of the most
obvious manifestations of
poverty and ill health
Vulnerable Group Development
Program: Bangladesh
Aim: integrate food and nutrition
security with development and income
generation
Target population: ultra poor women
Program design: monthly allocation of
wheat in exchange for participating in
training (in literacy, numeracy, savings
and nutrition)
(International Food Policy Research Institute, 2004)
Progress can be achieved in
short time periods
In 7 years
LIFE
EXPECTANCY
In 9 years
POTABLE
WATER
PRIMARY SCHOOL
ENROLLMENT
POVERTY
56 yrs
15m
33%
48 yrs
7m
18%
Sri Lanka
1946 - 53
South Africa
1994-2001
In 15 years
China
1990 - 99
89%
46%
Botswana
1970 - 85
Presentation Outline
Basic needs
Action as if people mattered
Health as the driver
‘Causes of the causes’
Putting it into action
Mutually reinforcing areas of work to
achieve these outcomes
Leadership
Action
Learning
Advocacy
Communication/Exchange
The Commissioners
Fran Baum – Professor of Public Health, Flinders University,
Australia
Giovanni Berlinguer – member of the European Parliament
Monique Begin – former Canadian Minister of National Health
and Welfare
Mirai Chatterjee – Coordinator of Social Security for India’s
Self-employed Women’s Association
Manuel Dayrit – Secretary of Health of the Philippines
Bill Foege – Emeritus Presidential DistinguishedProfessor of
International Health, Emory University and Gates Fellow
Kiyoshi Kurokawa – President of the Science Council of
Japan and the Pacific Science Association
Ricardo Lagos – President of Chile
The Commissioners
Stephen Lewis – UN special envoy for HIV/AIDS in Africa
Seyed Marandi – Former Minister of Health in Iran
Michael Marmot (chair) – Director of International Centre
for Health and Society, UCL
Charity Ngilu – Minister of Health, Kenya
Hoda Rashad – Director, Social Research Center of the
American University in Cairo
David Satcher – President of Morehouse School of
Medicne, former US Surgeon General
Amartya Sen – Nobel Laureate, Lamont Professor,
University of Harvard
Anna Tibaijuka – Executive Director of UN-HABITAT
Denny Vagero – Professor of Medical Sociology, Director
of Centre for Health Equity Studies, Stockholm.
KNOWLEDGE NETWORK THEMES
Financing
Social
Programmes
Measurement
Diseases
of Public
Health
Impt
Health
systems
Early child
Development
+ education
Building
Health &
Health
Equity
Women +
Gender
inequities
Globalization
Employment
conditions
Social
Exclusion
Urban
Settings
What would success look like?
Knowledge, leadership and debate
Action
Institutional change
Policy change
SOCIAL JUSTICE IMPERATIVE
HEALTH IS A MARKER OF HOW WELL
POLICIES MEET HUMAN AND SOCIAL
NEEDS
‘THE SUCCESS OF AN ECONOMY AND
OF A SOCIETY CANNOT BE SEPARATED
FROM THE LIVES THAT THE MEMBERS
OF THE SOCIETY ARE ABLE TO
LEAD…WE NOT ONLY VALUE LIVING
WELL AND SATISFACTORILY, BUT ALSO
APPRECIATE HAVING CONTROL OVER
OUR OWN LIVES’
Amartya Sen, Development as Freedom
(1999)