COMMISSION ON SOCIAL DETERMINANTS OF HEALTH

Michael Marmot Launching Ceremony of CNDSS PAHO/WHO Country Office, BRAZIL March 15, 2006

CSDH: Knowledge for action

WHO Director-General LEE Jong-Wook, address to the World Health Assembly, May 2004

“ The goal is not an academic exercise, but to marshal scientific evidence as a lever for policy change — aiming toward practical uptake among policymakers and stakeholders in countries”.

CSDH

improving health and health equity through action on the socially determined causes of health inequities

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

then send them back to the conditions that made them sick?

Why Emphasize Social Determinants?

Social determinants of health have a direct impact on health Social determinants structure other causes of health: – Environment – Behaviour – Services The ‘causes of the causes’

INEQUALITIES BETWEEN COUNTRIES

UNDER 5 MORTALITY RATE PER 1000 LIVE BIRTHS SIERRA LEONE 316 BOLIVIA KYRGYZSTAN SRI LANKA ICELAND 80 63 20 3

SOURCE: THE WORLD HEALTH REPORT 2004,WHO

% PROBABILITY OF DYING BETWEEN AGES 15 AND 60 (males) LESOTHO RUSSIA BOLIVIA SRI LANKA 90.2

46.9

26 23.8

COLOMBIA 23.6

PAKISTAN SWEDEN 22.7

8.3

SOURCE: THE WORLD HEALTH REPORT 2004,WHO

INEQUALITIES WITHIN COUNTRIES

UNDER 5 MORTALITY RATES BY SOCIOECONOMIC QUINTILE OF HOUSEHOLD Under 5 mortality per 1000

200 150 100 50 0 Indonesia Poorest fifth 2nd richest fifth Brazil India 2nd poorest fifth Richest fifth

Victora et al Lancet , 362, 233-241 (2003)

Kenya Middle fifth

MORTALITY AND EDUCATION IN MEN* AGED 45-90 IN MATLAB, BANGLADESH, 1982-1998 Rate ratio

1.05

1 0.95

0.9

0.85

0.8

0.75

0.7

0.65

0.6

None Own education Wife's education

*married at entry

Koranic 1 to 4 years formal

Education

5+ formal

(Hurt, Ronsmans & Saha JECH 2004, 58, 315-320)

GROWING INEQUALITIES

TRENDS IN PROBABILITY OF SURVIVAL IN RUSSIAN MEN BY EDUCATION (RELATIVES STUDY)

elementary university 0.7

0.65

0.6

0.55

0.5

0.45

0.4

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 Calendar year 45 p20 = probability of living to 65 yrs when aged 20 yrs

Murphy et al, in press

A Growing Crisis

: Large ageing population and an increase in chronic disease is creating a financial burden on health systems

ESTIMATED % POPULATION OVER 60 YRS %

35 30 25 20 15 10 5 0 Italy Sweden Japan USA 1997 2025 China India Mexico

Vaupel et al, 1998

ADULT MORTALITY: THE DOUBLE BURDEN OF DISEASE (WHO 2005)

LEADING CAUSES OF DISEASE BURDEN AMONG ADULTS (15-59) WORLDWIDE HIV/AIDS Unipolar depressive disorders Tuberculosis Road traffic injuries Ischaemic heart disease Alcohol use disorders Hearing loss (adult onset) Violence Cerebrovascular disease Self-inflicted injuries 0 World Health Report 2003 19567 19486 18962 18749 18522 28380 27264 26155 57843 68661 10000 20000 30000 40000 50000 60000 70000 80000 DALYS(000)

Commission on Macroeconomics and Health (CMH) CMH called for increased public expenditure on health for economic development CMH focused on low- and middle-income countries CMH focused primarily on communicable diseases

World Health Report 2002

Ten Tips for Staying Healthy 2.

3.

4.

5.

6.

7.

8.

1.

9.

10.

Don't be poor. If you can, stop. If you can't, try not to be poor for long.

Don't have poor parents.

Own a car.

Don't work in a stressful, low paid manual job.

Don't live in damp, low quality housing. Be able to afford to go on a foreign holiday and sunbathe.

Practice not losing your job and don't become unemployed.

Take up all benefits you are entitled to, if you are unemployed, retired or sick or disabled.

Don't live next to a busy major road or near a polluting factory.

Learn how to fill in the complex housing benefit/ asylum application forms before you become homeless and destitute.

Dave Gordon, 1999

‘The causes of the causes’

CSDH GOALS

To support policy change in countries by promoting models and practices that effectively address the social determinants of health. To support countries in placing health as a shared goal to which many government departments and sectors of society contribute. To help build a sustainable global movement for action on health equity and social determinants, linking governments, international organizations, research institutions, civil society and communities.

Commissioners Knowledge networks Civil society Country action Global initiative WHO

COMMISSIONERS

The twenty Commissioners are global and national leaders from political, government, civil society and academic fields and from all geographic regions of the world.

KNOWLEDGE NETWORK THEMES Measurement Diseases of Public Health Impt Early Child Development Health systems Globalization Employment Conditions Building Health & Health Equity Social Exclusion Women + Gender Equity Urban Settings

Civil Society

"The presence, advice and testimony of civil society actors is essential to the work of the Commission and will be decisive to the general awakening we wish to promote". Commissioner Ndioro Ndiaye, Comments on first meeting of CSDH regional civil society facilitators

Update Regional and Regional activities

Regional Meeting National Meeting Next National Meeting Country Participants

Countries

Expressions of interest Discussing collaboration India Mozambique Peru Algeria Kyrgyzstan China In process of formalizing collaboration Brazil Canada Chile England Iran Kenya Sweden

Three strands within country stream 1.

• • • • • • Within country creating space for dialogue e.g Iran putting SDs & inequities on the policy agenda e.g Brazil, Kenya focus, priorities, benchmarks, concrete areas of work e.g Chile brokering people and institutional mechanisms e.g. Kyrgzstan Influencing national resources and investments e.g. England, Canada Collecting information on country situation

Three strands within country stream 2. Between countries – facilitating supportive networking across countries – exchanging and sharing know-how – documentation and exchange of information – training support – and other demand driven support

Three strands within country stream 3. Global international identifying the way that global/international institutions are enabling or disabling country action bringing concrete experience on how to act upstream on global policies (e.g. MDGs) multi-country and regional alliances re-enforcing change within WHO

REGIONAL ACTIVITIES

Nordic Latin America East Asia Europe

Global Initiative

Advancing the CSDH agenda by engaging global institutions

WHO ACTION

The Commission will work with WHO to institutionalize social determinants capacities and approaches within WHO global and regional policies and programmes. This will be accomplished by integrating WHO country, regional and global personnel in all activities of the Commission.

COMMISSION MEETINGS

CHILE – March 2005 CAIRO – May 2005 INDIA – September 2005 IRAN – Jan 2006

‘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)