“WHY SOCIAL DETERMINANTS OF HEALTH? THE EVIDENCE” Commission on Social Determinants of Health

1. “WHY SOCIAL DETERMINANTS OF HEALTH? THE EVIDENCE”Commission on Social Determinants of Health Michael Marmot Fiocruz National School of Public Health June 27th 2005

2. Basic needs Action as if people mattered Health as the driver ‘Causes of the causes’ Putting it into action Presentation Outline

3. Basic needs Action as if people mattered Health as the driver ‘Causes of the causes’ Putting it into action Presentation Outline

4. INEQUALITIES BETWEEN COUNTRIES

5. UNDER 5 MORTALITY RATE PER 1000 LIVE BIRTHS SOURCE: THE WORLD HEALTH REPORT 2004,WHO

6. % PROBABILITY OF DYING BETWEEN AGES 15 AND 60 (males) SOURCE: THE WORLD HEALTH REPORT 2004,WHO

7. ADULT MORTALITY: THE DOUBLE BURDEN OF DISEASE (WHO, 2003)

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

9. INEQUALITIES WITHIN COUNTRIES

10. 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.

11. 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)

12. 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).

13. Probability of Survival From Age 15-65 Years Among US Blacks & Whites % probability of survival US White Poor White US Black Poor Black Males Males Males Males Geronimus et al, NEJM 1996

14. GROWING INEQUALITIES

15. THE WIDENING TREND IN MORTALITY BY EDUCATION IN RUSSIA,1989-2001 45 p20 = probability of living to 65 yrs when aged 20 yrs Murphy, Bobak, Nicholson, Rose, and Marmot, 2005 under review

16. QUALITY OF LIFE

17. FEMALES: LE AND HLE AT BIRTH BY DEPRIVATION DECILES, ENGLAND, 1994-99 Years of life Affluent deprivation deciles Deprived Source: Health Survey for England Madhavi Bajekal, National Centre for Social Research

18. HEALTH AS A MEASURE OF ‘SOCIAL SUCCESS’

19. 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

20. GDP PER CAPITA AND LIFE EXPECTANCY: SELECTED COUNTRIES Source: Human Development Report 2004 and World Health Report 2004

21. HUMAN FLOURISHING SOCIAL PARTICIPATION AUTONOMY HEALTH

22. Published by Holt 2004

23. Basic needs Action as if people mattered Health as the driver ‘Causes of the causes’ Putting it into action Presentation Outline

25. THE SOCIAL GRADIENT STRESS EARLY LIFE SOCIAL EXCLUSION WORK UNEMPLOYMENT SOCIAL SUPPORT ADDICTION FOOD TRANSPORT THE SOLID FACTS: 10 MESSAGES

26. Basic needs Action as if people mattered Health as the driver ‘Causes of the causes’ Putting it into action Presentation Outline

27. CHILE: Social programmes for health • Chile Solidario • Child development and well-being • Family-focussed primary health care

28. Basic needs Action as if people mattered Health as the driver ‘Causes of the causes’ Putting it into action Presentation Outline

29. What good does it do to treat people's illnesses ... then send them back to the conditions that made them sick?

30. Early Life • The effects of early development last a life-time: a good start in life means supporting mothers and young children.

31. YOUTH LITERACY SCORES (16-25 YEARS) AND PARENTS’ EDUCATION Literacy Scores Sweden Canada US Parents’ Education (years) Willms 1999

32. Addiction • Individuals turn to alcohol, drugs and tobacco and suffer from their use. Use is influenced by the wider social setting.

33. COMPARISON OF SMOKING PREVALENCE BETWEEN LOW AND HIGH SOCIOECONOMIC GROUPS SMOKING RATE RATIO BETWEEN LOW AND HIGH SOCIOECONOMIC GROUPS Bobak et al in ‘Tobacco control in developing countries’ ed: Jha & Chaloupka, 2000

34. Food • Healthy food is a political issue.

35. OBESITY PATTERNS ACROSS THE DEVELOPING WORLD % (Popkin, Development Policy Review, 2003)

36. Transport • Healthy transport means reducing driving and encouraging more walking and cycling, backed up by better public transport.

37. More than a million people worldwide are killed in road crashes every year • Low and middle-income countries account for 86% of the world’s road deaths but have only 40% of the world’s motor vehicles.

38. INCOME?

39. Kerala and other Indian states compared.

40. “RELATIVE DEPRIVATION IN THE SPACE OF INCOMES CAN YIELD ABSOLUTE DEPRIVATION IN THE SPACE OF CAPABILITIES” Amartya Sen, Inequality Re-examined, 1992

41. LEADERSHIP IS NEEDED TO MAKE A DIFFERENCE

42. 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

43. Economic and social security Conditions in childhood and adolescence Healthier working life Environments and products Participation in society Health promoting medical care SWEDISH PUBLIC HEALTH POLICY Alcohol drugs tobacco Eating Safe food Physical activity Sexual health Prevention communicable disease

44. Early Child Development The effects of early development last a life-time: a good start in life requires supporting mothers and young children

45. 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).

46. '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 2003coverage 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

47. "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

48. Health Systems The organization of health systems fundamentally contributes to health outcomes

49. Health Systems Targeting health care system to local needs in Morogoro and Rufiji areas of Tanzania: 40% reduction in child mortality

50. Food Security Hunger is one of the most obvious manifestations of poverty and ill health