Taking action on social determinants of health

1. Taking action on social determinants of health Michael Marmot Wellington July 2011

2. Inequalities between countries Glasgow men(Lenzie) 82* Glasgow men (Calton) 54 National data WHO 2009, Glasgow data: Hanlon et al. 2006

3. Trends in life expectancy at birth: Zambia, Viet Nam, Costa Rica, Sri Lanka (1950 – 2005, both sexes) UN data

4. Social justice • Material, psychosocial, political empowerment • Creating the conditions for people to have control of their lives www.who.int/social_determinants

5. Translating the CSDH recommendations into different country/regional contexts

9. United Nations, ECOSOC meeting July 2009 • “…Yet, inequities in health outcomes persist within and among countries. Most of the difference is attributable to the conditions in which people are born, grow, live, work and age.”

10. Review of the Social Determinants of Health and the Health Divide in the WHO European Region The CSDH – closing the gap in a generation The Marmot Review – Fair Society Healthy Lives

11. A Fair Society

12. Life expectancy and disability-free life expectancy at birth by neighbourhood income deprivation, 1999-2003

13. Social determinants of health across the lifecourse

14. Fair Society: Healthy Lives: 6 Policy Objectives • Give every child the best start in life • Enable all children, young people and adults to maximise their capabilities and have control over their lives • Create fair employment and good work for all • Ensure healthy standard of living for all • Create and develop healthy and sustainable places and communities • Strengthen the role and impact of ill health prevention

15. Marmot Review: 6 Policy Objectives • Give every child the best start in life • Enable all children, young people and adults to maximise their capabilities and have control over their lives • Create fair employment and good work for all • Ensure healthy standard of living for all • Create and develop healthy and sustainable places and communities • Strengthen the role and impact of ill health prevention

16. Inequality in early cognitive development of children in the 1970 British Cohort Study, ages 22 months to 10 years Feinstein 2003

17. Links between socioeconomic status and factors affecting child development, 2003-4 Source: Department for Children, Schools and Families

18. Socio-emotional difficulties at age 3 and 5:Millennium Cohort Study Age 3 Age 5 Fully adjusted = for parenting activities and psychosocial markers Kelly et al, 2010

19. Per cent achieving ‘a good level of development’* by deprivation decile: England *in personal, social and emotional development and communication, language and literacy at age 5 Source: Department for Education

20. Per cent 5 year olds achieving ‘good development score’,* Birmingham LA, West Midlands & England % *in personal, social and emotional development and communication, language and literacy Source: Department for Education

21. Marmot Review: 6 Policy Objectives • Give every child the best start in life • Enable all children, young people and adults to maximise their capabilities and have control over their lives • Create fair employment and good work for all • Ensure healthy standard of living for all • Create and develop healthy and sustainable places and communities • Strengthen the role and impact of ill health prevention

22. Percentage of pupils achieving 5+ A*–C grades inc English and Maths at GCSE by income deprivation of area of residence, England, 2008/9

23. Marmot Review: 6 Policy Objectives • Give every child the best start in life • Enable all children, young people and adults to maximise their capabilities and have control over their lives • Create fair employment and good work for all • Ensure healthy standard of living for all • Create and develop healthy and sustainable places and communities • Strengthen the role and impact of ill health prevention

24. Seasonally adjusted trends in unemployment for young people in the UK, 1993-2011 37.7% 16-17 18.3% 18-24 8% 16 and over Source: Office for National Statistics, Labour Force Survey

25. Population attributable Risk (PAR) for all combined* 46%95% CI 37%-53% adjusted for other predictors 34%95% CI 24%-43% ERI= Effort reward imbalance *calculated from odds ratios adjusted for age, sex, employment grade J Head et al,2007

26. Fair Society: Healthy Lives: 6 Policy Objectives • Give every child the best start in life • Enable all children, young people and adults to maximise their capabilities and have control over their lives • Create fair employment and good work for all • Ensure healthy standard of living for all • Create and develop healthy and sustainable places and communities • Strengthen the role and impact of ill health prevention

27. Minimum Income Standard by family type as a percentage of median income, April 2008

28. Poor Prospects for living standards • 12% addition to price level over next 4 years • Rise in import prices (commodities including foodstuffs, base metals and cotton) • Rise in energy prices • Rise VAT “in 2011 real wages are likely to be no higher than they were in 2005. One has to go back to the 1920s to find a time when real wages fell over a period of six years” Source: Speech given by Mervyn King, Governor of the Bank of England At the Civic Centre, Newcastle 25 January 2011

29. Pain delayed but not avoided • Despite falls in GDP and employment, average take-home incomes continued to grow in 2009-10 mainly driven by growth in income from benefits and tax credits; • “In 2011–12 and beyond, the coalition government’s cuts to benefits and tax credits are likely to reduce household incomes, all else being equal” Source: Poverty and Inequality in the UK: 2011 IFS Commentary 13th May 2011

30. Odds ratios (OR) for risk of mental illness in people with increasing numbers of debts:GB unadjusted (♦), adjusted for income (■) adjusted for income and key sociodemographic variables (age, ethnicity, marital status, household size, household tenure, education, social class,employment status, urban or rural, and region ( ). Source: Jenkins et al 2008

31. Fair Society: Healthy Lives: 6 Policy Objectives • Give every child the best start in life • Enable all children, young people and adults to maximise their capabilities and have control over their lives • Create fair employment and good work for all • Ensure healthy standard of living for all • Create and develop healthy and sustainable places and communities • Strengthen the role and impact of ill health prevention

32. Published by Friends of the Earth and Marmot Review Team Parliamentary Launch 12th May 2011

33. Direct health impacts - Mortality • Excess winter deaths are almost three times higher in the coldest quarter of housing than in the warmest quarter • 40% excess winter deaths attributable to cardio-vascular diseases • 33% excess winter deaths attributable to respiratory diseases

34. Direct health impacts - Morbidity • Children living in cold homes more than twice as likely to suffer from respiratory problems than children living in warm homes • More than 1 in 4 adolescents living in cold housing are at risk of multiple mental health problems, compared to 1 in 20 adolescents in warm housing • Cardio-vascular and respiratory diseases • Mental health • Colds and flu, exacerbates existing conditions such as arthritis and rheumatisms

35. Indirect health and social impacts • Cold housing negatively affects: • children’s educational attainment, emotional well-being and resilience • family dietary opportunities and choices • dexterity; and increases the risk of accidents and injuries in the home • Investing in the energy efficiency of housing can help stimulate the labour market and economy, as well as creating opportunities for skilling up the construction workforce

36. We can do better – international comparisons

37. Countries with more energy efficient housing have lower excess winter deaths (Healy 2003)

38. Greener living environments: lower health inequalities, England Deaths from circulatory disease Income group 4 is most deprived Source: Mitchell & Popham, Lancet 2008

39. Marmot Review: 6 Policy Objectives • Give every child the best start in life • Enable all children, young people and adults to maximise their capabilities and have control over their lives • Create fair employment and good work for all • Ensure healthy standard of living for all • Create and develop healthy and sustainable places and communities • Strengthen the role and impact of ill health prevention

40. Only 4 per cent of NHS funding is spent on prevention

41. Average weekly alcohol consumption by sex and socioeconomic class, GB: 2008 Mean number of units a week ONS General Lifestyle Survey 2008

42. Alcohol-attributable hospital admissions by small area deprivation quintile in England,2006-07

43. Action on the wider determinants - to tackle health inequalities • “Every sector a health sector” • Local authorities, Health and Social Services, Voluntary Sector have a key role to play at local level • Empower individuals and communities – create the conditions for people to take responsibility www.marmotreview.org

44. Marmot Review: recommended targets Across the social gradient: • Life expectancy • Healthy life expectancy • Readiness for school • Young people not in education, employment or training Target that progressively increases: • Proportion of households that have an income, after tax and benefits that is sufficient for healthy living

45. Public Health White Paper recognises: • that disadvantage accumulates over lifetime; • the need to address the wider determinants of health; • and approved the use of proportionate universalism as in Fair Society Healthy Lives • role of local authorities in leading on public health in partnership with the NHS

46. But: • Giving local communities control is challenging when they face budget cuts of 20-25%; • “responsibility deals” • Evidence from history suggests that public health advances – clean water, reduction of air pollution, healthier working conditions, reduction in drink-driving – have come to greater degree from action by local and central government than by voluntary agreements with industry. • While the White Paper picked up five of the six domains of recommendations from the Marmot Review it was silent on ensuring a healthy standard of living for all

47. Cost-Related Access Problems in the Past Year, by Income (Adjusted) percent experienced at least one of three problems** Note: Percentages adjusted based on logistic regression to control for health status, age, and—in the U.S.—insurance status. * Indicates significant within-country differences with below-average income (p < 0.05). ** Did not fill/skipped prescription, did not visit doctor with medical problem, and/or did not get recommended care. Source: 2010 Commonwealth Fund International Health Policy Survey in Eleven Countries.

48. Percentage shares of equivalised total gross and post-tax income, by quintile groups for all households, 1978 – 2007/8

49. Trends in income share among top income decile, US: 1913-2007 Source: Piketty and Saez (2003), series updated to 2007 by Saez in 2009

50. International comparisons of income mobility Higher score = lower intergenerational mobility Source: Blanden (2009) in NEP 2010.