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GLOBAL ACTION AND SOCIAL DETERMINANTS OF HEALTH

GLOBAL ACTION AND SOCIAL DETERMINANTS OF HEALTH Michael Marmot 11 th World Congress of Public Health Rio de Janeiro 2006 OUTLINE The Challenge Conceptual Framework Inequalities within and between countries Explanations Linking poverty and the gradient OUTLINE The Challenge

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GLOBAL ACTION AND SOCIAL DETERMINANTS OF HEALTH

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  1. GLOBAL ACTION AND SOCIAL DETERMINANTS OF HEALTH Michael Marmot 11th World Congress of Public Health Rio de Janeiro 2006

  2. OUTLINE • The Challenge • Conceptual Framework • Inequalities within and between countries • Explanations • Linking poverty and the gradient

  3. OUTLINE • The Challenge • Conceptual Framework • Inequalities within and between countries • Explanations • Linking poverty and the gradient

  4. ONE APPROACH TO UNDERSTANDING HEALTH INEQUALITIES IN RICH AND POOR COUNTRIES

  5. OUTLINE • The Challenge • Conceptual Framework • Inequalities within and between countries • Explanations • Linking poverty and the gradient

  6. ANALOGY WITH DEVELOPMENT ECONOMICS

  7. “SIMPLE VIEW” GROWTH DEVELOPMENT

  8. “SIMPLE VIEW” MATERIAL CIRCUMSTANCES HEALTH

  9. BEYOND GDP • AND INCOME POVERTY DEVELOPMENT GROWTH DEVELOPMENT EMPOWERMENT

  10. 2) BEYOND MATERIAL CIRCUMSTANCES AND HEALTHCARE HEALTH MATERIAL CIRCUMSTANCES HEALTH EMPOWERMENT

  11. MORE THAN AN ANALOGY GROWTH DEVELOPMENT HEALTH EMPOWERMENT

  12. OUTLINE • The Challenge • Conceptual Framework • Inequalities within and between countries • Explanations • Linking poverty and the gradient

  13. THE SOCIAL GRADIENT IN HEALTH

  14. MORTALITY OVER 25 YEARS ACCORDING TO LEVEL IN THE OCCUPATIONAL HIERARCHY:WHITEHALL (Marmot & Shipley, 1996)

  15. LIFE EXPECTANCY IN LONDON BOROUGH OF CAMDEN: MEN • Cycle from Hampstead in the north of Camden to UCL in the south. Travel from area where life expectancy for men is 81 years; within 30 min by bike life expectancy drops by eleven years to 70 years.

  16. WIDENING LIFE EXPECTANCY Source: ‘Let Glasgow Flourish’ Hanlon,P.,Walsh,D. & Whyte,B.,2006

  17. Source: Murray et al 1998

  18. 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).

  19. Oscar winning actors and actresses lived an astonishing 4 years longer than their co-stars and the actors nominated who did not win. (Redelmeier & Singh) • Winning the Oscar is like reducing your chance of dying from a heart attack from about average to zero. Status Syndrome

  20. MEN AGED 64 IN 1990 WHO DIED UP TO 1996 BY EDUCATION SWEDISH NATIONAL SAMPLE Erikson 2001

  21. IT MAY BE A GRADIENT BUT THERE ARE THOSE AT THE BOTTOM

  22. LIFE EXPECTANCY AT BIRTH (*http://www.hreoc.gov.au, Social Justice Report 2005;**Human Development report 2005)

  23. LIFE EXPECTANCY AND ETHNICITY IN NEW ZEALAND European females Pacific females European males Pacific males Maori females Maori males (Tobias & Cheung, 2003)

  24. UNDER 5 MORTALITY RATES BY SOCIOECONOMIC QUINTILE OF HOUSEHOLD per 1000 Source: Gwatkin et al 2000

  25. MORTALITY* AND EDUCATION, SOUTH KOREA *Mortality in Korean working population aged 20-64, 1993-1997, adjusted for age (Source: Son et al. JECH 56:798, 2002)

  26. LIFE EXPECTANCY AT AGE 20 ACCORDING TO YEARS OF EDUCATION, FEMALES, CHILE Source: Vega et al.

  27. INEQUALITIES BETWEEN COUNTRIES

  28. (Source: Angus Deaton)

  29. OUTLINE • The Challenge • Conceptual Framework • Inequalities within and between countries • Explanations • Linking poverty and the gradient

  30. EXPLANATIONS: • “IT’S THE NATURAL ORDER”

  31. TRENDS IN LIFE EXPECTANCY Human Development Report 2005

  32. The widening trend in mortality by education in Russia, 1989-2001 45 p20 = probability of living to 65 yrs when aged 20 yrs Source: Murphy et al, AJPH, 96, 1293-9, 2006

  33. Vågerö, Erikson The Lancet 1997

  34. EXPLANATIONS: POVERTY IN THE POOR COUNTRIES & BAD BEHAVIOUR IN THE RICH?

  35. YES, BUT…

  36. (Source: Angus Deaton)

  37. Ten Tips for Staying Healthy • 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

  38. RICHER UNDERSTANDING OF POVERTY

  39. Life expectancy and GDP in $US (PPP) in 2003

  40. INFANT MORTALITY/1000 LIVE BIRTHS (*http://www.hreoc.gov.au, Social Justice Report 2005;**Human Development Report 2005)

  41. GDP PER CAPITA AND LIFE EXPECTANCY: SELECTED COUNTRIES Source: Human Development Report 2005 and World Health Report 2005

  42. Global pattern of disease communicable Non-communicable injury WHO 2005

  43. PROJECTED INCREASE IN ELDERLY POPULATION (OVER 65): 2000-2030, SELECTED COUNTRIES % increase US Census Bureau, 2001

  44. PEOPLE IN PROFESSIONAL AND MANAGERIAL CLASSES REACH THE SAME LEVEL OF DISABILITY AS THOSE IN ROUTINE AND MANUAL CLASSES ABOUT 15 YEARS EARLIER. ENGLISH LONGITUDINAL STUDY OF AGEING

  45. OUTLINE • The Challenge • Conceptual Framework • Inequalities within and between countries • Explanations • Linking poverty and the gradient

  46. 2) BEYOND MATERIAL CIRCUMSTANCES AND HEALTHCARE HEALTH MATERIAL CIRCUMSTANCES HEALTH EMPOWERMENT

  47. EMPOWERMENT • INDIVIDUAL CONTROL (EFFICACY) • COLLECTIVE CONTROL (EFFICACY)

  48. SELF-REPORTED JOB CONTROL AND CHD INCIDENCE WHITEHALL MEN AND WOMEN Bosma et al, 1998

  49. EFFORT-REWARD IMBALANCE AND CHD INCIDENCE WHITEHALL MEN AND WOMEN Bosma et al, 1998

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