Health Status: A Matter of Class?

1. Health Status: A Matter of Class? by The Hon. Monique Bégin, PC, FRSC, OC University of Ottawa WHO Commission on Social Determinants of Health 2nd Annual Faculty of Health Sciences Distinguished Lecture,University of Western Ontario, London (ON) March 29, 2007

2. Today… • We want to explore « why are some people healthy and others not ? », to paraphrase Bob Evans. • If genetics and individual risk factors are not the best predictors of staying healthy or becoming ill, what are the predictors society should know about? Monique Bégin

3. Social determinantsis the answerand the key to understanding patterns of health and illness. Monique Bégin

4. The « classless » society?... • Canadians and Americans like to think that they are very egalitarian and don’t have social classes. • We mask reality by referring to « socio-economic status ». • The Brits who acknowledge that their society is a well-entrenched class system have a long tradition of research of the connection between health and class. Monique Bégin

5. Two famous British studies: *Black *Whitehall

6. The Black Report • Sir Douglas Black et al • First released in 1980 • Tracked patterns of inequalities of health across Britain through health records. • Made recommendations for health improvement. • Thatcher tried to suppress the report. • Finally published in 1988 together with Margaret Whitehead’s update The Health Divide.  Monique Bégin

7. The Black Report showed… • Improvement in health across all the classes since creating the National Health Service (1948). • Still a correlation between social class, and infant mortality rates, life expectancy and unequal use of medical services. • Lower occupational groups experience poorer health at all stages of life. Monique Bégin

8. The Whitehall I Study • Sir Michael Marmot (joined in 1976) • Published 1986-1987 • 10,000+ male civil servants, over 10 years. • Divided in 4 groups: • administrative (such as permanent secretaries/ Deputy Ministers); • professional and executive (such as senior executive officers); • clerical; • other (unskilled manual workers - as porters, messengers). Monique Bégin

9. Why Whitehall I ? • Initially undertaken in 1967, separate from the Black research, to investigate cardiorespiratory disorders and their precursors. • Main topics covered: • cardiovascular function, smoking, angina • diabetes, clinical examination, ECG measurements • car ownership, leisure/hobbies and grade of employment. Monique Bégin

10. Research’s assumption was: Individuals with big jobs and big responsibilities are those prone to cardiac accidents. Monique Bégin

11. Research results: Monique Bégin

12. Monique Bégin

13. Whitehall I and II concluded: • People at the bottom of the hierarchy had a higher risk of heart attacks. The lower you were in the hierarchy, the higher the risk. • The same applied to all the major causes of death -- cardiovascular disease, gastrointestinal disease, renal disease, stroke, accidental and violent deaths, cancers that were not related to smoking as well as cancers that were related to smoking. Monique Bégin

14. Whitehall’s social determinants: • Low job control. • Job stress, tension • Lack of skill utilization • Lack of clarity in tasks. • Household income or wealth • Conflicting work and family demands. • No socially cohesive neighbourhood. Monique Bégin

15. Long spells of sickness absence by grade (Men, Whitehall II study) Monique Bégin

16. Gradient in Psychological Stress by Executive Level in Canadian Civil Servants p<0.0001;Lemyre, Beauregard, Corneil & Barette (CRSH-INE 2002-05) «The Federal Public Service as a Learning Organization: Stress and Learning in Executives » Louise Lemyre, Ph.D, FRSC School of Psychology, Faculty of Social Sciences R. S. McLaughlin Research Chair Groupe d’Analyse Psychosociale de la Santé (GAP-Santé) Institute of Population Health, University of Ottawa louise.lemyre@uottawa.ca www.gapsante.uottawa.ca Monique Bégin

17. Do socioeconomic differences in mortality persist after retirement? Relative differences in mortality between low and high employment grades are less after retirement, suggesting the importance of work in generating inequalities in health.

18. On the lighter side…"People with PhDs live longer than those with masters degrees. Those with a masters live longer than those with a degree, while those with a degree live longer than those who left school early.Similarly, actors who have won an Oscar will live on average 3 years longer than those who were nominated for the award but missed out. " Monique Bégin

19. British milestones studies: • The Black Report (1980) • The Whitehall Studies I and II (1967-1987 and 1987-2007 +) • Margaret Whitehead’s The Health Divide (Black updated 1992) • The Acheson Inquiry (1998) • Modernising Government White Paper (1999) • Saving Lives - Our Healthier Nation White Paper (1999) • The NHS Plan (2000) • Tackling Health Inequalities Cross-Cutting Review (2002) • Tackling Health Inequalities. A Programme for Action (2003) • The Wanless Reviews (2002, 2004) • Choosing health: making healthy choices easier (2004) • Tackling Health Inequalities: Status Report (2005) Monique Bégin

20. These studies tell us about: • The social determinants of health: we now know that factors other than genetic/biological do determine health status. • The gradient theory: we also know that « social classes » or different socio-economic status do predict health status. Monique Bégin

21. The Lalonde report is the Canadian «ancestor» of the social determinants approach (Health Canada, 1974)

22. The Ottawa Charter (1986): Towards Healthy Public Policy Monique Bégin

23. Dr. Fraser Mustard conceptualized the social determinants of health around 1989-90. Monique Bégin

24. Dahlgren and Whitehead 1991 Monique Bégin

25. Inequality Wilkinson (1996) argues that what matters most is not whether you have a smaller or larger home or better or lesser care but what these differences mean socially and what they make you feel about yourself and the world around you. (Richard Wilkinson, University of Nottingham, UK) Monique Bégin

26. Health inequality: An observable, often measurable, difference in health status between individuals or between groups, whatever its cause. Health inequity: A moral category rooted in social stratification, embedded in political reality and the negotiations of social power relations. From health inequalityto health inequity Monique Bégin

27. Consequently: Health equity can be defined as the absence of unfair or unavoidable or remediable differences in health among populations or groups defined socially, economically, demographically or geographicaly. Monique Bégin

28. How egalitarian a society are we? There is now good evidence that the healthiest and happiest societies are those with the most equaldistribution of income. Monique Bégin

29. Inequalities in health outcomes:* Do they exist within other countries?* Between countries? Monique Bégin

30. …arriving home in Maryland…life expectancy is 77 years. Leaving downtown Washington (DC) at 5 P.M., life expectancy is 57 years. The same within most countries: Monique Bégin

31. 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 Monique Bégin Geronimus et al, NEJM 1996

32. The Widening Trend in Mortality by Education in Russia,1989-2001 45 p20 = probability of living to 65 yrs when aged 20 yrs Monique Bégin Murphy, Bobak, Nicholson, Rose, and Marmot, 2005 under review

33. Inequality in a Canadian context 1990-2000: * Wealthiest 10% of Canadians increased their income by $23,000 per person per year. * Poorest 10% of Canadians increased theirs by $81 per person per year. Monique Bégin

34. CANADA: more facts… • Food insecurity exists among 10.2% of Canadian households representing 3 million people. Monthly food bank use is 747,665 or 2.4% of total Canadian population, double the 1989 figure. Monique Bégin

35. Over last 10 years, welfare benefits have dropped in most provinces below half of basic living costs.In 2001, just 39% of unemployed Canadians were eligible for unemployment insurance benefits. The program must be more accessible.Minimum wages are inadequate to achieve a decent standard of living. Homelessness and housing constitute a national emergency. Monique Bégin

36. Aboriginal health Monique Bégin

37. … and health inequalities exist between countries: Monique Bégin

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

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

40. Under-five mortality rate, change over period 1990-2000 Monique Bégin

41. No comments… • In Kumasi, Ghana, a country which privatized public toilets in the 1990s, private toilet use once a day for a family costs 10% of the basic wage. Monique Bégin

42. WHO Commission on Social Determinants of Health(March 2005 – April 2008) Monique Bégin

43. Michael Marmot, Chair 19 members (volunteers)–One Canadian (M. Bégin) Small Secretariat in Geneva Smaller scientific team around Marmot in London. Meetings in-person 3-4 times per year. Pillars of our work: 8 knowledge networks Countries (and regions) involved Civil society and global partners involved (World Bank, etc.) World Health Organisation (WHO) How is the Commission organized? Monique Bégin

44. KNOWLEDGE NETWORK THEMES Monique Bégin

45. 3 Knowledge Networks funded by Canada: • Early Childhood Development (Dr. Clyde Hertzman, UBC) • Globalization and Health (Dr. Ron Labonte, UofO) • Health Systems (via IDRC, in South Africa) Monique Bégin

46. My personal “mission” as a Commissioner • Ensure that unique challenges of the worlds’ Indigenous people are addressed in CSDH work • Working in partnership with Australia, NZ, South American countries to explore ways to address unique determinants of Indigenous peoples’ health • Ensure that CSDH recommendations address inequalities in developed as well as developing countries • Facilitate moving Canada beyond ‘pilot projects’ to a systemic approach to addressing determinants of health Monique Bégin

47. Canada’s participation: • The PHAC created a Canadian Reference Group with various stakeholders • Engaging the Canadian society • A joint project with UK and Sweden on «whole-of-government»* strategies • An Aboriginal Sub-Committee Challenges: how do we beat the « silos » approach to public policy when most determinants of health are outside health ministries?... How do we make poverty visible to Canadians? Monique Bégin

48. Is action possible?... • Yes it is and it’s urgent! • How? By shedding «the culture of contentment» in which we live. • By saying loud and clear that social policies do matter to Canadians. • By addressing upstream factors through «whole-of-government» policies instead of focusing on downstream problems: Monique Bégin

49. To conclude: Global Health Watch… • reports that the cost of achieving and maintaining universal access to basic education, basic health care, adequate food, and safe water and sanitation for all has been estimated at less than 4% of the combined wealth of the 225 richest people in the world. • They consider poverty and development as a public health issue. Monique Bégin

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