Social determinants of health inequalities

TL;DR: A Commission on Social Determinants of Health is launching, which will review the evidence, raise societal debate, and recommend policies with the goal of improving health of the world's most vulnerable people.

About: This article is published in The Lancet.The article was published on 2005-03-19 and is currently open access. It has received 3670 citations till now. The article focuses on the topics: Social determinants of health & Health policy.

Summary

Panel 1: The commission on Social Determinants of Health

• The Commission will not only review existing knowledge but raise societal debate and promote uptake of policies that will reduce inequalities in health within and between countries.
• The Commission's aim is, within three years, to set solid foundations for its vision: the societal relationships and factors that influence health and health systems will be visible, understood, and recognised as important.
• On this basis, the opportunities for policy and action, and the costs of not acting on these social dimensions will be widely known and debated.
• Success will be achieved if institutions working in health at local, national, and global level will be using this knowledge to set and implement relevant public policy affecting health.
• The Commission will contribute to a long-term process of incorporating social determinants of health into planning, policy and technical work at WHO.

Children

• Under five mortality varies from 316 per 1000 live births in Sierra Leone to 3, 4 and 5 in Iceland, Finland and Japan.
• Figure 1 shows under five mortality rates for four countries with households classified according to socioeconomic quintile.
• 9 Within countries, not only is child mortality highest among the poorest households, but also there is a social gradient: the higher the socioeconomic level of the household the lower the mortality rate.

Adults

• Differences in adult mortality among countries are large and growing.
• But poor health is not confined to poor population or those who are socially excluded.
• As with child mortality, there is a socioeconomic gradient in adult mortality rates within countries.
• 18 Second, and related, international policies have not been pursued as if they had people's basic needs in mind.
• Dirty water, lack of calories and poor antenatal care cannot account for the 20-year deficit in life expectancy of Australian Aboriginal and Torres Strait Islanders peoples.

Panel 2: The solid facts

• Because the causes of the causes are not obvious, the WHO Regional Office for Europe asked a group at University College London to summarise the evidence on the Social Determinants of Health published as the Solid Facts.
• As an indication that there was a ready audience for these messages, in the first twelve months after publication of the second edition it was downloaded from the web 218,000 times.
• It is well known that among rich countries, there is little correlation between gross national product (GNP) per person and life expectancy.
• The social processes that lead to this beneficial state of health need not wait for the world order to be changed to relieve poverty in the worst off countries.
• In rich countries, with low levels of material deprivation the gradient changes the focus from absolute to relative deprivation.

Action is possible and necessary

• 10 Although the reason for the policies was not necessarily to improve health, they were nevertheless relevant to health: taxation and tax credits, old-age pensions, sickness or rehabilitation benefits, maternity or child benefits, unemployment benefits, housing policies, labour markets, communities, care facilities.
• In Sweden, the new strategy for public health is "to create social conditions that will ensure good health for the entire population".
• 31 Of eleven policy domains five relate to social determinants: participation in society, economic and social security, conditions in childhood and adolescence, healthier working life, environment and products.
• To qualify, families must ensure their children receive preventive health care, enrol in school and attend classes.
• Favourable growth of children and fewer episodes of diarrhoea, also known as The results are encouraging.

Meeting human needs

• Two linked themes provide the rationale for the Commission on Social Determinants of Health.
• Treating existing disease is urgent and will always receive high priority but should not be to the exclusion of taking action on the underlying social determinants of health.
• One standard answer is to measure economic well-being using measures such as GNP, average income, or consumption patterns.
• 37 There is a great deal of dogmatic dispute about the rights and wrongs of economic and social policies.
• 38 There is no necessary biological reason why life expectancy should be 48 years longer in Japan than in Sierra Leone or 20 years shorter in Australian Aboriginal and Torres Strait Islander Peoples than in other Australians.

Figures

Figure 1: Under-5 mortality rates per 1000 live births by socioeconomic quintile of household (Reprinted from reference 9 with permission of Elsevier)

Figure 4: Increase in educational

Figure 5: Projected percentage increase in the elderly population (older than 65 years) from 2000 to 2030 in selected countries Adapted from reference 17 with permission of the US Census Bureau

Figure 2: Trends in adult mortality by sex in regions of the world, 1970-2002 The graphs show the probability of death between 15 and 60 years of age per 1000 population. Reprinted from reference 7 with permission of the World Health Organization.

Frequently asked questions

Q1. What are the contributions in this paper?

The gross inequalities in health that the authors see within and between countries present a challenge to the world. As a response to this global change, WHO is launching a Commission on Social Determinants of Health, which will review the evidence, raise societal debate, and recommend policies with the goal of improving health of the word ’ s most vulnerable people. 

Q2. What is the purpose of the new strategy for public health?

In Sweden, the new strategy for public health is “to create social conditions that will ensure good health for the entire population”. 

Q3. What causes the high rate of adult mortality?

Their high rate of adult mortality is from cardiovascular diseases, cancers, endocrine nutritional and metabolic diseases (including diabetes), external causes (violence), respiratory disorders, and digestive diseases. 

Q4. How many deaths were due to non-communicable diseases in 2002?

Of the 45 million deaths among adults aged 15 years and over in 2002, 32 million were due to non-communicable disease and a further 4.5 million to violent causes. 

Q5. What are the five policy domains that relate to social determinants?

Of eleven policy domains five relate to social determinants: participation in society, economic and social security, conditions in childhood and adolescence, healthier working life, environment and products. 

Q6. What is the purpose of the Commission on Social Determinants of Health?

Disease control, properly planned and directed, has a good history, but so too does social and economic development, in combating major disease and improving population health. 

Q7. How many people died under the age of five?

By 2002, for example, men in the high mortality countries of Europe had more than 40% probability of death between 15 and 60 compared to a 25% probability in southeast Asia. 

Q8. What were the reasons for the policies?

Although the reason for the policies was not necessarily to improve health, they were nevertheless relevant to health: taxation and tax credits, old-age pensions, sickness or rehabilitation benefits, maternity or child benefits, unemployment benefits, housing policies, labour markets, communities, care facilities. 

Q9. What is the importance of a social determinants perspective?

It is also crucial to enquire whether the action that is taking place to relieve poverty is having the desired effect not only on average incomes but on income distribution and hence on the poorest people. 

Q10. What is the main argument of the critics of the economic policies pursued by the IMF?

The critics of the policies pursued by the International Monetary Fund in the global South have argued eloquently that the economic policies pursued under structural adjustment have not benefited the disadvantaged in poor countries. 

Q11. How can the authors understand the impact of poverty on the lives of people in Sierra Leone?

It is not difficult to understand how poverty in the form of material deprivation – dirty water, poor nutrition – allied to lack of quality medical care, can account for the tragically foreshortened lives of people in Sierra Leone.