Marmot (2005) - L1: Social determinants - KEY Flashcards
What does life expectancy range from across the world?
Life expectancy at birthranges from 34 years in Sierra Leone to 81·9 years in Japan
Under-5 mortality varies from 316 per 1000 livebirths in Sierra Leone to 3 per 1000 livebirths in Iceland
The probability of a man dying between age 15 and 60 years is 8·3% in Sweden, 82·1% in Zimbabwe, and 90·2% in Lesotho
What are life expectancy gaps within countries?
There is, for example, a 20-year gap in life expectancy between the most and least advantaged populations in the USA
A particularly telling example of health inequalities within countries is the 20-year gap in life expectancy between Australian Aboriginal and Torres Strait Islander peoples—life expectancy is 56·3 years for men and 62·8 years for women—and the Australian average.
Why has the WHO set up an independent Commission on Social Determinants of Health?
To understand the social determinants of health, how they operate, and how they can be changed to improve health and reduce health inequalities
What is the social gradient of health?
Aboriginal and Torres Strait Islander peoples are a socially excluded minority within their country.
But poor health is not confined to poor populations or those who are socially excluded. As with child mortality, there is a socioeconomic gradient in adult mortality rates within countries. Figure 3 shows that in Bangladesh, adult mortality rates vary inversely with level of education.11 This gradient in mortality is quite remarkable. Within rich countries, with strikingly different material conditions from Bangladesh, there is a social gradient in mortality prompting consideration of the causal links between status and health.12 Whether the social gradient in poor countries can be attributed to the same causal pathways is an urgent task for review. It is especially important because, in many countries, inequalities in health have been increasing.
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 Islander peoples. On a world scale, their infant mortality rate, at 12·7 per 1000 livebirths, is low. 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.10 This fact is not to deny that poverty is important. But the form that poverty takes and its health consequences are quite different when considering chronic disease and violent deaths in adults, compared to deaths from infectious disease in children. It entails a richer understanding of the social determinants of health.
The health experience of Aboriginal and Torres Strait Islander peoples has relevance for the health of disadvantaged people worldwide. While in Africa the major contributor to premature mortality is communicable disease, in every other region of the world it is non-communicable disease.1 Careful analysis of the global burden of disease has pointed to the importance of risk factors, such as being overweight, smoking, alcohol, and poor diet.20 These are indeed potent causes. But would it be helpful to go into a deprived Australian Aboriginal population and point out that they should really take better care of themselves—that their smoking and obesity were killing them; and if they must drink, please do so in moderation? Unlikely. To borrow Geoffrey Rose’s term, we need to examine the causes of the causes:21 the social conditions that give rise to high risk of non- communicable disease whether acting through unhealthy behaviours or through the effects of impossibly stressful lives
What is the second highest disease burden amongst adults age 15-59 worldwide?
unipolar depressive disorder
What is disease burden?
Disease burden is the impact of a health problem as measured by financial cost, mortality, morbidity, or other indicators. It is often quantified in terms of quality-adjusted life years or disability-adjusted life years, both of which quantify the number of years lost due to disease.
Explain why there is not simply a direct link between economic prosperity and health
although it might be obvious that poverty is at the root of much of the problem of infectious disease, and needs to be solved, it is less obvious how to break the link between poverty and disease. Income poverty provides, at best, an incomplete explanation of differences in mortality among countries or among. subgroups within countries. It is well known that among rich countries, there is little correlation between gross national product (GNP) per person and life expectancy. Greece for example, with a GNP at purchasing power parities of just more than US$17 000, has a life expectancy of 78·1 years; the USA, with a GNP of more than $34 000, has a life expectancy of 76·9 years. Costa Rica and Cuba stand out as countries with GNPs less than $10 000 and yet life expectancies of 77·9 years and 76·5 years.
There are many examples of relatively poor populations with similar incomes but strikingly different health records.8 Kerala and China, famously, have good health, despite low incomes.24 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. A social determinants perspective is crucial. It is also important to enquire whether the action that is taking place to relieve poverty is having the desired effect not only on average incomes but also on income distribution and hence on the poorest people
What are policies countries have put in place to address the SDOH?
In Sweden, the new strategy for public health is “to create social conditions that will ensure good health for the entire population”. Of 11 policy domains, five relate to social determinants: participation in society, economic and social security, conditions in childhood and adolescence, healthier working life, and environ- ment and products. These are in addition to health promoting medical care and the usual health behaviours. The UK set reduction of health inequalities as a key aim of health policy. It assembled evidence and expert judgments on areas suitable for policy development. These then formed the basis of a plan of action to reduce health inequalities.
These are examples from rich countries. There are further encouraging examples. Familias en Accion in Colombia transfers cash to poor families. To qualify, families must ensure their children receive preventive health care, enrol in school, and attend classes. The results are encouraging: favourable growth of children and fewer episodes of diarrhoea.34 The Oportunidades programme in Mexico had somewhat similar aims with similarly encouraging results
