the social determination of health

Summer School Towards a right to health without borders

Interdisciplinary approaches for social change (RHEACH)

Izmir (Turkey), 8th - 18th July 2014

The Social Determination of Health

Centre for International Health (CSI) Alma Mater Studiorum University of Bologna

A construc*on worker’s 10-‐story fall from scaffolding

•  Insufficiently conscious of safety •  Exhausted due to his long commute •  Sleepless night because of noise •  Thin walls of his poor dwelling •  Low earning due to no minimum

wage policy and precarious status •  Poor safety regula>ons •  No training from employer •  Poor quality of scaffolding •  Free market system: profit vs safety •  Weak Unions: threat of job losses

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A construc*on worker’s 10-‐story fall from scaffolding

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•  Insufficiently conscious of safety •  Exhausted due to his long commute •  Sleepless night because of noise •  Thin walls of his poor dwelling •  Low earning due to no minimum

wage policy and precarious status •  Poor safety regula>ons •  No training from employer •  Poor quality of scaffolding •  Free market system: profit vs safety •  Weak Unions: threat of job losses

A personal accident? Or

The product of interlocking social, economic, and political factors?

Different perspec*ves on Health

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•  Bio-‐medical Model

•  Behavioural Model

•  Poli*cal-‐economy Approach

Dahlgren & Whitehead 1991

Determinants of Health - 'Policy Rainbow'

Samir, senegalese,

50yrs, in Italy since early ‘90s, acute miocardial

infartion

SOCIAL NETWORKS assistance during hospital admission and discharge,

family support

LIFE STYLES / RISK FACTORS

smoking, hypertension, overweight

WORK Lost previous

job, now occasional

manual jobs

LEGAL STATUS No work documents

GEOGRAPHICAL ORIGIN Senegal

Life exp: 63 anni GDP/pc/yr ≈ 2.000$ Migration history

SOCIAL CONDITIONS ability to (empowered to)

understand, Possibility to choose

INCOME medicines, user-

charges, (physical activity, nutrition...)

INCOME

GENERAL SOCIO-ECONOMIC CONDITIONS (national-international)

SERVICES Accessibility,

competence, equity...

Causes of Preventable Deaths (U.S., 2006) From Kirsti A. Dyer MD, MS, FT, former About.com Guide

Personal behaviour / free choice

How personal and free?

SOCIAL COHESION

Marmot, Lancet 2006

INCOME

INCOME

EDUCATION

*adjusted by age and area of birth

Coronary heart events by education. Turin, 1996-99

WOMEN

MEN

1.61 (1.44-1.80)

Primary school or less

1.41 (1.26-1.58)

Middle school

1 University/high school

1.31 (1.24-1.38)

Primary school or less

1.26 (1.19-1.33)

Middle school

1 University/high school

Incidence HR* (95% IC)

Education

HEALTH SERVICES

Global Inequalities

ECONOMIC CRISIS AND HEALTH

Hopkins 2006

Open Ques*on Time

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•  Health inequali*es caused by the unequal distribu>on of power, income, goods, and services, globally and na*onally

•  Not a ‘natural’ phenomenon but the “result of a toxic combina*on of poor social policies and programmes, unfair economic arrangements, and bad poli*cs”

•  Together, the structural determinants and condi*ons of daily life cons*tute the social determinants of health

•  A new approach to development: economic growth by itself is not enough without redistribu>on

Social vs Societal Determinants

•  Social Determinants –  Public policies and private sector ac*ons shaping hierarchies of exposure to factors that determine health.

–  Act mainly on rec*fying levels of exposure.

•  Societal Determinants –  The poli*cal-‐economic order and structures of power, in which health inequi*es derive from elite groups exercising power against oppressed groups.

–  Need for rec*fying unequal poli*cal power. Birn 2009

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Approaches to account for health inequi*es i.e. for the paYern of distribu*on of health

1.  The Psycho-‐Social Theory / Social Capital (Wilkinson RG, Kawachi I.)

2.  The Socio-‐Poli*cal / Neo-‐Materialis*c / Social Produc*on Of Health (Davey Smith G., Muntaner C.)

3.  The Mul*level Eco-‐Social Theory (Krieger N., Fassin D.)

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Psycho-‐Social Theory

•  Social position •  The “Status Syndrome”

Education

Occupation

Income

SOCIOECONOMICPOLITICAL

CONTEXT

IMPACT ONEQUITY INHEALTH

ANDWELL-BEING

Health System

Material Circumstances(Living and Working, Conditions, FoodAvailability ,etc)

Behaviors andBiological Factors

Psychosocial Factors

SocioeconomicPosition

Governance

MacroeconomicPolicies

Social PoliciesLabour market,Housing, Land.

Culture andSocietal value

Public Policies,Education, Health,Socialprotection,

Social ClassGender

Ethnicity (racism)

Social cohesion & Social Capital

(d)

INTERMEDIARY DETERMINANTSOF HEALTH

STUCTURAL DETERMINANTS OFHEALTH INEQUITIES

Figure 6–4d. The WHO Commission on the Social Determinants of Health (2007).

The Social (vs Societal) Determinants of Health

214 EPIDEMIOLOGY AND THE PEOPLE’S HEALTH

(Journal of Biosocial Science , 2009 ) was, until 1968, called the Eugenics Review (founded in 1909) (Mazumdar, 2000 ).

To begin, the ecosocial question “Who and what is responsible for current and changing patterns of health inequities?” necessarily engages with the query “Who and what drives overall patterns and levels of morbidity and mortality?” — both among people and also, as warranted, among other species. It consequently is obligate, not optional, to link the theo-rizing to specifi c diseases, and their historically-specifi c and spatially-patterned rates and trends, both singly and in concert with other specifi c outcomes. Awareness of disease-specifi c patterns, including which are leading causes of morbidity and mortality in speci-fi ed social groups at particular ages, at which historical moment, in turn is essential for comprehending the patterning of commonly used “summary” outcomes (e.g., all-cause mortality, premature mortality, and life expectancy). As ecosocial theory underscores,

Lifecourse:

in utero

Populationdistribution

of health

genderinequality

Levels: societal& ecosystem

global

national

regional

area or group

household

individual

historicalcontext +

generation

ECOSOCIAL THEORY:LEVELS, PATHWAYS & POWER

--Embodiment--Pathways of embodiment--Cumulative interplayof exposure, susceptibility & resistance--Accountability & agency

POLITICAL ECONOMY

& ECOLOGY Processes:production,exchange,consumption,reproduction

infancy childhood adulthood

classinequality

racial/ethnicinequality

Figure 7–1. Ecosocial theory and embodying inequality: core constructs. (Krieger, 1994 ; Krieger, 2008a ) Core constructs , referring to processes conditional upon extant political economy and political ecology : 1. Embodiment , referring to how we literally incorporate, biologically, in societal and ecological context, the material and social world in which we live; 2. Pathways of embodiment , via diverse, concurrent, and interacting pathways, involving adverse exposure to social and economic deprivation; exogenous hazards (e.g., toxic substances, pathogens, and hazardous conditions); social trauma (e.g., discrimination and other forms of mental, physical, and sexual trauma); targeted marketing of harmful commodities (e.g., tobacco, alcohol, other licit and illicit drugs); Inadequate or degrading health care; and degradation of ecosystems, including as linked to alienation of indigenous populations from their lands 3. Cumulative interplay of exposure, susceptibility, and resistance across the lifecourse , referring to the importance of timing and accumulation of, plus responses to, embodied exposures, involving gene expression, not simply gene frequency; and 4. Accountability and agency , both for social disparities in health and research to explain these inequities.

The Mul*level Eco-‐Social Theory

Biological, social and cultural categories such as gender, race, class, sexual orienta*on, and other axes of iden*ty interact on mul*ple and ocen simultaneous levels, crea*ng a system of oppression that reflects the "intersec*on" of mul*ple forms of discrimina*on.

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The Issue of Intersec.onality

“Label infant mortality a problem of ‘minori.es’ and present data only on racial/ethnic differences in rates, and the white poor will disappear from view;

Label it a ‘poverty’ issue and present data stra.fied only by income, and the impact of racism on people of colour at each income level will be hidden from sight…

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…Any par.cular approach necessarily affects our ability to understand and alter social inequali.es in health.“

(N. Krieger 1992)

The Issue of Intersectionality (2)

Barriers to Effec*ve Ac*on on the Societal Determinants of Health

(Dennis Raphael, www.piY.edu/~super7/8011-‐9001/8511.ppt)

Ø  Lack of Epidemiological Theory Health officials and reporters seem unaware of recent developments in social epidemiological theory and popula*on health research findings.

Ø  Ideology of Individualism in Health, Illness and Health Promo.on Neo-‐liberal and neo-‐conserva*ve agendas are at root of, and reinforce the individualis*c/vic*m blaming approach to health problems, absolving governments for their health threatening policies that create poverty, inequality, and social exclusion.

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The Spirit of 1848 A Network Linking Politics, Passion, & Public Health an officially recognized caucus within the American Public Health Association http://www.spiritof1848.org/

the social determination of health

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