health status: a matter of class?

Health Status: A Matter Health Status: A Matter of Class?of Class?

bybyThe Hon. Monique Bégin, PC, FRSC, OCThe Hon. Monique Bégin, PC, FRSC, OC

University of OttawaUniversity of OttawaWHO Commission on Social Determinants of HealthWHO Commission on Social Determinants of Health

22ndnd Annual Faculty of Health Sciences Distinguished Lecture, Annual Faculty of Health Sciences Distinguished Lecture, University of Western Ontario, London (ON) University of Western Ontario, London (ON) March 29, 2007March 29, 2007

Monique BéginMonique Bégin 22

Today…Today…

We want to explore « why are some We want to explore « why are some people healthy and others not ? », to people healthy and others not ? », to paraphrase Bob Evans.paraphrase Bob Evans.

If genetics and individual risk factors are If genetics and individual risk factors are not the best predictors of staying healthy not the best predictors of staying healthy or becoming ill, what are the predictors or becoming ill, what are the predictors society should know about? society should know about?


Social determinantsSocial determinants is the answeris the answer

and the key to understanding and the key to understanding patterns of health and illness.patterns of health and illness.


The « classless » society?...The « classless » society?... Canadians and Americans like to think that Canadians and Americans like to think that

they are very egalitarian and don’t have they are very egalitarian and don’t have social classes.social classes.

We mask reality by referring to « socio-We mask reality by referring to « socio-economic status ».economic status ».

The Brits who acknowledge that their The Brits who acknowledge that their society is a well-entrenched class system society is a well-entrenched class system have a long tradition of research of the have a long tradition of research of the connection between health and class.connection between health and class.

Two famous British Two famous British studies: studies:

*Black *Black *Whitehall*Whitehall


The Black ReportThe Black Report Sir Douglas Black et al Sir Douglas Black et al First released in 1980First released in 1980 Tracked patterns of inequalities of health Tracked patterns of inequalities of health

across Britain through health records.across Britain through health records. Made recommendations for health Made recommendations for health

improvement. improvement. Thatcher tried to suppress the report.Thatcher tried to suppress the report. Finally published in 1988 together with Finally published in 1988 together with

Margaret Whitehead’s update Margaret Whitehead’s update The Health The Health Divide. Divide.


The The BlackBlack Report Report showed…showed…

1.1. Improvement in health across all the Improvement in health across all the classes since creating the National classes since creating the National Health Service (1948).Health Service (1948).

2.2. Still a correlation between social class, Still a correlation between social class, and infant mortality rates, life and infant mortality rates, life expectancy and unequal use of medical expectancy and unequal use of medical services. services.

3.3. Lower occupational groups experience Lower occupational groups experience poorer health at all stages of life.poorer health at all stages of life.


The Whitehall I StudyThe Whitehall I Study

Sir Michael Marmot (joined in 1976)Sir Michael Marmot (joined in 1976) Published 1986-1987Published 1986-1987 10,000+ male civil servants, over 10 10,000+ male civil servants, over 10

years.years. Divided in 4 groups: Divided in 4 groups:

– administrativeadministrative (such as permanent secretaries/ (such as permanent secretaries/ Deputy Ministers); Deputy Ministers);

– professional and executiveprofessional and executive (such as senior (such as senior executive officers);executive officers);

– clerical;clerical;– otherother (unskilled manual workers - as porters, (unskilled manual workers - as porters,

messengers). messengers).


Why Whitehall I ?Why Whitehall I ? Initially undertaken in 1967, separate from the Initially undertaken in 1967, separate from the

Black research, to investigate Black research, to investigate cardiorespiratory cardiorespiratory disordersdisorders and their precursors. and their precursors.

Main topics covered: Main topics covered: – cardiovascular function, smoking, angina cardiovascular function, smoking, angina – diabetes, clinical examination, ECG measurementsdiabetes, clinical examination, ECG measurements– car ownership, leisure/hobbies and grade of car ownership, leisure/hobbies and grade of

employment. employment.


Research’s assumption was:Research’s assumption was:

Individuals with Individuals with big jobs and big big jobs and big responsibilities responsibilities are those prone are those prone

to cardiac to cardiac accidents.accidents.

BOSS

No. 2a No. 2b No. 2c


Research results:Research results:


Whitehall I and II concluded:Whitehall I and II concluded: People People at the bottom of the hierarchyat the bottom of the hierarchy had a had a

higher risk of heart attacks. The lower you were higher risk of heart attacks. The lower you were in the hierarchy, the higher the risk. in the hierarchy, the higher the risk.

The same applied The same applied to all the major causes of to all the major causes of deathdeath -- cardiovascular disease, gastrointestinal -- cardiovascular disease, gastrointestinal disease, renal disease, stroke, accidental and disease, renal disease, stroke, accidental and violent deaths, cancers that were not related to violent deaths, cancers that were not related to smoking as well as cancers that were related to smoking as well as cancers that were related to smoking.smoking.


Whitehall’s social determinants:Whitehall’s social determinants:

Low job control.Low job control. Job stress, tensionJob stress, tension Lack of skill utilizationLack of skill utilization Lack of clarity in tasks. Lack of clarity in tasks. Household income or wealthHousehold income or wealth Conflicting work and family demands.Conflicting work and family demands. No socially cohesive neighbourhood.No socially cohesive neighbourhood.


Long spells of sickness absence by grade Long spells of sickness absence by grade (Men, Whitehall II study)(Men, Whitehall II study)


30.00

32.00

34.00

36.00

38.00

40.00

Stress

1

Occupational level

EX 1

EX 2

EX 3

EX 4

EX 5 & 6

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, FRSCSchool of Psychology, Faculty of Social Sciences

R. S. McLaughlin Research ChairGroupe d’Analyse Psychosociale de la Santé (GAP-Santé)

Institute of Population Health, University of [email protected] www.gapsante.uottawa.ca

Gradient in Psychological Stress by Executive Level in Canadian Civil Servants

mailto:[email protected]

Do socioeconomic differences in Do socioeconomic differences in mortality persist after retirement?mortality persist after retirement?

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


On the lighter side…On the lighter side…

"People with PhDs live longer than those with "People with PhDs live longer than those with masters degrees. Those with a masters live longer masters degrees. Those with a masters live longer than those with a degree, while those with a than those with a degree, while those with a degree live longer than those who left school early.degree live longer than those who left school early.

Similarly, actors who have won an Oscar will live Similarly, actors who have won an Oscar will live on average 3 years longer than those who were on average 3 years longer than those who were nominated for the award but missed out. "nominated for the award but missed out. "


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


These studies tell us about:These studies tell us about:

The social determinants of healthThe social determinants of health: we : we now know that factors other than now know that factors other than genetic/biological do determine genetic/biological do determine health status.health status.

The gradient theoryThe gradient theory: we also know : we also know that « social classes » or different that « social classes » or different socio-economic status do predict socio-economic status do predict health status.health status.

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


The Ottawa Charter (1986): The Ottawa Charter (1986): Towards Healthy Public PolicyTowards Healthy Public Policy


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


Dahlgren and Whitehead 1991Dahlgren and Whitehead 1991


InequalityInequality

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


From From health inequalityhealth inequality to to health inequityhealth inequity

Health inequality:Health inequality: An observable, An observable,

often measurable, often measurable, difference in health difference in health status between status between individuals or individuals or between groups, between groups, whatever its cause.whatever its cause.

Health inequity:Health inequity: A moral category A moral category

rooted in social rooted in social stratification, stratification, embedded in embedded in political reality and political reality and the negotiations of the negotiations of social power social power relations.relations.


Consequently:Consequently:

HHealth equityealth equity can be defined can be defined as the absence of unfair or as the absence of unfair or unavoidable or remediable unavoidable or remediable differences in health among differences in health among populations or groups defined populations or groups defined socially, economically, socially, economically, demographically or demographically or geographicalygeographicaly..


How egalitarian a society are we?How egalitarian a society are we?

There is now good evidence that the healthiest and happiest societies are

those with the most equal distribution of income.


Inequalities Inequalities in health outcomesin health outcomes::

* * Do they existDo they exist within other within other countries?countries?

* Between countries?* Between countries?


The same The same withinwithin most countries: most countries:

……arriving home in arriving home in Maryland…life Maryland…life expectancy is expectancy is 77 77 years.years.

Leaving downtown Leaving downtown Washington (DC) at Washington (DC) at 5 P.M., life 5 P.M., life expectancy is expectancy is 57 57 yearsyears..


Probability of Survival From Age 15-65 Probability of Survival From Age 15-65 Years Among US Blacks & WhitesYears Among US Blacks & Whites

20

30

40

50

60

70

80

% p

roba

bilit

y of

su

rviv

al

Geronimus et al, NEJM 1996

US White Poor White US Black Poor BlackMales Males Males Males


The Widening Trend in Mortality by Education in Russia,1989-2001

0,4

0,45

0,5

0,55

0,6

0,65

0,7

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

Calendar year

45 p

20

elementary university

45 p20 = probability of living to 65 yrs when aged 20 yrs

Murphy, Bobak, Nicholson, Rose, and Marmot, 2005 under review


Inequality in a Canadian contextInequality in a Canadian context

1990-20001990-2000: :

** Wealthiest 10% Wealthiest 10% of Canadians of Canadians increased their income by increased their income by $23,000$23,000 per person per year.per person per year. * * PPoorest 10%oorest 10% of Canadians of Canadians increased theirs by increased theirs by $81$81 per person per person per year.per year.


CANADA: more facts…CANADA: more facts…

Food insecurityFood insecurity exists among 10.2% exists among 10.2%

of Canadian households representing of Canadian households representing

3 million people. Monthly food bank 3 million people. Monthly food bank

use is 747,665 or 2.4% of total use is 747,665 or 2.4% of total Canadian population, Canadian population, double the double the

1989 figure.1989 figure.


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.


CanadaCanada Status Status IndiansIndians

InuitsInuits

Life Life expectancy expectancy at birthat birth

Female 82Female 82

Male 76Male 76

7777

6969

6868

7070Infant Infant mortality mortality (1000)(1000)

5.35.3 8.08.0 15.015.0

Deaths by Deaths by suicidesuicide(100,000)(100,000)

1313 2828 7979

Aboriginal healthAboriginal health


… … and health inequalities and health inequalities exist between countries:exist between countries:


% PROBABILITY OF DYING BETWEEN % PROBABILITY OF DYING BETWEEN AGES 15 AND 60 (males)AGES 15 AND 60 (males)

LESOTHOLESOTHO 90.290.2RUSSIARUSSIA 46.946.9BOLIVIABOLIVIA 2626SRI LANKASRI LANKA 23.823.8COLOMBIACOLOMBIA 23.623.6PAKISTANPAKISTAN 22.722.7SWEDENSWEDEN 8.38.3

SOURCE: THE WORLD HEALTH REPORT 2004,WHO


UNDER 5 MORTALITY RATE PER UNDER 5 MORTALITY RATE PER 1000 LIVE BIRTHS1000 LIVE BIRTHS

SIERRA LEONESIERRA LEONE 316316

BOLIVIABOLIVIA 8080

KYRGYZSTANKYRGYZSTAN 6363

SRI LANKASRI LANKA 2020

ICELANDICELAND 33

SOURCE: THE WORLD HEALTH REPORT 2004,WHO


Under-five mortality rate, change over Under-five mortality rate, change over period 1990-2000period 1990-2000


No comments…No comments…

In Kumasi, Ghana, In Kumasi, Ghana, a country which a country which privatizedprivatized public public toilets in the 1990s, toilets in the 1990s, private toilet use private toilet use once a dayonce a day for a for a family costs 10% of family costs 10% of the basic wage.the basic wage.


WHO Commission on Social WHO Commission on Social Determinants of HealthDeterminants of Health

(March 2005 – April 2008)(March 2005 – April 2008)


How is the Commission organized?How is the Commission organized?

Michael Marmot, ChairMichael Marmot, Chair 19 members 19 members

(volunteers)–One (volunteers)–One Canadian (M. Bégin) Canadian (M. Bégin)

Small Secretariat in Small Secretariat in Geneva Geneva

Smaller scientific team Smaller scientific team around Marmot in around Marmot in London. London.

Meetings in-person 3-4 Meetings in-person 3-4 times per year.times per year.

Pillars of our work: Pillars of our work: 8 knowledge networks8 knowledge networks Countries (and Countries (and

regions) involvedregions) involved Civil society and Civil society and

global partners global partners involved (World Bank, involved (World Bank, etc.)etc.)

World Health World Health Organisation (WHO) Organisation (WHO)


Diseases of Public

Health Impt

Early ChildDevelopment

Women + GenderEquity

Urban Settings

Social Exclusion

EmploymentConditions

Globalization

Health systems

Measurement

Building Health & Health Equity

KNOWLEDGE NETWORK THEMES


3 Knowledge Networks funded 3 Knowledge Networks funded by Canada:by Canada:

Early Childhood DevelopmentEarly Childhood Development(Dr. Clyde Hertzman, UBC)(Dr. Clyde Hertzman, UBC)

Globalization and HealthGlobalization and Health(Dr. Ron Labonte, UofO)(Dr. Ron Labonte, UofO)

Health Systems Health Systems (via IDRC, in South Africa)(via IDRC, in South Africa)


My personal “mission” as a My personal “mission” as a CommissionerCommissioner

Ensure that unique challenges of the worlds’ Ensure that unique challenges of the worlds’ Indigenous people are addressed in CSDH workIndigenous people are addressed in CSDH work– Working in partnership with Australia, NZ, South Working in partnership with Australia, NZ, South

American countries to explore ways to address unique American countries to explore ways to address unique determinants of Indigenous peoples’ healthdeterminants of Indigenous peoples’ health

Ensure that CSDH recommendations address Ensure that CSDH recommendations address inequalities in developed as well as developing inequalities in developed as well as developing countriescountries

Facilitate moving Canada beyond ‘pilot projects’ Facilitate moving Canada beyond ‘pilot projects’ to a systemic approach to addressing to a systemic approach to addressing determinants of healthdeterminants of health


CanadaCanada’’s participation:s participation: The PHAC created a The PHAC created a Canadian Reference Group Canadian Reference Group with with

various stakeholdersvarious stakeholders Engaging the Canadian societyEngaging the Canadian society A joint project with UK and Sweden on «whole-of-A joint project with UK and Sweden on «whole-of-

government»* strategiesgovernment»* strategies An Aboriginal Sub-CommitteeAn Aboriginal Sub-Committee

Challenges:Challenges: how do we beat the « silos » approach how do we beat the « silos » approach to public policy when most determinants of health to public policy when most determinants of health are outside health ministries?...are outside health ministries?...

How do we make poverty visible to Canadians?How do we make poverty visible to Canadians?


Is action possible?...Is action possible?... Yes it is and it’s urgent!Yes it is and it’s urgent! How? By shedding «the culture of How? By shedding «the culture of

contentment» in which we live.contentment» in which we live. By saying loud and clear that social By saying loud and clear that social

policies do matter to Canadians.policies do matter to Canadians. By addressing By addressing upstreamupstream factors factors

through «whole-of-government» through «whole-of-government» policies instead of focusing policies instead of focusing

on on downstreamdownstream problems: problems:


To conclude: Global Health Watch…To conclude: Global Health Watch…

reports that the cost of achieving and reports that the cost of achieving and maintaining universal access to basic maintaining universal access to basic education, basic health care, adequate education, basic health care, adequate food, and safe water and sanitation food, and safe water and sanitation for allfor all has been estimated at less than has been estimated at less than 4%4% of the of the combined wealth of the 225 richest people combined wealth of the 225 richest people in the world.in the world.

They consider poverty and development They consider poverty and development as a public health issue.as a public health issue.


What good does it do to treat What good does it do to treat people's illnesses ...people's illnesses ...

…then send them back to the conditions that made them sick?

health status: a matter of class?

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