The global burden of non-communicable disease and the policy challenge

Professor Sir Michael Marmot

• NCDs in high, middle and low income countries

• Health inequalities and the social gradient in health

• Policy challenge: national and local

Source: WHO, 2008

Projected deaths by cause for high-, middle, and low-income countries

CVD

Cancer

OtherNCDs

• NCDs in high, middle and low income countries• Health inequalities and the social gradient in

health• Policy challenge: national and local

HEALTH DIFFERENCES BETWEEN ENGLAND AND THE US 55-64 year olds

0

5

10

15

20

25

England US England US England US

Low income Middle income High Income

Heart disease Diabetes CancerSource: Banks, Marmot, Oldfield and Smith; JAMA 2006

% Prevalence

Cardiovascular deaths of people aged 45 - 64 and social inequalities: Porto Alegre, Brazil

050

100150200250300350400

High Mediumhigh

Mediumlow

Low ALL

CVD deaths Attributable CVD deaths

CVD deathsper 100,000inhabitants

Socioeconomic level of districts

(Source: Bassanesi, Azambuja & Achutti, Arq Bras Cardiol, 2008)

Age standardised circulatory disease death rates at ages under 75, by local ward deprivation level, 1999 and 2001-2003:England

Life expectancy at age 25 by education, men

Source: Health inequalities in the EU 2013

Life expectancy at age 25 by education, women

Source: Health inequalities in the EU 2013

Obesity prevalence according to educational attainment, averaged across 19 EU Member States

(Source: Eurothine 2007 reported in Robertson et al 2007)

Social patterning of diabetes by education and by monthly income, Buenos Aires, Argentina

Fleisher et al 2008

Occupational stress in European countries

0

10

20

30

40

50

Very low Low High Very high

Effort rewardimbalance

Low control

Per cent

Occupational class

ALCOHOL CONSUMPTION RELATIVE TO ITS PRICE: UK

0

2

4

6

8

10

12

Litr

es o

f alc

oh

ol p

er p

erso

n

aged

15+

0

50

100

150

200

250

Pri

ce r

elat

ive

to in

com

e

alcohol Price

Tighe, 2003

• NCDs in high, middle and low income countries• Health inequalities and the social gradient in

health• Policy challenge: national and local

The causes of the causes

• Fairness at the heart of all policies.

• Health inequalities result from social inequalities – requires action on all the social determinants.

• Focusing solely on the most disadvantaged will not reduce inequalities sufficiently – action is needed across the social distribution.

Social determinants of health across the lifecourse

A. Give every child the best start in life

B. Enable all children, young people and adults to maximise their capabilities and have control over their lives

C. Create fair employment and good work for all

D. Ensure healthy standard of living for all

E. Create and develop healthy and sustainable places and communities

F. Strengthen the role and impact of ill health prevention

Fair Society: Healthy Lives: 6 Policy Objectives

The Commission on Social Determinants of Health (CSDH) – Closing the gap in a generation

Strategic Review of Health Inequalities in England:

The Marmot Review – Fair Society Healthy Lives

Review of Social

Determinants of Health and

the Health Divide in the WHO Euro

Region

Country clusters by level of policy response

• Cluster 1: Relatively positive and active response to health inequalities. – At least one national response to HIs or

comprehensive regional HI policy responses.

• Cluster 2: Variable response to health

inequalities. – No explicit national policy on HIs, but at least

one explicit regional response or a number of

other policies with some focus on health

inequalities.

• Cluster 3: Relatively undeveloped response to health inequalities. – No focused national or regional responses to

health inequalities, no explicit health inequality

reduction targets (though there may be

targeted actions on the social determinants of

health).Source: Report on Health Inequalities in the EU

LOCAL ACTION:• Local authorities

– 75% of local authorities have been significantly influenced by Marmot, evidence by their Health and Well-being Strategies and JSNAs (joint Strategic Needs Assessments)

– We have worked directly with 40 plus local authorities

• English Partnership Local government partnership between IHE and 7-8 local authorities until 2014/15 – intensive working to develop SDH approach to health inequalities. Disseminate findings

Priorities agreed by 65 Health and Well-being Boards – Local Government England

Kings Fund 2013

Prevention Inequality Ageing Mental health

Unhealthy behaviours

Marmot Principles

0

10

20

30

40

50

60

5 7 9

2328

49

West Midlands Fire Service Supporting Young People into Employment and Training

Keeping Vulnerable Communities Safe

• over 80 years are 4 X more likely to die from fire

• Smoking materials contributory factor in 49% of fatal fires

• Alcohol or drugs were present in 47% of fatal fires

• The householder known to mental health or social care providers in 39% of fire deaths

• 70% of accidental house fires take place in the lower quintile of Super Output Area (WMFS)

• 72% of house fires caused by arson take place in the lower quintile of Super Output Areas (WMFS)

WMFS

Malmö, Sweden

• Commission for a Socially Sustainable Malmo, chaired by Sven-Olof Isaacson, March 2011

• to translate the findings of the CSDH into a form suitable to address social determinants and health inequalities in Malmo

• Report March 2013

Malmö:Six areas for action

• Children and young people´s livings conditions

• Living environment and urban planning• Education• Income and employment• Health services’• Changes in processes for socially

sustainable development

Action to tackle health inequalities

• “Every sector a health sector”

• Empower individuals and communities – create the conditions for people to take responsibility

www.who.int/social_determinants/en

A world where social

justice is taken

seriously