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Social Inequalities in Health

Yawen Cheng, ScD Associate Professor Institute of Health Policy and Management, College of Public Health, National Taiwan University

Essentials of Global HealthMarch 15, 2013

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Study Objectives

1. Concept of “health equity” and “health rights”

2. Health inequalities Evidences and extent Causes?

3. A historical review on collective actions for achieving health equity

The role of public health policies On health care systems On overall living environment (social determinants of health)

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Public Health

Public health is the science and art of preventing disease, prolonging life, and promoting health through the organized efforts of society.

Goal: to promote biological, physical and mental well-being of all members of society.

3 major disciplines Biological and medical sciences Environmental and occupational health sciences Health policy and management

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Core values Definition of health equity – absence of unfair and

avoidable or remediable differences in health among social groups.

Primary responsibility for protecting health equity rests with government (importance of state role).

Human right – Are health and health care parts of human rights? 1948 UN declaration 1966 ICESCR 2000 Human Right to Health What are human rights? The story of human rights https://

www.youtube.com/watch?v=oh3BbLk5UIQ (9:51) Empowerment of disadvantage communities

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Health inequalities?

Are there systematic differences in health outcomes?

Are these differences unnecessary, avoidable by reasonable action, and are considered unfair or unjust (moral judgment)?

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Inequalities in Mortality according to occupational grade in British civil servants (the Whitehall Study)

Source: Marmot (2006) Health in an unequal world, Lancet 368, 2081-2094.

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Age-adjusted Morbidity by Employment Grade: The Whitehall II Study

(Marmot, et al. Lancet 1991; 337:1387-93)

0

5

10

15

20

25

1 2 3 4 5 6empl oyment gr ade

%

Pre-menstrual syndrome

DiabetesHypertension

Ischaemia

Cough with phlegm

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Difference in cardiovascular mortalities by income level

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Cumulative Economic Hardship and Physical, Psychological, Cognitive and Social Functioning

(Lynch & Kaplan, NEJM 1997; 337: 1889-95)

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1

2

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4

5

Dif f icultywith IADL

DSM-II I-RDepression

Lack ofoptimism

Cognitivedif f iculties

Socialisolation

Odd

s R

atio

*

Once below 200% poverty (1965, 1974, 1983) Twice All

* Adjusted for age, sex, BMI, pack-years of smoking, alcohol intake, and physical activity

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Ethnic Group Male Female

Taiwanese 73 79

Plain Aborigine 62 (-11) 72 (-7)

Mountain Aborigine 58 (-15) 69 (-10)

Life expectancy of aborigines and Han Chinese in Taiwan （ 2000 ）

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What are the causes of health differences across population? Health care services

Factors outside of health care sector – social environment Living conditions Working condition Exposure to environmental hazards Social control Social security Psychosocial stress …

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The role of “social determinants of health”

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In Sickness and wealth: health in America (from Unnatural causes) (4:38) https://www.youtube.com/watch?v=w98GSXBEyQw&list=UUt1Df8qkClmfBpctQMoFFfA&index=17

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What are the “structural drivers” of unhealthy social environment?

Source: Solar and Irwin (2007). A conceptual framework for action on social determinants of health. WHO CSDH Report.

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A historical review on major interventions for the improvement of population health Provision of medical and health cares

Improvement of living conditions

18Source: http://www.gresham.ac.uk/uploads/Demography(1).ppt

Poor Law (1601)Essay on Populat ions (Malthus, 1798)

New Poor Law (1834)

PH Law (1848)

Factory Law (1802)

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Edwin Chadwick (1800-1890)

Report of the Poor Law Commission (1832)

New Poor Law (1834) Report on the Sanitary Condition

of the Laboring Population (1842)

Public Health Act (1848) Sanitary idea - miasma theory Drainage system Central and local boards of health

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Bismarck's social legislation (1884)

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After WWII: Health Care Reform – Beverage model in UK

On the way … 1911: National Health Insurance Act 1920: Dawson’s interim report - regionalization 1939: EMS 1942: Beverage report

National Health Service 1944: NHS white paper - comprehensive and free

1946: NHS Act 1948: NHS inauguration

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60

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1650 1700 1750 1800 1850 1900 1950 2000

Changes in life expectancy in England

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0

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15

20

25

3019

00

1905

1910

1915

1920

1925

1930

1935

1940

1945

1950

1955

1960

1965

1970

1975

1980

1985

1990

1995

2000

2005

2010

人口

數（

百萬

）

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20

30

40

50

60

出生

率與

死亡

率（

/1000

）

人口數 出生率 死亡率

Demographic Transformation (Taiwan)

資料來源：行政院衛生署、內政部統計處、 Mirzaee (1979)

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40

50

60

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90

1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010 2020

Life

Exp

ecta

ncy a

t B

irth

(ye

ars

)

Han Chinese(Male)Han Chinese(Female)Aborigines(Male)Aborigines(Female)

Changes in life expectancy in Taiwan: comparisons of Han Chinese and Aborigines

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Withdraw from UN

US De-Recognition

Democratic Progressive Party

Full Congress Election

President Election

THE BIRTH OF TAIWAN’s NHI

NHI Law

Slide made by Prof. Tung-Liang Chiang

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1964 SG Report

1974 Lalonde Report

1978 Alma Ata Declaration

1986 Ottawa Charter

2005 WHO CSDH

Traditional Public Health New Public Health

Historical Evolution of Public Health

1883 Germany-SI

1948 UK-NHS1961 Japan-NHI

1971 Canada-NHI

1989 Korea-NHI

1995 Taiwan-NHI1911 Germany-RVO

2001 Thai-Mix

1848 UK-Public Health Act1884 Koch’s Postulates

1928 Penicillin

Laissez-faire EfficiencyEquity in Access Cost Control

1948 WHO

Slide made by Prof. Tung-Liang Chiang, NTU

Medical care systems

Social environment

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3 legs for public health policy

Public HealthPolicy

Knowledge base(scientific evidences and social strategies)

Politics (power struggle)

Social values/Attitude/ethics

28Source: Solar and Irwin (2010). A conceptual framework for action on social determinants of health.

WHO CSDH Report.

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Interventions on “social determinants of health” US Federal Indian Policies and Health (2:39) https://

www.youtube.com/watch?v=i4ExGtLxb_w&list=UUt1Df8qkClmfBpctQMoFFfA&index=20

An US governmental video, give examples of possible interventions for improving ‘social environment’ https://www.youtube.com/watch?v=5Lul6KNIw_8 (5:12)

Michael Marmot, the chair of CSDH on social determinants of health, 4:47) https://www.youtube.com/watch?v=kXUsYrzUKyU

Ichiro Kawachi - Advice to the Next President: 7 Ways to Fight Health Inequities http://www.youtube.com/watch?v=Vh8XcosZzTo (2:20)

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Actors

State

Private sectors

Civil society (NGOs)

The role of researchers

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Two questions for small group exercise

1. Do you agree that all people should be entitled to medical care, regardless of their ability to pay? Or do you think medical care services should be treated as “commodities”, and the extent of services we receive will depend on how much you pay? What are the situations in your home countries?

2. Identify a health problem, and suggest a policy level intervention strategy, targeting on its social determinants (instead of individual risk factors).

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Some hints for the discussion session

Childhood obesity – regulations on infant formula/ on advertisement of fast food or unhealthy products

Mental health problems among the unemployed – expanding social welfare/unemployment security

Road injuries – mass transportation system, policy and enforcement on helmet wearing…