Mental Health and Inequality

Mental health and inequalities: what’s happening to the

soci(et)al determinants of health?

Lynne Friedli

Socialist Health AssociationHealth Inequality in England and Scotland

Edinburgh9th June 2012

what's happening to social determinants? [email protected]

Picture source: Sleeping with spirit #2 Bradley Guiboche courtesy of www.artbeatstudio.ca

As material inequalities grow,

the pursuit of non material explanations

proliferates

The paradox....

http://www.artbeatstudio.ca/


Source: Banksie – grafitti, London, England

I own, therefore I am....

[email protected]

What can 'capabilities' contribute?

Life Bodily health

Bodily integrity Sense, imagination, thought

Emotions Practical reason

Affiliation Other species

Play Control over environment:a) Politicalb) MaterialSource: Nussbaum

2011

Nussbaum’s capabilities

Commission on the Social Determinants of Health

• material requisites• psycho-social (control over lives)• political voice (participation in decision making)


Status Control Relatedness

Some living conditions deliver to people a life that is worthy of the human dignity that they possess, and others do not. Dignity can be like a cheque that has come back marked ‘insufficient funds’

Martha NussbaumFreedom to

live a valued life

Amartya Sen


Meta analysis: comparative odds of decreased mortality

The relative value of social support/ social integrationSource: Holt-Lundstad et al 2010

Social Epigenesis: biological embedding *

“The most effective interventions will require a deeper understanding of how common social risks “get under the skin” to affect human biology and influence the causal pathways to disease”

* Clyde Hertzman 2012

*Clyde Hertzman 2011


Status Control Relatedness

In 2012 there’s no talk of getting out. It’s more important to be somebody where they live, than to be nobody outside. Status and respect are valued above everything Lisa McKenzie 2012

Relative importance of early social and biological risk factors

(PAR %)

Clinical risk factors

Social risk factors

Source: Jutte, Brownell, Roos, Schippers, Boyce, Syme, 2010

age


Reasons to be concerned?

• An analysis of injustice? Who/what creates

inequalities?

• Are Scotland’s problems psychological &

cultural?

• Stigmatising dependency and need?

• Avoiding the hard questions?


I knew about inequality, how unfair life could be. But I thought it was something to do with me, with my family, what we’d done.....

Lisa McKenzie ‘Thinking allowed’


Myth No 1: ‘What we’ve tried, though well meaning, hasn’t worked....’

Nearly a third of workers in Scotland -4% of public sector28% of private sector -earn less than a living wage(£7.20 per hour)(ASHE 2010)

Trends by political leader or

‘30 years of brutal global capitalism’

Source: Brewer M, Goodman A, Muriel A, Sibieta L. Poverty and Inequality in the UK: 2007. Institute of Fiscal Studies, London.what's happening to social determinants? [email protected]

m


1975

1976

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2008

2009

2010

0.22

0.24

0.26

0.28

0.30

0.32

0.34

0.36

0.38

0.40

0.42Trends in inequality of disposable income

Gin

i coe

ffici

ent o

f inc

ome

ineq

ualit

yUK Inequalities well above OECD average ‘If the rich could hire others to die for them, we, the poor,

would all make a nice living’Fiddler on the Roof

Source: OECD 2011 Divided We Stand


Persistence of intergenerational earnings

Ideas that massacre the welfare state:

Myth No 2: ‘dependency’‘an assets rather than a deficits approach to tackling poverty and inequality..... moving from welfare to wellbeing and from dependency to self determination.’

Scottish Government 2011 • Deficit approach of public services

• Culture of dependency folks haven’t a clue how the rest of us are having to make ends meet

A man goes to work full time and still has to get the social because wages is so low; he needed that money to keep his kids

Source: Dundee Equally Well/ONS Fairness & Wellbeing Debate



Image: Banksy;

Holding on to an inequalities analysis

Declaration of Intent of the Mental Patients Union • We proclaim the dignity of society's so-called mental

patients• We challenge repressive psychiatric practice and its ill-

defined concepts of 'Mental illness'• We state that the present appalling situation in

'Mental health' primarily arises from the acute problems in housing, unemployment and social inequality

• Mental patients in our society are treated as people with no human rights

Source: The Survivors’ History Group Pageant of Survivor History http://studymore.org.uk/mpu.htm


http://studymore.org.uk/mpu.htm


Not ‘every family in the land’

Findings from 9 large scale population based studies:

• Material and relative deprivation• Childhood socio-economic position• Low educational attainment• Unemployment• Environment: poor housing, poor resources,

violence• Adverse life events• Poor support networks

(Melzer et al 2004; Rogers & Pilgrim 2003; Stansfeld et al 2008; APMS 2007)

Cycle of invisible barriers:• Poverty of hope, self-worth, aspirations

Mental health and deprivation

Explaining the social gradient: mental illness journeys...

• Adverse childhood experiences/stressful life events

• Racism and other forms of discrimination• Contact with criminal justice system • Socio economic status – parental income,

tenure, education, occupation• Institutional care in childhoodwhat's happening to social determinants? [email protected]

m

Most of the experiences that cause mental distress are directly linked to a lack of money....... powerlessness linked to poverty

Peter Campbell Beyond the Water Tower 2005

0%

5%

10%

15%

20%

25%

under£100

£100-£199 £200-£299 £300-£399 £400-£499 £500-£599 £600-£770 Over £770

Gross weekly household income

Pe

rce

nta

ge

of

ch

ild

ren

wit

h a

me

nta

l d

iso

rde

r

Source: Meltzer et al 2000 Mental health of children and adolescents in Great Britain

Mental health of children by parental income



Source: Fair Society, Healthy Lives: Marmot Review 2010

Mental health and the social gradient

“Infants develop the attachment behaviours that optimally enhance their survival in their own characteristic environments.” Crittenden, 2000


Rates of poor social/emotional adjustment by father’s social class

at birth

Low levels of (adult) mental wellbeingby concerns about income

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

Living comfortably onpresent income

Coping on presentincome

Finding it difficult onpresent income

Finding it very difficulton present income

Pe

rce

nta

ge

wit

h a

lo

w l

ev

el

of

we

llb

ein

g

Source: NW Wellbeing Survey


Austerity rhetoric



Austerity solutions....


Source: http://streetartlondon.co.uk/

Big fish/little fish: questions of power are

unavoidable


Return to the social....

what's happening to social determinants?

Equity and Social Justice

Freedom to live a valued life

Solidarity and the core economy

I am, because we are...

[email protected]

And what I shall endure, you shall endureFor every atom belonging to me as good belongs to you......

Walt Whitman


Select bibliography

Beckfield J and Krieger N (2009) Epi + demos + cracy: A Critical Review of Empirical Research Epidemiologic Reviews 31(1):152-177Birn Anne-Emanuelle (2009) Making it politic(al): Closing the Gap in a Generation: health equity through action on the social determinants of health Social Medicine 4:3 p166-182 Christie C (2011) Report on the Future Delivery of Public Services by the Commission chaired by Dr Campbell Christie http://scotland.gov.uk/Publications/2011/06/27154527/18

CSDH (2008) Closing the gap in a generation: health equity through action on the social determinants of health Final Report of Commission on Social Determinants of Health Geneva: World Health Organization.

http://whqlibdoc.who.int/publications/2008/9789241563703_eng.pdf

Friedli L (2009) Mental health, resilience and inequalities WHO Europe London/ Copenhagen http://www.euro.who.int/document/e92227.pdf

Nussbaum M (2011) Creating capabilities: the human development approach Belknap Harvard

http://scotland.gov.uk/Publications/2011/06/27154527/18



http://www.euro.who.int/document/e92227.pdf


Select bibliographyMair C, Zdeb K and Markie K (2011) Making better places: making places better the distribution of positive and negative outcomes in Scotland Improvement Service www.improvementservice.org.uk/.../3400-making-better-places-making-places-better-distribution-of-positive-and-negative-outcomes-in-scotland/McKendrick et al 2011 Poverty in Scotland Child Poverty Action GroupPeople First Scotland http://www.viascotland.org.uk/webfm_send/304/citizens-grand-jury-report.pdf

OECD 2011 Divided we stand: why inequality keeps rising http://www.oecd.org/document/51/0,3746,en_2649_33933_49147827_1_1_1_1,00.htmlStuckler D, Basu S, Suhrcke M et al (2011) Effects of the 2008 recession on health: a first look at European data The Lancet Vol. 378, Issue 9786, Pages 124-125 http://jech.bmj.com/content/65/8/653.full Tackling Poverty Board: A Summary of the Evidence http://www.scotland.gov.uk/Topics/People/tackling-poverty

http://www.improvementservice.org.uk/.../3400-making-better-places-making-places-better-distribution-of-positive-and-negative-outcomes-in-scotland/









http://www.viascotland.org.uk/webfm_send/304/citizens-grand-jury-report.pdf

http://www.viascotland.org.uk/webfm_send/304/citizens-grand-jury-report.pdf

http://www.oecd.org/document/51/0,3746,en_2649_33933_49147827_1_1_1_1,00.html

http://www.oecd.org/document/51/0,3746,en_2649_33933_49147827_1_1_1_1,00.html

http://jech.bmj.com/content/65/8/653.full

http://www.scotland.gov.uk/Topics/People/tackling-poverty



Variation of growth of genetically identical marbled crayfish in an aquarium: how well would epidemiologists be able to predict outcomes?Source: Davey Smith G (2012) picture: Journal of Experimental Biology

Mental Health and Inequality

Health & Medicine

social epigenesis

mental health

banksy whats

material inequalities

politicalb material

uk inequalities

inequalities analysisimage

mental patients unionwe