presentation

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

Town hall meetingTown hall meeting Sunday, March 9, 2008 - 2:00pm Sunday, March 9, 2008 - 2:00pm Holy Rosary Parish Hall, 354 St.Clair Ave. WestHoly Rosary Parish Hall, 354 St.Clair Ave. West

The Causes and the The Causes and the Causes of the Causes Causes of the Causes

of Healthof Health

Monique BéginMonique Bégin 22

« Why are some people « Why are some people healthy and others not » ?healthy and others not » ?

"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 degree than those with a degree, while those with a degree live longer than those who left school early.live longer than those who left school early.

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

Today…Today…

We want to explore: We want to explore: If If geneticsgenetics and and individual risk factorsindividual risk factors are not the best predictors of staying are not the best predictors of staying healthy or becoming ill, what are the healthy or becoming ill, what are the

predictors society should know predictors society should know about? about?


Different socio-economic status = Different socio-economic status = different health statusdifferent health status

The first observation one must make is The first observation one must make is

that of that of health inequality: health inequality: People are People are not all healthy the same way, at the not all healthy the same way, at the same level. Is it only due to biology same level. Is it only due to biology and one’s genetic make-up? Or to and one’s genetic make-up? Or to

unhealthy individual life style?unhealthy individual life style?NO!NO!


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 Tracked patterns of

inequalities of health inequalities of health across Britain through across Britain through health records.health records.

Thatcher tried to Thatcher tried to suppress the report.suppress the report.

Finally published in Finally published in 19881988


The Whitehall Study I & IIThe Whitehall Study I & II Sir Michael Marmot Sir Michael Marmot

(joined in 1976)(joined in 1976) Published 1986-87 +Published 1986-87 + 10,000+ male civil 10,000+ male civil

servants, studied over servants, studied over 10 years.10 years.

Divided in 4 groups:Divided in 4 groups:– Administrative (top)Administrative (top)– ProfessionalsProfessionals– ClericalClerical– UnskilledUnskilled


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’sWhitehall’s social determinants: 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, etc.No socially cohesive neighbourhood, etc.


The Black, Whitehall and other studies The Black, Whitehall and other studies have told us about:have told us about:

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

The gradient theoryThe gradient theory: «social classes» : «social classes» or different socio-economic status do or different socio-economic status do predict health status in every predict health status in every society.society.


Health gradients in British householdsHealth gradients in British households‘‘

Office for National Statistics (2001). Living in Britain: results from the 2000 General Household Survey. London: Stationery Office


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


Fair/poor self rated health 3 times more likely Fair/poor self rated health 3 times more likely among lower income men and women in Canadaamong lower income men and women in Canada

0

0,5

1

1,5

2

2,5

3

3,5

Odd

s ra

tio

Men WomenIncome group

LowestMid-lowMiddleMid-highHighest

Note: Adjusted for age, social roles, and health behaviours.Source: Orpana, H. & Lemyre, L. (2004). Explaining the social gradient in health: Using the National Population Health Survey to examine the role of stressors. Int J Beh Med. 11(3) 143-151.


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 health (2001)Aboriginal health (2001)


… … and health inequalitiesand health inequalities existexist between between countries: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


InequalityInequality

What matters most is not whether What matters most is not whether you have a smaller or larger home or you 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)


Kashechewan (ON)

1,100 Crees evacuated

FOR MONTHSbecause of

contaminated water

October 2005


Jane & Finch, in Toronto, has been fighting for four decades to overcome

isolation, hardship, and stigma.


Montreal has the highest rate

of low incomes of all the Quebec regions. That rate of 21.5% means that 1

Montrealer out of 5 lives with very

little financial means.

Institut de la Stat. du Québec 2005


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.


Narrowing health gapsNarrowing health gaps Health inequality is the gap between the Health inequality is the gap between the

health of the best-off and worst-off health of the best-off and worst-off groups. groups.

Narrowing health gaps means ‘raising Narrowing health gaps means ‘raising the health of the poorest, fastest’.the health of the poorest, fastest’.

It requires both improving the health of It requires both improving the health of the poorest and doing so at a rate which the poorest and doing so at a rate which outstrips that of the wider population.outstrips that of the wider population.


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.


UN Agency* states that Canadais failing the poor

Over last 10 years, welfare benefits are 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.

* Reference: UN Committee on Economic, Social and Cultural Rights’ report (2006)


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


More information:More information: Research reports of the Commission: Research reports of the Commission:

www.who.int/socialdeterminantswww.who.int/socialdeterminants– Early child developmentEarly child development– GenderGender– Social exclusionSocial exclusion– Employment conditionsEmployment conditions– Health systemsHealth systems– Urban settingsUrban settings– Priority public health issuesPriority public health issues– Globalisation Globalisation

www.phac-aspc.gc.ca/sdh-dsswww.phac-aspc.gc.ca/sdh-dss www.parl.gc.ca/common/Committeewww.parl.gc.ca/common/Committee (Senate) (Senate) www.moniquebegin.telfer.uottawa.cawww.moniquebegin.telfer.uottawa.ca

http://www.who.int/socialdeterminants

http://www.phac-aspc.gc.ca/sdh-dss

http://www.parl.gc.ca/common/Committee

http://www.moniquebegin.telfer.uottawa.ca/

presentation

Documents

causes of health

health gradients

health behaviours

health records

aboriginal health

different health status

world health report

fairpoor self rated