Professor Sir Michael Marmot's Charles Cully Lecture on health inequalities and cancer

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The Irish Cancer Society hosts the annual Charles Cully Lecture in memory of one of the Society's founding members. Professor Sir Michael Marmot, one of the world's leading international experts on health inequalities, was the recipient of the Charles Cully Medal and gave the 2013 lecture on health inequalities and cancer.

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  • CSDH 3 principles of action: Improve the conditions of daily life Tackle the inequitable distribution of power, money and resources – globally, nationally and locally Measure the problem, evaluate action, expand the knowledge base, develop the work force
  • Source: Central Statistics Office (2010A, p3) Mortality Differentials in Ireland [online]. Available at: http://www.cso.ie/ census/documents/Mortality_Differentials_in_Ireland.pdf [20 January 2010]. 2.19 Social class was also a strong predictor of life expectancy (
  • Source: Central Statistics Office (2010B, p3) Mortality Differentials in Ireland [online]. Available at: http://www.cso.ie/ census/documents/Mortality_Differentials_in_Ireland.pdf [20 January 2010].
  • Cancer is the second major cause of death in Ireland, after cardiovascular disease, accounting for over 8,000 deaths per year. [12] An average of nearly 30,000 new cases of cancer are diagnosed each year. [13] This is 50% more cancers per year than in the mid-1990s. The number of newly diagnosed cancers is increasing by 6-7% annually and unless a major reversal of trends occurs in the near future, the number is likely to double in the next 20 years. [14] The underlying risk of developing cancer is increasing by less than 1% annually and the expected increase is primarily due to the higher proportion of elderly people in the population but may also be influenced by the projected growth in the total population. This is the biggest predicted rise in the 27 EU Member States. [15]
  • Commission on Social Determinants of Health Conceptual Framework
  • Fig 2.8, page 25 in Obesity and socio-economic groups in Europe: Evidence review and implications for action” A Robertson, T Lobstein, C Knai
  • Fig.4.18 Child and Working-Age Poverty in Northern Ireland from 2010 to 2020 IFS Report R78 James Browne; Andrew Hood; Robert Joyce
  • The tables are ranked by each country’s average rank in four dimensions of child well-being – material well-being, health, education, and behaviours and risks – for which comparable data are available towards the beginning and end of the first decade of the 2000s.
  • Values are all statistically significant Source: OECD PISA 2009 database, Table II.5.5.
  • ‘ possibly’ means the evidence is less strong for these health outcomes Homicides= killing another human, includes murder, manslaughter… Fewer road traffic fatalities likely because lower incomes means less car use (and less commuting to work because of unemployment?) Those infectious diseases likely to increase will depend on location-specific factors such as existing prevalence of infectious diseases within the population Short-term mortality effects are less clear-cut
  • Trends in the numbers of suicides and unemployment claimants in England, 2000-10, by sex
  • Homeless: Number of London households accepted as homeless by LAs between 2010 and 2011 rose by 20.4% (from 9700 to 11,680). It was reported the number of rough sleepers rose by 8%, while those under 25 rose by at least 32%. Overcrowding: number of children in overcrowded housing increased by 18% in London between 2008-11, to 24% of all children. Fuel poverty: Over half a million (560,000) Londoners live in fuel poverty. Eg. Unemployed individuals, particularly the LT unemployed, have a higher risk of poor mental and physical health compared with those in employment. The health and social effects resulting from a long period of unemployment can last for years. Self-rated health can also be worse in an economic downturn for those who remain in work. Particular groups = those more likely to become unemployed (low skilled/edu, men, young people); those on low incomes.
  • Neighbourhoods affordable to housing benefit recipients in 2011 and 2016
  • Professor Sir Michael Marmot's Charles Cully Lecture on health inequalities and cancer

    1. 1. Fair Society Healthy Lives Annual Irish Cancer Society Charles Cully Memorial Lecture 2013 Michael Marmot
    2. 2. • Health inequalities: social gradient • Social determinants: the causes of the causes • Evidence into policy
    3. 3. 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
    4. 4. Deviation of life expectancy at birth from average life expectancy by deprivation ranking: Ireland Burke & Pentony, Eliminating Health Inequalities – A Matter of Life and Death —TASC 2011
    5. 5. Life expectancy by social class: Ireland Burke & Pentony, Eliminating Health Inequalities – A Matter of Life and Death —TASC 2011 years
    6. 6. Social distribution of cancer varies depending on type of cancer: Ireland
    7. 7. Social distribution of cancer varies depending on type of cancer: Ireland Source: Cancer incidence in men and women in Ireland 1994 - 2009
    8. 8. Social distribution of cancer varies depending on type of cancer: Ireland Source: Cancer incidence in men and women in Ireland 1994 - 2009
    9. 9. Social distribution of cancer varies depending on type of cancer: Ireland Source: Cancer incidence in men and women in Ireland 1994 - 2009
    10. 10. International comparison: prostate cancer incidence rate per 100,000 in 2008
    11. 11. Prostate cancer: smoothed relative risks: 2002-2007
    12. 12. • Cancer is the second major cause of death in Ireland, after cardiovascular disease, • An average of nearly 30,000 new cases of cancer are diagnosed each year. • The number of newly diagnosed cancers is increasing by 6-7% annually • Largely due to increasing proportion of elderly people Source: Healthy Ireland: a framework for improved health and wellbeing 2013-2025
    13. 13. • Clearly identified modifiable risk factors: smoking, unhealthy diet, physical inactivity, obesity • Need to look at the causes of the causes of the social and area distribution
    14. 14. Social determinants of health and health inequities Socioeconomic and political context Governance Policy Macroeconomic Social Health Cultural and societal norms and values Education Occupation Income Gender Ethnicity/race Social position Material circumstances Social cohesion Psychosocial factors Behaviours Biological factors Health care system Distribution of health and well-being CSDH Conceptual Framework
    15. 15. 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
    16. 16. Obesity prevalence according to educational attainment, averaged across 19 EU Member States (Source: Eurothine 2007 reported in Robertson et al 2007)
    17. 17. 0 10 20 30 Latvia Ireland Finland Spain Norway Portugal Italy Percent obese Overall prevalence of obesity Highest education Second Highest Second Lowest Lowest education 0 10 20 30 England Germany Hungary Sweden Denmark Estonia Percentobese Obesity and education level, females, Eurothine study Low High Source: Roskam et al.
    18. 18. Causes of the causes • A life course approach • Context matters
    19. 19. Prenatal Early Years Working Age Older Ages Family building Accumulation of positive and negative effects on health and wellbeing LIFE COURSE STAGES MACROLEVEL CONTEXT WIDER SOCIETY SYSTEMS Perpetuation of inequities
    20. 20. Taxation revenue (Including social contributions) as a percentage of GDP: Ireland and the EU Burke & Pentony, Eliminating Health Inequalities – A Matter of Life and Death —TASC 2011
    21. 21. Total state expenditure v. total tax revenue (including social contributions) in €ms: Ireland Burke & Pentony, Eliminating Health Inequalities – A Matter of Life and Death —TASC 201
    22. 22. The effect of tax and benefit reforms on relative child poverty to 2020: UK and Northern Ireland, incomes measured before housing costs Source: IFS Report R78, 2013
    23. 23. Impact of modelled tax and benefit reforms since Jan 2010, by income decile group (percentage points) Source: IFS Green Budget 2013, Ch 7 Fig 7.4
    24. 24. Prenatal Early Years Working Age Older Ages Family building Accumulation of positive and negative effects on health and wellbeing LIFE COURSE STAGES MACROLEVEL CONTEXT WIDER SOCIETY SYSTEMS Perpetuation of inequities
    25. 25. Early child care and education • Parenting and family support – Perinatal services – Care before and during pregnancy – Help for new mothers • Pre-school education and care • Primary, secondary and tertiary education and training
    26. 26. Country comparison on average rank in four dimensions of child wellbeing – material, health, education, behaviours & risks, in early 2000s and late 2000s UNICEF 2013 Report Card 11
    27. 27. Differences in PISA scores by attending preschool for more than one year before and after accounting for socioeconomic background OECD PISA 2009 database
    28. 28. 0 10 20 30 40 50 60 Romania Latvia Bulgaria Lithuania Italy Greece Spain Poland Portugal Luxembourg Hungary United Kingdom Malta Estonia Switzerland Ireland Slovakia France Belgium Netherlands Germany Austria Czech Republic Sweden Finland Cyprus Slovenia Denmark Norway Iceland Poverty rate Before social transfers After social transfers Child poverty rates <60% median before and after social transfers 2009 Source: EU SILC
    29. 29. Children achieving a good level of development at age five, local authorities 2011: England Source: LHO (2012)
    30. 30. Areas for improving outcomes: • Child Development – Cognitive – Communication & language – Social & emotional – Physical • Parenting – Safe and healthy environment – Active learning – Positive parenting • Parent’s lives – Mental wellbeing – Knowledge & skills – Financially self-supporting
    31. 31. Birmingham Brighter Futures • Aims to improve the lives of all the city's children and young people; • Focus on improving children’s physical health, literacy and numeracy, behaviour, emotional health, social literacy, and job skills. • Specific programmes relevant to early years include: Family Nurse Partnership (FNP), Incredible Years Parenting Programme, Promoting Alternative Thinking Strategies (PATHS), Triple P Parenting Programme.
    32. 32. Per cent 5 year olds achieving ‘good development score’,* Birmingham LA, West Midlands & England *in personal, social and emotional development and communication, language and literacy Source: Department for Education: preliminary data %
    33. 33. Prenatal Early Years Working Age Older Ages Family building Accumulation of positive and negative effects on health and wellbeing LIFE COURSE STAGES MACROLEVEL CONTEXT WIDER SOCIETY SYSTEMS Perpetuation of inequities
    34. 34. Occupational stress in European countries 0 10 20 30 40 50 Very low Low High Very high Effort reward imbalance Low control Per cent Occupational class
    35. 35. Unemployment rates by education and country of origin in selected countries Source: Eurostat database
    36. 36. Evidence from previous economic downturns suggests that population health will be affected: • More suicides and attempted suicides; possibly more homicides and domestic violence • Fewer road traffic fatalities • An increase in mental health problems, including depression, anxiety and lower levels of wellbeing • Worse infectious disease outcomes such as TB + HIV • Negative longer-term mortality effects • Health inequalities are likely to widen
    37. 37. Trends in the numbers of suicides and unemployment claimants in England, 2000-10, by sex. Barr B et al. BMJ 2012;345:bmj.e5142©2012 by British Medical Journal Publishing Group
    38. 38. Social Protections: unemployment and suicide Each 100 USD per capita greater social spending reduced the effect on suicides by: 0.38%, active labour market programmes 0.23%, family support 0.07%, healthcare 0.09%,unemployment benefits Spending> 190 USD no effect of unemployment on suicide Source: Stuckler et al 2009 Lancet
    39. 39. Income, employment, housing and health • Unemployment, low incomes and poor housing contribute to worse health; • These problems are more likely to occur among particular groups within the population and among those already on low incomes.
    40. 40. Neighbourhoods affordable to housing benefit recipients in 2011 and 2016
    41. 41. Rough sleeping counts and estimates by London and rest of England Housing Statistical Release Autumn 2012 DCLG Number
    42. 42. We can do better: • Political prioritisation of health equity – Advocacy – Leadership • Development of effective interventions • Measure and monitor
    43. 43. www.instituteofhealthequity.org A Fair Society Creating conditions in which individuals and communities have control over their lives

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