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  • 1. Edited by Erik Blas and Anand Sivasankara Kurup
  • 2. Equity, socialdeterminantsand public healthprogrammesEdited by Erik Blas and Anand Sivasankara Kurup
  • 3. About this bookThis book was commissioned by the Department of Ethics, Equity, Trade and Human Rights as part of thework undertaken by the Priority Public Health Conditions Knowledge Network of the Commission on SocialDeterminants of Health, in collaboration with 16 of the major public health programmes of WHO: alcohol-relateddisorders, cardiovascular diseases, child health, diabetes, food safety, HIV/AIDS, maternal health, malaria, mentalhealth, neglected tropical diseases, nutrition, oral health, sexual and reproductive health, tobacco and health, tubercu-losis, and violence and injuries. In addition to this, through collaboration with the Special Programme of Research,Development and Research Training in Human Reproduction, the Special Programme for Research and Trainingin Tropical Diseases, and the Alliance for Health Policy and Systems Research, 13 case studies were commissioned toexamine the implementation challenges in addressing social determinants of health in low-and middle-income set-tings. The Priority Public Health Conditions Knowledge Network has analysed the impact of social determinantson specific health conditions, identified possible entry-points, and explored possible interventions to improve healthequity by addressing social determinants of health.For more information on the work of WHO on social determinants of health, please visit more information on the content of the book, please write to pphc@who.intWHO Library Cataloguing-in-Publication DataEquity, social determinants and public health programmes / editors Erik Blas and Anand Sivasankara Kurup.1.Health priorities. 2.Health status disparities. 3.Socioeconomic factors. 4.Health care rationing. 5.Patient advocacy.6.Primary health care. I.Blas, E. II.Sivasankara Kurup, A. III.World Health Organization. ISBN 978 92 4 156397 0 (NLM classification: WA 525)© World Health Organization 2010All rights reserved. Publications of the World Health Organization can be obtained from WHO Press, World Health Organization, 20Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: Requests forpermission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – should be addressed toWHO Press, at the above address (fax: +41 22 791 4806; e-mail: designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatso-ever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities,or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which theremay not yet be full agreement.The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by theWorld Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the namesof proprietary products are distinguished by initial capital letters.All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication.However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility forthe interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damagesarising from its use.The named authors alone are responsible for the views expressed in this publication.Design and Layout: Inís CommunicationCover photos: Column 1 (1) © 2005 Todd Shapera, Courtesy of Photoshare; (2) Alejandro Lipszyc / World Bank; (3) © 2005 StéphaneJanin, Courtesy of Photoshare; Column 2 (1) 123RF; (2) © 2009 Kyaw Thar, Courtesy of Photoshare; (3) iStockphoto; Column 3(1) 123RF; (2) Tran Thi Hoa, 2002 / World Bank; (3) Inís Communication; Column 4 (1) © Manoocher Deghati / IRIN; (2) © 2007Galina Toktalieva, Courtesy of Photoshare; (3) © 2003 Bale-Robe Health Center, Courtesy of PhotoshareThe photographs in this material are used for illustrative purposes only; they do not imply any particular health status, attitudes, behav-iours, or actions on the part of any person who appears in the photographs.Printed in Switzerland.
  • 4. AcknowledgementsThis book was produced under the overall direction of Tim Evans (Assistant Director-General),Jeanette Vega, Nick Drager (former Directors of the Department of Ethics, Equity, Trade andHuman Rights) and Rüdiger Krech (present Director of the Department of Ethics, Equity, Tradeand Human Rights). Financial contribution of the Department of Health, United Kingdom forthe publication of the book is also gratefully acknowledged.The authors of various chapters of the book are: Jens Aagaard-Hansen, Awa Aidara-Kane, AmitavaBanerjee, Fernando C. Barros, Erik Blas, Claire-Lise Chaignat, Joanne Corrigall, Annette David,Chris Dye, Katharine Esson, Christopher Fitzpatrick, Alan J. Flisher, Michelle Funk, DavidsonGwatkin, Sean Hatherill, Norman Hearst, Ernesto Jaramillo, Jean-Louis Jouve, Stella Kwan,Knut Lönnroth, Crick Lund, Pia Mäkelä, Shawn Malarcher, David Meddings, Shanthi Mendis,Les Olson, Vikram Patel, Anne-Marie Perucic, Poul Erik Petersen, Sophie Plagerson, MarioRaviglione, Jürgen Rehm, Helen Roberts, Gojka Roglic, Robin Room, Robert W. Scherpbier,Laura A. Schmidt, Anand Sivasankara Kurup, Nigel Unwin, Cesar G. Victora, David Whiting andBrian Williams.Valuable inputs in terms of contributions, peer reviews and suggestions on various chapters werereceived from a number of WHO staff at headquarters, regional offices and country offices, as wellas other partners and collaborators, including Palitha Abeykoon, Marco Ackerman, Thérèse AngeAgossou, Awa Aidara-Kane, Daniel Albrecht, Mazuwa Banda, Amal Bassili, Sara Bennett, DouglasBettcher, Anjana Bhushan, Adriana Blanco, Claire-Lise Chaignat, Pierpaolo de Colombani, Verada Costa Silva, Catherine D’Arcangues, Denis Daumerie, Hernan Delgado, Ridha Djebeniani,Martin Christopher Donoghoe, Alberto Concha Eastman, Fatimah Elawa, Jill Farrington, EdwigeFaydi, Mario Festin, Christopher Fitzpatrick, Sharon Friel, Michelle Funk, Gauden Galea, LuizAugusto Galvao, Massimo Ghidinelli, Francisco Martínez Guillén, Anthony Hazzard, NormanHearst, Samuel Henao, James Hospedales, Tanja Houweling, Ernesto Jaramillo, Brooke RonaldJohnson, Tigest Ketsela, Gauri Khanna, Mary K. Kindhauser, Rüdiger Krech, Stella Kwan,Jerzy Leowsky, Knut Lönnroth, Prerna Makkar, Shawn Malarcher, Emmalita Manalac, MichaelMarmot, Matthews Mathai, David Meddings, Shanthi Mendis, Patience Mensah, MaristelaMonteiro, Charles Mugero, Davison Munodawafa, Benjamin Nganda, Carla Obermeyer, PatriciaPalma, Anne-Marie Perucic, Poul Erik Petersen, Vladimir Pozyak, Kumanan Rasanathan, DagRekve, Eugenia Rodriguez, Gojka Roglic, Ritu Sadana, Sarath Samrage, Alafia Samuels, RobertScherpbier, Santino Severino, Iqbal Shah, Aushra Shatchkute, Sameen Siddiqi, Sarah Simpson,Johannes Sommerfeld, Birte Holm Sørensen, Shyam Thapa, Luigi Toma, Jaana Marianna Trias,NicoleValentine, Pieter van Maaren, EugenioVillar, Xiangdong Wang, Susan Watts and Erio Ziglio.Technical Editor: John Dawson Acknowledgements iii
  • 5. Abbreviations and acronymsADHD . . . . . attention deficit hyperactivity disorderBCG . . . . . . bacille Calmette–GuérinCVD . . . . . . cardiovascular diseaseDALY. . . . . . disability-adjusted life yearDHS . . . . . . Demographic and Health SurveyDPT . . . . . . diphtheria–pertussis–tetanus (vaccine)EPPI-Centre . . Evidence for Policy and Practice Information and Co-ordinating CentreFAO . . . . . . Food and Agriculture Organization of the United NationsGDP . . . . . . gross domestic productGISAH . . . . . Global Information System on Alcohol and HealthHACCP. . . . . Hazard Analysis Critical Control Point SystemHIV/AIDS . . . human immunodeficiency virus/acquired immunodeficiency syndromeHKD . . . . . . hyperkinetic disorderIMCI . . . . . . Integrated Management of Childhood IllnessMICS . . . . . . Multiple Indicator Cluster Surveymmol/l . . . . . millimoles per litreNTD . . . . . . neglected tropical diseasePEPFAR . . . . United States President’s Emergency Plan for AIDS ReliefPROGRESA . . Programa de Educación, Salud y AlimentaciónSAFE . . . . . . surgery, antibiotics, facial cleanliness, environmental improvementTB . . . . . . . tuberculosisTRIPS . . . . . trade-related intellectual property rightsUNAIDS . . . . Joint United Nations Programme on HIV/AIDSUNDP . . . . . United Nations Development ProgrammeUNESCO. . . . United Nations Educational, Scientific and Cultural OrganizationUNFPA . . . . . United Nations Population FundUNICEF . . . . United Nations Children’s FundUSAID . . . . . United States Agency for International DevelopmentWHO . . . . . World Health Organizationiv Equity, social determinants and public health programmes
  • 6. ContentsList of figures and tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viForeword: Equity, social determinants and public health programmes . . . . . . . . 11. Introduction and methods of work Erik Blas and Anand Sivasankara Kurup . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32. Alcohol: equity and social determinants Laura A. Schmidt, Pia Mäkelä, Jürgen Rehm and Robin Room . . . . . . . . . . . . . . . . . . . . . . 113. Cardiovascular disease: equity and social determinants Shanthi Mendis and A. Banerjee. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 314. Health and nutrition of children: equity and social determinants Fernando C. Barros, Cesar G.Victora, Robert W. Scherpbier and Davidson Gwatkin. . . . . . . . . . . . . . 495. Diabetes: equity and social determinants David Whiting, Nigel Unwin and Gojka Roglic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 776. Food safety: equity and social determinants Jean-Louis Jouve, Jens Aagaard-Hansen and Awa Aidara-Kane . . . . . . . . . . . . . . . . . . . . . . 957. Mental disorders: equity and social determinants Vikram Patel, Crick Lund, Sean Hatherill, Sophie Plagerson, Joanne Corrigall, Michelle Funk and Alan J. Flisher . 1158. Neglected tropical diseases: equity and social determinants Jens Aagaard-Hansen and Claire Lise Chaignat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1359. Oral health: equity and social determinants Stella Kwan and Poul Erik Petersen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15910. Unintended pregnancy and pregnancy outcome: equity and social determinants Shawn Malarcher, L.G. Olson and Norman Hearst . . . . . . . . . . . . . . . . . . . . . . . . . . . 17711. Tobacco use: equity and social determinants Annette David, Katharine Esson, Anne-Marie Perucic and Christopher Fitzpatrick . . . . . . . . . . . . . . 19912. Tuberculosis: the role of risk factors and social determinants Knut Lönnroth, Ernesto Jaramillo, Brian Williams, Chris Dye and Mario Raviglione . . . . . . . . . . . . . 21913. Violence and unintentional injury: equity and social determinants Helen Roberts and David Meddings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24314. Synergy for equity Erik Blas and Anand Sivasankara Kurup . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285 Contents v
  • 7. List of figures Figure 1.1 Priority public health conditions analytical framework . . . . . . . . . . . . . . . . . . . . . . . 7 Figure 2.1 Application of priority public health conditions analytical framework to alcohol-attributable harm . 13 Figure 2.2 Relationship between per capita purchasing power parity-adjusted GDP and adult consumption (litres) of alcohol per year, 2002 (weighted by adult population size) . . . . . . . . . . . . . . . . . . . . . 15 Figure 2.3 Relationship between per capita purchasing power parity-adjusted GDP and proportion of male abstainers, 2002 (weighted by adult population size) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Figure 2.4 Hazard ratios for alcohol-related mortality and hospitalizations by drinking category and socioeconomic status as measured by manual vs non-manual labour . . . . . . . . . . . . . . . . . . . . . 18 Figure 3.1 Conceptual framework for understanding health inequities, pathways and entry-points . . . . . . 39 Figure 3.2 Prevention and control of noncommunicable diseases: public health model . . . . . . . . . . . . 43 Figure 3.3 Complementary strategies for prevention and control of CVD . . . . . . . . . . . . . . . . . . 44 Figure 4.1 Prevalence of exclusive breastfeeding in children 0–3 months, by wealth quintile and region of the world . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 Figure 4.2 Skilled delivery care, by wealth quintile and region of the world . . . . . . . . . . . . . . . . . 58 Figure 4.3 Percentage of under-5 children receiving six or more child survival interventions, by wealth quintile and country . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 Figure 4.4 Oral rehydration therapy during diarrhoea, by wealth quintile and region of the world . . . . . . 59 Figure 4.5 Prevalence of diarrhoea, by wealth quintile and region of the world. . . . . . . . . . . . . . . . 60 Figure 4.6 Under-5 mortality rate, by wealth quintile and region of the world . . . . . . . . . . . . . . . . 61 Figure 5.1 Estimated number of people with diabetes in developed and developing countries. . . . . . . . . 79 Figure 5.2 Changing associations between economic development, socioeconomic status (SES) and prevalence of diabetes or diabetes risk factors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 Figure 5.3 Proportion of people with known diabetes by overall health system performance . . . . . . . . . 83 Figure 5.4 Overview of diabetes-related pathways . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 Figure 6.1 Social determinants of food safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 Figure 7.1 Vicious cycle of social determinants and mental disorders . . . . . . . . . . . . . . . . . . . . . 121 Figure 9.1 Adults with total tooth loss over time by social class, United Kingdom . . . . . . . . . . . . . . 161 Figure 9.2 Dental decay trends in 12-year-olds as measured by the average number of decayed, missing due to caries and filled permanent teeth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163 Figure 9.3 Relationship between education and dentate status among Danish elderly (65 years or more) with no natural teeth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165 Figure 9.4 Relationship between education and dentate status among Danish elderly (65 years or more) with over 20 functioning teeth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165 Figure 9.5 Percentage of 7–15-year-old children who consume soft drinks daily, Denmark, by ethnicity . . . . 167 Figure 9.6 Oral health problems at age 26 years according to socioeconomic status at childhood, New Zealand 167 Figure 10.1 Women’s reported ideal family size and total fertility by wealth quintile for selected countries . . . 181 Figure 10.2 Type of abortion provider by women’s status in selected regions and countries . . . . . . . . . . 182 Figure 10.3 Percentage of women reporting recent receipt of family planning messages by wealth quintile in selected countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185 Figure 10.4 Maternal mortality plotted against percentage of births with skilled attendance . . . . . . . . . . 187 Figure 10.5 Relationship between per capita annual public health expenditure in PPP-adjusted US$ and the percentage of births with skilled attendance for countries with per capita GDP less than US$ 10 000 (PPP) . . 187 Figure 10.6 Relationship of percentage of all births with skilled attendance to ratio of the rate for the poorest 20% of the population to the rate for the richest 20% . . . . . . . . . . . . . . . . . . . . . . . . 188 Figure 10.7 Number of maternal deaths per 100 000 live births, by year, Romania, 1960–1996 . . . . . . . . 190 Figure 11.1 Tobacco use as a risk factor for six of the eight leading causes of death in the world. . . . . . . . 201 Figure 11.2 Prevalence of daily tobacco smoking by income group and income quintile . . . . . . . . . . . 201 Figure 11.3 Low socioeconomic status and differential health outcomes due to smoking . . . . . . . . . . . 204 Figure 12.1 Tuberculosis deaths modelled from available data . . . . . . . . . . . . . . . . . . . . . . . . 222 Figure 12.2 Decline in TB mortality in England and Wales, and its association in time with the two world wars, and the introduction of chemotherapy against TB . . . . . . . . . . . . . . . . . . . . . . . . 222 Figure 12.3 Predicted trends of global TB incidence 2007–2050, with full implementation of Stop TB Strategy, and desired for reaching TB elimination target. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228vi Equity, social determinants and public health programmes
  • 8. Figure 12.4 Association between GDP per capita (US$ purchasing power parities) and estimated TB incidence . 228 Figure 12.5 Framework for downstream risk factors and upstream determinants of TB, and related entry- points for interventions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230 Figure 13.1 Distribution of global injury mortality by cause. . . . . . . . . . . . . . . . . . . . . . . . . 244 Figure 13.2 Road traffic deaths worldwide by sex and age group, 2004. . . . . . . . . . . . . . . . . . . . 245 Figure 13.3 Worldwide spending on public health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254 Figure 14.1 Social gradients in under-5 mortality rate by asset quintile and region (low- and middle-income countries for which related DHS data are available) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 262 Figure 14.2 Percentage of under-5 children receiving six or more child survival interventions, by socio- economic group and country. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 262List of tables Table 1.1 Two complementary frameworks for viewing obstacles to achieving effective and equitable outcome of health care interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Table 2.1 Economic development and alcohol-attributable disease burden, 2000 (in 1000 DALYs) . . . . . . 16 Table 3.1 Comparison of trend of deaths from noncommunicable and infectious diseases in high-income and low- and middle-income countries, 2005 and 2006–2015. . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Table 3.2 Major burden of disease (leading 10 diseases and injuries) in high mortality developing countries, low mortality developing countries and developed countries . . . . . . . . . . . . . . . . . . . . . . . . 34 Table 3.3 Economic development status and cardiovascular mortality and CVD burden, 2000. . . . . . . . . 35 Table 3.4 Economic development and summary prevalence of cardiovascular risk factors in WHO subregions . 37 Table 3.5 Main patterns of social gradients associated with CVD . . . . . . . . . . . . . . . . . . . . . . 39 Table 3.6 Inequity and CVD: social determinants and pathways, entry-points for interventions, and information needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Table 4.1 Framework for the analysis of inequities in child health and nutrition: indicators and their availability in DHS, MICS or from the published literature. . . . . . . . . . . . . . . . . . . . . . . . . . 52 Table 4.2 Structural interventions, entry-points and barriers relevant to child health and nutrition . . . . . . 54 Table 4.3 Matrix of interventions for which equity impact evaluations are available. . . . . . . . . . . . . . 64 Table 4.4 Typology of interventions acting on equity, with examples from the five programmes reviewed . . . 66 Table 4.5 Examples of responsibilities for various intervention components . . . . . . . . . . . . . . . . . 68 Table 4.6 Testing the implementability of interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 Table 5.1 Summary of prevalence (%) ranges of diabetes complications (all diabetes) . . . . . . . . . . . . . 84 Table 6.1 Examples of foodborne hazards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 Table 7.1 Interventions for mental disorders targeting socioeconomic context, differential exposure and differential vulnerability, with indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126 Table 7.2 Interventions for mental disorders targeting differential health outcomes and consequences, with indicators. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 Table 8.1 Relationship of the 13 NTDs to the selected social determinants and the five analytical levels . . . . 145 Table 9.1 Proportion of subjects reporting oral health problems in the previous 12 months, by country . . . . 162 Table 9.2 Social determinants, entry-points and interventions . . . . . . . . . . . . . . . . . . . . . . . . 169 Table 11.1 Cigarette smoking/tobacco use prevalence (%) by sex, age, WHO region and country income groups 202 Table 12.1 Relative risk, prevalence and population attributable fraction of selected downstream risk factors for TB in 22 high TB burden countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231 Table 14.1 Main patterns of social gradients in health with brief examples and references to relevant chapters for more detail . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263 Table 14.2 Social determinants occurring on the pathways of six or more of the 13 conditions examined in Chapters 2 to 13 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265 Table 14.3 Entry-points, interventions and movers at the socioeconomic context and position level . . . . . . 266 Table 14.4 Entry-points, interventions and movers at the differential exposure level . . . . . . . . . . . . . 267 Table 14.5 Entry-points, interventions and movers at the differential vulnerability level . . . . . . . . . . . . 269 Table 14.6 Entry-points, interventions and movers at the differential health care outcomes level. . . . . . . . 270 Table 14.7 Entry-points, interventions and movers at the differential consequences level . . . . . . . . . . . 271 Contents vii
  • 9. FOREWORDEquity, social determinantsand public health programmes T h e re p ort of the Commission on Social Determinants of Health, issued in September 2008, challenged conventional public health thinking on several fronts.The report responded to a sit- uation in which the gaps, within and between countries, in income levels, opportunities, health status, life expectancy and access to care are greater than at any time in recent history. As the report argued, improving the health of populations, in genuine and lasting ways, ulti- mately depends on understanding the causes of these inequities and addressing them.The Commission found abundant evidence that the true upstream drivers of health inequi-ties reside in the social, economic and political environments. These environments are shaped bypolicies, which makes them amenable to change. In the final analysis, the distribution of healthwithin a population is a matter of fairness in the way economic and social policies are designed.By showing how social factors directly shape health outcomes and explain inequities, the reportchallenged health programmes and policies to tackle the leading causes of ill-health at their roots,even when these causes lie beyond the direct control of the health sector.This publication takes these challenges several steps forward, with the aim of translating knowl-edge into concrete, workable actions. Individual chapters represent the major public healthprogrammes at WHO, reflecting the premise that health programmes must lead the way by dem-onstrating the relevance, feasibility and value of addressing social determinants. Each chapter isorganized according to a common framework that allows a fresh but structured look at manyfamiliar problems. Levels in this framework range from the overall structure of society, to differ-ential exposure to risks and disparate vulnerability within populations, to individual differencesin health care outcomes and their social and economic consequences.Throughout the volume, an effort is made to identify entry-points, within existing health pro-grammes, for interventions that address the upstream causes of ill-health. Possible sources ofresistance or opposition to change are also consistently identified. The result is a sound and sys-tematic analysis that gives many long-standing obstacles to better health a fresh perspective withan encouraging message.In its traditional concern with prevention, public health has much to gain when biomedicalapproaches to health and disease are extended by a focus on the true root causes of ill-health, suffer-ing and premature death. As obvious examples, the health sector can treat the costly consequences Foreword 1
  • 10. of obesity, tobacco use, the harmful use of alcohol and unintentional injuries, including thosearising from road traffic crashes. But prevention – which is by far the better option – depends onaction in other sectors, whether involving trade agreements, food production and marketing pol-icies, road design, or regulations and their enforcement. Health programmes do not need to investin these other sectors, but they do need to work with them to realize shared benefits in a whole-of-government approach to health.Equally important, arguments and experiences collected in this volume offer ways to operation-alize the renewed commitment to primary health care, an approach that has long recognized thevalue of fairness and the importance of intersectoral action. In my view, a concern with the socialdeterminants of health can further energize the renewed enthusiasm for primary health careexpressed in all WHO regions.I warmly welcome this publication. Decades of experience tell us that this world will not becomea fair place for health all by itself. Health systems will not automatically gravitate towards greaterequity or naturally evolve towards universal coverage. Economic decisions within a country willnot automatically protect the poor or promote their health. Globalization will not self-regulatein ways that ensure fair distribution of benefits. International trade agreements will not, by them-selves, guarantee food security, or job security, or health security, or access to affordable medicines.All of these outcomes require deliberate policy decisions.In my view, Equity, social determinants and public health programmes makes the enormous challengesuncovered in the Commission’s report look more manageable and more inviting. Policy-mak-ers and programme managers would do well to accept this invitation. Despite decades of efforts,supported by powerful technical interventions, the health of the people of Africa and of womenstill lags far behind the goals set in international commitments. The sheer magnitude of unmetneeds compels us to consider the fresh – and sometimes daring – proposals for action set out inthis volume.Dr Margaret ChanDirector-GeneralWorld Health Organization2 Equity, social determinants and public health programmes
  • 11. Introduction andmethods of workErik Blas and Anand Sivasankara Kurup 1Contents1.1 Introduction . . . . . . . . . . . . . . 41.2 Key terms and concepts . . . . . . . . 51.3 Framework of analysis . . . . . . . . . 61.4 Towards an actionable agenda. . . . . . 81.5 Process: organizational learning. . . . . 91.6 Bringing it all together . . . . . . . . . 9References . . . . . . . . . . . . . . . . . 10FigureFigure 1.1 Priority public health conditions analytical framework . . . 7TableTable 1.1 Two complementary frameworks for viewing obstacles toachieving effective and equitable outcome of health care interventions 8 Introduction and methods of work 3
  • 12. 1.1 Introduction of new public health challenges and result from them. Most ministries of health, health systems and healthThe work presented in this volume was carried for- programmes are still primarily concerned with deliv-ward with the conviction that achieving greater equity ering the downstream interventions responding toin health is a goal in itself, and that achieving the various the incidental needs and demands of individuals thatspecific global health and development targets without constitute the traditional intramural health care serv-at the same time ensuring equitable distribution across ices. These are important and need to be provided inpopulations is of limited value. Most literature on equity any decent society. However, they are not effectiveand the social determinants of health is based on data responses to the old and new public health problemsthat are from high-income countries and that focus that continue to be produced and reproduced. In theon possible causal relationships. Even in high-income public health community there is a growing recogni-countries there is limited documentation of experiences tion that if we are to deal with both the old and thewith interventions and implementation approaches to new challenges and to achieve global targets, such ashalt growing or reduce existing inequities in health. the health-related Millennium Development Goals, especially from a health equity perspective, we will haveThis shortfall is addressed within the World Health to go far beyond the traditional health interventionsOrganization (WHO) system by the Priority Public and address the upstream determinants of health.Health Conditions Knowledge Network, which aimsto widen the discussion on what constitutes public The Priority Public Health Conditions Knowledgehealth interventions by identifying the social determi- Network was established as one of nine knowledgenants of health inequities and appropriate interventions networks by the Commission on Social Determinantsto address the situation. The work of the Network has of Health, which was created in 2005 by WHO to mar-been focused on practice, establishing the knowledge shal evidence and provide recommendations on whatbase as a starting-point and then quickly and pragmat- can be done to promote health equity and to fosterically moving on to exploration of potential avenues a global movement to achieve it (1 ). From the outset,and options for action. While the scientific review of it was anticipated that the Network could contrib-evidence has played a major role in the work of the ute to the work of the Commission in at least twoNetwork, the main aim has been to expand the known unique ways: from a health conditions perspective, asterritory and move, in a responsible and systematic way, distinct from the topical perspectives of social determi-into the unknown, by suggesting new paths of action nants pursued by the other knowledge networks; andfor public health programmes. Effectively address- from a programmatic perspective, as public health pro-ing inequities in health involves not only new sets of grammes in their various shapes are key actors on theinterventions, but modifications to the way that public ground. A large number of WHO-based public healthhealth programmes (and possibly WHO) are organized programmes participated in the work, which resultedand operate, as well as redefinition of what constitutes in the 12 individual chapters and synthesis chapter thata public health intervention. comprise the remainder of this volume. The number of programmes was large enough for the resulting propos-While old public health problems persist, such as als to have a general value.malaria, tuberculosis and sexually transmitted diseases,new challenges are presenting themselves. Many of the During the work of the Priority Public Health Con-old problems persist because we have failed to effec- ditions Knowledge Network a number of eventstively apply the tools that we have at hand – and some occurred with direct relevance to or bearing on theof those tools have even been destroyed in the process, future work of public health programmes:for example by creating drug resistance. Another set of • The Commission on Social Determinants of Healthreasons for the failure is that we have not sufficiently completed its work and presented its final reportrecognized and appropriately dealt with the inequities documenting the magnitude of health inequities,underlying average health statistics. This has meant that identifying their social causes and proposing direc-even when overall progress has been made, large parts tions for action (1 ). The Priority Public Healthof populations, and even whole regions of the world, Conditions Knowledge Network, as one of the net-have been left behind. works of the Commission, assisted in generating evidence and proposals for action, and gained inspi-Most if not all of the new public health challenges that ration from the work of the Commission and thewe are facing – be it in the areas of communicable, other knowledge networks.maternal, perinatal and nutritional conditions, non- • The 2008 World Health Report placed health equitycommunicable conditions or injuries – are directly as the central value for the renewal of primaryrelated to how we organize our societies and live our health care and called for priority public health pro-lives, with inequities among and within populations grammes to align with the associated principles andagain standing out. Inequities both fuel the emergence approaches (2 ).4 Equity, social determinants and public health programmes
  • 13. • A global financial crisis and recession developed dur- 1.2 Key terms and concepts ing 2008, first impacting high-income countries and later extending to low- and middle-income coun- The Priority Public Health Conditions Knowledge tries. The recession, following three decades that Network shares the holistic and value-driven view of have seen a gradually reduced role in many coun- social determinants taken by the Commission on Social tries for the state in direct provision and financing Determinants of Health, namely that the structural of social and health service provision and increased determinants and conditions of daily life constitute the reliance on the demand and supply mechanisms of social determinants of health and that they are cru- the market, will certainly pose challenges to health cial to explaining health inequities. More specifically and equity in health. As trade protectionism is loom- these include distribution of power, income, goods and ing and jobs are lost, those who are most vulnerable services, globally and nationally, as well as the immedi- are becoming even more vulnerable, not only in ate, visible circumstances of peoples lives, such as their terms of access to health care services, but also with access to health care, schools and education; their con- regard to other determinants of health, including ditions of work and leisure; their homes, communities, degree of social exclusion, education, housing and and rural or urban settings; and their chances of lead- general living conditions, quality of diet, vulnerabil- ing a flourishing life (1 ). In addition, these structural ity to violence and alcohol consumption. determinants influence how services are provided and received and thereby shape health care outcomes andIn May 2009, the World Health Assembly called upon consequences.the international community and urged WHO Mem-ber States to tackle the health inequities within and Health equity is a moral position as well as aacross countries through political commitment on the logically-derived principle, and there are both politi-main principles of “closing the gap in a generation”. cal proponents and opponents of its underlying values.It emphasized the need to generate new, or make use The Commission clearly acknowledges the values baseof existing, methods and evidence, tailored to national of equity in the following definition:“Where systematiccontexts in order to address the social determinants differences in health are judged to be avoidable by rea-and social gradients of health and health inequities. sonable action they are, quite simply, unfair. It is this thatThe Assembly requested the WHO Director-General we label health inequity” (1 ). While expecting oppo-to promote addressing social determinants of health sition to the health equity position, it is important toto reduce health inequities as an objective of all areas note that most individuals and societies, irrespective ofof the Organization’s work, especially priority public their philosophical and ideological stance, have limits ashealth programmes and research on effective policies to how much unfairness is acceptable. These limits mayand interventions (3 ). change over time and with circumstances (4 ). To sup- port the equity position in the public policy dialogueThe vehicle for change to improve health equity over it will therefore be crucial to firmly document thewhich the Priority Public Health Conditions Knowl- extent of health inequities and demonstrate that theyedge Network would have the most direct influence are avoidable, in that there are plausible interventions.was seen as the programmes themselves. The focus wastherefore on what programmes could do and less on Three principal measures are commonly used towhat others should do. This meant that the work set describe inequities: health disadvantages, due to dif-out to address four groups of questions: ferences between segments of populations or between• What can public health programmes do individually? societies; health gaps, arising from the differences• What can public health programmes do collectively? between the worse-off and everyone else; and health• What can public health programmes do vis-à-vis gradients, relating to differences across the whole spec- other sectors? trum of the population (5 ). All three measures have• What must be done differently? been used by the Priority Public Health Conditions Knowledge Network, depending on the context andAn important implication of these questions is that availability of data. However, equity is clearly not onlywhile addressing social determinants requires intersec- about numbers that can be statistically processed andtoral action, there are crucial programmatic tasks that presented in tables and charts – it is about people, theirneed to be undertaken within the health sector before values and what they want from life. There is a need toasking other sectors to do their part. It is with this in “focus not only on the extremes of income poverty butmind that the methods and processes of work were on the opportunity, empowerment, security and dig-chosen. nity that disadvantaged people want in rich and poor countries alike” (6 ). While the general relationship between social factors and health is well established, the relationship is not Introduction and methods of work 5
  • 14. precisely understood in causal terms, nor are the pol- Regional Office for Europe (8 ), Diderichsen, Evans andicy imperatives necessary to reduce inequities in health Whitehead (9 ) and by the work on a comprehensiveeasily deduced from the known data. Because of these conceptual framework for the Commission on Socialuncertainties and the theoretical differences in expla- Determinants of Health (10 ).The priority public healthnations, there is little guidance available internationally conditions analytical framework (Figure 1.1) has threeto assist policy-makers and practitioners to act on the dimensions of activity – to analyse, intervene and meas-full range of social determinants (5 ). Consequently, the ure – and five levels of analysis. The top level relates toPriority Public Health Conditions Knowledge Net- the structure of society, the second to the environment,work has taken practical guidance from some of the the third to population groups, and the last two to thekey principles for creating an evidence base: a commit- individual.ment to the value of equity; identifying and addressinggradients and gaps; focusing on causes, determinants The five levels can briefly be described as follows:and outcomes; and understanding social structure and • Socioeconomic context and position. Social positiondynamics (5 ). exerts a powerful influence on the type, magnitude and distribution of health in societies. The controlThe term “priority” has different meanings to different of power and resources in societies generates strat-people and in different contexts. While the job of the ifications in institutional and legal arrangementsPriority Public Health Conditions Knowledge Net- and distorts political and market forces. While socialwork was not to impose a ranking on public health stratification is often seen as the responsibility ofconditions, it did prove useful to apply four main cri- other policy sectors and not central to the healthteria in identifying those public health conditions that sector per se, understanding and addressing stratifi-merit priority attention: cation is critical to reducing health inequity. Factors• They represent a large aggregate burden of disease. defining position include social class, gender, ethnic-• They display large disparities across and within ity, education, occupation and income. The relative populations. importance of these factors is determined by the• They disproportionately affect certain populations national and international context, which includes or groups within populations. governance, social policies, macroeconomic policies,• They are emerging or epidemic prone. public policies, culture and societal values. • Differential exposure. Exposure to most risk factorsAt the core of all four perspectives is a concern about (material, psychosocial and behavioural) is inverselythe health of populations, and it is this concern that has related to social position. Many health programmesguided the analysis and proposals for action. do not differentiate exposure or risk reduction strategies according to social position, though anal-Health systems are considered to include all activities ysis by socioeconomic group would clarify whichwhose primary purpose is to improve health (7 ). Public risk factors were important to each group, andhealth programmes are thus an integral part of health whether these were different from those impor-systems. However, while health systems are not uni- tant to the overall population. Understanding thesefied organizational entities but loose conglomerates of “causes behind the causes” is important for devel-organizations, institutions and activities, public health oping appropriate equity-oriented strategies forprogrammes are distinct managerial units with objec- health. There is increasing evidence that peopletives, directors, managers, lines of command, budgets and in disadvantaged positions are subject to differen-action plans. The notion of a public health programme tial exposure to a number of risk factors, includinghas in this volume been used broadly to include the natural or anthropogenic crises, unhealthy housing,health condition-related WHO programmes as well as dangerous working conditions, low food availabilitytheir health counterparts in countries and internation- and quality, social exclusion and barriers to adoptingally, whether governmental, nongovernmental, private, healthy behaviours.intergovernmental or international. • Differential vulnerability. The same level of exposure may have different effects on different socioeco- nomic groups, depending on their social, cultural1.3 Framework of analysis and economic environments and cumulative life course factors. Clustering of risk factors in someGiven that the aim of the Priority Public Health population groups, such as social exclusion, lowConditions Knowledge Network was to arrive at income, alcohol abuse, malnutrition, cramped hous-something with practical meaning, and given the the- ing and poor access to health services, may be asoretical differences in explanation expressed by the important as the individual exposure itself. Further,Measurement and Evidence Knowledge Network (5 ), coexistence of other health problems, such as coin-a five-level framework was chosen. The framework was fection, often augments vulnerability. The evidenceinformed by discussion papers prepared for the WHO base on the amplifying effects of reinforcing factors6 Equity, social determinants and public health programmes
  • 15. FIGURE 1.1 Priority public health conditions analytical framework INTERVENE ANALYSE MEASURE Socioeconomic context & position (society) Differential exposure (social & physical environment) Differential vulnerability (population group) Differential health outcomes (individual) Differential consequences (individual) is still limited, though it is clear that they exist for population groups are better protected, for exam- low-income populations and marginalized groups. ple in terms of job security and health insurance, for It is important that attempts to reduce or eliminate the disadvantaged, ill-health might result in further them identify appropriate entry-points for breaking socioeconomic degradation, crossing the poverty the vicious circles in which vulnerable populations line and accelerating a downward spiral that further find themselves trapped. damages health.• Differential health care outcomes. Equity in health care ideally implies that everyone in need of health For each level, the analysis aimed to establish and care receives it in a form that is beneficial to them, document: regardless of their social position or other socially • social determinants at play and their contribution determined circumstances. The result should be the to inequity, for example pathways, magnitude and reduction of all systematic differences in health out- social gradients; comes between different socioeconomic groups in • promising entry-points for intervention; a way that levels everyone up to the health of the • potential adverse side-effects of eventual change; most advantaged. The effects of the three upper • possible sources of resistance to change; levels of the analytical framework may be further • what has been tried and what were the lessons amplified by health systems providing services that learned. are not appropriate to or less effective for certain population groups or disadvantaged people com- There are potential overlaps, in particular between the pared to others. differential exposure and vulnerability levels. Further,• Differential consequences. Poor health may have several a pathway across the levels does not necessarily imply social and economic consequences, including loss of moving from the top to the bottom level of the frame- earnings, loss of ability to work and social isolation work, passing through all the intermediate levels. For or exclusion. Further, sick people often face addi- example, a change in public policy may have an imme- tional financial burdens that render them less able diate effect on how health care services are provided and to pay for health care and drugs. While advantaged thereby positively or negatively impact equity in health Introduction and methods of work 7
  • 16. care outcomes without passing through the exposure the analogy of a staircase that an individual has to climband vulnerability levels. The framework should there- in order to fully benefit from a service, consideredfore be seen as a practical way of organizing the work interventions aimed at addressing provider compliancefrom analysis to action in a manner that is consistent and consumer adherence in addition to the three struc-with the conceptual framework of the Commission tural intervention categories described above. Table 1.1on Social Determinants of Health and the frameworks shows a combination of two intervention frameworksused by most of the other knowledge networks. dealing with access to and provision and use of health care services. The Tanahashi framework (12 ) focusesThe analysis for each of the public health conditions on access and proposes a four-step staircase that a pro-took its departure from the differential health care out- spective user of health care needs to climb before ancomes level, looking upstream to investigate where effective contact with the health service is established.these differences originated. After having mapped the Once the contact is established there are still, accordingmain pathways, attention went to proposing interven- to Tugwell, Sitthi-Amorn et al. (13 ), three additionaltions at each promising entry-point and to issues of steps before a successful outcome is achieved. Themeasurement. obstacles to climbing each of these seven steps depend on a combination of service provision factors and social determinants related to the user. Tugwell, de Savigny et1.4 Towards an actionable al. suggest that poorer people have a greater reductionagenda in benefit at each step than the less poor (14 ). However, it is one thing to propose interventions, andThere are five clusters of possible interventions cor- quite another to put them effectively to work in oftenresponding to each of the five levels of the analytical very complex circumstances, where powerful interestsframework, ranging from the top societal level to the may oppose them. General considerations related totwo individual levels. One of the prime tasks of public implementing interventions include:health programmes is to translate knowledge on causes • Replicability. Can the intervention be implementedinto concrete action. Consideration of interventions in different contexts and circumstances?and how these are to be implemented, while being sen- • Sustainability. Are the required human, technical andsitive to possible risks and assumptions, has therefore financial resources such that the interventions canbeen key to the work. be continued for long enough to have the desired lasting effect?Implementing such action may be the responsibility • Scalability. Can the interventions be expanded to theof public health programmes, the wider health sector scale required to be meaningful?or sectors beyond health. The upstream levels of the • Political feasibility. Can the intervention be imple-framework, namely context and position, differential mented in different political circumstances, forexposure and differential vulnerability, can be usefully example with respect to timing, values and powerconsidered in relation to the classification of structured structure?interventions suggested by Blankenship, Bray and Mer-son (11 ):• interventions that acknowledge health as a func- tion of social, economic and political power and TABLE 1.1 Two complementary frameworks for viewing resources, and thus seek to manipulate power and obstacles to achieving effective and equitable outcome of resources to promote public health; health care interventions• interventions based on the assumption that health Four-step framework Five-step framework problems result from deficiencies in behaviours, set- tings, or the availability of products and tools, and Tugwell, de Savigny et al. Tanahashi (12) thus seek to address those deficiencies; (14)• interventions that recognize that the health of a Availability coverage society and of its members is partially determined Access Accessibility coverage by its values, cultures and beliefs, or those of sub- Access groups within it, and thus seek to alter those social Acceptability coverage norms that are disadvantageous to health. Contact coverage EffectivenessAt the two individual levels of the framework – differen- Diagnostic accuracytial health care outcomes and differential consequences Provider compliance Effectiveness coverage– the design characteristics of services may contributeto increasing inequity. In this respect the Priority Pub- Consumer adherencelic Health Conditions Knowledge Network, applying8 Equity, social determinants and public health programmes
  • 17. • Economic feasibility. What are the required invest- case studies are presented in the synthesis chapter of ments and are they reasonable? How can the this volume, while fuller reports are presented in a sep- necessary finances be made available? What has to arate volume. Finally, a learning node was established be given up by other sectors? to facilitate and document the organizational learning• Technical feasibility. Are the tools required to make processes. the intervention happen available or can they be made available? A steering group consisting of the leaders of the above fourteen programme and research and learning nodesA comprehensive social determinants strategy must oversaw the process and met monthly from Januaryconsider the political dimension at all levels. Inequity 2007 to June 2008. This was a very successful part ofis intrinsically related to power relations and con- the set-up. It provided within WHO an opportunitytrol of resources. Attempting to reduce inequities in for a number of programme representatives from acrosspublic health inevitably means confronting the more conditions and organizational units to come togetherpowerful to benefit the less powerful, whether at the around a common concrete technical project extend-greater societal or the individual health clinic level. ing over a long period.Comprehensive intervention strategies therefore needto include approaches to dealing with resistance and Overall, the work of the Priority Public Health Condi-opposition. tions Knowledge Network had four phases: (a) analysis of conditions; (b) interventions and implementation considerations; (c) measurement; and (d) synthesis,1.5 Process: organizational implications and conclusions. The first three phaseslearning included peer reviews, where one node would review and give feedback on another node’s work in order to foster mutual learning.These reviews were extended toEqually important to the tangible outputs of the pro- the WHO regions when the difficulties of expandingcess was the organizational learning process. Therefore, the networks for the individual programme nodes werethe work of the Priority Public Health Conditions realized. Most regions responded well to the opportu-Knowledge Network was planned using an extensive nity for active participation of both regional advisersnetwork spanning a range of conditions and organi- and country staff.zational units and levels. Fourteen programme nodeswere established to include sixteen of the major publichealth programmes of WHO. Thirteen of those nodes 1.6 Bringing it all togethercompleted all phases of their work and their outputsare presented as chapters of this volume (with Chap- The analysis and proposals for each of the conditionster 10 comprising the work of both the maternal health have value in their own right and are presented in sep-and the sexual and reproductive health nodes). The arate individual chapters of this volume (Chaptersintention was that each of the nodes would extend 2 to 13) as follows:their networks to cover WHO regions, countries and 2. Alcoholacademia. Some of the nodes responded well to this 3. Cardiovascular diseasechallenge; others were less successful and only man- 4. Health and nutrition of childrenaged to expand their networks through contracting 5. Diabetesconsultants. 6. Food safety 7. Mental disordersA research node comprising three research pro- 8. Neglected tropical diseasesgrammes (the Special Programme for Research and 9. Oral healthTraining in Tropical Diseases, the Special Programme 10. Unintended pregnancy and pregnancy outcomeof Research, Development and Research Training in 11. Tobacco useHuman Reproduction, and the Alliance for Health 12. TuberculosisPolicy and Systems Research) and the Department of 13. Violence and unintentional injuryEthics, Equity, Trade and Human Rights posted a callfor case study research to learn from implementation of The synthesis process, therefore, involved establishingsocial determinant approaches in countries. The studies the common ground – what are the common les-covered five themes related to expanding implemen- sons and what could be the basis for common actiontation beyond pilot projects and experiments, namely – rather than summarizing the finding of each of thegoing to scale, managing policy change, managing individual chapters. Its aim was to focus on and takeintersectoral processes, adjusting design and ensuring advantage of the large amounts of work undertakensustainability. Fourteen studies were commissioned and by the individual programme nodes and case studies,completed. The summary lessons learned from these and to draw on the elaborate analyses and work of the Introduction and methods of work 9
  • 18. 3. World Health Assembly of the World Health Organiza-other eight knowledge networks of the Commission tion. Reducing health inequities through action on the socialon Social Determinants of Health. The synthesis pro- determinants of health. Resolution WHA62.14. Geneva,cess thus involved seven major steps: World Health Organization, 2009:21–25 (http://• map the different types of patterns of inequity across the public health conditions; WHA62_REC1-en-P2.pdf, accessed 20 October 2009).• identify the social determinants at each level of the 4. Blas E. 1990–2000: a decade of health sector reform in devel- priority public health conditions framework com- oping countries – why and what did we learn? Göteborg, mon to six or more of the conditions and for each Nordic School of Public Health, 2005. level identify three promising entry-points for 5. Kelly PM et al. The social determinants of health: devel- intervention; oping an evidence base for political action. Final Report of• propose for each of these entry-points three possible the Measurement and Evidence Knowledge Network interventions with key movers; to the Commission on Social Determinants of Health.• propose three actions that public health programmes Geneva, World Health Organization, 2007. can take at each level of the priority public health 6. Marmot M. Health in an unequal world. Lancet, 2006, conditions framework; 368(9552):2081–2094.• discuss major lessons on implementation learned 7. Gilson L et al., with inputs and contributions from the from the case studies; members of the Health Systems Knowledge Network.• discuss the needs and options for data collection and Final report of the Health Systems Knowledge Network to monitoring to inform policy formulation and pro- the Commission on Social Determinants of Health. Geneva, World Health Organization, 2007. gramme management;• discuss the implications for public health pro- 8. Dahlgren G,Whitehead M. Levelling up: a discussion paper grammes and for WHO in taking up the proposed on European strategies for tackling social inequities in health (part 2). WHO Regional Office for Europe, 2006. actions. 9. Diderichsen F, Evans T, Whitehead M. The social basisBy taking the two-pronged approach of identifying of disparities in health. In: Evans T et al., eds. Challenging inequities in health. New York, Oxford UP, 2001.which characteristics are unique to each condition,and which are common to all and should be addressed 10. Solar O, Irwin A. A conceptual framework for action onin a collective and concerted way, the work presented the social determinants of health. Discussion paper for the Commission on Social Determinants of Health. Geneva,in this volume should contribute to expanding the World Health Organization, 2007.conceptual framework related to public health condi-tions and increasing the effectiveness of public health 11. Blankenship KM, Bray SJ, Merson MH. Structural inter- ventions in public health. AIDS, 2000, 14(1):S11–S21.interventions and programmes that address them, and,equally importantly, will provide input for operational- 12. Tanahashi T. Health service coverage and its evalu-izing the primary health care agenda described in the ation. Bulletin of the World Health Organization, 1978, 56(2):295–303.World Health Report 2008 (2 ). 13. Tugwell P, Sitthi-Amorn C et al. Health research profile to assess the capacity of low and middle income coun-References tries for equity-oriented research. BMC Public Health, 2006, 6:151.1. Closing the gap in a generation: health equity through action 14. Tugwell P, de Savigny D et al.Applying clinical epidemio- on the social determinants of health. Commission on Social logical methods to health equity: the equity effectiveness Determinants of Health Final Report. Geneva, World loop. British Medical Journal, 2006, 332(7537):358–361. Health Organization, 2008.2. The World Health Report 2008. Primary health care: now more than ever. Geneva, World Health Organization, 2008.10 Equity, social determinants and public health programmes
  • 19. Alcohol: equity andsocial determinantsLaura A. Schmidt, Pia Mäkelä, Jürgen Rehm and Robin Room1 2Contents2.1 Summary . . . . . . . . . . . . . . . . 12 Monitoring change: generating an evidence base for effective action . . . . . . . . . . . . . 242.2 Introduction . . . . . . . . . . . . . . 12 2.7 Conclusion . . . . . . . . . . . . . . . 24 Alcohol and inequity: a complex relationship. . 12 References . . . . . . . . . . . . . . . . . 25 Causal pathways linking alcohol and health inequity . . . . . . . . . . . . . . . . . 132.3 Analysis: differential distribution of Figures alcohol use and problems . . . . . . . . 14 Figure 2.1 Application of priority public health conditions analytical framework to alcohol- Alcohol consumption . . . . . . . . . . . . 14 attributable harm. . . . . . . . . . . . . . . 13 Health outcomes of alcohol use. . . . . . . . 15 Figure 2.2 Relationship between per capita Socioeconomic consequences of alcohol use . . . 18 purchasing power parity-adjusted GDP and adult consumption (litres) of alcohol per year, 20022.4 Discussion of causal pathways . . . . . 19 (weighted by adult population size) . . . . . . 15 Socioeconomic context and position . . . . . . 19 Figure 2.3 Relationship between per capita purchasing power parity-adjusted GDP and Differential vulnerability . . . . . . . . . . 19 proportion of male abstainers, 2002 (weighted by Differential exposure . . . . . . . . . . . . 20 adult population size). . . . . . . . . . . . . 152.5 Interventions: promising entry-points. . 20 Figure 2.4 Hazard ratios for alcohol-related mortality and hospitalizations by drinking Possible interventions related to socioeconomic category and socioeconomic status as measured context and position . . . . . . . . . . . . 20 by manual vs non-manual labour . . . . . . . 18 Possible interventions to impact differential vulnerability . . . . . . . . . . . . . . . 22 Tables Possible interventions to impact differential Table 2.1 Economic development and alcohol- exposure . . . . . . . . . . . . . . . . . 22 attributable disease burden, 2000 (in 1000 DALYs) . . . . . . . . . . . . . . . . . . . 162.6 Implications and lessons learnt . . . . . 23 Side-effects and resistance to change. . . . . . 231 The authors would like to acknowledge Dag Rekve and Maria Renström for their contribution. Alcohol: equity and social determinants 11
  • 20. 2.1 Summary 2.2 IntroductionAlcohol is a psychoactive and potentially dependence-producing substance with severe health and social Alcohol and inequity: a complexconsequences. It is estimated that 2.5 million people relationshipdied worldwide of alcohol-related causes in 2004, andalcohol ranks as the third leading risk factor for pre- While there is a large body of evidence on the effective-mature deaths and disabilities in the world. Evidence ness of policies targeting the harmful effects of excesssuggests that groups of low socioeconomic status expe- alcohol consumption, little is known about interven-rience a higher burden of alcohol-attributable disease, tions that can reduce inequities in alcohol-attributableoften despite lower overall consumption levels. Health harm across the social gradient. In the absence of rel-outcomes and socioeconomic consequences are deter- evant data, policy-makers may either target groups ofmined not only by the amount of alcohol consumed, low socioeconomic status with interventions knownbut also by the pattern of consumption and the qual- to be generally effective, or implement interventionsity of alcohol consumed. These three determinants are known to reduce the burden of harm in the populationagain shaped by – and shape – the wider social deter- as a whole and thereby hope to impact the higher bur-minants related to socioeconomic context and position, den of harm borne by groups of low socioeconomicexposure and vulnerability. The level of abstention, status. There is a need to test both approaches againstreflecting such issues as gender and poverty levels, is an the evidence.important mediating factor that often serves a protec-tive role. While much recent work has been undertaken on international experiences with alcohol policy (1–6 ),Alcohol consumption rates are markedly lower in policy-making on social inequity and alcohol remainspoorer than in wealthier societies. However, within- hazardous, and the many different sociopolitical, eco-society differences in alcohol-related health outcomes nomic and cultural factors giving rise to inequitiesby socioeconomic status tend to be more pronounced in alcohol problems mean that predicting the impactthan differences in alcohol consumption. In other of any given intervention is a complex undertaking.words, for a given amount of consumption, poorer Much of the uncertainty stems from one simple, butpopulations may experience disproportionately higher empirically robust, finding: because alcohol is a com-levels of alcohol-attributable harm. Such nuances in modity that requires disposable income to obtain, thethe relationships between alcohol and inequity demand poorest segments of the population are usually the leastfurther empirical exploration, particularly in develop- likely to drink. This opens up the possibility that oth-ing countries. erwise beneficial decreases in socioeconomic inequity can lead to an increased burden of alcohol-attributableInequities stemming from the harmful use of alcohol health problems in low-income populations. The con-can be reduced by interventions directly targeting soci- ditions under which this is in fact the case are still notoeconomic context and differential vulnerability and fully understood.exposure. While many existing alcohol interventionshave proved effective, few have focused on reducing Other basic questions remain unanswered: Do reduc-health disparities or the negative consequences of alco- tions in alcohol-attributable harms at the populationhol on the poor, and new approaches are required. level necessarily lead to declines in alcohol-attrib- utable health inequities between groups along theAlcohol use is an integral part of many cultures; conse- social gradient? How can inequities be reduced with-quently effective interventions to reduce alcohol-related out imposing unfair constraints on individual choiceharm and inequities often meet with considerable among economically disadvantaged groups? How canresistance. Concerted and bold actions at all levels of increases in alcohol-attributable harm be prevented ingovernment are needed to tackle alcohol-related ineq- people of low socioeconomic status in the context ofuities worldwide. This will require increased awareness economic development, such as that which has recentlyand acceptance of the public health issues and of the been enjoyed throughout portions of Asia and easterneffectiveness of strategies among policy-makers and in Europe?public discourse. There is a great need to generate and disseminate new knowledge about the complex relationship between alcohol and social and health inequity, particularly in developing countries, and to build the evidence base on how interventions can be appropriately used to target alcohol-attributable disparities across the social gradient. This chapter represents an initial attempt to12 Equity, social determinants and public health programmes
  • 21. FIGURE 2.1 Application of priority public health conditions analytical framework to alcohol-attributable harm Socioeconomic context and Differential vulnerability position, etc. Gender Alcohol production, distribution, regulation Alcohol consumption Age Health and welfare systems Poverty marginalization Volume Pattern Differential exposure Health outcome Drinking environment Drinking culture Chronic Acute conditions conditions Alcohol quality Socioeconomic consequences Loss of earnings, unemployment Stigma Barriers to accessing health caredefine what is already known, and to identify what on other disease outcomes, but in some, most notablymore needs to be known and done to reduce world- heart disease, moderate consumption may be protec-wide health inequities attributable to alcohol. tive of health. Figure 2.1 offers a simplified illustration of how theCausal pathways linking alcohol and three top levels in the priority public health conditionshealth inequity analytical framework might be applied to the case of alcohol-attributable health inequities. Two end-pointsWhile application of the priority public health condi- are of interest for this analysis: health outcomes andtions analytical framework may suggest some new ways socioeconomic consequences attributable to alcoholto think about alcohol-attributable health inequities, consumption.causal pathways involving alcohol differ markedly fromthose pertaining to other conditions addressed in this The health outcomes include a wide range of chronicvolume. While alcohol consumption is an intermediate diseases and acute conditions, and unintentional andfactor in the causal chain linking social determinants to intentional injuries (7 ). Health outcomes includea variety of end-point health conditions, including can- chronic and acute alcohol use disorders, such as alcoholcer, tuberculosis, HIV/AIDS and cardiovascular disease, dependence, harmful use, acute intoxication and alco-it also has its own end-point disease states, including hol poisoning. Among the chronic noncommunicablealcohol dependence and other alcohol use disorders. In health conditions, alcohol has a detrimental impact onmost cases, alcohol consumption has deleterious effects various cancers (8 ), diseases of the gastrointestinal tract, Alcohol: equity and social determinants 13
  • 22. neuropsychiatric disorders and cardiovascular disease. socioeconomic status. Cultural prohibitions on drink-Certain patterns of drinking have a beneficial impact ing by women and children are common to moston ischaemic disease, but this is by far outweighed by cultures, resulting in reduced vulnerability to alco-the detrimental effects (7 ). Finally, alcohol may impact hol-attributable health outcomes for members ofthe initiation of active tuberculosis and may play a role these groups. However, for those who break with suchin HIV/AIDS initiation. cultural prohibitions, vulnerability to the social con- sequences of drinking, particularly stigmatization, mayAlcohol can also impact the course of disease, partly be increased. Another aspect of differential vulnera-by weakening of the immune system (9 ) and partly bility involves alcohol’s negative effects on the coursethrough its influence on behavioural factors, such as of illness or injury. Nutritional deficiencies and otherhelp seeking and adherence to therapy. Both effects consequences of low socioeconomic status can alsohave been found to impact especially poor and mar- increase vulnerability to the harmful health effects ofginalized people, as they interact with malnutrition alcohol.and other aspects of the living situation (for example,homelessness). Differential exposure. Throughout the developing world, heightened exposure to alcohol-related harmInequities in the burden of alcohol-attributable disease results from the consumption of poor-quality alcohol,can, in turn, lead to a second end-point: differen- which may be contaminated with harmful chemicaltial social and economic consequences, including loss additives such as methanol. Unsafe housing and publicof earnings, unemployment, family disruptions, inter- drinking settings, and some group drinking practices,personal violence and stigmatization. Cultural stigma may increase the risk of unintentional injury and expo-is typically most acute for the more marginalized seg- sure to certain infectious diseases, such as tuberculosisments of the population (10 ), and can in turn lead those and HIV/AIDS.with alcohol use disorders to experience increased dif-ficulty accessing health and welfare services. 2.3 Analysis: differentialHealth outcomes and socioeconomic consequences are distribution of alcohol use anddetermined by the overall amount or volume of alco-hol consumed, and by the pattern in which that alcohol problemsis consumed. For example, the cumulation of a volumeof alcohol over a period of years is a predictor of many This section examines evidence that alcohol use andchronic illnesses, while a pattern of drinking more problems vary along social gradients both withinper occasion significantly increases the risk of injury, and between societies, given the limitation that mostincluding alcohol overdose or poisoning. Also, regular research to date has focused on measures of overallmoderate drinking may reduce the risk of contracting wealth and socioeconomic status rather than inequityischaemic heart disease, while excessive consumption per se.will increase the risk.The priority public health conditions analytical frame- Alcohol consumptionwork directs attention to three causal pathways thatlink social determinants with health outcomes and In cross-national comparisons, the relationship betweensocioeconomic consequences: national affluence and alcohol consumption is rela- tively close. Figure 2.2, in which each circle representsSocioeconomic context and position. The glo- a country, shows the relationship between per capitabal, national and subnational contexts in which alcohol purchasing power parity-adjusted gross domestic prod-is legally produced, distributed and consumed have an uct (GDP) and per capita alcohol consumption2 ofimpact on alcohol-attributable health outcomes. Pol- adults aged 15 years and older. The positive relation-icy choices at all levels of government can determine ship between per capita GDP and alcohol consumptionthe availability of alcohol to the population as a whole is stronger among poorer countries, as shown by theand the differential availability to populations of low steeper incline of the trend line at GDP levels belowsocioeconomic status. Once health-related outcomes US$ 10 000.3are present, aspects of the socioeconomic context canfurther impact the availability of health and welfareservices that provide remediation. 2 Includes estimated unrecorded consumption. The difficulty of obtaining such estimates is reflected in an overall PearsonDifferential vulnerability. In most parts of the correlation of, vulnerability to alcohol-related harm differs 3 Correlation among 115 countries below US$ 10  000 = 0.84;across social groupings as defined by gender, age and correlation among 46 countries above US$ 10 000 = –0.06.14 Equity, social determinants and public health programmes
  • 23. FIGURE 2.2 Relationship between per capita purchasing FIGURE 2.3 Relationship between per capita purchasingpower parity-adjusted GDP and adult consumption power parity-adjusted GDP and proportion of male(litres) of alcohol per year, 2002 (weighted by adult abstainers, 2002 (weighted by adult population size)population size) 20 100 Abstainers (%)Adult per capita consumption 90 80 15 70 60 10 50 40 30 5 20 10 0 0 0 10 000 20 000 30 000 40 000 0 10 000 20 000 30 000 40 000 Per capita purchasing power parity-adjusted GDP Per capita purchasing power parity-adjusted GDPFigure 2.3 shows the relationship between per cap- Health outcomes of alcohol useita purchasing power parity-adjusted GDP and therate of abstention in the country’s adult male popula- Variations between richer and poorer regions of thetion. Below a per capita GDP of about US$ 5 000 the world in alcohol’s contribution to the global burdenabstention rate falls sharply with increasing affluence; of disease will now be considered. Table 2.1 comparesabove that level there is little relationship between the alcohol-attributable harm across regions of the worlddegree of affluence and the rate of abstention. using disability-adjusted life years (DALYs), which reflect a combination of the number of years lost fromInterpreting the meaning of these relationships is not early death and fractional years lost when a personstraightforward. For Figure 2.2, alcohol consumption is disabled by illness or injury. The proportion of allmay serve as an indicator of the type of goods that DALYs lost attributable to alcohol is higher in the mid-become part of everyday life when economies start to dle- and high-income regions than in the low-incomeprosper. After a certain threshold is reached, the rela- regions. This is partly due to an overall higher burdentionship between affluence and alcohol consumption of disease attributable to other causes in poorer partsmay no longer be as strong because most people can of the world. The eastern Europe and central Asianafford alcohol and other commodities. grouping shows the greatest proportion of alcohol- attributable DALYs lost (12.1%).One interpretation of Figure 2.3 suggests that abstentionmay be a matter of religious or principled commit- In absolute terms, or DALYs per 1000 adults, the alco-ment. It may also result from broader cultural practices hol-attributable burden remains by far the highest inand norms, or it may reflect extreme poverty, where the eastern Europe and central Asia groupings (36.48meagre resources leave funds unavailable for alcohol. DALYs per 1000 adults), with the lowest tolls found inThis is supported by work showing that between-soci- the industrialized countries and in the Islamic Middleety differences in rates of abstention account for a large East and Indian subcontinent.part of the variation between rich and poor subregionsin levels of alcohol consumption (11 ). This implies The relative importance of different alcohol-attribut-that if the laudable goal of ending extreme poverty able conditions also varies by region. Unintentionalthroughout the world were attained there is the poten- injuries account for a higher proportion of the over-tial, in the absence of countermeasures, for a substantial all disease burden in the two low-income categories,increase not only in rates of people who drink but also and in the eastern Europe and central Asia rates of heavy drinking. The burden of DALYs lost from intentional injuries is particularly high in poorer parts of the world where consumption levels are high, and in eastern Europe and central Asia. Alcohol use disorders (for example alco- hol dependence, harmful use) account for a large part Alcohol: equity and social determinants 15
  • 24. 16 TABLE 2.1 Economic development and alcohol-attributable disease burden, 2000 (in 1000 DALYs) Developing countries Developed countries World Very high or high Very high or high Low mortality Very low mortality Former Socialist: mortality; lowest mortality; low low mortality consumption consumption Islamic Middle East and Poorest countries in Better-off developing North America, Eastern Europe and Indian subcontinent Africa and America countries in America, Western Europe, Japan, central Asia Asia, Pacific Australasia DALYs % DALYs % DALYs % DALYs % DALYs % DALYs % Perinatal conditions 29 0.5% 48 0.7% 29 0.1% 6 0.1% 11 0.1% 123 0.2% Malignant neoplasms 154 2.6% 502 7.0% 2 321 9.1% 828 10.5% 395 3.4% 4 200 7.2% Neuropsychiatric conditions 1 780 29.8% 1 692 23.5% 10 142 39.7% 5 697 72.1% 2 591 22.1% 21 902 37.6% in total Only alcohol use disorders 1 578 26.4% 1 328 18.5% 2 906 36.7% 5 100 64.6% 2 299 19.6% 19 671 33.7% (also part of neuropsychiatricEquity, social determinants and public health programmes disorders) Cardiovascular diseases 899 15.1% 442 6.1% 2 260 8.9% –1 548 –19.6% 1 931 16.4% 3 984 6.8% Other noncommunicable 303 5.1% 594 8.3% 1 864 7.3% 787 10.0% 1 010 8.6% 4 558 7.8% diseases Unintentional injuries 2 293 38.4% 2 740 38.1% 5 961 23.4% 1 571 19.9% 3 929 33.5% 16 494 28.3% Intentional injuries 506 8.5% 1 183 16.4% 2 940 11.5% 558 7.1% 1 874 16.0% 7 061 12.1% Total alcohol-related burden 5 966 100.0% 7 199 100.0% 25 519 100.0% 7 897 100.0% 11 742 100.0% 58 323 100.0% in DALYs Total alcohol-related burden in 6.99 18.70 15.54 11.75 36.48 DALYs per 1000 adults Total burden of disease 458 601   364 117   409 688 115 853 96 911 1 445 169 in DALYs % of total disease burden that 1.3% 2.0% 6.2% 6.8% 12.1% 4.0% is alcohol related Source: Rehm et al. (7).
  • 25. of the burden in the richest group of countries, and in health harm tends to be more prevalent in lower socialmiddle-income developing countries. Cancers account strata, and that this is particularly the case for men. Infor disproportionately more of the disease burden in Nordic countries, for example, groups of lower soci-high- and middle-income regions. oeconomic status have significantly higher rates of alcohol-attributable hospitalization (19 ). In establishedCultural patterns of drinking can also be a factor in market economies, clinical populations of patients inthe differential burden of alcohol-attributable health treatment for alcohol problems typically have an over-outcomes across societies. A broad measure of cul- representation of people of low socioeconomic statustural variation is the “hazardous drinking score”, compared to the general population (20, 21 ). There arewhich captures the extent to which drinking to intox- few studies of self-reported alcohol problems and soci-ication predominates in the society’s drinking culture. oeconomic position in developing countries, but thosePrior analyses suggest that poorer societies tend to that exist point to a relatively strong negative social gra-have higher hazardous drinking scores (7 ). This sug- dient. In a study in southern Brazil, the prevalence ofgests that cultural differences in the safety of drinking alcohol use disorders was 2.7% in the group of highpractices help account for differential exposure to alco- socioeconomic status and 13.7% in the lowest (22 ).hol-related harms. Studies in developed countries, with very few excep-Turning next to within-society variations by gen- tions, have shown that deaths from alcohol-attributableder, age and socioeconomic status, the literature is causes are more common in lower than higher soci-rather limited and tends to focus on Nordic and Eng- oeconomic groups. For example, alcohol-attributablelish-speaking societies, though the World Health mortality ratios between 3.2 and 6.1 have been reportedOrganization (WHO) has sponsored recent efforts to among men between lowest and highest educational,broaden the geographical base for studies (12, 13 ). occupational and income groups in the Nordic coun- tries and in Russia (23–25 ). Ratios often vary markedlyGender. The health and social burden from women’s by age and gender. This is illustrated by the case of thedrinking is everywhere substantially less than for men. United Kingdom, where the ratio in alcohol-relatedIt has been estimated that globally, alcohol accounted mortality between the lowest and highest occupationalfor 1.4% and 7.1% of the DALYs lost among women categories has been as high as 15 among men agedand men, respectively, in 2002. Alcohol-attributable 25–39, and as low as 0.3 among women aged 55–64deaths account for 1.1% of all deaths among women (26 ).and 6.1% among men. The most obvious explanationfor these differences is the large, universally observed, Drinking patterns, at least in part, may help account forgender difference in alcohol consumption: compared this differential burden of harm. Individuals in higherto women, men are less often abstainers, drink more socioeconomic groups are more likely to be drinkers,frequently and in larger quantities, and consequently and they tend to have more drinking occasions, partic-experience more problems from drinking than women ularly more light-to-moderate drinking occasions, than(14–17 ). their counterparts in lower social strata (27, 28 ), while the proportion of drinking occasions that involve bingeAge. The relationship between age and alcohol-attrib- drinking is typically greater for drinkers of low socio-utable harm seems dependent, in part, on variations in economic status (27, 29 ).drinking cultures. In some developed societies wherealcohol is primarily viewed as an intoxicant, as in most Education has also been shown to be a factor. ResultsEnglish-speaking countries, younger people tend to from a comparative study (30 ) of Brazil, Israel, Mexicoexperience relatively more harm. In most develop- and 13 European countries found that among womening societies, alcohol consumption and related harm is educational differences in heavy drinking were small,highest in middle-aged adults. Worldwide, fatal injuries while among men, in most countries, heavy drink-tend to be more prevalent among the young and young ing and heavy episodic drinking were more prevalentadults (18 ). Patterns of drinking again help explain these among those with a limited education. Other resultsfindings, with the proportion of young people’s drink- from India imply a negative gradient between alcoholing that takes place during heavy drinking occasions use and income, and alcohol use and education amongtending to be large compared to that of older people. men (31, 32 ). Overall, income, which is a measure ofAnother factor is cultural variations in “drunken com- purchasing power, seems to have a special role withportment”, or behaviour while drinking; young people respect to alcohol use and heavy drinking, in that ittend to be less risk averse and may engage in more increases the likelihood of consumption when otherreckless behaviour while drinking (4 ). factors, such as education, are held constant (33, 34 ).Socioeconomic status. A general observation from From the above results, it may be concluded that dif-different parts of the world is that alcohol-attributable ferences in alcohol-related health outcomes tend to be Alcohol: equity and social determinants 17
  • 26. FIGURE 2.4 Hazard ratios for alcohol-related mortality and hospitalizations by drinking category and socioeconomic statusas measured by manual vs non-manual labour Hazard ratio 80 70 60 Non-manual 50 Manual 40 30 Other 20 10 0 I II III IV V Consumption categoryNote: Consumption categories: (I) 1–26, (II) 27–116, (III) 117–364, (IV) 365–999 and (V) more than 1000 centilitres of 100 per cent alcohol per year.Model based on drinkers only.more pronounced than differences in alcohol consump- International evidence suggests that, in particular, thetion across the social gradient. Differences in disease stigmatization of alcohol problems is a common threadburden and mortality by socioeconomic status seem linking societies throughout the world. In a 14-countryhigher than would be expected on the basis of differ- WHO cross-cultural study of disabilities, key inform-ences in alcohol use alone (19, 24, 33 ). Recent work in ants assigned “alcoholism” an average rank of 4th outFinland has provided some of the first direct evidence of 18 conditions in terms of the degree of social dis-that this may indeed be the case. In a new study (35 ), approval or stigma in the society. In most societies,participants in a drinking habits survey were followed this amounted to greater disapproval towards alcohol-up to observe long-term alcohol-related mortality and ism than for being “dirty or unkempt” or for having ahospitalization outcomes. As Figure 2.4 illustrates, the “chronic mental disorder” (36 ). Particularly in affluentgroup with lower socioeconomic status experienced societies, there seems to be a strong overlap betweenmore severe health outcomes at all levels of consump- the most marginalized population and those defined astion compared to the group with the highest status. A having serious alcohol problems.noteworthy finding was that even the pattern of drink-ing could not account for these differences between The effects of stigmatization often lead to other soci-the groups. oeconomic consequences, such as loss of earnings, unemployment, homelessness and poverty. Thus, a sur- vey of those entering treatment for alcohol problemsSocioeconomic consequences of in Stockholm, Sweden, found that 77% were not in thealcohol use workforce and 67% did not have a fully stable living situation (21 ). A particularly important consequenceThus far, evidence has been reviewed of differential of stigmatization may be reduced access to health andalcohol consumption and health outcomes across social welfare services. In many parts of the world, those per-gradients within and between societies. Attention will ceived as “drunks” have difficulties obtaining healthnow be turned to the socioeconomic consequences care services (37–39 ), and a summary of six studies fromattributable to the harmful use of alcohol, including Australia, the United Kingdom and the United Statesloss of earnings, unemployment, family disruption and reported that respondents felt that heavy alcohol usersstigmatization. should receive less priority in health care (40 ). Often the justification given was the belief that the alcohol users’ behaviour contributed to their own illness.18 Equity, social determinants and public health programmes
  • 27. 2.4 Discussion of causal – that the highest rates of alcohol consumption arepathways seen, along with a disproportionately high burden of alcohol-attributable harm.The experience of countries in central Asia and eastern Europe today may, in fact,In line with the priority public health conditions ana- foreshadow the future for developing countries, which,lytical framework, social determinants may be linked as they grow more affluent and susceptible to alcoholto alcohol-attributable health disparities through three marketing, are likely to see substantial increases in alco-causal pathways: socioeconomic context and position, hol consumption and resultant public health harmsdifferential vulnerability and differential exposure to from drinking (4 ), with an inequitable impact fallingrisk factors. In all three cases, there is evidence sup- on the poor.porting the applicability of these causal mechanisms toalcohol-attributable health disparities. Socioeconomic context and position also impact the availability of health and welfare services for alcohol-related health problems that, as shown, dispro-Socioeconomic context and position portionately impact populations of low socioeconomic status. Welfare states around the globe vary significantlyThe most important way that the broader socioeco- in the degree to which they provide equal access tonomic context impacts alcohol-attributable health services for those affected by alcohol-related prob-outcomes is by shaping the overall availability of alco- lems (47 ). Substantial barriers to health care access arehol (41 ). It is now widely accepted that rates of alcohol present in both wealthier and poorer societies, althoughconsumption and related problems are heavily influ- the reasons for the barriers differ. In the United States,enced by the availability of alcohol, which is, in turn, for example, insurance exclusions may deny healthlargely determined by societal choices with respect to care coverage for alcohol-related conditions (48, 49 ).the production, importation, advertising, distribution In developing societies, in contrast, shortages of serv-and pricing of alcoholic beverages, which can have dif- ices pose a greater barrier; for example, deficiencies inferential effects on groups along the socioeconomic health care for chronic diseases may mean that an alco-gradient. hol-related illness becomes fatal when it need not be.A general finding in English-speaking and Nordicsocieties over the last 50 years is that, as market liber- Differential vulnerabilityalization, increased advertising and growing affluencehave made alcohol more available in general (42 ), and In most parts of the world, vulnerability to alcohol-to the poor in particular, rates of alcohol problems have related harm differs across social groupings, as definedclimbed, particularly for those of lower socioeconomic by gender, age and socioeconomic status. A number ofstatus (43 ). For example, in the United Kingdom, alco- factors impact this differential vulnerability. For exam-holic cirrhosis used to be a rich man’s disease (44 ), but ple, more affluent drinkers are likelier to have a widerthere was a shift (in England and Wales) in the rela- “social margin” or buffer that insulates them from thetive index of inequality in male liver cirrhosis mortality negative consequences of their actions, whereas drink-by social class from 0.88 in 1961 to 1.4 in 1981 (i.e. ing by groups of lower socioeconomic status takesfrom lower to higher mortality in lower socioeconomic place more often in public settings, where drunkencategories). On the other hand, in southern Europe, behaviour is more likely to be noticed by the police orwhere there has been a marked decline in wine con- other authorities (50 ). Men in higher socioeconomicsumption among the rural poor with urbanization and groups may also be more advantaged by the impor-increased affluence, the traditional excess of cirrhosis tant social constraint of being accountable to a wifemortality among poor men seems to have somewhat and family (51 ).decreased (45, 46 ). A compelling explanation for the differential vul-The dynamics of increasing affluence and alco- nerability of groups of lower socioeconomic statushol availability are a particular concern for countries to alcohol-related problems is cumulative disadvan-throughout the developing world. As shown earlier, tage, which suggests that socioeconomic disadvantagesdeveloping countries currently have lower levels of per occurring early in life can multiply, sometimes expo-capita alcohol consumption, high levels of abstention nentially, over the course of time, contributing toby adult males, and consequently an overall lower bur- adverse health outcomes. Thus in one Finnish study,den of alcohol-attributable disease, though patterns in education, occupational class, personal income, house-some cultures may sometimes gear drinkers towards hold net income and housing tenure each remainedconsuming alcohol in more hazardous situations. In statistically significant as predictors of alcohol-attribut-contrast, it is precisely in the fastest-developing regions able mortality after adjusting for other socioeconomicin the recent past – central Asia and eastern Europe dimensions, with each showing a negative gradient (23 ). Alcohol: equity and social determinants 19
  • 28. The effects can be intergenerational; some studies find 2.5 Interventions: promisingthat, even when the subject’s own socioeconomic status entry-pointshas been controlled, a low childhood socioeconomicposition can increase the risk of alcohol-attributabledeath (52, 53 ). However, a review of the literature sug- From the perspective of public health policy, thegests that a similar generational effect for alcohol use causal pathways between social determinants and alco-and harmful use has not been found (54 ). hol-attributable health outcomes represent potential entry-points for interventions that could prove effec-The cumulation of socioeconomic disadvantages over tive in reducing health disparities.While there are manytime also heightens the risk for alcohol problems that existing alcohol interventions that have been shown tooccur in combination with other health conditions. be effective, few have been implemented with the spe-Nutritional deficiencies linked to low socioeconomic cific goal of reducing health disparities. The followingstatus may, for example, adversely affect the course subsections propose a range of possible interventionof alcohol-related health outcomes by affecting the strategies that flow from the analysis above of the causalimmune system, as has been shown for tuberculosis, pathways linking social determinants with alcohol-HIV/AIDS and recovery from injury. attributable health disparities.Differential exposure Possible interventions related to socioeconomic context and positionPopulations along the social gradient experience dif-ferential exposure to the harmful effects of alcohol. For Enhancing and protecting the ability ofexample, those who are less affluent or of lower educa- governments at various levels to act totion are more likely to access non-beverage and other reduce alcohol problemslow-quality alcohol (55, 56 ). Throughout the develop-ing world, heightened exposure to alcohol-related harm As noted above, one of the most effective ways to pre-can occur due to poor-quality alcohol, which may be vent alcohol-attributable disease is by reducing thecontaminated with harmful chemical additives, such as overall availability of alcohol, which can generallygasoline or methanol, to give an added “kick”, occa- impact the average amount of alcohol consumed. Alco-sionally with fatal consequences. Contamination of the hol control policies, which involve alterations in legalwater supply in making non-commercially produced rules for producing, distributing, taxing, marketing andalcohol is a related problem (56 ). However, contami- pricing alcohol, are some of the most effective tools innation of alcoholic beverages is, overall, much less of a the public health arsenal and may disproportionatelyproblem than the harmful effects of the alcohol itself. impact populations of low socioeconomic status (2, 5, 63, 64 ).There is also evidence that drinking cultures and con-texts shape the differential exposure of groups along While not explicitly focused on reducing social inequi-the social gradient to alcohol-related harms. People ties, there is evidence that taxation and pricing policiesin developing countries, and in groups of low soci- can disproportionately impact lower-income drink-oeconomic status in developed countries, are often ers by making alcohol less affordable for them andspecifically targeted by alcohol advertisers and dis- reducing their consumption (65–68 ). Consequently,tributors. Ecological research in the United States reductions in the alcohol-attributable burden of dis-has thus documented that alcohol-related health and ease will tend to be greater for the poorer than for thesocial problems are disproportionately high in those richer segments of the population, holding other effectslow-income communities that are heavily exposed to constant. It has been argued that the relatively stringentalcohol advertising and that have a high density of alco- alcohol policies of the Nordic countries have contrib-hol sales outlets (57–59 ). uted to holding down health inequalities there (69, 70 ). The reverse effect has also been noted: data from Fin-Differential exposure may also result from variation in land, where in 2004 alcohol taxes were decreased bythe safety of the drinking context and nature of the an average of one third, show that increases in alcohol-drinking culture. Groups of low socioeconomic status related mortality in the two years following the tax cutsare more likely to consume alcohol in unsafe settings were, in absolute terms, most notable among those lesswhere the risks include violence, police encounters privileged in society, such as those outside the work-and unintentional injury (60–62 ), and exposure to cer- force, or with a low income or education (68 ).tain infectious diseases, such as tuberculosis and HIV/AIDS, in public drinking places frequented by people Taxation and pricing policies may be most effectiveat high risk. when they gently discourage consumption by pop- ulations of low socioeconomic status and channel20 Equity, social determinants and public health programmes
  • 29. consumption into less problematic forms. Appropri- such measures in developing countries can be moreate measures might include licensing the production, difficult for many reasons, such as a thriving informalimport and sale of alcoholic beverages, and enforcing market outside the tax system, although solutions domarket controls; specifying what forms and strengths exist (72 ). Such topics are natural ones upon whichof alcohol may be sold; setting and collecting taxes on to base cooperation between WHO and other inter-alcoholic beverages at rates sufficient to discourage national agencies, such as the World Bank and Worldoverconsumption, and to favour consumption of less Trade Organization (4 ).harmful, low-alcohol forms of beverage; and organ-izing and regulating the retail trade to limit the sales Successful interventions of this kind may require pol-network density and hours of opening. icy-makers to take advantage of spontaneous cultural change rather than to try to initiate change. Some ofThere are, however, political and ideological barriers to the most dramatic changes in aggregate alcohol con-measures that would more strongly affect poorer than sumption and related health problems have occurredricher people. A common argument against increased when governments have responded to shifts in publicalcohol taxation is that it is regressive, in that it confis- opinion, rather than the other way around, for examplecates a higher proportion of the poor drinker’s than the due to pressure from social and religious anti-alcoholrich drinker’s income.The issue of regressiveness can be movements (4, 73 ). In the context of developing socie-neutralized by earmarking the tax receipts for purposes ties, anti-alcohol movements have frequently coalescedthat benefit the poor. when indigenous groups have come to see foreign alcohol as a tool of elite domination (74–78 ).In an era of free markets and consumer sovereignty,the ability of governments to control the marketing There are some notable cases in which governmentsof alcohol and contexts of drinking has been compro- have successfully capitalized on the shifting tides of pub-mised, at the national level by courts or commissions lic opinion to help bring about marked shifts in alcoholenforcing internal free markets, and at the international consumption and problems. In Poland, for example, perlevel by regional trade agreements and activities to lib- capita alcohol consumption decreased by 24% duringeralize trade between nations, for example under the 1980–1981 during an anti-alcohol campaign launchedauspices of the World Trade Organization. One alter- by the Solidarity trade movement, which was laternative to counter such trends is formulation of an coopted by national officials who instituted alcoholinternational agreement based on consensus that alco- rationing (79 ). In a developing society context, socialhol is not an ordinary commodity that can be marketed movements instigated by women, including temper-without restriction (71 ). Such an agreement would ance movements in the Pacific Islands and Africa, arerespect the domestic laws and arrangements of indi- further examples of how the momentum created byvidual nations, empowering governments to act in the indigenous movements could be built upon by gov-interests of reducing health inequities, even when such ernments seeking to promote public health regulationsactions cut across market interests. (4, 78 ).The political feasibility of an international pub- Shaping norms and the place of alcohollic health treaty on alcohol is likely to be hampered in the culture to decrease stigmatizationby the power relationships between government andcommercial alcohol interests, including producers, Changes in health, education and welfare policy candistributors and retailers. In many countries, the pro- influence access to health and social services, withduction and sale of alcohol is an important economic positive consequences for stemming alcohol’s adverseactivity that generates profits, jobs and foreign currency effects on the course of existing health problems,in a range of sectors, including agriculture and tour- including alcohol dependence and alcohol-attributableism. While these dynamics have limited the capacity of health conditions such as cirrhosis and coronary heartstates and regional bodies to place formal controls on disease. Generic measures that promote good nutri-the marketing and advertising of alcohol (4, 57 ), the tion and diet among the poor, for example, can helpsuccessful experience negotiating these dynamics with to buffer heavy drinkers from cirrhosis mortality. Withtobacco control provides some hope that similar efforts respect to reducing the burden of alcohol use disorders,may be possible with respect to alcohol. national and local laws that mandate compulsory treat- ment via criminal justice and child welfare authoritiesAnother limitation is the technical capacity and admin- have produced higher rates of treatment engagementistrative infrastructure required to successfully adopt and adherence in low-income populations (80, 81 ).alcohol control policies, both at national and interna-tional levels. Governments in developed countries have However, as has been shown, stigmatization is a majorevolved a range of mechanisms for progressively estab- barrier to accessing health and welfare services, par-lishing control over the alcohol market, but establishing ticularly among disadvantaged and dependent groups. Alcohol: equity and social determinants 21
  • 30. Reducing this stigma thus becomes a potential way Policy interventions that target at-risk drinkers in med-of reducing alcohol-related health inequities. This is a ical and primary health care settings show particularrelatively untapped field, and it is in fact a matter of promise for reducing health disparities and could helpexperiment to see whether and under what conditions reduce the stigma associated with obtaining tertiarysuch reductions in stigma can be managed, and what care for alcohol-related problems. Since 1980, WHOtheir effects are. has focused on developing effective approaches to detect individuals with harmful alcohol consumption before the onset of adverse health consequences. BriefPossible interventions to impact interventions, usually confined to a few sessions ofdifferential vulnerability counselling and education within a primary care con- text, have been shown to be effective in internationalCommunity mobilization and clinical trials (41, 88, 89 ).empowerment Mutual aid approaches, notably Alcoholics AnonymousCommunity mobilization is one type of intervention (AA), also hold promise because they are free to all.Thethat has proven successful in responding to the differen- AA approach has demonstrated its ability to transcendtial marketing of alcohol to vulnerable groups. Under cultural boundaries (90, 91 ) and provides an effective,this approach, prevention specialists target community low-cost alternative and adjunct to professional treat-leaders in a campaign to raise awareness of problems ments for alcohol use disorders. It has been argued,associated with drinking and to develop specific solu- with some evidence, that both the growth of AA andtions that involve stakeholders in the community (82, the provision of specialty care for alcohol use disorders83 ). One outcome of community mobilization efforts can reduce rates of alcohol problems in the popula-in the United States has been to strengthen the enforce- tion; thus studies have found an association betweenment of public drunkenness and alcohol outlet zoning decreased hospital discharges for liver cirrhosis andordinances in low-income communities (84 ). Unfortu- increased treatment and AA attendance (92–94 ). Thenately, the effectiveness and long-term sustainability of provision of treatment and mutual help approachescommunity mobilization approaches is unclear (85, 86 ). may thus impact alcohol-related health outcomes.Political barriers can interfere with attempts to cur-tail the selected commercial marketing of alcoholic Possible interventions to impactbeverages to vulnerable populations. Civil protec- differential exposuretions on commercial activity and freedom of speechcan limit the capacity of government to regulate the Controls on alcohol qualitymarketing and advertising of alcohol products, even topopulations that are vulnerable from a public health The main strategy for controlling the quality of alco-standpoint. Governments that seek to protect the pub- hol involves government safety regulations, applied tolic health through counteradvertising campaigns have alcohol producers, on the potency and purity of alco-met with limited success in the alcohol field, perhaps hol products. Such interventions are likely to have adue to ineffective messages, low frequency and inap- moderate effect on all health outcomes in all societies,propriate placing in the media (87 ). but can be expected to disproportionately impact the health of poorer societies, particularly developing socie-Enhancing access to services for groups ties (70 ). However, harmful additives can be introducedof low socioeconomic status at the level of alcohol distributors and retailers. For example, high rates of cirrhosis in regions of MexicoCumulative disadvantage may increase the vulnera- have been linked to the consumption of commerciallybility of populations of low socioeconomic status to sold pulque, a popular fermented beverage that is oftenalcohol-attributable health problems and consequences, contaminated at the retail stage (95 ). Interventions heresuggesting a potentially greater need for health and may include providing assistance to subnational gov-welfare services that are integrated along a continuum ernments to tighten retailer licensing and enforcementof care. At the same time, stigmatization and economic mechanisms, improve quality and safety standards, andbarriers limit access to health and welfare services for raise consumer awareness.those with the greatest need. The limited resources andnumbers of health professionals in developing coun- Using contextual controls to limit thetries pose a particular challenge to meeting the needs of harm from a given level of drinkingindividuals with alcohol use disorders and related med-ical problems. There are a variety of measures to reduce rates of alcohol-related problems in communities of low soci- oeconomic status that operate through pathways other22 Equity, social determinants and public health programmes
  • 31. than cutting down the level of consumption. Harm considered in the previous section have previouslyreduction policies oriented to lower socioeconomic been implemented.groups have a political advantage in that they seek littleor no change in individual drinking behaviour, focus- Trading one alcohol problem for anothering instead on making the drinking context safer forthose who do drink. They include planning require- Experience shows that aggressive restrictions on alco-ments on the design of drinking places or off-sale hol availability through prohibition, alcohol bans,outlets, controls on drink sizes and drink promotions, taxation and rationing can lower alcohol consump-server interventions to deny service to those already tion and reduce alcohol-attributable health harms, butintoxicated, random breath tests of drivers, and pro- often with adverse side-effects in the form of increasedgrammes that provide free transportation home to violence and criminality associated with illicit pro-intoxicated bar-goers (5 ). Unfortunately, to date, there duction and trade (5, 110 ). Also, in complex markets,is little evidence that these strategies are effective (96 ). alcohol tax increases may be partially neutralized by strategic changes in pricing by alcohol producers andA potentially effective approach for reducing alcohol sellers, effectively substituting consumption of one typeconsumption in poorer communities is to place regu- of alcohol for another (59 ). Price variation and substi-latory controls on the number of alcohol sales outlets tution can, however, be geared to serve public healththat can be opened (97 ), though to date there is lit- goals, as demonstrated in Nordic countries that havetle direct testing and evidence of the effectiveness of taxed more concentrated ethanol products, such as dis-targeting poor communities for reductions in out- tilled spirits, at a higher rate than less concentratedlet density. However, researchers have shown that the ones, such as wine and beer (64, 111, 112 ).density of retail alcohol outlets is related to acute alco-hol-attributable health conditions, particularly auto Moreover, what seems to be an effective taxation policyfatalities and accidents (58, 98, 99 ). In developed coun- for society in general can still have negative collat-tries the economically disadvantaged may do more of eral effects on low-income drinkers and their families.their drinking in public settings and may migrate to While poor consumers do often change their drink-poorer neighbourhoods to drink (100, 101 ), further ing habits in the face of regressive alcohol taxation (5,suggesting that environmental approaches could have a 70 ), there may well be adverse effects on family incomedisproportionate impact on these groups. and well-being if they do not (32 ). For example, a study in Karnataka, India, found that per capita expendituresResponsible beverage service programmes train bar- on food, health and education were significantly lowertenders, managers and other servers in skills for in households where men drank than in non-drinkingrecognizing and refusing service to intoxicated people. households (113 ).Attempts to implement this approach have met withmixed success (102–104 ). Typically, these interventions Symbolic politics and enforcement failuresare carried out in a context where there are laws inplace, but they are poorly enforced (105 ), and enforce- History shows that alcohol problems often creep intoment has been shown to be crucial to the success of debates over poverty and inequity for symbolic rea-these programmes. A related approach holds servers sons (114–116 ). In some cases, the public debate overlegally liable for the consequences of providing alcohol an alcohol policy may be more important than itsto intoxicated or under-age individuals. When tried in actual implementation for the policy-makers involved;the United States, this approach has had some efficacy in the United States, for example, many of the federalwith respect to reducing traffic fatalities and homicide guidelines to address alcohol problems in poor peo-(106, 107 ). ple receiving welfare payments have not actually been implemented by welfare agencies despite the exist- ence of formal regulations (117, 118 ). On a symbolic2.6 Implications and lessons level, however, the emphasis on addiction in the welfarelearnt reform debate played a key role in discrediting long- term welfare dependency and the open-ended system of public entitlements that welfare reformers hoped toSide-effects and resistance to change replace.The history of alcohol policy provides many exam- Without active enforcement, most alcohol policies areples of the potential hazards inherent in attempts to likely to have, at best, minimal effects. Of course, theimplement social policies targeting alcohol-attributa- corollary of this statement is: potentially effective alco-ble health disparities (108, 109 ). This section discusses hol policies that are failing may be rendered effectivesome of the unintended consequences, or side-effects, through more active enforcement. This was vividlythat have arisen when alcohol interventions of the kind demonstrated by a study in Scotland that documented a Alcohol: equity and social determinants 23
  • 32. 20% reduction in arrests resulting from a simple change such smaller-area statistics are potentially important inin enforcement, that of having police occasionally visit tracking and studying alcohol-related health inequal-alcohol retailers to ensure that local alcohol policies ities. Also needed are regular surveys (at least everywere being observed (119 ). On the other hand, in much five years) of general populations, and subpopulationsof the developing world, only a portion of alcohol pro- of interest, concerning types of alcohol consumed,duction and sales is subject to official controls, and it amounts and patterns of drinking, attitudes to absten-may be difficult for a government to enforce tax col- tion, drinking and drunkenness, and attitudes to alcohollection or other sales restrictions on the unofficial and policy interventions.unreported market (57 ). Alcohol-related problemsIntergovernmental and intragovernmentalconflicts The main data available in this area internationally are found in WHO’s annual accumulation of mortality dataIt is clear from the history of public health policy- to the three-character level, which has assisted in estab-making that governments have divided interests when lishing the broad dimensions of alcohol-related healthit comes to alcohol: on the one hand, alcohol is an problems. However, there are major causes of deathindustry that can provide societies with a source of where alcohol plays a substantial role, including inju-production and commodity for retail sales, and govern- ries, cardiovascular disease and infectious diseases, butments with tax income; on the other hand, alcohol is a that connection is not recorded, making it difficult tosource of public disorder and harm that falls within the establish the alcohol-attributable fraction and its varia-mandate of government protection (120 ). The dynam- bility by social class, marginality and other factors.Thusics of alcohol policy in the developing world exemplify there is a need for studies in particular cultures andsuch conflicts. In some developing countries, alco- social groups of the extent of the role of alcohol inhol taxation is an important source of government specific causes of death. There is also a strong need torevenue; for example, in some states of India, alcohol move beyond mortality in building an evidence basetaxes account for as much as 23% of total taxes, com- on alcohol-related health inequalities. Efforts shouldpared to 2.4% of taxes in European Union countries be made to improve the recording of alcohol-spe-(4 ). Dependence by governments on the liquor trade cific codes in multiple-cause hospitalization records. Incan ultimately tie policy-makers’ hands when it comes implementing this, the results of WHO’s internationalto implementing control policies to reduce alcohol- collaborative study of alcohol in emergency depart-attributable harm. ments should be drawn on. Analysis from a health equity perspectiveMonitoring change: generating anevidence base for effective action Analysing the survey data on drinking from a health equity perspective will require attention to the socialThe alcohol literature is blessed with substantial tra- location of drinking patterns and drinking problems.ditions of policy evaluation studies, which have been What is important from a health inequities perspective,collated and summarized in a number of publications however, is to move beyond these analyses to examine(4–6, 70 ). Unfortunately, the literature is derived pri- the question of harm per litre, cross-tabulating drink-marily from a relatively limited range of countries; ing patterns and the occurrence of drinking problems.also, alcohol-related health inequities have often not Such analysis can be carried out at the individual levelbeen a central concern of studies undertaken. Data and in survey data, or at the level of population subgroupsmeasures should accordingly be promoted in the areas – for instance, by age, gender, social class and margin-described in the following subsections. alization – by collating results from different datasets. As implied above, the differential harm from a givenAlcohol consumption amount of drinking is a crucial variable in tackling alcohol problems among the poor and particularly theWhile data are often available at the national level on marginalized. Finally, monitoring and analysis of thealcohol on which tax has been paid, in much of the harm done to others in the social context of problemsdeveloping world this is a relatively small proportion of drinkers would give a more complete picture of thethe alcohol consumed. Alcohol consumed by the poor impact on low-income particularly likely to be unrecorded. In 2008, WHOinitiated several new activities to improve its data col-lection, for example from Member States via the 2.7 ConclusionGlobal Survey on Alcohol and Health. Where possible,alcohol consumption statistics should also be collected There is a substantial research literature on policiesand collated at subnational and socioeconomic levels; that are effective in reducing or holding down rates of24 Equity, social determinants and public health programmes
  • 33. alcohol-attributable problems. However, relatively few to control health problems attributable to alcohol.interventions are designed to target social inequities Since 1997, the Management of Substance Abuse teamwithin societies or between societies, and there remains in the WHO Department of Mental Health and Sub-plenty of unexploited terrain for applying existing and stance Abuse has been building the Global Informationevolving evidence-based approaches to groups of low System on Alcohol and Health (GISAH). This providessocioeconomic status and the developing world. There a reference source of information for global epide-is an urgent need for a programme of strategically cho- miological surveillance of alcohol use, alcohol-relatedsen demonstration projects on alcohol policy initiatives problems and alcohol policies. GISAH should serve astargeting health disparities, with full evaluation, in the a starting-point for developing a necessary epidemio-context of developing societies and low-income pop- logical base for tackling inequities in health related toulations living within developed ones, paying close harmful use of alcohol.attention to measuring differences in effects by socialclass, income and other social differentiations. In a broader perspective, there is a clear need for the promotion of a global approach to reduce alcohol-Stimulating and enforcing measures to reduce alco- related harm. WHO is in a strong position to play ahol-related harm will typically involve a variety of significant role in formulating and implementing angovernment departments, and often reach across them. evidence-based global approach aimed at supportingIn sum, there is a need for a comprehensive alcohol Member States and regions in their work to reduce thestrategy with an agency centrally responsible for coordi- harmful use of alcohol and associated inequities. WHOnating the actions of different government departments. has particularly important roles to play in providingThis agency should have the task of evaluating national scientific and statistical support, administrative capacityexperience in the diverse areas, and transmitting that building, support for tackling issues across regions moreexperience to an international clearing house provided effectively, disseminating evidence-based strategies, andby WHO or other international agencies. collaborating with other international organizations and institutions. WHO should take the responsibilityThere is also a serious need for close monitoring of for leading this global process in order to build consen-the increased affordability of alcoholic beverages in sus around values, interventions and policies that woulddeveloping countries, which is likely to increase alco- contribute to reducing inequities in the harmful usehol consumption and harm. 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  • 38. Cardiovasculardisease: equity andsocial determinantsShanthi Mendis and A. Banerjee 3Contents Figures3.1 Summary . . . . . . . . . . . . . . . . 32 Figure 3.1 Conceptual framework for understanding health inequities, pathways and3.2 Introduction: the global CVD burden . 32 entry-points . . . . . . . . . . . . . . . . . 393.3 Analysis: inequities and CVD . . . . . . 33 Figure 3.2 Prevention and control of noncommu- nicable diseases: public health model. . . . . . 43 Differential (health and health care) outcomes . 33 Figure 3.3 Complementary strategies for Differential consequences . . . . . . . . . . 35 prevention and control of CVD . . . . . . . . 44 Differential exposure . . . . . . . . . . . . 36 Social stratification and differential vulnerability 36 Tables3.4 Discussion of entry-points for tackling Table 3.1 Comparison of trend of deaths from inequities in cardiovascular health and noncommunicable and infectious diseases in high- CVD outcomes . . . . . . . . . . . . . 38 income and low- and middle-income countries, 2005 and 2006–2015 . . . . . . . . . . . . . 333.5 Interventions: addressing the entry-points . . . . . . . . . . . . . . 38 Table 3.2 Major burden of disease (leading 10 diseases and injuries) in high mortality developing3.6 Implications . . . . . . . . . . . . . . 43 countries, low mortality developing countries and developed countries . . . . . . . . . . . . . 34 Programmatic implications . . . . . . . . . 43 Table 3.3 Economic development status and WHO strategy for prevention and control of cardiovascular mortality and CVD burden, CVD . . . . . . . . . . . . . . . . . . 44 2000 . . . . . . . . . . . . . . . . . . . . 353.7 Conclusion . . . . . . . . . . . . . . . 44 Table 3.4 Economic development and summary prevalence of cardiovascular risk factors in WHOReferences . . . . . . . . . . . . . . . . . 45 subregions . . . . . . . . . . . . . . . . . . 37 Table 3.5 Main patterns of social gradients associated with CVD . . . . . . . . . . . . . 39 Table 3.6 Inequity and CVD: social determinants and pathways, entry-points for interventions, and information needs . . . . . . . . . . . . . . 40 Cardiovascular disease: equity and social determinants 31
  • 39. 3.1 Summary public health strategy that addresses inequities in CVD include a life course approach to prevention of riskCardiovascular disease (CVD) is a leading public health factors of CVD and their social determinants; meas-problem that contributes 30% to the annual glo- ures to ensure equity in the utilization of limited publicbal mortality and 10% to the global disease burden. sector resources; recognition of the participatory roleWhile there are downward trends in CVD mortality of civil society; and commitment by government toin most developed countries, the mortality trends in place equity and health at the centre of all governmentlow- and middle-income countries are rising. Evidence policies.on social determinants and inequities related to CVD,mainly from developed countries, indicates an inverserelationship between socioeconomic status and CVD 3.2 Introduction: the globalincidence and mortality. CVD burdenCVD includes coronary heart disease, cerebrovascu-lar disease, rheumatic heart disease and Chagas disease. Noncommunicable diseases (NCD) were responsi-Rheumatic heart disease and Chagas disease are caused ble in 2005 for 35 million deaths (60% of all deaths)by infections. They continue to be major public health worldwide; 80% of these deaths occurred in low- andproblems in low- and middle-income countries, par- middle-income countries. Between 2006 and 2015,ticularly in poorer social classes. Coronary heart disease noncommunicable disease deaths are expected toand cerebrovascular disease make the largest contribu- increase by more than 20% in low-income countries,tion to the global CVD burden. They develop slowly with the greatest increase in sub-Saharan Africa (Tablethrough life due to atherosclerosis of blood vessels 3.1) (1 ).caused by lifelong exposure to behavioural risk factors,tobacco use, physical inactivity and unhealthy diet. An CVD (heart disease and stroke) is the leading noncom-individual’s social status influences behavioural risk fac- municable disease, measured by global mortality andtors, the development of CVD and outcomes of CVD. morbidity, and is projected to remain so for the foresee-Other material and psychosocial factors also have an able future. An estimated 17.5 million people died fromimpact on CVD, operating differentially through the CVD in 2005, representing 30% of all global deaths. Oflife course. They include limited access to social sup- these, 7.6 million were due to coronary heart diseaseport, lack of perception of control and job stress, lower (heart attacks) and 5.7 million to cerebrovascular diseasehealth-seeking behaviours, less access to medical care (stroke). Around three quarters of these deaths occurredand greater comorbidity. in low- and middle-income countries (2 ).The conven- tional risk factors of CVD are tobacco use, raised bloodA balanced combination of cost-effective approaches, pressure, raised blood cholesterol and diabetes mellitus.targeted at the whole population and particularly at Many other factors increase the risk of CVD, includinghigh-risk segments, is required for prevention and con- low socioeconomic status, unhealthy diet, physical inac-trol of CVD. Many determinants of behavioural risk tivity, obesity, age, male sex, family history of early onsetfactors and CVD lie outside the health domain and of coronary heart disease and insulin resistance (3, 4 ).have a strong link to root social causes, such as pov- Other social determinants include income distribution,erty and illiteracy, that also impact health in general. education and literacy, housing and living conditions,Policy action and structural interventions are needed employment and employment security, social exclu-to address these root social causes so that the exposure sion and health care services. The relationship betweenand vulnerability of disadvantaged groups to CVD and the various causative pathways is complex and givesinequitable CVD outcomes may be reduced. Research rise to a number of inequities in cardiovascular healthis needed to study the impact of interventions to reduce status within and between populations. Certain typesinequities and to understand their political feasibility. of CVD, such as rheumatic heart disease and Chagas disease, are directly linked to poverty, undernutrition,Protecting the cardiovascular health of those in lower overcrowding and poor housing (5, 6 ).socioeconomic strata through population-based pre-vention strategies is a priority. The needs of those at Although CVD usually manifests itself in middle age, ithigh risk of CVD should be addressed, with a special is a condition with a long incubation period. Changesfocus on disadvantaged sectors. A policy continuum in blood vessels begin in early childhood and gradu-that takes in all sectors that have an impact on cardio- ally progress to manifest as heart attacks and strokes invascular risk factors and their determinants, including later life (7–9 ). Socioeconomic status can influence car-finance, transport, education, agriculture, social secu- diovascular health differentially along the life courserity and youth affairs, is vital. The most appropriate (10, 11 ). In childhood, poor living conditions and thehealth service entry-point identified for addressing parents’ social class have a strong impact on cardiovas-equity issues is primary care. Other components of a cular health status. In middle age, risk factors such as32 Equity, social determinants and public health programmes
  • 40. smoking, physical inactivity, unhealthy diet, obesity, years (DALYs), which reflect a combination of numberhypertension, raised cholesterol and diabetes increase of years lost from premature deaths and fractional yearsthe risk of CVD, which may be counteracted by mate- lost when a person is disabled by illness or injury. Evenrial conditions that make healthy behaviours affordable in low-income countries coronary heart disease isand facilitate health information seeking, and educa- among the 10 leading causes contributing to the dis-tion (12–15 ). In later life access to medical care, social ease burden (Table 3.2).The proportions attributable toand family support, and a sense of control over life and CVD mortality and the disease burden (Table 3.3) arehealth have an impact on cardiovascular health (16 ). In higher in developing than in developed countries (32 ).middle-income societies where basic material needs areavailable, the psychosocial components of the socioeco-nomic status framework (a sense of control over healthy 3.3 Analysis: inequities andbehaviour and life in general, perceived status in social CVDhierarchy) are likely to be relatively more important forcardiovascular health than material factors (17 ). Differential (health and health care)Differences in socioeconomic status have been con- outcomessistently associated with CVD incidence and mortalityacross multiple populations (18–23 ). CVD and its risk There are substantive equity gaps in the implemen-factors were originally more common in upper socioe- tation of cost-effective interventions and provision ofconomic groups in the developed world, but CVD has quality care for CVD and noncommunicable diseasesgradually become more common in lower socioeco- in general (33, 34 ). They are particularly pronouncednomic groups over the last 50 years (24–26 ). In a recent in low-income countries where health systems areSwedish study, age-standardized incidence of coronary not geared to providing chronic care and the per cap-heart disease was found to be high in high-deprivation ita expenditure is inadequate even to cover the cost ofneighbourhoods (27 ). The inverse association between a basic set of health care interventions (4, 35 ). In lowsocioeconomic status and CVD is strongest for mor- income countries, these gaps can be addressed only iftality and incidence of stroke, with low socioeconomic there is at least a modest increase in public spendinggroups showing lower survival (8 ) and higher stroke coupled with efficient use of resources and investmentincidence in many populations in developed countries in strong prevention programmes (2, 32 ). Such meas-(26, 28–31 ). ures will particularly benefit the poor segments of the population, who suffer most from the consequences ofCoronary heart disease and cerebrovascular disease are the high cost of diagnostic tests and drugs and inade-among the 10 leading causes contributing to the disease quate accessibility to health care in general.burden in better-off developing countries and in devel-oped countries, as measured by disability-adjusted lifeTABLE 3.1 Comparison of trend of deaths from noncommunicable and infectious diseases in high-income and low- andmiddle-income countries, 2005 and 2006–2015 2005 2006–2015 (cumulative) Geographical regions Total deaths NCD deaths NCD deaths Trend: Death Trend: Death (WHO classification) (millions) (millions) (millions) from infectious from NCD disease Africa 10.8 2.5 28 +6% +27% Americas 6.2 4.8 53 -8% +17% Eastern Mediterranean 4.3 2.2 25 -10% +25% Europe 9.8 8.5 88 +7% +4% South-East Asia 14.7 8.0 89 -16% +21% Western Pacific 12.4 9.7 105 +1 +20% 58.2 35.7 388 -3% +17%Source: World Health Organization (1). Cardiovascular disease: equity and social determinants 33
  • 41. Some low-income countries meet more than two thirds a hypertensive patient may postpone seeking treat-of their total health spending through out-of-pocket ment due to lack of affordability and develop a strokeexpenditure. In low-income families, people are often or a heart attack as a result. Such an acute major illnessunable to pay for needed care, particularly for non- will compel the household to pay for the patient’s carecommunicable diseases such as CVD. They fail to seek using a large portion of the household income, drasti-timely treatment when it is still effective and thus risk cally increasing the risk of impoverishment.deterioration of their health condition. For example,TABLE 3.2 Major burden of disease (leading 10 diseases and injuries) in high mortality developing countries, low mortalitydeveloping countries and developed countries Poorest countries in Africa, Better-off countries in Developed countries of America, South-East Asia, America, South-East Asia, Europe, North America, Middle East Middle East, Pacific Western Pacific Countries with high child and Countries with low child Countries with very low child adult mortality, or high child and adult mortalitya or adult mortality, or low and very high adult mortalitya child and adult mortality, or low child and high adult mortalitya AFR-D, AFR-E, AMR-D, AMR-B, EMR-B, SEAR-B, AMR-A, EUR-A, EUR-B, EMR-D, SEAR-Db WPR-Bb EUR-C, WPR-Ab % DALYs HIV/AIDS 9.0 Lower respiratory infections 8.2 4.1 Diarrhoeal diseases 6.3 Childhood cluster diseases 5.5 Low birth weight 5.0 Malaria 4.9 Unipolar depressive disorders 3.1 5.9 7.2 Coronary heart disease 3.0 3.2 9.4 Tuberculosis 2.9 2.4 Road traffic injury 2.0 4.1 2.5 Cerebrovascular disease 4.7 6.0 Chronic obstructive pulmonary 3.8 2.6 disease Birth asphyxia and trauma 2.6 Alcohol use disorders 2.3 3.5 Deafness 2.2 2.8 Dementia and other central 3.0 nervous system disorders Osteoarthritis 2.5 Trachea bronchus and 2.4 lung cancersa. World Health Organization (WHO) child and adult mortality strata range from A (lowest) to E (highest).b. Key to WHO regions: AFR Africa, AMR Americas, SEAR South-East Asia, EUR Europe, EMR Eastern Mediterranean, WPR Western Pacific. The appended letters A–E give subregions based on mortality strata.Source: World Health Organization (32).34 Equity, social determinants and public health programmes
  • 42. TABLE 3.3 Economic development status and cardiovascular mortality and CVD burden, 2000 Better-off countries in Poorest countries in America, South-East Developed countries of Africa, America, South- Asia, Europe, Middle Europe, North America, East Asia, Middle East East, Western Pacific Western Pacific Countries with high child Countries with low child Countries with very low and adult mortality, or high and adult mortality, or child and adult mortality, child and very high adult low child and high adult or low child and adult mortalitya mortalitya mortalitya AFR-D, AFR-E, AMR-D, AMR-B, EMR-B, EUR-C, AMR-A, EUR-A, EUR-B, EMR-D, SEAR-Db SEAR-B, WPR-Bb WPR-Ab Mortality Deaths (000) (sequenced by 482, 503, 100, 757, 3226 773, 280, 2171, 571, 3350 1106, 1760, 1111, 395 subregion) % of global CVD deaths (sequenced 2%, 3%, 0.6%, 4.6%, 19.4% 4.7%, 1.7%,13.1%, 6.7, 10.6%, 6.7%, 2.3% by subregion) 3.4%, 20.2% % of global CVD deaths (subtotal) 29.6% 43.1% 26.3% Burden of disease in DALYs DALYs (000) (sequenced by 5388, 5976, 1001, 7194, 2935, 16440, 6950, 9201, 8495, 2391 subregion) 8855, 35427 6104, 28115 % of global CVD DALYs (sequenced 3.7%, 4.1%, 0.7%, 4.9%, 2%, 11.4%, 4.8%, 6.4%, 5.9%, 1.7% by subregion) 6.1%, 24.5% 4.2%, 19.4% % of global CVD DALYs (subtotal) 39.1% 41.9% 18.8%a. World Health Organization (WHO) child and adult mortality strata range from A (lowest) to E (highest).b. Key to WHO regions: AFR Africa, AMR Americas, SEAR South-East Asia, EUR Europe, EMR Eastern Mediterranean, WPR Western Pacific. The appended letters A–E give subregions based on mortality strata.Source: World Health Organization (32).Differential consequences and the observed benefits are not restricted to any par- ticular subgroup of patients or model of stroke unitA higher case fatality of myocardial infarction has been care (42 ). However, access to stroke unit care is limitedreported in persons of low socioeconomic position (33, for low-income countries and for low-income groups36 ). People of higher socioeconomic status have been within countries (43 ).found more likely to receive treatment in larger or spe-cialist hospitals, and have been reported to be prescribed Comorbidity could also be a potential explana-medications for secondary prevention more often than tion for the higher case fatality and worse prognosisthose of low status (35, 37, 38 ). Further, there is poor of patients in low social categories. It is probable thataccess to revascularization for people of low socioeco- diseases other than coronary heart disease may accu-nomic status due to its expense (34 ). Differential stress mulate among persons of low socioeconomic positionamong socioeconomic tiers and social isolation have and influence the case fatality and prognosis after myo-also been shown to play a part in the causation and cardial infarction and stroke. Poorer patients are moreprognosis of myocardial infarction in patients after the likely to smoke or have undetected and uncontrolledacute stage (39 ). Sociodemographic factors and social hypertension or diabetes (44 ) and have a higher casesupport can have a positive impact on exercise toler- fatality from myocardial infarction as a result (45 ).ance in men attending cardiac rehabilitation (40 ). Socioeconomic factors such as occupational status andThose of low socioeconomic position have a poorer income have been shown to have an effect on mortal-risk factor profile at stroke onset, including greater ity through their impact on lifestyle-related risk factorslevels of hypertension, diabetes and a trend towards both before and after a stroke (46 ). After stroke, thosehigher rates of smoking compared to those of higher of lower socioeconomic status seem to have signifi-socioeconomic position (41 ). Stroke units seem to con- cantly worse long-term health outcomes in terms ofsiderably improve patient outcomes in the long term, disability and handicap six months after the event (41 ). Cardiovascular disease: equity and social determinants 35
  • 43. Although differences in access to inpatient rehabilita- prevalence of cardiovascular risk factors in developedtion services between different ethnic and social classes and developing countries, based on WHO compara-were not found in studies conducted in the Nether- tive risk factor survey data (32 ). Findings are consistentlands and the United States (41, 47 ), patients of lower with those of higher socioeconomic status in the devel-socioeconomic status were more likely to be admitted oping world having higher mean cholesterol levels andto institutional care for long-term management. Low systolic blood pressure and greater tendency to besocioeconomic status has also been reported to be an overweight than those of lower socioeconomic status.independent predictor of five-year health-related qual- However, if the trends seen in the developed countriesity of life after stroke (29, 48 ). are repeated these patterns will reverse with economic development.Complications of CVD, such as myocardial infarctionand stroke, are serious illnesses that require prolonged A recent study found that in the industrialized world,periods of care and rehabilitation, resulting in loss of countries in the middle and highest (vs lowest) tertilesproductivity and loss of income, with particular impact of income inequality demonstrated positive associationson economic development in developing countries between higher income inequality and mean body(49 ). Also, those in lower socioeconomic strata are less mass index, mean systolic blood pressure, obesity prev-likely to have insurance coverage and may be driven alence and coronary heart disease DALYs and mortalityinto catastrophic expenditure as a result (50 ). rates. Overall, the findings were compatible with harm- ful effects of income inequality at the national scale on CVD morbidity, mortality and selected risk factors,Differential exposure particularly obesity (63 ).Part of the variation in coronary heart disease incidence The adverse impact on cardiovascular health of bothacross the social gradient is explained by established risk globalization and urbanization is greater for poorerfactors (18, 51, 52 ). Associations have also been reported countries and for the poor within countries (64, 65 ),between social support, health-seeking behaviour, job for example through the increase in disposable incomestress and incidence of coronary heart disease (53–55 ), spent on tobacco products (66 ), growth of the fast foodthough not all studies have supported this association industry and increased availability of processed foods(56, 57 ). rich in salt (66 ) and urban infrastructures placing bar- riers to healthy behaviours such as physical activityIndices showing low socioeconomic status, educa- (67, 68 ). Exposure to tobacco use and unhealthy diettion, occupation and income are associated with higher is inversely related to social position (see Chapter 11 ).mortality from coronary heart disease (58–60 ). Fur- Consumption of high-salt and high-calorie food con-ther, studies conducted in high-income countries have tributes to the high prevalence of intermediate riskreported that certain environmental factors associated factors such as raised blood pressure and diabetes inwith residing in neighbourhoods with socioeconomic lower middle social classes living in urban areas indeprivation affect coronary heart disease mortality (61 ), developing countries (69 ). There is increasing evidenceincluding poor availability and accessibility of health of differential exposures of people in disadvantagedservices; infrastructure deprivation (lack of parks, sports positions, for example with respect to availability ofcentres, public spaces with smoking bans); the prevailing healthy food such as fruits and vegetables (70 ), qual-attitudes towards health and health-related behaviours ity of food (71, 72 ) and constraints to adopting healthyin the community; and lack of social support (62 ). behaviours, such as lack of access to physical activity facilities (67 ).The social gradient in stroke could be driven by var-iation in stroke risk factors, health-seeking behavioursor psychosocial risk factors by social status. Most stud- Social stratification and differentialies attempting to explain the socioeconomic gradient vulnerabilityin stroke suggest that it is largely driven by conven-tional stroke risk factors such as hypertension, diabetes, Most existing data suggest that low childhood soci-smoking and alcohol (28, 31 ). Any excess risk in lower oeconomic status negatively impacts levels of adultsocioeconomic groups that persists after adjusting for cardiovascular risk factors (73 ). Several studies haverisk factors in different studies has been attributed to attempted to examine the effect of childhood or ado-psychosocial factors such as work stress, low job con- lescent socioeconomic status on risk of adult CVD (73,trol, lack of social support or confounding (23, 57 ). 74 ). Pollitt, Rose and Kaufman (74 ) outline four types of life course model to describe the impact of socioe-Investigations of the cross-country relations between conomic status on CVD risks and outcomes: the latentincome inequality and CVD morbidity, mortality and effects model, which suggests that adverse life experi-risk factors are sparse. Table 3.4 shows the summary ences during early “sensitive periods” increase the risk36 Equity, social determinants and public health programmes
  • 44. TABLE 3.4 Economic development and summary prevalence of cardiovascular risk factors in WHO subregions Better-off countries in Poorest countries in Africa, America, Europe, South- Developed countries of America, South-East Asia, East Asia, Middle East, Europe, North America, Middle East Western Pacific Western Pacific High child and adult Low child and adult Very low child and adult mortality, or high child and mortality, or low child and mortality, or low child and very high adult mortalitya high adult mortalitya adult mortalitya AFR-D, AFR-E, AMR-D, AMR-B, EMR-B, EUR-C, AMR-A, EUR-A, EUR-B, EMR-D, SEAR-Db SEAR-B, WPR-Bb WPR-Ab Overweight (body mass index) 21.3, 21.8, 26.0, 22.3, 19.9 26.0, 25.2, 26.5, 23.1, 22.9 26.9, 26.7, 26.5, 23.4 Physical inactivity (proportion with 12%, 11%, 23%, 18%, 17% 23%, 19%, 24%,15%, 16% 20%, 17%, 20%, 17% no physical activity) Low fruit and vegetable intake: 350, 240, 340, 360, 240 190, 350, 220, 220, 330 290, 450, 380, 410 average intake per day (grams) Blood pressure (mean systolic 133, 129, 128, 131, 125 128, 133, 128, 128, 124 127, 137, 138, 133 pressure mmHg)c Mean cholesterol (mmol/l)d 4.8, 4.8, 5.1, 5.0, 5.1 5.1, 5.0, 5.8, 4.7, 4.6 5.3, 6.0, 5.1, 5.2a. World Health Organization (WHO) child and adult mortality strata range from A (lowest) to E (highest).b. Key to WHO regions: AFR Africa, AMR Americas, SEAR South-East Asia, EUR Europe, EMR Eastern Mediterranean, WPR Western Pacific. The appended letters A–E give subregions based on mortality strata.c. mmHg = millimetres of mercury.d. mmol/l = millimoles per litre.Source: World Health Organization (32).of CVD in later life, independent of other risk factors socioeconomic environments and life course factors or(75 ); the pathway model, which hypothesizes that early lack of early detection of risk factors. Being born tolife events and circumstances place an individual onto an undernourished mother of a poor family increasesa certain “life trajectory”, eventually impacting adult the chances of developing cardiovascular risk profiles inhealth (76 ); the social mobility model, which holds that later life due to programming in utero (85 ). Children“social mobility across the life course impacts adult in poor families also have a higher likelihood of devel-health” (74, 77 ); and the cumulative life course model, oping Chagas disease or rheumatic fever due to poorwhich hypothesizes that “psychosocial and physiolog- living conditions and undernutrition (5, 6 ).ical experiences and environments during early andlater life accumulate to influence adult disease risk” (74, Adult socioeconomic status (as indicated by, for exam-78 ). Of these, the cumulative life course model is the ple, levels of education, occupational status and income)most consistently supported (79 ). affects CVD outcomes by association with the car- diovascular risk factors and the overall cardiovascularMarmot has defined 10 major social determinants of outcome measures. In developed countries diabetes,health: social gradient, unemployment, stress, social sup- which is a major cardiovascular risk factor, is associ-port, early life, addiction, social exclusion, food, work ated with low socioeconomic status and poverty (seeand transport (80 ). Different studies have linked them Chapter 5). Other cardiovascular risk factors associ-to cardiovascular health and disease (81 ). However, ated with lower socioeconomic status include smoking,more research is required to improve the understand- raised blood pressure, dislipidaemia, central obesitying of how these determinants affect the pathogenesis and inflammatory markers (20, 73, 86–88 ). It has alsoand progression of CVD. Potential pathways that may been reported that low socioeconomic status exerts aplay a role in mediating social differences in cardiovas- stronger adverse influence on cardiovascular risk factorscular risk include the pathogen burden and differences of women than it does on those of men (89 ).in risk factor prevalence (82–84 ). Some ethnic groups have been found to be at higherThe same level of exposure may have different effects risk of CVD. There is a high prevalence of coronaryon different socioeconomic groups depending on their artery disease among urban and migrant Asian Indians, Cardiovascular disease: equity and social determinants 37
  • 45. who are vulnerable to type 2 diabetes mellitus, which 3.5 Interventions: addressingis a powerful risk factor of coronary heart disease (2 ). the entry-pointsPreliminary investigations indicate that psychosocialadversity contributes to increased vulnerability to cor-onary heart disease in male South Asians resident in the At present, the evidence base on interventions thatUnited Kingdom. Compared with white males, they have been implemented to reduce inequities in thelive in significantly more crowded homes and experi- determinants, outcomes and consequences of CVDence lower job control, greater financial strain, lower is limited, and more research is needed to unravel theneighbourhood social cohesion and more racial har- exact mechanisms through which social determinantsassment (90 ). Greater CVD risk factor clustering is contribute to the social gradient of CVD and whatalso seen among non-Hispanic blacks of low socio- works to reduce these inequities (100 ). For example,economic status than among other ethnic groups and there is evidence that individuals who live on a lowcertain ethnic minorities (91 ). income are more likely to smoke, become overweight and suffer coronary heart disease (100, 101 ), but exactly how living on a low income impacts health behaviour3.4 Discussion of entry- is still poorly understood. Similar considerations applypoints for tackling inequities to such factors as employment, educational attain- ment and housing tenure (22, 92 ). Table 3.6 outlines ain cardiovascular health and number of possible interventions to address CVD ineq-CVD outcomes uities (many of which also have relevance to general health) within the context of the pathways and entry- points discussed thus far in this chapter, and suggestsThis chapter explores the social determinants of CVD the measurements that might be applied to guide inter-based on a hierarchical model of causation. This model ventions and assess summarized in Figure 3.1 and is based on several dif-ferent levels: social stratification leading to differences From a public health perspective, it is important toin exposure, leading to differences in vulnerability to recognize that for people to take on board messagesCVD and its health outcomes, leading to differences in advocating lifestyle changes (tobacco cessation, healthyconsequences for quality of life. Inequities in CVD may diet, weight loss, physical activity) they need at least tobe addressed within the WHO Global Strategy for the have primary education. It is only then that they willPrevention and Control of Noncommunicable Diseases be in an intellectual position to receive such messages,(see section 3.6) through interventions targeting causal understand them and act upon them. Further, meas-pathways (section 3.5), based on the framework pro- ures such as housing and poverty alleviation may alsoposed by the Commission for Social Determinants of be important for addressing the social gradient of CVDHealth (92, 93 ). Such interventions could be targeted to: because there is evidence that personal lack of control(a) decrease social stratification; (b) reduce exposure to over life and environment increases risk of morbidityrisk factors; (c) lessen vulnerability; (d) reduce unequal from coronary heart disease (102 ). Rheumatic heartconsequences; and (e) reduce differential outcomes. disease and Chagas disease are types of CVD that are directly linked to socioeconomic status and housingAs alluded to in previous sections, there are different (5, 6 ).patterns of social gradient (Table 3.5), and complexlinks of CVD and cardiovascular risk factors to poverty, As outlined in Figure 3.1, from the moment of con-literacy, employment and other social determinants, ception, during intrauterine life and over the course ofwhich give a key to possible entry-points to address an individual’s lifetime, the cumulative risk of coronaryCVD inequities. Two complementary approaches are heart disease and cerebrovascular disease develops byrequired: first, strategies for primary and secondary way of a complex interplay of genetics, in utero envi-prevention must pay special attention to disadvantaged ronment, biological risk factors and social determinantsgroups; and second, policy and structural interventions (103, 104). To address CVD inequities, social protectionmust also address root social causes such as poverty, illit- therefore needs to be extended to all people through-eracy, unemployment and deprived neighbourhoods. It out their life courses. The social gradient of CVD mayis only then that disadvantaged segments of the pop- be attributed to multiple interacting factors, includingulation will be able to utilize opportunities to make cardiovascular risk factors, social determinants, comor-choices that protect and promote cardiovascular health. bid conditions, general health status, health-seeking behaviours, use of specialized cardiac and stroke serv-Table 3.6 (next section) shows how the entry-points ices, access to health care services and clinical practicearising from consideration of the factors discussed in patterns (59, 105–107).this chapter might be linked with particular interven-tion to address CVD inequities.38 Equity, social determinants and public health programmes
  • 46. FIGURE 3.1 Conceptual framework for understanding health inequities, pathways and entry-pointsSocial context Age Economic development, urbanization, globalizationa Social stratificationa Lifetime exposure to advertising of fast foods, tobacco, vehicle use, Social deprivationa Differential disposable income, urban infrastructure, physical inactivity, high Unemployment exposure calorie intake, high salt intake, high saturated fat diet, tobacco usec, Illiteracy lack of control over life and work, high deprivation neighbourhoods Deprived neighbourhoods Adverse intrauterine life Raised cholesterol, raised blood sugar, raised blood Differential pressure, overweight, obesityb, lack of access to health Less access to: vulnerability information, health services, social support and welfare • Health services assistance, poor health care-seeking behaviour • Early detection • Healthy foodb Differential Higher incidence, frequent recurrences, Povertya outcomes higher case fatality, comorbiditiesb Overcrowding Poor housing Differential High out-of-pocket expenditure, poor adherence, lower survival, loss of employment, loss of productivity and income, social and financial Rheumatic heart diseaseconsequences consequences, entrenchment in poverty, disability, poor quality of lifeb Chagas diseaseDeterminants:a. Government policies: influencing social capital, infrastructure, transport, agriculture, food.b. Health policies at macro, health system and micro levels.c. Individual, household and community factors: use of health services, dietary practices, lifestyle.TABLE 3.5 Main patterns of social gradients associated with CVD Main patterns Examples Changing direction In the past CVD was considered to be a disease of affluent countries and the affluent in low-income countries. While of gradient CVD trends are declining in developed countries, the impact of urbanization and mechanization has resulted in rising trends of CVD in developing countries. With economic development the prevalence of cardiovascular risk factors will shift from higher socioeconomic groups in these countries to lower socioeconomic groups, as has been the case in developed countries (94). Monotonous The risk of late detection of CVD and cardiovascular risk factors and consequent worse health outcomes is higher among people from low socioeconomic groups due to poor access to health care. This gradient exists in both rich and poor countries (95, 96). Bottom-end People with coronary heart disease of a lower socioeconomic status are more likely to be smokers and more likely to be obese than others. They usually have higher levels of comorbidity and depression and lower self-efficacy expectations, and are less likely to participate in cardiac rehabilitation programmes (97). Top-end In some countries, upper-class people gain preferential access to services even within publicly-funded health care systems compared to those with lower incomes or less education (98). Threshold Some types of CVD, such as Chagas disease and rheumatic heart disease, are associated with extreme poverty due to poor housing, malnutrition and overcrowding (5, 6). Clustering In low- and middle-income countries cardiovascular risk profiles are more unhealthy in urban than in rural populations because of the cumulative effects of higher exposure to tobacco promotion, unhealthy food and fewer opportunities for physical activity due to urban infrastructure (2, 32). Dichotomous In some populations women are much less exposed to certain cardiovascular risk factors, such as tobacco, due to cultural inhibitions (99). Cardiovascular disease: equity and social determinants 39
  • 47. 40 TABLE 3.6 Inequity and CVD: social determinants and pathways, entry-points for interventions, and information needs Priority public health conditions level Social determinants and pathways Main entry-points Interventions Measurement Socioeconomic context Social status Define, institutionalize, Universal primary education Access to employment opportunities, and position protect and enforce poverty alleviation schemes and Education Programmes to alleviate undernutrition in women of childbearing age human rights education (entry-points and and pregnant women Occupation to education, interventions are common Level of investment in interventions employment, living Tax-financed public services, including education and health to other areas of health) Poverty that improve health (including conditions and health Multifaceted poverty reduction strategies at country level, including cardiovascular health) that lie outside Parents’ social class Redistribution of power employment opportunities the health sector Ageing of populations and resources in populations Poor governance Differential exposure Poor living conditions in childhood Strengthen positive and International trade agreements that promote availability and Information on policies and structural counteract negative affordability of healthy foods environment measures conducive Community structures health effects of to healthy behaviour, e.g. tobacco International agreements on marketing of food to children Control over life and work modernization cessation, consumption of fruits and Use tobacco tax for promotion of health of the population vegetables, reduce salt in processed Attitudes towards health Community food, regular physical activity infrastructure Develop urban infrastructures to facilitate physical activityEquity, social determinants and public health programmes Marketing development Information on legislative and Government legislation and regulation, e.g. tobacco advertising and Television exposure regulatory frameworks to support Reduce affordability of pricing healthy behaviour Psychosocial and work stress harmful products Voluntary agreement with industry, e.g. trans fats and salt in Measurement of gaps in Unemployment Increase availability processed food implementation of policies and of and accessibility to High-deprivation neighbourhoods User-friendly food labelling to help customers to make healthy food legislative and regulatory frameworks healthy food choices Availability of preventive health services Health-related behaviours Residence: urban/rural Continues…
  • 48. Continued from previous page Priority public health conditions level Social determinants and pathways Main entry-points Interventions Measurement Differential vulnerability Access to education Subsidize healthy Provide healthy meals free or subsidized to schoolchildren Access to media, e.g. print, radio items to make healthy and television and health education Comorbidity Subsidize fruits and vegetables in worksite canteens and restaurants choices easy choices programmes broadcast through these Lack of social support Facilitate a price structure of food commodities to promote health, media Compensate for lack of e.g. lower price for low-fat milk Access to welfare assistance opportunities Affordability of fruits, vegetables and Improve early case detection of individuals with diabetes and low-fat food items Health care-seeking behaviours Empower people hypertension by targeting vulnerable groups, e.g. deprived Population coverage of screening and Accessibility of health services neighbourhoods, slum dwellers early detection of high-risk groups Undernutrition Improve population access to health promotion by targeting Access to treatment and follow-up vulnerable groups in health education programmes Physical inactivity including to essential drugs, basic Combine poverty reduction strategies with incentives for utilization of technologies and special interventions, Access to health education preventive services, e.g. conditional cash transfers, vouchers e.g. bypass surgery Gender Provide social insurance and fee exemptions for basic preventive and curative health interventions Education and employment opportunities for women Differential health care Cost of appropriate care Medical procedures Increase awareness among providers of ethical norms and patient Access to essential medicines and outcomes rights basic technologies in primary health Differential utilization by patients Provider practices: care compensate for Provide universal access to a package of essential CVD interventions Prescription practices not based on evidence differential outcomes through a primary health care approach Levels of population coverage related Poor adherence to essential CVD interventions Provide incentives within public and private health systems Discriminating services to increase equity in outcomes, e.g. fees and bonuses for Support for smoking cessation disadvantaged groups for high-risk groups among low Poor access to essential medicines socioeconomic segments of the Provide dedicated services for particular groups, e.g. smoking Frequent recurrences and hospitalizations population cessation programmes for people in deprived neighbourhoods Life stress and social isolation Lack of education Comorbidity Differential consequences Lower survival and worse outcomes Social and physical Policies and environments in worksites to reduce differential Social and economic effects of health access consequences outcomes Loss of employment Increase access of services for people with specific health conditions, Access to cardiac rehabilitationCardiovascular disease: equity and social determinants Social and financial consequences e.g. cardiac rehabilitation Policies for linking health and social Lack of access to welfare assistance Improve referral links to social welfare and health education services welfare Heavy health expenditure41 Lack of safety nets
  • 49. Disadvantaged populations are more exposed to risk working among disadvantaged communities, such asdue to lack of power and knowledge. Choices that chronic staff shortages, lack of time to perform profes-a person makes regarding smoking, physical activ- sional duties and lack of resources to provide necessaryity or diet and outcomes of CVD are influenced by aids and adaptations, also promote inequities (113).the “opportunity” that society offers to an individual Local policies must rectify all such fiscal and structural(108, 109). Economic and social policies that decrease factors that perpetuate the disadvantages experiencedsocial stratification can offer people freedom of oppor- by individuals of low socioeconomic status.tunity to utilize their capabilities and make healthychoices in relation to behavioural risk factors such as Policy measures to address gaps in both primary andtobacco use, physical activity and diet (22, 110). Appro- secondary prevention can play an important role in pre-priate government legislation (32 ) can support this venting excess prehospital deaths from coronary heartprocess, for example through action on tobacco adver- disease among persons of low socioeconomic positiontising and pricing, voluntary agreements with industry (2, 43). Improved investments in coordinated cardiacto reduce trans fats and salt in processed food, and user- and stroke rehabilitation services and community-friendly food labelling (32 ). Environmental policies based rehabilitation can also alleviate the unfavourablecan make the infrastructure of deprived neighbour- health situation of disadvantaged groups.hoods conducive to regular physical activity throughthe establishment of cycle paths, sports centres and safe Health care policies and structural interventions arespaces for socializing. essential to reduce differential consequences and to prevent further socioeconomic degradation amongPolicy interventions are also needed to shield disadvan- disadvantaged people who develop CVD (92 ). Ineq-taged groups from differential health care outcomes due uities are exacerbated by health care systems that doto their social position by targeting medical care deliv- not provide essential noncommunicable disease serv-ery strategies, for example those that integrate primary ices through a primary health care approach. Potentialand secondary prevention of heart attacks and strokes, entry-points for action include provider incentives forgiven their common pathogenesis, risk factors, preven- equitable services and shifting of public resources fromtion and treatment approaches (2, 43). A primary health high-technology, high-cost interventions that benefit acare focus will help to address issues of equity-related few people to interventions that have a high impactservice delivery for CVD prevention and control. Fur- and a high public health effect, for example a pack-ther, all primary and secondary prevention activities, age of essential CVD and noncommunicable diseasefrom smoking cessation support to exercise and diet interventions for primary health care financed by pub-programmes and services for detection and treatment lic funds.of CVD, should be delivered within a framework ofuniversal health care. Lack of health care support, for example for people with hypertension and diabetes, may expose them to cata-Social determinants also have a substantial impact strophic health care costs due to acute cardiac eventson the uptake of services by poorer individuals (111). or stroke. Potential entry-points for action includeIn addition to affordability and accessibility, these coverage of the disadvantaged populations for earlyinclude the effect of social distance on the quality of detection of high-risk individuals, health care financingthe doctor–patient interaction; differences in health mechanisms that reduce out-of-pocket expenditure onknowledge, beliefs and behaviour; and “professional health and proper design of the social welfare systemcontrol”, whereby cardiologists may control the con- to compensate for loss of employment due to illness.sultation process. Steps need to be taken to strengthen In a universal health system in which medical serv-the capabilities of the health care workforce to address ices are available to all citizens regardless of income, ainequities. For example, provision of simple adequate patient’s age and the presence of pre-existing CVD andinformation to patients and increased awareness among traditional vascular risk factors accounted for most dis-health workers of the importance of the participatory parities in mortality rates between income groups (114).role of patients in care decisions, are key components This finding suggests that the socioeconomic gradientof care for CVD. in cardiovascular mortality may be partially ameliorated by more rigorous management of known risk factorsSeveral studies have also identified that differences in among less affluent people.the distribution of resources can lead to inequitableuptake of services. Difficulties associated with main- There are other interventions that can help to reducetaining ongoing support for and close monitoring inequities in CVD through a general impact on health.of the chronically ill, domiciliary health care services Most of these interventions empower people by giv-and community care provision (112) have been seen to ing them educational and economic opportunities andvary substantially according to socioeconomic status. removing barriers to healthy choices. They includeResource constraints experienced by medical personnel universal health insurance (114, 115), empowerment for42 Equity, social determinants and public health programmes
  • 50. FIGURE 3.2 Prevention and control of noncommunicable diseases: public health model Policies and programs Housing, access to Employment healthy food security Link medical Target and social Social determinants vulnerable services groups Monitor Primary health care Engage the inequities community Protec tion of population health Environment for Education and healthy living and Life course approach health literacy physical activityself-care (116), adequate investment in health to pro- 3.6 Implicationsvide public health services (117), balanced investment inpreventive and curative care (118), regulation and gov-ernance of the private health sector (119), monitoring Programmatic implicationssocial responsibility of pharmaceutical and technologycompanies (120) and social welfare schemes for people In order to achieve the above, social determinantswith long-term illnesses (121). Coherent government approaches need to be mainstreamed across CVD andaction across education, finance, housing, employ- noncommunicable disease programmes. Many mana-ment, industry, urban planning and agriculture, as well gerial and organizational issues need to be addressedas health, is important for achieving equity in cardio- to make this a reality. Dedicated human and finan-vascular health. cial resources need to be identified within CVD and noncommunicable disease programmes to deal withWhile the need for more evidence remains, action to social determinants across promotion, prevention andaddress social inequities in cardiovascular health needs management areas of work in an integrated fash-to be based on already available evidence. Such action ion. The shared nature of social determinants and theneeds to progress from a business-as-usual, medical interventions that address them also calls for effec-model to application of a public health model (Figure tive collaboration mechanisms across clusters within3.2). Changes based on this transition are likely to meet WHO, for example those related to communicablemany sources of resistance. For example, addressing the diseases, noncommunicable diseases, environmentaldeterminants of exposure related to CVD will require health and health systems. To make such collabora-interventions to influence availability and accessibility tion operational, dedicated funds need to be identifiedof certain products and will therefore encounter pow- and linked to common products with a focal pointerful commercial interests. Other potential sources of coordinating the work across clusters. Further, socialresistance to change include health professionals, peer determinant approaches should be explicitly identifiedgroups, family, households and individuals themselves. and addressed in all treatment guidelines, policy docu- ments, training modules and implementation research related to CVD. At the country level, policy dialogue and public discourse are essential to deal with the inter- sectoral collaboration and social, economic and political change processes required for prevention and control of CVD through an equity lens. Capacity strengthening efforts at country level need to impart knowledge and skills to managers and policy-makers so that they can Cardiovascular disease: equity and social determinants 43
  • 51. competently deal with the complex challenges related people with obesity, tobacco addiction, diabetes, hyper-to policy dialogue and public debate for addressing the tension or high lipid levels. In those with establishedsocial gradient of CVD. CVD or those who are at high risk of developing the disease, aspirin, beta-blockers, angiotensin-converting enzyme inhibitors and lipid-lowering therapies reduceWHO strategy for prevention and the risk of future cardiovascular events by about a quar-control of CVD ter each (43 ). The benefits of these interventions are largely independent, so that when used together withA promising framework for addressing the challenges smoking cessation about three quarters of future vas-outlined in the previous paragraph is the WHO Global cular events could be prevented. Primary health careStrategy for the Prevention and Control of Noncom- offers the best approach to deliver all cost-effectivemunicable Diseases, which was developed in response interventions the rising burden of noncommunicable diseases,including CVD. The strategy was adopted in May 2000by the World Health Assembly at its 53rd session, and 3.7 Conclusionthe action plan for its implementation was endorsed bythe World Health Assembly at its 61st session in May Social injustice is contributing to inequities in cardio-2008 (122). It calls for a comprehensive approach to the vascular health. Many of the possible interventions toprevention and control of CVD through a combination address CVD inequities also have relevance to generalof complementary and synergistic strategies, targeting health. Reducing inequities in cardiovascular health isboth the whole population and those with disease or an ethical imperative that can best be achieved throughat high risk of developing disease (Figure 3.3) (2, 123). a public health approach. Key components of such an approach are:WHO has also provided guidance and support to the • a life course approach to prevention of CVD riskefforts of countries for populationwide prevention of factors and their social determinants, protectingCVD through the Framework Convention on Tobacco cardiovascular health by supporting the health ofControl (124) and the Global Strategy for Diet, Phys- pregnant women, early child development, universalical Activity and Health (125). Such strategies support primary education, healthy behaviours, fair employ-efforts to combat CVD and other major noncommu- ment conditions and social protection for the elderly;nicable diseases, including cancer, chronic respiratory • improvement of the health status of the whole pop-disease and diabetes. It is essential that individual strat- ulation through health promotion and upstreamegies targeting people at high cardiovascular risk be policies that address the needs of those at high riskintroduced in parallel with, and complementary to, and with CVD through health care systems that focuspopulationwide strategies. Individual strategies might on equity through a primary health care approach;focus, for example, on reducing cardiovascular risk in • balanced investment in prevention and curative care; • ensuring equity and social justice in the utilization of limited public sector resources through fair financ- ing, good governance, attention to social norms, andFIGURE 3.3 Complementary strategies for prevention and policies and actions that enable equitable allocationcontrol of CVD of resources to prevention and control of CVD; • recognition of the participatory role of patients with CVD and the community in general, and their Population Strategy High Risk Strategy empowerment to participate in health decisions by giving them educational and economic opportuni- ties and removing barriers to healthy choices; Optimal distribution • intersectoral collaboration and partnerships to address social determinants outside the health sec- % of world population tor that drive the CVD epidemic; • public sector leadership and commitment of gov- Present distribution ernment to place equity and health at the centre of all government policies across education, finance, housing, employment, industry, urban planning and agriculture; 05 10 15 20 25 30 35 40 • regulation of goods and services (tobacco, cer- tain foods, alcohol) that have a negative impact on 10 year cardiovascular disease risk cardiovascular health, and monitoring the social responsibility of pharmaceutical and technologySource: Mendis (123). companies in the private sector.44 Equity, social determinants and public health programmes
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  • 56. 4Health and nutrition ofchildren: equity andsocial determinantsFernando C. Barros, Cesar G. Victora, Robert W. Scherpbier and Davidson Gwatkin1Contents Figures4.1 Summary . . . . . . . . . . . . . . . . 50 Figure 4.1 Prevalence of exclusive breastfeeding in children 0–3 months, by wealth quintile and4.2 Introduction . . . . . . . . . . . . . . 50 region of the world. . . . . . . . . . . . . . 57 Background to inequities in child health Figure 4.2 Skilled delivery care, by wealth and nutrition . . . . . . . . . . . . . . . 50 quintile and region of the world. . . . . . . . 58 Methods . . . . . . . . . . . . . . . . . 51 Figure 4.3 Percentage of under-5 children receiving six or more child survival interventions,4.3 Analysis: socioeconomic differentials in by wealth quintile and country . . . . . . . . 59 child survival and nutritional status . . . 56 Figure 4.4 Oral rehydration therapy during Socioeconomic context and position . . . . . . 56 diarrhoea, by wealth quintile and region of the Differential exposure . . . . . . . . . . . . 56 world . . . . . . . . . . . . . . . . . . . . 59 Differential vulnerability . . . . . . . . . . 57 Figure 4.5 Prevalence of diarrhoea, by wealth Differential health and nutrition outcomes . . . 60 quintile and region of the world. . . . . . . . 60 Differential consequences: mortality and Figure 4.6 Under-5 mortality rate, by wealth human capital. . . . . . . . . . . . . . . 61 quintile and region of the world. . . . . . . . 614.4 Discussion: review of interventions addressing social determinants . . . . . 61 Tables Entry-points and interventions . . . . . . . 61 Table 4.1 Framework for the analysis of inequities in child health and nutrition: indicators and their Evaluations of existing programmes and availability in DHS, MICS or from the published interventions . . . . . . . . . . . . . . . 62 literature. . . . . . . . . . . . . . . . . . . 52 Emerging lessons . . . . . . . . . . . . . 66 Table 4.2 Structural interventions, entry-points and4.5 Interventions and implementation . . . 67 barriers relevant to child health and nutrition . 54 Table 4.3 Matrix of interventions for which4.6 Implications: measurement . . . . . . . 68 equity impact evaluations are available . . . . . 64 Importance of measurements and targets . . . . 69 Table 4.4 Typology of interventions acting on Data shortcomings . . . . . . . . . . . . . 70 equity, with examples from the five programmes Data needed for management, monitoring reviewed. . . . . . . . . . . . . . . . . . . 66 and evaluation . . . . . . . . . . . . . . 70 Table 4.5 Examples of responsibilities for Data needed to manage and monitor possible various intervention components . . . . . . . 68 side-effects of interventions . . . . . . . . . 70 Table 4.6 Testing the implementability of Solutions where data are absent or limited . . . 70 interventions. . . . . . . . . . . . . . . . . 69 Approaches where capacity to generate data and information is limited. . . . . . . . . . 714.7 Conclusion . . . . . . . . . . . . . . . 71References . . . . . . . . . . . . . . . . . 711 The authors would like to acknowledge the following people for their invaluable assistance: Joanna Armstrong Schellenberg, Carmen Casanovas, Denise Coitinho, Valerie Cromwell, Don de Savigny, Darcy Galluccio, Gerry Killeen, Steve Lindsay, Jo Lines, Elizabeth Mason, Thomas Smith and Sergio Spinaci. Health and nutrition of children: equity and social determinants 49
  • 57. 4.1 Summary In light of the mandate of the World Health Organ- ization (WHO), this review was purposefully biasedChildren under 5 years of age are especially susceptible towards health sector interventions. Policy-makers,to the effects of socioeconomic inequities, due to their planners and health workers should be aware that thedependence on others to ensure their health status. way in which they plan and implement preventiveThis review relies on the framework developed by the and curative interventions often contributes to furtherPriority Public Health Conditions Knowledge Net- increasing inequities. Mainstreaming equity considera-work of the Commission on Social Determinants of tions in the health sector is essential for ensuring thatHealth (see Chapter 1).The main data sources included those involved become part of the solution, rather thanover 100 national surveys and a systematic review of part of the problem.the post-1990 literature on child morbidity, mortality,nutrition and services utilization in low- and middle-income countries. 4.2 IntroductionPoor children and their mothers lag systematicallybehind the better-off in terms of mortality, morbidity Background to inequities in childand undernutrition. Such inequities in health outcomes health and nutritionresult from the fact that poor children, relative to thosefrom better-off families, are more likely to be exposed Equity in health implies that ideally all individualsto disease-causing agents; once they are exposed, they should attain their full health potential. Socioeconomicare more vulnerable due to lower resistance and low inequities include differences that are “systematic,coverage with preventive interventions; and once they socially produced (and therefore modifiable) andacquire a disease that requires medical treatment, they unfair” (1, 2). “Health inequities result from unequalare less likely to have access to services, the quality of distribution of power, prestige and resources amongthese services is likely to be lower, and life-saving treat- groups in society” (3). Because the physical and men-ments are less readily available. There were very few tal development of young children is still under wayexceptions to this pattern – child obesity and inade- and they depend on others to ensure their health, theyquate breastfeeding practices were the only conditions are particularly susceptible to socioeconomic inequi-more often reported among the rich than the poor. ties that lead to marked differentials in morbidity and mortality.Health services play a major role in the generation ofinequities. This is due both to inaction – lack of proac- Most deaths of children under 5 years of age in thetive measures to address the health needs of the poor world are caused by a few conditions, namely neona-– and to pro-rich bias – such as geographical acces- tal causes, pneumonia, diarrhoea, malaria, measles andsibility of services and user fees. Evaluations of the HIV/AIDS (4), with malnutrition being an underlyingequity impact of health programmes and interven- cause in about a third of these deaths (5). Child deathstions are scarce. Nevertheless, those available show that are usually the result of the joint action of several riskinnovative approaches can effectively promote equity factors (4), a fact that has to be taken into considerationthrough, for example, prioritizing diseases of the poor; when understanding their determination and planningtaking the pattern of inequity into account; deploying their prevention.or improving services where the poor live; employingappropriate delivery channels; removing financial bar- The deaths of children are not evenly distributed, butriers; and monitoring implementation, coverage and occur mainly in poor countries; 90% of these deathsimpact with an equity lens. take place in only 42 countries (4). Between-country differentials in child undernutrition are also unaccept-Tackling inequities requires the involvement of vari- ably large (6). Although under-5 mortality rates haveous programmes and stakeholders, both within and declined recently in most low- and middle-incomeoutside the health sector, that can help address social countries, equity analyses have shown that the mortal-determinants. This review shows that there are many ity gap between rich and poor countries, and betweenintervention entry-points, providing room for differ- rich and poor children within most countries, is wid-ent sectors to contribute. Actors involved in any given ening, as reductions tend to be greater among theapproach need to realize that their efforts constitute better-off (7–9).only part of the solution, and they must support thework of those promoting complementary approaches. Addressing socioeconomic inequities in child healthFinally, there is a need for a general oversight function and nutrition will be essential for achieving the firstto ensure that all relevant issues are considered. (poverty and hunger), fourth (child survival) and sixth (malaria, HIV and other diseases) Millennium Devel- opment Goals. A mathematical simulation showed that50 Equity, social determinants and public health programmes
  • 58. it is possible – albeit undesirable – to achieve those goals health care outcomes), can also be determinants ofwithout improving the stake of the children belonging vulnerability (third level) because of the long-recog-to the poorest 20% of all families through rapid progress nized interaction between nutritional status and diseaserestricted to the better-off (10 ).This is not an implausi- severity (5, 17). This model, however, is extremely use-ble scenario, given that wealthy families are more likely ful for a systematic discussion of inequities in childto adopt preventive and therapeutic innovations (11 ). health and nutrition. This review provides such a sys-Such an approach, however, would be unfair and lead tematic analysis and focuses on:to greater inequity. It is possible to both achieve the • socioeconomic inequities (rather than gender, eth-goals and improve equity concomitantly (12 ). nic group, urban/rural or other inequities); • within-country inequities in low- and middle-Whereas current rates of progress in most low- and income countries (rather than between-countrymiddle-income countries are insufficient for reaching inequities);the Millennium Development Goals (13 ), countries can • major causes of mortality and morbidity, includingget on track “if they can combine good policies with malaria, in children under 5 years of age;expanded funding for programs that address both the • nutritional status in under-5 children;direct and the underlying determinants of the health- • evidence-based interventions impacting on nutri-related goals” (14 ), that is, effective programmes that tional status and mortality of children under the agetake equity considerations into account. of 5; • data since 1990 (except for classical references).Socioeconomic factors are not the only type of inequi-ties that are relevant to child health. Gender inequities Table 4.2 describes the priority public health con-are important in specific societies (8) and urban/rural ditions analytical framework with links to potentialinequities are also relevant, particularly as these affect structural interventions, entry-points and barriers.the availability of health care (15 ). In addition, themagnitude of socioeconomic inequities is often differ- This review relies primarily on the description ofent between urban and rural areas (15 ). Although this socioeconomic inequities. Wealth quintiles based onreview will concentrate on socioeconomic inequities, household assets have been used as a stratification var-other disparities will be discussed when relevant. iable to understand differentials between population subgroups. No attempt has been made to disentangle the roles of distal social determinants such as income,Methods parental education, power structures or social capital. Asset quintiles were used because they are available inTo properly understand socioeconomic inequities and a comparable format for almost 100 countries, provid-to design interventions to reduce them, a conceptual ing data on tens of health indicators, and they relatemodel is required. In the early 1980s, Mosley and Chen directly to the first level of the priority public health(16 ) proposed that the determinants of child health conditions analytical framework, namely socioeco-and survival should be divided into proximate factors, nomic context and position.which are directly responsible for the health problems,and underlying factors, which affect the child indirectly The review starts with a description of differentials inthrough their effect on the proximate causes. In this terms of socioeconomic context and position, differ-latter group are the socioeconomic variables, usually ential exposure and vulnerability, and access to healthevaluated through family income, parental education services and coverage of health interventions. It thenand family assets, and access to health services. More addresses differentials in child morbidity and nutri-recently, the factors contributing to inequities in the tional status, and finally differentials in survival andhealth and nutrition of children in low- and middle- the long-term consequences of inequities, in terms ofincome countries were reviewed by Victora et al. (8) human capital (section 4.3). Entry-points for interven-and by Wagstaff et al. (9). tions against unfavourable social determinants of health, in particular wealth inequities, are then described, andThe priority public health conditions analytical frame- actual evaluations of existing programmes are reviewedwork (Chapter 1) builds upon these previous models (section 4.4). Implementation issues are discussed inby systematizing the role of social determinants of section 4.5, and finally monitoring and evaluationhealth into five major hierarchical categories, which are approaches with an equity lens are described in sec-applied to child health and nutrition in Table 4.1, along tion 4.6.with their availability in Demographic Health Surveys(DHS) and Multiple Indicator Cluster Surveys (MICS). The study of social determinants of child health andLike all models, this framework is a simplified version nutrition requires information on household economicof reality. For example, low birth weight and under- status. Because income and expenditure data are difficultnutrition, outcomes at the fourth level (differential and time consuming to obtain and are often unreliable, Health and nutrition of children: equity and social determinants 51
  • 59. TABLE 4.1 Framework for the analysis of inequities in child health and nutrition: indicators and their availability in DHS,MICS or from the published literature Relevant factors for child Literature Category (level) health/nutrition Indicators DHS MICS review Socioeconomic Family income, assets Asset index X X X context and position Parental education Education among women X X X Education among men X X Differential Water, sanitation, handwashing Water supply X X exposure Sanitation X X X Handwashing facility in household X X Sanitary disposal of children’s stools X Crowding, housing, air pollution Solid fuel for cooking X X Crowding X X Disease vectors Exposure to disease vectors X Differential Factors affecting incidence: Timely initiation of breastfeeding X vulnerability Infant and young child feeding Exclusive breastfeeding X X X a Immunization Bottle-feeding X X X Timely complementary feeding X X Antenatal and delivery care Antenatal care X X X HIV prevention Skilled delivery care X X X Postnatal visit Insecticide-treated mosquito Use of bed net, insecticide-treated X X X nets mosquito net Factors affecting severity: Vitamin A intake X X X Poor nutrition (breastfeeding, Zinc supplementation X X complementary feeding, Iron supplementation X micronutrients – vitamin A, zinc, iron, iodine) Use of iodized salt X Case management (access to Care-seeking for acute respiratory infection X X X first-level and referral care) of Antibiotics for pneumonia X X X diarrhoea, pneumonia, sepsis, malaria (including intermittent Care-seeking for diarrhoea X X X preventive treatment), measles, Oral rehydration therapy to treat diarrhoea X X X HIV, severe malnutrition, neonatal morbidity Care-seeking for fever X Antimalarial treatment X Quality of care X Referral care X Differential health Morbidity Diarrhoea prevalence X X X and nutrition Acute respiratory infection prevalence X X X outcomes Fever prevalence X X X Undernutrition: stunting, wasting, Anaemia X X underweight Low birth weight X # X Stunting X X X Underweight X X X Wasting X X Overweight, obesity Overweight, obesity X X Continues…52 Equity, social determinants and public health programmes
  • 60. Continued from previous page Relevant factors for child Literature Category (level) health/nutrition Indicators DHS MICS review Differential Mortality Neonatal mortality X X consequences Infant mortality X X X Under-5 mortality X X X Cause-specific mortality X Disability Prevalence of disability X Human capital (height, Human capital X reproductive performance, schooling, income) Economic consequences to the Economic losses X family# Data available but quality of the information is questionable.a. Not covered in this reviewan alternative is to use information on household pos- 2007 were reviewed. DHS and MICS results by coun-sessions and the characteristics of a family’s house (18 ). try and region are presented in Webannex1 (24 ). DHSSuch information, which is available in data from DHS and MICS datasets usually include thousands of chil-and MICS (19, 20), can be combined into a single index dren, and the consistent equity gradients observed inof wealth through principal component analysis. The most countries leave little doubt that the associationsindex can then be used to construct asset quintiles, and are not due to chance.the ratios of lowest and highest quintiles are reportedas low:high ratios. In addition to the analyses of national surveys, a system- atic review of the literature was performed in PubMed,Asset indices present some limitations. First, differ- covering the period 1990–present, using several key-ent choices of assets used in the index can result in word combinations of “socioeconomic factors” orchanges in the classification of families (18 ). Second, synonyms with terms related to child morbidity, mor-those in the wealthiest quintile in some countries tend tality, nutrition, services utilization and coverage. Theto reside in urban areas, particularly in the capital city search was restricted to articles from low- and middle-(21 ), so that wealth inequities are closely associated income countries or global analyses.with urban/rural disparities. A third limitation is thatthe poorest quintile in a middle-income country, for This led to the identification of over 10  000 articles,example, may be better off than one of the wealthier and after revising the titles and summaries 244 arti-quintiles in a low-income country, so that only rela- cles were found to be potentially relevant to the review.tive differences are being studied. Other limitations These were obtained in full and read. Additional ref-include the fact that asset quintiles do not fully address erences were identified by examining articles cited byinequities conferred by age, gender, ethnic group or these papers. This search located only five programmesposition within the household family structure (22 ). or strategies for improving child health and nutritionThese limitations, however, do not preclude the use of for which an effect on equity was reported; these areasset indices for documenting the wide gaps between described in section 4.4 below. The literature searchrich and poor that are present in most low- and mid- was essential for completing the conceptual frame-dle-income countries. work, presented in Table 4.2 and Webannex2 (25 ), upon which the rest of this chapter is based.The World Bank’s PovertyNet initiative (23 ) has col-laborated with DHS to produce tables of a variety ofindicators of child health and nutrition for 56 coun-tries, broken down by asset quintiles (21 ). Additionaldata were obtained from MICS. All 59 country reportsor standard tables from the second (circa 2000) andthird (circa 2005) rounds of MICS available by April Health and nutrition of children: equity and social determinants 53
  • 61. TABLE 4.2 Structural interventions, entry-points and barriers relevant to child health and nutrition Determinants/pathways Potential interventions Entry-points Potential barriers Socioeconomic context and Laws that regulate availability and advertisement National legislative Resistance from the food position of breast-milk substitutes, baby bottles, etc. bodies and political industry to changing lobbies marketing practices or Lack of protective legislation for Legislation for food fortification with food fortification mothers and children micronutrients Country offices of international Resistance from Economic inequity Laws that regulate maternity and paternity leave organizations employers regarding Inequities in education Regulation of health services, e.g. universal care maternity and paternity Food industry leave Gender inequity Promote human rights, etc. High-level decision- Resistance from the Equal rights/preferential treatment, e.g. for makers in the ministries private medical sector ethnic minorities, girls of health, finance, and medical professional education, food/ Universal women’s education bodies to health care agriculture and others reform Voluntary industry codes of conduct, e.g. for Civil society: community breast-milk substitutes Resistance from the groups, women’s ruling classes regarding Redistribute resources, e.g. through tax, groups, faith-based legislation on human minimum wages, welfare systems or direct cash organizations, consumer rights, redistribution of transfers protection groups and wealth or land reform other nongovernmental Redistribute power, e.g. through land reforms, organizations or public– Resistance from title deeds private partnerships politicians and political Microcredit for women lobbies regarding Political parties empowerment of the Legal system poor Professional Perceived cost organizations implications of changing legislation to protect health Differential exposure Elimination of malaria vectors National, provincial Costs of providing and local governments, housing, water and Social and physical environment Avail/subsidize means, e.g. for indoor pollution including departments of sanitation services control Unemployment health, water/sanitation, Resistance from industry Provision of sanitation and clean water housing, environment, Poor housing, water supply and regarding regulation and finance, food/agriculture sanitation Improved housing to prevent crowding changes in pricing or and others production practices Exposure to advertising and Targeted availability of tools and means, e.g. Civil society: community marketing of unhealthy products antimalarials, oral rehydration treatment, Resistance from the groups, women’s and practices antibiotics for sepsis/pneumonia population regarding groups, faith-based changes in established High cost of essential Standards for advertising of specific products, organizations, consumer behaviours commodities (water, soap, e.g. infant foods protection groups, social antibiotics, antimalarials, marketing initiatives and Reversal of the burden of proof, e.g. with insecticide-treated mosquito other nongovernmental respect to foods marketed for children nets, etc.) organizations or public– private partnerships Lack of incentives for appropriate behaviours Political parties Legal system Industry: medicines, infant foods, hygiene products, chemicals, textiles Continues…54 Equity, social determinants and public health programmes
  • 62. Continued from previous page Determinants/pathways Potential interventions Entry-points Potential barriers Differential vulnerability Budgeting health services and interventions National, provincial and Resistance of health according to burden of disease local health authorities workers at different Population group levels to new priorities Threshold coverage of e.g. insecticide- Nongovernmental and Poverty and work practices treated mosquito nets, micronutrients and private sector involved in Inability to pay user fees immunizations providing health services Cost implications of providing new services Illiteracy Social marketing for soap, insecticide-treated Civil society: community and inputs mosquito nets groups, women’s Low status of women groups, faith-based Resistance of Dedicated maternal and child health services Lack of access (geographical, organizations, consumer professional near to where disadvantaged population groups economic, cultural) to adequate protection groups and organizations reside, e.g. outreach facilities, community health health care by poor families other nongovernmental workers, nongovernmental organizations Resistance of industry organizations or public– Mismatch between burden of and commerce to a Provision of referral care facilities private partnerships disease and available health perceived reduction services Availability of contraception Mass media and in profits due to lower advertising firms costs of commodities or Lack of knowledge about Work with community and religious leaders free provision of inputs adequate hygiene and feeding etc. to change health-damaging norms and Schools and educators practices practices, particularly in vulnerable population Resistance of ministries Transportation groups and departments of Limited access to safe authorities finance, and budgetary contraception Infant and young child feeding education and Social services constraints relative promotion Low coverage with effective administrators to cash transfers and interventions Promotion of early child development similar interventions Poor health care-seeking Improving care-seeking behaviours Cultural resistance of the behaviours population to educational Counter-advertising interventions, Lack of knowledge about key Role modelling, portraying of conducive norms, empowerment of family and community practices e.g. on television women, and other behavioural interventions Hygiene education Empowerment of e.g. women in families or communities to make better health choices, such as improved diets Targeted social and health services based on need Interventions that combine economic and behavioural interventions, e.g. cash transfers conditional on utilization of maternal and child health services Improved transportation systems for ensuring access to maternal and child health services Health and nutrition of children: equity and social determinants 55
  • 63. 4.3 Analysis: socioeconomic family’s income, to reinforce her authority and makedifferentials in child survival decisions in the family, to make better use of existing services and to provide better childcare.and nutritional statusThis section reviews differentials across socioeconomic Differential exposurestrata in determinants of child survival and associatedmajor risk factors.2 The results are presented accord- Environmental conditions are important determinantsing to the framework outlined in Table 4.1 (22 ). The of child health. Poor water, sanitation and hygienereview starts with differentials in socioeconomic con- conditions are associated with increased incidence oftext and position, continues with factors that lead to waterborne diseases, particularly diarrhoea; crowdingdifferential exposure and differential vulnerability, and is associated with increased incidence of pneumonia,moves downstream to the effects on morbidity and measles and other airborne infections; indoor pollutionpoor nutrition in childhood, and finally to the conse- increases the risk of respiratory conditions; and vectorquences for mortality and human capital. The focus is density affects many diseases, particularly malaria (31 ).on nationally representative results, but findings fromother studies identified in the literature review are There is a clear association between the wealth of aincluded in topics for which national studies provide country and the availability of water and sanitation toinadequate information. Table 4.1 shows which of the its population (32, 33). The literature also shows directrelevant indicators are available from DHS and MICS, associations between adequate water and sanitation andor from the literature. socioeconomic indicators such as maternal education (34 ) and family income (35 ). Several MICS provide supporting data.Socioeconomic context and position Two behavioural practices – handwashing and sanitaryGlobal-level determinants of health inequities related disposal of infant faeces – affect exposure to the globalization process were addressed in a sepa- Sixteen DHS provide information on handwashingrate report of the Commission on Social Determinants prior to food preparation. In 12 countries, nine or moreof Health (26 ). Key distal determinants of inequities in out of ten informants reported that they washed theirchild health at country level, including economic, edu- hands, in all asset quintiles. This raises the possibility ofcational and gender inequities, and lack of protective reporting bias (36 ). Twenty-five DHS provided infor-legislation for mothers and children, are listed in Table mation on sanitary disposal of children’s stools. All but4.2 and Webannex2 (25 ). one survey show that these practices tend to be more frequent among the rich than the poor.In this review, asset indices were used to stratify fam-ilies with young children according to their relative The use of solid fuels for cooking increases the riskwealth in each country and to document inequities at of pneumonia in children (37 ). Information from fivedifferent levels of determination. There is a close asso- countries shows that poor households are consistentlyciation between wealth and parental education. For all more likely to use solid fuels for cooking than wealthyregions, the percentage of women with five years or households. Analyses of 11 WHO low- and middle-more of education was close to 80% for the wealthi- income subregions confirm this association (33 ).est compared to about 30% for the poorest quintile; formen, the corresponding figures were about 85% and Crowding within households is well known to increase45% (24 ). Consistent patterns were observed within the risk of infectious diseases (38 ). Crowding at com-each region. munity level is also important, as demonstrated by increased infectious morbidity in slums (39 ). As DHSNo attempt was made to disentangle the effects of and MICS have no specific information on crowding,education from those of wealth (27 ). Nevertheless, sev- this analysis uses a close proxy to crowding – the totaleral studies show that maternal education is strongly fertility rate. DHS shows that the total fertility rate isassociated with child health (28, 29). Improvements in twice as high in the poorest quintile as in the wealth-parental education account for part of the progress in iest one. A Brazilian study shows that the number ofchild survival in past decades (30 ). Maternal education persons per bedroom also presents important socioeco-may impact child survival through several pathways, nomic gradients (35 ).including ability of the mother to contribute to the Disease vector concentration is another environmental factor that seems to be higher in poor than in wealthy2 The full version of the original review on which this chapter is based, with 51 data tables supporting the findings of the review, is households. Several studies in Africa and Asia report available in Webannex1 (24). significantly higher densities of Anopheles mosquitoes56 Equity, social determinants and public health programmes
  • 64. in the more loosely constructed types of houses that Regarding timely complementary feeding (breastfeed-poorer families tend to live in (40–45). House location ing plus complementary foods among children agedis also a risk factor: mosquito densities have been found 6–8 months) the picture is not consistent. In countriesto be higher in houses near to breeding sites (46 ) and in where breastfeeding at age 6–8 months is nearly uni-those around the periphery of villages, where the poor- versal, timely complementary feeding tends to be moreest families tend to live (47 ). prevalent among the rich. In regions where breastfeed- ing duration is short, children from wealthy families areSumming up, children from poor households are at taken off the breast earlier and do not comply with theconsistently higher risk of being exposed to inadequate timely complementary feeding recommendations.water and sanitation, crowding and indoor pollutionthan are children from wealthy families. Their caregiv- These analyses confirm earlier observations that breast-ers are also less likely to adopt behaviours associated feeding is the only beneficial practice that is generallywith reduced risk of exposure to infectious agents, more prevalent among the poor than the rich (48 ).Thesuch as handwashing or safe disposal of stools. There is exception to this pattern is seen in sub-Saharan Africa,also evidence on higher exposure of poor children to where there are no clear socioeconomic differentials.Anopheles mosquitoes. Early initiation of breastfeeding is an important behav- iour for neonatal health (49 ). The standard equityDifferential vulnerability analyses of DHS do not include this variable, but tab- ulations by maternal education are available for Benin,According to the Priority Public Health Conditions where the highly educated are more likely to practiseKnowledge Network model, the concept of vulnera- early initiation (50 ), and in Brazil, where the oppositebility is based on the premise that “the same level of trend is observed (51 ).exposure may have different effects on different socio-economic groups, depending on their social, cultural While appropriate breastfeeding practices tend to beand economic environments and cumulative life-course more frequent among the poor than the rich, promo-factors”.Two levels of exposure are distinguished in this tion of exclusive breastfeeding can still contribute toreview: factors affecting disease incidence and factors reducing mortality inequalities, because fewer than halfaffecting disease severity. of the poorest children in low- and middle-income countries are exclusively breastfed.Vulnerability: factors affecting diseaseincidence Antenatal care and delivery by a skilled attendant are essential for preventing a large number of neonatal andPoverty affects how vulnerable children are to diseases.This subsection focuses on factors associated with dis-ease incidence, such as behaviours (breastfeeding), FIGURE 4.1 Prevalence of exclusive breastfeeding inhome practices (use of insecticide-treated mosquito children 0–3 months, by wealth quintile and region ofnets) and utilization of health services (antenatal, deliv- the worldery and postnatal care), and then discusses variablesassociated with severity. Data on disease incidence are 70presented in the differential health and nutrition out- 60comes subsection. 50Immunization coverage is a major factor affecting the 40incidence of selected diseases. Although this topic isnot covered in the present review, clear socioeconomic 30differentials have been described elsewhere for most 20countries (21 ). 10Exclusive breastfeeding reduces both the incidence 0and severity of infectious diseases, such as diarrhoea. Poorest 2nd 3rd 4th Least poorWith the exception of sub-Saharan Africa, where thefrequency of exclusive breastfeeding does not show an East Asia, Pacific Latin America, Caribbeanassociation with wealth, in all other regions this prac- Middle East. North Africa South Asiatice is more common among the poor than among the Sub-Saharan Africabetter-off (Figure 4.1). On the other hand, childrenfrom wealthy families, in all regions, are much morelikely to be bottle-fed than those from poor families. Source: Data from Gwatkin et al. (21). Health and nutrition of children: equity and social determinants 57
  • 65. child conditions (52 ). A great amount of information Vulnerability: factors affecting diseaseis available on inequities in these two indicators. DHS severityand MICS consistently show very clear gradients inall regions of the world (Figure 4.2 shows these gra- Once a child acquires an infectious illness, the severitydients for skilled delivery care). Antenatal and delivery of the episode is largely determined by the child’s gen-care show “top inequity” (53 ) in Africa, where access eral nutritional status and specific nutrient deficiencies,in the top wealth quintile is considerably greater than as well as by the coverage of effective curative interven-for the rest of the population, whereas in regions with tions. Undernutrition is both a contributing cause andhigh overall coverage, such as Europe, East Asia and a consequence of morbidity. Breastfeeding helps reduceLatin America, a “bottom inequity” pattern is observed, the severity of infectious diseases by providing activewhere the poorest are considerably worse off. and passive immunity and antimicrobial substances.Gwatkin, Bhuiya and Victora analysed inequities in Zinc and vitamin A play important roles in reducingantenatal and delivery care in the private and pub- the severity of infectious diseases (5). In non-malariouslic sector, showing that these are considerable greater areas, iron is also a key micronutrient; however, recentamong women relying on private services (12 ). Access research has shown that where malaria is prevalent ironto emergency obstetric and neonatal care can represent supplementation can increase severe morbidity (63 ).the difference between life and death for mothers and Data on anaemia prevalence are discussed in the sub-neonates. Using DHS data, Ronsmans, Holtz and Stan- section on malnutrition (below).ton (54 ) found that in 38 out of 42 countries, womenbelonging to the poorest socioeconomic quintile had Animal-based foods are excellent sources of dietarycaesarean sections rates below 5%, which is regarded as zinc and iron. Low intake of these foods is part of thethe minimum required for saving maternal and neona- causal pathway leading from poverty to undernutrition.tal lives (55 ). An analysis of 12 DHS showed that children from poor families were consistently less likely to eat meat, poul-Several studies from Brazil show that although coverage try, fish or eggs (5). Low vitamin A intake due to poorwith one or more visits for antenatal care is high, poor diets is another determinant of undernutrition, andmothers are likely to have fewer visits and to start visits many countries have adopted vitamin A supplementa-at advanced gestational ages (56, 57). The quality of care tion programmes to correct this deficiency. With a fewprovided to poor women tends to be worse than that exceptions in 50 different surveys, vitamin A coveragereceived by the rich (58, 59). Prevention of mother-to- was higher among the rich than the poor (24 ).child transmission of HIV through antenatal care is animportant aspect in reducing overall under-5 mortalityin high HIV prevalence areas. A postnatal visit aroundthe third day after delivery is essential for the health ofmothers and neonates. In Ghana (60 ) and Bangladesh FIGURE 4.2 Skilled delivery care, by wealth quintile and(61 ), socioeconomic inequities were observed for both region of the worldvariables.Insecticide-treated mosquito nets are the main pre- 100ventive measure against malaria. DHS results from 9018 countries show that overall net use by children 80(not necessarily insecticide-treated) is more common 70among the rich than the poor in 13 countries. Infor- 60mation on whether the child slept under a treated net, 50available from 21 MICS, shows that equity gaps seem 40to be bigger for treated nets than for any bednet use. 30 20The information above focuses on socioeconomic 10 0differences, whereas geographical differences in behav-iours, home practices and utilization also affect disease Poorest 2nd 3rd 4th Least poorincidence, with certain behaviours usually resulting in East Asia, Pacific Europe, Central Asiahigher risk for rural children (15, 62). Differential strat-egies for urban and rural areas may be required. Latin America, Caribbean Middle East, North Africa South Asia Sub-Saharan Africa Source: Data from Gwatkin et al. (21).58 Equity, social determinants and public health programmes
  • 66. Iodine deficiency is considered an area where inter- Curative interventions will now be considered. Inventions are highly needed, as it is the most preventable order to have access to curative care, families should because of mental retardation in children (64 ). Most able to recognize signs and symptoms requiring profes-countries have salt fortification programmes. In 20 of sional care, and have geographical and economic accessthe 25 countries with available MICS data, iodized salt to health care. A survey in rural areas of the Uniteduse was directly related to wealth. Information is also Republic of Tanzania (66 ) showed that mothers fromavailable from DHS showing equity gaps in nearly all the top quintile were more likely to know about dan-countries studied, the exceptions being three Latin ger signs, to live near a health facility and to attend suchAmerican countries (Bolivia, Guatemala and Haiti). a facility when ill.In the above analyses, each intervention was considered Data on oral rehydration therapy during diarrhoea areseparately. How many of these essential interventions available for several DHS and MICS. DHS results (Fig-each child receives may also be assessed – in other ure 4.4) are consistent for all regions of the world, withwords, the co-coverage of interventions (53 ). An analy- higher use among the better-off, a pattern that is alsosis of DHS datasets showed that the nine interventions evident in 17 of the 26 MICS. DHS data also show thatstudied – including three vaccines (BCG, DPT and care seeking for diarrhoea from a health facility wasmeasles)3, tetanus toxoid for the mother, vitamin A sup- clearly higher for children from wealthier families.plementation, antenatal care, skilled delivery and safewater – were clustered on wealthy children, who often Care seeking from a qualified provider during acutereceived most available interventions, whereas many respiratory infections was studied in DHS and againpoor children received few or none. clear socioeconomic gradients were observed. This was confirmed in 20 of the 26 MICS. The latter also pro-The analysis of co-coverage also showed variability in vide information on coverage with antibiotic treatmentthe patterns of inequity (Figure 4.3). Whereas in coun- for probable pneumonia for four countries, three oftries with high coverage, such as Brazil and Nicaragua, which showed direct associations with wealth.the poorest quintile lagged significantly behind theother four, in low-coverage countries, such as Cam- As regards treatment of fever with antimalarials inbodia and Haiti, the richest quintile tended to be children under 5, in 17 of the 20 countries studied,substantially ahead of the rest. These patterns were antimalarial treatment coverage increased with wealth.described as “bottom inequity” and “top inequity” Care-seeking for fever from a health provider was(53 ), or alternatively as “marginal exclusion” or “mas- markedly greater among the better-off.sive deprivation” (65 ).These patterns are relevant to thechoice of strategies for reducing inequities that are dis- The DHS and MICS tabulations do not dis-cussed in section 4.4. criminate between types of provider. A survey in Bangladesh showed that children from wealthy familiesFIGURE 4.3 Percentage of under-5 children receiving six FIGURE 4.4 Oral rehydration therapy during diarrhoea, byor more child survival interventions, by wealth quintile wealth quintile and region of the worldand country 80100% 70 80% 60 60% 50 40% 40 20% 30 20 0% Poorest 2nd 3rd 4th Least poor 10 Bangladesh Benin Brazil Cambodia Eritrea 0 Haiti Malawi Nepal Nicaragua Poorest 2nd 3rd 4th Least poor East Asia, Pacific Latin America, CaribbeanSource: Victora et al. (53). Middle East, North Africa South Asia Sub-Saharan Africa3 BCG = bacille Calmette–Guérin vaccine; DPT = diphtheria– pertussis–tetanus vaccine. Source: Data from Gwatkin et al. (21). Health and nutrition of children: equity and social determinants 59
  • 67. are substantially more likely to be brought to a medi- cough – a proxy for acute respiratory illness – was morecal doctor, while poorer children were often taken to frequent among the poor than among the better-off.unqualified practitioners (67 ). DHS results confirm the MICS findings in all regions except Europe and central Asia. Fever prevalence wasCompliance with the advice provided by health work- higher for poor than for rich children in most coun-ers is also essential. In Sudan, compliance with referral tries, although differences were often small. A reviewwas greater among more educated mothers (68 ), but in of the literature on malaria incidence – mostly basedrural areas of the United Republic of Tanzania reported on reported fever – and poverty showed mixed resultscompliance with advice on follow-up visits, referral or (69 ), while several large-scale cross-sectional surveystreatment was similar in all socioeconomic groups (66 ). have higher frequencies of malaria infection among the poor in Asia and Africa (70–73).This subsection has documented important socioeco-nomic differentials in vulnerability to severe illness. In short, reported morbidity tended to be more com-Poverty is associated with lower dietary quality and mon among the poor, but the magnitude of thelower coverage with vitamin A supplementation. Once differences was often small, with a 20–40% excess riska child is ill, care-seeking and treatment practices tend relative to the be worse among children from poor families. Lessevidence is available on the quality of care received by Malnutritionpoor and wealthy children within a facility, but isolatedstudies suggest that the better-off are more likely to be The term malnutrition covers undernutrition – ex-taken to qualified providers. pressed either as anthropometric deficits or micronu- trient deficiencies – as well as overweight or obesity.Differential health and nutrition Micronutrient deficiencies tend to be more commonoutcomes among the poor. Anaemia – for which the main causes are iron deficiency and malaria – shows clear inverseThis subsection provides evidence on socioeconomic socioeconomic gradients with wealth, as shown in 18differentials in terms of health outcomes other than countries by DHS. Vitamin A deficiency has been his-mortality, which is discussed in the next subsection. torically associated with poverty (74 ).Morbidity Low birth weight in low- and middle-income coun- tries is an indicator of fetal malnutrition (75 ). ABoth DHS and MICS provide information on the study by WHO and the United Nations Children’sprevalence of diarrhoea, acute respiratory infections Fund (UNICEF) showed a strong inverse correlationand fever in the two weeks preceding the survey. In between low birth weight and level of developmentthe great majority of DHS and MICS, caregivers of (76 ). In countries where a high proportion of neonatespoor children reported that diarrhoea prevalence was are weighed, such as Brazil, there is convincing evi-30% or more above the rate in the top quintile (Fig- dence of a direct association between birth weight andure 4.5). Also, 20 of 26 MICS countries reported that wealth (77, 78). Stunting and underweight are substantially more preva-FIGURE 4.5 Prevalence of diarrhoea, by wealth quintile lent among poor than rich children in all regions of theand region of the world world, usually by a factor of 2. As observed for mortal- ity, African children in the top quintile present a sharp25 reduction in undernutrition compared to the other20 four wealth groups, whereas in the other regions pat- terns are more or less linear.1510 Childhood overweight is a growing global con- 5 cern (79 ). Only four national MICS surveys – from 0 the Dominican Republic, Ghana, Sierra Leone and Poorest 2nd 3rd 4th Least poor Tajikistan – reported on this outcome, which was sys- tematically more common among the rich than among East Asia, Pacific Europe, Central Asia the poor (24 ). Other studies – mostly from middle- Latin America, Caribbean Middle East, North Africa income countries – reveal similar trends (80, 81). South Asia Sub-Saharan Africa The analysis demonstrates that, with the single excep-Source: Data from Gwatkin et al. (21). tion of overweight, indicators of nutritional and60 Equity, social determinants and public health programmes
  • 68. morbidity outcomes are considerably worse among socioeconomic indicators. Isolated studies, however,poor than among better-off children. Because inade- suggest that the inequities observed for all-cause mor-quate nutritional status is part of the vicious cycle of tality also apply to different causes, as for malaria in themalnutrition and infection, higher prevalence of under- United Republic of Tanzania (84 ) and infectious dis-nutrition further contributes to the incidence, severity eases in Brazil (29, 85).and case fatality of childhood illnesses. Inequities in mortality are closely related to differentials in nutritional status, as poor nutrition is an underly-Differential consequences: mortality ing cause of about a quarter of all under-5 deaths (5 ).and human capital In addition, socioeconomic differentials in under-5 mortality are much wider than those observed for mor-Socioeconomic differentials in child death rates are bidity. This suggests that mortality gaps are largely dueconsistently found throughout the globe. Wide socio- to differences in disease severity and case management,economic differentials in infant and under-5 mortality rather than differences in incidence.exist (Figure 4.6) (24 ). Inequities are slightly moremarked for under-5 than for infant mortality, sug- Finally, the long-term consequences of growing up ingesting that deaths of children 1–4 years old are more poverty, suffering from ill-health and undernutrition,strongly socioeconomically determined. The magni- are addressed. Recent analyses of five cohort studiestude of poor:rich mortality ratios tends to be inversely from low- and middle-income countries showed strongrelated to the overall mortality rate in the country. In associations between poverty in childhood and adultAfrica, mortality in the better-off quintile is consid- human capital outcomes, including attained height,erably lower than in the other four, poorer quintiles. achieved schooling, income and offspring birth weightIn the other regions, inequity patterns are quite linear, (86 ), as well as with low cognitive development at laterbut when countries are analysed separately (21 ), a com- ages (87 ). Disease and undernutrition are definitelymon pattern in low-mortality countries is the poorest major pathways leading to reduced human capital, asquintile showing considerably higher mortality than studies of iron deficiency in Costa Rica show (88 ).the other four. The next section focuses on potential interventionsThe importance of neonatal mortality as a major against social determinants of health.component of under-5 deaths has received growingattention (82 ). DHS data reveal consistently higherneonatal mortality rates for those in the poorest 4.4 Discussion: review of20% of households than for those in the top quin- interventions addressingtile (83 ). Although aggregate national-level estimatesof cause-specific under-5 mortality are now available social determinants(62 ), neither DHS nor MICS provide breakdowns by This section focuses on those components of the causal pathways of the priority public health conditionsFIGURE 4.6 Under-5 mortality rate, by wealth quintile and analytical framework, under each level of social deter-region of the world mination, that are amenable to modification (22 ), and considers potential entry-points for interventions that200 can help reduce inequities (Table 4.2) in child health180 and nutrition (8, 9, 25, 89).160140120 Entry-points and interventions100 80 Interventions related to socioeconomic context and 60 position include universal women’s education, prefer- 40 ential treatment for minority groups, redistribution of 20 resources (for example welfare systems or cash trans- 0 Poorest 2nd 3rd 4th Least poor fers) and microcredit for women. Entry-points include political parties, governmental institutions (execu- East Asia. Pacific South Asia tive, legislative and judiciary) and civil society. These Latin America. Caribbean Middle East. North Africa interventions are by definition broad, and also include South Asia Sub-Saharan Africa measures such as income redistribution through taxa- tion or increasing minimum wages, and land reform.Source: Data from Gwatkin et al. (21). Because these measures will affect multiple health Health and nutrition of children: equity and social determinants 61
  • 69. outcomes, not only those related to maternal and child universal health care and free provision of medicineshealth, they are not covered in detail in the present for sick children. Entry-points include governmentalchapter. and private providers, and involvement of civil society is also essential for improving utilization and accounta-As regards reduction of environmental hazards, most bility of existing services.potential interventions affect availability, including pro-vision of sanitation and clean water, elimination of Whereas understanding the multiple levels of socialvectors, improved housing to prevent crowding and determination is essential, this does not imply that onlycontrol of indoor pollution. The entry-points are mul- solutions that tackle all different levels are effective.tisectoral and include governmental institutions, civil Successful interventions may address a single level – forsociety and nongovernmental organizations. example within health services – and yet contribute to improving equity. This seems to be particularly true forMarked disparities in access to preventive services and child health and nutrition, where the pathways linkinginterventions suggest that key interventions for reduc- poverty to disease are relatively well known and whereing inequities (Table 4.2) must include improved access effective biological and behavioural interventions areto, utilization of and coverage of antenatal, deliv- plentiful.ery, postnatal and child health services (25 ). The mainentry-points include working within the health sec- Actors operating at a given level need to realize thattor at different levels (national, district, local) and with their efforts constitute only part of the solution, andother health providers. Many preventive interventions, they therefore need to support the work of those deal-however, are more likely to reach high and equitable ing with other issues rather than focus exclusivelycoverage if delivered through outreach or community on their own. Because health sector interventions inchannels. For example, several innovative entry-points childhood often contribute to exacerbating rather thanhave been tried for improving insecticide-treated reducing inequities, mainstreaming equity considera-mosquito net coverage, including integration with tions in the health sector is particularly relevant andimmunization and micronutrient supplementation in falls well within the mandate of WHO and its national-national immunization or health days, social marketing, level counterparts. For these reasons, this review isand subsidized or free insecticide-treated mosquito nets strongly focused on what the health sector can do tofor pregnant women and children. reduce inequities.Micronutrient deficiencies markedly increase vulnera-bility to disease, and also show marked social disparities. Evaluations of existing programmesThree key approaches for improving micronutrient and interventionsstatus are fortification, supplementation and dietarydiversification (5 ). Interventions that may reduce ineq- Criteria for selecting interventionsuities in micronutrient status at different levels ofdetermination include legislation for food fortification, There are many potential interventions (Table 4.2)threshold coverage (for example delivery of supple- against social determinants (25 ). Identification of thosements with vaccinations), education on infant and interventions that had been properly evaluated in theyoung child feeding, empowerment of women, cash field was guided by the distinction made by Grahamtransfers leading to improved child diets, and training and Kelly (90 ) and adopted by the WHO Measurementstaff in nutrition counselling. Different actors will need and Evidence Knowledge Network (91 ):to be involved, including legislators, the food industryand pressure groups. The factors which lead to general health improvement – improvements in the environ-Entry-points for interventions to improve disease man- ment, good sanitation and clean water, betteragement show considerable overlap with those aimed nutrition, high levels of immunizations, goodat preventing disease, and include provision of antena- housing – do not reduce health inequity. Thistal, delivery and child health care facilities, provision is because the determinants of good health areof referral care facilities, targeted availability of tools not the same as the determinants of inequitiesand means (for example antimalarials, oral rehydration, in health.antibiotics for sepsis and pneumonia), improved care-seeking behaviours, dedicated services near to where Therefore, no attempt was made to summarize thedisadvantaged population groups reside (for exam- ample evidence on interventions aimed at improvingple outreach facilities, community health workers, child health or nutrition in whole populations (52, 92,nongovernmental organizations), improved quality of 93). Rather, the focus was on the lessons learned fromservices (for example training staff on nutrition coun- interventions or programmes identified in the litera-selling), fee exemption, voucher systems for children, ture review, which were specifically evaluated in terms62 Equity, social determinants and public health programmes
  • 70. of their contribution to equity. These are listed in Table the perceived long duration of training (the original4.3, according to their position in the priority public course takes 11 days) and professional corporate behav-health conditions matrix. iours (for example, doctors being against antibiotic prescription by non-medics) (97, 98).This list is not intended to be exhaustive in terms ofpotential interventions against social determinants of Promotion of insecticide-treatedhealth and nutrition, but it is limited by the availability mosquito netsof equity-oriented evaluations. These studies addressedone or more of three related questions: (a) whether There has been heated debate regarding whetherthe programme preferentially reached the poor; (b) insecticide-treated mosquito nets should be sold orwhether it reduced inequities in access or coverage; and distributed free of cost to poor families. A review of(c) whether it reduced inequities in outcomes (mor- national surveys in 26 African countries found thattality or nutritional status). Most evaluations addressed inequities in untreated nets were considerably lowerthe first two questions, whereas only two – Integrated than for treated nets, and concluded that “the pub-Management of Childhood Illness (IMCI) and cash lic-health value of commercial net markets has beentransfers – addressed inequities in nutritional status. greatly underestimated, and that these markets have so far contributed more to equitable and sustainable cov-The programmes or interventions selected are reviewed erage of mosquito nets, and hence to the preventionin the following subsections. of malaria in Africa, than have the insecticide-treated mosquito nets delivered by public-health systems andIntegrated Management of Childhood projects” (99 ). These findings are supported by a studyIllness in the United Republic of Tanzania, which concluded that social marketing in the presence of an active pri-The Integrated Management of Childhood Illness vate sector was associated with increased equity in(IMCI) programme was designed in the mid-1990s to mosquito net coverage (100).address five major causes of death among poor children:pneumonia, diarrhoea, malaria, measles and undernu- On the other hand, there is also considerable evidencetrition (94 ). It included three components: improving that free mass distribution increases equity. Grabowskyhealth worker performance, health systems support and et al. studied distribution of insecticide-treated mos-family and community practices.Victora and colleagues quito nets linked to vaccination campaigns in Ghanaassessed whether IMCI was effective in reaching the and Zambia, concluding that inequities were virtu-poorest areas of Brazil, Peru and the United Repub- ally eradicated by this approach (101). A study in Kenyalic of Tanzania (95 ).The results suggested that although found that inequities were reduced when subsidizedIMCI addressed diseases of the poor, it was not success- nets were introduced, and near-perfect equity achievedful in preferentially reaching poor communities. with free distribution (102). Side-effects from the use of treated nets are rare, though some subjects reportA separate evaluation was carried out in four districts of headaches related to the smell of the insecticide (103).the United Republic of Tanzania, where two districts In a broader view of side-effects, free distribution ofthat implemented IMCI showed overall reductions nets has been criticized for its dependence on the pub-in mortality and improvements in nutritional status. lic sector, and potential lack of long-term sustainabilityInequities in six child health indicators (underweight, (104). The debate regarding subsidized or free nets con-stunting, measles immunization, access to treated nets, tinues, but it is reassuring that both approaches seem toaccess to untreated nets, treatment of fever with anti- be able to reduce inequities, at least in the short term.malarials) were significantly reduced in IMCI districtscompared to control districts, while inequities in four Conditional cash transfersother indicators (wasting, DPT coverage, caregivers’knowledge of danger signs and appropriate care seek- Several governmental programmes that provide cash toing) improved more in the comparison districts (96 ). families conditional on their use of health and edu- cational services have been implemented, particularlyThe lesson learned from these two separate studies is in Latin America. These programmes address socialthat IMCI, when implemented under routine condi- determinants of health at several different levels (seetions, is not preferentially reaching the poor. However, Table 4.3). In Mexico, the PROGRESA4 programmeonce it is strongly implemented, as in the United was subjected to a high-quality evaluation in whichRepublic of Tanzania – with high training coverage of over 500 communities were randomized to receive orfacility-based workers and health systems strengthen- not to receive the programme (105). The interventioning, in a setting where services utilization is high – itmay contribute to reducing inequities. Resistance to 4 Programa de Educación, Salud y Alimentación: Programme forchange – that is, to IMCI implementation – included Education, Health and Food. Health and nutrition of children: equity and social determinants 63
  • 71. 64 TABLE 4.3 Matrix of interventions for which equity impact evaluations are available Interventions / Accessibility Compliance Determinants Availability interventions Acceptability interventions interventions interventions Adherence interventions Socioeconomic context and Family Health Programme, Brazil (universal Conditional cash transfers Conditional cash transfers position care) (mandatory school attendance, (cash transfers to the including girls) poorest) Differential exposure Differential vulnerability Contracting (e.g. Cambodia) (family planning) IMCI (feeding counselling; care- Insecticide-treated mosquito seeking behaviours; compliance with nets (community promotion) Integrated Management of Childhood Illness health workers’ advice) (IMCI) (health education) Conditional cash transfers Insecticide-treated mosquito nets (empowerment of women Family Health Programme (health education) (health education) through direct payment to IMCI (prioritizing burden of disease; providing mothers) Conditional cash transfers (health micronutrients, insecticide-treated mosquito and nutrition education; regular nets, medicines) contact with health facilities) Insecticide-treated mosquito nets (subsidized prices; linked to vaccination campaigns)Equity, social determinants and public health programmes Family Health Programme (provision of maternal and child health services; free medicines) Contracting (provision of facilities; antenatal and delivery care; micronutrients) Conditional cash transfers (food supplements; mandatory facility attendance for preventive interventions; mandatory birth registration) Differential health care Family Health Programme (targeting of IMCI (improved quality) IMCI (free medicines) IMCI (supervision) IMCI (first dose given in outcomes poorest areas, community health workers, facility) Family Health Programme Family Health Programme Family Health Programme staff incentives) (improved quality) (free medicines; universal (provider incentives) Family Health Programme Contracting (targeting of the poorest) access) (compliance advice by Contracting (provider community health workers) Conditional cash transfers (targeting of the incentives) poor) Differential consequences Family Health Programme (child development; nutrition rehabilitation)
  • 72. consisted of providing fortified nutrition supple- includes the high cost of the programme, about US$20ments to children and nutrition education, health care per person-year (120).and cash transfers to their families. PROGRESA wasassociated with faster growth in height among the Contracting to provide primary healthpoorest and younger infants and a reduction in anaemia careprevalence. PROGRESA and its successor, the Opor-tunidades programme, were shown in other studies To address the problem of poor access to public healthto be efficiently targeted at the poorest families (106). care facilities in Cambodia, the government, with theAmong all programmes evaluated in this review, PRO- Asian Development Bank, devised alternative healthGRESA/Oportunidades is the one with the strongest care delivery models: contracting in (reinforcing gov-scientific evidence of a pro-poor impact. ernment primary health care services) and contracting out (hiring nongovernmental organizations to pro-A similar programme, Bolsa Familia, operates in Bra- vide these services). These two options were comparedzil, where the 30% poorest families in the country to traditional government centres (121). Emphasis wasreceive 80% of the benefits (107–109). There is strong given to reaching the poorer half of the population.evidence that the programme is well targeted at the Contracting out appears to have led to higher coveragepoorest and that dietary quality improved as a result, of immunization, vitamin A and antenatal care, but notthough the results of impact and coverage evaluations of delivery care, than government services, with con-are mixed (110, 111).5 In Nicaragua, increases in growth tracting in being between these two in most indicators.monitoring and immunization coverage were reported An equity impact assessment found that compared toas a consequence of the conditional cash transfer pro- routine services, contracting out was significantly associ-gramme (112). ated with reduced inequalities in immunization, skilled delivery, use of facilities and contraceptive knowledge.Taken together, the items of evidence for conditional Contracting in was associated with greater equity incash transfer programmes suggest that they are one immunization and contraceptive knowledge. Govern-of the most promising initiatives for addressing social ment services continued to be primarily directed at thedeterminants of child mortality and malnutrition, non-poor. The statistical methods used in the analysesand improving equity. Conditional cash transfer pro- are not fully laid out in the report (121) and it is uncleargrammes, however, may have negative aspects, including if the units of analyses were the geographical areas –an increase in fertility in order to qualify for the bene- as they should have been – or individual children andfits (113), and cash benefits being paid to families who women. The authors concluded that “the contractedshould not qualify because of their high socioeconomic districts outperformed the government districts in tar-status (114). geting services to the poor”.Family Health Programme While contracting appeared to have an effect on reduc- ing inequitable coverage levels, the effect on quality ofIn Brazil, the 1989 Constitution established a univer- care was not reported in the study. To assess the qualitysal health system without any type of user fees. Because of care, a standardized health facility survey (122) washealth facilities were concentrated in the urban and carried out in three types of Cambodian facilities: withwealthier areas, the Family Health Programme was IMCI training and additional health system supportlaunched in 1994 to deploy teams of doctors, nurses by partners; with IMCI training but limited additionaland community health workers in the country’s poor- health system support by partners; and with healthest areas. Equity-oriented evaluations of the programme system support but without IMCI training. Most con-have showed that targeting was effective and programme tracting areas were in the third group. The results ofuptake was markedly higher in poor municipalities and the surveys showed that health workers performed lessin poor neighbourhoods in urban areas (115, 116). Sev- well in assessment, case management and particularlyeral ecological analyses suggest that the programme in counselling in the areas with system support alonehad a positive impact on infant mortality (116, 117), par- compared to the areas with IMCI (123).ticularly through reduction of diarrhoea deaths (118),but studies are lacking on whether or not the pro- Programmes and interventions: summarygramme reduced inequities in mortality or nutritional and typologystatus. Resistance to introduction of the programmehas come from medical specialists (such as paediatri- Summing up, the priority public health conditionscians) who complain that family doctors are unable to analytical framework was used to lay out the differentprovide optimal care to children (119). Resistance also types of programmes or interventions that may address the social determinants of health. Based on the litera- ture review, five programmes were identified that had5 Olinto P, personal communication. been field-tested in terms of their equity performance. Health and nutrition of children: equity and social determinants 65
  • 73. TABLE 4.4 Typology of interventions acting on equity, with examples from the five programmes reviewed Effect on mortality, Type of Level of Explicitly Effect on nutritional status intervention intervention targets poor inequities coverage IMCI Medical Programme – + + (stunting) Insecticide-treated Medical Programme – ++ ? mosquito nets Family Health Programme Medical and financial Health sector ++ ? + (infant mortality rate) Contracting Medical and financial Health sector – + + (coverage) Conditional cash transfers Financial Multisectoral ++ +++ ± (nutrition coverage)– no effect; + small effect; ++ moderate effect; +++ major effect; ± uncertain; ? unknownMost of these programmes have multiple components closely to the local epidemiological profile of condi-(see Table 4.3) that address different levels of social tions affecting the poor (124). Prioritizing diseases ofdeterminants (from differential socioeconomic con- the poor requires assessing the burden of disease andtext to differential consequences) as well as addressing allocating resources on the basis of need. Decision-different intervention dimensions (from availability to making tools for matching health sector investmentsadherence). Whereas none of the programmes tackled to the local burden of disease are available and shouldthe differential exposure level of the framework, the be widely promoted (125).The IMCI experience, how-other four levels were contemplated. ever, showed that prioritizing diseases of the poor is not enough, if the services are primarily implementedThe review of the literature and the five case studies in better-off areas.described above suggest a typology of three groups ofprogrammes against social determinants of ill-health Consider the pattern of inequity. This shouldand malnutrition in children (Table 4.4). There are be taken into account when deciding how to delivermedical interventions delivered by the health sector interventions. For a “bottom inequity” or “marginalthrough programmes (IMCI, promoting insecticide- exclusion” pattern, programmes that are targeted attreated mosquito nets) that – although not targeted the family level are appropriate because the poorestexclusively to the poor – have an effect on inequities. children are lagging behind all others. If on the otherThere are also health interventions that incorporate hand there is a pattern of “massive deprivation” or “topa strong financial component (Family Health Pro- inequity” – when all groups except the wealthiest aregramme, contracting). Finally, there is a purely financial affected – individual targeting does not make sense andintervention with a multisector delivery approach that widespread interventions are needed. Geographicalexplicitly targets the poor with a strong impact on targeting may still be advisable, even when individual-inequities. level targeting is not recommended. Deploy or improve services where the poor live.Emerging lessons Poverty maps have been prepared in a large number of countries by the World Bank, the United NationsThe emerging lessons from this review, directed to Development Programme (UNDP) and other nationalhealth sector managers and policy-makers, are sum- and international agencies (126). These serve as impor-marized below. Innovative approaches are required to tant inputs for assessing how well the distribution ofensure that programmes effectively promote equity. current services matches the neediest areas, and provideThese include the needs to prioritize diseases of the a basis for deployment of new services or improvingpoor; take the pattern of inequity into account; deploy the quality of existing services. The usual logic of pro-or improve services where the poor live; employ appro- gramme implementation may have to be subverted.priate delivery channels; abolish any type of user fees; Rather than introducing new interventions or pro-and monitor implementation, coverage and impact grammes initially in the capital and nearby districts, thewith an equity lens. remote areas of the country, where mortality and mal- nutrition are usually highest, should be prioritized (127).Prioritize diseases of the poor. When choos-ing which interventions should be prioritized in a Employ appropriate delivery channels. Even whengiven geographical area, it is essential to match them a health facility-based approach is favoured, the same66 Equity, social determinants and public health programmes
  • 74. biological intervention may be delivered through more interventions listed in Table 4.2 (25 ), but they do coverthan one channel (124). Micronutrients or nutritional multiple levels of the social determinants and requirecounselling may be delivered to mothers and chil- strong involvement of the health sector. By focusingdren who spontaneously attend the facilities, through this discussion on programmes that were rigorouslyoutreach sessions in communities by facility staff, or evaluated, it is possible to identify common issues thatthrough community health workers (paid or voluntary) will apply more broadly to programmes and inter-on a door-to-door basis. Equity considerations are fun- ventions in general. Relevant upstream interventionsdamental in choosing the most appropriate delivery include legislation on the availability and advertisementchannel for reaching the poorest families, who often of breast-milk substitutes and on maternity leave, set-live far away from the facilities and require community ting standards for advertisement of infant foods, andor household delivery strategies. Appropriate delivery provision of breastfeeding education and promotionchannels must also ensure that provider compliance to population groups. Downstream interventions areand recipient adherence are optimized. Understanding aimed at individual mothers and children and includesociocultural norms and practices, both of providers general improvements in the availability of mother andand users, is essential for this purpose. child health services and training health staff in face-to- face nutrition counselling (93 ).Reduce financial barriers to health care. Out-of-pocket payments are the principal means of financing Ensuring access to essential health services for poorhealth care in most of Africa and Asia (128, 129). This children is a complex task involving a number ofheavy reliance on out-of-pocket payments means that different ministries and agencies in implementingpooling of risks is reduced and health care costs fall interventions (Table 4.5). Implementation responsi-more directly on the sick, who are most likely to be bilities will vary from country to country. Some willpoor, children or elderly. Evidence suggests that out- fall outside the scope of disease-specific programmes,of-pocket payments for public and private health care mainly issues related to non-health sector interventionsservices are driving more than 100 million people into such as education or women’s empowerment. Broaderpoverty every year (130). The introduction of user fees public health responsibilities related to general healthin governmental health facilities in the late 1980s and policies and planning – such as targeting the poor orearly 1990s contributed to this situation. As WHO has the deployment and quality of services – will generallyfound, “experience suggests that even where official fall under the responsibility of ministries of health as auser fees are well-regulated and help revitalize previ- whole, rather than under specific programmes withinously moribund services, the drawbacks for the poor the ministry. Disease programmes may assume respon-usually exceed the benefits” (131). In these cases where sibility for provision of specific services such as healthfees have not worked, there is clear need for reform worker training, distribution of equipment and supplies,through one or more of the several mechanisms avail- and dissemination of specific information, educationable: reducing or abolishing fees, finding some way of and communication materials and health messages.exempting the poor from them or developing insur-ance programmes to cover the cost of fees incurred by As health depends on multiple social determinants,disadvantaged as well as by better-off groups. User fees many responsibilities are shared between programmes,would probably not have been instituted in most coun- within the health sector and between different minis-tries had equity considerations been high in the health tries. The ministries of agriculture, education, finance,agenda. Countries adopting a universal health system interior, planning and social affairs are natural partnerswithout any type of user fees, such as Brazil, have effec- of the ministry of health. Nongovernmental and civiltively removed inequities in access to first-level health society institutions must also be involved.facilities (115). When assessed against the benchmarks of replicability,Monitor implementation, coverage and impact sustainability, scalability, political feasibility, economicwith an equity lens. This is an essential component feasibility and technical feasibility, the five programmesthat will be discussed in section 4.6. reviewed in the preceding section do well as a whole (Table 4.6). With regard to replicability of the Family Health Programme, there is no evidence other than4.5 Interventions and from Brazil; however, the four other interventions areimplementation implemented in at least three countries. If implemen- tation history is used as an indicator for sustainability, two out of five interventions have been implementedThis section relies heavily on the experience of pro- for more than 10 years. Most of the five interventionsgrammes that have been evaluated from an equity have been scaled up to cover more than 250 000 people.perspective (see previous section). These pro- With regards to political feasibility, all five interven-grammes constitute only a small fraction of pro-equity tions required some form of government involvement, Health and nutrition of children: equity and social determinants 67
  • 75. TABLE 4.5 Examples of responsibilities for various intervention components Non-health sector Responsibility of Responsibility of or multisector a specific health the health sector responsibility Intervention component programme as a whole (ministry) Mandatory school attendance No No Yes (education) Empowerment of women No No Yes (interior, social affairs) Mandatory birth registration No No Yes (interior, planning) Cash transfer policies No Yes Yes (finance, social affairs) Provision of facilities No Yes Yes (finance, planning) Provider incentives No Yes Yes (finance, planning) Targeting of poorest areas Yes Yes Yes (finance, planning) Universal access policy Yes Yes Yes (finance, planning) Family planning Yes Yes Yes (planning) Provision of micronutrients Yes Yes Yes (agriculture, finance) Provision of food supplements Yes Yes Yes (finance) Free provision of medicines Yes Yes Yes (finance) Free provision of insecticide-treated nets Yes Yes Yes (finance) Health education Yes Yes Yes (education, interior) Care-seeking counselling Yes Yes Yes (education, interior) Feeding counselling Yes Yes Yes (education, interior) Community promotion Yes Yes Yes (interior, social affairs) Integrated service delivery Yes Yes No Ensuring quality of health services Yes Yes No Ensuring supportive supervision Yes Yes No Ensuring provider user-friendliness No Yes No Ensuring adequate opening hours No Yes Noinitiative or collaboration, and are therefore likely to bepolitically feasible. Cost-effectiveness evaluations exist 4.6 Implications: measurementfor IMCI and insecticide-treated mosquito nets only, andfor two other interventions (conditional cash transfers The availability of reliable information at country leveland contracting) there seems to be a reasonable return on child health and nutrition is second to none. Sur-on investment. Availability of tools, considered to be veys such as DHS and MICS are carried out everyimportant for technical feasibility, is not an implemen- four to five years in most low- and middle-incometation barrier for most of the interventions reviewed. countries. Country data are compiled and published annually by UNICEF (136). Widespread use of soci-The small number of programmes for which equity- oeconomic stratification variables, in particular assetoriented evaluations are available makes it difficult quintiles, allows monitoring inequities in coverage andto generalize these findings to other interventions to impact indicators on a regular basis. Most surveys arereduce inequities in child health. On the other hand, representative for subnational areas, thus also allowingthe above results suggest that it is possible to implement the study of regional inequalities.initiatives to improve equity that are affordable, effec-tive, feasible and sustainable.68 Equity, social determinants and public health programmes
  • 76. TABLE 4.6 Testing the implementability of interventions Insecticide- treated mosquito Conditional cash Family Health IMCI nets transfers Programme Contracting Replicability Yes: more than Yes: many malaria- Yes: reported from Maybe: Yes: reported from 100 countries have endemic countries Brazil, Mexico and reported from Cambodia only, but 13 adopted IMCI have adopted Nicaragua Brazil only contracting sites were insecticide-treated identified in a recent mosquito nets review (132) Sustainability Yes: exists since Yes: countries Yes: exists since Yes: exists since Maybe: requires 1995. Countries have have incorporated 2003. Countries 1994 substantial donor support incorporated IMCI in insecticide-treated have incorporated their national health mosquito nets in conditional cash sector plans and their national health transfers into their budgets sector plans and national health sector budgets plans and budgets Scalability Yes: 10 countries Yes: more Yes: large national Yes: covers Yes: the 13 identified have more than 75% than 358 210 programmes in more over half of the contracting sites cover of districts where insecticide-treated than 10 countries population in between 250 000 and 15 IMCI was initiated mosquito nets Brazil million people distributed in 27 countries (133) Political Yes: more than Yes: many malaria- Yes: in Brazil Yes: endorsed Maybe: requires feasibility 100 countries have endemic countries originally linked to the by successive substantial donor support adopted IMCI have adopted President’s Office, governments insecticide-treated now interministerial with different mosquito nets management ideological positions Economic Yes: IMCI costs as Yes: one of the Yes: in Brazil, while Maybe: high Maybe: in Bangladesh feasibility much as current most cost-effective costing a small share costs were the cost of contracting care, and is cost- interventions of total income, it considered was $0.65 per capita. In effective (134) against malaria produced a 21% fall in a barrier to Costa Rica and Pakistan (135) Gini index implementation less costs were incurred for more efficient services. Overall cost-effectiveness is unknown Technical Yes: tools available Yes: tools available Yes: tested in rigorous Yes: relies on Maybe: reportedly more feasibility evaluations in several evidence-based an art than a science. countries algorithms Tools available for managing common diseasesThe framework proposed by the Measurement and systems – should incorporate measurement of socioeco-Evidence Knowledge Network report comprises five nomic position. If collecting information on householdelements (generating an evidence base for effective assets is too complex, as may be the case for vital reg-action; creating evidence-based guidance; collecting istration, then simpler indicators such as schooling orand collating evidence for how to implement effective broad occupational categories (as in the English “socialpolicies; learning from practice; and policy monitoring class” classification) may be adopted (137). Supervisionand evaluation). Specific issues that arise when using and feedback are necessary to ensure that these datathis framework are described next. fields are filled in correctly. An alternative is to use sur- veys to assess socioeconomic position in samples of vital registration events or of service users that can beImportance of measurements and later compared to the population distribution (138).targets The next step is to ensure that health information isAs mentioned above, the first prerequisite is that health disaggregated by socioeconomic indicators, dissem-information tools – both surveys and routine reporting inated widely and fed back to policy-makers and Health and nutrition of children: equity and social determinants 69
  • 77. managers. It has been argued (12 ) that “an obvious way allowed a unique evaluation. This example should beto start in orienting health systems toward the poor more widely used by other programmes.The second setis to establish objectives whose achievement requires of issues relates to the measurement of indicators. Thethat the poor benefit fully from the services provided, evaluation of large-scale programmes such as IMCIand to monitor progress in terms of those goals. For showed that even basic data on implementation, such asexample, one could set targets in terms of progress, not the number and location of trained staff, were not keptamong all people in the population, but among those in any of the countries studied, a fact that made its eval-people within the population who live in poverty.” For uation rather difficult (139). Data on quality of IMCIexample, instead of reaching 80% coverage with skilled care is even harder to obtain, because health facilitydelivery, one would set a target of 80% coverage among surveys tend to be restricted to small portions of eachthe lowest wealth quintile, or for families living below country and to be carried out irregularly. Furthermore,the poverty line. many evaluations address overall change in outcomes rather than trying to assess changes in equity as well,When information is presented to policy-makers and which is possible with small investments in further datamanagers it is important to discuss the implications of collection (96, 100).the shape of the equity curves, rather than concentratingjust on the ratio or difference between the poorest andbetter-off groups. As discussed above, different shapes of Data needed to manage and monitorcurves may lead to different intervention approaches. possible side-effects of interventionsIncorporation of the socioeconomic dimension in There are huge gaps in this area, because this objectiveinformation systems is essential for mainstreaming requires measurement of outcomes other than those inequity considerations in health. This applies not only the main interest area. For example, initiatives such asto the national or district level, but also to international the United States President’s Emergency Plan for AIDSinstitutions such as WHO and UNICEF. Relief (PEPFAR) or polio eradication campaigns have been accused of detracting attention from child sur- vival, but unless evaluations of these programmes alsoData shortcomings include measurement of child survival indicators, no evidence on this possible side-effect will be availa-As mentioned, more data seem to be available for child ble. The issue of side-effects definitely requires greaterhealth and nutrition than for any other health outcome. attention.Nevertheless, several important gaps have been iden-tified, including indicators related to neonatal healthand quality of case management. Also, although data Solutions where data are absent oron coverage are plentiful, little information is availa- limitedble on delivery channels – for example, from what typeof provider did a child receive a given intervention. The widespread use of survey data for estimatingThis information is essential for better understanding under-5 mortality levels and differentials constitutesinequities and for proposing remedial actions. Another a response to the absence of reliable vital statistics inlimitation is that, for the main outcome indicator – most low- and middle-income countries. Reliancemortality – estimates are retrospective and usually refer on surveys, however, does not preclude the need forto a time period a couple of years before the survey, continued efforts to improve vital registration. For esti-so that recent changes are not picked up by surveys. mating coverage, a mixture of routine reporting andFinally, the fact that surveys are carried out every five small-scale surveys has been used with success for mon-years or so has recently been criticized due to the itoring immunization levels and trends. Surveys havedemand for timely data on the Millennium Develop- the added advantage of easily incorporating socioeco-ment Goals; as a result UNICEF has decided to carry nomic indicators, which is often difficult to do whenout MICS every three years. routine data or vital statistics are used. Finally, small sam- ple sizes reduce the precision of estimates for subgroups (for example wealth quintiles) but use of statistics thatData needed for management, rely on the entire sample distribution – for examplemonitoring and evaluation concentration indices – can help reduce the variabil- ity of equity assessments (140). New approaches haveThis issue has two dimensions: design and measure- been proposed when data on inequities do not exist –ment. Regarding design, programmes are seldom for example, the comparison of simplified asset indicesimplemented in a way that allows rigorous evalua- collected from mothers and children attending a facil-tion; an exception was PROGRESA in Mexico, where ity with those obtained from national censuses for therandomized allocation during the scaling-up phase same geographical area (138).70 Equity, social determinants and public health programmes
  • 78. Approaches where capacity to gen- the poor live; employ appropriate delivery channels;erate data and information is limited abolish any type of user fees; and monitor implementa- tion, coverage and impact with an equity lens.Interim approaches for collecting data and estimat-ing health indicators when information systems are Ensuring access to essential health services for poorunderdeveloped include targeted questions in popula- children is a complex task, requiring assignment oftion censuses, sample registration systems, demographic responsibility to various programmes and stakehold-surveillance sites and household surveys (141). A major ers, both within and outside the health sector, that canglobal effort – the Health Metrics Network – is under help address social determinants. Understanding theway to build national capacity for collecting, process- multiple levels of determination of inequity is essentialing, disseminating and using health statistics (142). for improving the health and nutrition of poor chil-Incorporating an equity dimension in health infor- dren globally. This review shows that there are manymation systems does not necessitate waiting until the intervention entry-points, providing room for differ-system is fully developed, but should instead become an ent sectors to contribute. This does not imply that onlyintegral component of the capacity-building process. solutions that involve multiple institutions and tackleThe Global Equity Gauge Alliance, an initiative involv- all levels of determination are effective. Nevertheless,ing 12 centres in low- and middle-income countries, is it suggests that actors involved in any given approachan example of a low-technology approach combining need to realize that their efforts constitute only part ofresearch and monitoring of inequities, advocacy and the solution, and they must support the work of thosepublic participation in promoting use of information promoting complementary approaches. Finally, there isfor change, and community involvement (143). a need for a general oversight function to ensure that all relevant issues are considered.4.7 Conclusion In light of WHO’s mandate, this review was purpose- fully biased towards interventions that can be deliveredIn this chapter the priority public health conditions within the health sector.At the very least, health workersanalytical framework has been used to search the pub- should be aware that the way in which they implementlished literature and databases from two major survey preventive and curative interventions often contributesinitiatives (DHS and MICS) on the topic of socioeco- to further increasing inequities (11, 53). Mainstreamingnomic differentials in child health and nutrition. Data equity considerations in the health sector is essential forfrom nearly 100 countries suggest that poor children ensuring that those involved become part of the solu-and their mothers lag well behind the better-off in tion, rather than part of the problem.terms of mortality and nutrition. These inequities inhealth outcomes result from the fact that poor children,relative to those from wealthy families, are more likely Referencesto be exposed to disease-causing agents. Once they areexposed, they are more vulnerable due to lower resist- 1. Whitehead M, Dahlgren G. Levelling up (part 1): a dis-ance and low coverage with preventive interventions; cussion paper on concepts and principles for tackling socialand once they acquire a disease that requires medical inequities in health. Copenhagen, WHO Regional Office for Europe, 2006.treatment, they are less likely to have access to services,the quality of these services is likely to be lower, and 2. 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  • 83. Diabetes: equity andsocial determinantsDavid Whiting, Nigel Unwin and Gojka Roglic 5Contents 5.5 Interventions . . . . . . . . . . . . . . 86 What has been tried and learned? . . . . . . 865.1 Summary . . . . . . . . . . . . . . . . 78 Potential interventions . . . . . . . . . . . 885.2 Introduction . . . . . . . . . . . . . . 78 5.6 Implications . . . . . . . . . . . . . . 89 Background . . . . . . . . . . . . . . . 78 Managing the change process . . . . . . . . 89 Diabetes: description, classification and risk factors . . . . . . . . . . . . . . . . . . 78 Measuring the impact of interventions. . . . . 895.3 Analysis: equity and social determinants 79 5.7 Conclusion: significance for public health programmes and the diabetes programme Equity issues: between- and within-country at WHO . . . . . . . . . . . . . . . . 90 distribution of diabetes . . . . . . . . . . . 79 Societal and environmental determinants of References . . . . . . . . . . . . . . . . . 91 obesity and type 2 diabetes: economic development, urbanization and globalization . . . . . . . 80 Figures Differential vulnerability to type 2 diabetes . . 80 Figure 5.1 Estimated number of people with diabetes in developed and developing countries 79 Differential vulnerability through differential access to health care . . . . . . . . . . . . 81 Figure 5.2 Changing associations between economic development, socioeconomic status Differential health care outcomes: diabetes control, (SES) and prevalence of diabetes or diabetes complications and mortality . . . . . . . . . 82 risk factors . . . . . . . . . . . . . . . . . . 81 Differential consequences: quality of life and Figure 5.3 Proportion of people with known socioeconomic status . . . . . . . . . . . . 84 diabetes by overall health system performance . 835.4 Discussion: approaches to addressing Figure 5.4 Overview of diabetes-related the social determinants of diabetes and pathways . . . . . . . . . . . . . . . . . . 87 reducing their impact . . . . . . . . . . 85 Summary of the pathways leading to diabetes Table and its consequences . . . . . . . . . . . . 85 Table 5.1 Summary of prevalence (%) ranges of Entry-points for interventions . . . . . . . . 86 diabetes complications (all diabetes) . . . . . . 84 Diabetes: equity and social determinants 77
  • 84. 5.1 Summary population more than the less well off.While this char- acterization of diabetes is not entirely without basis,Three to four percent of the world’s population has it is a deeply misleading oversimplification. For exam-diabetes, which leads to a markedly increased risk of ple, over 70% of the world’s population with diabetesblindness, renal failure, amputation and cardiovascular live in low- and middle-income countries; the preva-disease, and reduces average life expectancy by 10 or lence of diabetes in some of the world’s poorest cities ismore years. Currently, 70% of people with diabetes live as high, or higher, than in high-income countries; andin low- and middle-income countries, and while dia- the impact of diabetes on individuals and their familiesbetes is increasing the world over, its greatest increase is greatest in situations with poor access to health carewill be in these countries, more than doubling over the and no or limited social 25 years. This chapter begins with a brief description of diabetesThere is strong social patterning in the incidence of and its complications and known risk factors. Next istype 2 diabetes, which accounts for over 90% of all summarized what is known of the social and economicdiabetes. This arises through differential exposure to distribution of diabetes, from international compari-“obesogenic environments”, leading in particular to sons down to socioeconomic groups within countries.lower levels of physical activity and the consumption The rest of the chapter is structured around the hierar-of excess calories. Some ethnic groups, for reasons that chical causal model of the social determinants of healthare not fully understood, are particularly vulnerable to described in Chapter 1.The diabetes-specific version ofsuch environments. In the poorest countries type 2 dia- this model is shown in Figure 5.4 of this chapter.betes tends to be commoner in the better-off, but witheconomic development this is soon reversed, with theincidence being highest in the poor. The incidence Diabetes: description, classificationof type 1 diabetes, the etiology of which is not well and risk factorsunderstood, is not socially patterned. The outcomesand consequences of both type 1 and type 2 diabe- Diabetes is a disease in which reduced insulin secre-tes tend to be worse in the poor in all countries. This is tion and insulin action lead to chronic hyperglycaemia.particularly the case in countries where access to health This in turn has adverse catabolic effects on carbo-care is dependent on the ability to pay. hydrate, fat and protein metabolism (1, 2). Diabetes is classified according to etiological type. There are fourThe evidence base for the prevention of type 2 dia- main groups: type 1, type 2, gestational and other typesbetes and the prevention of complications in all types (1 ). Most cases of diabetes (95–99%) fall into types 1of diabetes is relatively strong. However, evidence on and 2, with type 2 the most prevalent form of diabetes,how to intervene to reduce socioeconomic inequali- accounting for 80% to over 95% of cases, depending onties in diabetes incidence, outcomes and consequences the much less comprehensive. Coordinated action willbe needed from the level of international and national In type 1 diabetes insulin secretion is reduced or absentpolicy, particularly to reduce exposure to obesogenic as a result of destruction of the pancreatic beta cellsenvironments, down to local measures, such as improv- by autoimmune or idiopathic processes. In most pop-ing access to and the quality of care in individual health ulations type 1 diabetes accounts for around 5–10%facilities. Interventions will need to be fully evaluated of cases of diabetes and is usually diagnosed in child-for their impact on reducing socioeconomic inequali- hood. Untreated, the total absence of insulin leads toties, and redesigned and re-evaluated accordingly. ketoacidosis, which can cause loss of consciousness and, without intervention, death. More than 90% of peo- ple who develop type 1 diabetes carry known genetic5.2 Introduction markers for the disease.Yet, the vast majority of people with genetic markers do not develop type 1 diabetes (3 ). It seems clear that exposure to environmental trig-Background gers in genetically susceptible individuals is needed. At present, with poor knowledge of the environmentalThere is a tendency to think of some conditions as triggers of type 1 diabetes, there are currently no effec-diseases of poverty, and conversely others as diseases tive approaches to its prevention.of affluence. Causes of maternal and infant mortality,malaria and tuberculosis are strongly related to extreme Type 2 diabetes is characterized by both a reduction inpoverty. In contrast, diabetes (type 2 diabetes in par- insulin action and a relative deficiency of insulin secre-ticular) is often thought of as a disease of affluence, tion. The extent of the reduction in action or secretionaffecting rich countries more than poor, and within can vary considerably between individuals. It is clearpoor countries affecting the better-off sections of the from family and twin studies that the risk of type 278 Equity, social determinants and public health programmes
  • 85. diabetes is strongly influenced by genetic background, substantially reduce the incidence of diabetes-relatedalthough until recently the genetic markers that had complications (19 ). Differential or lack of access tobeen identified could account for only a few percent good diabetes education and health care is thereforeof the risk. an important cause of differential outcomes in people with diabetes.There are well-defined biological and behavioural riskfactors for type 2 diabetes, most of which are thought tooperate through increasing insulin resistance. The most 5.3 Analysis: equity andimportant of these are overweight and obesity, partic- social determinantsularly abdominal obesity, and physical inactivity (4–6).Other behavioural risk factors include certain dietarypatterns (over and above any effect on obesity), such as Equity issues: between- and within-diets low in whole grains and other sources of fibre (7 ), country distribution of diabetesand smoking tobacco (8 ). The risk of type 2 diabetes inadulthood is increased in babies who are small for their Distribution between low-, middle- andgestational age (9 ). It has been hypothesized that lower high-income countriesbirth weight represents poorer fetal nutrition and thatthis has a programming effect on aspects of physiology The World Health Organization (WHO) estimates thatand metabolism, producing a so-called “thrifty pheno- in the year 2000 around 171 million people, roughlytype” that enables the child and adult to survive better 3% of the total world population, had diabetes, within a situation of nutritional scarcity. The risk of type 2 the prevalence increasing with age (20 ). This number isdiabetes and cardiovascular diseases is increased when projected to increase to 366 million by 2030, by wheninstead of nutritional scarcity there is relative excess. more than 80% of people with diabetes will live in low- and middle-income (developing) countries, whereThere have been several highly successful trials show- most new cases will occur in people aged 45 to 64 (Fig-ing that prevention, or at least delaying the onset, of ure 5.1) (20 ).type 2 diabetes is possible. In individuals at high risk acombination of moderate weight loss, increased physi- Distribution within countriescal activity and dietary advice lead to a 60% reductionin incidence (10, 11). Within low- and middle-income countries, but not in high-income countries, the prevalence of diabetesGestational diabetes refers to diabetes that is first recog- tends to be higher in urban than in rural areas, largelynized during pregnancy (1 ). Although type 1 diabetes due to greater levels of obesity and physical inactivitymay occasionally present in pregnancy, gestational dia- in urban areas (21 ).There is also evidence from a varietybetes is largely a form of type 2 diabetes. Around 90% ofwomen with gestational diabetes return to normal glu-cose tolerance within a few weeks of delivery, thoughthey are at markedly increased risk of developing type FIGURE 5.1 Estimated number of people with diabetes in2 diabetes over the coming years (12, 13). Gestational developed and developing countriesdiabetes is associated with increased risks to the fetus,including increased fetal death, malformation and mac- 160rosomia (13, 14). In addition, babies from mothers with 2000gestational diabetes appear to be at increased risk of 140 2030type 2 diabetes and cardiovascular disease as an adult. 120Much of the suffering that is caused by diabetes is the 100result of complications, with a markedly increased risk 80of disease of large and small blood vessels, and of theperipheral and autonomic nervous system. At least 50% 60of people with diabetes die from cardiovascular disease 40(15 ); diabetic nephropathy is the leading single cause ofend-stage renal disease in the United States of Amer- 20ica and Europe (16 ); and diabetes is the leading cause 0of blindness in people under 60 years of age in indus- 20–44 45–64 65+ 20–44 45–64 65+trialized countries (17 ) and the leading cause of lowerlimb amputation (18 ). While diabetes remains for many Developed Developinga cause of morbidity and premature mortality, thereare some highly effective health care interventions to Source: Wild et al. (20). Diabetes: equity and social determinants 79
  • 86. of settings that the prevalence and incidence of type 2 patterns associated with urbanization, aspects of glo-diabetes is related to socioeconomic position within a balization strongly promote other factors that directlycountry. In most high-income countries the prevalence contribute to the risk of obesity, diabetes and otherand incidence is inversely related to socioeconomic noncommunicable diseases.position, with the highest prevalence in those of lowestsocioeconomic position (22–28). Examples from low- The trend towards increased consumption of energy-and middle-income countries show a different picture, dense foods, high in saturated fat, sugar and salt, thatwith a higher prevalence in groups of high socioeco- is associated with urbanization in the vast major-nomic status (29, 30), though it is likely that the impact ity of low- and middle-income countries has beenof diabetes is greatest in the groups of lower socioeco- referred to as the “nutrition transition” (40, 41). A fac-nomic status, as reviewed later. tor encouraging this trend is increasing foreign direct investment1 by transnational corporations. In the foodThere is little evidence that the incidence of type 1 dia- sector, transnational corporations penetrate new mar-betes varies by socioeconomic status, and for this reason kets in developing countries by buying shareholdingsonly type 2 diabetes is considered in the following two in local food industries, concentrating particularly on,subsections examining the social determinants of the and further developing, the lucrative processed fooddistribution of diabetes. However, for anyone who has sector (42–44).diabetes, type 1 or type 2, its impact is strongly relatedto socioeconomic status, as the subsections on differen- Studies of the relationship between neighbourhoodtial vulnerability and impact show. socioeconomic position and access to healthy food, for example from supermarkets (45 ), and of the relation- ship between fast-food consumption and being heavierSocietal and environmental (46, 47), have not produced consistent results, and fur-determinants of obesity and type 2 ther examination of the issues is required (45 ).diabetes: economic development, Beliefs about what is a desirable body size and shape,urbanization and globalization a healthy diet and appropriate levels of physical activ- ity may interact positively or negatively with theHuman and economic development has taken place at obesogenic environments created by urbanization anddifferent rates in different countries and populations, globalization. For example, a study from Cameroonbut generally involves the same major themes: mecha- (48 ) found that it was generally considered desirablenization; urbanization and the way towns and cities are for men and women to be large, a sign of wealth andorganized; changes in the type of work we do and the health. More research is needed in this area, includingway we work; and changes in the way we produce, pro- to what extent, if at all, different beliefs contribute tocess and consume our food. These changes, along with socioeconomic inequities in obesity and type 2 diabe-developments in health care, help to drive demographic tes. It is likely that globalization can have both positiveand epidemiological transitions in which reduced mor- (such as the spread of knowledge on healthier lifestyles)tality rates, particularly in infants and children, followed and negative (such as the promotion of highly proc-by reduced fertility rates lead to an ageing population essed foods) influences on the risk of diabetes (49 ) and(31 ). Ageing of the population will of itself increase the other chronic diseases.prevalence of type 2 diabetes and other age-related dis-eases. With economic development, the age-specificrisks of type 2 diabetes also increase as environments Differential vulnerability to type 2become more urbanized and “obesogenic”, promot- diabetesing the consumption of more energy-dense foods andlower levels of physical activity (32 ). Obesity and body fat distribution by socioeconomic statusEconomic development is strongly associated with agri-cultural mechanization and urbanization (33 ). Between Underlying the distribution of type 2 diabetes bythe years 2000 and 2030 it is estimated that the percent- socioeconomic status is the distribution of obesity.age of the world’s population living in urban centres In general, it has been found that in more developedwill increase from 47% to 60%, with the most dra- economies obesity is associated with lower socioeco-matic increases in Africa and Asia (34 ). Urban living is nomic status while in less developed economies it isoften associated with lower levels of physical activity associated with higher socioeconomic status, thoughthan traditional rural living (35–37), increasing the riskof overweight and obesity, metabolic syndrome, diabe- 1 Foreign direct investment: “Investment by an enterprise from onetes, cardiovascular disease and certain cancers (38, 39). country into an entity or affiliate in another, in which the parentIn addition to the changing living and physical activity firm owns a substantial but not necessarily majority interest” (42).80 Equity, social determinants and public health programmes
  • 87. FIGURE 5.2 Changing associations between economic the implications of this is that they spend a greater development, socioeconomic status (SES) and prevalence length of time exposed to the risk of diabetes-related of diabetes or diabetes risk factors complications. E.g. Russia or China E.g. USA Population groups at particularly high risk HigherPrevalence of diabetes or diabetes risk factors of type 2 diabetes Some groups have much higher rates of diabetes Lower SES than others. For example, at a country level it is esti- mated that over 30% of adults in Nauru, 20% in the United Arab Emirates and 10% in Mexico have dia- betes, compared to 2.9% in the United Kingdom (59 ). Within countries, higher rates of diabetes have been Higher SES found among indigenous peoples and minority ethnic groups. The reasons for these differences are not fully known. Poorer socioeconomic circumstances among marginalized groups may contribute to higher levels Lower of obesity and other risk factors, such as smoking and Less More alcohol excess. Differences in genetic susceptibility may Economic development also play a role. It has also been postulated – the “thrifty phenotype hypothesis” (60 ) – that poor nutrition in early life can leave individuals vulnerable to obesity and type 2 diabetes if they grow up in an environment ofthis picture is changing rapidly (40, 50) (Figure 5.2). relative excess, as may occur in a society undergoingThere is evidence from richer countries that for a given rapid economic development.level of obesity, lower socioeconomic status is relatedto a greater tendency to store fat within and around Differential vulnerability over the life coursethe abdomen (51 ), a risk factor for type 2 diabetes (52 ).Factors affecting body fat distribution include genetic There is some evidence to support the notion thatmake-up and certain behaviours, such as smoking and the thrifty phenotype leads to increased vulnerabilityexcessive alcohol intake (53 ). Neuroendocrine mecha- to other risk factors over the life course. For example,nisms may also be a factor but their relative importance in women in the United States, those most at risk ofis unclear (54–57). Obesity is often associated with a low coronary heart disease and stroke were those who hadlevel of physical activity, which tends to be distributed low birth weight and were overweight as adults (61 ).by socioeconomic status in the same way as obesity. While longitudinal datasets to assist investigation of the relative influence of exposures from birth throughDietary factors and smoking to adulthood on the risk of adult disease are relatively rare, those that have been analysed generally supportBoth dietary patterns and smoking tend to be strongly a cumulative risk model, which hypothesizes that riskrelated to socioeconomic status, and typically will fol- accumulates in an additive way over the life course (62 ).low the same socioeconomic pattern as obesity. Asnoted in section 5.2, there is evidence that aspects ofdiet, over and above the calorie content of the diet, Differential vulnerability throughare related to the risk of type 2 diabetes. These include differential access to health carediets that are low in whole grains and other sources offibre and high in saturated fat (58 ). There is also evi- Overview of the care needed for diabetesdence that tobacco smoking independently increasesthe risk of type 2 diabetes (8 ). Diabetes care and management requires a partnership between health care providers and people with dia-Age betes. The chapter on diabetes (19 ) in the joint World Bank and WHO publication Disease control priorities inThe prevalence and incidence of type 2 diabetes is developing countries, 2nd edition (DCP2) (63 ) dividesstrongly associated with age. There is some evidence interventions into three levels based on an assessmentthat lower socioeconomic status is associated with of their cost-effectiveness and feasibility. The doc-an earlier onset of type 2 diabetes (25 ). It may sim- ument helps to provide countries that have differentply be that in socioeconomic groups at highest risk of health system capabilities with a structured approachtype 2 diabetes the onset tends on average to occur to the establishment of effective and affordable care forat younger ages than for those at lower risk. One of diabetes. Diabetes: equity and social determinants 81
  • 88. Illustrative overview of global issues In countries without universal access to health care,related to access to care ability to pay, whether for health insurance or directly for health care, is likely to play an important role inWhile the diabetes chapter of DCP2 (19 ) does not access to care for diabetes. Several surveys in the Unitedexplicitly address issues of inequality, the proposed States have shown that people without health insur-levels of care are an acknowledgement that there are ance have less frequent examinations (for example ofinequalities in the current capabilities of countries to eyes and feet) and worse outcomes (poorer blood glu-deliver care for people with diabetes. Developed coun- cose control and more eye disease) (73 ). Health care fortries, such as the United Kingdom, attempt to deliver diabetes in some countries in Africa is very limited (64 ),almost all of the recommended interventions. At the and tends to be concentrated in urban centres and inother extreme, access to and quality of diabetes care in secondary health facilities (74 ), which may exacerbateAfrica is very limited (64 ). problems of coverage if health care for diabetes is not expanded at the same rate as projected urban growthLikely expenditure on diabetes care in various coun- (and a consequent increase in the geographical spreadtries was estimated by the International Diabetes of people with diabetes within African countries).Federation and reported in “international dollars” (ID)to allow for purchasing power in each country (59 ). Known (diagnosed) diabetes versusHuge differences were found in health care resources unknown (undiagnosed) diabeteslikely to be spent on diabetes care in different coun-tries. For example, the United States is estimated to An important aspect of coverage of diabetes care isspend 24 times more money per person on diabetes the distinction between known and unknown diabe-care than India (59 ). tes. While it might be assumed that identification and appropriate management of people at risk of diabetes isFor people with type 1 diabetes (and for some with better in developed countries, the evidence that theretype 2) the supply of insulin is crucial for survival. In is an association between economic development andmany countries in Africa the supply of insulin has been the proportion of people with undiagnosed diabeteserratic, even at large hospitals, for many years (65–70), is not convincing. Figure 5.3 plots, for those countriesand the prospects for people with type 1 diabetes are for which data are available, the proportion of peoplepoor (67 ). Exemption from import duty and local pro- with known diabetes against the country’s health sys-duction may reduce costs (66 ) and lessons could be tem ranking in the World Health Report (75 ).learned from the arrangements made to make antiret-roviral drugs available in developing countries (67 ). A There is much variation within each region, and othersecond supply issue is the poor availability and high than at the extremes, with over 70% known in Northcost (often borne by the patient) of materials for blood America and only around 20–30% in the few coun-glucose monitoring. tries representing Africa, there is no strong association between level of development and the proportion ofThe result of differential access to health care for dia- people with known diabetes. One factor that may con-betes can be differences in outcomes for people with tribute to this is survival bias; in countries in whichdiabetes, and complication prevalence has been found health system performance is poor those with undi-to be inversely related to fairness (access) (71 ). agnosed diabetes may be more likely to die than those with diagnosed diabetes.Socioeconomic status and access tohealth care within countries Within countries there are varying associations between socioeconomic position and the likelihoodInequalities in access to diabetes care within countries of being diagnosed. In the United States there was nocan result from various factors, including the level of relationship between socioeconomic status, educationeducation of those who need care; the geographical or health insurance and the likelihood of being diag-distribution of health services and therefore the dis- nosed (76, 77). In Bangladesh, however, the proportiontance needed to travel to access them; and how health of people who were not diagnosed was higher in ruralcare for diabetes is paid for. The incidence of diabetes than in urban areas (30 ).has been shown to be higher in low-education groups,and people with lower levels of education are less likelyto be diagnosed and to adhere to treatment (72 ). Self- Differential health care outcomes:management is an important component of diabetes diabetes control, complications andcare and in the United States adherence to medica-tion is related to education, possibly mediated through mortalityhigher-level reasoning (72 ). There are several important diabetes outcomes at the individual level, including glycaemic and blood82 Equity, social determinants and public health programmes
  • 89. FIGURE 5.3 Proportion of people with known diabetes by socioeconomic status (73, 80). In countries with uni-overall health system performance versal health care that is free at the point of access income-related measures of socioeconomic status should not be associated strongly with control, but 0 50 100 150 associations with other measures of socioeconomic sta-Percent with known diabetes South-East Asia Western Pacific 80 tus, such as area deprivation or education, remain (24, 60 81, 82). In countries that do not have universal health 40 care, such as the United States, health insurance appears 20 to be an important factor in the quality of care and gly- Europe North America South & Central America caemic control (73 ), while lack of health insurance is 80 associated with worse control (83 ). 60 40 As reviewed by the diabetes chapter of DCP2 (19 ), 20 blood pressure control, alongside blood glucose con- All regions Africa E. Med. & Middle East trol, is one of the most cost-effective interventions for 80 the prevention of both macro- and microvascular dia- 60 40 betes-related complications in people with diabetes. 20 Studies from developed countries are largely consistent 0 50 100 150 0 50 100 150 in finding that blood pressure (in the general popula- tion) is inversely related to socioeconomic status (84 ), Overall health system performance (rank, 1=best, 191=worst) a relationship that has also been found in urban areas of the United Republic of Tanzania (85 ). However, theSources: International Diabetes Federation (59) and World Health limited evidence available on the relationship betweenOrganization (75). Each circle represents a country. blood pressure and socioeconomic status in people with diabetes is less consistent, with evidence both for (86 ) and against (87 ) an inverse relationship.pressure control; other risk factors for diabetes-related Diabetes-related complicationscomplications, particularly dyslipidaemia; diabetes-related complications, including cardiovascular disease; Rates of diabetes complications can be difficult toand premature mortality. This subsection examines the compare internationally because there are no stand-relationships between socioeconomic position and ard international definitions of diabetes complications.diabetes control, complications and mortality by first Other factors add further difficulties to making validcomparing differences in outcomes across the world, comparisons, including age structure, duration of dia-and then differences within countries. betes, type of diabetes and whether the data are from a clinic or population sample. Table 5.1 summarizes theBlood glucose and blood pressure control maximum and minimum prevalence rates of four cate- gories of diabetes complications from the Diabetes atlasDiabetes is generally not well controlled in a large pro- (59 ). These ranges are broadly similar for each regionportion of people, and the proportion of people with and mask the variation within regions. Two multicen-diagnosed diabetes who are poorly controlled is inversely tre studies (88, 89) of people with type 1 diabetes foundassociated with country-level economic development. a broad association between health system performanceFor example, an evaluation of the management of dia- and prevalence rates of diabetes complications, withbetes in the United Kingdom found that just under half higher rates of complications in countries with poorerof the patients were poorly controlled (HbA1c > 7.5%) health system performance.(78 ). However, control of people with diabetes in sub-Saharan Africa is generally much poorer: few ever have Within countries, diabetes-related complications havetheir HbA1c checked, assessment of fasting blood glu- been shown to be more frequent in people of lowercose is also much less frequent than in higher-income socioeconomic status in North America and Europecountries, and control is poor in those who are assessed (73, 80). In England people with less education were(64 ). In a survey of people with known diabetes in Dar more likely to suffer from complications such as retin-es Salaam, United Republic of Tanzania, only 10% had opathy and heart disease (83 ). However, one healthgood HbA1c (below 6.5%) (79 ). area of the United Kingdom that implemented a dia- betes information system designed to improve careThere is also clear evidence of an association between found that there was no association between com-socioeconomic status and glucose control within coun- plications and socioeconomic status, suggesting thattries, particularly from North America and Europe, improvements in systems can be equitable (90 ). Therewhere glycaemic control is worse in people of lower is also some evidence of an association between Diabetes: equity and social determinants 83
  • 90. TABLE 5.1 Summary of prevalence (%) ranges of diabetes complications (all diabetes) Neuropathy (various definitions) Nephropathy (overt) Retinopathy Coronary heart disease Region Min Max Min Max Min Max Min Max Africa 27.6 31.2 5.3 23.8 15.1 55.4 n.a. n.a. East Mediterranean 21.9 56.0 6.7 6.7 14.4 64.1 15.0 19.8 and Middle East Europe 16.8 33.7 7.6 15.0 11.3 44.7 3.3 25.2 North America 28.5 47.6 6.1 6.1 28.5 62.1 9.8 43.4 South and Central n.a. n.a. 11.3 11.3 n.a. n.a. n.a. n.a. America South-East Asia 12.7 15.0 3.8 3.8 11.0 30.2 2.0 33.7 Western Pacific 7.3 44.0 1.0 57.1 21.0 48.6 1.0 31.1 Overall 7.3 56.0 5.3 23.8 11.0 64.1 1.0 43.4n.a. not available.Source: Diabetes atlas (59).socioeconomic position and avoidable hospitalizations. Differential consequences: quality ofIn Canada avoidable hospitalization rates were higher life and socioeconomic statusin people with diabetes from low-income neighbour-hoods, although the relationship was much weaker than There is more literature on the consequences of type 1seen in the United States (91 ), but there was no gradi- than on the consequences of type 2 diabetes, and thisent in access to health care (92 ). section therefore draws more on research on type 1 diabetes than previous sections.Diabetes-related mortality rates Depression and quality of lifeThere is very little direct evidence available regard-ing global inequalities in diabetes mortality rates. An There are few studies that explicitly examine quality ofimportant reason for this is that diabetes is often not life in people with diabetes or present results by socio-recorded on death certificates in countries that have economic group. There is good evidence, however, thatwell-functioning vital registration systems (93 ), and in diabetes can lead to depression and negatively impactmany countries of the world vital registration systems the quality of life. A meta-analysis of 39 studies con-do not function and deaths and causes of death are not cluded that the likelihood of depression in people withrecorded at all (94 ). However, those studies that have diabetes is double that of those without (99 ). There isbeen undertaken show higher mortality rates in people some indirect evidence of a link between socioeco-with diabetes across all ages, with the greatest relative nomic status and diabetes-related depression (100). It isdifference in younger adults (15 ). likely that depression and quality of life in people with diabetes are related to socioeconomic status throughWithin-country analyses of mortality in cohorts of differential complication and control rates by socioeco-people with diabetes by socioeconomic status generally nomic status. However, there currently seems to be noshow an inverse relationship with socioeconomic sta- literature that describes the relationship between soci-tus, as typically found in the non-diabetic population. oeconomic status and depression or quality of life inIn studies from the United Kingdom (86, 95) excess people with diabetes given the same level of glycaemicmortality from cardiovascular disease accounted for control or severity of complications.much of the socioeconomic gradient (86, 96). Althoughmuch more limited, there are some data on mortal- Income, costs and lossesity in people with diabetes by socioeconomic statusfrom developing countries. For example, in the United There are few studies that directly address the issue ofRepublic of Tanzania mortality rates were more than social inequities in income or costs for people withdouble for those with no formal education and lower diabetes, and few of those report outcomes by soci-for those who worked in offices (97, 98). oeconomic group. Diabetes does seem to result in84 Equity, social determinants and public health programmes
  • 91. additional costs or losses, and these might be expected 5.4 Discussion: approachesto have a greater impact along an income gradient. For to addressing the socialexample, a study in the United Kingdom concludedthat while a small proportion of people with type 2 determinants of diabetes anddiabetes (6%) or their carers (11%) lose earnings as a reducing their impactresult of diabetes, the amounts they lose are large (101).In the United States, the proportion of income spenton health care was 80% higher in families with a child Summary of the pathways leading towith type 1 diabetes than in families without (102). A diabetes and its consequencesnationally representative study in India found a gradi-ent in the proportion of household income spent on This chapter has explored the social determinants ofdiabetes care, with the highest proportion (34%) in the diabetes and its consequences following a hierarchicallow-income group and the smallest (4.8%) in the high- model of causation. As indicated in the introduction,income group (103). this model has been used to structure the chapter. The model is summarized in Figure 5.4, and is based onAccess to health insurance and care five different levels, with socioeconomic context lead- ing to differences in exposure, which in turn leads toWhere health insurance is an important part of the differences in vulnerability to diabetes and health carehealth system, access to insurance and care may be lim- outcomes, which leads to differences in consequencesited in people with diabetes. One study that compared on quality of life and socioeconomic circumstances.families with and without children with type 1 diabetes Each of these levels is discussed in the subsections thatfound that children with type 1 diabetes are more likely comprise section be refused health insurance than those who do nothave diabetes (102). Another study of mostly African- In summary, the model suggests that the followingAmerican and Hispanic young people with diabetes pathways operate in increasing the risk of diabetes andin the United States concluded that they were “largely its consequences. Globalization and human develop-excluded from health insurance at age 18 years” (104). ment through industrialization involve, among other things, increased mechanization and urbanization,Education and employment which result in diets with higher energy and lower fibre content, and reduced physical activity. ChangesA review of the social and economic consequences of in diet and physical activity lead to increased risk ofchildhood-onset type 1 diabetes found many mixed obesity and diabetes. In the early stages of economicresults (105). Overall it seems that although people with development these changes affect people in groups oftype 1 diabetes tend to miss more school than those higher socioeconomic status, but relatively rapidly thiswithout, there is no difference in ultimate educational situation becomes inverted and groups of lower socio-attainment. However, poor glycaemic control, serious economic status are affected more than those of higherhypoglycaemic events, early onset of type 1 diabetes socioeconomic status. In general, poorer and less edu-and longer duration were all associated with worse cated people in urban centres are more vulnerable toschool attainment. This may indicate that the effects of poor diet and physical inactivity, and the availabilitydiabetes on work might be more sensitive than they are of healthy food options may be limited or they mayon education (105). Another example of the effect of be more expensive. Certain groups, such as people oftype 1 diabetes on employment comes from the United South Asian origin, are more prone to type 2 diabetesStates, where 21% of those aged 20 years and above given the same level of risk factors and are thereforehad been denied employment because of their diabetes at increased risk when their way of life becomes more(104). These effects on employment and income could urbanized and mechanized, such as through migrationpotentially increase the vulnerability of people with or economic development.diabetes, particularly in countries that do not have uni-versal access to health care. Those who are at high risk of diabetes, and especially those who get diabetes, need to be identified and engage in an intervention programme that involves the health system, the community and the patient. In countries that do not provide universal, well-distrib- uted health care or where patients have to pay for medication or the costs of monitoring, people who are disadvantaged will be more adversely affected. If insur- ance, monitoring and treatment costs are not covered by the health care system then people with diabetes will incur greater health care expenditure and this, as Diabetes: equity and social determinants 85
  • 92. a proportion of income, follows a social gradient. Peo- risk factor or whether obesity is a marker for poor dietple with diabetes who are not well controlled develop and physical inactivity (107), the two main effects ofcomplications earlier, develop more severe complica- the “obesogenic environment” (108). There is certainlytions and suffer reduced quality of life.This causes them evidence that physical inactivity is a risk factor for dia-to miss more work, and possibly lose or be refused betes independent of its relationship with high bodywork, ultimately reducing their income. Both quality mass index (4 ).of life and life expectancy are reduced. Potential entry-points at this level include improving diet, increasing physical activity and reducing smokingEntry-points for interventions in disadvantaged populations. Modifying these require action at the individual level and also at the level ofFigure 5.4 gives an overview of diabetes-related path- society by changing the exposures. Recently there hasways. Socioeconomic gradients are seen at every stage. been sufficient political and popular will to changeThe top half of the model is based on type 2 diabetes; exposure with respect to smoking by the introductionthe determinants of type 1 diabetes are less well under- of bans on smoking in public places and limitations onstood but the outcomes are similar.The lines (pathways) advertising for smoking. Changes to elements that cre-between each of the nodes provide opportunities for ate the obesogenic environment, such as the design andintervention that could help to reduce inequities in construction of urban environments, the marketing ofdiabetes incidence, outcomes and consequences. food and social norms are also possible given sufficient popular and political will.Starting from the position of differential health careoutcomes in the pathway, people who are more dis- At the top levels, fundamental changes to the wayadvantaged are more likely to develop diabetes and that we live, eat, work and organize health care sys-are likely to have worse glucose control. The proximal tems have the potential to change the environment thatfactors that make people more vulnerable to inci- contributes so much to driving the increase in diabe-dent diabetes and poor control are access to and type tes prevalence in those who are disadvantaged and toof health care; the interaction of genes and early life ensure that being from a disadvantaged population doesexperience, obesity, physical inactivity and poor diet; not have an effect on access to good-quality care forsmoking (entry-points and interventions for smoking diabetes.are not covered here as they are covered in Chapter11 on tobacco); and being older. Many of these fac- Returning to the bottom of the model, differentials intors, except genes and being older, can potentially be the consequences of diabetes are addressed. People frommodified in the most disadvantaged to reduce the dif- disadvantaged groups are more likely to develop diabe-ferentials in the outcomes at the individual level. tes complications and suffer premature mortality. The data for the other consequences of diabetes are some-Access to and type of health care covers a range of what limited and rarely available separately for differentissues, including universal care versus access to care socioeconomic groups. Loss of income means that peo-dependent on the ability to pay, or limited access to ple with diabetes are economically disadvantaged andinsurance schemes; the geographical distribution of increased costs of health care will have a greater effecthealth care for diabetes; the type, quantity and train- on those with lower incomes, especially when healthing of personnel for the treatment of diabetes; and insurance payments are required or if health insurancethe methods and language used to educate people in companies exclude people with diabetes.self-management (106). Improving these reduces thedifferential in vulnerability to poor diabetes outcomes.Early life experience can be modified by improving 5.5 Interventionsnutrition and other conditions of women during preg-nancy. Knowledge of which genes increase the risk ofdiabetes or its complications might be employed in the What has been tried and learned?future to target interventions in high-risk groups andagain reduce the differential in vulnerability. There is a relatively strong evidence base for the pre- vention of type 2 diabetes and the prevention ofObesity is strongly associated with diabetes risk and diabetes-related complications. A WHO report (109)poor diabetes outcomes and is also more common on the prevention of diabetes and its complica-in disadvantaged populations, except perhaps in rural tions reviews the evidence and provides guidance onlow-income countries. There is increasing awareness of its implementation, particularly in low- and middle-this association and the focus in the popular media has income countries. However, while the overall evidencebeen on reducing obesity. There is some debate as to base on prevention is strong, there is very little evi-the extent to which obesity itself is an independent dence on interventions that have been implemented to86 Equity, social determinants and public health programmes
  • 93. FIGURE 5.4 Overview of diabetes-related pathways Industrialization, Social Ageing urbanization Social stratification population and globalization context ‘Obesogenic’ environment Social Local food Urban Environments Differential norms environments infrastructures promoting exposure tobacco use Differential vulnerability Access to and type of Genes and Excess calories Physical Smoking health care, including early life Old age and poor diet inactivity self-management experience Obesity Diabetes incidence, glucose control, Diabetes complications Differential health blood pressure control and premature mortality care outcome and lipid control Costs for health Quality Loss of Differential and social care of life income consequences Diabetes: equity and social determinants 87
  • 94. reduce inequities in the determinants, outcomes and inequities in diabetes risk and diabetes care. These mayconsequences of diabetes (110). Most intervention stud- take the form of noble targets or more forceful nationalies note any inequities observed, but do not attempt or international law, and would primarily be aimed atto change them, or they are designed to show that limiting the availability of unhealthy food or environ-they work in a specific high-risk group, but are not ments, and increasing the availability of healthy choices.compared to a general population control group; the These interventions would need to be implementedcontrols are usually members of the high-risk group in a way that does not hinder the economic develop-who receive “normal” care as opposed to the interven- ment of low- and middle-income countries, and willtion being evaluated. increasingly need to be focused on a wider age range to counter the risk posed by increasing childhood obes-The most direct attempt to reduce inequities that ity at one end of the spectrum and ageing populationsinclude inequities in diabetes is seen in the REACH at the other.2010 project in the United States, a large, multifactorialcommunity-based attempt to reduce racial and eth- Interventions at the level of exposure would mostlynic inequities in six key health areas, one of which is address the obesogenic environment and would involvediabetes (110). There are many interventions involved, changes on a large but manageable scale. These wouldincluding developing partnerships, supporting faith- include measures to address the social norms regardingbased groups, nutrition and physical activity classes, desirable body size, changing urban infrastructures toand classes specifically designed to change social and promote physical activity, and changing local food envi-cultural norms. This project is being evaluated using ronments so that they promote healthy food options.quantitative and qualitative methods, including riskfactor surveys, and its results are awaited with interest. Interventions to address inequities in vulnerability would include improved access to health care, reduc-It is reasonable to ask why so few interventions to tion or removal of patient-borne costs, improved earlyreduce inequities in the determinants of diabetes have life experiences for those who are currently disadvan-been conducted. One possibility is that there is sur- taged, and possibly gene profiles to identify those atprisingly little evidence about interventions that reduce high risk. However, while these interventions are caus-the determinants generally, let alone in specific disad- ally closer to the main diabetes outcomes, evidence tovantaged groups. Returning to the pathway model, support them is generally important entry-point is tackling the two compo-nents of the obesogenic environment. While there is Health care outcome interventions to improve compli-evidence in a research setting that diets and pharma- ance and adherence are supported by reasonably goodcological measures can lead to a reduction in obesity evidence (80, 115, 116) and could include increasedwhen implemented as focused interventions at the screening of those at high risk, use of folk media toindividual level (111, 112), there is very little evidence reach the disadvantaged, culturally and linguisticallyto support public health interventions to improve food appropriate health education, and improved self-helpenvironments or increase physical activity (113, 114). and follow-up. Such measures should help to reduce inequities, although the screening tools need further work to improve their performance in populationsPotential interventions other than those descended from Europeans. The pri- mary intervention that is likely to have the greatestAs indicated above the evidence base on interventions impact on inequities in care for diabetes is the establish-specifically designed to reduce the social determinants ment of a system that provides access irrespective of theof diabetes is very limited, so the interventions sug- ability to pay, including access to consultations, med-gested here are largely untested. The majority of the ication and materials for monitoring. It is, of course,potential interventions are not specific to diabetes but acknowledged that inequities by socioeconomic sta-applicable to other chronic diseases, including cardio- tus also exist in health systems that do provide accessvascular disease, chronic respiratory disease and many irrespective of the ability to pay, and that providing uni-cancers. Arguably therefore it is of limited value to con- versal access compared to limited access will reduce butsider separately the potential interventions for closely not eliminate them.related chronic diseases, which tend to share very sim-ilar determinants. It is more efficient, and likely to be There is very little information regarding inequitiesmore effective, to consider diseases with similar deter- in the consequences of diabetes, other than that theminants together. economically disadvantaged will suffer greater adverse consequences where the health system requires userInterventions at the level of society are policy-type fees or is based on private health insurance.interventions, agreements within and between govern-ments regarding the primary upstream determinants of88 Equity, social determinants and public health programmes
  • 95. Tackling inequalities in the obesogenic environment food labelling and advertising) should provide a com-requires action on a large scale, and while the broad plementary framework for prevention.issues are reasonably well established there is very lit-tle evidence supporting interventions to change theobesogenic environment or the inequalities seen in Measuring the impact ofsuch environments. There are three main elements to interventionsthe obesogenic environment: social norms regardingdesirable body size and shape; local food environments; There is limited information available regarding changesand the design of urban areas. Integrated interventions in some of the key upstream determinants of diabeteswould be required and would probably need to take and of diabetes prevalence itself and this has contrib-place across an entire municipality or district. Appro- uted to the steady rise in prevalence of type 2 diabetespriate professionals would need to measure the health generally, and particularly in disadvantaged groups andand economic impact of the changes to provide evi- populations. Now that we are beginning to broadlydence on whether or not the changes worked. If such understand the key issues, it is important to monitorinterventions can be shown to work it would increase the prevalence of diabetes risk factors and of diabe-the chances for their introduction in other areas. Such tes at country level and within countries. WHO hasevidence could be particularly important for low- and developed a three-stepped approach to the use of rep-middle-income countries where urbanization is cur- resentative and repeated surveys for noncommunicablerently taking place more rapidly because it could help diseases (118) that allows for differences in the resourcesthem to plan their urban development to create envi- available for countries to conduct large surveys. Con-ronments that help to avoid or reduce the increase in ducting representative surveys of diabetes prevalence isdiabetes. difficult and expensive, and even economically devel- oped countries do not perform such surveys regularly.5.6 Implications Every three years the International Diabetes Fed- eration produces the Diabetes atlas (59 ), in which it pulls together summary statistics of diabetes preva-Managing the change process lence and complications from across the world. These are presented in tables and figures that facilitate com-Very few of the interventions can be implemented parisons across countries. This work could potentiallyby the health sector alone, or even at all. Most of the be extended in two directions: to provide this infor-interventions in the matrices are broad, structural and mation within countries and perhaps regardingpolicy-type interventions, rather than specific clini- population subgroups; and also to include informa-cal interventions. This, and the assessment that political tion on upstream determinants of diabetes and diabetesfeasibility is often the weakest aspect of many of the inequities, such as the walkability of urban centres, dis-interventions, means that implementing them requires tribution of food outlets and distribution of health carepolitical will at high levels. Many of the interven- for diabetes relative to need. Some of these data maytions at this level are likely to be opposed by people already be available but are not yet organized or col-or groups that might see the interventions as a direct lected together, while for many low-income countriesthreat to their business model or as a likely source of additional data collection may be required. Gatheringadditional expense, for example through the need to this information would take a considerable amount ofdevelop new practices or approaches. Much has been effort in the first instance, and the data would rapidlywritten on the importance of advocacy for change, and become out of date in low-income countries that arerelevant recent initiatives from within WHO include growing and changing with urbanization.the production and promotion of the report Preventingchronic diseases: a vital investment (39 ), and a programme There are many items of data that would help to mon-run jointly with the International Diabetes Federation itor and evaluate progress and interventions at the levelknown as Diabetes Action Now (117). Both of these of exposure, relating directly to data needs at the soci-initiatives have emphasized the relationships between ety level. Whereas the society level is concerned morepoverty and chronic diseases, or specifically diabetes, with broad policy-level data, the exposure level requiresand their consequences, and have promoted approaches data for measuring exposures more directly. Some ofto prevention appropriate to low- and middle-income the data required at this level could be obtained usingsituations. These initiatives have drawn attention to the health survey questionnaires, while other data fit moreimportance of an integrated, cross-sectoral approach to naturally within the purview of other sectors of localchanging policy to prevent and improve outcomes for government. Most data collection activities involvepeople with diabetes and other chronic diseases. Ideally, costs and, for many of the data items at this level,policies on health financing, health systems, the built arrangements would need to be made to plan and payenvironment, and legislation and regulation (such as on Diabetes: equity and social determinants 89
  • 96. for the collection of the data and then disseminate and used are culturally and linguistically appropriate (80 ).share the results between these sectors of government. One way to do this is through formal ethnographic research, although this may be too expensive andThe data needed to measure aspects of vulnerability time consuming to repeat on a large scale. An alterna-and the effect of interventions on inequities are mostly tive approach may be to foster the creation of patientwithin the realm of the health system. Some of the data self-help groups, supported by medical profession-would ideally be obtained from representative popula- als to ensure that core messages are being transmittedtion-based surveys, although alternative means may also possible. Population-based data are best to ensurethat people from the general population who are more To properly measure the effects of interventions ondisadvantaged are not excluded from the data collec- inequities in the consequences of diabetes in countriestion process, as may happen if surveys are only based that currently do not have universal access to healthon those engaged in formal employment or using exit care will be hard to do without population-based sur-interviews from health facilities. veys of people with diabetes. This is because some of those who are most disadvantaged may be excludedThe data to measure outcomes can largely be obtained from health care that is funded by private health insur-from routine health administrative records, assuming ance or user fees. In countries where universal accessthat these are collected and recorded accurately. In set- to health care is available and the health system func-tings where there is much migration and medical records tions reasonably well most of the data required can beare not well integrated, as in many low- and middle- obtained from routine clinic data or additional clinic-income countries, aggregating routine administrative based will be challenging. Maintaining medical recordsfor the clinical management of diabetes is already dif- Perhaps the most important conclusion that comesficult in these circumstances, and patient-held records from considering the information needs for measur-(for example a school exercise book) have been used to ing the impact of interventions at all levels, from socialcompensate for the lack of integrated health informa- context through to differentials in consequences, is thattion systems in such settings (119). This approach could at present there is very little information available, evenbe formalized and integrated within the health system, for high-income countries, and the information that isfor example by using a standard approach for generat- available is rarely integrated into health unique identifiers that is not dependent on a singlehealth facility’s records system or a computerized sys-tem. A sample of the patient-held records could then 5.7 Conclusion: significancebe audited on a periodic basis to provide the aggre- for public health programmesgate statistics required for monitoring outcomes. Anymechanism for monitoring patient outcomes would and the diabetes programmealso need to report on and tackle those who default at WHOfrom clinics. In countries where communication sys-tems are weak, and especially where distances are large,managing this could be difficult. This chapter has reviewed the determinants of diabetes, its complications and its consequences for social andIdentifying people at high risk of diabetes is impor- economic well-being.The information presented is nottant because it has been demonstrated that intensive new and will be familiar to many in the field of diabetes.interventions in this group can reduce the incidence Arguably, however, the approach taken here is unusualof diabetes (10, 11) and reduce inequalities in compli- and illuminating in its scope. Most epidemiologicalcations (72 ). Risk scores that use routine health facility work on the causes of diabetes and its complicationsdata (in economically developed countries) have been tends to focus on the identification of personal char-shown to be an effective way of detecting Europid peo- acteristics (risk factors), such as lifestyle and physicalple at high risk but they need further validation work and biochemical characteristics. Sometimes personalfor other ethnic groups (116). Again, poorly integrated measures of social and economic status are considered,medical records or health information systems will as reviewed in this chapter, but they are often ignoredmake it more difficult to collect these data and report (either entirely or through controlling them out in theon them, although the risk score approach could still be statistical analysis). While the paradigm of risk factorused with individuals to identify them and refer them epidemiology for diabetes and other chronic diseasesfor the intervention. has had notable success in adding to knowledge on dis- ease causation and feeding directly into some highlyAn important part of making health interventions work effective preventive interventions (almost alwaysfor people with diabetes (or indeed for those at high directed at individuals at high risk), it has also beenrisk of diabetes) is to make sure that the approaches criticized for ignoring the wider environment within90 Equity, social determinants and public health programmes
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  • 101. Food safety:equity and socialdeterminantsJean-Louis Jouve, Jens Aagaard-Hansen and Awa Aidara-Kane 6Contents Addressing food safety in relation to food security, malnutrition and comorbidity. . . . 1066.1 Summary . . . . . . . . . . . . . . . . 96 Addressing the root causes of inequity in6.2 Introduction . . . . . . . . . . . . . . 96 relation to food safety. . . . . . . . . . . 107 Food safety: scope and burden . . . . . . . . 96 6.6 Implications . . . . . . . . . . . . . 107 Equity and social determinants . . . . . . . 97 Measurements, evaluation and data requirements . . . . . . . . . . . . . . 107 Modes of food consumption, handling and production . . . . . . . . . . . . . . . . 98 Managerial implications and challenges . . . 108 Interaction with food security, malnutrition and 6.7 Conclusion . . . . . . . . . . . . . . 109 comorbidity . . . . . . . . . . . . . . . 100 References . . . . . . . . . . . . . . . . 109 Structural social determinants . . . . . . . 1016.4 Discussion of entry-points for Figure intervention . . . . . . . . . . . . . 103 Figure 6.1 Social determinants of food safety . . 986.5 Interventions: recommendations for addressing social determinants of food Table safety . . . . . . . . . . . . . . . . . 104 Table 6.1 Examples of foodborne hazards. . . . 96 Strengthening food safety systems . . . . . 104 Food safety: equity and social determinants 95
  • 102. 6.1 Summary (“hazards”) that enter the body through the inges- tion of food. Foodborne diseases are a major causeFoodborne diseases are the illnesses, generally infec- of suffering and death throughout the world. Besidestious or toxic in nature, caused by pathogenic agents direct health consequences, the economic costs asso-that enter the body through the ingestion of food. The ciated with foodborne diseases represent a significantincidence of foodborne diseases varies greatly between economic burden on consumers, the food industrycountries, and low-income countries bear the brunt and governments. Foodborne illnesses can also reduceof the problem. However, episodes of foodborne ill- labour productivity, impose substantial stress on theness continue to constitute a challenge to public health health care system, and reduce economic output as aeven in industrialized countries, despite advances in result of loss in confidence in the food production andfood hygiene, food protection and food control. Inap- marketing system. Food can be the vector of a largepropriate modes of food consumption, handling and number of hazards. More than 200 known diseases canproduction entail exposure to food hazards, dispro- be transmitted by food (1 ). Table 6.1 provides someportionately affecting the most disadvantaged groups. examples of broad categories of foodborne hazards.Certain conditions, such as food insecurity, malnutri-tion and comorbidity, may increase vulnerability to Foodborne diseases share some common characteristicsunsafe food items. At the structural level a number regarding their determinants and possible preventiveof social determinants (ethnicity, gender, education, interventions:migration, trade, urbanization, demographic factors • Infectious foodborne biological pathogens are inci-and poverty) imply inequity in relation to food safety. dentally introduced into foods following improperAccordingly, this chapter leads to three main lines of hygiene and sanitation at any stage in food pro-recommended interventions: strengthening food safety duction, collection, processing, transport, handling,systems; addressing the conditions leading to increased distribution and preparation for final consumption.vulnerability; and addressing the root causes of ineq- • A large part of microbiological or chemical food-uity in food safety. borne diseases are directly (for example from drinking-water pollution) or indirectly (for exam- ple from air, water or soil through plants or animals)6.2 Introduction attributable to environmental factors. • Infectious foodborne pathogens have, in most cases,Food safety: scope and burden an animal reservoir from which they can spread directly or indirectly to humans (2). Infectious food-Foodborne diseases are the illnesses, generally infec- borne diseases are very often foodborne zoonoses.tious or toxic in nature, caused by pathogenic agentsTABLE 6.1 Examples of foodborne hazards Type of hazard Examples Biological hazards Zoonotic agents that may enter the food chain (e.g. Brucella, Salmonella, prions) Pathogens predominantly foodborne (e.g. Listeria monocytogenes, Trichinella, Toxoplasma, Cryptosporidium, Campylobacter jejuni, Yersinia enterocolitica) Established pathogens emerging in new vehicles or new situations (e.g. Salmonella enteritidis in eggs, hepatitis A virus in vegetables, Norwalk/Norwalk-like virus in seafoods) Pathogens newly associated with foodborne transmission (e.g. Escherichia coli O157:H7, Vibrio vulnificus, Vibrio cholerae, Cyclospora cayetanensis) Antimicrobial-resistant pathogens (e.g. Salmonella typhimurium DT104) Chemical hazards Naturally occurring toxicants (e.g. phytoestrogens, marine biotoxins, mycotoxins) Environmental or industrial contaminants (e.g. mercury, lead, polychlorinated biphenyls, dioxins, radionucleides) Residues of agricultural chemicals, veterinary drugs, surface sanitizers Toxic compounds generated during food processing (e.g. polycyclic aromatic hydrocarbons, acrylamide) Toxic substances derived from packaging or other materials in contact with foods New issues in toxicology, including allergenicity, endocrine disruption (e.g. phytoestrogens, pesticide residues), mutagenicity, genotoxicity, immunotoxicity Physical hazards (not considered in this chapter)96 Equity, social determinants and public health programmes
  • 103. • The factors that influence exposure to foodborne globally, of which 99.8% occur in developing coun- pathogens are often tied to human behaviour, in tries and 90% occur in children. Indirectly, 12 to 13 particular consumption, handling, preparation and million die from the combined effects of diarrhoea and storage behaviours. malnutrition.• Due to the globalization of food trade, foodborne pathogens can spread rapidly and worldwide. Foodborne diseases have profound socioeconomic• A variety of food crises and information on out- consequences related to inequities. For example, the breaks have heightened consumer awareness, costs incurred can represent a significant economic creating a large social demand for improving the burden, inequitably impacting the poor. Direct costs science base of decisions and for enhancing the can be categorized as costs borne by the ill individu- guarantee of food safety. als or their families, public health costs to society and costs incurred by the industry (13, 14). Additional eco-Foodborne diseases comprise a variety of clini- nomic consequences and indirect costs can be incurredcal syndromes. Gastroenteritis is the most frequent; by governments (for example costs of epidemiologicalwhile generally mild, it may also result in serious ill- investigations and disease eradication), the food indus-ness requiring hospitalization and possibly leading to try (litigation costs, product recall and market impact),long-term disability or death (3 ). Some foodborne and the overall economy of a country (market andpathogens can cause systemic infections and other trade losses) (15 ). The costs can be significant (16, 17);acute syndromes, for example meningitis, septicaemia, for example, in the United States of America, estimatesacute neurological symptoms, perinatal loss or acute of annual financial losses vary from US$ 2.9–6.7 billionhepatitis (4, 5) and may also lead to serious compli- (18 ) to US$ 8.43 billion (13 ).cations and long-term consequences, perhaps in 2–5%of cases (6 ), including reactive arthritis, Guillain-Barré Direct cost estimates for foodborne diseases in devel-syndrome (the most common cause of acute paraly- oping countries are rarely available. However, in somesis in children and adults) and haemolytic uraemic countries, episodes of diarrhoeal diseases are one ofsyndrome (4, 7). Chronic sequelae may be more detri- the most frequent reasons for paediatric hospitalizationmental than acute disease and thus increase the global (19 ). In poorer countries, although the cost of treat-burden of foodborne diseases. Chemical toxicology ment is lower than in industrialized countries, thesefocuses primarily (except for allergy or occupational costs represent a huge economic burden due to theirillness) on long-term effects such as endocrine disrup- frailer economies and higher rates of incidence (10 ).tion, immunotoxicity, mutagenicity, carcinogenicity The economic consequences to individuals can be dra-or teratogenicity (8). An attempt to elaborate a com- matic. In Argentina, for example, treatment of a case ofprehensive evidence map of clinical presentations by diarrhoea in a government hospital, with five days hos-etiology has recently been made by the World Health pitalization, has been estimated to cost about US$ 2000Organization (WHO) in the framework of its estima- (10 ). Long-term costs of seeking care often impover-tion of the global burden of foodborne diseases (5).The ish poorer households, reinforcing pre-existing socialscientific evidence available on the biological hazards is stratification. At national level, epidemics of foodbornemuch more substantial than that on the chemical haz- diseases may affect tourism and the food trade and bearards, with regard to burden of disease in general and heavily on a country’s income. A typical example wasequity aspects in particular. the outbreak of cholera in 1991 that cost Peru more than US$ 700 million in loss of export of fish and fish-The incidence of foodborne diseases varies greatly ery products and the decline in tourism (10 ).between countries, with low-income countries bear-ing the brunt. In industrialized countries, continuingadvances in food hygiene, food protection and food Equity and social determinantscontrol are highly effective in improving the safety ofthe food supply. Nevertheless, episodes of foodborne The World Declaration on Nutrition (1992) of theillness still constitute a challenge to public health. For Food and Agriculture Organization of the Unitedexample, each year foodborne diseases cause approxi- Nations (FAO) and WHO (20 ) states that “access tomately 2 366 000 cases, 21 138 hospitalizations and 718 nutritionally adequate and safe food is a basic indi-deaths in England and Wales (9). Though estimates vary vidual right”. As reaffirmed by the 1996 World Foodgreatly, the frequency of foodborne diseases is probably Summit, access to safe and nutritious food is not a lux-of the same order of magnitude in most industrial- ury of the rich but a right of all people. Food safetyized countries (10, 11). In many developing countries, constitutes an effective platform for poverty alleviationthe high prevalence of diarrhoeal diseases suggests that and social and economic development, while openingmany underlying food safety problems still prevail. and enlarging opportunities for trade.The CommissionWith some uncertainty WHO (12 ) has estimated that on Social Determinants of Health understands healthdiarrhoeal diseases cause an annual 1.9 million deaths as a social phenomenon and intends to advance health Food safety: equity and social determinants 97
  • 104. FIGURE 6.1 Social determinants of food safety Structural Intermediary determinants determinants Differential exposure Food borne Socio-economic diseases: position Differential vulnerability Differential outcomes Differential Manifested in: Resulting from such factors as: consequences Poverty Education • Modes of food consumption Physiological [ Lifestyles – Preferences – Behavior – conditions Ethnicity Psychological factors ] Food insecurity Gender • Modes of food handling Malnutrition Demographic factors [ Poor hygiene – Improper practices – Inadequate environment – Co-morbidity Living and working Lack of safe water and sanitation ] conditions E.g. urbanization, • Modes of food production migration [ Agricultural productions and practices ] Tradeequity.Where food safety is concerned, this view invites As the focus of this chapter is specifically on inequitiestwo approaches: first, an exploration of which social related to food safety, not all food safety issues are com-determinants may interact, and how, with the safety of prehensively addressed. Though food insecurity is onethe food consumed; and second, a translation of this of the most important global public health problems, itinformation into interventions that will contribute to a is considered in this chapter only in so far as it createsmore equitable approach to ensuring food safety. inequities with regard to accessing safe food.To guide analysis of linkages between social determi- 6.3 Analysis: socialnants of health and food safety a conceptual frameworkwas developed, adapted and simplified from the determinants of food safetymodel of the Commission on Social Determinants ofHealth (Figure 6.1). It outlines the social determinants This section will provide an overview of social deter-described later in this chapter and will help identify the minants of food safety. The three main subsections willmain entry-points to related policies and interventions. deal with the factors leading to differential exposure;The figure shows how the structural determinants that the causes of increased vulnerability; and differences ingenerate social stratification (left) may further oper- socioeconomic context and position.ate through more specific intermediary determinants(centre) to result in differential outcomes and conse-quences of foodborne diseases, leading to differential Modes of food consumption,exposure to foodborne hazards and vulnerability to handling and productionconditions that compromise food safety (see next sec-tion). The structural and intermediate determinants The analysis of potential pathways leading to dif-may overlap or operate at several levels; for example, ferences in exposure to foodborne diseases generallyliving and working conditions or trade are related to proceeds through the various chronological links insocioeconomic context and position and also operate the food chain, including farm inputs, farm production,at the level of exposure. collection (harvest or slaughter), processing, transport and distribution (wholesale, retail or food services),98 Equity, social determinants and public health programmes
  • 105. down to final consumer handling and consumption. food safety risk management processes, whether atOnly some of these steps will be outlined below, in individual or collective level (42 ). An important factorreverse order (consumption, handling and production). is the way in which information is obtained; it should come from reliable sources, should not be too detailedModes of food consumption or too scientific, and should be understandable and in a “what and how to do” format (44 ).Perceptions of food safety risks are multidimensionaland complex and may affect people’s concerns and Modes of food handlingreactions about food safety. Contemporary lifestyle andconsumer preferences may adversely affect exposure to A substantial proportion of foodborne diseases is attrib-foodborne hazards, with many consumers appearing utable to improper food handling practices in themore interested in saving time and in convenience than consumer’s home (25 ). Increased exposure to food-in proper food handling and preparation (21–23). Those borne hazards results from defective hygiene practices,usually responsible for meal preparation in the home lack of safe water and sanitation and inadequate envi-may have taken paid employment, leaving other family ronmental conditions, which often act synergisticallymembers or domestic helpers, who are often less expe- (45 ). Factors shown to have contributed to foodbornerienced or ill-trained, to prepare meals (10 ). Decreased diseases include improper cooking, storage or holdingopportunities for food safety instruction, declining food temperature (for example in Bacillus cereus, Clostridiumpreparation skills and insufficient food safety informa- perfringens, Salmonella, E. coli O157:H7, C. jejuni, Sta-tion often lead to diminished appreciation of the basic phylococcus aureus and group A Streptococcus outbreaks),principles of food preparation (24 ). Furthermore, even poor personal hygiene of the food handler, such as lackwhen people are informed or educated with regard to of or inefficient handwashing (for example in Shig-food safety issues, attitudes do not always translate into ella, hepatitis A, Norwalk virus and Giardia outbreaks),improved food handling, and a substantial number of cross-contamination, contaminated raw food ingredi-educated consumers frequently implement unsafe food ents and food obtained from an unsafe source (46–49).handling practices (24–27). In extreme conditions, lack of water, poor sanitation, absence of facilities for adequate storage and absenceTypically, consumers in industrialized countries appear of fuel for cooking (wood, gas, electricity) hamper safeto perceive foodborne hazards as mainly generated by preparation and increase the risk of exposure to food-the industry, a defiant attitude often associated with borne hazards (50 ). Breastfeeding has been shown todiminished faith in science and technology (28, 29). have a strong protecting effect in reducing the risk (51 ).A parallel process has been an increase in consumer For people of low socioeconomic status handwash-demand for foods that are fresh (less processed and ing, even if quite frequently practised, was often of lowpackaged), natural (no chemical preservatives) and effectiveness, as demonstrated by faecal coliform bac-without a perceived negative health effect (low fat, salt teriological counts on both hands (52, 53). Numerousor sugar levels). As a consequence, today’s marketplace studies (10, 54–56) have demonstrated contaminationhas more perishable products, with less secondary bar- of complementary (weaning) foods prepared underriers to oppose microbiological build-up, which leads unhygienic conditions. In developing countries, theto an increased risk from food handling errors (23 ). highest risk of complications and death due to domes- tically acquired cases of typhoid occurred in childrenPeople might also be subjective and unrealistic about from birth through 1 year of age, and adults older thanthe risks they incur, even if they have the appropriate 31 (57 ). Poor sanitation increases the risk of morbid-information, and may demonstrate judgements termed ity and mortality from diarrhoea among poor children“optimistic bias” and “illusion of control” related to the (58 ). Several studies have emphasized the associationnotion of perceived invulnerability to food poisoning between unsanitary excreta and waste disposal and high(30–34). A study showed that food handlers perceived prevalence of diarrhoeal diseases in affected communi-their business to be at relatively low risk, and yet all ties (59–61).businesses in the study prepared high-risk foods (35 ).The perception of the risk characteristics of poten- As a consequence of the rapid rise in the informaltial hazards has been explored, in particular, under the economy, there is an expansion in street food vendingparadigm of the psychometric model (36–39). Women in developing countries. This plays an important soci-generally perceive higher food safety risks (40 ). Those oeconomic role in terms of employment and incomewho perceive higher risks often exhibit safer food han- inflows (62 ). In modern cities throughout the worlddling practices (41 ). Elevated perception of food safety people frequently eat outside the home (24, 63). Thisrisks in relation to personal health has sometimes been practice is a risk factor for certain foodborne diseasesfound in low-income groups of people, associated with (1).The major concern with street foods is their micro-perceptions of social exclusion (42, 43). Individuals in biological safety, as street vendors generally operatethese groups felt frustrated at having less control over from places that lack appropriate hygiene and sanitation Food safety: equity and social determinants 99
  • 106. facilities (64, 65). Foods can also be contaminated example through the Hazard Analysis Critical Controlbecause of lack of personal hygiene and unhygienic Point (HACCP) system (1). Food safety problems mayhandling practices, and can serve as a vehicle for a nevertheless arise in all countries, due to the existencenumber of pathogens (64, 66, 67), including cholera (68, of weak points in commercial and business processes,69). A characteristic feature of informal street vending is structural obsolescence, drifts in the application ofthat it escapes formal food safety inspection by official control and assurance schemes, and managerial deficitauthorities, as most vendors operate without licence (84 ). Conditions that may introduce breaches in foodand from undesignated places (70 ). In Mexico, chil- safety are more often found in the small business sec-dren of women working as street vendors had increased tor, which in many countries is responsible for a largeprevalence of gastrointestinal diseases compared to the share of the food consumed and a large part of the totalgeneral population (71 ). employment in the food sector, but is often a major source of foodborne illness transmission (85 ). Opera-Modes of food production tors of small and less developed businesses often lack appropriate education and training, and the technicalFoodborne illnesses can be caused by unsafe food con- and financial resources, to provide on-site solutions andtaminated during agricultural production. For example, to improve food safety (86, 87).pathogens on raw vegetables or fruits may result fromirrigation with polluted water or inadequately treatedwastewater (72–74), and aflatoxins in staple crops, such Interaction with food security,as maize and groundnuts, have been linked with impair- malnutrition and comorbidityment of child growth (75 ). In developing countries,the spread of zoonotic infections is encouraged by the Whereas the issues dealt with above mainly relate to dif-close association between the rural poor and animals, ferentials in exposure, this section will concentrate ondispersed and heterogeneous smallholder livestock sys- differential vulnerability to foodborne diseases, whichtems, the predominance of the informal rural economy depends primarily on biological and physiological con-and markets, poor infrastructure and lack of resources ditions that alter the host defences and suppress the(76, 77). In rural areas, poverty and associated unsani- function of the immune system. Crucial determinantstary living conditions increase the risk of exposure to of the number of cases and the severity of infection arewaterborne and other indirectly transmitted zoonotic age (young or old), pregnancy and immunosuppressivepathogens, for example waterborne parasitic zoonoses, conditions (the so-called “YOPI” conditions).including those caused by Giardia, Cryptosporidium orToxoplasma (78 ), or the recent upsurge of Taenia solium Food insecurity is a major global public health prob-cysticercosis in Africa (79, 80). Globally, the prevalence lem with close links to inequity. It may exist at nationalof foodborne zoonoses is increasing (2), with much of (or regional) level due to a variety of factors that affectthe impact falling on poor people (76 ). food supply, such as the food production–population imbalance; lack of employment; low national income;Some agricultural practices, such as the use of manure shifts in international food prices; natural disasters;rather than chemical fertilizer, the use of untreated sew- blockage and disruption of transport routes; civil warage, contaminated irrigation and surface runoff water, and unrest; and environmental degradation (88 ). Foodpoor personal hygiene of workers and lack of sanita- insecurity also exists at the household level, and thetion through all stages of handling, contribute to an importance of sustained access to food within house-increased risk of product contamination by Salmonella, holds is increasingly recognized (89 ). Household foodE. coli (for example VTEC O157:H7), Campylobacter, insecurity goes beyond insufficient food availability andV cholerae, parasites and viruses (73, 81). In developed . includes uncertainty and worry about the food sup-and developing countries, population growth, urbani- ply; inadequate food quality, including food safety; andzation and increasing income are resulting in a marked the social unacceptability of procurement practices (90,increase in demand for livestock products (82 ).The risk 91). Food insecurity may have broad social implications,posed by chicken as a vehicle for Campylobacter and Sal- including a state of frustration due to being deprived ofmonella has increased, and contamination of beef and access to food, and feelings of guilt, shame and inequityred meat with Salmonella or E. coli (VTEC) remains a associated with lack of control over the situation (92,significant problem. 93). Food safety is not sufficiently prominent in inter- national and national development plans intended toIn most countries the food industry is a major sector, tackle food insecurity (94, 95). Achievements in foodsometimes accounting for the highest proportion of the safety and food security can act synergistically andgross domestic product (83 ). In many parts of the food effective improvement of food safety should capitalizeindustry, increased market size and greater geographical on the positive impacts of food security policies.distribution has led to consolidation of businesses, facil-itating broader application of good hygiene practice, for100 Equity, social determinants and public health programmes
  • 107. Malnutrition is the most severe manifestation of poverty Ethnicity is closely intertwined with disadvantagedand food insecurity, and the leading cause of increased position, for example due to low income, poor hous-host vulnerability to foodborne infections. In children, ing and living environment or poor education. Thesemalnutrition is associated with both the incidence and cumulative disadvantages also lead to conditions prej-duration of diarrhoea (96, 97). In countries with inade- udicial to food security and safety. Some aspects ofquate sanitation, rotavirus diarrhoea is one of the main foodborne diseases involve transmission via foods thatcauses of morbidity, with children the most likely to be are more commonly consumed by ethnic populations,infected (98 ). There is emerging evidence of the long- as a consequence of their traditional eating habits. Interm consequences of early childhood diarrhoea for examples from the United States, outbreaks of Y. ente-growth and physical and cognitive development, effects rocolitica in African-American communities have beenthat may translate into costly impairment of human associated with preparation and consumption of pigpotential and productivity (99–102). intestines (112), and brucellosis from consumption of raw milk and cheeses affects Hispanic communitiesThe number of new cancer cases has steadily increased (113). In some societies in developing countries, andover the past 20 years, and patients are also surviving in particular among disadvantaged groups, diarrhoea islonger. Complex procedures such as heart, liver, kid- not seen as a symptom of a disease with serious healthney, lung, bone marrow or even full-face transplants consequences but as a “natural” health problem (10 ).have been developed. Patients undergoing these pro- In a number of countries, the perception of cleanlinesscedures often receive intensive chemotherapy with is not always based on germ theory, but is viewed inimmunosuppressive drugs, leaving the patient with lit- the larger socioreligious context of purity and impu-tle defence against opportunistic infections, including rity: washing oneself serves physical and spiritual needsfoodborne illnesses (96, 103). Hospitalized people may and is performed according to defined patterns thatbe at increased risk due to weakening of the immune may not effectively prevent food contamination by thesystem by other diseases or injuries, or exposure to anti- handlers (10 ). Ethnicity is often structurally linked tobiotic-resistant strains. Genetic predisposition (certain inequity within local national contexts.human antigenic determinants duplicated or mim-icked by microorganisms) or other underlying medical Genderconditions may predispose to more severe outcomes(1, 13). External pressures, such as prolonged stress, are Women during pregnancy may be at increased riskplausibly linked to immune responses and increased from certain foodborne pathogens, for example hep-vulnerability to infectious diseases (104–106). The pop- atitis E from contaminated water (114) and listeriosisulation of patients with AIDS is still alarmingly high. (115, 116). Beyond biological conditions, gender trans-An estimated 33.2 million people are living with HIV, lates into practices and behaviours that affect foodand 2.1 million people died of AIDS in 2007 (107). safety. Social norms and concepts of masculinity may be reflected in a tendency towards risk-taking behaviours by adult men, including with regard to food safety, asStructural social determinants reflected in greater consumption of raw food and fre- quency of risky food handling practices. Against this,Inequity aspects of food safety are embedded in the in the food cultures of industrialized countries, die-broad socioeconomic and political context of a given tary recommendations are moving towards increasedcountry, which involves governance and public adminis- consumption of foods that are markers of feminin-tration, macroeconomic policies (fiscal, monetary, trade, ity (for example yogurt, fresh fruit and vegetables) andlabour market), social policies (labour, social welfare, decreased consumption of foods that are markers ofhousing, land distribution), public policies (agriculture, masculinity (such as red meat) (117, 118).industry, education, medical care, water, environment),culture and other societal values. A number of struc- Traditionally, women have the primary responsibil-tural and mutually interconnected social determinants ity for daily household tasks and caring for the family.of relevance to food safety and particularly related to In this role, food handling and preparation for con-the analytical level of differential socioeconomic con- sumption is essential to household food safety, and ittext and position will be dealt with below. In some has been recognized that mothers are usually the finalcases these determinants also operate at the levels of line of defence against foodborne illnesses among theirvulnerability (demographic factors) or exposure (trade). children (119), and lack of access to safe water and sani- tation severely compromises this function (120). FemaleEthnicity heads of households constitute a particularly vul- nerable group, due to higher rates of poverty, lack ofThere are large variations in the effect of risky economic opportunities and social marginalization (87,behaviours according to ethnicity, but patterns vary 121). There is a positive relationship between female-depending on the factors considered (108–111). headed households, poverty, illiteracy and ill-health Food safety: equity and social determinants 101
  • 108. (diarrhoeal diseases) in poor urban and rural areas unsafe foods and practices in the country of destina-(122, 123). Women show greater sensitivity to chemical tion (133, 134).exposure due to differentials in absorption, metabolismand excretion of fat-soluble substances (124). Wom- The daily geographical migration (commute) ofen’s organizations have grown and matured and have workers within the same country or region does notbecome important players in the social debate sur- have a significant impact on food safety in developedrounding gender and equity. countries, due to the development and control of insti- tutional or commercial food service sites. However, inEducation low-income countries the infrastructure for appro- priate food services is often non-existent, and poorFemale literacy rate and education make significant workers take their food from informal street vendors,contributions to food availability and food safety. Gen- who are often characterized by inadequate hygieneeral educational achievement is not distributed equally practices and food a society. People living under disadvantaged cir-cumstances have less access to educational services and Tradeconsequently tend to have lower levels of educationalachievement. Education is a powerful social stratifier The international trade in food and feed may lead, at(125). Parental (particularly maternal) education and times, to the rapid transfer of microorganisms from oneeconomic status act synergistically as risk factors for country to another, and to the international diffusiondiarrhoeal diseases in children under 5 years of age. of unhealthy foods, raw or processed. Examples aboundHowever, the effect of maternal education appears to where outbreaks of foodborne diseases have been tracedbe more protective for children in wealthy families than to imported foods and include, for instance, an out-for children in poor families; paternal education is also break of Salmonella typhi infection in Aberdeen, Unitedprotective and operates independently of economic Kingdom, following importation of canned cornedstatus (126). A significant number of women do not beef from Argentina (135), and outbreaks of shigello-have easy access to education, and children of women sis in several northern European countries as a resultwho have never received an education are 50% more of the importation of iceberg lettuce contaminatedlikely to suffer malnutrition and to die before the age with Shigella sonnei from Spain (136). In a more recentof 5 (127). case, adulterated food and feed products exported from China included fish preserved with forbidden antibiot-Migration ics, mushrooms containing pesticides and wheat gluten for petfoods mixed with melamine (137). The incidentMigration of populations for economic or sociopoliti- led to worldwide calls for increased food safety regu-cal reasons may result in the emergence of diseases in a lations and international discipline. As these exampleslocal population, or the re-emergence of diseases pre- show, even the relatively affluent countries are exposedviously eliminated (1, 113, 128). Migrants often share to unsafe food through international trade. Finally,common disadvantages, such as poverty, social isolation international trade has a major (often negative) influ-and poor housing, which impair access to safe food and ence on food security in the developing countries thatsafe preparation of food. Refugee camps or reception is outside the scope of the present chapter.centres are examples of extreme situations where thesudden arrival of a great number of people, associated Urbanizationwith unsanitary conditions, have resulted in epidemicsof cholera and other infectious intestinal diseases (129, Increasing urbanization creates a major challenge for130). Irrespective of the kind of migration, migrants public health in the 21st century. In industrializedare generally in a relatively vulnerable position in their nations, urban life offers a number of benefits that havenew environments. a positive effect on food safety, including availabil- ity of potable drinking-water, hygienic waste disposalAn important and rapidly increasing form of migra- systems, general access to quality food, good publiction is tourism, whether for leisure, holidays, business, education and appropriate public health or pilgrimage, which has increased the potential In such settings, food safety is generally ensured.for diseases to be transmitted to locations far from thesource of infection within a very short time. Interna- In both developed and developing countries poor peo-tional travellers run a greater risk of being exposed to ple, living in disadvantaged urban areas, are excludedfoodborne illness (“travellers’ diarrhoea”), with causa- from many of the benefits of urban life. In crowdedtive agents including bacteria, viruses or protozoa (131). urban slums and informal settlements the lack of sani-Few travellers meticulously avoid potentially dangerous tation facilities creates conditions conducive to a highfood items (132), due often to lack of information on incidence of waterborne disease (138, 139). Half of the urban population in Africa, Asia and Latin America102 Equity, social determinants and public health programmes
  • 109. is suffering from at least one disease attributable to differences observed was found to be variation in thethe lack of safe water and inadequate sanitation, with hygiene level of food preparers.women and girls being more exposed (140). Withinthe fast-growing urban sprawls of developing coun- Povertytries, lack of basic hygiene, close association betweenhuman population groups and animals, consumption of Poverty is widespread: 2.5 billion people, 40% ofunpasteurized milk and dairy products, illegal slaugh- the world population, live on less than US$  2 a daytering and inappropriate waste disposal are factors (106). Poverty interacts with food safety through foodperpetuating infections in humans, with foodborne and insecurity and associated malnutrition (leading to vul-waterborne zoonoses (for example salmonellosis, hepa- nerability), faulty individual hygiene practices and lacktitis A) of increasing concern (141). of appropriate infrastructure for water, sanitation and environmental hygiene. Poverty can be viewed eitherIn East and South Asia, large-scale poultry and pig from an absolute perspective, where simple lack ofproduction units are often located in peri-urban envi- resources has serious consequences for the people inronments characterized by high-density, poor-quality question (for example lack of access to food and healthhousing, a low level of health and social services, and care); or from a relative perspective, which takes greaterlimited access to basic services such as water and sanita- account of income differences in the society. In thistion, a series of conditions conducive to the emergence chapter the former approach is adopted. Despite theand rapid spread of infectious diseases (76, 128). It has close link between poverty and inequity in relation tobeen argued that this factor might have contributed to food safety, no studies have shown any gradients.the emergence of the avian influenza epidemic in Asia. Poverty exists in developed countries and may beDemographic factors increasing. In France, in 2002, about 8% of the pop- ulation had income below the poverty level, or 50%Changing demographic characteristics of consumers of average income (146). While programmes are beingaffect the incidence of foodborne illness and reinforce implemented in various countries to mitigate thedifferences due to increased vulnerability to foodborne effects of food insecurity, disadvantaged people mayhazards. As the world’s population continues to grow, experience nutritional deficiencies (147, 148) and areconstant rates of disease will increase the total number more exposed to unsanitary food-related behaviours.of cases. In addition, the proportion of the population For example, drinking raw milk, an indicator of pov-that is at high risk of foodborne infections, illness and erty, was one of the main risk factors for tuberculosisdeath is rising (1).With people living longer, the elderly in the Russian Federation (149). A specific point is thatare an increasingly vulnerable group, and it is expected low-income people often buy cheap foods to copethat foodborne illness will affect this group more fre- with serious budgetary constraints.This raises the ques-quently and more severely, even in relatively well-off tion as to whether, in developed societies, low-pricecommunities. Elderly people living in long-term facil- foods bought by low-income people present a higherities are more vulnerable (142). food safety risk (146). In the European Union, regula- tions require that all products put on the market fulfilAbsorption, disposition and toxicity of food chemical the same safety characteristics, regardless of their price.contaminants are determined by factors such as age andsex that interact with other factors such as food com-position or dietary habits (8). Infants and children may 6.4 Discussion of entry-potentially be at greater risk from exposure to certain points for interventionenvironmental pollutants (for example pesticides ordioxins through breast milk or polluted water). Expo-sure of pregnant women to chemical contaminants (for In the previous section the intermediary and struc-example lead or methylmercury) may have negative tural social determinants of importance to equity andeffects on the health of the fetus. Young adults have a food safety have been outlined, in three subsections.number of risky food handling, preparation and con- First, the modes of food consumption, handling andsumption practices (1, 109, 143) and are more likely to production were described, supported with a range ofengage in poor hygiene practices (110, 144). Christensen examples from production to consumption, as well aset al. (145) designed a model to address individual trade. Second, the interaction between inequity andpractices during food preparation in private homes, food insecurity, malnutrition and certain medical con-establishing links with age and gender. The probability ditions that affect the immune response was dealt with.of ingesting a risky meal was highest for young males Finally, a large number of structural social determi-(aged 18–29 years) and lowest for the elderly (above nants were outlined, mostly linked with socioeconomic60 years of age). The main factor accounting for the context and position. This structure leads to three clus- ters of determinants related to differentials in terms of Food safety: equity and social determinants 103
  • 110. exposure, vulnerability, and socioeconomic context and food which is safe and suitable for consumption” (150).position, respectively. With regard to food safety, access From a public health perspective, interventions shouldis a key issue – namely, access to safe food. emphasize promotion of food safety, consumer protec- tion and foodborne disease prevention. AppropriateTo identify and classify the sets of policies and actions funding is essential.that may contribute to reducing inequities in foodsafety, three general entry-points for intervention have Contemporary trends have led to the development ofbeen identified, as outlined in the following paragraphs a conceptual model for long-term policy-making andand discussed further in section 6.5. food safety risk management (151) consisting of four phases:The first entry-point mainly comprises issues of dif- 1. identification of a food safety issue, gathering sci-ferential exposure to unsafe food and relates to the entific information and aggregating it into a riskrecommendation below regarding strengthening food profile;safety systems. Such systems are very complex and only 2. identification and evaluation of a variety of possiblea few aspects will be dealt with in detail (health com- options for managing the risk;munication, promotion of safe food handling and trade 3. implementation by relevant stakeholders of the pre-regulations).There is strong evidence from a number of ferred risk management options;industrialized countries regarding the effectiveness of 4. carrying out monitoring and reviewing safety systems. When dealing with a specific food safety issue, thisThe second entry-point involves food security, malnu- model can be entered at any phase and the cyclical pro-trition and comorbidity, which have been shown above cess (the “risk management cycle”) can be repeated asto be important causes of differential vulnerability and, many times as necessary (152).to a certain extent, exposure to food safety. Relevantrecommendations are suggested, though the available Recently a risk-based approach presented as “risk anal-evidence for this cluster of recommendations is scarce. ysis” has been introduced as a means of improving foodNevertheless, they are backed up by a number of stud- safety decision-making, encompassing three interactingies as well as by more theoretical considerations. activities (153): • quantitative risk assessment, the scientific processThe third entry-point refers mainly to differentials at that addresses the magnitude of the risk and identi-the level of socioeconomic context and position, where fies factors that control it;the analysis has shown that a number of structural • risk communication, a social and psychological pro-social determinants affect food safety via the levels of cess that promotes dialogue between the differentexposure and vulnerability, giving rise to a number of parties with an interest in managing the risk;appropriate recommendations. The evidence is strong • risk management, which combines science, politics,for the importance of these many structural social economics and other relevant social factors to arrivedeterminants with regard to food safety, though the at a decision regarding what to do about the risk.exact modalities are not well studied. One of the main implications of a risk analysis approach is that governments and regulatory agencies, the food6.5 Interventions: industry and other professionals, consumers and otherrecommendations parties involved should develop active partnership to improve food safety management.for addressing socialdeterminants of food safety Tugwell et al. (154) have introduced an “equity effec- tiveness loop” intended to systematically explore equity issues in relation to the various stages of public healthOngoing work to improve food safety involves a vari- management, which may prove a useful supplement toety of actions and players in interventions that integrate the risk management cycle.general environmental hygiene; provision of adequateinfrastructures and facilities; use of appropriate (andinnovative) material and technology; education, infor- Strengthening food safety systemsmation gathering and research; implementation ofgood hygiene practices and sanitation; and implemen- A national food safety system is the institutional set-uptation of food safety assurance schemes based on the whose primary purpose is to ensure the safety of theprinciples of the HACCP system. All these interven- food supply. It encompasses national policies and goalstions should be “flexibly and sensibly applied with a governing food safety; laws and regulations; organiza-proper regard for the overall objectives of producing tional and technical arrangements between involved104 Equity, social determinants and public health programmes
  • 111. BOX 6.1 Main elements of food safety systems  Development of food safety goals  Planning and implementation of food control and food inspection activities  Incorporation of the tenet of risk analysis  Development, updating and effective enforcement of food legislation, regulations and standards  Building and maintaining food safety from production to consumption  Implementation of good hygiene practices  Provision of adequate infrastructures and use of appropriate technologies in production, processing, manufacturing, retail sale, transportation, and preparation and handling of foods  Response and adaptation to new technologies and to changing consumer needs  Advocacy, information and education  Monitoring and surveillance  Science-based research and development  Appropriate capacity buildingpartners at all relevant levels; and the infrastructures oratories, surveillance infrastructure) is often weak orand technologies necessary for the proper function- of the food chain. Specific activities are outlinedin Box 6.1. National food safety systems operate within The following subsections describe three of the keythe global context of multinational arrangements (for elements of food safety systems – health communica-example the Agreement on the Application of Sanitary tion, regulation and control of food handling, and tradeand Phytosanitary Measures and Codex Alimentarius). regulation. The surveillance and research elements of food safety systems are considered in section 6.6.The food safety system should provide a framework forthe dynamic interaction of, and collaboration between, Health communicationa number of players, including government, producersand industry, consumers, academia, research organiza- Health communication is a key element in addressingtions and the media. Evidence gained in a number of the lack of knowledge on the part of food handlersdeveloped countries demonstrates that comprehensive, or consumers and negligence in safe food consump-well-planned, effective and appropriately funded food tion and handling. Education of consumers gives themsafety systems have the potential to contribute affirm- the knowledge to be selective when choosing theiratively to the availability of, and access to, safe food, food and to refuse food that is of doubtful hygienicthereby addressing inequities related to differential quality, encouraging good manufacturing and hygieneexposure, in addition to securing outcomes indirectly practices and playing a role in improving food safetyrelated to food safety, such as environmental quality, standards. Empowerment with regard to securing foodeconomic opportunity and sustainable development. safety is an important outcome of education.Modern food safety systems are sophisticated con- Education was effective in reducing listeriosis in indus-structs that require application of significant resources, trialized countries following the education of pregnantwhich are generally out of reach of low-income coun- women, and in reducing the incidence of foodbornetries, and the development of such systems may not diseases in some Latin American countries followingbe of immediate priority compared to other concerns a series of cholera epidemics (10 ). Monte et al. (51 )(155).The lack of financial resources limits the ability of observed that all mothers of underprivileged childreninstitutions in low-income countries to carry out their invited to adopt defined behaviours through an infor-control, enforcement and education tasks efficiently, mation campaign initiated the advocated behavioursand the necessary infrastructure (logistical support, lab- and most of them (53–80%) sustained those improved behaviours. Official campaigns of education can have Food safety: equity and social determinants 105
  • 112. a positive impact on food preparation and safety prac- hazards, particularly in developing countries, includ-tices, in particular if social marketing takes advantage ing through controlling zoonotic agents in animal andof multiple culturally-relevant channels (156, 157). poultry reservoirs; improving the viability of infor-Education of food handlers and managers has led to mal food vending; promoting food safety assurance andimprovement of sanitary conditions in food service management in small and less developed businesses; andestablishments (158). Certain factors may inhibit uptake ensuring that differences in standards between domesticof lessons: whereas formal training-related activities in and international markets should not result in inequi-south Wales were generally found in large food busi- ties in local access to safe food.nesses, small businesses reported that time and financialfactors constrained continual and systematic train- Trade regulationsing (159). Basic hygiene knowledge had an effect onhygiene practices, reducing incidence of food-associ- National food safety systems evolve in the context ofated illnesses (160). multinational agreements on food standards, including the Agreement on the Application of Sanitary and Phy-Education is effective only when conditions permit tosanitary Measures of the World Trade Organizationimplementation of the recommendations and advice. and the standards, guidelines and recommendationsEducation and economic status operate synergistically: elaborated by the Codex Alimentarius Commissionpoverty alleviation efforts occurring in concert with and its subsidiary bodies. The resulting policies andeducation programmes to educate women and girls standards are indispensable elements of the infrastruc-have proven to be more effective for improving chil- ture for ensuring the safety of internationally tradeddren’s health than either approach alone (126). Food food. As far as possible they should also apply to foodsafety education cannot replace essential infrastruc- for local consumption, thus making it easier for coun-ture and services. It is also important to remember that tries to meet standards for export and thus keep theirfood safety education is not only a matter of knowl- share of global food markets.edge transfer, but also involves fostering activities aimedat developing willingness to adopt an hygienic attitude. However, there is often a perceived excess of formalism in the food safety management guidance issued throughRegulation and control of food handling international agreements (such as the Codex Alimen- tarius), which may create or widen disparities betweenEffective control needs to be supported by appropriate nations in relation to securing a safe food supply. Ininspection services responsible for the enforcement of low-income countries, high compliance costs may befood safety legislation and for the inspection of premises, prohibitive for small producers, working against ruralprocesses and foods to prevent unsafe food entering development objectives (94 ). Most importantly, newlythe food chain at any level. As modern food safety sys- improved food systems may focus on profit and export,tems have evolved towards a preventive approach, food and may fail to address the social determinants of foodauthorities should ensure that food business operators safety at national or local level, resulting in a wideningdevelop and implement food safety assurance schemes gap between export-driven and domestically-orientedbased on the principles of the HACCP methodology production and levels of food safety, with the risk ofto the extent that capacity, experience and resources prompting further migration of the rural poor to dis-permit. Effective control and management also relies advantaged and already crowded urban areas (161, 162).upon analytical capabilities and the linkage between Benefit would be gained from identifying the appro-laboratories and the public system, so that information priate level of protection that should be guaranteed,on foodborne diseases can be linked with food moni- and establishing performance objectives and food safetytoring and lead to appropriate risk-based food control objectives that offer a means to convert public healthoptions. goals into targets that can be used by regulatory agen- cies and food manufacturers (163).In a “farm-to-fork” approach to food safety, goodagricultural practices contribute to provision of rawmaterials and ingredients with improved microbio- Addressing food safety in relationlogical safety, and good manufacturing and hygiene to food security, malnutrition andpractices set basic standards for hazard control and facil-ity sanitation. Recent initiatives to develop risk-based comorbidityapproaches offer the opportunity for science-based, As described in section 6.3, the risk of harm causedthough flexible, control, and there is potential for fur- by unsafe food may be heightened by differential vul-ther development and implementation of food safety nerability due either to food insecurity leading tostrategies along these lines. Additional efforts should malnutrition, or to certain medical conditions thatfocus on addressing weak links that are important compromise the immune system. This issue requiresdeterminants of inequities in exposure to foodborne serious consideration when providing health services,106 Equity, social determinants and public health programmes
  • 113. including through community-based nutrition inter- Monitoring the impactventions aiming at alleviating food insecurity andmalnutrition, and through clinical assistance to patients Addressing food safety inequities involves evaluatingwith ailments compromising their immune system. the effectiveness of interventions in reducing inequali-Training of health staff should address this issue.Though ties in food safety. The two main aspects to this processthe inequity aspects in this cluster of recommendations are an evaluation of the potential impact of food safetyare not well documented they cannot be neglected. policies and interventions on equity issues; and the use of evidence from epidemiology and research to add, where appropriate, an equity dimension to plannedAddressing the root causes of food safety programmes and interventions. Potentialinequity in relation to food safety efficacy could be assessed with regard to both technical gains in reducing exposure to foodborne hazards andThe roots of inequities in health are the complex inter- other factors, such as availability of resources, acces-actions between socioeconomic, environmental and sibility to vulnerable populations, acceptability andpersonal factors (164, 165). In this context, and notwith- adherence of consumers and compliance of providersstanding general policies aimed at promoting social (154, 166).justice and reducing overall poverty and social exclu-sion, empowerment of people and their progressive Subsequently, monitoring assesses success in mitigatingrealization of the right to safe food involves introduc- inequities related to food safety. The progress towardsing specific consideration of food safety issues into mitigating inequity in food safety should be meas-the more general measures intended to improve food ured against the overall long-term goals and There is also a need to collect data on a range of indi- cators that could provide a measure of progress made inMost of the structural and social determinants out- the short and medium term, including foodborne dis-lined above are directly linked to inequities in social ease morbidity and mortality, with particular attentioncontext and position and operate through enhancing to monitoring the evolution of the foodborne diseasedifferentials in vulnerability or exposure to unsafe food. burden in the targeted groups.These aspects are a directTrade is ideally addressed as part of a well functioning reflection of the fourth phase of the risk managementfood safety system. Other determinants, such as urban- cycle described in section 6.5.ization and migration, primarily call for concertedefforts of intersectoral planning based on political will Methodologies and protocols for conducting foodborneand allocation of sufficient funds. Determinants such as disease burden studies should combine syndromic andethnicity and gender have elements of marginalization etiologic agent-specific approaches to estimate the bur-based on attitudes and cultural factors and may require den of foodborne diseases (5) and should include another appropriate measures. Poverty stands out as a fun- attribution of the proportion of disability-adjusted lifedamental root cause related to unsafe food and a large years (DALYs)1 that is likely to be foodborne. Core datanumber of other public health conditions. Common to requirements at country level include magnitude, dis-all these social determinants is the basic need for deci- tribution and health impact data; possible exposure andsion-makers at all levels to address the issues based on sources of pathogens and chemicals; monitoring asso-allocation of adequate funds according to local priori- ciated diseases as indicators; and data on the presenceties and contexts. of etiologic agents and disease in domestic animals or wildlife consumed as food (5, 167). Data should be sys- tematically linked to comprehensive demographic data,6.6 Implications allowing an accurate mapping of populations. Data may be available from a variety of sources,Measurements, evaluation and data including national surveillance systems on the inci-requirements dence of foodborne diseases, epidemiological surveys to investigate sporadic cases and outbreaks of disease,The main areas for data collection relevant to measur- governmental monitoring activities of foods and watering food safety inequities include determination of the for regulatory purposes or routine testing, industry,burden of foodborne diseases and exploring exposure and published literature and research results (168–170).and consumption patterns. These should be specifically In developing countries epidemiological data may belinked to detailed demographic data. insufficient, specifically with regard to disadvantaged 1 DALYs reflect a combination of the number of years lost from early deaths and fractional years lost when a person is disabled by illness or injury. Food safety: equity and social determinants 107
  • 114. groups, requiring application of improved data collec- segments of the food supply. Further data are requiredtion techniques, as discussed in the second FAO/WHO on syndromically-defined diarrhoeal diseases. SuchGlobal Forum of Food Safety Regulators (163). Food- data can be gathered systematically in selected areas orborne disease surveillance and monitoring can allow for defined community groups, and can include infor-early detection of hazards and illnesses, build capacity mation about the severity of the disease, its impactto respond to outbreaks of foodborne illnesses, enable on work loss, medical visits, cost of treatment, hospi-identification of weaknesses in the food safety system tal admission and mortality. Environmental surveys addand provide essential data for assessing food safety risks further dimension to any analysis.from primary production to consumption (24 ).Knowledge gaps Managerial implications and challengesAlthough there is now a wealth of information avail-able, it is generally recognized that lack of scientific Side-effectsdata is a very substantial factor limiting enhancementof food safety, and that active collection of appropriate Improving food safety with a specific focus on reduc-data throughout the food production and process- ing differentials in access to safe food has the potentialing system is vital (1 ). The limitations of current food to generate side-effects. On the positive side, effortssafety data and key data needs have been extensively to improve food safety will support, and benefit from,discussed (1, 168–173), and it is clear that the food safety efforts to improve food security and fight malnutrition.information database needs to be expanded to provide They also have the potential to benefit from inter-more complete and in-depth information on food- ventions in fields that are indirectly linked with foodborne hazards and their sources and on the incidence safety, such as environment or urbanization. Improve-of foodborne illness by pathogen, by food, by contrib- ment in the safety of locally-produced foods mayuting factor and, most importantly for equity issues, generate increased revenue for poor rural producersby socioeconomic group. There is also a need for fur- and informal sector vendors and be an effective wayther scientific evidence on chemical hazards and on the out of poverty. On a global scale, improvement in foodcomplex links between food safety and food insecurity, safety to meet international requirements would bene-malnutrition and comorbidity. fit national economies.An effective food safety system needs to support both On the negative side, increased prices of food pre-long-term research and short-term research in response sented on local markets may add further constraints toto emerging problems, requiring some shifting of the budgets of poor consumers and maintain or evenresources and emphasis. Research priorities should be widen inequities in access to safe food if not paralleledestablished in partnership with stakeholders, including by efforts to improve the socioeconomic status of dis-private industry, academia and consumers. The research advantaged groups or individuals. The benefits of thebudget, especially for long-term projects, should be development of the agro-food business may not beprotected: perhaps more than for other fields, the com- shared by all. Unless governments also enhance theplex problems of ensuring a safe food supply require livelihoods of rural and urban communities that mighttime and the significant application of effort, patience be disadvantaged, small-scale operators may not be ableand resources to create a cross-disciplinary force of to compete with larger businesses.dedicated scientific investigators from the biomedical,social and economic disciplines (24 ). Points of resistanceIn order to better identify and assess inequities in There might be some resistance to the introductionfood safety across vulnerable groups, information is of food safety systems. People in very poor personalalso required on factors underlying food safety-related situations may have other priorities, and may lack thebehaviours and preparation practices in those groups. resources and information that could facilitate theirThis involves collection of data on environmen- access to safe food. Also, where national resources aretal conditions (housing, water supply, sanitation), food scant, public authorities may recognize other priorities,preparation and storage facilities, consumption patterns, shifting resources toward other issues. This is particu-and on knowledge, attitudes, skills, practices and per- larly relevant when food safety policies compete withceptions with regard to food safety, foodborne hazards food security considerations and reduce access to aand control measures. It is also necessary to gather data secure food supply (for example by increasing prices).on the structure of the food safety system within which In this regard, it has been argued that access to a whollyaction takes place, its resources and the extent to which safe and nutritious food supply is a basic right thatit encourages safe habits, safe food handling and ade- should not be compromised in order to achieve costquate food and hygiene control in all stages and in all savings (174). Another approach would be to select108 Equity, social determinants and public health programmes
  • 115. policies that favour increases in the safety of food urbanization, demographic factors and poverty) havewhenever the benefits of doing so outweigh costs aris- been outlined. This led to the identification of threeing from the decrease in the security of access (175, 176). entry-points for recommended interventions. First,The introduction of food safety systems will necessarily adequate food safety systems should be established orinfringe on economic interests and will consequently strengthened in all countries. Second, there is a needentail resistance. to focus not only on the health care system but on the negative impacts on food safety of food insecurity andImplications for management malnutrition. Third, all relevant stakeholders need to join hands in order to address the root causes, namelyIn a globalized world, international actors can have a the structural social determinants such as poverty, thatsignificant influence on the development of national keep people in marginalized and disenfranchised posi-initiatives regarding food safety and on inequities in tions, thereby perpetuating lack of food safety as aaccess to safe food. International organizations are in global health problem.the best position to provide technical analyses andassistance to orientate and support national or regional In developed countries, a high level of protectionactions tackling food safety inequities. WHO, in par- regarding food safety, within an overall context ofticular, should ensure that it has sufficient capacity and consumer protection, has been obtained and shouldexpertise to provide Member States with technical be maintained. Certainly food safety has a cost, butguidance and support on how they can improve food food safety is not negotiable, and levelling down foodsafety while effectively addressing potential inequities. safety is not an option. In developing countries, and further to the most proximal actions to improve house-Lack of financial, technical and human resources is a hold hygiene, improvements in food safety can onlypowerful barrier to improving food safety in its differ- go hand-in-hand with wider socioeconomic develop-ent aspects, particular in low-income countries. Lack ments. If inequities are to be reduced, these countriesof consensus on priority-setting is another barrier, due have to face in the transition stage the daunting chal-to rivalry (institutional or professional), competition, lenge of balancing the quality of food, the price ofinstitutional separation and poor linkages (for example food, and foodborne risks.between the ministry of health and other ministries).Such sources of resistance can be overcome by specificefforts to promote collaboration, integration, network- Referencesing and partnership. 1. Emerging microbiological food safety issues: implications forIn many countries, organizational difficulties may arise control in the 21st century. Chicago, Illinois, Institute of Food Technologists, 2002 (,as food control activities are implemented through accessed 20 March 2009).different agencies or under different governmentdepartments, a situation that needs to be overcome by 2. Zoonosis in the European Union. 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