Talk at Canadian Mental Health Summit


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Dr Lynne Friedli sets out the case for a different approach to improving mental health - one rooted in an understanding of social justice.

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  • Mental health – it’s the scaffolding in our lives, our children’s lives, in the lives of our communitiesSo, I’m going to talk about:the profound importance of mental health to life chances and life outcomes - across many different domainswhat we know about key influences – the social determinants of mental health and wellbeing – for individuals, families, communities and society   some priorities for effective (and cost effective) action to improve population mental health and wellbeingAnd I’m going to suggest that we can do a great deal more than we think to protect and enhance mental healthDef of sd – something we can do something about
  • Which means that this agenda is also informed by – and relevant to – people with lived experience:Psychiatric survivor movement, the voices of consumers, the recovery movementThe wider struggles for the rights of people with disabilities – UN conventionPrinciples of Dignity in entitlement, equality of worth and value, everyone having something to contributePrinciples that respect people’s strengths, potential, capacity – particularly the strengths of those whose value is overlooked or denied ...Manitoba’s Rising to the challenge
  • So, mental wellbeing – how we feel about and experience our lives – individually and collectivelyA recognition that:how people feel matters...mental wellbeing is more than absence of mental illness, learning from survivor movement and recovery about what supports wellbeing, even when mental illness persistsat root, mental wellbeing is a hearts and minds response to our lives
  • Before moving on, take a moment to reflect on what we all need for our own wellbeingInsights from neuroscience and also work of Sen and others on capabilities – attempt to identify what people need from others in order to function wellWe all need – heard, believed, understood, respected – but profound inequalities in whose story is heard, whose truth believed, in who feels understoodThe greatest (and most painful) inequality may be inequality in the distribution of respect – how this is linked to material inequalities – and the impact of both – materialinequalities and inequalities in respect - on mental wellbeing
  • I want to look now at why mental health matters how understanding mhdeepens our understanding of the social determinants of healthAlso good reasons why mental health is sometimes referred to as mental capital...Mental health is a precious resource – something we passionately want for our children
  • So let’s explore a few key reasons why its worth paying attention to mental health in more depth:There’s a broad understanding of link between mental illness and poorer outcomes = but absence of wellbeing – ‘ill-being’ – also influences outcomes – whether or not we have a mental illnessMental Wellbeing helps to account for the unexplained excess – what does that mean? Whether we look at crime, education, health, issues like alcohol, drugs – classical risk factors – behaviour or material factors – poverty, housing - don’t account fully for the level of variation – Those four dimensions – think, feel, relate, meaning – give a richer picture of what influences outcomesAs I’ll show, improving mental health makes good economic sense, as well as social valueAnd understanding mental health fundamental to reducing health and other inequalities
  • Worthwhile in itself – most people value a sense of emotional and social wellbeingAlso a key pathway through which life events/life circumstances – social determinants - impact on outcomesAs we raise levels of wellbeing, we reduce prevalence of mental illnessRisk of physical health problems and improve recoveryEmotional wellbeing fundamental to our children’s capacity to learn, influencing educational outcomes right through school years and beyondStrong links between poor mental health and risk of crime, violence, anti social behaviourImproves Quality of lifeAll these outcomes have very considerable economic consequences
  • So how come mental health influences so many outcomes3 things:Because of the Social nature of human beings – Impact of mind on bodyContribution of mental health to inequalities
  • at 10 minutes old, the human baby is mimicking mum’s expression – making a valiant attempt to gain recognition and to secure care – on which her survival depends and will depend, throughout life. That baby knows what we often seem to forget- We depend on each other, which is why the social matters so muchWe see from this very powerful meta analysis based on around 145 studies the importance of social support/social integration on mortality riskThe size of this effect (someone to turn to, sense of belonging) is comparable with quitting smoking and it exceeds many well-known risk factors for mortality (e.g., obesity, physical inactivity, alcohol)Community-belonging is strongly related to higher self rated health, mental heath and health-behaviour change in Canada and may be an important component of population health preventionThese studies raise crucial questions about factors that support or undermine Community belonging
  • Grandma was right - It’s all in the mind, but it’s written on the bodyRobust evidence of impact of common mental health problems – depression/anxiety – on risk of and mortality from cvd, cancer, respiratory disease, metabolic disease – 2-3 fold increase – link between schizophrenia and reduced life expectancy (in order of 20 years)Beyond diagnosis– relationship between poor wellbeing and somatised pain, medically unexplained symptoms – influencing how people use services - frequent attendance/A&E, crisis care etc.Psychic pain is transformed into bodily complaints - body contains and expresses psychic painWe know this – but is it reflected in how we design and deliver public health and social care?Enormous economic and human value of addressing these issues
  • We know about the profound effects of stress – stress ‘gets under the skin’ – influencing hormones, health of our hearts, immunityBut what are the primary sources of stress?International comparative studies suggest that status – we’re back to that issue of respect – control - influence over the things that affect our lives/ - and relatedness - affiliation, sense of belonging - are universal determinants of wellbeingWe need to pay much greater attention to the factors that injure these needs and to the impact of injuries to these needs – lack of status, lack of control, lack of affiliation – primary causes of stress - undermining what Sen has called ‘freedom to live a valued life’.Lack of respect, lack of control, alienation/isolation – these are not generally seen as public health priorities – but there’s growing evidence of how these non material dimensions of deprivation influence disease
  • What we also see is that once people are ill, levels of wellbeing influence how people experience and recover from illness – Improving mental health can make a significant difference for the increasing numbers of people living with – and trying best to manage – a long term condition. And of course, managing chronic disease and its consequences is set to place significant additional pressures on health, social care, welfareImproving mental health – resilience in the face of adversity
  • For all these reasons, as you might expect, mental health makes a significant contribution to inequalitiesPicture you’ll recognise – levels of inequalities, here by life expectancy – gap by healthy life expectancy likely to be very much widerBurntwood/Churchill – 71.3 (68 for men, 74 for women)Brandon, South eastern – both average over 80 (78 men, 82 women)LE for racialised groups is 8-10 years less than the averageThere’s an overall difference of around 10 years between LE and HLE (78.3m, 83w vs 68.3m and 70.9s)
  • That’s a map of health inequalities, but whichever domain of inequality we look at – education, employment, recovery - mental heath has a significant influenceEmotional wellbeing of children and readiness for schoolheath behaviour – we’re finally starting to see that diet, exercise, sensible drinking etc are outcomes not causesRelationship to services – whether we feel valued, respected etcPoor mental health often reinforces inequalities, because those who are most disadvantaged are most likely to experience both mental illness and poorer mental wellbeing. So, mental health is a consequence and a cause of inequalities and a crucial factor in understanding the limitations of focusing on ‘health behaviour’
  • What I’ve argued is that Mh needs to sit at the heart of our thinking about social determinantsThat mh reminds us of the Social nature of human beings – importance of designing population health around thatMental wellbeing is dynamicIt’s produced socially, mutually, reciprocally As we’ll see - It’s deeply affected by all those factors that impact on the social – relative income, wealth, housing, the environmentIt’s a particularly precious asset in times of change, adversity, insecurity‘you knew that’... But do we act or make policy like we know ... Or hold politicians to account like we know..And of course it’s only half the picture – if mh is so important ....
  • What protects and what is toxic to mhstatus, control, sense of belonging, respect, relatedness (to each other and other species), meaning and purpose, feeling valued – of course these things don’t drop from the sky, but are embedded in wider issues of power, privilege and political voice – What influences mental health?
  • Mental health is an intermediary determinants – it’s back to the cause of the causesThe social determinants: Distribution of power, privilege and resourcesOur children see it, systematic reviews demonstrate it:how social position influences our exposure to health risks and health assets – disadvantage and advantage – iDeeper understanding of mental health helps us to understand the nuances of all this – how it intersects with gender, ethnicity, disability, age - the relationship between the material and self respect, holding your head up, ‘what Sen has called ‘the ability to go about without shame’ And how all this Impacts on intimate relationships, care of children and care of the self...
  • This also involves understanding the wider structural factors that influence individual mental illness journeys – individual and collective experiences of pain, anger, demoralisation, despairAt this stage, I guess some people in the audience are getting restive – you knew all this – many of you may feel you can’t do anything about most of itI was recently at a public meeting in the North of England where a regional DPH was being challenged about health inequalities. And she said ‘ I can’t do anything about poverty, unemployment – the social determinants. And a community rep said ‘ we know that. We understand that. But what you could do is show you know what we’re up against.That story is about the importance of Respectful optimism – recognising the power of human spirit but also acknowledging what people are up againstIt’s about the Importance of connecting with collective traditions of making meaning out of adversity – anti poverty movements, civil rights, trades unions, feminism, gay liberation, mad pride, disability rightsHow we explain inequalities is a mental health issue.... Fix the individual? Or fix society?
  • If mental health is about relationships - our relationship to each other – questions of power are unavoidable We need to work towardsPower with – solidarityPower to – agencyPower within – confidenceAnd away from Power over Issues of accountability and vested interests
  • A further important element is how all this links to some very important current debates about the pressures of consumerism, materialism – what impact this has on mental health – especially of childrenRange of recent studies suggest that children are very aware of and influenced by these pressures
  • See here the scale of the increase since the late seventiesManitoba The gap in average householdincome has more than doubled in just 20 years for bothrural and urban communities. In 1986, the wealthiest rural households in Manitoba earned an average of $21,790 more than the poorest households. Twenty years later, the difference was $47,005. The gap was even bigger in Winnipeg and Brandon, with a difference of almost $80,000 in 2006. On average, the wealthiest urban households earned $114,300, while the poorest households made do on $34,400. This growing gap in income was accompanied in many cases by profound and growing health gaps.
  • And here the relatively limited levels of redistribution‘stickiness’ of position. For example, about half of the children who were in the bottom quintile of the group’s income distribution in 1994 were again observed in the bottom quintile in 2004; only 4 percent of these children had moved up to the top in a lone-parent family, having a parent without paid work, living in one of the Atlantic provinces, or having a parent who is non-white. Atlantic provinces, Quebec, Manitoba/Saskatchewan or BC are more likely than children from Ontario to have ‘ever’ had family equivalent income in the bottom quintile, with the size of the association largest for children living in the Atlantic region.
  • What can we do?Huge amount of effective practice across Canada – featured over next two daysFinal section:Direction of travel/key principlesStimulate some discussion on what we can stop doing…
  • Some key themes in the cost effectiveness literature that strongly support greater investment in population mental health:Use of economic modelling means that we can factor in the very wide range of outcomes influenced by mental health - physical health, employment, crime, suicide etc. – using a longer timescale – across the life course – to demonstrate the extent of savings accruedThe majority of serious mental health problems begin early in life and, unlike cancers and most heart disease, they cause disability when those affected would normally be at their most productive. early manifestation of poor mental health and its persistence over the lifetime are untypical of poor health generally and constitute a major reason why the overall cost of poor mental health is so large. Commissioning for social value – sometimes called SROI – means asking how each intervention $ also protects or enhances the social – supports family life, creates local jobs, empowers communities, strengthens control, uses local resources or skills, builds connectionsDeclustering disadvantage is based on growing recognition that positive and negative outcomes cluster – Take debt advice– cost effectiveness is due to ‘problem clustering’– that debt influences individual health, family health, school attendance in children, sickness absence, frequent attendance in primary care and damages the local economyaddressing outcome clusters involves whole community or total place approaches – and recognising that some disadvantage is particularly ‘Corrosive’ - poor education and racial discrimination for example.Mental health is an important factor in explaining the clustering of disadvantage and the urgent need for public health to move away from single issue, single outcome interventions. Not least because of substitution – if we fail to address the underlying issues, even if everyone stops smoking, stops drinking – tobacco, alcohol, will be replaced by something else and health inequalities will remain.
  • “targeting individuals case by case, in the absence of change at the community level has not worked, could not work. Targeting specific outcomes in isolation from the rest of a community’s life and circumstances has not worked, and could not work. The evidence points to targeted, integrated and holistic support and intervention at a community level” (Colin Mair)Strengths based approaches – should contribute to struggle for social justice, not distract from it... Psycho social assets are not an alternative to a fairer distribution of material assets
  • Range of work on best buys in improving mental health – your own Institute of Health Economics in AlbertaBut I want to start with the work of Shelley Phipps and her observation:It’s notable just how many of the poorer outcomes she found in canada related to mental health Low birthweight, asthma, accidents, anxiety, activity limitations, trouble concentrating, disobedience at school, bullying, lying, hyperactivityBest buys across a population would include: and there are no surprises hereSupporting family life – work-life balance, quality of childcare, pre-school education, but also, crucially, the home learning environment – building the capacity and confidence of parents and communities as educators of their children – need to be careful that contact with professionals doesn’t undermine parents – stronger focus on factors that inhibit positive parentingSupporting life long learning - Adult education and basic skills - increase education of women from no qualifications to basic qualifications significantly reduces depression Improving quality of work – more important than ever for mental health to be on the agenda in the workplace – cost effectiveness case for quite simple awareness raising, as well as access to support, rehab, and a focus on keeping people in workGrowing evidence on effectiveness of environmental improvements, green space/blue space, stop and chat, walkability, reducing low level, street level incivilities
  • the pull of ‘life style drift’ is so very strong – and is often supported by the wellbeing agendaBut the overwhelming theme to emerge in the research literature is the importance of the social, the collective, the material and that this is where the balance of our efforts should lieFire fighting: responding to immediate need/distressIndividual skills and resilienceParents, family, social relationships /networks Material circumstances (income, wealth, housing, debt, benefits, credit)Social justice (reducing inequalities in the distribution of valued resources – including employment)Environmental justice (green/blue/play space, noise, pollution, street level incivilities)–
  • These themes have led to calls for a return to the social – Which raises questions about what protects the social – the role of Equity and Social Justice – but also the nature of the relationship between professionals and disadvantaged communities
  • I’ve argued that mental health is an important pathwayThat a deeper understanding of mental health deepens our understanding of how social position influences the chance of a life well lived – the mental heath impact of our experiences of employment, housing, income, education, discrimination – is both immediate and far reachingI’ve argued for the universal importance of the need – of each individual, family and community – for respect, control, affiliation . These needs are of course consistent with equality of human dignity and the wider human rights agenda.Recognition of these mental health needs can and should shape policy, planning and the design and delivery of interventions and I hope very much can contribute to the nature of our conversations over the next two days.So, I began by suggesting we can do more to promote mental health than we imagine:Share your income: what does that mean? Wouldn’t most of us here do a better job if we drew on the expertise of people living on low incomes – so – work in partnership and share your pay accordingly Develop an inequalities imagination – use it, along with the evidence from epidemiology, epigenetics and neuroscience Listen – hear, believe, understand ,respect
  • Talk at Canadian Mental Health Summit

    1. 1. The (equal) chance of a life well lived: acting on the social determinants of mental health and wellbeing Dr Lynne Friedli Mental Health Summit 2012 Winnipeg, Manitoba 15th/16th February 2012
    2. 2. Summary Why mental health matters What influences mental health Effective (& cost effective) actionPhoto credit: JacquelineYoung of a life well livedThe chance Reasons to be cheerful.......
    3. 3. Something to hold on to …. I did not hear the bird sounds They had left. I did not see the speechless clouds. I saw only the little white dish of my faith, breaking in the crater. I kept saying: I’ve got to have something to hold on to. Picture source: Sleeping with spirit #2 Bradley Guiboche courtesy www.artbeatstudio.caThe chance of a life well lived Anne Sexton
    4. 4. ‘too often the price of receiving support is exclusion from the life ofcitizenship’ Simon Duffy The chance of a life well lived
    5. 5. (Mental)...Wellbeing...... A subjective evaluation of how we feel about and experience our lives It’s a hearts and minds thing....The chance of a life well lived
    6. 6. Dimensions of mental wellbeing If I am not for myself, who will be for me? And if I am only for myself, what am I? If not now, when? Primo Levi How we feel... How we think ... coping style, mood, learning, knowledge, emotions, flexibility, innovation, subjective wellbeing Mental creativity wellbeing Meaning and purpose .... sense Relationships with of coherence, others… listening, values, goals, communicating, co spirituality, politics, operating, empathy, beliefs toleranceThe chance of a life well lived
    7. 7. What we all need.... To be: • Heard • Believed • Understood • Respected Picture Source: Warm Shore by Tedd Tribe www.artbeatstudio.caThe chance of a life well lived
    8. 8. Why mental health matters He worked hard for respect, but he could not find it. There was in the world a great shortage of respect and Chanu was among the famished Monica Ali Brick LaneThe chance of a life well lived
    9. 9. Because it’s worth it.... While there are multiple barriers to economic growth, the growth of human potential is unlimited Coote and •Contribution mental health and mental illness make to Franklin 2010 wide range of outcomes •The ‘unexplained excess’ – classical risk factors do not account for level of variation in outcomes •Improving mental wellbeing saves (a lot of) money •Improving mwb delivers social (as well as economic) returns •Improving mental health reduces inequalitiesThe chance of a life well lived
    10. 10. Mental wellbeing is a key pathway A worthwhile goal in itself and leads to better outcomes: • prevalence of mental illness • health behaviour • physical health/recovery/chronic disease management • capacity to learn/educational attainment • employability, productivity, earnings • crime / violence reduction • pro-social behaviour/social integration/relationships • quality of lifeThe chance of a life well lived
    11. 11. How does mental health influence so many outcomes? Some living conditions deliver to people a life that is worthy of the human dignity that they possess, and others do not. Dignity can be like a cheque that has come back marked ‘insufficient funds’. Martha Nussbaum Picture source: The open road by Loral Hildebrand courtesy of www.artbeatstudio.caThe chance of a life well lived
    12. 12. Meta analysis: comparative oddsof decreased mortality The relative value of social support/ social integration The chance of a life well lived Source: Holt-Lundstad et al 2010
    13. 13. Written on the body... • protection from heart disease Somatised pain • stroke incidence and survival • Reduces/mitigates harmful health behaviours • overall lifetime mortality rates and life expectancy • management of chronic disease Medically Frequent unexplained attendance symptomsThe chance of a life well lived
    14. 14. Psycho-biological pathways Status Control Relatedness Chronic low level stress ‘gets under the skin’ through the neuro-endocrine, cardiovascular and immune systems, influencing : Freedom to • hormone release e.g. cortisol live a valued • cholesterol levels life Amartya Sen • blood pressure • inflammation e.g. C-reactive proteins Sources: Steptoe 2005; Friedli 2009The chance of a life well lived
    15. 15. Recover from, and manage illness soonerOdds of reporting illness as "limiting“ compare with most well Adults reporting chronic muscular-skeletal illness (first) in HSE 2006 (odds of reporting illness as "limiting" - adjusted for age and self assessed pain) 3.5 3 Influencing costs for: employers, 2.5 health & social care, independent living 2 1.5 1 0.5 0 best second third fourth worst quintiles of wellness Source: Tom Hennell The nature of wellbeing and its relationship to inequalities 2010
    16. 16. Inequalities: life expectancy by health regionThe chance of a life well lived
    17. 17. Contribution of mental health to inequalitiesKey domains: education/employment/health behaviour /health/ consequences of illness /services (Whitehead & Dahlgren 2006) Mental health is a significant intermediary determinantin each case, influencing: • readiness for school/learning • employability • capacity, motivation and rationale for healthy behaviours • risk for physical health (e.g. coronary heart disease), • chronic disease outcomes (e.g. diabetes) • relationship to health services, including uptake/treatmentThe chance of a life well lived
    18. 18. What we’ve learnt.... Mental health, and the factors that influence mental health, have never been more important Menta lS Social Determinants Healt hThe chance of a life well lived
    19. 19. What influences mental health? Tend to the social and the individual will flourish Jonathon Rutherford All societies cater for the disabilities of the average person Martha NussbaumThe chance of a life well lived
    20. 20. Commission on the Social Determinants of Health Closing the health gap in a generation - three key domains for action/empowerment: • material requisites • psycho-social (control over lives) • political voice (participation in decision making)• Best start, education & skills, quality work,The income, healthy places, prevention chance of a life well lived
    21. 21. Mental health and deprivation Not ‘every family in the land’ Findings from 9 large scale population based studies: • Material and relative deprivation • Childhood socio-economic position • Low educational attainment • Unemployment • Environment: poor housing, poor resources, violence • Adverse life events • Poor support networks (Melzer et al 2004; Rogers & Pilgrim 2003; Stansfeld et al 2008; APMS 2007) Cycle of invisible barriers:The chance of a life well lived • Poverty of hope, self-worth, aspirations
    22. 22. Explaining the social gradient: mental illness journeys... Most of the experiences that cause mental distress are directly linked to a lack of money....... powerlessness linked to poverty Peter Campbell Beyond the Water Tower • Adverse childhood experiences/stressful life 2005 events • Racism and other forms of discrimination • Contact with criminal justice system • Socio economic status – parental income, tenure, education, occupationThe • Institutional care in childhood chance of a life well lived
    23. 23. Big fish/little fish: questions of power are unavoidable Source: chance of a life well lived
    24. 24. I own, therefore I am.... Source: Banksie – grafitti, London, EnglandThe chance of a life well lived
    25. 25. Money Economy, Core EconomyWell-being depends on certain freedoms being upheld, as well as oneconomic assets Amartya Sen Economic/ environmental instability Economic fiscal policy recession focussed on GDP psycho-social Social instability recession materialis consumerism individualism m The chance of a life well lived
    26. 26. Rising income inequalities in Canada the rich could hireall make adie for them, ‘If we, the poor, would others to nice living’ 0.42 Fiddler on the Roof Trends in inequality of disposable income 0.40Gini coefficient of income inequality 0.38 0.36 0.34 0.32 0.30 0.28 0.26 0.24 1975 1980 1985 1990 1995 2000 2005 2010 OECD Divided we stand 2012
    27. 27. Redistribution lower than OECD 0.55 average 0.50 Redistribution through taxes and transfers Gini coefficient of income inequality Inequality of market income Inequality of disposable income (↗) 0.45 0.40 0.35 0.30 0.25 0.20 0.15 0.10 0.05 0.00The chance of a life well lived
    28. 28. Effective and cost effective action “it’s better to be roughly right than precisely wrong”The chance of a life well lived
    29. 29. Scope of Action Material resources Relationships andIncreasing equitable access Respect to assets that support Social support, collectivity, mental wellbeing respect for people experiencing Interventio misfortune ns to promote Inner mental resources Meaningful wellbeing Opportunities to activity develop Opportunities senses, imagina to contribute tion, reason, tho The chance of a life well lived ught (Martha Nussbaum Capabilities)
    30. 30. Summary of themes in (cost) effectiveness • Economic modelling • Promotion, prevention, early intervention, recovery • Commissioning for social value – SROI – how can each $ spent also produce wider community wellbeing? • De-clustering of disadvantage • chance of aPlace/Whole SystemThe Total life well lived
    31. 31. Doing things differently… Re-orienting services and programmes Assessing policy impact Addressing individual well-being holistically Addressing social and community factors Tackling wider well-being determinants Focusing on strengths and assets Measuring well-being outcomesThe chance of a life well lived
    32. 32. ‘best buys’There is not a single case in which children in eitherCanada or the US have better outcomes than children inNorway Phipps 2002• Supporting family life: household production activities -parenting/ HLE/ play/reading 8:1 return• Supporting lifelong learning: early years; healthpromoting schools and continuing education 25-45:1 return• Improving work: employment/ workplace up to 30%saving• social support/integration: befriending, volunteering,timebanks cost effective
    33. 33. Focus of interventions Policy responses that enhance connections, collectivity and financial security material social collectiv e individual ‘Public disregard ruins the spine’The chance of a life well lived Brecht
    34. 34. Return to the social.... And what I shall endure, you shall endure For every atom belonging to me as good belongs to you...... Walt Whitman Solidarity Equity and Freedom and the Social to live a core Justice valued life economy I am, because we are...The chance of a life well lived
    35. 35. Yes, but what can I do.... That’s it • Share your income folks! • Share your time • Develop an inequalities imagination* • Acknowledge what people are up against • Hear, believe, understand, respect... * Angie HartThe chance of a life well lived
    36. 36. So many roads, so much atstakeSo many dead ends, I’m atthe edge of the lakeSometimes I wonder what it’sgonna takeTo find dignity Bob DylanThe chance of a life well lived
    37. 37. Seeing things ‘What are illusions?’ Milo asked ‘Illusions,’ explained Alec, ‘ are like mirages. And mirages are things that aren’t really there that you can see very clearly.’ ‘How can you see something that isn’t there’? yawned Humbug ‘Sometimes it’s much simpler than seeing things Escape by Kathleen V Crosby that are’, said Alec.The chance of a life well lived
    38. 38. Select bibliography Beckfield J and Krieger N (2009) Epi + demos + cracy: A Critical Review of Empirical Research Epidemiologic Reviews 31(1):152-177 CSDH (2008) Closing the gap in a generation: health equity through action on the social determinants of health Final Report of Commission on Social Determinants of Health Geneva: World Health Organization. Friedli L (2009) Mental health, resilience and inequalities WHO Europe London;Copenhagen Nussbaum M (2011) Creating capabilities: the human development approach Belknap Harvard Stiglitz JE, Sen A and Fitoussi JP (2009) Report by the Commission on the Measurement of Economic Performance & Social Progress Wilkinson RG and Pickett KE (2006) Income inequality and population health: a review and explanation of the evidence Social Science and Medicine 62:1768-1784. Zaveleta RD (2007) The ability to go about without shame: a proposal for internationally comparable indicators of shame and humiliation OPHIWhat can capabilities contribute? Working Paper 3