Social Determinants of Health: Why Should We Bother?


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Presentation delivered during the 2nd Social Oncology Forum with the theme "Social Determinants of Health in Agricultural Communities." November 10, 2013, Benguet State University, La Trinidad, Benguet.

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  • But we are not just waiting for action outside the health sector – we medical students are also doing our part!
  • The Lancet called climate change the biggest global health threat of the 21st century.
  • There is a huge evidence showing the links between climate change and health.
  • Climate change will breed more health inequity, as the effects are not the same in all regions. In fact, the developing world will suffer more the health consequences.
  • My country, the Philippines, is not exempted from climate change’s impact on human health and survival.
  • Approximately 20 typhoons hit the Philippines each year. Due to climate change, typhoons have become more frequent, more severe, more erratic, and more unpredictable.
  • Even Hippocrates taught us to understand the environment as it shapes our patients’ health.
  • Health is important in society. We should talk about it and make sure it is at the core of every climate discussion, because without it, everything will just be made in vain.
  • Social Determinants of Health: Why Should We Bother?

    1. 1. Ramon Lorenzo Luis R. Guinto, MD Consultant, International Organization for Migration and Department of Health Member, Lancet-University of Oslo Youth Commission on Global Governance for Health
    2. 2. Source: Ravi Narayan, SOCHARA, India
    3. 3. Source: Ravi Narayan, SOCHARA, India
    4. 4. Source: Ravi Narayan, SOCHARA, India
    5. 5. Source: Ravi Narayan, SOCHARA, India
    6. 6. From Beaglehole and Bonita, 2012
    7. 7. Glasgow, Scotland (deprived suburb) 54 India 61 Philippines 65 Korea 65 Lithuania 66 Poland 71 Mexico 72 Cuba 75 US 75 UK 76 Glasgow, Scotland (affluent suburb) 82 (WHO World Health Report 2006; Hanlon,P.,Walsh,D. & Whyte,B.,2006)
    8. 8. Source: Dr. Ramon Paterno, University of the Philippines
    9. 9. Poorest Less poor Middle Less rich Morocco Peru Richest 350 300 250 200 150 100 50 0 Mali India (Houweling et al, 2007) Kyrgyz Republic
    10. 10. Infant mortality in Brazil by race and mother's education, 1990 (Pinto da Cunha, 1997)
    11. 11. (Murphy et al, 2005) (probability of living to 65 yrs when aged 20 yrs)
    12. 12. (Bramley et al, 2005)
    13. 13. (Marmot & Shipley, BMJ, 1996)
    14. 14. The Jubilee Line of Health Inequality Travelling east from Westminster, each tube stop represents up to one year of male life expectancy lost at birth (2002-06) Male Life Expectancy 78.6 (CI 76.0-81.2) Canning Town Female Life Expectancy 84.6 (CI 82.5-86.7) Male Life Expectancy 72.8 (CI 71.1-74.6) Female Life Expectancy 81.4 (CI 79.3-83.6) Westminster London Bridge River Thames Canada Bermondsey Water Canary Wharf North Greenwich Waterloo Southwark London Underground Jubilee Line 1 Electoral wards just a few miles apart geographically have life expectancy spans varying by years. For instance, there are eight stops between Westminster and Canning Town on the Jubilee Line – so as one travels east, each stop, on average, marks up a year of shortened lifespan. 1 Source: Analysis by London Health Observatory using Office for National Statistics data revised for 2002-06. Diagram produced by Department of Health
    15. 15. Definitions • Inequalities/Disparities in health – „differences‟ in health across individuals / population groups • Inequities in health – avoidable differences • „Where systematic differences in health are judged to be avoidable by reasonable action they are, quite simply, unfair. It is this that we label health inequity.‟ WHO Commission on Social Determinants of Health (2008) From Mike Rowson, 2011
    16. 16. Definitions • Horizontal equity – equal access for equal needs • Vertical equity – unequal access for unequal needs From Mike Rowson, 2011
    17. 17.        Doctor Pathologist Biologist Politician First to recognize leukemia Elucidated embolism Founded “Social Medicine”
    18. 18. Do we not always find the diseases of the populace traceable to defects in society? Dr. Rudolf Virchow Father of Social Medicine
    19. 19.  Prosperity  Education  Liberty
    20. 20. Source: Ravi Narayan, SOCHARA, India
    21. 21. Source: David Sanders, South Africa
    22. 22. 5 4 3 2 1 0 1838 1860 1880 1900 1920 1940 1960 TB deaths David Werner and David Sanders, Questioning the Solution: The Politics of Primary Health Care and Child Survival.
    23. 23.    Conditions in the social, physical, and economic environment in which people are born, grow, live, work, an d age, including access to health care Policies, programs, and institutions Social structure, community factors
    24. 24. Dahlgren and Whitehead, 1991
    25. 25. From Fran Baum
    26. 26. From Fran Baum
    27. 27. “Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity… a fundamental human right”
    28. 28. “Economic and social development… is of basic importance to the fullest attainment of health for all and to the reduction of the gap between the health status of the developing and developed countries...
    29. 29. …Involves, in addition to the health sector, all related sectors and aspects of national and community development, in particular agriculture, animal husbandry, food, industry, education, housing, public works, communications and other sectors…”
    30. 30. Alma Ata, 1978 The International Conference on Primary Health Care calls for urgent action by all governments, all health and development workers, and the world community to protect and promote the health of all the people of the world by the year 2000.
    31. 31.  The Ottawa Charter for Health Promotion (WHO 1986) identified 8 key determinants (prerequisites) of health: peace, shelter, educati on, food, income, a stable ecosystem, sustainable resources, social justice, and equity.
    32. 32. 1.Improve Daily Living Conditions 2. Tackle the Inequitable Distribution of Power, Money, and Resources 3. Measure and Understand the Problem and Assess the Impact of Action.
    33. 33. Basic question: What good does it do to treat people‟s Illnesses … only to send them back to the conditions that made them sick?
    34. 34.     Social determinants of health have a direct impact on health Social determinants predict the greatest proportion of health status variance (health inequity) Social determinants of health structure health behaviours Social determinants of health interact with each other to produce health
    35. 35. “Unequal distribution of health-damaging experiences is not in any sense a „natural' phenomenon, but is a result of the toxic combination of poor social policies and programs, unfair economic arrangements and bad politics.” WHO Commission on Social Determinants of Health, 2008
    36. 36. Daily Living Conditions      Power, Money and Resources       Knowledge, Monitoring and Skills   Equity from the start Healthy places- healthy people Fair employment –decent work Social protection across the life course Universal health care Health Equity in All Policies Fair financing Market responsibility Gender equity Political empowerment – inclusion and voice Good global governance Monitoring, research, training Building a global movement Full report downloadable at Source: Fran Baum, Flinders University
    37. 37. WHO Commission on Social Determinants of Health
    38. 38. Vicente Navarro
    39. 39. AVERAGE HOUSEHOLD MONTHLY INCOME Poorest 5,958 Poor Middle Income 8,594 12,269 Rich 18,497 Richest 40,590 FOOD EXPENDITURE SHARE 67% 57% 49% 40% 27% FIES, 2009
    40. 40. 100 80 60 40 55 20 51 45 39 34 0 Poorest Poorest Middle Rich Richest Income National Demographic and Health Survey, 2008
    41. 41.    Immigration less than 20,000 foreign nationals annually (0.3-0.5% of Philippine population) Emigration: 10.4 million Filipinos in more than 200 countries and territories (10% of Philippine population) Institutionalized labor migration: 1.8 million OFWs deployed in 2012
    42. 42. MIGRATION HEALTH OUTCOMES affects individual health stress, mental health problems influences other determinants noncommunicable diseases drives marginalization and vulnerability limited access to healthcare; health inequity contributes to spread of infectious diseases disease outbreaks or epidemics
    43. 43. Source: National Epidemiology Center, July 2013
    44. 44. No. 6 in the Climate Change Vulnerability Index No. 3 most vulnerable to disaster risks and natural hazards in the World Risk Index 2011, next to Vanuatu and Tonga
    45. 45. Whoever would study medicine aright must learn of the following subjects. First he must consider the effect of the seasons of the year and the differences between them. Secondly he must study the warm and the cold winds, both those which are in common to every country and those peculiar to a particular locality. Lastly, the effect of water on health must not be forgotten. On Air, Water, and Places By Hippocrates Father of Medicine
    46. 46. 1. Liberalisation of international food trade 2. Increased foreign direct investment 3. Globalised advertising and marketing From Sharon Friel, Australia
    47. 47. Top 10 manufacturers of packaged foods Three quarters of world food sales involve processed foods, for which the largest manufacturers hold over a third of the global market. From Sharon Friel, Australia Stuckler et al (2012) Manufacturing Epidemics: The Role of Global Producers in Increased Consumption of Unhealthy Commodities Including Processed Foods, Alcohol, and Tobacco. PLoS Med 9(6): e1001235. doi:10.1371/journal.pmed.1001235
    49. 49. 1. To adopt better governance for health and development 2. To promote participation in policy-making and implementation 3. To further reorient the health sector towards reducing health inequities 4. To strengthen global governance and collaboration 5. To monitor progress and increase accountability
    50. 50. SDH to shape the post-MDG world eradicate extreme poverty and hunger achieve universal primary education promote gender equality and empower women reduce child mortality improve maternal health combat HIV/AIDS, malaria and other diseases ensure environmental sustainability develop a global partnership for development
    51. 51. • Health as a Precondition/Contributor • Health as a Beneficiary • Health as an Indicator
    52. 52. Revitalize the SDH movement and enhance capacity for SDH action at national and sub-national levels
    53. 53. Reorientation of health professions education – equity-based, systems-oriented, global perspective, SDH thinking
    54. 54. The 21st century Filipino health professional as champion of social determinants approach to health
    55. 55. From Fran Baum
    56. 56. The Power of Medicine "Medicine is a social science, and politics is nothing else but medicine on a large scale. Medicine, as a social science, as the science of human beings, has the obligation to point out problems and to attempt their theoretical solution; the politician, the practical anthropologist, must find the means for their actual solution....The Dr. Rudolf physicians are the natural attorneys Virchow of the poor, and social problems fall Father of Social Medicine to a large extent within their jurisdiction.”
    57. 57. The Power of Young People “The youth are the hope of the Fatherland.” Dr. Jose Rizal National Hero of the Philippines
    58. 58. "Health is not everything, but without health everything is nothing." Arthur Schopenhauer German Philosopher