PPT for a class on health inequalities.

1. APPROACHING PUBLIC HEALTH FROM AN EUROPEAN PERSPECTIVE
Fall 2018
Javier Padilla
Axes of health inequalities in Europe:
gender, social class (income, education,
work), age and ethnic group.

2. • InequaliWHAT?
• Social determinants of health: when Anna Diez Roux met
Rudolph Virchow.
• Main axes of health inequalities (gender, social class, age,
ethnic group).
• Gender inequalities: concept and main aspects.
• Social class inequalities: concept and main aspects.
• What can we do to close the gap? From healthcare to
universal basic income.

3. inequaliWHAT?

4. Health inequalities: it’s not just about the
rich and the poor.

5. ¿?
¿?
¿?
inequity
inequality
disparity

6. inequidad
desigualdad
diferencia
¿?
¿?
¿?
inequity
inequality
disparity

9. A difference or inequality becomes an inequity in health when it is:
a) Avoidable
b) Unnecesary
c) Unfair

13. Gardasil: from bench, to bedside, to blunder. Peter B. Bach. 2010.

14. https://www.ted.com/talks/richard_wilkinson/transcript#t-195192

15. Social determinants of health.

16. Medicine is a social science and
politics is nothing else
but medicine on a large scale

18. Welfare
policies
Labor market
Collective
political
and
cultural
values
Gender
Ethical framework
Social class
Territory
Psychosocial
factors
Healthcare services
Working conditions
Care and housework
Housing resources
Residential environment
Macropolitic
actions
HEALTH ASSETS
STRUCTURAL DETERMINANTS INTERMEDIATE DETERMINANTS
Age
Ethnic group
Powerrelationships
Biological and
conductual factors
Income and economic situation
Social determinants of health and development of health inequalities. Adapted from Borrell et al (2010).

24. Estado de salud
físico y mental.
Condiciones
materiales
Condiciones
físicas
Condiciones
psicosociales
Condiciones
conductuales
Condiciones
biológicas
Renta y
estatus
familiar
Formación y
educación
Profesión
Ocupación
laboral
Renta
Red
social
Condicionales estructurales y servicios de protección social
Bienestar
Ruta causal entre renta y
estado de salud. Basado
en Benzaval et al. 2014.
Elaborada por Padilla J y
López V.

25. Main axes of health inequalities.

26. Looking beyond the still picture

27. Looking beyond the still picture

28. Main axes of health inequalities.
EDUCATION

29. Main axes of health inequalities.
EDUCATION
• Main determinant of health.
• Implications on adoption of lifestyles.
• Lifestyles: an individual decision or a socially-determined habit?
• Intersections: gender, ethnic groups, age.
Variable Size of the risk (CI 95%) Publication
Low educational
level
Cardiovascular disease risk 1,64 (1,42-1,90) [men]
1,31(1,02-1,68) [women]
MORGAN Study,
2014
Bad self-rated health 7,63 (6,29-9,28)
1,49(1,27, 9,28)
Calcedo B, 2015
Oshio T, 2014
Mortality 1,45 (1,39-1,51) [men] and 1,15 (1,04-1,26)
[women] for the lowest values of the review
2,93 (2,87-2,98) [men] and 2,24 (2,16-2,33)
[women] for the highest values of the review
Mackenbach JP,
2015

30. Main axes of health inequalities.
EDUCATION Trends in health inequalities in 27 European countries. Mackenbach. 2018

31. Main axes of health inequalities.
EDUCATION
Trends in health inequalities in 27 European countries.
Mackenbach. 2018

32. Main axes of health inequalities.
INCOME

33. Main axes of health inequalities.
INCOME
• Importance of social gradient.
• Influence of economic dependance.
• The role of the state in income transfers.
• Intersections: age, gender.

34. "Status syndrome: How social standing affects our health and longevity" Michael Marmot.
Main axes of health inequalities.
INCOME

36. How does money influence
health? Benzaval et al. 2014.

37. Main axes of health inequalities.
WORK

38. Main axes of health inequalities.
WORK
• Is having a bad job better for health than having no job?
• Effects of temporary employment and job insecurity.
• Formal and informal work. Gender concerns.
• Intersections: gender, age (retirement), education.
Variable Size of the risk (CI 95%) Publication
Unemployment Mortality 1,63 (next 10 years)
2,13 (1,71-2,65) (next 5 years)
Roelf DJ, 2011
Morris JK, 1994
Cardiovascular mortality 1,82 (1,29-2,45) Stuckler D, 2009
Suicide (2,04-9,04)
Depression 2,33 (1,35-4,03)
1,72(p<0,001)
Leach LS, 2011
Gili M, 2012
Drugs and alcohol abuse 1.36 (p<0,05) Gili M, 2012
Self-rated health 1,10 (1,05-1,15) Giatti L, 2008
Informal work Self-rated health 1,06 (1,03-1,15) Giatti L, 2008

39. Main axes of health inequalities.
GENDER

40. Main axes of health inequalities.
GENDER
• Gender roles.
• Care.
• Domestic labour.
• The role of biology.
• Gender bias and medical care.
• Intersections: ethnic group, age,
education, work.

41. Main axes of health inequalities.
GENDER
• Gender roles.
• Care.
• Domestic labour.
• The role of biology.
• Gender bias and medical care
Women:
• Greater life
expectancy.
• Greater percentage of
non-healthy life years.

42. Main axes of health inequalities.
GENDER
• Gender roles.
• Care.
• Domestic labour.
• The role of biology.
• Gender bias and medical care

43. Main axes of health inequalities.
GENDER
• Gender roles.
• Care.
• Domestic labour.
• The role of biology.
• Gender bias and medical care

44. Main axes of health inequalities.
GENDER
• Gender roles.
• Care.
• Domestic labour.
• The role of biology.
• Gender bias and medical care

45. Summarizing… main characteristics of health
inequalities in Europe.
• Four groups of countries according to health inequalities profiles.
• Different evolution of health inequalities in crisis years according to…
• Some common aspects to most European countries:

46. Summarizing… main characteristics of health
inequalities in Europe.
• Four groups of countries according to health inequalities profiles.
• Beveridgean social-democracies.
• Bismarckian social security systems.
• Southern post-dictatorial countries.
• Eastern countries.

47. Summarizing… main characteristics of health
inequalities in Europe.
• Four groups of countries according to health inequalities profiles.
• Beveridgean social-democracies. (universal services, high taxes, very cohesive societies)
• Bismarckian social security systems. (tight links to job status, tendencies to liberal policies)
• Southern post-dictatorial countries. (weak institutions, suffer from assymetric EU, cultural aspects)
• Eastern countries. (weak institutions, hard transition communism/socialism-liberalism, political
challenges)

48. Summarizing… main characteristics of health
inequalities in Europe.
• Four groups of countries according to health inequalities profiles.
• Beveridgean social-democracies.
• Bismarckian social security systems.
• Southern post-dictatorial countries.
• Eastern countries.
• Different evolution of health inequalities in crisis years according to:
• Social protection systems. (the broader the better, social protection as a SDoH)
• Austerity or anti-austerity policies. (is austerity bad for PH? Can austerity increase inequalities?)
• Basal-line situation. (crisis are not opportunities for countries with weak public health situations)

49. Summarizing… main characteristics of health
inequalities in Europe.
• Four groups of countries according to health inequalities profiles.
• Beveridgean social-democracies.
• Bismarckian social security systems.
• Southern post-dictatorial countries.
• Eastern countries.
• Different evolution of health inequalities in crisis years according to:
• Social protection systems.
• Austerity or anti-austerity policies.
• Basal-line situation.
• Some common aspects to most European countries:
• Precarization of working conditions. (is working a health asset or a determinant of disease?)
• Gender roles affecting women’s health. (problems concerning reproductive health, women’s role,…)
• Macroeconomics policies affecting downstream determinants such as housing.

50. What can be done to close the gap?

51. What can be done to close the gap?
Upstream public
health policies
Downstream public
health policies

52. What can be done to close the gap?
Upstream public
health policies
Downstream public
health policies
O
b
e
s
i
t
y
¿? ¿?¿?

53. What can be done to close the gap?

54. What can be done to close the gap?

55. What can be done to close the gap?

56. What can be done to close the gap?

57. All the women are white,
all the black are men,
but some of us are brave.
(Akasha G. Hull)

58. Wishes, questions, demands?
Javier Padilla javierpadillabernaldez@gmail.com @javierpadillab