Health Status: A Matter of Class?

1
Health Status A Matter of Class?

• by
• The Hon. Monique Bégin, PC, FRSC, OC
• University of Ottawa
• WHO Commission on Social Determinants of Health
• 2nd Annual Faculty of Health Sciences
  Distinguished Lecture, University of Western
  Ontario, London (ON)
• March 29, 2007

2
Today

• We want to explore  why are some people healthy
  and others not ? , to paraphrase Bob Evans.
• If genetics and individual risk factors are not
  the best predictors of staying healthy or
  becoming ill, what are the predictors society
  should know about?

3
Social determinants is the answerand the key to
understanding patterns of health and illness.
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The  classless  society?...

• Canadians and Americans like to think that they
  are very egalitarian and dont have social
  classes.
• We mask reality by referring to  socio-economic
  status .
• The Brits who acknowledge that their society is a
  well-entrenched class system have a long
  tradition of research of the connection between
  health and class.

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Two famous British studies

• Black
• Whitehall

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The Black Report

• Sir Douglas Black et al
• First released in 1980
• Tracked patterns of inequalities of health across
  Britain through health records.
• Made recommendations for health improvement.
• Thatcher tried to suppress the report.
• Finally published in 1988 together with Margaret
  Whiteheads update The Health Divide. 

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The Black Report showed

1. Improvement in health across all the classes
   since creating the National Health Service
   (1948).
2. Still a correlation between social class, and
   infant mortality rates, life expectancy and
   unequal use of medical services.
3. Lower occupational groups experience poorer
   health at all stages of life.

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The Whitehall I Study

• Sir Michael Marmot (joined in 1976)
• Published 1986-1987
• 10,000 male civil servants, over 10 years.
• Divided in 4 groups
• administrative (such as permanent secretaries/
  Deputy Ministers)
• professional and executive (such as senior
  executive officers)
• clerical
• other (unskilled manual workers - as porters,
  messengers).

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Why Whitehall I ?

• Initially undertaken in 1967, separate from the
  Black research, to investigate cardiorespiratory
  disorders and their precursors.
• Main topics covered
• cardiovascular function, smoking, angina
• diabetes, clinical examination, ECG measurements
• car ownership, leisure/hobbies and grade of
  employment.

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Researchs assumption was

• Individuals with big jobs and big
  responsibilities are those prone to cardiac
  accidents.

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Research results
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(No Transcript)
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Whitehall I and II concluded

• People at the bottom of the hierarchy had a
  higher risk of heart attacks. The lower you were
  in the hierarchy, the higher the risk.
• The same applied to all the major causes of death
  -- cardiovascular disease, gastrointestinal
  disease, renal disease, stroke, accidental and
  violent deaths, cancers that were not related to
  smoking as well as cancers that were related to
  smoking.

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Whitehalls social determinants

• Low job control.
• Job stress, tension
• Lack of skill utilization
• Lack of clarity in tasks.
• Household income or wealth
• Conflicting work and family demands.
• No socially cohesive neighbourhood.

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Long spells of sickness absence by grade (Men,
Whitehall II study)
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Gradient in Psychological Stress by Executive
Level in Canadian Civil Servants
plt0.0001 Lemyre, Beauregard, Corneil Barette
(CRSH-INE 2002-05) The Federal Public Service
as a Learning Organization Stress and Learning
in Executives 
Louise Lemyre, Ph.D, FRSC School of Psychology,
Faculty of Social Sciences R. S. McLaughlin
Research Chair Groupe dAnalyse Psychosociale de
la Santé (GAP-Santé) Institute of Population
Health, University of Ottawa louise.lemyre_at_uottaw
a.ca www.gapsante.uottawa.ca
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Do socioeconomic differences in mortality
persist after retirement?

• Relative differences in mortality between low and
  high employment grades are less after retirement,
  suggesting the importance of work in generating
  inequalities in health.

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On the lighter side"People with PhDs live
longer than those with masters degrees. Those
with a masters live longer than those with a
degree, while those with a degree live longer
than those who left school early.Similarly,
actors who have won an Oscar will live on average
3 years longer than those who were nominated for
the award but missed out. "
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British milestones studies

• The Black Report (1980)
• The Whitehall Studies I and II (1967-1987 and
  1987-2007 )
• Margaret Whiteheads The Health Divide (Black
  updated 1992)
• The Acheson Inquiry (1998)
• Modernising Government White Paper (1999)
• Saving Lives - Our Healthier Nation White Paper
  (1999)
• The NHS Plan (2000)
• Tackling Health Inequalities Cross-Cutting Review
  (2002)
• Tackling Health Inequalities. A Programme for
  Action (2003)
• The Wanless Reviews (2002, 2004)
• Choosing health making healthy choices easier
  (2004)
• Tackling Health Inequalities Status Report
  (2005)

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These studies tell us about

• The social determinants of health we now know
  that factors other than genetic/biological do
  determine health status.
• The gradient theory we also know that  social
  classes  or different socio-economic status do
  predict health status.

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The Lalonde report is the Canadian ancestor of
the social determinants approach (Health
Canada, 1974)
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The Ottawa Charter (1986) Towards Healthy
Public Policy
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Dr. Fraser Mustard conceptualized the social
determinants of health around 1989-90.
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Dahlgren and Whitehead 1991
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Inequality

• Wilkinson (1996) argues that what matters most
  is not whether you have a smaller or larger home
  or better or lesser care but what these
  differences mean socially and what they make you
  feel about yourself and the world around you.
• (Richard Wilkinson, University of Nottingham,
  UK)

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From health inequality to health inequity

• Health inequality
• An observable, often measurable, difference in
  health status between individuals or between
  groups, whatever its cause.

• Health inequity
• A moral category rooted in social
  stratification, embedded in political reality and
  the negotiations of social power relations.

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Consequently

• Health equity can be defined as the absence of
  unfair or unavoidable or remediable differences
  in health among populations or groups defined
  socially, economically, demographically or
  geographicaly.

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How egalitarian a society are we?

• There is now good evidence that the healthiest
  and happiest societies are those with the most
  equal distribution of income.

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Inequalities in health outcomes Do they
exist within other countries? Between
countries?
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The same within most countries

• arriving home in Marylandlife expectancy is 77
  years.

• Leaving downtown Washington (DC) at 5 P.M., life
  expectancy is 57 years.

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Probability of Survival From Age 15-65 Years
Among US Blacks Whites
probability of survival
US White Poor White US Black Poor Black Males
Males Males Males
Geronimus et al, NEJM 1996
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The Widening Trend in Mortality by Education in
Russia,1989-2001
45 p20 probability of living to 65 yrs when
aged 20 yrs
Murphy, Bobak, Nicholson, Rose, and Marmot, 2005
under review
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Inequality in a Canadian context

• 1990-2000
• Wealthiest 10 of Canadians
• increased their income by 23,000
• per person per year.
• Poorest 10 of Canadians
• increased theirs by 81 per person
• per year.

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CANADA more facts

• Food insecurity exists among 10.2 of Canadian
  households representing 3 million people. Monthly
  food bank use is 747,665 or 2.4 of total
  Canadian population, double the 1989 figure.

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Over last 10 years, welfare benefits have dropped
in most provinces below half of basic living
costs.In 2001, just 39 of unemployed Canadians
were eligible for unemployment insurance
benefits. The program must be more
accessible.Minimum wages are inadequate to
achieve a decent standard of living.
Homelessness and housing constitute a national
emergency.
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Aboriginal health
Canada Status Indians Inuits
Life expectancy at birth Female 82 Male 76 77 69 68 70
Infant mortality (1000) 5.3 8.0 15.0
Deaths by suicide (100,000) 13 28 79
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and health inequalities exist between countries
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PROBABILITY OF DYING BETWEEN AGES 15 AND 60
(males)
LESOTHO 90.2
RUSSIA 46.9
BOLIVIA 26
SRI LANKA 23.8
COLOMBIA 23.6
PAKISTAN 22.7
SWEDEN 8.3
SOURCE THE WORLD HEALTH REPORT 2004,WHO
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UNDER 5 MORTALITY RATE PER 1000 LIVE BIRTHS
SIERRA LEONE 316
BOLIVIA 80
KYRGYZSTAN 63
SRI LANKA 20
ICELAND 3
SOURCE THE WORLD HEALTH REPORT 2004,WHO
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Under-five mortality rate, change over period
1990-2000

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No comments

• In Kumasi, Ghana, a country which privatized
  public toilets in the 1990s, private toilet use
  once a day for a family costs 10 of the basic
  wage.

                                                            
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WHO Commission on Social Determinants of
Health(March 2005 April 2008)
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How is the Commission organized?

• Pillars of our work
• 8 knowledge networks
• Countries (and regions) involved
• Civil society and global partners involved (World
  Bank, etc.)
• World Health Organisation (WHO)

• Michael Marmot, Chair
• 19 members (volunteers)One Canadian (M. Bégin)
• Small Secretariat in Geneva
• Smaller scientific team around Marmot in London.
• Meetings in-person 3-4 times per year.

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KNOWLEDGE NETWORK THEMES
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3 Knowledge Networks funded by Canada

• Early Childhood Development
• (Dr. Clyde Hertzman, UBC)
• Globalization and Health
• (Dr. Ron Labonte, UofO)
• Health Systems
• (via IDRC, in South Africa)

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My personal mission as a Commissioner

• Ensure that unique challenges of the worlds
  Indigenous people are addressed in CSDH work
• Working in partnership with Australia, NZ, South
  American countries to explore ways to address
  unique determinants of Indigenous peoples health
• Ensure that CSDH recommendations address
  inequalities in developed as well as developing
  countries
• Facilitate moving Canada beyond pilot projects
  to a systemic approach to addressing determinants
  of health

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Canadas participation

• The PHAC created a Canadian Reference Group with
  various stakeholders
• Engaging the Canadian society
• A joint project with UK and Sweden on
  whole-of-government strategies
• An Aboriginal Sub-Committee
• Challenges how do we beat the  silos 
  approach to public policy when most determinants
  of health are outside health ministries?...
• How do we make poverty visible to Canadians?

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Is action possible?...

• Yes it is and its urgent!
• How? By shedding the culture of contentment in
  which we live.
• By saying loud and clear that social policies do
  matter to Canadians.
• By addressing upstream factors through
  whole-of-government policies instead of
  focusing
• on downstream problems

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To conclude Global Health Watch

• reports that the cost of achieving and
  maintaining universal access to basic education,
  basic health care, adequate food, and safe water
  and sanitation for all has been estimated at less
  than 4 of the combined wealth of the 225 richest
  people in the world.
• They consider poverty and development as a public
  health issue.

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What good does it do to treat people's illnesses
...
then send them back to the conditions that made
them sick?