Social determinants of health

What is our focus?

Interview with Professor Sir Michael Marmot, Chair of the Commission on Social Determinants of Health

What will the Commission on Social Determinants of Health do?

People's health suffers because of the social conditions in which they live and work. The end goal of the Commission—and its follow-up—is to change this reality. The task of the Commission is to identify and support the application of interventions that will do the most to improve the social conditions that determine health. The Commission will do this in a number of ways. It will review evidence on health inequities and knowledge on the best approaches and interventions on social determinants to improve health. It will advocate for the uptake of evidence by decision-makers. It will work with national authorities to support policies and programmes to address social determinants. Working with authorities in countries will be vital to the Commission's work, as it will look to them to exert leadership and take forward global action on addressing the social determinants of health.

At the core of the Commission's work is the belief that a society that has organized its social conditions so that its population has better health is a better society. Health is a measure of the degree to which the society delivers a good life to its citizens. This commission is aiming to help countries to progress towards that ideal. These social conditions don't just impact child mortality. They have a powerful impact on adult mortality, so powerful that a poor person at the age of 30 in Lesotho has far fewer years in front of him/her than does a poor person of the same age in Sweden.

What are the social determinants of health?

Let's start at the beginning: if you are a fifteen-year-old boy in Lesotho, your chance of reaching the age of 60 is about 10%. If you are a fifteen-year-old boy in Sweden, your chance of reaching 60 is 91%. This difference is due to social conditions, which are determinants of health. They include education and the nature of jobs. They include living conditions such as housing and availability of adequate nutritious food. They also entail access to quality health care.

Similarly, there are big health inequalities within countries. Let's take the United States, for example. If you catch the metro train in downtown Washington, D.C., to suburbs in Maryland, life expectancy is 57 years at beginning of the journey. At the end of the journey, it is 77 years. This means that there is 20-year life expectancy in the nation's capital, between the poor and predominantly African American people who live downtown, and the richer and predominantly non-African American people who live in the suburbs. Now, a poor man in inner-city Washington, D.C., is rich in material terms when compared to a poor man in Lesotho. The social determinants of these two individual's lives are different, and we must acknowledge this and think of poverty in a different way. It is about opportunities in life and control over one's life, in addition to social conditions that shape the physical environment one lives in.

Realistically, can anything be done about the social determinants of health?

There is much that we can do about the social determinants of health, having the knowledge and the will. We know, for example, that unemployment, insecure employment or employment in poor working conditions harm health. Creating jobs that are secure and improving conditions of employment will lead to improvements in health. This has been recognized in some countries. It now needs to be more broadly applied. Secondly, we know that where there are concentrations of poverty, with poor infrastructure, low levels of social cohesion, more than health suffers. But there are other effects such as high rates of crime. The benefits of investing in better human habitats are likely not only to improve health, but also lead to safer and more secure environments for residents and visitors alike. Third, education is a route to better chances in life. Those better chances in life translate into better health. We have the knowledge and the means to guarantee a good education for all. We have to exercise the will.

What is an example of an effective intervention?

In some countries in Latin America, people living in poor conditions have underweight children with slowed growth. Poor families can't afford for their children to go to school, and those who do go don't learn well because malnutrition hinders their ability to learn and develop. This is the crux of a terrible cycle where poverty causes ill-health and ill-health, in turn, perpetuates poverty. We are very encouraged by the results of some programmes in Latin America to break this cycle. In some countries, there are programmes that give families a small economic subsidy to take children to nutrition clinics and have them enrolled in school. Children are malnourished because their parents are poor. With more money, the children get better nutrition. As the programme is dependent on the children staying in school, they also get better education. This is a low cost intervention, and it helps to break the poverty=ill-health cycle by empowering and improving the health of children, making a difference in their lives that will last into adulthood.

Why were these Commissioners chosen?

The Commissioners represent a wide range of experience in all of the areas that make up the social determinants of health. There are academics who have worked on the science base. There are doctors who have worked in various parts of the health field. There are people from government and from non-governmental organizations who have been actively involved in the development and implementation of policies. In bringing representatives from these groups for a Commission, we want to benefit from their experience, their wisdom, and their leadership. Because they are people who have played prominent roles in various spheres, they will not only benefit the process of identifying effective means to address the social determinants of health, but they are also in positions to advocate for the uptake of these means by decision-makers.

What kind of impact will the Commission actually make in countries?

Let's take, the example, the eastern European and Central Asia region. Life expectancy in some of the countries of the former USSR has fallen for men in the past ten years. This is at a time when, in many other parts of the world, it continues to increase. In the 1990s in many countries of eastern Europe and Central Asia, there was a sharp increase in poverty and, with it, a deterioration of working conditions and health and education systems, and a disruption of family and community life. There was little hope for the future, and stress and social strife increased. Harmful behaviours such as binge drinking, smoking, and drug use increased, adding to the region's heavy burden from non-communicable diseases and accidents and injuries. However, despite this bleak picture, we must see the window of opportunity. If life expectancy decreased within such a short period of time, it can also change for the better within a short period of time, provided that countries take the steps necessary to improve social conditions. The role of the Commission is to help them do this by providing them with the best possible evidence and knowledge on effective strategies and supporting the adaptation of these strategies in national contexts.

People might say that the Commission is going to be just another talking shop. What is your response?

The Commission will talk but with a purpose. Its purpose is to go beyond the discussion and synthesis of evidence, and to work with countries to see the implementation of action on social determinants of health. We want to change the climate of understanding of social determinants and help formulate and implement policies in countries and in international bodies that seek to improve the social conditions under which people live and work, with the end goal of reducing inequalities in health, saving lives, and preventing unnecessary suffering due to illness.

With HIV/AIDS becoming of ever-increasing importance, why should governments look at the social causes behind sickness, which - some people might say - are basically impossible to tackle anyway?

If you look now at who in the world gets HIV/AIDS, it is what Paul Farmer calls a "pathology of power". It is the poor and the disempowered, it is those for whom "society does not work", it is those who are lacking education and the inputs and systems they require to protect themselves. Seeing HIV/AIDS as simply too many people having a virus is too limited an approach to the problem. We have to look at the social conditions that have led to the rise of this appalling epidemic. And this has to take place alongside the very welcome aim of increasing the number of people with the virus who are receiving treatment.

Micheal Marmot, Commmissioner