RECODE DNA FOR 21ST CENTURY DWELLING
HEALTH INEQUALITIES
A CLEAR VILLAGE DISCUSSION WITH THE UNIVERSITY COLLEGE LONDON, ILARIA GEDDES, DPT. OF PROF SIR MICHAEL MARMOT LONDON, 18-20 MAY 2010 PUT CAUSES OF HEALTH INEQUALITIES IN FOCUS, NOT THEIR SYPTOMS!
THE MARMOT REVIEW -a clear village discussion ‘Inequalities are a matter of life and death, of health and sickness, of well-being and misery. The fact that in England today people in different social circumstances experience avoidable differences in health, well-being and length of life is, quite simply, unfair. Creating a fairer society is fundamental to improving the health of the whole population and ensuring a fairer distribution of good health.’ states Prof Sir Michael Marmot, chair of the Strategic Review of Health Inequalities in England Post-2010, in his Review Report*.
figure 2: Populations living in areas with, in relative terms, the least favourable environmental conditions, 2001-6
SOCIAL GRADIENT IN HEALTH
The Marmot Review clearly shows that the lower one’s social position, the worse his health. To cite the report it can be stated that in ‘England, people living in the poorest neighbourhoods, will, on average, die seven years earlier than people living in the richest neighbourhoods’ as following figure shows: figure 1: Life expectancy and disability-free life expectancy (DFLE) at birth, persons by neighbourhood income level, England, 1999-2003
©CLEAR VILLAGE 2010
THE CONTEXT The Marmot Review - in 2008, Professor Sir Michael Marmot was asked by the former Secretary of State for Health to chair an independent review to propose the most effective evidence-based strategies for reducing health inequalities in England from 2010, incl. following tasks (shortened): • identify the evidence most relevant to underpinning future policy and action • show how this evidence could be translated into practice • advise on possible objectives and measures • publish a report of the Review’s work.
HEALTH & WELL-BEING
In turn we can say that health inequalities result from social inequalities, e.g. from early child development & education, employment & working conditions, housing & neighbourhood conditions, standards of living and lack of freedom to participate equally in benefits of society.
*Information, pictures and visualisations sourced from: The Marmot Review - Strategic Review of Health Inequalities in England Post-2010
Health inequalities, as described above, do not arise by chance. Bad as those factors might be, inequalities can not be attributed simply to genetic makeup, bad and unhealthy behaviour (smoking, junk food) or people’s access to medical care. Social and economic differences in health status reflect and are caused by social and economic inequalities in our society. These inequalitites are influenced by a range of interacting factors that shape health & well-being, e.g. material circumstances, the social environment, psychosocial factors, behaviours and biological factors; which are,
in turn, shaped by people’s social position which is grown by education, occupation, income, gender, ethnicity and race. All these influences are set in a socio-political, cultural and social framework. To pick just one example, there is empirical evidence that the more deprived areas are that people live in, the more environmental conditions can be found in those areas that might influence inhabitant’s health. As a recommendation, the Review states that to focus solely on the most disadvantaged will not reduce health inequalities. Actions must be universal with a scale and intensity that is proportionate to the level of disadvantage.
THE MARMOT REVIEW -a clear village discussion WELL-BEING & ECONOMY The benefits of reducing health inequalities are economic as well as social. As the report utters, costs of health inequalities can be quantified in human terms, years of life lost and years of active life lost; and in economic terms, by the cost to the economy of additional illness. Referring back to fig. 1 and the DFLE curve and its levels of disability shown, more than three-quarters of the population do not have disability-free life expectancy as far as the age of 68, which is currently discussed as the prospective pension age in England. The Marmot review argues that ‘if society wishes to have a healthy population, working until 68 years, it is essential to take action to both raise the general level of health and flatten the social gradient.’
©CLEAR VILLAGE 2010
BEYOND ECONOMIC GROWTH We agree with the Review in another point: it is indeed time to move beyond economic growth as the sole measure of social success; a holisticly observed well-being should be a more important societal goal than simply more economic growth. Climate change and all actions taken against it have the worst effects on the poorest and most vulnerable
people globally. The Marmot team thinks that action to reduce health inqualities is completely compatible with action to create sustainable futures. Fostering sustainable local communities, active transport, healthy food production, zero-carbon houses will not only ensure the future of manhood but also have health benefits across society!
photo: Bromley by Bow Centre NHS Portsmouth City PCT
Figure 6 Inequality in early cognitive development of children in the 1970 British Cohort Study, at ages 22 months to 10 years
Figure 2.6 Age standardised mortality rates by socioeconomic classification (NS-SEC) and region, men aged 25–64, 2001–2003
Average position in distribution
Mortality rate per 100,000
100
800
Routine Semi-routine
700
High socioeconomic status Low socioeconomic status
High Q at 22m
90
Lower supervisory & technical
80
Small employers, own account workers 600
Intermediate
photo: Gary Sludden/Getty Images
70
Lower managerial, professional
500
Photo: Anthony Strack/Getty Images
Higher managerial, professional
60
400
Figure 10 Populations living in areas with, in relative terms, the least favourable environmental conditions, 2001–6
50 300 200
POLICY RECOMMENDATION Based on the evidence the research team has assembled their recommendations are grouped into six policy objectives, which are underpinned by policy mechanisms, e.g. considering equality and health equity in all policies, across the whole of government, not just the health sector: • Give every child the best start in life • Enable all children, young people and adults to maximise their capabilities and have control over their lives • Create fair employment & good work for all • Ensure a healthy standard of living for all • Create and develop healthy and sustainable places and communities • Strengthen the role and impact of illhealth prevention
*Information, pictures and visualisations sourced from: The Marmot Review - Strategic Review of Health Inequalities in England Post-2010
40
Percentage of the population
30
100
100
Mortality rate per 100,000 800
Mortality rate per 100,000
20
0
Semi-routine Lower supervisory & technical Region
800 600 700 500 600
Routine
Small employers, own account workers 100
Semi-routine
Intermediate
Lower supervisory & technical
Lower managerial, professional
Small employers, own account workers
Higher managerial, professional
Intermediate
400
Lower managerial, professional
500
Average position in distribution
22
England & Wales
Figure 9 Taxes as a percentage of gross income, by quintile, 2007/8
England & Wales
26
30
34
38
42
46
50
54
58
62
Standardised 66 70 74 78 82 Mortality Rate 190
90
94
98
170
All direct taxes Employed in 1981
50
Karsten Stampa, team member of Clear Village Charitable Trust, met Ms. Ilaria Geddes who is part of the Marmot Review research team and responsible for observing the operationalisation of suggested policy recommendations. We discussed Clear Village’s view on the Marmot Review and its policy recommendations intensively, especially our holistic view on societal well-being, the importance of economic growth in today’s global and political setting. It came to fore that we completely share the holistic view of the Review, which goes far
20
All indirect taxes
Source: Office for National Statistics 21
executive summary —
4th
Top
1 condition 2 conditions
70
3 or more conditions
102 106 110 114 118
I
II
IIIN
IIIM
IV
Least favorable conditions
10
Prof. Micheal LeastSir favorable conditionsMarmot
0
2 conditions 1 condition 3 or habitat more favourable conditions Environmental conditions: river water quality, air quality, green space, to biodiversity, flood risk, litter, detritus, housing conditions, road accidents, regulated sites (e.g. landfill) 2 conditions
3 or more conditions
3 or more conditions
Source: Department for Environment, Food and Rural Affairs 23
executive summary — 1
40 30 20
10
0
0
Unemployed in 1981 Least deprived areas
Least deprived areas
50
Top
Quintile of household equivalised disposable income
3rd
98
20
70
10
Least deprived areas
70
4th
94
No conditions Least favorable Least deprived areas conditions No conditions 1 condition Most deprived areas Level of deprivation Least favorable conditions No conditions 2 conditions 1 condition 1 condition No conditions 3 or more conditions 2 conditions
80
20
0
0
90
3rd
90
60 Note: Q = cognitive score 17 Source: 1970 British Cohort Study 50
90
30
10
10
110
0
2nd
86
beyond the border of pure health issues, and that Clear Village would be able to assist the implementation process with our co-creative methodology especially in creating and developing healthy and sustainable places and communities, to improve communities’ well-being thus diminish health inequalities. In the end we invited Ilaria to our network of experts and agreed on a partnership between the UCL department & Clear Village. 20
10
Quintile of household equivalised disposable income
82
50
30
30
130
20
Bottom
78
100
40
40
40
150
30
0
74
Percentage of the population
50
50
102 106 110 114 118
All indirect taxes
40
10
70
70
60
60 86
Months
HIGHLIGHTS OF OUR DISCUSSION
20
66
Months
80
80
70
Low Q at 22m 22
All direct taxes
62
Figure 8 Mortality of men in England status at 80and Wales in 1981–92, by social class and employment60 70 the 1981 Census 60
20
50
30
58
photo: 90 NHS South West
90
90
0
Percent
40
54
100
100
100
10
Region
No conditions
80
50
Percentage of the population
Percentage of the population
Percentage of the population
photo: NHS South West
Region
50
46
30
30
2nd
42
40 — executive summary
40
0
Bottom
38
Source: Office for National Statistics 51 80
50
100 200
0
34
High socioeconomic status Low socioeconomic status
High Q at 22m
60 200
300
100
30
70
400
Percent
26
: health inequalities and the social determinants of health —
Higher managerial, professional
300
Low Q at 22m
0
90
Least favorable conditions
90
10
Routine England & Wales
700
V
Social Class
Level of deprivation
I
II
IIIN
IIIM
Least deprived areas
Level of deprivation Most deprived areas
Most deprived areas
Level of deprivation Most deprived areas Level of deprivation Most deprived areas
IV
V
Source: Office for National Statistics Longitudinal Study19
executive summary —
MORE INFORMATION
+ Marmot Review website: www.marmotreview.org + UCL / Marmot Department website: www.ucl.ac.uk/gheg/marmotreview
THE MARMOT REVIEW - POLICY RECOMMENDATIONS A - Give every child the B - Enable all children, best start in life young people & adults to maximise their capabilities and have control over life
C - Create fair employment and good work for all
D - Ensure healthy standard of living for all
E - Create and develop healthy & sustainable places and communities
A1: increase proportion of overall expenditure allocated to early years
B1: reducing social inequalities in pupil’s education
C1: Prioritise active labour market programmes
A2: support families to achieve progressive improvements in early year development
B2: reducing social inequalities in life skills
C2: Implementation of measures to improve quality
D1: Develop & implement standards for a minimum income for healthy living
E1: Prioritise policies & interventions that reduce health inequalities and mitigate climate change
•
•
• • • •
priority to pre- & post natal interventions providing paid parental leave provide routine support to families through parenting programmes develop programmes for transition to school
A3: provide good quality early years education & childcare • •
combined with outreach to increase take-up by children provided on basis of evaluated models & meet quality standards
• •
extend role of school supporting families and communities, taking the ‘whole child’ approach implementation of full range of extended services in & around schools develop school-based workforce across schoolhome boundaries
B3: Increase access and use of life-long learning • • •
providing support and advice for 16-25 year olds providing work-based learning for young people increasing availability of non-vocational life-long learning
•
public & private sector adhere to guidance & legislation guidance on stress management, wellbeing, physical & mental health
C3: Develop greater security and flexibility in employment • •
retirement age encouraging employers to create jobs suitable for lone parents, carers and disabled
D2: review and implementation of systems of taxation, benefits, pensions, tax credits to provide minimum standard of healthy living
• • • •
improve active travel improve open & green space improve food environment improve energy-efficiency of housing
E2: fully integrate planning, transport, D3: remove ‘cliff edges’ for housing, environment, those moving in and out health systems in each of work locality E3: support locally developed and evidencebased community regeneration programmes that • • community well-being
remove barriers to community participation reduce social isolation
F - Strengthen the role and impact of ill health prevention F1: Prioritise investment in ill health prevention & health promotion across government departments F2: implement evidencebased programmes of ill health prevention • • •
scale & quality of drug treatment programmes focussing on public health interventions such as smoking cessation improving programmes to address causes of obesity
F3: Focus core efforts of public health departments on effective interventions related to the social determinants of health