Summer School
Towards a right to health without borders Interdisciplinary approaches for social change (RHEACH) Izmir (Turkey), 8th - 18th July 2014
The Social Determination of Health Centre for International Health (CSI) Alma Mater Studiorum University of Bologna
A construc*on worker’s 10-‐story fall from scaffolding • • • • • • • • • •
Insufficiently conscious of safety Exhausted due to his long commute Sleepless night because of noise Thin walls of his poor dwelling Low earning due to no minimum wage policy and precarious status Poor safety regula>ons No training from employer Poor quality of scaffolding Free market system: profit vs safety Weak Unions: threat of job losses 2
A construc*on worker’s 10-‐story fall from scaffolding • • • • • • • • • •
Insufficiently conscious of safety Exhausted due to his long commute Sleepless night because of noise Thin walls of his poor dwelling A personal accident? Low earning due to no minimum wage policy and precarious sOr tatus The of interlocking social, economic, and Poor sproduct afety regula>ons political factors? No training from employer Poor quality of scaffolding Free market system: profit vs safety Weak Unions: threat of job losses 3
Different perspec*ves on Health • Bio-‐medical Model • Behavioural Model • Poli*cal-‐economy Approach
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Determinants of Health - 'Policy Rainbow' Dahlgren & Whitehead 1991
GEOGRAPHICAL ORIGIN Senegal Life exp: 63 anni GDP/pc/yr ≈ 2.000$ Migration history
WORK Lost previous job, now occasional manual jobs
INCOME LIFE STYLES / RISK FACTORS smoking, hypertension, overweight
GENERAL SOCIO-ECONOMIC CONDITIONS (national-international) LEGAL STATUS No work documents
Samir, senegalese, 50yrs, in Italy since early ‘90s, acute miocardial infartion
SOCIAL NETWORKS assistance during hospital admission and discharge, family support
INCOME medicines, usercharges, (physical activity, nutrition...)
SOCIAL CONDITIONS ability to (empowered to) understand, Possibility to choose
SERVICES Accessibility, competence, equity...
Causes of Preventable Deaths (U.S., 2006) From Kirsti A. Dyer MD, MS, FT, former About.com Guide
Personal behaviour / free choice
How personal and free?
How personal and free?
How personal and free?
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SOCIAL COHESION
INCOME
Marmot, Lancet 2006
INCOME
WORK
EDUCATION
Coronary heart events by education. Education University/high school
MEN
Turin, 1996-99
Incidence HR* (95% IC) 1
Middle school
1.26 (1.19-1.33)
Primary school or less
1.31 (1.24-1.38)
University/high school
1
WOMEN
Middle school
1.41 (1.26-1.58)
Primary school or less
1.61 (1.44-1.80)
*adjusted by age and area of birth
HEALTH SERVICES
Global Inequalities
ECONOMIC CRISIS AND HEALTH
Hopkins 2006
Open Ques*on Time
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• Health inequali*es caused by the unequal distribu>on of power, income, goods, and services, globally and na*onally • Not a ‘natural’ phenomenon but the “result of a toxic combina*on of poor social policies and programmes, unfair economic arrangements, and bad poli*cs” • Together, the structural determinants and condi*ons of daily life cons*tute the social determinants of health • A new approach to development: economic growth by itself is not enough without redistribu>on 33
Social vs Societal Determinants • Social Determinants – Public policies and private sector ac*ons shaping hierarchies of exposure to factors that determine health. – Act mainly on rec*fying levels of exposure.
• Societal Determinants – The poli*cal-‐economic order and structures of power, in which health inequi*es derive from elite groups exercising power against oppressed groups. – Need for rec*fying unequal poli*cal power. Birn 2009
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Approaches to account for health inequi*es i.e. for the paYern of distribu*on of health 1. The Psycho-‐Social Theory / Social Capital (Wilkinson RG, Kawachi I.)
2. The Socio-‐Poli*cal / Neo-‐Materialis*c / Social Produc*on Of Health (Davey Smith G., Muntaner C.) 3. The Mul*level Eco-‐Social Theory (Krieger N., Fassin D.)
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Psycho-‐Social Theory
• Social position • The “Status Syndrome” 36
(d)
The Social (vs Societal) Determinants of Health
SOCIOECONOMIC POLITICAL CONTEXT Governance Macroeconomic Policies
Socioeconomic Position
Social Policies Labour market, Housing, Land.
Social Class Gender Ethnicity (racism)
Public Policies, Education, Health, Socialprotection,
Education
Culture and Societal value
Occupation
Material Circumstances (Living and Working, Conditions, Food Availability ,etc) Behaviors and Biological Factors Psychosocial Factors Social cohesion & Social Capital
Income Health System
STUCTURAL DETERMINANTS OF HEALTH INEQUITIES
Figure 6–4d. The WHO Commission on the Social Determinants of Health (2007).
INTERMEDIARY DETERMINANTS OF HEALTH
IMPACT ON EQUITY IN HEALTH AND WELL-BEING
--Embodiment --Pathways of embodiment --Cumulative interplayof exposure, susceptibility & resistance --Accountability Y OM N & agency O EC AL OGY C I T OL LI PO & EC
The Mul*level Eco-‐Social Theory ECOSOCIAL THEORY: LEVELS, PATHWAYS & POWER
racial/ethnic inequality
Levels: societal & ecosystem global national
Population distribution of health
class inequality historical context + generation
gender inequality
Processes: production, exchange, consumption, reproduction
regional area or group household individual
Lifecourse: in utero
infancy
childhood
adulthood
Figure 7–1. Ecosocial theory and embodying inequality: core constructs. (Krieger, 1994; Krieger, 2008a) Core constructs, referring to processes conditional upon extant political economy and political
The Issue of Intersec.onality Biological, social and cultural categories such as gender, race, class, sexual orienta*on, and other axes of iden*ty interact on mul*ple and ocen simultaneous levels, crea*ng a system of oppression that reflects the "intersec*on" of mul*ple forms of discrimina*on.
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The Issue of Intersectionality (2) “Label infant mortality a problem of ‘minori.es’ and present data only on racial/ethnic differences in rates, and the white poor will disappear from view; Label it a ‘poverty’ issue and present data stra.fied only by income, and the impact of racism on people of colour at each income level will be hidden from sight… …Any par.cular approach necessarily affects our ability to understand and alter social inequali.es in health.“ (N. Krieger 1992) 40
Barriers to Effec*ve Ac*on on the Societal Determinants of Health (Dennis Raphael, www.piY.edu/~super7/8011-‐9001/8511.ppt)
Ø Lack of Epidemiological Theory Health officials and reporters seem unaware of recent developments in social epidemiological theory and popula*on health research findings. Ø Ideology of Individualism in Health, Illness and Health Promo.on Neo-‐liberal and neo-‐conserva*ve agendas are at root of, and reinforce the individualis*c/vic*m blaming approach to health problems, absolving governments for their health threatening policies that create poverty, inequality, and social exclusion. 41
The Spirit of 1848 A Network Linking Politics, Passion, & Public Health an officially recognized caucus within the American Public Health Association http:// www.spiritof1848.org /
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