Individual choices and the social circumstances

It is now widely accepted that non-communicable chronic diseases are a global concern, rising in prevalence in rich countries and also increasingly in middle- and low income countries. The World Health Organization’s 2005 report on preventing chronic diseases dispelled the myth that chronic diseases affect only the developed countries. Annually at least 60% of all deaths worldwide are due to chronic diseases, and 80% of these occur in developing countries. (WHO 2005) Low and middle income countries are facing infectious diseases and chronic diseases, including respiratory diseases, diabetes, cardiovascular diseases and cancer. Deaths due to chronic diseases are predicted to increase in low and middle income countries over the next 20 years. (WHO 2005) Chronic diseases by their nature are diseases of potentially long duration which are likely to have a major impact on people’s quality of life.

Social gradient in health

Evidence from developed countries shows that a number of chronic conditions follow a social gradient: the lower the level in the social hierarchy, the higher the risk. There are systematic differences in health within countries between groups that can be measured by occupation, education, class, gender, ethnicity, disability, and geography. (CSDH 2008)

National data for England and Wales shows a gradient in mortality according to levels of neighbourhood deprivation, and a 2.5 fold difference between the best off and the worst off areas. (Romer/Baker/Griffiths 2006) There is a 17 year gap in disability free life expectancy between the worst off and the best off areas in England, and a gradient in between. People in deprived areas are more likely to suffer disability from chronic conditions at younger ages (55-65 years).

As developing countries undergo economic and demographic transition their disease burden changes, with non-communicable chronic disease becoming increasingly important. International comparisons of developing countries show high levels of stunting (a sign of undernutrition) in very low income countries, in countries with higher levels of national per capita income stunting decreases and levels of obesity increase. Underweight and overweight co-exist in a number of developing countries, and in some areas within the same households. (Hawkes 2007)

Childhood undernutrition is a persistent, immediate and serious problem in the world. Epidemiological studies indicate that nutritional and other factors which affect growth and development in utero and during the early years of life influence the risk in adulthood of developing certain chronic diseases such as hypertension, obesity, type 2 diabetes or cardiovascular disease. (ECDKN 2007) Growing up in societies where cultural and social norms favour being overweight as a sign of health, attractiveness and high social status, and living in the increasing obesogenic environment that accompanies urban growth led economic development contribute to the risk of chronic disease, such as hypertension, diabetes, or cardiovascular disease. The urban environment is increasingly characterised by a predominance of sedentary occupations, stress, easily available cheap high fat foods, reduced opportunities for physical activity and reliance on motorised transport, all of which contribute to the potential for increasing levels of chronic diseases.

Chronic stress is associated with increased risk of heart disease. The Whitehall longitudinal study of British civil servants, found that stress at work is associated with a 50% excess risk of coronary heart disease. Evidence from the same study shows that prolonged exposure to stress at work more than doubles the risk of the metabolic syndrome which is a cluster of the most dangerous heart attack risk factors. (Chandola/Brunner/Marmot 2006) Precarious or insecure employment conditions damage mental health. (CSDH 2008)

Responsive to social environment

As the prevalence of chronic diseases increases within developing countries, the distribution of chronic diseases shifts to resemble that in developed countries. A comparison of countries at different stages of economic development showed that in countries with lower per capita national income obesity is more prevalent in women from higher socioeconomic groups, while obesity is lower in higher socioeconomic groups in countries that have reached higher per capita national income. (Monteiro/Conde/Lu/Popkin 2004) Studies comparing body mass index (BMI) by education in Russia and the Czech Republic found that men in Russia with university education had higher BMI than men with primary education, while the reverse is true in the Czech Republic, which follows the same pattern as western European countries with higher education linked to lower BMI. (Pikhart et al. 2007)

Brazil is a rapidly developing country that has already undergone this transition in urban areas. A study on cardiovascular deaths in Porto Alegre, reported that premature mortality (deaths below the age of 65) is 2.6 times higher in lower compared with higher districts classified by socioeconomic factors. (Bassanesi/Azambuja/Achutti 2008) The distribution of premature deaths in Porto Alegre follows a gradient, with people of working age in poorer districts more affected by cardiovascular disease. Chronic disease can adversely affect the livelihoods of people who are already poor, and their families.

Gradients exist for a number of health outcomes across a number of social dimensions, in countries at all levels of development, and these gradients in health vary between countries and within countries over time. (CSDH 2008) Population health is highly responsive to the social environment. Premature mortality soared in Russia following the political, social and economic upheaval after the breakup of the Soviet Union, especially in less educated men. (Murphy et al. 2006) Between 1980 and 2001, the likelihood of surviving to age 65 for men aged 20 diminished for men with only elementary education, while it increased in men with university education. This contributed to widening the gap in life expectancy at age 20 between men with elementary education and men with university education from 3 years to 11 years during this period. (Murphy et al. 2006)

The Commission on Social Determinants of Health

The frequent response to chronic diseases such as cardiovascular disease, respiratory diseases, obesity, and diabetes, is to emphasize individual responsibility based on healthy lifestyles. The social gradient in health suggests that the individual choices people make are influenced by the social circumstances in which they live, which in turn are influenced by social, economic and political factors, and cultural norms and values.

The Commission on Social Determinants of Health (CSDH) was set up by the World Health Organisation in 2005 to collect and integrate global evidence, raise societal debate and recommend policies with the goal of improving overall population health and reducing health inequities. The Commission emphasised that systematic differences in health that are avoidable or preventable are inequitable and that it is a matter of social justice to take action to reduce health inequities. By focusing global attention on health inequities within and between countries, the Commission sought to lever public health knowledge into political action that makes a difference to people’s lives.

Explanatory framework

The Commission based its work on an explanatory framework that extended previous frameworks. (Solar/Irwin 2005) The distribution of health is influenced by differential exposures to disease-causing influences associated with social stratification by education, income, gender, race or ethnicity or by geographical area of residence. Different groups within society experience different material circumstances, psychosocial influences, behavioural choices and biological factors that can make them more or less vulnerable to disease. Differential experience of the health care sector is an important influence on distribution of health outcomes. Behavioural choices include health related behaviours that are risk factors for chronic disease, such as smoking, harmful use of alcohol, diets that are high in saturated fats, sugar and salt, and physical inactivity. The wider socioeconomic context, governance, economic and social policy, and cultural and societal norms and values affect the nature and level of social stratification and the differential exposure and vulnerability of groups to health damaging conditions. (CSDH 2008)

The fundamental driver of health inequities is the unequal distribution of power, money and resources within and between countries. The Commission argued that empowerment is the key to improving health equity, describing empowerment in three dimensions operating at individual, community and national level – the material requirements for a decent life, psychosocial – control over one’s life, and political – participation in the decisions that affect lives. To improve the distribution of health, the Commission outlined three principles of action:
1) improve the circumstances in which people are born, grow, live, work and age,
2) tackle the structural drivers of these conditions – the distribution of power, money and resources, and
3) measure the size of the problem and evaluate action.

The Commission identified systemic drivers for change, connected with the distribution of power, money and resources, and made recommendations in the areas of: health equity in all policies, good global governance, fair financing, market responsibility, gender equity, and political empowerment – inclusion and voice. Recommendations to improve the conditions of daily living focused on early life and education, healthy places, social protection, fair employment and universal health care.

The Commission emphasised the importance of coherent action across a number of thematic areas, and made recommendations aimed at multilateral agencies and the WHO, national and local governments, civil society, private sector and research institutions. How the recommendations are taken forward within countries depends on local, national and regional priorities depending on context. A number of countries and regions are in the process of translating the Commission’s recommendations to develop strategies relevant to their own context. In England, for example, the Government commissioned the independent Strategic Review of Health Inequalities in England Post 2010 (the Marmot Review), chaired by Sir Michael Marmot, to review the evidence and advise on strategies to improve health equity in England. (www.ucl.ac.uk/gheg/marmotreview)

Health equity in all policies

Economic and social inequalities underpin the health inequities we see between countries and within countries. Asymmetries of power in the global economy and within countries have contributed to the uneven distribution of the benefits of economic growth over the last 25 years. (GKN 2007) There has been a decline in global poverty, measured by the number of people living under US$2/day between 1980 and 2005, with most of this decline accounted for by China. (Chen/Ravallion 2008) The number of people living in poverty at under US$2 a day in India and sub Saharan Africa has increased.

Evidence from developing countries shows that even relatively modest distributive social policies can contribute to poverty reduction. In Brazil, the Family Stipend Programme, or Bolsa Familia, a form of conditional cash transfer targeted at poor and extremely poor families has mitigated some effects of extreme poverty and reduced inequality. Evidence from high income countries shows that more generous and universal social policies are associated with lower levels of poverty, better population health and better outcomes for socially disadvantaged groups. (CSDH 2008)

Whole range of approaches

Health is not only affected by policies in the health care sector but by policies in areas across the whole of government, such as trade, education, agriculture and employment. A coherent approach across policy areas is necessary to tackle health inequities. The expansion and integration of global markets and the increased transnational flow of goods, services and capital that characterise processes of globalization since the 1970s mean that coherent approaches are necessary between countries as well as within countries. For example, there are a whole range of approaches that have potential to combat the increasing prevalence of obesity, diabetes, and cardiovascular disease, including ensuring availability and affordability of nutritious food through agricultural and trade policies, poverty reduction measures, improved availability and accessibility of maternal and child care, fair employment practices that ensure a living wage, and less stressful employment and working conditions, urban planning to encourage access to healthier food options and participation in physical activity, bans on advertising for food high in fats and sugars during television programmes aimed at children, food labelling, reductions in salt content of processed foods, and healthy options offered for school dinners. (CSDH 2008) These approaches need to be extended to developing countries.

Diets high in fat, sugar and salt, physical inactivity, stress, misuse of alcohol, indoor air pollution from cooking, tobacco smoking – all contribute to the increasing burden of chronic disease, and they are all influenced by the environments in which people live. Living conditions and health-related behaviours are influenced by the wider social, economic and political context in which people live. Smoking is more prevalent in lower socioeconomic groups in countries at all stages of development, but there is a higher prevalence of smoking overall in lower middle income countries than low income countries. The international response to smoking led to the Framework Convention on Tobacco Control which came into force in 2005. It is the first treaty negotiated through the World Health Organization and 167 countries have signed up to it. Yet half of all countries in the world do not implement any of the WHO’s five recommended policies for tobacco control. (WHO 2008)

The ‘implementation gap’ was a major theme of the World Health Organization’s 7th Global Health Promotion Conference held in Nairobi in November 2009. The Call to Action from the Nairobi Conference reflected widespread agreement that, while more research and evidence is needed, there is extensive knowledge on how to improve health and to reduce health inequities, but this knowledge is not applied consistently, or where it is most needed.

Global, national and local action

In summary, there is evidence that there is a growing epidemic of chronic diseases in developing countries, evidence that action needs to take place on the social determinants of chronic diseases, and evidence that action needs to take place at global, national and local levels. Chronic diseases need to be pushed higher up the global development agenda. At national and local levels intersectoral action is necessary across government, and at local levels, community empowerment is needed so that communities can control the influences on their health.

*Ruth Bell is a Senior Research Fellow in the Department of Epidemiology and Public Health at University College London. She was a member of the scientific Secretariat and final report writing team within the Commission on Social Determinants of Health (CSDH, 2005 - 2008) that was set up by the World Health Organization. She is active in research and advisory roles to advocate and implement the global health agenda for health equity set out by the CSDH. Contact: r.bell@ucl.ac.uk

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