NCDs, health equity and social determinants of health

Remarks in opening expert plenary session at NCD conference in Montevideo (18 October 2017)

NCDs are a global health problem. One purpose of our meeting here in Montevideo is to plan for an NCD summit to be held in at the UN in New York in September 2018. If you attend that summit and, while there, go to Central Park for a little exercise in green space – good for mental as well as physical health –  you may find your life at risk. Mown down by hordes of high-income joggers.

Much as I applaud people taking responsibility for their health, these high-income New Yorkers are atypical. Globally, the burden of NCDs is in middle-income and, increasingly, low-income countries. Within countries, the so-called diseases of affluence are no longer; the lower people are in the social hierarchy, the higher the risk of NCDs. We cannot deal with NCDS, without dealing with the social determinants of health inequities.

There is a rumour going around that poor people are poor because they make poor choices; and that poor people are unhealthy because they make unhealthy choices. This rumour is a myth. It has the causal connection backwards. More accurately, it is not mythical that the rumour exists – I read it in the press nearly daily – but the evidence points the other way. It is not poor choices that lead to poverty, but poverty that leads to poor choices. An Indian villager is more likely to invest in longer term strategies if the harvest has been good. If it has been poor, he will focus on how to get calories for his family tomorrow, not on strategies for future prosperity. A single mother may respond to the admonition to read bed time stories to her children – it’s good for their long-term future – that she would if she could be sure that they would have a bed, let alone a book.

So it is with healthy choices. Change circumstances and people of low income are more likely to adopt the choices that are good for health. Having time to think about exercise is a luxury that people at the economic margins may not have, quite apart from lack of amenities; healthy food may be beyond a household budget. The stress of marginal employment would be happily forgone if better jobs were available.

Globally, to take effective action on NCDs, we need to address inequities in NCDs, and this entails action on the social determinants of health. What can we do?

In the wake of the WHO Commission on Social Determinants of Health, I was invited by the British Government to conduct a review to answer a question: how can we apply the findings of your global Commission to one country, England. In the Marmot Review, Fair Society Healthy Lives, we identified six domains of recommendations necessary for reducing avoidable health inequalities, promoting health equity:

• Give every child the best start in life
• Education and life-long learning
• Employment and working conditions
• Minimum income for healthy living – every one should have at least the minimum income that would enable them to live a healthy life
• Healthy and sustainable places and environments in which to live and work
• Taking a social determinants approach to prevention. Not just looking at smoking and unhealthy diet, for example, but looking at the causes of the social distribution in these behaviours – the causes of the causes.

As I have but a few minutes I encourage you to read the Marmot Review, or my book, The Health Gap. I will, though, touch on how these six are relevant to prevention of NCDS.

Early child development sets a basis for everything that follows in the life course. Good early child development, leads on to better educational outcomes, better jobs on graduation, more income, better living conditions, and longer lives. People in these favoured conditions are more empowered to make the healthy choices that will reduce the burden of NCDs.

Education is a step on this life-course journey. There has been emphasis on health literacy, very welcome, but we should not forget literacy, more generally. Better educational outcomes give people the life skills not just to negotiate the health system but to negotiate life.

Employment and working conditions are vital not just because work earns money that enables other things to happen. But conditions at work may influence stress pathways that change NCD risk, in addition to influence on healthy behaviours.

Minimum income for healthy living. Universal basic income is on the agenda. It is a health issue. Do I need to make the case for why people need enough money to live healthy lives? The Minister of Finance may have more influence on health equity than the Minister of Health.

Healthy environments. Housing, of course. Working conditions, too. But we now have estimates for the millions of deaths globally caused by air pollution, respiratory and cardiovascular deaths principal among them. Increasingly, environmental pollution is an equity issue.

Social Determinants and prevention. Alcohol is a good example. We know, in general, that the higher the mean alcohol consumption of a country, the greater the frequency of alcohol-associated problems. One strategy, then, must be to aim for lower mean consumption in the population. It is often said that we should find ways to collaborate with the private sector. But we are on a collision course with industry. The brewers don’t want to reduce mean consumption.

When we turn to inequalities and alcohol, we need a further strategy. In the UK, and other countries, the higher the socioeconomic position of people the higher their mean alcohol consumption. Harm goes the other way. The lower the socioeconomic position, the higher the risk of alcohol-related hospital admissions and alcohol-associated deaths. We need, then, to address the social causes that put people at progressively higher risk the lower they are in the social hierarchy; as well as pursuing the first strategy of reducing population mean consumption.

Increasingly health inequity means inequity in the burden of NCDs. Therefore, to address NCDs, we must address health inequity, and that means concerted action on the social determinants of health. Cross government action is a priority.