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1
erColloque de l’ITMO Sante´ Publique (Aviesan)
De´terminants sociaux de la sante´ : les apports de la recherche en sante´ publique Paris, 26 octobre 2012
De´terminants sociaux des ine´galite´s de sante´ : une priorite´
absolue pour la recherche en sante´ publique
Social determinants of health inequalities: A public health research priority
L’alliancenationalepourlessciencesdelavieetdelasante´
(AVIESAN)estuncadresoupledecoordinationdel’ensemble desacteursdelarecherchepubliquedudomainebiome´dicalet sanitairemisenplacedepuis2009.Lesyste`medesalliances, dontAVIESANestundescinqpiliers1,s’estvureconnaıˆtreun roˆle strate´gique dans la programmation et l’animation de l’ensembledelarechercheenFrancea` l’occasiondesassises nationalesdel’enseignementsupe´rieuretdelarecherchequise sont de´roule´es au cours de l’e´te´ et de l’automne 20122. AVIESANachoisidesestructurerendixinstitutsthe´matiques multi-organismesdontl’Institutthe´matiquedesante´ publique (ISP).
Lepremiercolloquedel’ISP,dontrendcomptecenume´rode laRevue d’E´ pide´miologie et deSante´ Publique,s’est tenu le 26octobre2012surlethe`medes«De´terminantssociauxdela sante´ : les apports de la recherche en sante´ publique ». Ce colloquearappele´ troisgrandese´vidences,de´sormaisconforte´es parunemultitudedere´sultatsderecherche,etquisontde´cline´es parlesdiffe´rentescontributionspre´sente´esdanscenume´ro.
Lapremie`ree´videncee´taitde´ja` aucœurdurapportd’aouˆt 2008delacommissionsurlesde´terminantssociauxdelasante´ de l’Organisation mondiale dela sante´, pre´side´e parl’e´pide´mio- logiste britannique Sir Michael Marmot, qui s’exprime ici conjointementavecsoncolle`guePeterGoldblatt.Ilsouligneque les ine´galite´ssocialesde mortalite´ et d’espe´rancedevie sans incapacite´ sontmalheureusement un phe´nome`neuniversel, et celaquellesquesoientlesvariablesutilise´espourrendrecompte
dugradientsocial(cate´gorieprofessionnelle,niveauderevenu, niveau d’e´ducation,etc.) [1].De plus, en de´pitde l’e´le´vation ge´ne´rale du niveau de vie et de sante´ des populations, ces ine´galite´sseperpe´tuentvoires’aggraventpartoutdanslemonde [2]. Les recherches attirent e´galement l’attention sur le fait qu’au-dela` ducaracte`reuniverselduphe´nome`ne,cenesontpas toujours les meˆmes pathologies ou proble`mes de sante´ qui contribuentprioritairementa` alimentercesine´galite´s:ainsien France,a` ladiffe´renceduRoyaume-Unietdespaysscandinaves, ce sont les pathologies cance´reuses qui sont les principales pourvoyeusesd’ine´galite´s[3].
Toutesles contributionsdecenume´ro illustrentleschaıˆnes causales complexes quiconduisent desine´galite´ssocioe´cono- miques,ge´ographiquesoudegenre,ainsiquediffe´rentesformes de vulne´rabilite´ culturelleetsociale,a` setraduireende´terminants d’ine´galite´sdesante´.Cesme´canismesinterviennenta` tousles aˆges delaviedesindividus:l’articledeMarie-Aline Charles rappelle que les conditions de de´veloppement durant la vie embryonnaireetfœtalepeuventavoirunimpactdurablesurla sante´ ulte´rieure de l’individu et que certaines carences ou perturbations nutritionnelleschez lame`re, voire chezle pe`re, peuvent meˆmemodifier durablement desmarqueurs e´pige´ne´- tiques chez la descendance, ce qui a une incidence sur l’expression des ge`nes et les adaptations physiologiques de l’individu a` son environnement [4,5] ; alors que celui de Dartiguesetal.discute,autraversdel’exemplede larelation entre niveau d’e´ducation et de´mences, le roˆle des facteurs sociauxdansl’incidencedesmaladieschroniqueslie´esa` l’aˆge.
D’autres contributions, comme celle de Rosemary Dray- Spira,appellentl’attentionsurlarelationinversequi,a` l’avenir, devrait se voir consacrer un nombre plus important de recherches : en quoi un choc de sante´ ou/et l’installation d’unepathologiechronique,peuventcontribuera` aggraverles ine´galite´ssocialesete´conomiquespre´existantesvoireentraıˆner lespatientsetleurentouragedansunprocessusdede´gradation www.sciencedirect.com
Revued’E´ pide´miologieetdeSante´ Publique61S(2013)S123–S125
1Outre AVIESAN,ont e´galement e´te´ constitue´es l’alliancenationale de coordinationde larecherchepour l’e´nergie(ANCRE), l’alliancenationale derecherchepourl’environnement(AllEnvi),l’alliancedessciencesettech- nologiesdu nume´rique (ALLISTENE) et l’alliance nationale des sciences humainesetsociales(ATHENA).
2Assisesdel’enseignementsupe´rieuretdelarecherche.RapportauPre´si- dentdelaRe´publique,17de´cembre2012,Paris(http://www.assises-esr.fr/).
0398-7620/$–seefrontmatter#2013Publie´ parElsevierMassonSAS.
http://dx.doi.org/10.1016/j.respe.2013.05.012
deleur situationsociale.Lesanalysesconduitesa` partirdela premie`reenqueˆtenationalede2002surlessurvivantsaucancer deuxansapre`slediagnosticonte´galementpermisdemontrer detelseffetsentermesdemoindreparticipationaumarche´ du travailouplusge´ne´ralementdede´te´riorationdesconditionsde viedesme´nagesfrappe´sparlamaladie[6].Lare´e´ditiondecette enqueˆte, re´alise´e en partenariat entre l’Institut national du cancer(INCa)etl’Insermetdontlacollectededonne´ess’est termine´eaude´but2013,devrait permettred’ame´liorerencore nosconnaissancessurcetterelation.
Enfin, comme nous y incitent, chacune a` leur fac¸on, les contributionsd’e´conomistes (Alain Trannoy, Andrew Clark), d’e´pide´miologistes(JoelleKivitsetal.)etdesociologues(Peter Hall et al.), la compre´hension des ine´galite´s de sante´ doit s’inscriredanslesdimensionsplusvastesd’analysesglobales delaqualite´ devieetdubien-eˆtreenarticulantlesde´terminants individuelsaveclesphe´nome`nescollectifsdecomparaisons,de compe´titionmais aussidesolidarite´ sociales.
Ladeuxie`me e´videnceestquel’essentieldesine´galite´sde sante´ se joue en amont ou a` coˆte´ du syste`me de soins proprementdit.Certes,ende´pitduprincipee´galitairedenotre se´curite´ socialeetdeseffets redistributifsde ce principe,qui sontanalyse´sende´taildansl’articledeNathalieFourcadeetal., il subsiste des variations dans l’acce`s et la qualite´ dessoins prodigue´sauxpersonnesatteintesd’unemeˆmepathologie,qui contribuent sansnul doute aux ine´galite´ssociales etge´ogra- phiquesde mortalite´ et de morbidite´. Florence Jusot discute danssacontributiondestendancestemporellesd’e´volutionde cesine´galite´sa` l’e´garddusyste`me desoins.
Iln’endemeurepasmoinsquelesfacteursexplicatifsdela surmortalite´ qui frappe les cate´gories les moins favorise´es, interviennentpour l’essentiel enamont de laprise encharge proprement me´dicale des diffe´rentes pathologies. Ces ine´ga- lite´s de mortalite´ re´ve`lent d’abord un e´chec relatif de la pre´vention dans notre pays (par rapport a` d’autres pays comparables comme la Grande-Bretagne). Les cate´gories de´favorise´es cumulent en effet les facteurs de risque des principales pathologies : expositions plus fre´quentes a` des facteurs de risque environnementaux (toxiques cance´rige`nes danslemilieuprofessionnel;polluantsatmosphe´riquesdansla zoned’habitat),pre´valence pluse´leve´edesfacteursde risque comportementauxlie´sauxmodesdevie(tabac,alcool,facteurs nutritionnels,etc.), moindreacce`sauxde´pistagespre´coces et diagnosticplustardifdespathologiesgraves.
A` la demande de son conseil scientifique international, l’INCa a produit en de´cembre 2012, en partenariat avec l’Institutdesante´ publique d’AVIESAN,unrapportsurl’e´tat des lieux de la recherche en matie`re de « changements de comportementslie´sa` lasante´ etleursde´terminantsindividuels etcollectifs»3.Cerapport plaideavecvigueurpouruneffort spe´cifiqueetsoutenuderecherches,a` vise´esa` lafoiscognitives etinterventionnellesenpopulations,enmatie`redepre´vention
primairedansnotrepays.A` l’avenir,l’Institutthe´matiquemulti- organismes sante´ publique d’AVIESAN s’efforcera de faire convergerl’actiondesnombreuxpartenairesconcerne´spourun soutien,sipossibleunifie´,a` larechercheenpre´ventionprimaire, enparticulierdanslecadredugroupementd’inte´reˆtscientifique (GIS)–Institut de recherches en sante´ publique (IReSP), qui associelesorganismesderechercheauxprincipauxde´cideurset financeursdelasante´ publiqueetdelaprotectionsociale.
L’objectifdede´velopperdesrecherchesvisanta` promouvoir descomportementsfavorablesa` lapre´ventionetaumaintienen bonnesante´ n’estbiensuˆr,enaucuncas,synonymed’adhe´sion a` un quelconque paradigme « individualiste » ou
« moralisateur » [7]. Comme l’illustreBasile Chaix dans sa contribution,lapromotiondel’activite´ physique,unanimement reconnuecomme undese´le´ments essentielsde lapre´vention des pathologies chroniques en ge´ne´ral, suppose par exemple une compre´hension fine du roˆle des transformations de l’environnement baˆti et social comme de´terminants de la se´dentarite´.Demeˆme,lacontributiondePatrickPeretti-Watel souligne l’importancede la recherche en scienceshumaines, e´conomiques et sociales pour faire prendre conscience aux de´cideurs que des actions de de´pistage et de pre´vention,au de´part les mieux intentionne´es, peuvent involontairement aggraver lesine´galite´s, etpour identifierles moyenslesplus adapte´safind’e´viter oulimiterdetelseffetspervers.
La troisie`me e´vidence qui ressort de la recherche internationale sur les ine´galite´s de sante´ incite a` proposer desmodalite´sinnovantesetrisque´esderechercheeta` inscrire plusdirectementlarechercheensante´ publiqueauservicede l’action. Il est clairque la recherche ne doit plus seulement porter sur la mesure des ine´galite´set sur leurs de´terminants mais aussi sur la de´finition et l’e´valuation rigoureuse d’interventionsetdepolitiquespubliquesvisanta` lesre´duire.
Les expe´riences de terrain conduites au Que´bec ou dans certaines villes europe´ennes comme Birmingham en Angle- terre,GlasgowenE´ cosseouMalmo¨ enSue`de,commecelles ques’efforcentdesoutenirenFrancelere´seauVilles/sante´ de l’OMSetl’Institutnationaldepre´ventionetd’e´ducationpourla sante´ (INPES),confirmentquecesinterventionsnepeuventse contenterd’impliquerleseulsyste`medesoinsmaissedoivent d’eˆtreintersectoriellessiellesveulenteˆtreefficaces[8].Touten maintenantdesexigencesabsoluesdequalite´ etdevalidation des re´sultats par la publication dans les meilleures revues scientifiques, il nous faut promouvoir des recherches moins acade´miques, non pas dans la rigueur de leur me´thodologie, mais dans leurcaracte`re derecherche interventionnelle, dans leurs objectifs mieux tourne´s vers l’aide a` la de´cision et l’action,etdansleursmodalite´sdemiseenœuvrequidoivent associerplusdirectementauxchercheurslesprofessionnelsde sante´, mais aussi (peut-eˆtre meˆme surtout) les patients eux- meˆmes,leursprochesetleursassociations.
Contrairementa` uneide´erec¸ue,laproductivite´ scientifique delarechercheensante´ publiqueenFranceestbonne:quand on utilise les bons indicateurs bibliome´triques, si re´ducteurs soient-ils,onserendmeˆmecomptequ’ellefiguredanslescinq domaines les plus performants de la recherche biome´dicale franc¸aiseparexemple,enproportiond’articlespublie´sdansles
3http://www.e-cancer.fr/publications/91-recherche/624-http://www.e-cancer.
fr/publications/91-recherche/624-les-changements-de-comportements-a-risque- de-cancer-et-leurs-determinants-individuels-et-collectifs.
1erColloquedel’ITMOSante´ Publique(Aviesan)/Revued’E´ pide´miologieetdeSante´ Publique61S(2013)S123–S125 S124
10% ou1 %de revueslesplusprestigieuses desdisciplines concerne´es. Le proble`me tient moins a` la qualite´ de notre recherchequ’a` notredifficulte´ a` fondernospolitiquesdesante´
surlese´videncesscientifiquesproduitesparcetterecherche.S’il este´tabliquemoinsd’unquartdelapratiqueme´dicalecourante estve´ritablement«fonde´esurl’e´videncescientifique»,ausens de reposant sur des essais cliniques controˆle´s ou/et sur une compre´hensiondesme´canismesphysiopathologiquesimplique´s, cetteproportionestbienmoindrepourcequiestdespolitiques publiques de sante´ et de pre´vention [9]. Notre pays est inde´niablementenretardparrapporta` beaucoupdenosvoisins europe´enssurcepointdelapolitiquedesante´ «fonde´esurles preuves»(evidence-basedhealthpolicy).
Pourlapremie`refoisdansl’histoiredespolitiquesdesante´
denotrepays,ledeuxie`meplancancer(2009–2013),construita`
partirdurapportduPrJean-PierreGru¨nfeld,avaitfaitdelalutte contre lesine´galite´s,non pas unsimpleindicateur parmides dizaines d’autres, mais la priorite´ centrale de toute l’action publique face aux cancers4. Le Pre´sident de la Re´publique franc¸aise a re´affirme´ cette priorite´ en de´cembre 2012, non seulementpourletroisie`meplancancer,maispourl’ensemble delapolitiquedesante´ publique,quidoitd’ailleursfairel’objet d’unde´batdefonda` l’occasiondelare´visiondelaloidesante´
publiqued’aouˆt2004queleparlementdevraitexaminerdans les mois a` venir5. Il y a dans ce contexte une opportunite´
historique pour que la communaute´ de recherche en sante´
publique de notre pays contribue directement a` ce que les de´cideurspolitiquesfassent(enfin)deschoixmieuxa` meˆmede concilier,d’unepart,l’efficiencedansl’ame´liorationdelasante´
de la population et, d’autre part, la justice sociale par la re´ductiondesine´galite´s. Cenume´rodelaRevued’E´ pide´mio- logieetdeSante´ Publiquenousaidera,jel’espe`revivement,a`
sesaisirdecette opportunite´.
Re´fe´rences
[1] MarmotSM. Closing thehealth gap in a generation:thework ofthe CommissiononSocialDeterminantsofHealthanditsrecommendations.
GlobalHealthPromot2009;16(1):S23–7.
[2] LeclercA,ChastangJF,MenvielleG,LuceD.Socioeconomicinequalities inprematuremortalityinFrance:havetheywidenedinrecentdecades?Soc SciMed2006;62:2035–45.
[3] Saurel-Cubizolles MJ, ChastangJF, Menvielle G,Leclerc A, LuceD, EDISCGroup.Socialinequalitiesinmortalitybycauseamongmenand womeninFrance.JEpidemiolCommunityHealth2009;63:197–202.
[4] deRooijSR,WoutersH,YonkerJE,PadinterRC,RoseboomTJ.Fromthe cover:prenatalundernutritionand cognitivefunctionin lateadulthood.
PNAS2010;107(39):16881–6.
[5] SommerA.DOHAD:from‘‘hypothesis’’topractice.JDevOrigHealthDis 2012;3:2–3.
[6] MarinoP,Sagaon-TeyssierL,MalavoltiL,LeCorroller-SorianoAG.Sex differencesinthereturn-to-workprocessofcancersurvivors2yearsafter diagnosis: results from a large French population-based sample. JCO 2013;38:5401[PublishedonlineonJanuary28,2013].
[7] Peretti-WatelP,MoattiJP.Leprincipedepre´vention.Lecultedelasante´ et sesde´rives.Paris:EdsduSeuil,LaRe´publiquedesIde´es;2009.
[8] PotvinL,MoquetMJ,JonesC.Re´duirelesine´galite´ssocialesensante´.
Saint-Denis:INPES,coll.Sante´ enaction;2010.
[9] BuseK,MaysN,Walt G.Making healthpolicy(understandingpublic health).Maidenhead(UK):OpenUniversityPress(MacGrawHillInter- national);2005.
J.-P.Moatti Professeurd’e´conomiede lasante´
(universite´ d’Aix-Marseille– AMSE), Directeurdel’Institutthe´matiquemulti-organismes desante´ publique,Alliancenationalepour lessciencesdelavieetdelasante´ (AVIESAN), 101,ruedeTolbiac,750013Paris,France Adressee-mail:jean-paul.moatti@inserm.fr
4www.e-cancer.fr/plancancer-2009-2013.
5http://www.elysee.fr/declarations/article/discours-du-president-de-la-repu- blique-aux-journees-annuelles-du-cancer/.
1
erColloque de l’ITMO Sante´ Publique (Aviesan)
De´terminants sociaux de la sante´ : les apports de la recherche en sante´ publique Paris, 26 octobre 2012
Action on the social determinants of health
Agir sur les de´terminants sociaux de la sante´
M. Marmot * , R. Bell, P. Goldblatt
UCLInstituteofHealthEquity,UniversityCollegeLondon,1-19TorringtonPlace,LondonWC1E7HB,UnitedKingdom Received6May2013;accepted17May2013
Abstract
ClosingtheGapinaGeneration,thefinalreportoftheCommissiononSocialDeterminantsofHealth(CSDH)proposedthatinequitiesin power,moneyandresourceswereresponsibleformuchoftheinequalitiesinhealthwithinandbetweencountries.Atoxiccombinationofpoor policiesandprogrammes,unfaireconomicarrangementsandbadgovernanceledtoinequalitiesintheconditionsofdailylife:thecircumstancesin whichpeopleareborn,grow,live,work,andage.Ourmessageisthatthereneedstobeacross-governmentcommitmenttoactiononsocial determinantsofhealth.Withthiscommitment,theknowledgesynthesisedinourreportsuggeststhatthereismuchthatcanbedoneatthepractical level.
#2013ElsevierMassonSAS.Allrightsreserved.
Keywords:Socialdeterminants;Socialinequalities;WHO;Daily-livingconditions Re´sume´
Lerapportintitule´Comblerlefosse´ enunege´ne´rationdelaCommissionsurlesde´terminantssociauxdelasante´ del’OMSsugge`requeles ine´galite´sdepouvoir,d’argentetderessourcessontresponsablesd’unegrandepartiedesine´galite´sdesante´,quecesoitauseind’unmeˆmepaysou entre diffe´rents pays. Un ensemble depolitiques et de programmes insuffisants,de dispositions e´conomiques ine´quitables et demauvaise gouvernanceaconduita` desine´galite´sdanslesconditionsdeviequotidienne,a` savoirlescirconstancesdanslesquelleslesindividusnaissent, grandissent,vivent,travaillentetvieillissent.Lemessagequenousfaisonspasserestqu’ilyaunre´elbesoind’engagementintergouvernemental pouragirsurlesde´terminantssociauxdelasante´.Lese´le´mentsdurapportsugge`rentque,parcetengagement,beaucoupdechosespeuventeˆtre misesenplacedemanie`reconcre`te.
#2013ElsevierMassonSAS.Tousdroitsre´serve´s.
Motscle´s: De´terminantssociaux;Ine´galite´ssociales;OMS;Conditionsdevie
1. Anewapproachto health,globallyandnationally In2008,theWorld HealthOrganisation(WHO)published Closing the Gap in a Generation, the final report of the Commission on Social Determinants of Health (CSDH) – chaired by Michael Marmot [1]. The CSDH,acknowledging
thatglobalhealthhadrevolvedarounddisease controlefforts and development of health systems, stated thatinequities in power,moneyandresourceswereresponsibleformuchofthe inequalities in healthwithin and between countries.We said that a toxic combination of poor policies and programmes, unfair economic arrangements and bad governance led to inequalitiesintheconditionsofdailylife:thecircumstancesin whichpeopleareborn,grow,live,work,andage.Itisinequality intheseconditionsofdailylifewhichleadstoinequalitiesin health between groups defined by socioeconomic position, ethnicityorgeographicresidence.
Availableonlineat
www.sciencedirect.com
Revued’E´ pide´miologieetdeSante´ Publique61S(2013)S127–S132
*Correspondingauthor.
E-mailaddress:m.marmot@ucl.ac.uk(M.Marmot),r.bell@ucl.ac.uk (R.Bell),p.goldblatt@ucl.ac.uk(P.Goldblatt).
0398-7620/$–seefrontmatter#2013ElsevierMassonSAS.Allrightsreserved.
http://dx.doi.org/10.1016/j.respe.2013.05.014
Basedon thisunderstanding,the CSDHmaderecommen- dations.
First, infive areasgrouped underdaily-livingconditions:
equity from the start – the importance of early child developmentandeducation;
healthy place healthy people – dealing with housing and environmentalconditions;
fairemploymentanddecentwork;
socialprotectionacrossthe lifecourse;
universalhealthcare.
Second, in six areas grouped under the inequitable distributionofpower,moneyandresources:
healthequityinallpoliciessystemsandprogrammes;
fairfinancing– nationallyandinternationally;
marketresponsibility;
genderequity;
politicalempowerment, inclusionandvoice;
goodglobalgovernance.
Third,inordertomeasureandunderstandtheproblemand assess the impact of action, there was need for monitoring researchandtraining.
Withaglobalreportitwasamajorchallengetoformulate recommendations suitable for 193 countries, with different histories, cultures, socioeconomic conditions, environments and governments. We made a virtue of necessity and recommendedthateffortsshouldbemadeatregional,country orsub-countryleveltodevelopspecificplanstoimplementour recommendations. Much has happened [2]. In Britain, the government commissioned Michael Marmot to conduct a strategicreviewofhealthinequalitiesinEnglandtoreviewnew evidenceand‘‘translate’’the CSDHrecommendations intoa formsuitableforaction,nationallyandlocally.Thetitleofthe MarmotReview’sfinalreport,FairSocietyHealthyLives[3], wasastatementthatifweputfairnessattheheartofallpolicy makingthehealthofthepopulationwouldimproveandhealth inequalitieswoulddiminish.
Socloseisthelinkbetweensocialandeconomicconditions and health, we argued, that fairness of policies could be assessedbytheirsuccessinreducingavoidableinequalitiesin health.AmeasureoftheimpactoftheReviewisthattwothirds oflocalauthoritiesinEnglandhavedevelopedimplementation plansbasedonitsrecommendations.
Inthewakeofthesetworeports,thedirectoroftheEuropean RegionofWHO,DrZsuzsannaJakab,commissionedMichael MarmottoleadaconsortiumtoconducttheEuropeanReview ofSocialDeterminantsofHealthandtheHealthDivide.What follows is based on the work underpinning this European Review.TheExecutiveSummarywaspublishedin2012[4].
2. Inequalitiesin healthbetween andwithincountries Tables1aand1bshowlifeexpectancyforselectedcountries intheEuropeanRegion.Amongwomen,thereisa10-yeargap
inlifeexpectancybetweenRussiaandtheUkrainetothe‘‘east’’
andSpain,France,Italy,andSwitzerlandtothe‘‘west’’.Forthe CentralAsianrepublics,lifeexpectancyis12yearslowerthan thebestintheRegion.Amongmen,thedifferencesarebigger:
a 17-year gap between Russia and the healthiest countries.
Womenlivelongerthanmenbutalsohavemoreyearsspentnot ingoodhealth.Itisareminderthatitisvitaltokeepfocuson qualityoflifeas wellaslengthoflife.
Manycountrieshavenowproducedevidenceofinequalities in health within countries. The Eurothine1 Study compared inequalitiesinhealthaccordingtoeducationacrossEurope.All countries show such health inequalities – the lower the education the higher the mortality – but the inequalities are biggerinSlovenia,the CzechRepublic, Poland,Estonia,and Lithuania than they are in countries of Western Europe [6].
Therehasbeenmuchdiscussionofwhetherhealthinequalities are smaller in the Nordic welfare states. This remains unresolved[6–9].
Table1a
Malelifeexpectancy–WHOEuropeanRegion.
Country Year Lifeexpectancy
Highest
Israel 2009 80
Iceland 2009 80
Sweden 2010 80
Switzerland 2007 80
Lowest
Ukraine 2010 65
RepublicofMoldova 2010 65
Kyrgyzstan 2009 65
Belarus 2009 65
Kazakhstan 2009 64
RussianFederation 2009 63
Source:WHOHealthforAlldatabase[5].
Table1b
Femalelifeexpectancy–WHOEuropeanRegion.
Country Year Lifeexpectancy
Highest
Spain 2009 85
France 2008 85
Italy 2008 85
Switzerland 2007 85
Lowest
Ukraine 2010 75
RussianFederation 2009 75
Turkey 2008 74
Kazakhstan 2009 74
RepublicofMoldova 2010 74
Uzbekistan 2005 73
Kyrgyzstan 2009 73
Source:WHOHealthforAlldatabase[5].
1Project‘‘TacklinghealthinequalitiesinEurope’’(Eurothine)-ErasmusMC -UniversityMedicalCentreRotterdam,TheNetherlands.
AstrongcaseputforwardbytheNEWSgroup,convenedto examinetheNordicExperienceofWelfareStates(NEWS),is that one marker of success in tackling health inequalities is improvementinhealthinthemostdisadvantaged[7].Inmany countries of the European Region, we have indeed seen improvements in life expectancy in the most disadvantage groups.But,improvementhasbeengreaterinmoreprivileged groupswiththeresultthathealthinequalitieshaveincreasedin manycountries[3,10,11].
3. FrameworkfortheEuropeanReviewofSocial Determinantsof HealthandtheHealthDivide
TheEuropeanReview,inthetraditionoftheCSDH,adopted theCSDHconceptualframework[1].Theformthishastaken for the European Review is to group our analysis and recommendationsunderfourheadings:
lifecoursestage;
widersociety;
macrolevelcontext;
systems.
In this paper we present examples of the evidence that underpinnedtheEuropeanReview’srecommendations[4].
3.1. Earlychildhoodandeducation
The CSDH emphasised thatearly childhood development embracescognitiveandlinguisticdevelopmentandsocialand emotionaldevelopmentinadditiontogoodphysicaldevelop- ment.Allthreedimensionsareimportantforanequitablestart in life that will, through the life course, influence health inequalitiesinadultlife.
Inequitiesintheconditionsaffectingchildrenvarymarkedly among OECD (rich) countries as shown in Table 2 [12].
Denmark,Finland,The Netherlands,Switzerlandhave achie- vedanequitable distributionof the conditions markingchild well-being. Other rich countries have done much less well.
Basedoncurrentknowledge,itisentirelyfeasibletoenvisage howacountrycouldmoveuptheequity ranking.
Attendanceatpre-schooleducationismarkedlyunequalin manycountries–childrenfromhigherincomefamilies being more likely to attend. This has consequences. Countries participate in the Programme on International Student Assessment (PISA) which tests young people at age 15.
Fig.1showsthatchildrenwhoattendedpre-schoolforatleast oneyearhavebetterPISAscoresthanthosewhodidnot[13].
Some of the apparent benefit can be traced to the fact that children from higher socioeconomic backgrounds are more likely to attend pre-school. Even allowing for that, the advantageinbetterscholasticperformanceistheretobeseen.
It is likely that children with better PISA scores will secure better educational qualifications, go on to better jobs, with higher incomes,morefavourablelivingconditionsandbetter health.
We speak of socioeconomic background, rather than poverty, because the outcomes in which we are interested showasocialgradient–thehigherthesocioeconomicposition thebettertheoutcome,beitchilddevelopmentorhealth.That said, poverty isimportant as it representschildren below an acceptablethreshold.Fig.2showsthatlevelsofchildpoverty (defined as living ina family withless than 60% of median income) can be greatly affected by government policy. For example,beforetaxesandtransfers,inAustria41%ofchildren wereclassifiedaslivinginpoverty;higherthanthe35%figure inLatvia.Aftertaxesandtransfers,thepovertyrateis14%in Austria; 25% inLatvia [14]. The level of child povertywill influence child development and subsequent health. Policy makes adifference.
Fig.3illustratesthattwokindsofpoliciesareneeded.The datacomefromlocalauthoritiesinEngland.Afterpublishing theMarmotReviewin2010,inthetwosubsequentyears,for every local authority we published figuresfor five measures relevanttoSDH2:earlychild development;the proportionof
Table2
Countryranking:equalityinchildwell-being–material,education,andhealth.
Score Country
8 Denmark,Finland,Netherlands,Switzerland 7 Iceland,Ireland,Norway,Sweden
6 Austria,Canada,France,Germany,Poland,Portugal
5 Belgium,CzechRepublic,Hungary,Luxembourg,Slovakia,Spain, UnitedKingdom
3 Greece,Italy,UnitedStates
Source:UNICEFReportCard 9[12],ranking24OECD countriesbytheir performanceineachofthreedimensionsofinequalityinchildwell-being.
Rankseachcountrybyitsoverallinequalityacrossthreedimensionsofchild well-being.Threepointswereawardedforabetterthanaverageperformance, twopointsforaperformanceatorclosetotheOECDaverage,andonepointfor abelowaverageperformance.Countriesinalphabeticalorderwithingroups.
Fig.1. DifferencesinPISAscoresbyattendingpre-schoolformorethanone yearbeforeandafteraccountingforsocioeconomicbackground.
Source:OECDPISA2009database[13].
2SocialDeterminantofHealth.
M.Marmotetal./Revued’E´ pide´miologieetdeSante´ Publique61S(2013)S127–S132 S129
16–18-year-oldnotineducation,employment,ortraining;an adultpovertymeasure;lifeexpectancy;anddisability-freelife expectancy. The proportion of children rated as having a
‘‘good’’level ofchild developmentwhen theystartschoolis plottedagainstthe levelof deprivationof thelocal authority.
Localauthoritieswithhigherranks(leastdeprived)havemore childrenwitha‘‘good’’ranking. Thegradedrelationbetween affluence and early child development fits with the expert advicesubmittedtotheMarmotReview:toreduceinequalities in early child development we must reduce inequalities in society. Reductionof poverty,as justdiscussed inrelationto Fig.2,isonestrategy.
ButFig.3 showsvariationaroundtheline:atanylevelof deprivationsomelocalauthoritieshaveahigherproportionof their children rated as havinga ‘‘good’’ level of early child development than do others. It is possible to break the link betweenlevelofdeprivationandearlychilddevelopment.For example,theEnglishcityofBirminghamismoredeprivedthan theaverageforEngland.Asexpected,theirlevelsofearlychild development were worse than the England average. By introducingaprogramme,‘‘BrighterFutures’’,theywereable tobringlevelsofchilddevelopmentinBirminghamuptothe Englandaveragewithin 3years[16,17].
There is a general lesson to be learnt from the child developmentexample.Weneed tohaveatleasttwodifferent strategiestoreducesocialinequalitiesinhealth:reducesocial and economic inequalities in society; and, with better understanding of the causal mechanisms, break the link between level of deprivation or affluence and the outcome relevant tohealth – early child development inthe case just discussed.
3.2. Employmentandworking conditions
All over Europe there isevidence of aconsistent pattern:
with the economic downturn and a rise in unemployment, particularly affecting young people, the lower the level of education,thegreaterthelikelihoodofunemployment[18].We canseethelifecourseeffectinaction. Alowerlevelofearly childdevelopmentimpliesalowerlevelofreadinessforschool, worse performance in school, and greater likelihood of unemploymentwithadverseeffectsonhealth[19,20].
Employment is good for health but the quality of work matters.Abodyofresearch,focussedonthepsychosocialwork environment,showsparticularly thattwofeaturesofthework environmentarerelatedtoincreasedriskofphysicalandmental
Fig.2. Child poverty ratesless than60% median beforeand after social transfers,2009.
Source:EUSILC[14].
Fig.3. Childrenachieving a good levelof developmentatagefive, local authorities2011,England.
Source:LHO(2012)[15].
Fig.4. Percentreportingwork-relatedstressinEuropeancountriesbyoccu- pationalclass.
Source:WahrendorfandSiegrist,2011[21].
disease:highdemandsandlowcontrol;andimbalancebetween effortandreward.Fig.4showsthatbothlowcontrolandeffort reward imbalanceare progressively morecommon thelower theoccupationalstatus[21].Theseworkinfluencesarepartof thesocialdeterminantsofhealthandpotentialcontributorsto thesocialgradientinhealth.
3.3. Widersociety
TheEuropeanReviewofSocialDeterminantsofHealthand the Health Divide places emphasis on processes of social exclusion, that lead to ill-health in excluded groups such as Roma,gypsiesandtravellers;onbuildingsociallycohesiveand resilientcommunities;andonsocialprotectionthroughthelife course.Here,wefocusonsocialprotection.
Afall-outfromtheglobalfinancialcrisisis,asstatedabove, high levels of unemployment across Europe. Research has shown that, at the country level, a rise in the rate of unemploymentis associatedwitha riseinsuicide rates [22–
24].Thisrisecanbemitigatedbyspendingonsocialprotection:
activelabourmarketprogrammes,familysupport,healthcare, andunemploymentbenefits. The figuressuggest thatifthere were no spending on social protection, a 3% rise in unemployment would be associated with a 3% rise in the suicide rate [22]. In Eastern European countries where spending is of the order of US$37 a head, a 3% rise in unemploymentisassociatedwitha2–2.5%riseinsuicide.In WesternEuropeancountries,withsocialprotectionspendingat US$150ahead,a3%riseinunemploymentisassociatedwith lessthan1%riseinsuicide [22].
Thegeneralpointhereisanalogoustothatabovewithearly child development: we should think of two types of policy.
First,unemploymentisbadforhealth.Thereisvigorousdebate as towhether the response to the economic crisisshould be austerityor aKeynesiantype stimulus,withcounter cyclical investment. An important consideration should be that a predictableeffectofausterityishighlevelsofunemployment, withdisastrousconsequencesforhealth.Butspendingonsocial protectionisaformofresilienceof asocietythatcanprotect againstthe harmfuleffectof economicshocks.
3.4. Macrolevelcontext
The reference in the previous section toeconomic policy responsetothefinancialcrisisisanexampleoftheimportance oftheeconomiccontextforsocialdeterminantsofhealth.We argue for putting considerations of health equity into these economicdebates.Youthunemployment isapotentialpublic health emergency. High priority in economic policy making should be given to reducing youth unemployment. A fuller discussionoftheseissuesiswithinthereportoftheEuropean Review.
ThereportoftheCSDHarguedthatitwasimportanttobring togethertheagendaonsocialdeterminantsofhealthwiththat onsustainability.IntheEuropeanReviewwehavedonemore onfleshingoutwhatthiscanmeaninpractice.
Ataverypracticallevel,environmentalquality,ingeneral,is worse inmore deprivedareas. Poorenvironmental quality is likely tobeacontributortothe socialgradientinhealth.
At a more general level, sustainable development means balancing the environmental, the social and the economic.
When considering the response to climate change, we must ensure that mitigation and adaptation do not have adverse effects particularly on the poor and disadvantaged. For example, there is a good case for green consumptiontaxes.
But,ingeneral,consumptiontaxesareregressive.Ifgreentaxes are tobe pursued, the demands ofequityrequire thereto be other actions through taxes and transfers to counteract their regressiveeffect.
An important insight from sustainabledevelopment isthe need toconsider equityacross generations – to preservethe environment for future generations.Similarly the life course approachwehavetakentosocialdeterminantsofhealthmakes clear that social and economic conditions affecting this generation has clear implications for the health of children andgrandchildren.
4. Puttingit intoaction
A Swedish parliamentarian said at a recent meeting in Stockholm that most commission reports are ignored and forgotten. ThereportoftheCSDHwasinsharpcontrastwith theusual,hesaid,becauseitisstillbeingactivelydiscussedin the Swedish parliament. Putting recommendations on social determinantsofhealthintoactiondoesnotrequireonlynational governments. Across the UK and Europe there are many examples of cities developing action plans on social determinantsofhealth.InMalmoinSouthernSweden,ahigh level Commission for asocially Sustainable Malmo has just reported[25].TheMalmoCommissionaddressedthe notable inequalitiesinhealthwithinMalmoand,buildingontheCSDH, maderecommendationstothecitygovernmentandothersasto what shouldbedone.Thereisgreat interestinotherpartsof Swedenintakingactionatlocallevel,asthereisinDenmark, Norway,andotherEuropeancountries.
Our messageisthatthere needstobe across-government commitment toactionon socialdeterminantsof health.With this commitment, the knowledge synthesised in our reports suggests thatthere ismuch thatcan be doneat the practical level.
Perhapsunderpinningitall,istheimportanceofasocietal commitmenttofairness,toachievingequityinhealth.
Disclosure ofinterest
The authors declare thattheyhaveno conflictsof interest concerningthisarticle.
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1
erColloque de l’ITMO Sante´ Publique (Aviesan)
De´terminants sociaux de la sante´ : les apports de la recherche en sante´ publique Paris, 26 octobre 2012
Importance de la the´orie des origines de´veloppementales de la sante´
(DOHaD) pour les ine´galite´s sociales de sante´
Developmental origins of adult health and disease:
An important concept for social inequalities in health
M.-A. Charles
a,b,*
aInsermU1018,centrederechercheene´pide´miologieetsante´ despopulations(CESP),e´quipee´pide´miologieenvironnementaledescancers, InstitutGustave-Roussy,114,rueE´ douard-Vaillant,94807Villejuif,France
bUMRS1018,universite´ Paris-Sud,94807Villejuif,France Rec¸ule25avril2013;accepte´ le24mai2013
Abstract
Accordingtothetheoryofthedevelopmentaloriginsofadulthealthanddisease,developmentinuteroandinthefirstyearsoflifearecritical phasesduringwhichsusceptibilitytomanychronicdiseasesisset.Diseaseseventuallyoccuronlyiftheenvironmentandlifestyleinlaterlifeis favorable.Exposuretochemicals(environmentalordrug),toinfectiousagents,unbalancednutrition,orpsychosocialstressprenatallyorinthefirst months/yearsoflifeareallfactorswhichhavebeenshowntoimpactlong-termhealthofindividuals.Theconsequences,however,arenotlimitedto health.Ademonstrativeexamplewasprovidedbythestudyoftheinfluenzaepidemicof1918–1919intheUnitedStates.Nationwide,itwas estimatedthatthelossofincomeoveralifetimeforindividualsexposedduringfetallifetothisepidemicamountedto14billiondollars.This exampledemonstratesthatanexposureduringfetallife, whichisnotsociallydifferentiated,mayaffectthesocialsituationofindividualsin adulthood.Inmanysituations,itismuchmoredifficulttoseparatethespecificeffectofagivenexposurefromtheoveralleffectofthesocial environment.Indeed,ithasbeenshownthatsocioeconomicstatusinchildhoodisassociatedwithincreasedriskofmortalityinadulthood,even afteraccountingforthesocioeconomicstatusandriskybehaviorsinadulthood.Amongtheexplanations,thetheoryofdevelopmentaloriginsof healthcreditsofbiologicalplausibilitythemodelofcriticalperiodsearlyinwhichtheindividualisparticularlyvulnerabletocertainexposures.
Thus,ensuringthebestconditionsforthebiological,physical,emotionalandcognitivedevelopmentofchildreninearlylifewillenablethemto reachtheirpotential intermsof healthand socioeconomicreturntosociety.Investmentinthisperiod alsobringsthehope ofreducingthe perpetuationofsocialinequalitiesandhealthfromgenerationtogeneration.
#2013ElsevierMassonSAS.Allrightsreserved.
Keywords:Socialinequalities;Development;Children;Epidemiology Re´sume´
D’apre`slathe´oriedesoriginesde´veloppementalesdelasante´,lede´veloppementintra-ute´rinetlede´veloppementdestoutespremie`resanne´esde viesontdesphasescritiquesaucoursdesquelless’e´tablitunesusceptibilite´ a` denombreusesmaladieschroniques.Maiscelle-cinesere´ve`le souventquesil’environnementetlemodedevieysontpropices.L’expositiona` desproduitschimiques(environnementauxoume´dicamenteux),a`
desagentsinfectieux,unenutritionde´se´quilibre´e,oubienunstresspsychosocialenpe´riodepre´nataleoudanslespremiersmoisouanne´esdevie sontautantdefacteurspourlesquelsonamontre´ desconse´quencesa` longtermesurlasante´ desindividus.Lesconse´quencesnesontcependantpas limite´esa` lasante´.Unexemplede´monstratifae´te´ apporte´ parl’e´tudedel’e´pide´miedegrippede1918a` 1919auxE´ tats-Unis.A` l’e´chelledupays, onestimequelapertederevenussurlavieentie`repourlesindividussusceptiblesd’avoire´te´ expose´spendantlaviefœtalea` cettee´pide´mies’e´le`ve a` 14milliardsdedollars.Cetexemplepermetdede´montrerqu’uneexpositionpendantlaviefœtalenonsocialementdiffe´rencie´epeutavoirdes
Disponibleenlignesur
www.sciencedirect.com
Revued’E´ pide´miologieetdeSante´ Publique61S(2013)S133–S138
*InsermU1018,centrederechercheene´pide´miologieetsante´ despopulations(CESP),e´quipee´pide´miologieenvironnementaledescancers,InstitutGustave- Roussy,114,rueE´ douard-Vaillant,94807Villejuif,France.
Adressee-mail:marie-aline.charles@inserm.fr.
0398-7620/$–seefrontmatter#2013ElsevierMassonSAS.Tousdroitsre´serve´s.
http://dx.doi.org/10.1016/j.respe.2013.05.013
