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Here are 2 truisms. Rich countries have better health than poor countries, and medical care improves health. Consider, then, the case of the United States, which is among the richest countries in the world and spends more than any other country on medical care, US $6350 per person in 2005.1 Does the United States then have the best health? Not quite. Life expectancy from birth to age 65 years is one useful measure of premature mortality: the United States ranks 36th in the world for men and 42nd for women.2 If not by greater national income or more spending on medical care, how should the task of improving health in the United States be approached? Pay attention to the social determinants of health.
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. 2009;301(11):1169-1171 (doi:10.1001/jama.2009.363) JAMA
Michael G. Marmot; Ruth Bell
Commission on Social Determinants of Health
Action on Health Disparities in the United States:
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132.
Action on Health Disparities
in the United States
Commission on Social Determinants of Health
Michael G. Marmot, FRCP
Ruth Bell, PhD
HERE ARE 2TRUISMS.RICH COUNTRIES HAVE BETTER
health than poor countries, and medical care im-
proves health. Consider, then, the case of the
United States, which is among the richest coun-
tries in the world and spends more than any other country
on medical care, US $6350 per person in 2005.1Does the
United States then have the best health? Not quite. Life ex-
pectancy from birth to age 65 years is one useful measure
of premature mortality: the United States ranks 36th in the
world for men and 42nd for women.2If not by greater na-
tional income or more spending on medical care, how should
the task of improving health in the United States be ap-
proached? Pay attention to the social determinants of health.
Commission on Social Determinants of Health
Because of concern with global health inequity the director-
general of the World Health Organization established the
Commission on Social Determinants of Health (CSDH) in
2005. The CSDH produced recommendations, based on evi-
dence, about what could be done to further the cause of health
equity.3The CSDH highlighted inequities between coun-
tries—life expectancy at birth in Zambia (41.2 years) is half
that of Japan (82.4 years)4—but also health inequities within
countries (such as the United States) that can be dramatic.
Within the Scottish city of Glasgow, there is a 28-year gap
in life expectancy between the richest and poorest areas;
among the poorest, male life expectancy is 8 years less than
the average life expectancy in India.3The gap in life expec-
tancy between men in Washington, DC, and in suburban
Maryland is 17 years.3Rich countries have no cause for com-
placency. The CSDH was oriented to countries at low, me-
dium, and high income.5
The gap between top and bottom highlights the magni-
tude of the difference in health outcomes but the CSDH em-
phasized the graded relation between socioeconomic posi-
tion and health, the social gradient that exists within
countries.6A previous comparison of men and women aged
55 to 64 years demonstrated the social gradient in health
and showed higher illness rates in the United States than in
England,7consistent with shorter life expectancy to age 65
years in the United States. At every point along the scale of
income or education, the health of Americans was worse than
that of the English.
Author Affiliations: International Institute for Society and Health and Depart-
ment of Epidemiology and Public Health, University College London, London, En-
gland. Dr Marmot was chair of the World Health Organization Commission on
Social Determinants of Health, 2005-2008. Dr Bell is a senior research fellow at
University College London and was a member of the Commission on Social De-
terminants of Health Secretariat.
Corresponding Author: Michael G. Marmot, FRCP, Department of Epidemiology,
University College London, 1-19 Torrington Pl, London, England WC1E 6BT (m
.marmot@ucl.ac.uk).
COMMENTARIES
©2009 American Medical Association. All rights reserved. (Reprinted) JAMA, March 18, 2009—Vol 301, No. 11 1169
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The CSDH call for action on social determinants of
health also applies to differences between ethnic groups.
It has been estimated that in the United States 886 202
deaths could have been averted between 1991 and 2000 if
mortality rates between white and black individuals had
been equalized.8
Health inequities between the worst off and the best off
in rich countries and the social gradient in health imply that
the focus should not only be on absolute material depriva-
tion. The poor of Glasgow or Washington, DC, are not poor
by global standards. In Glasgow and in Washington, DC,
tap water is fit to drink, food is rarely contaminated and is
plentiful, and although there are a few exceptions, no one
lives in squatter settlements. In India 76% of the popula-
tion live on $2 a day or less4; yet men in India, on average,
have longer life expectancy than the poorest men of Glasgow
and about the same as men in Washington, DC.
This comparison with India shows how powerful the ac-
tion of social determinants can be—rivaling the effects of
material deprivation—a lesson also conveyed by the gradi-
ent in health observed in both rich and poor economies. A
further and crucial implication of the gradient is that ineq-
uities in health apply to everyone below the top socioeco-
nomic position. Therefore, social action should deal with
the entire gradient, and all of society, not only with those
at the bottom.
Evidence shows that the slope of a health gradient is not
fixed; it is responsive to political, social, and economic
changes. The gradient in adult mortality by educational level
worsened in Russia after 1992 following the political, so-
cial, and economic upheaval caused by the breakup of the
Soviet Union.9In the United States, the gradient in life ex-
pectancy by socioeconomic deprivation has worsened for
both men and women since 1980.10
Health and Health Inequities
in the United States
The Commission’s recommendations for action to pro-
mote health equity are based on 3 principles of action: im-
prove the circumstances in which people are born, grow,
live, work, and age; tackle the inequitable distribution of
power, money, and resources—the structural drivers of con-
ditions of daily life—globally, nationally, and locally; and
measure the problem, evaluate action, and expand the knowl-
edge base.3
Several themes from the CSDH report that are, among oth-
ers, highly relevant to inequities within the United States
are as follows.
Health Care. Globally, every year at least 100 million in-
dividuals are forced into poverty because of out-of-pocket
health expenditures.3In the United States, the maldistribu-
tion of availability of health care rightly claims much atten-
tion. But this should not distract from attention to other
social determinants of health. The United States spends
about 2.5 times more per person on medical care than the
English. In the comparison of English and US adults, re-
ferred to above, more than 90% of participants had health
insurance.7Nevertheless, the Americans had worse health
than did the English.
Equity From the Start. The CSDH placed great empha-
sis on early childhood development and education. The
relation between education and health in adult life is clear.
To the extent that this relation is causal, it is important to
improve the education of children, particularly those born
to parents who themselves have low educational attain-
ment. A recent Organisation for Economic Co-operation
and Development (OECD) report11 gives scant encourage-
ment to the United States. It evaluated math scores of
15-year-olds in relation to their parents’ education. Those
whose parents had low educational achievement per-
formed worse than those whose parents were highly
educated—but the deficit in the United States was greater
than the average for all OECD countries. In Sweden, for
example, parents’ educational status made less difference
to the math scores of 15-year-olds.
Fair Financing. Within countries, observational data
show that income is correlated with mortality and life
expectancy; however, between rich countries, there is
little relation between a country’s national income and
life expectancy. An interpretation, then, of the correlation
of income to mortality within a rich country such as the
United States is that income is a marker of relative posi-
tion within society; relative position, in turn, is related to
social conditions that are important for health including
good early childhood development, access to good-
quality education, rewarding work with some degree of
autonomy, decent housing, and a clean and safe living
environment.
Increasing levels of income inequality in a society are likely
to lead to a worsening of the relative position of those with
lower standing in the socioeconomic hierarchy. This is not
to enter the debate as to whether income inequality, per se,
is related to a country’s overall level of life expectancy. It is
to say, however, that if relative position worsens, condi-
tions for those at the bottom will be relatively worse than
for those at the top.
Real earnings of US working men whose starting full-
time salaries were below the median declined between 1980
and 2005, while real earnings increased for men earning
higher incomes.11 By contrast, real earnings increased be-
tween 1980 and 2003 across all income deciles in the United
Kingdom, although the income of higher earners increased
more than that of lower earners.11 The United States has the
third highest poverty rate (50% median income) in OECD
countries, below Turkey and Mexico and well above aver-
age for OECD countries. Furthermore, the United States
ranks fourth in the OECD for disposable income inequal-
ity.11 Market income and disposable income inequalities and
poverty rates are susceptible to government economic and
social policy choices.
COMMENTARIES
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The Individual and Society
The way society is organized through political choices in-
fluences health outcomes, but the individual is not lost in
the CSDH’s approach,12 which emphasizes collective and in-
dividual empowerment, including material, psychosocial,
and political empowerment. Individuals need basic mate-
rial conditions for health, control over their lives, and ac-
tive participation in decisions that affect their lives. The aim
of public policy should be to create the social conditions to
meet these needs.3
Putting Social Determinants of Health
Into Practice to Improve Population Health
Positioning health equity as a key performance indicator in
all social and economic policy making has the potential
to drive significant reductions in health inequities.3
How would this work in practice? Early childhood
development—including the physical, social-emotional,
and language-cognitive domains—is among the key areas
for action described by the CSDH.3President Obama’s com-
mitment to prioritize early childhood education is therefore
promising.
The current global economic crisis brings work and em-
ployment conditions into sharp focus. Since December 2007,
the start of the recession, 3.6 million jobs have been lost in
the United States.13 Job insecurity, unemployment, and de-
terioration of working conditions are all potentially harm-
ful to population health and require urgent attention.
Former CSDH commissioners Wilensky and Satcher14 hold
the view that action across the social determinants may gain
bipartisan support in the United States. The Robert Wood
Johnson Foundation has set up the Commission to Build a
Healthier America with a strong focus on what can be done
across the social determinants of health.15
The CSDH’s findings and recommendations are neces-
sarily general because of their global application. The rec-
ommendations require “translation” into specific policies
for particular country contexts. Several countries are in the
process of doing this: Chile, Brazil, Argentina, Sri Lanka,
Thailand, and a number of European countries. In En-
gland, Prime Minister Gordon Brown16 said: “[T]he health
inequalities we are talking about are not only unjust,...they
also limit the development and the prosperity of commu-
nities, whole nations, and even continents.” He an-
nounced an independent review of health inequalities in En-
gland (chaired by M.G.M.) that is taking the CSDH’s
recommendations and developing evidence-based strategy
across social and economic policy areas to improve health
equity. Other countries around the world are taking ac-
tion.3What is needed? Put simply: leadership from the top
of government, action across social and economic policy
areas, and participation from communities across society.
Action needs to take place at local, regional, national, and
global levels.
The international response to the current global finan-
cial crisis provides the opportunity for the international com-
munity to recommit to a more representative multilateral
system with fairer participation by all countries and the op-
portunity to place health equity at the heart of multilateral
policy development in areas including trade, finance, re-
sponses to climate change, and international security. The
United States has a leading role internationally. A world of
hope and expectation rests on the new US president. How
will President Obama respond to the commission’s call to
action?
Financial Disclosures: None reported.
Funding/Support: Dr Marmot is supported by an MRC research professorship. The
CSDH was established by the World Health Organization and received financial
support from the International Development Research Centre, Open Society In-
stitute, Public Health Agency of Canada, Purpleville Foundation, Robert Wood
Johnson Foundation, Swedish National Institute of Public Health, United King-
dom Government, and the World Health Organization.
Role of the Sponsor: The organizations did not participate in preparing, review-
ing, or approving this manuscript.
Disclaimer: The views presented in this Commentary are those of the authors and
do not necessarily represent the views, decisions, or stated policy of the World
Health Organization.
Additional Contributions: We thank all those who contributed to the work of the
Commission on Social Determinants of Health (2005-2008).
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//www.csdhconference.org. Accessed December 20, 2008.
COMMENTARIES
©2009 American Medical Association. All rights reserved. (Reprinted) JAMA, March 18, 2009—Vol 301, No. 11 1171
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... In the U.S., marginalized racial and ethnic communities are more likely to have inadequate housing, lower quality education, an unclean environment, and negative health outcomes, even when controlling for personal characteristics [15][16][17]. Exposure to pollution and environmental contaminants is higher among these marginalized groups, highlighting continued instances of environmental injustice [14]. Research has shown that race and ethnicity are related to a community's obesity rates, exposure to air pollution, lack of access to green spaces, and lower overall life satisfaction [14,15,18,19]. ...
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... This literature has shown that low education is a risk factor for tobacco use in pregnancy [21,29,35,41]. Extensive work by Marmot [42][43][44][45], Link and Phelan [46][47][48], Ross and Mirowsky [13,14,49,50] and others [51] have shown SES as protective against risk behaviors such as tobacco. ...
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