Health inequities in a 9'obalising world of work: Commission on Social Determinants of Health ABSTRACT Health inequities within and between countries are a significant feature of the global health scene and a major policy concern of global institutions and national, regional and local governments. the recent report of the World Health Organization emphasises, Commission on Social Determinants As of Health work has a powerful influence on health and health e !Iity. Good employment and working conditions can provide financial security, soci~1 protection benefits, paid holiday, social Sir Michael Marmot, Professor of Epidemiology and Public Health, Department of Epidemiology and Public Health, University College London status, personal development, psychosocial social relations, self-esteem, hazards. The majority of the world's workers do not enjoy the benefits of good work defined in this way. The period of globalisation since the 1970s characterised pansion and integration of markets has seen increased competition share and profitability with direct effects on employment Key words: health inequities, globalisation, employment INTRODUCTION Professor Michael Marmot was Chair of the WHO Commission on Social Determinants of Health, 2005-2008. Dr Ruth Bell was a member of the secretariat of the Commission on Social Determinants of Health. and working conditions ex- for market that impact on conditions, working conditions between globalisation, inequities significant Corresponding author: Sir Michael Marmot, Department of Epidemiology and Public Health, University College London, 1-19, Torrington Place, London WC1 E 6BT E-mail: email@example.com by deregulation, between companies health and health equity. Health Ruth Bell, Senior Research Fellow, Department of Epidemiology and Public Health, University College London and protection from physical and within feature and between of the global health countries scene are a and are work and health inequities, drawing on the work of the Commission on Social Determinants of Health.1 national becoming a major policy concern of global institutions and governments.1 The World Health Organization's HEALTH INEQUITIES WITHIN AND BETWEEN Commission on the Social Determinants of Health advocated COUNTRIES concerted, coherent action to reduce health inequities across There are gross inequities in health between countries. As a n~mber of domains, 1 namely: an extreme example, life expectancy 1) improve the conditions of daily life - the circumstances in years.7 Within countries there are systematic which people are born, grow, live, work, and age; 2) tackle the inequitable distribution at birth for women in Zambia is 43 years while in Japan it is twice as long at 86 of power, money and health between groups according differences in to position in the social resources - the structural drivers of those conditions of hierarchy; this observation daily life - gIObally:""n1!1£:~l~';;ncffbcally; in health. Those at the bottom of the social hierarchy have and 3) measure the problem, evaluate action, expand the knowledge base, develop social determinants a workforce of health, and raise public awareness about the social determinants Globalisation, employment major social determinants across and working conditions knowledge has a major influence'-1n are networks.?-5 Work heaith<and he'alft, equiiy. Good and working conditions cial security, social protection worse health outcomes can provide finan- benefits such as sick pay, than those in the middle who in turn have worse health outcomes These systematic poorer countries of health. of health among those examined the Commission's employment that is trained in the is known as the social gradient differences than those at the top. in health are observed (e.g. for child mortality8) income and high income countries (e.g. for adult mortality1). Position in the social hierarchy and psychosocial resources is associated including incom~, fOOd, water, sanitation, over one's life arid participation ety thus creates differences in exposure personal ties, or avoidable and unjust inequalities protection from physical self-esteem, and and psychosocial hazards.1 The improvements housing, control in society. Position in soci- to health damaging social relations, with material that are important for health, maternity leave, and pensions, paid holiday, social status, development, in and in middle conditions and vulnerability that leads to health inequiin health.1 Where in material and psychosocial circumstances majority of the world's workers do not enjoy the benefits of are unequally distributed, good work defined in this way. The period of globalisation to the better off in society, there is potential for inequities in since the 1970s, characterised health to be exacerbated. and integration of markets, tion between companies by deregulation, has seen increased unemployment, informal employment) competi- for market share and profitability with direct effects on various dimensions (including expansion precarious of employment employment .and working conditions with gains accruing preferentially and that impact on health and health equity.z,6 In this article we explore links EMPLOYMENT AND PRECARIOUS EMPLOYMENT Achieving 'full and productive employment and decent work for all, including women and young people,g is a key element in eradicating are crucial determinants extreme poverty and hunger which of health in the developing world. Globally, 3 billion people are in work; 74 per cent of men SEWA members of working age and 49 per cent of women were employed conditions and health is in upgrading the homes ofthe poor; is making a difference to people's living more limited providing clean water and sanitation in slum areas costs US$ opportunities to participate in the labour market due to social work and 500 per household with community contributions of US$50 per household.1 Providing clean running water has curbed has the potential to provide financial secu- women, no longer needing to fetch water, to work to provide in 2007.10 This gender gap reflects women's bias, lack of jobs, and difficulties in combining the incidence of waterborne family responsibilities. Employment rity and sufficient income for the requirements of a healthy diseases and freed up time for income for their families. Access to credit, through small life, conditions that remain out of reach for millions of the loans arranged through. the SEWA bank, provides benefit world's workers. Worldwide, to poor women who would otherwise nearly half a billion workers do not earn enough to raise themselves and their dependent family members above the US$ 1 a day extreme poverty line, and 1.3 billion workers earn below US$ 2 a day.1o There are seek private loans at high interest rates. Micro credit is seen increasingly ished people to lift themselves as a way for impover-· out of poverty. For example, signmcant regional variations in the distribution of the working a small loan might enable poor. Countries in South Asia and sUb-~aharan Africa have moped to enable them to travel to work to earn income, a person to buy a bicycle or the highest rates of working poor, with over 80% of workers or it n:\ight p':,qyide a person with....s\.lfficient capital to build earning less than US$ 2 a day.1o a micro business enterprise, In addition, preliminary Labour Organization economic estimates by the International (ILO) indicate that the current global crisis could increase the number of working poor living on less than US$ 1 a day by 40 million, ahd the number living on less than US$ 2 a day by 100 million.11 Living on subsistence families extremely wages vulnerable makes workers to volatility and their in food and fuel prices and exposes workers to further financial risk when ill health requires out of pocket expenditure for health care, or trading on their own account. By the end of 2005, over 3000 institutions reported offering micro credit to more than 113 million people; 81 million of these were among the poorest when they took their first loan and of these 84% were womenn Micro credit schemes are integrated into many development programmes around the world.14 Evidence suggests t~f!t participation in programmes that provide micro''G£edr£i!lO~~~other education, . related participatory services, such as . learning, legal services and health senlcices is associated with poverty reduction, prevents them from working. increased household assets, reduction in child stunting and. INFORMAL WORK family size and increased In countries that have a relatively undeveloped formal"labour knowledge and use of qualified health care workers.14 Micro wasting through improved nutrition, reductions in preferred use of contraceptives, and,more market and that lack public provision for social protection, credit is potentially a means to empower women, improve people must earn income for the bare necessities of life and their social standing, and give them more control over their they must seek work in the informal sector that lies outside health and lives. A review of micro credit in Bangladesh the reach of government observes regulation, labour laws and the taxation system. By its nature the informal sector provides precarious employment, characterised by low incomes that micro credit has the potential to benefit health, but that its effects on exclusionary processes are variable.15 Research among communities in South Africa and a lack of financial and social security. Workers in the found .evidence for reduction informal sector are likely to have low or minimal levels of among women who had participated education and literacy. At least half the world's workforce is in scheme combined with participatory vulnerable employment a gender training curriculum emphasising women's health and reproductive rights.16 A study of poverty and common (defined by the ILO as own account workers and contributing family workers). South Asia and in intimate partner violence in a micro finance learning that delivered sub-Saharan Africa have the highest rates at 77 per cent and mental disorders in developing countries indicated that micro 73 per cent of total employment credit may reduce the risk of mental disorders.17 respectively.1o In India more than 80 per cent of female workers in both urban and rural areas are employed in the informal sector. The Self Employed Women's Association PRECARIOUS WORK IN DEVELOPED COUNTRIES (SEWA) is a union Global market expansion and integration of over a million women working in the informal sector in market forces to reduce costs of production Ahmedabad in northern India that provides a range of other- associated in employment wise inaccessible services to its members, including banking, can undermine health.6 In European countries, for example, micro credit, legal representation, there have been increases in part-time work and temporary employment since 1991.18 Studies in high income countries child care provision, health care provision, health insurance, house upgrading and pensions.12 SEWA amplifies the voice of the women, making ":lith changes have shown that temporary health outcomes. difference to their living and working conditions. To give one overall mortality was significantly example, self employed women vegetable sellers, frequently workers harassed by local authorities, campaigned through SEWA to municipal gain legal recognition. They linked together with vegetable growers to set up co-operative vegetable wholesale outlets. The women were able to work more safely in the market and than permanent workers have been conditions work is associated collective action possible to realise their rights and making a Kivimaki and competitive and colleagues with poor reported that higher among temporary workers in Finland that in a ten town study of 1990 and 2001.19 between Poor mental health outcomes are associated with precarious employment conditions and working in non-fixed such as working temporary with no contract contracts.20 Physical establish fairer prices for their produce, raising their income and mental health is also adversely affected in workers who and social status. Another area where collective action by experience job insecurity21,22 MARKET INCOME INEQUALITY with the highest unemployment In many countries the last decade has seen an increase in in the quartile of neighbourhoods with the lowest unemployment rates32 Blakely and colleagues33 reported that men and market income inequality, with the top 10 per cent of wage rates compared to those living earners seeing their wages increase faster than the bottom 10 per cent.23 This polarisation has been driven in part by labour women who were unemployed markets for management based on a national income expectations Conversely, expertise encouraging a transfer of in the US to other developed markets. at the lower end of income, globalisation commoditised has unskilled labour, giving rise to a trend to locate unskilled jobs in countries with low wages and relatively weak labour protection systems. The case of multinational clothes retailers has been well documented.5.24 In Bangladesh, the were two to three times as likely to commit suicide as their employed household peers. Evidence survey in Brazil, indicates that people are more likely to have poor self-rated health if they live in a household with an unemployed person or an informal worker regardless of their own employment and other individual and household factors.34 status While there is good evidence for an association between unemployment and health in developed countries, the garment industry accounts for around 75 per cent of exports relationship is difficult to study in developing economies where and employs 2.5 million people, over 80 per cent of whom are the majority of people work in the informal sector. women.5 Working conditions and wage rates are poor by international standards, but alternative employment opportunities, WORKING for example in agriculture, are worse. Women who work in the Exposure clothes factories have the advantage in the workplace of regular wages and government regulatory authorities between countries. Lower status workers in developed countries, especially immigrants,35 suffer higher rates of occupa- and civil society need to tional injuries and diseases. Developing countries experience higher rates of occupational paid a living wage and are fairly treated. developed inequality is associated and chemical hazards to health inequities within and capacity ensure that low skilled workers in supply chain factories are Income physical contributes companies, social networks, and achieve some decision-making in their family and personal lives. Multinational CONDITIONS AND HEALTH to psychosocial, with poor health out- accidents and diseases than countries, partly because more high risk jobs are located in developing countries and partly because develop- comes, although causal links are debated25,26 Nevertheless ing countries income inequality is an indicator of the unequal distribution of safety systems and high rates of informal' work36 goods and services within a country. Research using evidence from the Luxembourg Income Study indicates that in Nordic have less effective occupational health and Competitive forces in the global market economy, the drive for efficiency and cost saving, and advances in information fiscal and welfare policies lead to a much lower level of poverty than in the US and UK.27 Policy and communication technology have increased work pressure action by national governments years, A major corollary of pressure in the work environment is countries redistributive across social and economic domains can mitigate the effects of market income inequality on the distribution of income and social goods.1 in both the private and public sector over the past twenty-five work stress. Evidence from resear.ch in developed countries shows that stress at work is an important social gradient in health; employees contributor to the working in low status greater stress at work.37 A meta studies38 indicates an average 50% jobs are likely to experience UNEMPLOYMENT According to recent analysis by the ILO,11 the current global analysis of observational economic and financial crisis could increase world unemploy- excess risk for coronary heart disease among employees with ment from 190 million in 2007 by 20 million to 210 million in work stress, measured as a combination of high psychological late 2009. Over half~1i;·;Tt~Ii®"'f9D~ere States in November the recession 20G8'alone, lost in the United and between the start of in the US in December 2007 and November demands and low control or as an imbalance and reward. Compared with employees to work stress, employees between effort with no exposure with chronic exposure to work 2008 the number of unemployed in the US increased by 2.7 million28 Unemployment in developed economies is more with high demands concentrated vantaged groups, such as ethnic minorities, immigrants and of metabolic syndrome, a condition that predicts heart disease and type 2 diabetes.39 High efforts and low rewards at work the least skilled and educated. In the developed economies a are risk factors for common mental disorders,40 In addition, among young people (ages 15 - 25) and disad- young person's risk ofoeinguiierhployed'i;;- 2.4 ti;;;es that of an adult, 10and people with only primi;lry education are three times as likely to be unemployed education29 The changing as a person with tertiary nature of the labour market in developed economies has increased demand for more highly educated and skilled workers while demand for workers with and low control and with no supportive coworkers or supervisors have more than twice the likelihood Head and colle,agues showed that effort-reward imbalance and relational i~justice at work predicted long spells of sickness absence41 Despite robust evidence for the association of workplace stress with mental health, relatively few countries in Europe report programmes health at work42 to promote mental low education has decreased, While a proportion of the unemployed have been selected into unemployment population may because of existing POLICY IMPLICATIONS Employment and working conditions are major determinants ill health, there is a body of evidence mainly from high income of health inequities within and between countries. countries that unemployment interactions between the globalising world of work and health and excess mortality tional comparison, Netherlands, is associated with poor health in men and women.30,31 An interna- involving studies in the US, the UK, the Finland, Italy and Spain, identified an increased risk of mortality for men living in the quartile of neighbourhoods needs further research, there is sufficient While the evidence to take action at global, national and local level1 to: • make full and fair employment international economic a central goal of national and policy making; • ensure safe, and fairly work-life balance; and • improve working conditions stress and health healthy secure Achieving require action and at international hazards, and to developing worker work and national and will for collective coherent policy levels.1 ACKNOWLEDGEMENT This article draws Organization's Health, 2005 - 2008, The views sions on expressed or the stated The final ds of Health ld social_ report the Commission chaired work on of by Professor do not necessarily policy of the World of the Commission is available the Social to download determinants/final_repor'Jen/index. World Health Determinants Michael represent of Marmot. the deci- fiealth Organization. on Social Determinants m re pld Ie In -e 'e is 's e IS a Yo h 11 rt e k 3 f j M, Elovaino M, Pentti J, Ferrie JE. Temporary employment and risk of overall and cause specific mortality. Amer J Epidemiol. 2003;158:663-8. 20. Artazcoz L, Benach J, Borrell C, Cortes I. Social inequalities in the impact of flexible employment on different domains of psychosocial health. J Epidemiol Community Health. 2005 Sep;59(9):761-7. 21. Ferrie JE, Shipley MJ, Marmot MG, Stansfeld S, Davey Smith G. The health effects of major organisational change and job insecurity. Social Science & Medicine. 1998;46:243-54. 22. Ferrie JE, Shipley M, Stansfeld S, Marmot MG. Effects of chronic job insecurity and change in job security on self reported health, minor psychiatric morbidity, physiological measures and health related behaviours in British civil servants: Community Health.,2002;56:450-4. Gen~va: ILO; 2008. 24. War on Want. Fashion Victims at:. http://www.who.inU html the Whitehall II study. J Epidemiol II: how UK clothing retailers are keeping workers in poverty. London: War on Want; 2008. 25. Wilkinson RG. The impact of inequality: how to make sick societies healthier. London: Routledge: and New York: New Press; 2005. 26. Deaton A. Health, inequality, and economic development. Journal REFERENCES :e en/2/ef0698en.pdf 19. Kivimaki M, Vahtera J, Virtanen 23. International Labour Organization. Global wage report 2008/09, Minimum wages and collective bargaining: towards policy coherence. na- European Foundation for the Improvement of Living and Working Conditions, Fourth European Working Conditions Survey. Luxembourg: Office for Official Publications of the European Communities; 2007 . Available online at: http://www.eurofound.europa.eu/pubdocs/2006/98/ work-related standards mechanisms representation and year-round behaviours. employment commitment bargaining work, - material damaging these paid 1. Commission on Social Determinants of Health. CSDH Final Report: Closing the gap in a generation: health equity through action on the social determinants of health. Geneva: World Health Organization; 2008. 2. Employment Conditions Knowledge Network of the Commission on Social Determinants of Health. Employment conditions and health inequalities. Geneva: World Health Organization; 2007. 3. Globalisation Knowledge Network of the Commission on Social Determinants of Health. Towards health-equitable globalisation: rights, regulation and redistribution. Geneva: World Health Organization; 2007. 4. Women and Gender Equity Knowledge Network of the Commission on Social Determinants of Health. Unequal, unfair, ineffective and inefficient - gender equity in health: why it exists and how we can change it. Geneva: World Health Organization; 2007. 5. Sociai Exclusion Knowledge Network of the Commission on Social Determinants of Health. Understanding and tackling social exclusion. Geneva: World Health Organization; 2007. 6. Benach J, Muntaner C. Precarious employment and health: developing a research agenda. J Epidemiol Community Health. 2007 Apr;61 (4):276-7. 7. World Health Organization. World Health Statistics 2008. Geneva: World Health Organization; 2008. 8. Gwatkin DR, Rutstein S, Johnson K, Suliman E, Wagstaff A, Amouzou A. Socio-economic differences in health, nutrition, and population within developing countries: an overview. New York: World Bank; 2007. 9. United Nations. The Millennium Development Goals Report. New York: UN; 2008. 10. International Labour Organization. Global Employment Trends 2008. Geneva: International Labour Organization; 2008. 11. ILO. Global financial crisis to increase unemployment by 20 million, ILO press release. Geneva: ILO; 2008. Accessed 6th Dec 2008 at: http://www.i lo.erg/global! About_the _I L O/Medi a_a nd _pu bl ic_ information/Press _releases/lang--enIWCMS _ 099529/index.htm 12. Marmot M. Achieving health equity: from root causes to fair outcomes. The Lancet. 2007;370(9593):1153-63. 13. Daley-Harris S. State of the Microcredit Summit Campaign: Report 2006. Washington D.C.: Microcredit Summit Campaign; 2006. 14. Pronyk PM, Hargreaves JR, Morduch J. Microfinance Programs and Better Health: Prospects for Sub-Saharan Africa. JAMA: The Journal of the American Medical Association. 2007 Oct 24;298(16):1925-7. 15. Schurmann A. Microcredit, inclusion and exclusion in Bangladesh, background paper for the Social Exclusion Knowledge Network of the Commission on Social Determinants of Health. Geneva: World Health Organization; 2007. of Economic Literature. 2003;41(1):113-58. 27. Lundberg 0, Aberg Yngwe M, Kolegard Stjarne M, Bjork L, Fritzell J. The Nordic Experience: welfare states and public health (NEWS). Health Equity Stu~e~ f\\O:-:1f,;<~.e~rt fo~ the Commission on Social Determmants of He~-Sf~tknolm."·Centre for Health EqUity Studies (CHESS), Stockholm University/Karolinska Institutet; 2008. 28. US Bureau of Labour Statistics. The employment situation. November 2008, news release. Washington, D.C.: US Bureau of Labour Statistics; 2008. Accessed 9th Dec 2008 at http://www.bls. gov/news.release/empsit.nrO.htm. 29. International Labour Organization. Key indicators of the labour market, KILM 11. 5th edition. Geneva: ILO; 2008. http://wWw.ilo.org/ pUblic/english/employment/strat/kilm/download/kilm 11.pdf Accessed 6th Dec 2008. 30. Bartley M, Ferrie J, Montgomery SM. Health and labour market disadvantage: unemployment, non-employment, and job insecurity. In: Marmot M, Wilkinson RG, editors. Social determinants of health. 2nd ed. Oxford: OUP; 2006. p. 78-96. 31. McClean C, Carmona C, Francis S, Wohlgemoth C, Mulvihill C. Worklessness and health - what do we know about the causal relationship? London: HDA; 2005. 32. van Lenthe FJ, Borrell LN, Costa G, Diez Roux AV, Kauppinen TM, Marinacci C, et al. Neighbourhood unemployment and all-cause mortality: a comparison of six countries. J' Epidemiol Community Health. 2005;59:231-7. 33. Blakely TA, Collings SCD, Atkinson J. Unemployment and suicide. Evidence for a causal association? J Epidemiol Community Health. 2003 Aug 1;57(8):594-600. 34. Giatti L, Barreto SM, Cesar CC. Household context and self-rated health: the effect of unemployment and informal work. J Epidemiol Community Health. 2008 Dec 1;62(12):1079-85. 35. Schenker M. Work-related injuries among immigrants: a growing global health disparity. Occup Environ Med. 2008 Nov 1;65(11 ):717-18. 36. Internationl Labour Organization. World of work, promoting safe and healthy work: The ILO Global Programme on Safety. Geneva: Internationl Labour Organization; 2008. 37. Marmot M. Status Syndrome. London: Bloomsbury; 2004. 38. Kivimaki M, Virtanen M, Elovainio M, Kouvonen A, Vaananen A, Vahtera J. Work stress in the etiology of coronary heart disease - a meta-analysis. Scand J Work Environ Health. 2006 Dec;32(6):431-42. 39. Chandola T, Brunner E, Marmot M. Chronic stress at work and the metabolic syndrome: prospective study. Br Med J 2006 Mar;332:521-5. 40. Stansfeld S, Candy B. Psychosocial work environment and mental health-a meta-analytic review. Scand J Work Environ Health. 2006 17. Patel V, Kleinman A. Poverty and common mental disorders in devel- Dec;32(6):443-62. 41. Head J, Kivimaki M, Siegrist J, Ferrie JE, Vahtera J, Shipley MJ, et al. Effort-reward imbalance and relational injustice at work predict sickness absence: the Whitehall II study. J Psychosom Res. 2007 Oct;63(4 ):433-40. oping countries. Bull World Health Organ. 2003;81(8); 42. World Health Organization. 16. Pronyk PM, Hargreaves JR, Kim JC, Morison LA, Phetla G, Watts C, et al. Effect of a structural intervention for the prevention of intimatepartner violence and HIV in rural South Africa: a cluster randomised trial. Lancet. 2006 Dec 2;368(9551):1973-83. 18. Parent-Thirion A, Fernandez 609-15. Macias E, Hurley J, Vermeylen G. Practices and policies for mental health in Europe: meeting the challenges. Geneva: WHO; 2008.