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:
m.marmot@ucl.ac.uk
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
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The health effects of major organisational change and job insecurity.
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22. Ferrie JE, Shipley M, Stansfeld S, Marmot MG. Effects of chronic
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