Health Status: A Matter
of Class?
by
The Hon. Monique Bégin, PC, FRSC, OC
University of Ottawa
WHO Commission on Social Determinants of Health
2nd Annual Faculty of Health Sciences Distinguished Lecture,
University of Western Ontario, London (ON)
March 29, 2007
Today…

We want to explore « why are some
people healthy and others not ? », to
paraphrase Bob Evans.

If genetics and individual risk factors are
not the best predictors of staying healthy
or becoming ill, what are the predictors
society should know about?
Monique Bégin
2
Social determinants
is the answer
and the key to understanding
patterns of health and illness.
Monique Bégin
3
The « classless » society?...
Canadians and Americans like to think
that they are very egalitarian and don’t
have social classes.
 We mask reality by referring to « socioeconomic status ».
 The Brits who acknowledge that their
society is a well-entrenched class system
have a long tradition of research of the
connection between health and class.

Monique Bégin
4
Two famous British
studies:
*Black
*Whitehall
The Black Report
Sir Douglas Black et al
 First released in 1980
 Tracked patterns of inequalities of health
across Britain through health records.
 Made recommendations for health
improvement.
 Thatcher tried to suppress the report.
 Finally published in 1988 together with
Margaret Whitehead’s update The Health
Divide.

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The Black Report showed…
1.
2.
3.
Improvement in health across all the
classes since creating the National
Health Service (1948).
Still a correlation between social class,
and infant mortality rates, life
expectancy and unequal use of medical
services.
Lower occupational groups experience
poorer health at all stages of life.
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7
The Whitehall I Study
Sir Michael Marmot (joined in 1976)
 Published 1986-1987
 10,000+ male civil servants, over 10
years.
 Divided in 4 groups:

– administrative (such as permanent secretaries/
Deputy Ministers);
– professional and executive (such as senior
executive officers);
– clerical;
– other (unskilled manual workers - as porters,
messengers).
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8
Why Whitehall I ?

Initially undertaken in 1967, separate from the
Black research, to investigate cardiorespiratory
disorders and their precursors.

Main topics covered:
– cardiovascular function, smoking, angina
– diabetes, clinical examination, ECG measurements
– car ownership, leisure/hobbies and grade of
employment.
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9
Research’s assumption was:
Individuals with
big jobs and big
responsibilities
are those prone
to cardiac
accidents.
BOSS
No. 2a
Monique Bégin
No. 2b
No. 2c
10
Research results:
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11
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Whitehall I and II concluded:

People at the bottom of the hierarchy had a
higher risk of heart attacks. The lower you were
in the hierarchy, the higher the risk.

The same applied to all the major causes of
death -- cardiovascular disease, gastrointestinal
disease, renal disease, stroke, accidental and
violent deaths, cancers that were not related to
smoking as well as cancers that were related to
smoking.
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13
Whitehall’s social determinants:
 Low
job control.
 Job stress, tension
 Lack of skill utilization
 Lack of clarity in tasks.
 Household income or wealth
 Conflicting work and family demands.
 No socially cohesive neighbourhood.
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Long spells of sickness absence by grade
(Men, Whitehall II study)
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Gradient in Psychological Stress by Executive Level
in Canadian Civil Servants
40.00
38.00
Stress
EX 1
36.00
EX 2
34.00
EX 3
32.00
EX 4
30.00
1
EX 5 & 6
Occupational level
p<0.0001; Lemyre, Beauregard, Corneil & Barette (CRSH-INE 2002-05)
«The Federal Public Service as a Learning Organization: Stress and Learning in Executives »
Louise Lemyre, Ph.D, FRSC
School of Psychology, Faculty of Social Sciences
R. S. McLaughlin Research Chair
Groupe d’Analyse Psychosociale de la Santé (GAP-Santé)
Institute of Population Health, University of Ottawa
louise.lemyre@uottawa.ca
www.gapsante.uottawa.ca
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Do socioeconomic differences in
mortality persist after retirement?
Relative differences in mortality
between low and high employment
grades are less after retirement,
suggesting the importance of work in
generating inequalities in health.
On the lighter side…
"People with PhDs live longer than those with
masters degrees. Those with a masters live longer
than those with a degree, while those with a
degree live longer than those who left school early.
Similarly, actors who have won an Oscar will live
on average 3 years longer than those who were
nominated for the award but missed out. "
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British milestones studies:

The Black Report (1980)

The Whitehall Studies I and II (1967-1987 and 1987-2007 +)

Margaret Whitehead’s The Health Divide (Black updated 1992)

The Acheson Inquiry (1998)

Modernising Government White Paper (1999)

Saving Lives - Our Healthier Nation White Paper (1999)

The NHS Plan (2000)

Tackling Health Inequalities Cross-Cutting Review (2002)

Tackling Health Inequalities. A Programme for Action (2003)

The Wanless Reviews (2002, 2004)

Choosing health: making healthy choices easier (2004)

Tackling Health Inequalities: Status Report (2005)
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These studies tell us about:
 The
social determinants of health:
we now know that factors other than
genetic/biological do determine
health status.
 The
gradient theory: we also know
that « social classes » or different
socio-economic status do predict
health status.
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The Lalonde report is the Canadian
«ancestor» of the social
determinants approach
(Health Canada, 1974)
The Ottawa Charter (1986):
Towards Healthy Public Policy
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Dr. Fraser Mustard conceptualized the social
determinants of health around 1989-90.
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Dahlgren and Whitehead 1991
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Inequality
Wilkinson (1996) argues that what
matters most is not whether you
have a smaller or larger home or
better or lesser care but what these
differences mean socially and what
they make you feel about yourself
and the world around you.
(Richard Wilkinson, University of Nottingham, UK)
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From health inequality
to health inequity

Health inequality:
An observable,
often measurable,
difference in health
status between
individuals or
between groups,
whatever its cause.

Health inequity:
A moral category
rooted in social
stratification,
embedded in
political reality and
the negotiations of
social power
relations.
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Consequently:
Health
equity can be defined
as the absence of unfair or
unavoidable or remediable
differences in health among
populations or groups defined
socially, economically,
demographically or
geographicaly.
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How egalitarian a society are we?
There is now good evidence that the
healthiest and happiest societies are
those with the most equal
distribution of income.
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Inequalities in health outcomes:
* Do they exist within other
countries?
* Between countries?
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The same within most countries:
Leaving downtown
Washington (DC)
at 5 P.M., life
expectancy is 57
years.
…arriving home in
Maryland…life
expectancy is 77
years.
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Probability of Survival From Age 15-65
Years Among US Blacks & Whites
% probability of survival
80
70
60
50
40
30
20
US White Poor White US Black Poor Black
Males
Males
Males
Males
Geronimus et al, NEJM 1996 Monique Bégin
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The Widening Trend in Mortality by
Education in Russia,1989-2001
elementary
university
0,7
45 p 20
0,65
0,6
0,55
0,5
0,45
19
89
19
90
19
91
19
92
19
93
19
94
19
95
19
96
19
97
19
98
19
99
20
00
20
01
0,4
Calendar year
45 p20 = probability of living to 65 yrs when aged 20 yrs
Bégin
Murphy, Bobak, Nicholson, Rose, and Monique
Marmot,
2005 under review
32
Inequality in a Canadian context
1990-2000:
* Wealthiest 10% of Canadians
increased their income by $23,000
per person per year.
* Poorest 10% of Canadians
increased theirs by $81 per person
per year.
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CANADA: more facts…
 Food
insecurity exists among 10.2%
of Canadian households representing
3 million people. Monthly food bank
use is 747,665 or 2.4% of total
Canadian population, double the
1989 figure.
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Over last 10 years, welfare benefits have dropped
in most provinces below half of basic living costs.
In 2001, just 39% of unemployed Canadians were
eligible for unemployment insurance benefits. The
program must be more accessible.
Minimum wages are inadequate to achieve a
decent standard of living.
Homelessness and housing constitute a national
emergency.
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Aboriginal health
Canada
Life
expectancy
at birth
Status
Indians
Inuits
Female 82
77
68
Male
69
70
76
Infant
mortality
(1000)
5.3
8.0
15.0
Deaths by
suicide
(100,000)
13
28
79
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… and health inequalities
exist between countries:
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% PROBABILITY OF DYING BETWEEN
AGES 15 AND 60 (males)
LESOTHO
90.2
RUSSIA
46.9
BOLIVIA
26
SRI LANKA
23.8
COLOMBIA
23.6
PAKISTAN
22.7
SWEDEN
8.3
SOURCE: THE WORLD HEALTH REPORT 2004,WHO
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UNDER 5 MORTALITY RATE PER
1000 LIVE BIRTHS
SIERRA LEONE
316
BOLIVIA
80
KYRGYZSTAN
63
SRI LANKA
20
ICELAND
3
SOURCE: THE WORLD HEALTH REPORT 2004,WHO
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Under-five mortality rate, change over
period 1990-2000
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No comments…

In Kumasi, Ghana,
a country which
privatized public
toilets in the 1990s,
private toilet use
once a day for a
family costs 10% of
the basic wage.
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WHO Commission on Social
Determinants of Health
(March 2005 – April 2008)
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How is the Commission organized?





Michael Marmot, Chair
19 members
(volunteers)–One
Canadian (M. Bégin)
Small Secretariat in
Geneva
Smaller scientific team
around Marmot in
London.
Meetings in-person 34 times per year.
Pillars of our work:
 8 knowledge networks
 Countries (and
regions) involved
 Civil society and
global partners
involved (World Bank,
etc.)
 World Health
Organisation (WHO)
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KNOWLEDGE NETWORK THEMES
Measurement
Health
systems
Diseases
of Public
Health
Impt
Early Child
Development
Women +
Gender
Equity
Building
Health &
Health
Equity
Globalization
Urban Settings
Employment
Conditions
Social
Exclusion
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3 Knowledge Networks funded
by Canada:
 Early
Childhood Development
(Dr. Clyde Hertzman, UBC)
 Globalization and Health
(Dr. Ron Labonte, UofO)
 Health Systems
(via IDRC, in South Africa)
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My personal “mission” as a
Commissioner

Ensure that unique challenges of the worlds’
Indigenous people are addressed in CSDH work
– Working in partnership with Australia, NZ, South
American countries to explore ways to address unique
determinants of Indigenous peoples’ health


Ensure that CSDH recommendations address
inequalities in developed as well as developing
countries
Facilitate moving Canada beyond ‘pilot projects’
to a systemic approach to addressing
determinants of health
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46
Canada’s participation:




The PHAC created a Canadian Reference Group with
various stakeholders
Engaging the Canadian society
A joint project with UK and Sweden on «whole-ofgovernment»* strategies
An Aboriginal Sub-Committee
Challenges: how do we beat the « silos » approach
to public policy when most determinants of health
are outside health ministries?...
How do we make poverty visible to Canadians?
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Is action possible?...
 Yes
it is and it’s urgent!
 How? By shedding «the culture of
contentment» in which we live.
 By saying loud and clear that social
policies do matter to Canadians.
 By addressing upstream factors
through «whole-of-government»
policies instead of focusing
on downstream problems:
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To conclude: Global Health Watch…
reports that the cost of achieving and
maintaining universal access to basic
education, basic health care, adequate
food, and safe water and sanitation for all
has been estimated at less than 4% of the
combined wealth of the 225 richest people
in the world.
 They consider poverty and development
as a public health issue.

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What good does it do to treat
people's illnesses ...
…then send them back to the
conditions that made them sick?
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