Yawen Cheng, ScD
Associate Professor
Institute of Health Policy and Management,
College of Public Health, National Taiwan University
Essentials of Global Health
April 13, 2012
Unless noted, the course materials are licensed under Creative Commons AttributionNonCommercial-ShareAlike 3,0 Taiwan (CC BY-NC-SA 3.0)
1



Why are public health researchers concerned about
“health inequalities” and “social determinants of
health”?
• A brief review of the development of public health
sciences
Existence and trends of health inequalities
What are the causes? Explanations?
• Job stress problems as an example
• Causal explanations and the links to public policies

Documentary Unnatural Causes: In Sickness and In
Wealth (56 minutes)

Discussion in group & preparation for the homework
2
Public health is the science and art of preventing
disease, prolonging life, and promoting health
through the organized efforts of society.
 Goal: biological, physical and mental well-being of
all members of society.
 Core courses: biostatistics, epidemiology, health
sciences…
 3 major branches

• Biomedical sciences
• Environmental and occupational health sciences
• Health policy and management
3
 Before
the 20th century
• Contagion
• Miasma theory
• Social production of health
4
Historical Evolution of Public Health
Major health discourses
1848 UK-Public Health Act
1884 Koch’s Postulates
1974 Lalonde Report
1928 Penicillin
1948 WHO
1964 SG Report
Traditional Public Health
1978 Alma Ata Declaration
1986 Ottawa Charter
2005 WHO CSDH
New Public Health
1971 Canada-NHI
Medical care systems
1961 Japan-NHI
1989 Korea-NHI
1948 UK-NHS
1995 Taiwan-NHI
1911 Germany-RVO
2002 Thai-Mix
1883 Germany-SI
Laissez-faire
Tung-Liang Chiang
Equity in Access
Cost Control
Efficiency
5
Edwin Chadwick (1800-1890)




Report of the Poor Law
Commission (1832)
New Poor Law (1834)
Report on the Sanitary Condition
of the Laboring Population
(1842)
Public Health Act (1848)



Sanitary idea - miasma theory
Drainage system
Central and local boards of health
6
Wikimedia German Federal Archive
7
 In
the 20th century
• Golden age of Germ theory (1900-1950)
• Modern epidemiology (after 1950) – emphasize
on biomedical science and life styles
• Emerging of social epidemiology (1990s~) –
emphasize on ‘social determinants’
8
Germ Theory of
Disease
proposes that microorganisms
are the cause of many diseases.
Koch's postulates, formulated in
1884,
are four criteria designed
to establish a
causal relationship
between a
causative microbe
and a disease.
9
Slogan liked:
Eugenic movement
in the 1920s
(1) birth control
(2) marriage regulation
(3) Sterilization
(4) immigrant restriction
10
In 1988, Lalonde
received WHO Medal for
his exceptional
contribution to health
policy; in 2002, he was
selected by the Pan
America Health
Organization as one of
eleven Public Health
Heroes.
(1974)
11
RESPIRATORY TB MORTALITY
England & Wales, 1840-1970
David Coetzee
McKeown thesis
The role of medicine: dream, mirage, or nemesis? (London, 1976)
The modern rise of population (New York: Academic Press, 1976)
The origins of human disease (Great Britain: TJ Press Ltd, 1988)
12

Driving forces
• Long history of concept of social influence on health
• Social political changes – widening social
inequalities in health
• Changes in scientific knowledge on causality
 Psycho-medicine: Evidences of psychosocial stress on health;
all disease and health status are influenced by psychosocial
conditions
 Influences from other disciplines
13
 What
are the causes?
• Healthcare systems?
• Biomedical factors?
• Genetic factors?
• Life style?
• Environmental factors?
• “Social factors”? The spider of the causal web?
14
 Interventions
are closely linked to causal
interpretation
• Medical
• Biological
• Behavioral
• Environmental
• Social, political, structural
15

Health indicators
•
•
•
•
•
Life expectancy
Mortality (death rate)
Morbidity (disease rate)
Disease survival
Health-related quality of
life

Social factors
• Social class (Marxian),
•
•
•
•
•
•
Social economic status
(income, education,
occupation), early life
experiences
Gender, sex
Place, neighborhood
and community
Racial and ethnic groups
Policy and social
systems
Politics, culture, trade,
etc.
16
Source: Marmot, Health inequalities among British civil servants:
the WhitehallIIstudy, The Lancet Volume 337, Issue 8754, 8 June
1991, Pages 1387–1393
25
Pre-menstrual syndrome
20
Cough with phlegm
%
15
10
Ischaemia
Hypertension
5
Diabetes
0
1
2
3
4
5
6
emp loyment grade
National Taiwan University Yawen Cheng
17
No mod/vig exercise (%)
Currently smoking (%)
35
30
25
20
15
10
5
0
40
30
20
10
0
grade
National Taiwan University Yawen Cheng
Fruit/veg less than daily (%)
70
60
50
40
30
20
10
0
grade
grade
Source: Marmot, Health inequalities among British civil servants:
the WhitehallIIstudy, The Lancet Volume 337, Issue 8754, 8 June
1991, Pages 1387–1393
18
Height (cm)
179
178
177
176
175
174
173
172
171
170
Body mass index (kg/m2)
25.2
25
24.8
24.6
24.4
24.2
24
grade
grade
SBP (mmHg)
DBP (mmHg)
126
79.5
125.5
79
125
78.5
124.5
78
124
77.5
123.5
77
123
76.5
grade
grade
National Taiwan University Yawen Cheng Source: Marmot, Health inequalities among British civil
19 Issue
servants: the WhitehallIIstudy, The Lancet Volume 337,
8754, 8 June 1991, Pages 1387–1393
Cumulative Economic Hardship and Physical,
Psychological, Cognitive and Social
Functioning in Alameda County, 1994
(Lynch & Kaplan, NEJM 1997; 337: 1889-95)
National Taiwan University Yawen Cheng
* Adjusted for age, sex, BMI, pack-years of smoking, alcohol intake, and physical activity
20
Drever F, Whitehead M, Roden M
21
Year
Aborigines*
Han Chinese
M
F
M
F
1933
9.8
13.5
42.7
47.7
1964
48.3
52.2
64.6
69.1
1978-1980
58.4
67.7
68.7
73.9
1984-1986
59.3
69.4
70.7
75.7
1988-1990
59.1
68.8
71.1
76.5
1991-1993
59.6
69.9
71.7
77.3
* Average of plain and mountain aborigines
National Taiwan University Yawen Cheng
22
Life expectancy of aborigines and Han Chinese in
Taiwan （2000）
Ethnic Group
Taiwanese
Plain Aborigine
Mountain Aborigine
Male
73
62 (-11)
58 (-15)
Female
79
72 (-7)
69 (-10)
National Taiwan University Yawen Cheng
23
1995
1976
Tung-Liang Chiang
National Taiwan University Tung-Liang Chiang
Tung-Liang Chiang
24
 Social
selection
• Social heritage
• Social drifting
 Social
causation (exposure and resource)
• Material pathways
 environmental hazards, infection, poor diet, limited
access to health care
• Psychosocial pathways
 Stress, negative emotions, learned helplessness,
lower self-efficacy and self-esteem
25
0.36
0.34
0.32
0.3
0.28
0.26
0.24
0.22
2008
2006
2004
2002
2000
1998
1996
1994
1992
1990
1988
1986
1984
1982
1980
0.2
26
National Taiwan University Yawen Cheng
World Map of Gini coefficient (2009)
27
 Example
1:Job stress problems
28



Cases of “karoshi” (sudden death from overwork)
occurred frequently in Taiwan in recent years; most cases
were young or middle-aged men with cardiac or
cerebrovascular causes of death
These cases were from a wide range of occupations and
socioeconomic groups, including truck drivers,
engineers, physicians, trainees, managers, professors etc.
Controversies over “karoshi” claims for workers’
compensation intensified, and there are growing public
concerns and anxiety on work stress.
29
Labor Day’s March in Taipei
March in support of pro-labor
regulations
(May 1, 2011)
Main themes
• strengthen regulations on working hours
• strengthen regulations on outsourcing &
dispatched work
• Improve OSH standards & labor
inspection
Taiwan Labor Front
Taiwan Labor Front
Taiwan Labor Front
30
Regulations
Inspection
Work place
Occupational health services
Workplace
Monitoring of
workplace hazards
and risk
assessment
Workers
Health
monitoring,
health promotion
& education
Monitoring and reporting systems
Of occupational injuries and diseases
Compensation and
rehabilitation
National Taiwan University Yawen Cheng
2400
2300
2260
2165 2172 2181
2200
2100
1997 1999
2032 2050
2074 2088
2000
1911
1900
1825
1800
1704
1700
1762 1777
1658
National Taiwan University Yawen Cheng
Korea
Hong Kong
Mexico
India
Indonesia
Thailand
Singapore
Taiwan
Japan
USA
Canada
Brazil
Sweden
United Kingdom
Australia
Netherlands
Finland
Germany
Denmark
France
1500
Malaysia
1588
Philippines
1600
1738 1745 1747
1855
China Mainland
Yearly working hours
2295 2312
Data Source: IMD WORLD COMPETITIVENESS ONLINE 1995 - 201032
International comparison of
average annual working hours in
employees: 1870-2010
F
D
N
UK
C
US
J
Korea
TW1
TW2
Shiuan-Be Wu
Graph made by Shiuan-Be Wu.
Data source: (1) Huberman, M., Working Hours of the World Unite? New International Evidence of work time, 18701913. The Journal of Economic History, 2004. 64(04): p. 964-1001; (2) OECD (http://stats.oecd.org/index.aspx);
(3) US (http://www.bls.gov/cps/cps_aa2003.htm); (4) Japan (http://www.stat.go.jp/english/data/chouki/19.htm);
33
(5) Taiwan (Wu, 2011; Master thesis of the Institute of Health Policy and Management, NTU).
Major stressors
Demands (effort)
quan., qual., emotional,
sensory, etc.
Job control
authority, skill
Social support
supervisor,coworker
Work rewards
income, respect, esteem,
fairness, security,
support, etc.
Role conflicts
Shift work
Management
Hazardous exposure
Age, Sex,
Education,
Personality,
Coping
Other
stressors
National Taiwan University Yawen Cheng
Job strain
Psychological:
job dissatisfaction
depression
anxiety
Physiological:
somatic complaints
hypertension
hyperlipoidemia
immune depression
Behavioral:
smoking
drinking
sleep problems
Stressrelated
illnesses
disability;
accident;
illness
Other social
support
34
• Developed by Robert Karasek and Tores Theorell in
1970s
• “Alienation” as the main cause of job stress
• Emphasizing on job enrichment, democracy in the
workplace, and social support
• Product of social democratic movement; political
struggle to overcome ‘powerlessness’, ‘de-skilling’
and ‘alienation’
35
Active learning
＋
Low strain
jobs
Job
control
National Taiwan University
Passive
jobs
Active
jobs
High strain
jobs
strain
Psychological
Yawen Cheng demands
＋
36
Skill
discretion
1.
2.
3.
4.
5.
6.
Learn new things
No repetitive work
Require creativity
High skill level
Variety
Develop own abilities
Decision
authority
1.
2.
3.
Own decisions
Decision freedom
Lots of say
1.
2.
3.
4.
Supervisor concerned
Supervisor pays attention
Helpful supervisors
Supervisor good organizer National Taiwan University
Job
control
Psychological
demands
Supervisor
support
Coworker
support
1.
2.
3.
4.
1.
2.
3.
4.
5.
Coworker competent
Coworker interest in me
Coworker friendly
Coworkers helpful
Work fast
Work hard
Excessive work
Not enough time
Conflicting demands
Yawen Cheng
37
38
39
Photographed by National Taiwan University, Yawen Cheng, May, 2010.
40
www.osh.govt.nz
41
SF-36 mental health score in relation to
job control and demands
- micro-electronic workers in Taiwan (n=1,078)
SF-36 Mental Health
10
9.31
9
multivariate regression coefficients
8
6.92
7
6.09
6.12
6
5
5.09
4.3
4.2
4
3
2.9
2
1
High
0
0
Low
Intermediate
Job control
Low
High
Demands
National Taiwan University Yawen Cheng
Adjusted for age, sex, BMI, marital status, smoking, shift work, work hours,
job insecurity, and work-place social support.
42
Comparison of job demands and job control
measured by Job Content Questionnaire for Men*
80
CanadaQuebec(W)
EU-North
JOB CONTROL
75
Canada-Quebec
US(NMEC)
EU-Middle
70
Netherlands
Japan (JSTRESS)
EU-South
65
Japan (two
companies) Taiwan
60
25
30
35
JOB DEMANDS
40
National Taiwan University Yawen Cheng
* Sources: Karasek et al. 1998; Kawakami et al 2004; Cheng et al 2003; EUJACE study, 2002.
43
EU
US
100
80
Proportion of workers, %
Proportion of workers, %
90
70
60
50
40
High speed
Tight deadline
Control over methods
Control over speed
30
20
10
0
1990
1995
Source: European
Foundation Surveys
2000
100
90
80
70
60
50
40
30
20
10
0
Work Very Hard
Work Very Fast
Not Enough Time
A Lot of Say
Freedom to Decide
1977
1997
Source: The1977 Quality of Employment Survey
and 1997 National Survey of the Changing
Workforce in the US
National Taiwan University Yawen Cheng
44
Changes in Job Demands (2001-2010)
National Taiwan University Yawen Cheng
45
Changes in Job Control (2001-2010)
National Taiwan University Yawen Cheng
46
Micro level
Wage/benefit
Macro level
Mezzo level
Politics, policy,
law, enforcement
• Deregulation
• Globalization
• Employer-labor
power imbalance
“Flexible labor”
• Downsizing
Job security
Career prospect
• Outsourcing
• Contingent workers
• Multi-role workers
• Floating wage
Skill utilization
Skill development
Economic factors
Impacts of new
technology
Workloads
Profit-oriented
performance
evaluation
Influence
Participation
Social support
Mutual trust
Social integration
Cultural factors
National Taiwan University Yawen Cheng
Meaningfulness
47
WHO
48





Choose one type of the health problems, and answer the following
questions
• Occupational injuries or occupational diseases
• Coronary heart disease or hypertension
• Obesity
• Smoking
• Alcoholism
In your country or region, is there health inequality of this health
problem by social categories (e.g., education, occupational grade,
income, gender, ethnicity, neighborhood) ?
If so, what might be the cause (s)?
What kinds of public policies do we need to reduce social
inequalities of this health problem?
What obstacles and opportunities may exist?
49
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New Perspective on the Health of Canadian, A working
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This work is from : Drever F, Whitehead M, Roden M. Current
patterns and trends in male mortality by social class (based
on occupation). Popul Trends. 1996 Winter;(86):15-20.
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This work is from : Karasek, R. and T. Theorell (1990).
Healthy Work - Stress, Productivity, and the Reconstruction
of Working Life. New York,
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This work is from : Karasek, R. and T. Theorell (1990).
Healthy Work - Stress, Productivity, and the Reconstruction
of Working Life. New York,
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This work is from :WHO (2007). Employment conditions and
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Health
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