27/11/14&

Social&determinants&
of&health&&&health&inequities&

Postgraduate&TMIH,&Block&8:&Public&Health&
Werner&Soors,&27.11.2014&

Social&determinants,&why?&
Because&the&biomedical&model&alone&is&not&sucient&
to&understand&and&remedy&the&sufering&of&individuals&
and&populations&
Because&poverty&and&inequities,&though&being&
determinants&of&the&health&of&individuals&and&
populations,&are&largely&absent&from&our&medical&
schools&curricula&
Because&health&services,&mirroring&society,&are&
themselves&a&social&determinant&of&health&
Because&health&services,&led&by&informed&and&
committed&professionals,&are&an&important&point&of&
entry&to&tackle&the&social&determinants&of&health&

1&

27/11/14&

Social&determinants,&how?&
As&clinicians&by&design,&
We&might&need&to&familiarize&ourselves&with&non#
medical+terminology+(concepts,&denitions)&
We&might&benet&from&understanding&how&these&
concepts&and&denitions&evolved+over+time+
A&focus&on&the&suering+of+individuals+and+
populations+&linked&to&poverty,&inequities&and&social&
exclusion&&would&facilitate&our&understanding&
Hence&our&choice&to&deal&in&this&introduction&with&
poverty&and&inequities&from&a&historial+perspective,&and&
to&explain&step&by&step&their&interrelation+with+(ill)+
health+

Outline&
Concepts&&&dnitions&
What+is+poverty?+What+is+health?&

Theories&
How+does+poverty+inuence+health?+
How+does+(ill)+health+inuence+poverty?+
Social+exclusion+as+an+explanandum&

Strategies&(and&more&conceptual&stu)&
Poverty+reduction+strategies+
Millennium+development+goals+
Action+on+the+social+determinants+of+health+
Health#in#all+policies+(HiAP)+
Inequalities+or+inequities?+Determinants+of+what?+

2&

27/11/14&

Your&view&
What&makes&this&person&look&poor?&

Poor&=&not&rich&
England,+end+of+the+19th+century&
Charles(Booth(
Life&and&Labour&of&the&People&in&London&
1889_1903&
Poor+is+who+barely+got+the+means+to+live+a+decent+and+
independent+life,+as+compared+to+the+standard+of+living+
currently+in+use+in+this+country+
&First&use&of&the&term&poverty&line&

3&

27/11/14&

Poor&=&not&rich?&
England,+end+of+the+19th+century&
Benjamin(Seebohm(Rowntree(
Poverty:&A&Study&of&Town&Life&
1901&
A+poverty+line+of+21+shilling+and+8+pence+is+our+standard+
of+surviving+(calling+it+a+standard+of+living+would+be+too+
much+honour)+
&First&monetary&and&minimal&interpretation&of&a&poverty&
line,&based&on&income&
But&Rowntree&was&also&the&rst&to&introduce&a&life_cycle&
approach,&recognizing&the&dynamics&of&poverty&

Poor&=&lack&of&income?&
The+world,+end+of+the+20th+century&
The(World(Bank(
World&Development&Report&1980,&part&II:&
Poverty&and&Human&Development&
Poverty+cannot+comprehensively+be+measured+
&Recognition&of&the&complex&dynamics&of&poverty&
The+solution+for+poverty+is+economic+growth+
&Implicit&denition&of&poverty&as&shortage&of&money&or&
material&assets;&adherence&to&trickle_down&economics;&no&
recognition&of&inequalities&(average&income)&and&role&of&
redistribution+
&

4&

27/11/14&

Poverty&=&measurable?&
The(World(Bank(
World&Development&Report&1990:&Poverty&
Absolute+poverty+(are+these)+conditions+of+life+
below+any+reasonable+denition+of+human+dignity,+
characterised+by+malnutrition,+illiteracy+and+illness++
We+can+measure+absolute+poverty+along+a+universal+
1#dollar#a#day+poverty+line+
+
&

Calculated&per&person&in&his/her&family&in&his/her&country&
with&virtual&1985&PPP&(purchasing_power&parity)&dollars&

The&limits&of&1&dollar&a&day&
In&theory,&a&comprehensive&denition&of&poverty&as&opposed&
to&basic&wellbeing&
In&practice,&a&minimalist&denition&of&poverty&as&shortage&of&
money&
Labour_intensive&economic&growth&as&the&proposed&solution&
(the&social&dimension&still&seen&as&secondary)&
Poverty&line&more&frequently&based&on&comsumption&
Still&largely&used,&despite&several&additional&aws:&
No&recognition&of&inequalities&and&gradients&of&living&cost&within&a&
country&
No&recognition&of&temporary&and&chronic&poverty&
No&recognition&of&non_commercial&products&and&services&
No&recognition&of&the&composition&of&a&household,&and&of&inequalities&
within&a&household&

5&

27/11/14&

How&to&live&
on&less&than&a&dollar&a&day?&

Worse&is&possible&
Wagsta(
Child&health&on&a&dollar&a&day:&some&tentative&cross_country&comparisons&
Social+Science+&+Medicine+57(9):&1529_1538,&2003+

In+rich+countries,+one+child+in+160+dies+before+age+5+
In+poor+countries+and+in+households+on+less+than+1+dollar+a+day,+one+in+
12+up+to+1+in+6+die+before+age+5+

Woodward(&(Sims(
Growth&isnt&working:&the&unequal&distribution&of&the&benets&and&costs&of&
global&growth&
New+Economics+Foundation,&2006&

Of+those+children+that+survive,+1+in+3+up+to+1+in+2+is+malnourished+and+
stunted++

6&

27/11/14&

2&poverty&lines,&3&solutions&
The(World(Bank(
World&Development&Report&2000:&Attacking&poverty&
Extreme+abolsute+poverty+is+measured+along+a+universal+1#
dollar#a#day+poverty+line;+absolute+poverty+along+a+2#
dollar#a#day+poverty+line+

+
&

Recalculated&per&person&in&his/her&family&in&his/her&country&with&
virtual&1993&PPP&dollars&
&!The&Banks&proposed&triple&solution:&
1. Give&the&poor&chances&
&by&creating&economic&growth&
2. Give&them&voice&
&by&stimulating&responsive&governance&
3. Give&them&security&
&by&applying&risk&management&
&

Rethinking&poverty&
Amartya(Sen(
Development&as&freedom,&2000&
Inequality&reexamined,&2004&
Development+conceptualised+as+the+functionings+
of+the+potential+of+individual+possibilities+(capabilities)+
which+are+the+essential+freedoms+of+a+person+
to+live+the+life+he+or+she+nds+worthwhile+living+
Poverty,+by+contrast,+conceptualised+as+the+failure+of+this+
potential,+by+deprivation+of+these+capabilities+

7&

27/11/14&

Poor&=&more&than&not&rich&
United(Nations((UNDP)&
Poverty+is+more+than+an+economic+condition,+
more+than+the+lack+of+food,+housing+and+clothing+
Poverty+is+the+lack+of+means+to+change+these+conditions+
Poverty&in&other&words,&is&about&power&
and&as&we&will&see&next:&lack&of&power&makes&sick&

Our&aim:&
To&lessen&the&suering&

8&

27/11/14&

Health&=&more&than&not&sick&
World(Healh(Organization(
Constitution&of&the&World&Health&Organization,&1946&

Health+is+a+state+of+total+physical,+mental+and+social+
wellbeing,+and+not+solely+the+absence+of+illness+and+
incapacities+
United(Nations(
International&Covenant&on&Economic,&Social&and&Cultural&Rights,&1966&

Every+human+being+deserves+the+right+to+live+the+highest+
possible+standard+of+physoical+en+mental+health+

From&poverty&to&health?&
Central+Europe,+18th+&+19th+century&
Johann(Peter(Frank(
System&einer&volstndigen&medicinischen&Polizey&
1779_1819&
Misery+is+the+mother+of+disease+

9&

27/11/14&

From&poverty&to&health?&
Central+Europe,+19th+century&
Rudolf(Virchow(
Mitteilungen&ber&die&in&Oberschlesien&herrschende&
Typhus_Epidemie:&Die&Sorge&fr&die&Zukunft&
1849&
Disease+incidence+is+directly+related+to+miserable+and+
decient+nutrition+and+housing;+the+same+societal+
conditions+probably+determine+the+process+and+the+
outcome+of+disease+
!First&to&point&at&the&societal&and&structural&determinants&of&health&

Societal&determinants&
Central+Europe,+19th+century&
Alfred(Adler(
Gesundheitsbuch&fr&
das&Schneidergewerbe&
1889&
Not+to+worry+about+the+
suering+of+human+beings+
as+a+product+of+society+
is+unforgivable+
Importance&of&social&structures&
for&human&wellbeing,&preceding&
the&twin_concept&of&social&
exclusion_inclusion&by&a&century&

10&

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Society,&poverty&and&health&
Latin+America,+19th+century&
Eugenio(Espejo((Ecuador,&20&years&before&Virchow)(
Role&of&poverty,&decient&housing&and&malnutrition&
in&outbreaks&of&epidemics&

Society,&poverty&and&health&
Latin+America,+early+20th+century&
Max(Westenhofer((Chile,&student&of&Virchow)&
Salvador(Allende(
La&Realidad&Mdico_Social&Chilena,&1939&
Our+doctors+should+be+concerned+about+the+miserable+
working+conditions+and+about+the+lack+of+regulation+
between+work+and+capital+
Plea&for&socio_economic,&more&than&medical&solutions&for&
health&problems&(redistribution&of&income,&housing&projects,&)&

11&

27/11/14&

Rise&(and&fall)&of&social&medicine&
Latin+America,+early+20th+century&
Juan(B(Justo((Argentina,&1920s)&
Social+change+for+better+health;+
population+characteristics+at+the+core+
Critique&on&and&alternative&for&Rockefeller&public&health&
No&health&without&doing&away&with&poverty&and&inequity&

Rise&(and&fall)&of&social&medicine&
Latin+America,+mid+20th+century+
Intersectoral&inuences&
Frei(Betto((Brazil)&

Basic&communities&for&social&justice&

Paulo(Freire((Brsil)&
Education&in&empowerment&

Inuence&on&global&health&policy&
Juan(Csar(Garca((Director&of&Research&PAHO&1966_1984)&
Halfdan(Mahler((Director&WHO&1973_1988)&
Health&for&All&
Radicalisation&
Camilo(Torres,&Ernesto(Che(Guevara,&&

12&

27/11/14&

Poverty&&&ill&health&
The+world,+1980#2000+:+neoliberal+reforms&
Margaret(Whitehead,&Gran(Dahlgren(&&Tim(Evans(

Equity&and&health&sector&reforms:&can&low_income&countries&escape&the&
medical&poverty&trap?&The+Lancet+358:833_836,&2001&&

The&medical(poverty(trap(
More&or&deeper
&&&&&&&&&&&&&poverty
&
&
&&&&&&&&&&&Is&paid&for
&

&
&
&&&&&&Persisting&or&worsening&
&&&&&&&&&&&&
&
&&&&&&health&problem&
&&&&&&&&&Poor&and&in&
&&&&&&&&&&bad&health&
&
&&&&&&&&&&&&&&&&&&&&&&&&&&Is&not&paid&for&
&&&Price&of&health&care&

Poverty&&&ill&health&
Jerey(Sachs(et+al.+
Ending&Africas&poverty&trap&

Brooking&Papers&on&Economic&Activity&1:&117_240,&2004&

A&similar&causality&at&population&and&country&level:&
countries&with&a&higher&disease&burden&show&less,&
none&or&negative&economic&growth&

13&

27/11/14&

Poverty&&&ill&health&
Xu(et+al.+
Household&catastrophic&health&expenditure:&
a&multicountry&analysis&
The+Lancet+362:&111_117,&2003&

Catastrophic(household(expenditure&
In&many&countries,&10%&of&household&yearly&spend&more&
than&40%&of&their&free&income&on&health&care&

Poverty&&&ill&health&
Bruno(Meessen(et+al.+
Iatrogenic&poverty&

Tropical+Medicine+and+International+Health+8:&581_584,&2003&

Iatrogenic(poverty&
Even&if&the&consequences&will&be&catastrophic,&
people&spend&if&their&caregivers&tell&them&to&spend&

14&

27/11/14&

Social&exclusion&as&a&mechanism?&
Jennie(Popay(et+al.+
Understanding&and&tackling&social&exclusion.&
Final&report&Social&Exclusion&Knowledge&Network,&2008&
Exclusion+consists+of+dynamic,+multi#dimensional+
processes+driven+by+unequal+power+relationships+across+
four+main+dimensions++social,+political,+economic+and+
cultural++and+at+dierent+levels+including+individual,+
household,+group,+community,+country+and+global+levels.+
It+results+in+a+continuum+of+inclusion/exclusion+
characterised+by+unequal+access+to+resources,+
capabilities+and+rights+which+leads+to+health+inequalities++

Social&exclusion&as&a&mechanism?&
Jan(Vranken+
At&the&Antwerp&Health+Inc&conference,&2014&
Social+exclusion+is+one+of+the+four+forms+of+social+
dierences,+and+the+most+extreme+one.+Social+
exclusion+implies+two+conditions:+a+hierarchical+
relationship+between+individuals+or+groups,+and+a+
separation+by+clearly+discernible+fault+lines+
+
Hierarchy(
Fault(lines( No&

Yes&

No&

Social&dierentiation&

Social&inequality&

Yes&

Social&fragmentation&

Social(exclusion(

15&

27/11/14&

Social&exclsuion&as&a&mechanism?&
Werner(Soors,&Fahdi(Dkhimi(&&Bart(Criel(
Lack&of&access&to&health&care&for&African&indigents:&
a&social&exclusion&perspective&
International+Journal+for+Equity+in+Health+12:91,&2013&
No+doubt+that+the+common+African+is+quite+familiar+with+
the+existence+and+extent+of+social+exclusion+
Inclusion+and+exclusion+are+intertwined,+inclusion+more+
often+than+not+entails+adverse+incorporation,+and+exclusion+
reproduces+itself+

How&to&analyse&social&exclusion?&
The&SPECYbyYstep(tool+
Health+Inc+project,&2011_2014&
Combines&the&SPEC+perspective&(the&social,&political,&
economic&and&cultural&dimensions)&with&a&step_by_step&
deconstruction&(by#step)&as&developed&earlier&by&
Maurice&Piot&for&the&analysis&of&the&ecacy&of&a&disease&
control&programme&
Entry&point&for&the&analysis&of&social&exclusion&in&any&
sequential&health&programme,&health&nancing&
programme&or&social&health&protection&programme&

16&

27/11/14&

The&SPEC_by_step&tool&

The&millennium&failure&
Giovanni(Andrea(Cornia(&(Julius(Court(
Inequality,&growth&and&poverty&in&the&era&of&liberalization&
and&globalization&
World+Institute+for+Development+Economics+Research,&2001&
Structural+adjustment+would+foster+economic+growth,+
and+the+poor+would+ultimately+benet+
The+opposite+proved+to+be+true:+economic+growth+
remained+sub#standard,+inequity+increased,+and+the+
increase+in+inequity+was+directly+related+to+the+applied+
policy+

17&

27/11/14&

Health&outcomes&
World(Health(Organization(
2000&
50%+of+the+world+population+had+no+more+access+to+
essential+care+or+drugs+
In+low#+and+middle#income+countries+health+centres+did+
no+longer+attract+patients+
Disease+control+programmes+failed+where+patients+
voted+with+their+feet+against+the+rising+cost+of+care+
A&range&of&correcting&strategies(

Poverty&reduction&strategy&
World(Summit(for(Social(Development(
Copenhagen,&1995&
Poverty&for&the&1st&time&on&the&global&political&agenda&
James(Wolfensohn,&1998&
Comprehensive&Development&Framework&
La(Banque(Mondiale,&1999&
Poverty(reduction(strategies(as&replacement&for&
Structural&adjustment&policies&
Poverty&reduction&on&the&cover,&
global&development&on&the&rst&page,&
debt&relief&as&the&carrot&
but&health&rarely&mentioned&

18&

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Millennium&development&goals&
United(Nations(Millennium(Summit(
New&York,&2000&
Conrmation&of&values,&rights&and&goals&
Millennium(development(goals,&2001&
Reduction&of&the&goals&to&a&checklist&of&8&technical&mid_
term&(2015)&objectives&with&48&indicators&
Enters&health&(child&mortality,&maternal&mortality,&transmission&of&
HIV/Aids,&TB&and&malaria)&

Health&for&economic&development&
Commission(on(Macroeconomics(and(Health(
Invest&in&health&for&economic&development&
WHO,&2001&
To+reduce+poverty,+we+should+concentrate+on+the+path+
from+health+to+income,+instead+of+waiting+for+economic+
growth+to+improve+health:+health+nancing+is+an+
investment,+not+a+cost+

19&

27/11/14&

Health&for&economic&development&
Critiques&
Cohen(
Worse&than&a&crime,&a&mistake&
The+Lancet,&361:&876_877,&2003&
An+exclusively+economic+approach+
Quid+health+as+a+human+right+on+its+own?+
Waitzkin(
Report&of&the&WHO&Commission&on&Macroeconomics&and&
Health:&a&summary&and&critique&
The+Lancet,&361:&523_526,&2003&
Reborn+Rockefeller+politics:+improve+the+economic+
prospects+of+the+rich+in+the+North+and+the+South,+through+
palliative+measures+in+the+South+
+

Health&as&human&development&
Commission(on(the(Social(Determinants(of(Health(
WHO,&2005_2008&
The+vast+majority+of+inequalities+in+health+between+and+
within+countries+are+avoidable+and,+hence,+inequitable+
We+need+to+facilitate+change+to+improve+health+and+to+
reduce+inequity+

20&

27/11/14&

Action&on&social&determinants&
Closing(the(gap(in(a(generation:(
Health(equity(trough(action(on(the(social(determinants(
of(health(
CSDH,&WHO,&2008&
A&call&for&action,&based&on&3&principles:&
1. Improve+the+conditions+of+daily+life+
2. Tackle+the+inequitable+distribution+of+power,+money+and+
resources+
3. Measure+the+problem,+evaluate+action.+Expand+the+
knowledge+base,+develop+a+workforce,+raise+public+
awareness+

At&health&services&level&
Access+to+and+utilisation+of+health+care+is+vital+to+good+
and+equitable+health.+The+healthcare+system+in+itself+is+a+
social+determinant+of+health,+inuenced+by+and+
inuencing+the+eect+of+other+social+determinants+
Healthcare+systems+have+better+outcomes+when+built+on+
primary+health+care++that+is,+both+the+PHC+model+that+
emphasizes+locally+appropriate+action+across+the+range+of+
social+determinants,+where+prevention+and+promotion+are+
in+balance+with+investment+in+curative+interventions,+and+
an+emphasis+on+the+primary+level+of+care+with+adequate+
referral+to+higher+levels+of+care+

21&

27/11/14&

Beyond&health&services&level&
Universal+health+coverage+requires+that+everyone+within+a+
country+can+access+the+same+range+of+(good+quality)+
services+according+to+needs+and+preferences,+regardless+of+
income+level,+status,+or+residency,+and+that+people+are+
empowered+to+use+these+services+
Intersectoral+action+for+health++that+is,+policies+
coordinated+between+the+health+sector+and+other+sectors,+
is+a+key+condition+and+preferred+strategy+for+coherent+and+
eective+policies+

Health_in_All&policies&(HiAP)&
Adelaide(statement(on(health(in(all(policies:(moving(
towards(a(shared(governance(for(health(and(wellYbeing(
Adelaide,&2010&
Government+objectives+are+best+achieve+when+all+sectors+
include+health+and+well#being+as+a+key+component+of+policy+
development+
This+implies+the+need+for+a+new+social+contract+between+all+
sectors+to+advance+human+development,+sustainability+and+
equity,+as+well+as+to+improve+health+outcomes+
http://www.who.int/social_determinants/
hiap_statement_who_sa_nal.pdf&

&

22&

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Health_in_All&policies&(HiAP)&
European(Commission,(Public(Health(
2014&
Since+health+is+determined+to+a+large+extent+by+factors+
outside+the+health+area,+an+eective(health(policy(
must(involve(all(relevant(policy(areas,+in+particular:+
social+and+regional+policy,+taxation,+environment,+
education+and+research+
http://ec.europa.eu/health/health_policies/policy/index_en.htm&

Inequalities&or&inequities?&

23&

27/11/14&

Inequalities&or&inequities?&
Whitehead(
The&concepts&and&principles&of&equity&and&health&
WHO&Europe,&1990&
On&inequities&in(health:&
Variations+can+be+measured+in+health+statistics.+
However,+not+all+of+these+dierence+can+be+described+as+
inequities.+The+term+inequity+has+a+moral+and+ethical+
dimension.+It+referes+to+dierences+which+are+
unnecessary+and+avoidable,+but,+in+addition,+are+also+
considered+unfair+and+unjust(

Inequalities&or&inequities?&
Whitehead(
The&concepts&and&principles&of&equity&and&health&
WHO&Europe,&1990&
On&equity&in(healthcare(services:&
Equity+in+health+care+is+dened+as+equal(access(to(
available(care(for(equal(need,+and+equal(utilisation(
for(equal(need,+and+equal(quality(of(care(for(all(

24&

27/11/14&

Equality&of&what?&

Equality&of&what?&
Of(opportunity(
(meritocracy,&liberalism&
according&to&Friedman,&&
fair&competition)&
Of(process(
(fair&treatment)&
Of(outcome(
(socialism&according
to&Friedman,&the &
Dodo&in&Alice&in &
Wonderland)
&

&
&
&
&

&
&
&
&

&Everybody+
&must+win+and+
&all+must+get+
&prizes&

25&

27/11/14&

Health&inequities:&global&evidence&
The&most&aggregate&picture,&comparing&countries&
(not&population&groups,&not&individuals)&and&health&
in&toto&(not&health&problems&or&diseases),&at&one&point&
in&time&
Classic&graphic&representation,&since&1975:&the&
Preston(curve,&life&expectancy&plotted&against&
income&per&capita&
Already&shows&a&lot,&and&leaves&even&more&to&be&
explained&
Preston&S&(1975)&The&changing&relation&between&mortality&and&level&of&economic&development.&
Population+Studies&29(2):&231_248&
http://www.ssc.wisc.edu/~walker/wp/wp_content/uploads/2012/01/preston1975.pdf&

The&millennium&Preston&curve&

Deaton&A&(2004)&Health&in&an&age&of&globalization.&Princeton,&NJ:&Princeton&University.&
http://www.princeton.edu/rpds/papers/pdfs/deaton_healthglobalage.pdf&&

26&

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Interpreting&the&Preston&curve&
Correlation&between&health&achievement&and&income&
But&not&the&same&
&&&&correlation&in&
&&&&poorer&and&
&&&&wealthier&countries:&
&&&&less&correlation&in&
&&&&wealthier&
&&&&countries&
Wilkinson&R&&&Picket&K&(2009)&
The&spirit&level:&why&more&equal&
societies&almost&always&do&better.&
London:&Allen&Lane.&
A+presentation+of+
the+book++graphs+included++
is+freely+available+at+

http://www.equalitytrust.org.uk/sites/default/les/attachments/resources/SpiritLevel_jpg_0.pdf&&

&

Interpreting&the&Preston&curve&
Correlation&and&causality&not&&to&be&confounded:&
both&health&and&wealth&can&be&outcomes&
(phenomena),&or&inputs&(causes,&determinants),&or&
both&
In&poor&countries,&wealth&gains&might&be&associated&
with&health&gains&
In&rich&countries,&aggregate&health&gains&keep&
increasing,&whereas&inequitable&distribution&of&them&
widens&
Clearly(a(need(to(make(a(dierence(between(
determinants(of(health(and(of(health(inequities(

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SDH&vs&SDHI&
Hillary(Graham(
Social&determinants&and&their&unequal&distribution:&
clarifying&policy&understandings&
The+Milbank+Quarterly+82(1):+101#12+http://goo.gl/9od3TW+

A+combined+attack+on+the+social+causes+of+health+and+
health+inequalities+implies+a+dual,+not+a+single,+policy(
agenda.+It+requires+engaging+with+not+only+the+social+
inuences+on+health+and+how+peoples+social+conditions+
can+damage+their+health.+It+requires,+too,+simultaneously+
engaging+with+how+social+inequalities+are+maintained+
over+time+and+across+generations+

SDH&vs&SDHI&
Hillary(Graham(
Social&determinants&and&their&unequal&distribution:&
clarifying&policy&understandings&
The+Milbank+Quarterly+82(1):+101#12+http://goo.gl/9od3TW+

Policies+to+achieve+health+gain+seek+aggregate+
improvement+in+the+level+of+health+determinants++
(SDH,&model&1)+
Policies+to+promote+health+equity+address+the+unequal+
distribution+of+these+determinants+between+advantaged+
and+disadvantaged+groups++++++++++++++++++++++++++++++++++++++++
(SDHI,+model+2)+

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SDH&model&vs&SDHI&model&

Inequitable&progress&
In&Europe:&life&expectancy&+30&years&in&20th&century&
In&Asia:&life&expectancy&+13&years&1970_2000&
In&Africa:&life&expectancy&+4&months&1970_2000&

Marmot&M&(2007)&Achieving&health&equity:&from&root&causes&to&fair&outcomes.&Commission&on&
Social&Determinants&of&Health&interim&statement.&Geneva:&World&Health&Organization.&
http://whqlibdoc.who.int/publications/2007/interim_statement_eng.pdf&
&

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Large&gaps&remain&
Infant&mortality&between&rich&countries:&
more&than&money,&income&inequality&matters&

Wilkinson&&&Picket&(2009)&The&spirit&level&

Large&gaps&remain&
Under_5&mortality&between&poor&countries,&and&by&
wealth&group&

Available+in+Marmot&M&(2007)&Achieving&health&equity:&from&root&causes&to&fair&outcomes.&
Commission&on&Social&Determinants&of&Health&interim&statement.&Geneva:&World&Health&
Organization.&http://whqlibdoc.who.int/publications/2007/interim_statement_eng.pdf&
Based+on+Gwatkin&D,Rutstein&S,&Johnson&K,&Pande&R&&&Wagsta&A&(2000)&&
&

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Within_country&evidence&
Wherever&we&look:&(not&so)&social(gradients(

British+civil+servants,+all+with+a+reasonable+income,+all+enjoying+decent+health+services+
Available+from+Marmot&M&(2007)&Achieving&health&equity:&from&root&causes&to&fair&
outcomes.&Commission&on&Social&Determinants&of&Health&interim&statement.&
Geneva:&World&Health&Organization.&
http://whqlibdoc.who.int/publications/2007/interim_statement_eng.pdf++

Therefore&
Alfred&Adler&was&very&right:&not&to&worry&&and&not&
to&act&&is&unforgivable&

31&