U.N. Commission on Social Determinants of Health
February 19, 2006


By Michael Marmot

Let's start at the beginning: if you are a fifteen-year-old boy in Lesotho, your chance of reaching the age of 60 is about 10%. If you are a fifteen-year-old boy in Sweden, your chance of reaching 60 is 91%. This difference is due to social conditions, which are determinants of health. They include education and the nature of jobs. They include living conditions such as housing and availability of adequate nutritious food. They also entail access to quality health care.

Similarly, there are big health inequalities within countries. Let's take the United States, for example. If you catch the metro train in downtown Washington, D.C., to suburbs in Maryland, life expectancy is 57 years at beginning of the journey. At the end of the journey, it is 77 years. This means that there is 20-year life expectancy in the nation's capitol, between the poor and predominantly African American people who live downtown, and the richer and predominantly non-African American people who live in the suburbs.

Now, a poor man in inner-city Washington, D.C., is rich in material terms when compared to a poor man in Lesotho. The social determinants of these two individual's lives are different, and we must acknowledge this and think of poverty in a different way. It is about opportunities in life and control over one's life, in addition to social conditions that shape the physical environment one lives in.

Realistically, can anything be done about the social determinants of health?

There is much that we can do about the social determinants of health, having the knowledge and the will. We know, for example, that unemployment, insecure employment or employment in poor working conditions harm health. Creating jobs that are secure and improving conditions of employment will lead to improvements in health. This has been recognized in some countries. It now needs to be more broadly applied.

Secondly, we know that where there are concentrations of poverty, with poor infrastructure, low levels of social cohesion, more than health suffers. But there are other effects such as high rates of crime. The benefits of investing in better human habitats are likely not only to improve health, but also lead to safer and more secure environments for residents and visitors alike.

Third, education is a route to better chances in life. Those better chances in life translate into better health. We have the knowledge and the means to guarantee a good education for all. We have to exercise the will.

What is an example of an effective intervention?

In some countries in Latin America, people living in poor conditions have underweight children with slowed growth. Poor families can't afford for their children to go to school, and those who do go don't learn well because malnutrition hinders their ability to learn and develop. This is the crux of a terrible cycle where poverty causes ill-health and ill-health, in turn, perpetuates poverty.

We are very encouraged by the results of some programmes in Latin America to break this cycle. In some countries, there are programmes that give families a small economic subsidy to take children to nutrition clinics and have them enrolled in school.

Children are malnourished because their parents are poor. With more money, the children get better nutrition. As the programme is dependent on the children staying in school, they also get better education. This is a low cost intervention, and it helps to break the poverty=ill-health cycle by empowering and improving the health of children, making a difference in their lives that will last into adulthood.

Copyright World Health Organization 2006. All rights reserved