Annals of Epidemiology 26 (2016) 238e240 Contents lists available at ScienceDirect Annals of Epidemiology journal homepage: www.annalsofepidemiology.org From the American College of Epidemiology Social inequalities in health: a proper concern of epidemiology Michael Marmot FRCP *, Ruth Bell PhD Institute of Health Equity, Department of Epidemiology and Public Health, UCL, London, UK a r t i c l e i n f o a b s t r a c t Article history: Received 24 February 2016 Accepted 24 February 2016 Available online 3 March 2016 Social inequalities are a proper concern of epidemiology. Epidemiological thinking and modes of analysis are central, but epidemiological research is one among many areas of study that provide the evidence for understanding the causes of social inequalities in health and what can be done to reduce them. Understanding the causes of health inequalities requires insights from social, behavioral and biological sciences, and a chain of reasoning that examines how the accumulation of positive and negative influences over the life course leads to health inequalities in adult life. Evidence that the social gradient in health can be reduced should make us optimistic that reducing health inequalities is a realistic goal for all societies. Ó 2016 Elsevier Inc. All rights reserved. Keywords: Social inequalities in health Epidemiology Social determinants of health We doubt that any would question whether social inequalities in health are a proper concern of public health. If a concern of public health then they are a proper concern of epidemiology given its focus on the causes of the distribution of health and disease in populations. Understanding the causes of social inequalities in health requires looking beyond the immediate causes of ill-health, such as smoking or infections, to the determinants of the social distribution of these causesdwhat we have termed the “causes of the causes.” Recently, one of us published The Health Gap, which reviews global evidence on health inequalities and points to what can be done to reduce them. We would not like to count how many of the references in The Health Gap [1] are to epidemiological articles. Some are. But, The Health Gap also cites social psychology, developmental psychology, political economy, econometrics, welfare economics, sociology, behavioral genetics, biology, philosophy, and a variety of UN agencies; not to mention accounts of police officers, fire fighters, and community activists. There is no question that the way of thinking behind understanding the causes of the causes of health inequalitiesdpopulation thinkingdis epidemiological. But, the methods used to address the problem of health inequalities are much more varied. In contrast to some, we do not take the view point of a hierarchy of methods from case-control studies, through longitudinal studies to randomized control trials (RCTs). Almost none of the evidence for the interventions proposed in The Health Gap and in previous reviews of * Corresponding author. Institute of Health Equity, Department of Epidemiology and Public Health, UCL, London, UK. Tel.: þ44 207 679 1705. E-mail address: [email protected] (M. Marmot). http://dx.doi.org/10.1016/j.annepidem.2016.02.003 1047-2797/Ó 2016 Elsevier Inc. All rights reserved. the evidence [2e4] come from RCTs. Nor could it be so in the foreseeable future. Evidence-based policies and practice are vital; but the types of evidence that we touch on below do not lend themselves to a suite of RCTs. That said, Banerjee and Duflo have emphasized the possibility of RCTs in economics [5]. A good development. But RCTs won’t solve the problem of health inequalities. The challenges both for research and policy are the social gradient in health, accumulation of advantage and disadvantage through the life course, and the importance of orienting a country’s approach to development beyond a narrow focus on economics to one that emphasizes human flourishing. Challenge of the gradient: more than poverty The distribution of health within countries follows a social gradient: people lower in the social hierarchy have lower life expectancy and higher risk of illness than those higher-up in the social hierarchy. The nature of social stratification varies in form and magnitude across countries but includes dimensions such as income, wealth, education, occupation, gender, ethnicity, and area of residence. The social gradient means that not only the poorest but the majority have worse health and shorter lives than the best off in society. There must be a concern for poverty, of course, but also for social inequalities across society. The steepness of the social gradient in health varies across countries and over time. Although social stratification may be an inevitable feature of societies, the fact that the slope of the health gradient is not fixed provides grounds for optimism and suggests two strategies for reduction in health inequalities. First, address the M. Marmot, R. Bell / Annals of Epidemiology 26 (2016) 238e240 239 form and magnitude of social stratification by tackling gross inequalities in the distribution of power, money, and resources. Second, improve the conditions in which people are born, grow, live, work, and age, so position in the social hierarchy matters less for health [2]. Accumulation of advantage and disadvantage through the life course In epidemiology, rightly, we try to sort out which of a set of correlated variables is the key one related to ill-health. Much of the debate over diet, for example, arises because people do not eat nutrients, or even single foods; they have patterns of food intake. More of one thing commonly means less of another. This problem is even more acute when we look at social determinants of health. Low social position is related to many disadvantages, each of which may be playing a role in leading to health disadvantage. By way of illustration, in The Health Gap, readers meet two young men from Baltimore, MD. One, LeShawn, is from the Upton/Druid Heights neighborhood, a poor inner region of the city where half of all families are single parent families, median income is low at $US 17,000, 40% of children lack reading proficiency at age 10 years, over half of pupils miss at least 20 days of high school a year, and 90% do not go on to college. Each year, a third of boys aged 10e17 years are arrested for some kind of juvenile disorder, there are around 100 nonfatal shootings each year and nearly 40 homicides per 10,000 residents. Male life expectancy at birth is 63 years. The accumulation of disadvantage that faces LeShawn and other young people growing up in the Upton/Druid Heights neighborhood has implications for crime, for civil unrestdsuch as that which arose in 2015dand for health. Contrast LeShawn’s life chances with those of Bobby growing up in Roland Park, an affluent neighborhood of Baltimore where 93% of families are two parent families, median income is $US 90,000, 97% of pupils achieve “proficient or advanced” in third-grade reading, only 8% missed 20 or more days a year of high school, 75% complete college, juvenile arrests stand at one in fifty each year, there were no nonfatal shootings in 2005e2009 and four homicides per 10,000. In Roland Parkmale, life expectancy at birth is 83 years, 20 years higher than in the poor inner city area. Low education, low income, deprived neighborhoods all may be playing a role in causing health inequalities. Problems in early childhood may cast a long shadow over all these. Fig. 1. Socioeconomic position and cognition. Q ¼ cognitive score. Feinstein (2003) [6]. Similarly, chains of reasoning, backed up by different kinds of evidence, link experiences in early childhood with health in adult lifedthe life course approach. Using longitudinal studies that track a cohort over time, epidemiology can help to inform this life course approach to understanding the causes of health inequalities. A good level of development in the early years of life lays the foundation for future life chances and for health [7,8]. Good parenting is the key to good child development in the early years. There is a socioeconomic gradient in domains of child development that can be observed as young as age 3 years, including verbal ability and socioemotional difficulties. Children from poorer households have lower scores in verbal ability and higher scores for socioemotional difficulties than children from wealthier households [9]. However, there was a 50% reduction in the income gradient for socioemotional difficulties and between 27 and 49% reductions in cognitive test score gaps when factors indicative of good parenting (such as reading to children, and family routines) and psychosocial influences in the home (such as mother coping well) were taken into account. One way to intervene in this causal chain is through support in the early years. Good quality preschool improves educational attainment at older ages [10]. Figure 2 shows an association between preprimary school enrollment and school performance in grade 6 for a number of countries in Latin America. Cuba, Costa Rica, Equity from the start Social conditions in early childhood have a strong impact on early child development One piece of evidence, based on a longitudinal cohort study in the UK, shows an association between family socioeconomic status and children’s cognitive developmentdchildren from advantaged backgrounds have been shown to have a better trajectory in cognitive development than their peers from disadvantaged families, even overtaking by age 10 years those who were assessed as being higher in the distribution at age 22 months (Fig. 1) [6]. This evidence is a key but does not have health as an outcome. There is a chain of reasoning from early child development through educational attainment, transition from education or training to employment, good working and living conditions, income, and better conditions at older ages. It is a chain of reasoning. It requires a good causal model but will not be solved by one giant data set and fancy regression equations. The chain of reasoning is backed up by a chain of evidence [2e4]. And lived by young men like LeShawn and Bobby [1]. Fig. 2. Association between preschool enrollment and reading scores. Tinajero (2010) [11]. 240 M. Marmot, R. Bell / Annals of Epidemiology 26 (2016) 238e240 and Chile had the highest enrollment rates in preprimary education and obtained the highest scores in school achievement at grade 6 [11]. They also are the countries in Latin America with the longest life expectancy. Such evidence on its own does not “prove” the life course model but it is consistent with it. Likewise, fiscal policy to reduce poverty is almost certainly good for healthdsee chain of reasoning. Reducing poverty through taxes and benefits increases income, giving people more spending power certainly, but also, more control over their lives. And when researchers look at the effect of government welfare spending on educational inequalities in self-reported health, they find that countries across Europe with higher welfare spending have lower educational inequalities in health [12]. Similarly, gender equity in education: education is the route to empowerment, and enables men and women to have control over their lives. Enrollment in primary education has increased dramatically in all parts of the world in the last forty years with improvements in gender equity in enrollment. The last forty years have also seen dramatic increases in enrollment in secondary education, although there are still significant gender gaps in secondary enrollment in sub-Saharan Africa and South Asia. Women with secondary or higher education are likely to have fewer children than those with no education, they are more likely to make decisions within the family, and their children are more likely to survive and flourish. Optimism The United Nations Human Development Index is a composite index of health (assessed by national life expectancy at birth, education [mean years of schooling] and gross national income per capita). Figure 3 shows human development index values for countries in 2012 plotted against public expenditure on health and education per capita in 2000. A class of graduate students could spend a whole term arguing over the possible explanations for that graph [1]. One of them is that if you live in the kind of society that spends on education and health care, it is the kind of society that will do well on human development. Brazil has increased spending on health and education, and achieved health equity gains through action on the social determinants of health. One study examined stunting by family income quintile [13]; stunting is a sign of child undernutrition, and it causes poorer health and educational outcomes for children with lifelong consequences. Declines in child stunting were greater among the poorer groups, particular in the poorest group between 1996 and 2006/2007. As a result, the social gradient in stunting was reduced dramatically. This progress in Brazil has been attributed to socioeconomic development and equity-oriented policies, including the Bolsa Familia conditional cash transfer system, and increased accessed to education, health services, water, and sanitation [13]. Evidence that the social gradient in health can be reduced should make us optimistic that reducing health inequalities is a Fig. 3. Human development index values and previous public expenditures. HDI ¼ human development index. UNDP (2013) [14]. realistic goal for all societies. Epidemiological thinking and evidence from many disciplines fuels that optimism. References [1] Marmot M. The Health Gap: the challenge of an unequal world. London: Bloomsbury; 2015. [2] Commission on the Social Determinants of Health. Closing the gap in a generation: health equity through action on the social determinants of health. Final report of the Commission on Social Determinants of Health. Geneva: World Health Organization; 2008. [3] The Marmot Review Team. Fair Society, Healthy Lives: Strategic review of health inequalities in England post-2010. London: Marmot Review Team; 2010. [4] The Institute of Health Equity. Review of the Social Determinants and the Health Divide in the WHO European Region. Copenhagen: WHO Europe; 2013. [5] Banerjee A, Duflo E. Poor Economics: Barefoot Hedge-fund Managers, DIY Doctors and the Surprising Truth about Life on less than $1 a Day. London: Penguin Books; 2012. [6] Feinstein L. Inequality in the early cognitive development of children in the 1970 cohort. Economica 2003;70(277):73e97. [7] Hertzman C. The biological embedding of early experience and its effects on health in adulthood. Ann N Y Acad Sci 1999;896:85e95. [8] Hertzman C, Siddiqi A, Hertzman E, Irwin LG, Vaghri Z, Houweling TA, et al. Bucking the inequality gradient through early child development. Br Med J 2010;340:c468. [9] Kelly Y, Sacker A, Del BE, Francesconi M, Marmot M. What role for the home learning environment and parenting in reducing the socioeconomic gradient in child development? Findings from the Millenium Cohort Study. Arch Dis Child 2011;96(9):832e7. [10] Melhuish EC, Sylva K, Sammons P, Siraj-Blatchford I, Taggart B, Phan MB, et al. The early yearsdPreschool influences on mathematics achievement. Science 2008;321(5893):1161e2. [11] Tinajero AR. Scaling-up early child development in Cuba: Cuba’s educate your child programme: strategies and lessons from the expansion process. In: Wolfensohn Centre for Development. Brookings: Wolfensohn Center for Development; 2010. Working Paper 16. [12] Dahl E, van der Wel KA. Educational inequalities in health in European welfare states: a social expenditure approach. Soc Sci Med 2013;81:60e9. [13] Victora CG, Aquino EM, Leal MdC, Monteiro CA, Barros FC, Szwarcwald CL. Maternal and child health in Brazil: progress and challenges. Lancet 2011;28(377):1863e76. [14] UNDP. Human Development Report 2013: The Rise of the South: Human Progress in a Diverse World. New York: UNDP; 2013.
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