1. Health, social justice and sustainability Michael Marmot University College London PAHO XVIII Seminar Rio+20 June 6 th 2012

2. Trends in life expectancy at birth: Zambia, Viet Nam, Costa Rica, Sri Lanka (1950 – 2005, both sexes) UN data

3. Under 5 mortality per 1000 live births by wealth quintile Source: DHS Average U5M for high income countries is 7/1000 India 2005/6 Peru 2000

4. Social justice Empowerment – material, psychosocial, political Creating the conditions for people to take control of their lives www.who.int/social_determinants/en

5. Climate change – adds urgency to take action on SDH By 2030… –The world’s population will rise from 6 billion to 8 billion; –Demand for food will increase by 50% –Demand for water will rise by 30% –Demand for energy will increase by 50% John Beddington, UK Government’s Chief Scientific Adviser, 2009

6. Global progress towards the MDG target: trend in use of improved drinking-water sources 1990-2010, projected to 2015 Source: Progress on drinking water and sanitation 2012 update, UNICEF & WHO BUT: Quality and safety of drinking water sources is still an issue; Only 61% coverage in sub Saharan Africa

7. Access to piped drinking water in sub Saharan Africa: socioeconomic and urban/rural inequities Drinking water coverage by wealth quintiles and urban or rural areas, 35 countries, 2004-9 Source: Progress on drinking water and sanitation 2012 update, UNICEF & WHO

8. Access to sanitation in sub Saharan Africa: socioeconomic and urban/rural inequities Sanitation coverage by wealth quintiles and urban or rural areas, 35 countries, 2004-9 Source: Progress on drinking water and sanitation 2012 update, UNICEF & WHO

9. Distribution of deaths due to diarrhoea in low- and middle-income countries in 5 WHO regions Boschi-Pinto et al, 2008

10. Collection of water: usually a woman’s burden WHO & UNICEF 2012

11. Johannesburg water pricing Current – favours richer consumers Ideal – subsidises poorer consumers Source: GKN 2007 Water pricing: Johannesburg

12. Empowering communities: SEWA Case Study: The Parivartan Programme Improve the basic physical infrastructure within the slums and in the homes; Community development; City-level organisation for environmental upgrading of the slums SEWA Case Study 2008

13. SEWA: slum upgrading in India Slum upgrading in Ahmadabad, India, cost only US$ 500/household. Community contributions of US$ 50/household. Following the investment in these slums, there was improvement in health –decline in waterborne diseases, –children started going to school, – women were able to take paid work, no longer having to stand in long lines to collect water.

14. MELADI NAGAR BeforeAfter Slide courtesy of Gujarat Mahila Housing SEWA Trust

15. Global slum upgrading Cost estimate: less than US$ 100 billion. Finance on shared basis, for instance by –international agencies and donors (45%), –national and local governments (45%), and –households themselves (10%), helped by micro-credit schemes.

16. Social empowerment as a determinant of health, two stories: the first story “We get water maybe twice a week. My five-year- old daughter had fever and diarrhoea. I took her back to the clinic three times, but every time they said I should give her food and lots of water – that there was nothing they could do because they had no drugs. I thought about taking her to the central hospital, but it costs so much money. I just hoped… but my daughter died.” Resident of a high density area Harare, Zimbabwe McGreal, C (2008) in: Loewenson R, Health Exchange, 2009

17. Social empowerment as a determinant of health, two stories: the second story: “We approached the Municipality about the illegal dumping. They agreed to clean the dump site. Now it’s us, the community members who are monitoring that site. We are very determined that no-one should dump there again.” Community Health Committee, E Cape, South Africa in Boulle et al (2008) in Loewenson, R. Health Exchange, 2009

18. Health, sustainability and social justice

19. Non-communicable diseases in high, middle and low income countries

20. Age-standardised mortality rates for broad cause groups by subdistrict, Cape Town 2006 From Groenewald et al 2008 in Mayosi et al 2009

21. Women’s obesity by quartiles of years of education - various countries (GNP<745 US$ per capita) (GNP 745-2994 US$ per capita) (GNP≥2995 US% per capita) Prevalence ratio Monteiro et al, Int.J.Obesity,(2004)

22. Indigenous health Indigenous groups have worse health and lower life expectancy than general population

23. Progress towards MDG 4 (reduce child mortality by 2/3 from 1990 to 2015) Bell 2012 using UN data Under 5 mortality per 1000 live births

24. Under-5 mortality rate Probability of dying (per 1000) under age five years by wealth quintile in India, Bangladesh, Pakistan, Kenya and Uganda Source: Marmot & Bell 2012 using DHS data

25. Health Equity as a Development Outcome Participation Voice Agency Empowerment Psychosocial Material Political Health EquityDaily Living Conditions Early life Physical and social environments Working conditions Social Protection Health Care Structural Drivers Societal norms and values Social Inequities Governance and Financing Economic Growth and Social Policy

26. Early child development and education Healthy Places Fair Employment Social Protection Universal Health Care Health Equity in all Policies Fair Financing Good Global Governance Market Responsibility Gender Equity Political empowerment – inclusion and voice CSDH – Areas for Action

27. Prevention of neglected tropical diseases Addressing water, sanitation and household- related factors Reducing environmental risk factors Improving health of migrating populations Reducing inequity due to sociocultural factors and gender Reducing poverty Setting up risk assessment and surveillance systems Aagaard-Hansen & Chaignat 2010

28. Relative risk, prevalence and population attributable fraction of selected downstream risk factors for TB in 22 high burden TB countries Source: Lonnroth et al 2010 (analysis is preliminary) Importance of risk factors will be different in different countries and regions

29. Moderate and severe stunting rates for children under age 5 by national wealth (GNP per capita), 2008 EFA 2011

30. Prevalence of moderate or severe wasting, underweight and stunting (<2 SD) in children 0 -59 months (%) India HUNGaMA SURVEY 2011

31. Under nutrition in children is associated with cognitive deficits; Stunted children at risk of not achieving their full development potential

32. Education and nutrition for women and child health: Kerala compared with India as a whole Better education and nutrition for women Improved nutrition and health for families National Family Health Survey, India (NFHS-3: 2005-2006)

33. Prevalence of under- and over-weight in urban areas: women aged 20-49 in selected developing countries Mendez, Monteiro & Popkin 2005

34. Not just health care: taking action across sectors National Regional Local – community based interventions

35. Summary: Principles of action on SDH Values – social justice, sustainability, health equity Political will at highest level of government Working with partners across sectors Empowerment of individuals and communities Community participation Monitoring progress

36. Health inequalities matter Social Justice Empowerment Material Psychosocial political Creating conditions for people to lead flourishing lives