What we mean by social determinants of health

Thank you very much for inviting me to give the inaugural speech at the Eighth European Conference of the International Union of Health Promotion and Education, taking place in this beautiful setting in Turin, Italy. Let me start by congratulating you on choosing as a major theme of this conference the social determinants of health. As you know, the WHO Commission on Social Determinants of Health has just published its long-awaited report. The report has, deservedly, created worldwide interest and within a few days has monopolized the health and medical news worldwide – with some notable exceptions such as the US, where the report has barely been noticed in the media. I saluted the establishment of the WHO Commission and now applaud most of the recommendations in its report. But my enthusiasm for the report is not uncritical, and I will enlarge on this later in my presentation. Let’s start with some of the facts presented in the Commission’s report, facts that should cause discomfort for any person committed to the health and quality of life of our populations, because the problems described in the report – how death and poor health are not randomly distributed in the world – are easily solvable. We know how to solve them. The problem, however, is not a scientific one. But before touching on this issue – the major theme of my talk – let’s look at the facts. To quote one statistic directly from the report: “A girl born in Sweden will live 43 years longer than a girl born in Sierra Leone.” The mortality differentials among countries are enormous. But such inequalities also appear within each country, including the so-called rich or developed countries. Again, quoting from the report: “In Glasgow, an unskilled, working-class person will have a lifespan 28 years shorter than a businessman in the top income bracket in Scotland.” We could add here similar data from the US. In East Baltimore (where my university, The Johns Hopkins University, is located), a black unemployed youth has a lifespan 32 years shorter than a white corporate lawyer. Actually, as I have documented elsewhere (1), a young African American is 1.8 times more likely than a young white American to die from a cardiovascular condition. Race mortality differentials are large in the US, but class mortality differentials are even larger. In the same study, I showed that a bluecollar worker is 2.8 times more likely than a businessman to die from a cardiovascular condition. In the US as in any other country, the highest number of deaths could be prevented by interventions in which the mortality rate of all social classes was made the same as the mortality rate of those in the top income decile. These are the types of facts that the WHO Commission report and other works have documented. So, at this point, the evidence that health and quality of life are socially determined is undeniable and overwhelming.