Social determinants of Health

2019 Paris Accords of Science Communication fellows

Prof. Bettina Borisch, MD, MPH; FRCPath

Institute of Global Health
University of Geneva
Executive Director of the World Federation of Public Health
Associations
@BBorisch , fb Bettina Borisch, LinkedIn

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My First Question to all of
you -

Please raise your hand!

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Typhus Epidemic in Upper Silesia in
1848
Upper Silesia Rudolf Virchow

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 Report on the Typhus Epidemic in
Upper Silesia
Rudolf Virchow, 1848
• In only 8 months, in the district of Rybnik
14.3% of the population were affected by typhus,
of whom 20.46% died
At the beginning of the year, 3% of the population of both
districts were orphans

Virchow describes the social determinants of health:

Education, with its daughters, liberty and
prosperity. . . . Medicine has imperceptibly led us into
the social field and placed us in a position of confronting
directly the great problems of our time.
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Typhus Epidemic in Upper Silesia
For there can now no longer be any doubt that such
an epidemic dissemination of typhus had only been
possible under the wretched conditions of life that
poverty and lack of culture had created in Upper
Silesia.
If these conditions were removed, I am sure that
epidemic typhus would not recur. Whosoever wishes
to learn from history will find many examples.

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Radical methods as a remedy against the recurrence
of famine and of great typhus epidemics:

The earth brings forth much more food than

the people consume.
The interests of the human race are not
served when, by an absurd concentration of
capital and landed property in the hands of
single individuals, production is directed into
channels that always guide back the flow of
the profits into the same hands.
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Health is a political choice
The determinants of Health are
• Social
• Economic
• Environmental
• Cultural
• Commercial
• Urban
• Political and nowadays global
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Health is a Global Issue
Why?

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Why is health on the global
agenda?
Security agenda
global pandemics; intentional spread of disease;
managing risks
Economic agenda
economic impact of poor health on development, economic
impact of pandemic outbreaks on the global market place;
economic importance of the health sector and certain industries
Soft power and philanthropic agenda
Instrument of foreign policy, charity based global initiatives;
venture philanthropy
Social justice agenda
health as a human right; the social determinats of
health; equity, access; sustainable development goals: SDGs
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Health equity and social determinants of health are
inextricably linked with sustainable development

•Social, economic and environmental

development determines health
and
• Health equity is central to sustainable
human development

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All SDGs have potential to impact health equity either
directly or indirectly

• SDG 3 and 10 focus on health and

inequity explicitly
• Ensure healthy lives and promote
well-being for all
• Reduce inequality within and
among countries
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What is good for your health?
• Social network
• Democracy
• Peace
• Transparency
• Women

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Social relationships and physiological
determinants of longevity across the
human life span
Yang Claire Yang et al. , PNAS | January 19, 2016 | vol. 113 | no. 3
• Higher degree of social integration was associated with lower risk
of physiological dysregulation in a dose– response manner in
both early and later life.
• Conversely, lack of social connections was associated with vastly
elevated risk in specific life stages. For example, social isolation
increased the risk of inflammation by the same magnitude as
physical inactivity in adolescence, and the effect of social
isolation on hypertension exceeded that of clinical risk factors
such as diabetes in old age
• Physiological impacts of structural and functional dimensions of
social relationships emerge uniquely in adolescence and midlife
and persist into old age.
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There is evidence: biological,
epidemiological,...
• Social Relationships and Health: The Toxic Effects
of Perceived Social Isolation John T. Cacioppo,
Stephanie Cacioppo published: 4.2. 2014
• Social networks: Better together Chelsea Wald,
Nature volume 531, pages S14–S15 (03 March 2016) |
Social ties go hand-in-hand with cognitive health. Engaging with
others helps to keep the brain healthy.
• Social Ties, Health and Wellbeing: A Literature
Review and Model, A.Kemp et al. Neuroscience and
Social Science, 2017

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What is good for your health?
• Social network
• Democracy, rule of law
• Peace
• Transparency
• Women

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 Democracy
• The relationships between democratic experience,
adult health, and cause-specific mortality in 170
countries between 1980 and 2016: an
observational analysis 
• Thomas J Bollyky, JD, Tara Templin, MS, Matthew Cohen, BS, Diana Schoder, BA, Joseph L
Dieleman, PhD, Simon Wigley, PhD 

• The Lancet, vol 393, April 20, 2019 

• DOI: 10.1016/S0140-6736(19)30235-1

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 Figure 1

The Lancet DOI: (10.1016/S0140-6736(19)30235-1)Borisch-SDG-SDH-2019 22

Copyright © 2019 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC
BY 4.0 license Terms and Conditions
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 Evidence of positive effect:
diseases
• Our results show that a one-point increase
in democratic experience had significant
direct and indirect effects on reducing
mortality over 20 years from cardiovascular
disease (−1·97%, 95% CI −1·31 to −2·64),
other non-communicable diseases (−1·87%,
−0·87 to −2·87), including congenital heart
diseases and birth defects, and tuberculosis
(−1·83%, −0·42 to −3·23
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What democratic societies may
be better at:
• Social justice
• Material, psychosocial, political
empowerment
• Creating the conditions for people to have
control of their lives
• Tackle the Inequitable Distribution of Power,
Money, and Resources

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What is good for your health?
• Social network
• Democracy
• Peace
• Transparency
• Women

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What is good for your health?
• Social network
• Democracy
• Peace
• Women

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 LIFE EXPECTANCY AT BIRTH
MALE FEMALE

INDIGENOUS 69.1 73.7

AUSTRALIAN*

NON 79.7 83.1

INDIGENOUS
AUSTRALIAN*

http://www.aihw.gov.au/deaths/life-expectancy/
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Life expectancy :
Russia

B. Borisch - ISUOG 2018 30

mid-wife working at delivery
Terracotta, Cyprus, 5th century BC

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Midwifery and health knowledge
• Antiquity: the knowledge and application
of birth control and related methods
were well established
• “in Antiquity, anti-conceptional
technique had a definite role in
preventive medicine” - N.Himes, 1936
• Pre-modern peoples could limit family
size
• Contraceptive knowledge was primarily
transmitted by a network of women
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The first “hospitals” in Paris
and Vienna 1850
• Wise women’s knowledge was ultimately
transferred to the physicians who from
surgery moved to obstetrics –
gynaecology, starting in the 19th
century
• From experience based, holistic
approach of a female dominated mid-
wifery to technical, academic and
science – based male dominated
obstetrics in the mid 19th century

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Women in the health
workforce

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Diversity gaps in healthcare
Women comprise

4%
of healthcare
company CEOs

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Impact of diversity across
the globe for return on assets

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Average return-on-assets of publicly-traded
companies
Male-only Boards with
boards female execs
6.77
US – S&P 500 8.68%
%
India – CNX
200
6.68 7.53
UK – FTSE 350 6.18 6.71

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Michael Marmot: the importance
of childhood
A.Give every child the best start in
life
B.Enable all children, young people
and adults to maximise their
capabilities and have control over
their lives
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 SDG 5 : Gender
Equality
• No country has yet achieved gender equality;
all countries – high middle and low income
alike – come under the scrutiny of goal 5
• “Gender data gap” and one that means
sufficient accurate data are available for only
10 of the 54 gender specific indicators
(UNWomen, 2018)
• Gender equality frequently can be pinned
down to a legal issue: not only sexual and
reproductive health and rights (SRHR)

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 Gender in the legal
frame
• In countries where equality in economic rights
are not guaranteed, having a girl child places
an economic burden on families.
• This has led to practices of sex selective
abortions resulting in extremely unbalanced
sex-ratios, especially in Asian countries where
restrictions in family planning (China) or
cultural traditions amplify this burden further
(India).
• China, only 86 females are born per 100,
compared to a regular ratio of 95/100 in
Western Europe /USA
• Northern and Western India (79-87/100)
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 Gender in the legal
frame
• The causes of female feticide are
complex and not fully understood,
but the law – particularly property,
inheritance law and dowry rules – and
the perpetuation of structural
inequalities are part of the problem
• A surplus of single men, a
phenomenon associated with an
increase in violence, especially
coalitional violence, against women
and even more so between men
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 Women at risk

• Victims of violence
- domestic and intimate partner violence, sexual violence
(including rape), war crimes

• Human trafficking
• Forced sexual exploitation (including
child marriage)
• Female genital mutilation
• Selected abortion / girls “missing”
• In 2005: 63 Million women were “missing” in India
through sex-selective abortion, infanticide or other
means
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Girls spend 160 Million more
hours a day than boys doing
unpaid work
• Girls (5-14) are spending 40% more time
on unpaid domestic work than boys their
age
• Work such as cooking, cleaning, looking
after family members and collecting
water and firewood
• Doing these chores often means giving up
opportunities to learn, grow and enjoy
childhood. (UNICEF Anju Malhotra)

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Girls carry the burden of work

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 Economically speaking
• Due to the unequal participation in the labour
market and the gender pay gap, women
account for only 38% of human capital on a
global level.
• The World Bank recently estimated that closing
this gap, would increase global wealth by more
than US$160 000 000 000 000 000 000 (that is
US$ 160 trillion) (Wodon and de la Brière 2018)

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Gender stereotype
of caring
• Mothers …women “take care …”
–”natural”
• Moreover, the insidious effects of
gender-based stereotyping are not
limited to women.
• The international human rights law
framework is concerned with gender
stereotypes and stereotyping that
affects recognized human rights and
fundamental freedoms.
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Women’s place in
society
• Minority: a group of people who,
because of their physical or cultural
characteristics, are singled out from
the others in the society in which
they live for differential and unequal
treatment (Feagan 1985)

• Women are a ”symbolic” minority

• The current discourse allows racism,
sexism,..

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Physical security of
women

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Brideprice/Dowry/Weddingc
osts

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The WomenStats Project, V.Hudson

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 Indices of women’s
status
• Inequity in family law
• Discrepant government behavior
concerning women
• Laws concerning property rights for
women
• Practice of child marriage for girls
• Birth rates / maternal mortality
• Discrepancy in secondary education
• Informal employment and unpaid work
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Equitable family law AND state
fragility

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 Gender and World
peace
• The best predictor of a state's
stability and peacefulness is
how its women are treated.
(WomenStatsDatabase, V M
Hudson)

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Implications for policy
making
• The treatment of women in a
society is a real barometer of
the degree to which a society is
capable of peace.
• It becomes the template within
that society for dealing with all
differences— ethnic, religious,
cultural, and ideological.

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Accelerating the United Nation’s
2030 Global Agenda: Why
prioritization of the gender goal
is essential
• Paula Hepp, Ludwig-Maximilians-Universität Munich
• Claire Somerville, Gender Centre, The Graduate
Institute Geneva Bettina Borisch, Institute of Global
Health, University of Geneva
• Global Poliy, 2019

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Good for our health are

Equal , peaceful democratic

societies

We should fight for them in the first

place as public health professionals,
journalists, citizens!
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HOW ?

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A Global Charter for the Public’s
Health

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Why a Global Charter for the
Public’s Health?
• New challenges for PH in a globalized world
• Context of the Sustainable development goals
• Classical determinants of health: poverty, food, water,
inequity; but also environment, climate, economy
• How should the global PH community position
themselves to influence all actors across the whole
spectrum
• ”Public’s Health”

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A Global Charter for the Public’s
Health

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Institutions matter / Governance
• Governance is a basic measure of the stability
and performance of a society
• The way public functions are carried out, public
resources are managed and public regulatory
powers are exercised,…
• Needs new forms of leadership and international
aid / functioning

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How the obsession with quantifying human
performance threatens our schools, medical care,
businesses, and government and international aid

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Systems interventions vs
micro-projects in poverty
reduction – Nobel Price 2019
• Real problem with the “aid effectiveness” /
quantifying craze - it narrows our focus down to
micro-interventions at a local level that yield
results that can be observed in the short term.
• At first glance this approach might seem
reasonable and even beguiling.
• But it tends to ignore the broader
macroeconomic, political and institutional drivers
of impoverishment and underdevelopment.
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 International aid
“effectiveness“ – coming
back to Rudolf Virchow
• Projects might yield satisfying micro-results, but
they generally do little to change the systems
that produce the problems in the first place.
What we need instead is to tackle the real root
causes of poverty, inequality and climate change.
• Do not waste a great project to deal with trivial
and everyday issues concerning health – work on
the big issues that require strong commitment
and multi-sectoral action.
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 Challenges for Public Health and
whole society to address inequity:
can we meet them?
• We have to! Inequity will destroy our societies -
instability
• The best predictor of a state's stability, peacefulness
and health is how its women and other “minorities”
are treated. (WomenStatsDatabase, V M Hudson).
• Populist movements gain support by proposing a sham
version of solidarity: solidarity with only some people –
not all.
• Do not let political movements split people, those and
the “others”!
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‘you can have extreme inequality
or you can have democracy – you
cannot have both’

US Supreme Court Justice Louis Brandeis

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Conclusion

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