1. Social Inequalities in Health
Yawen Cheng, ScD
Associate Professor
Institute of Health Policy and Management,
College of Public Health, National Taiwan University
Essentials of Global Health
March 15, 2013
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2. Study Objectives
1. Concept of “health equity” and “health rights”
2. Health inequalities
 Evidences and extent
 Causes?
3. A historical review on collective actions for
achieving health equity
 The role of public health policies
 On health care systems
 On overall living environment (social determinants of health)
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3. Public Health
 Public health is the science and art of preventing
disease, prolonging life, and promoting health through
the organized efforts of society.
 Goal: to promote biological, physical and mental well-
being of all members of society.
 3 major disciplines
 Biological and medical sciences
 Environmental and occupational health sciences
 Health policy and management
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4. Core values
 Definition of health equity – absence of unfair and
avoidable or remediable differences in health among
social groups.
 Primary responsibility for protecting health equity
rests with government (importance of state role).
 Human right – Are health and health care parts of
human rights?
 1948 UN declaration
 1966 ICESCR
 2000 Human Right to Health
 What are human rights? The story of human rights https://
www.youtube.com/watch?v=oh3BbLk5UIQ (9:51)
 Empowerment of disadvantage communities
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5. Health inequalities?
 Are there systematic differences in health
outcomes?
 Are these differences unnecessary, avoidable
by reasonable action, and are considered
unfair or unjust (moral judgment)?
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6. Inequalities in Mortality according to
occupational grade in British civil servants
(the Whitehall Study)
Source: Marmot (2006) Health in an unequal world, Lancet 368, 2081-2094.
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7. 7

8. Age-adjusted Morbidity by Employment
Grade: The Whitehall II Study
(Marmot, et al. Lancet 1991; 337:1387-93)
25
Pre-menstrual syndrome
20
15 Cough with phlegm
%
10 Ischaemia
5 Hypertension
Diabetes
0
1 2 3 4 5 6
empl oy ment gr ade
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9. Difference in cardiovascular mortalities
by income level
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10. Cumulative Economic Hardship and Physical,
Psychological, Cognitive and Social Functioning
(Lynch & Kaplan, NEJM 1997; 337: 1889-95)
5
4
Odds Ratio*
3
2
1
0
Dif ficulty DSM-II I-R Lack of Cognitive Social
with IADL Depression optimism difficulties isolation
Once below 200% poverty (1965, 1974, 1983) Twice All
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* Adjusted for age, sex, BMI, pack-years of smoking, alcohol intake, and physical activity

11. 11

12. Life expectancy of aborigines and Han
Chinese in Taiwan （ 2000 ）
Ethnic Group Male Female
Taiwanese 73 79
Plain Aborigine 62 (-11) 72 (-7)
Mountain Aborigine 58 (-15) 69 (-10)
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13. What are the causes of health differences
across population?
 Health care services
 Factors outside of health care sector – social
environment
 Living conditions
 Working condition
 Exposure to environmental hazards
 Social control
 Social security
 Psychosocial stress
 …
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14. The role of “social determinants of health”
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15.  In Sickness and wealth: health in America
(from Unnatural causes) (4:38) https://
www.youtube.com/watch?v
=w98GSXBEyQw&list=UUt1Df8qkClmfBpctQMoF
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16. What are the “structural drivers” of
unhealthy social environment?
Source: Solar and Irwin (2007). A conceptual framework for action on
social determinants of health. WHO CSDH Report. 16

17. A historical review on major interventions
for the improvement of population health
 Provision of medical and health cares
 Improvement of living conditions
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18. PH Law
(1848)
New Poor Law (1834)
Poor Law (1601) Factory Law (1802)
Essay on Populations
(Malthus, 1798)
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Source: http://www.gresham.ac.uk/uploads/Demography(1).ppt

19. Edwin Chadwick (1800-1890)
 Report of the Poor Law
Commission (1832)
 New Poor Law (1834)
 Report on the Sanitary Condition
of the Laboring Population
(1842)
 Public Health Act (1848)
 Sanitary idea - miasma theory
 Drainage system
 Central and local boards of health
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20. Bismarck's social legislation (1884)
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21. After WWII:
Health Care Reform – Beverage model in UK
 On the way …
 1911: National Health Insurance Act
 1920: Dawson’s interim report - regionalization
 1939: EMS
 1942: Beverage report
 National Health Service
 1944: NHS white paper - comprehensive and free
 1946: NHS Act
 1948: NHS inauguration
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22. Changes in life expectancy in England
80
70
60
50
40
30
20
1650 1700 1750 1800 1850 1900 1950 2000
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23. 人口數（百萬）
0
5
10
15
20
25
1900 30
1905
1910
1915
1920
人口數
1925
1930
出生率
1935
1940
1945
死亡率
1950
1955
1960
1965
1970
Demographic Transformation (Taiwan)
資料來源：行政院衛生署、內政部統計處、 Mirzaee (1979)
1975
1980
1985
23
1990
1995
2000
2005
2010
0
10
20
30
40
50
60
出生率與死亡率（ /1000 ）

24. Changes in life expectancy in Taiwan:
comparisons of Han Chinese and Aborigines
90
Han Chinese(Male)
Han Chinese(Female)
80
Aborigines(Male)
Aborigines(Female)
70
Life Expectancy at Birth (years)
60
50
40
30
20
10
0
1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010 2020
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25. THE BIRTH OF TAIWAN’s NHI
Full Congress Election
Democratic Progressive Party
US De-Recognition
Withdraw from UN NHI Law
President Election
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Slide made by Prof. Tung-Liang Chiang

26. Historical Evolution of Public Health
Social environment
1848 UK-Public Health Act
1884 Koch’s Postulates 1974 Lalonde Report
1928 Penicillin 1978 Alma Ata Declaration
1948 WHO 1986 Ottawa Charter
1964 SG Report 2005 WHO CSDH
Traditional Public Health New Public Health
1971 Canada-NHI
1961 Japan-NHI 1989 Korea-NHI
Medical care systems
1948 UK-NHS 1995 Taiwan-NHI
1911 Germany-RVO
1883 Germany-SI 2001 Thai-Mix
Laissez-faire Equity in Access Cost Control Efficiency
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Slide made by Prof. Tung-Liang Chiang, NTU

27. 3 legs for public health policy
Knowledge base
(scientific evidences and social strategies)
Public
Health
Policy
Politics Social values/
(power struggle) Attitude/ethics
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28. 28
Source: Solar and Irwin (2010). A conceptual framework for action on social determinants of health.
WHO CSDH Report.

29. Interventions on “social determinants of
health”
 US Federal Indian Policies and Health (2:39) https://
www.youtube.com/watch?v
=i4ExGtLxb_w&list=UUt1Df8qkClmfBpctQMoFFfA&index=20
 An US governmental video, give examples of possible
interventions for improving ‘social environment’
https://www.youtube.com/watch?v=5Lul6KNIw_8 (5:12)
 Michael Marmot, the chair of CSDH on social determinants of health,
4:47) https://www.youtube.com/watch?v=kXUsYrzUKyU
 Ichiro Kawachi - Advice to the Next President: 7 Ways to Fight Health
Inequities http://www.youtube.com/watch?v=Vh8XcosZzTo (2:20)
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30. Actors
 State  The role of researchers
 Private sectors
 Civil society (NGOs)
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31. Two questions for small group exercise
1. Do you agree that all people should be entitled to
medical care, regardless of their ability to pay? Or
do you think medical care services should be
treated as “commodities”, and the extent of
services we receive will depend on how much you
pay? What are the situations in your home
countries?
2. Identify a health problem, and suggest a policy
level intervention strategy, targeting on its social
determinants (instead of individual risk factors).
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32. Some hints for the discussion session
 Childhood obesity – regulations on infant
formula/ on advertisement of fast food or
unhealthy products
 Mental health problems among the
unemployed – expanding social
welfare/unemployment security
 Road injuries – mass transportation system,
policy and enforcement on helmet wearing…
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