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Mental health and inequalities: what’s happening to the
soci(et)al determinants of health?
Lynne Friedli
Socialist Health AssociationHealth Inequality in England and Scotland
Edinburgh9th June 2012
what's happening to social determinants? [email protected]
Picture source: Sleeping with spirit #2 Bradley Guiboche courtesy of www.artbeatstudio.ca
As material inequalities grow,
the pursuit of non material explanations
proliferates
The paradox....
what's happening to social determinants? [email protected]
Source: Banksie – grafitti, London, England
I own, therefore I am....
What can 'capabilities' contribute?
Life Bodily health
Bodily integrity Sense, imagination, thought
Emotions Practical reason
Affiliation Other species
Play Control over environment:a) Politicalb) MaterialSource: Nussbaum
2011
Nussbaum’s capabilities
Commission on the Social Determinants of Health
• material requisites• psycho-social (control over lives)• political voice (participation in decision making)
what's happening to social determinants? [email protected]
Status Control Relatedness
Some living conditions deliver to people a life that is worthy of the human dignity that they possess, and others do not. Dignity can be like a cheque that has come back marked ‘insufficient funds’
Martha NussbaumFreedom to
live a valued life
Amartya Sen
what's happening to social determinants? [email protected]
Meta analysis: comparative odds of decreased mortality
The relative value of social support/ social integrationSource: Holt-Lundstad et al 2010
Social Epigenesis: biological embedding *
“The most effective interventions will require a deeper understanding of how common social risks “get under the skin” to affect human biology and influence the causal pathways to disease”
* Clyde Hertzman 2012
*Clyde Hertzman 2011
what's happening to social determinants? [email protected]
Status Control Relatedness
In 2012 there’s no talk of getting out. It’s more important to be somebody where they live, than to be nobody outside. Status and respect are valued above everything Lisa McKenzie 2012
Relative importance of early social and biological risk factors
(PAR %)
Clinical risk factors
Social risk factors
Source: Jutte, Brownell, Roos, Schippers, Boyce, Syme, 2010
age
what's happening to social determinants? [email protected]
Reasons to be concerned?
• An analysis of injustice? Who/what creates
inequalities?
• Are Scotland’s problems psychological &
cultural?
• Stigmatising dependency and need?
• Avoiding the hard questions?
what's happening to social determinants? [email protected]
I knew about inequality, how unfair life could be. But I thought it was something to do with me, with my family, what we’d done.....
Lisa McKenzie ‘Thinking allowed’
what's happening to social determinants? [email protected]
Myth No 1: ‘What we’ve tried, though well meaning, hasn’t worked....’
Nearly a third of workers in Scotland -4% of public sector28% of private sector -earn less than a living wage(£7.20 per hour)(ASHE 2010)
Trends by political leader or
‘30 years of brutal global capitalism’
Source: Brewer M, Goodman A, Muriel A, Sibieta L. Poverty and Inequality in the UK: 2007. Institute of Fiscal Studies, London.what's happening to social determinants? [email protected]
m
what's happening to social determinants? [email protected]
1975
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0.22
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0.28
0.30
0.32
0.34
0.36
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0.42Trends in inequality of disposable income
Gin
i coe
ffici
ent o
f inc
ome
ineq
ualit
yUK Inequalities well above OECD average ‘If the rich could hire others to die for them, we, the poor,
would all make a nice living’Fiddler on the Roof
Source: OECD 2011 Divided We Stand
what's happening to social determinants? [email protected]
Persistence of intergenerational earnings
Ideas that massacre the welfare state:
Myth No 2: ‘dependency’‘an assets rather than a deficits approach to tackling poverty and inequality..... moving from welfare to wellbeing and from dependency to self determination.’
Scottish Government 2011 • Deficit approach of public services
• Culture of dependency folks haven’t a clue how the rest of us are having to make ends meet
A man goes to work full time and still has to get the social because wages is so low; he needed that money to keep his kids
Source: Dundee Equally Well/ONS Fairness & Wellbeing Debate
what's happening to social determinants? [email protected]
what's happening to social determinants? [email protected]
Image: Banksy;
Holding on to an inequalities analysis
Declaration of Intent of the Mental Patients Union • We proclaim the dignity of society's so-called mental
patients• We challenge repressive psychiatric practice and its ill-
defined concepts of 'Mental illness'• We state that the present appalling situation in
'Mental health' primarily arises from the acute problems in housing, unemployment and social inequality
• Mental patients in our society are treated as people with no human rights
Source: The Survivors’ History Group Pageant of Survivor History http://studymore.org.uk/mpu.htm
what's happening to social determinants? [email protected]
what's happening to social determinants? [email protected]
Not ‘every family in the land’
Findings from 9 large scale population based studies:
• Material and relative deprivation• Childhood socio-economic position• Low educational attainment• Unemployment• Environment: poor housing, poor resources,
violence• Adverse life events• Poor support networks
(Melzer et al 2004; Rogers & Pilgrim 2003; Stansfeld et al 2008; APMS 2007)
Cycle of invisible barriers:• Poverty of hope, self-worth, aspirations
Mental health and deprivation
Explaining the social gradient: mental illness journeys...
• Adverse childhood experiences/stressful life events
• Racism and other forms of discrimination• Contact with criminal justice system • Socio economic status – parental income,
tenure, education, occupation• Institutional care in childhoodwhat's happening to social determinants? [email protected]
m
Most of the experiences that cause mental distress are directly linked to a lack of money....... powerlessness linked to poverty
Peter Campbell Beyond the Water Tower 2005
0%
5%
10%
15%
20%
25%
under£100
£100-£199 £200-£299 £300-£399 £400-£499 £500-£599 £600-£770 Over £770
Gross weekly household income
Pe
rce
nta
ge
of
ch
ild
ren
wit
h a
me
nta
l d
iso
rde
r
Source: Meltzer et al 2000 Mental health of children and adolescents in Great Britain
Mental health of children by parental income
what's happening to social determinants? [email protected]
what's happening to social determinants? [email protected]
Source: Fair Society, Healthy Lives: Marmot Review 2010
Mental health and the social gradient
“Infants develop the attachment behaviours that optimally enhance their survival in their own characteristic environments.” Crittenden, 2000
what's happening to social determinants? [email protected]
Rates of poor social/emotional adjustment by father’s social class
at birth
Low levels of (adult) mental wellbeingby concerns about income
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
Living comfortably onpresent income
Coping on presentincome
Finding it difficult onpresent income
Finding it very difficulton present income
Pe
rce
nta
ge
wit
h a
lo
w l
ev
el
of
we
llb
ein
g
Source: NW Wellbeing Survey
what's happening to social determinants? [email protected]
Austerity rhetoric
what's happening to social determinants? [email protected]
what's happening to social determinants? [email protected]
Austerity solutions....
what's happening to social determinants? [email protected]
Source: http://streetartlondon.co.uk/
Big fish/little fish: questions of power are
unavoidable
what's happening to social determinants? [email protected]
Return to the social....
what's happening to social determinants?
Equity and Social Justice
Freedom to live a valued life
Solidarity and the core economy
I am, because we are...
And what I shall endure, you shall endureFor every atom belonging to me as good belongs to you......
Walt Whitman
what's happening to social determinants? [email protected]
Select bibliography
Beckfield J and Krieger N (2009) Epi + demos + cracy: A Critical Review of Empirical Research Epidemiologic Reviews 31(1):152-177Birn Anne-Emanuelle (2009) Making it politic(al): Closing the Gap in a Generation: health equity through action on the social determinants of health Social Medicine 4:3 p166-182 Christie C (2011) Report on the Future Delivery of Public Services by the Commission chaired by Dr Campbell Christie http://scotland.gov.uk/Publications/2011/06/27154527/18
CSDH (2008) Closing the gap in a generation: health equity through action on the social determinants of health Final Report of Commission on Social Determinants of Health Geneva: World Health Organization.
http://whqlibdoc.who.int/publications/2008/9789241563703_eng.pdf
Friedli L (2009) Mental health, resilience and inequalities WHO Europe London/ Copenhagen http://www.euro.who.int/document/e92227.pdf
Nussbaum M (2011) Creating capabilities: the human development approach Belknap Harvard
what's happening to social determinants? [email protected]
Select bibliographyMair C, Zdeb K and Markie K (2011) Making better places: making places better the distribution of positive and negative outcomes in Scotland Improvement Service www.improvementservice.org.uk/.../3400-making-better-places-making-places-better-distribution-of-positive-and-negative-outcomes-in-scotland/McKendrick et al 2011 Poverty in Scotland Child Poverty Action GroupPeople First Scotland http://www.viascotland.org.uk/webfm_send/304/citizens-grand-jury-report.pdf
OECD 2011 Divided we stand: why inequality keeps rising http://www.oecd.org/document/51/0,3746,en_2649_33933_49147827_1_1_1_1,00.htmlStuckler D, Basu S, Suhrcke M et al (2011) Effects of the 2008 recession on health: a first look at European data The Lancet Vol. 378, Issue 9786, Pages 124-125 http://jech.bmj.com/content/65/8/653.full Tackling Poverty Board: A Summary of the Evidence http://www.scotland.gov.uk/Topics/People/tackling-poverty
what's happening to social determinants? [email protected]
what's happening to social determinants? [email protected]
Variation of growth of genetically identical marbled crayfish in an aquarium: how well would epidemiologists be able to predict outcomes?Source: Davey Smith G (2012) picture: Journal of Experimental Biology