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HomeWork 1:

Reflection 1:

Watch the 3 videos on storytelling below and after you have watched the videos write a reflection response (a full complete paragraph or two – of at least 300 words) about your thoughts on the importance of storytelling in your everyday life. Was there something said in these videos that you agreed with and aligned with your views? Or was there something, related to the art of storytelling, that you never thought about until you heard it in the video?

Try to avoid general interest comments but instead, try to speak to something very specific in the article that meant something to you or aligned with your thoughts on the importance of storytelling in your everyday life.

Video 1:

Video 2:

Video 3:

HomeWork 2:

Reflection 2:

After you read the PDF document attached “Reflection 2” discuss in a reflection response (a full complete paragraph or two – of at least 300 words) the importance of August Wilson as an American storyteller and why his work is important to American audiences.

HomeWork 3:

See the folder attached named (Instructor Assignment Template) and use that folder to do the assignment, and folder named (Assignment Example) it just example what the assignment should look like

1. Select one of the Leading Causes of Death from 2017 from folder attached named (Folder 1). Be sure that you can describe in 1-2 sentences what that cause of death is/refers to.

2. Briefly research and identify two Health Disparities that exist in regard to that cause of death (i.e., two groups that are more affected than others).

3. Identify and discuss two Social Determinants of Health (SDOH) that contribute to that disparity from folder attached named (Folder 2).

4. Propose (and describe) a health policy solution aimed at reducing the health disparity.

5. Assess your solution by identifying two Bioethical principles that best relate to your proposed solution by using the site below:

https://depts.washington.edu/bhdept/ethics-medicine/bioethics-topics/articles/principles-bioethics

Don’t forget references and in-text citations as an APA style.

Instructions

Use this template to complete the Course Introduction Assignment

Final submissions can be saved and submitted as Powerpoint or PDF files

Do not change or delete any text in GREEN

Add text were indicated in brackets, deleting the brackets when you are done.

Do not change formatting or background design.

You must include in-text citations and a reference slide (APA format)

Delete this instructions slide from your submission.

[Your Name Here]
Course Introduction Assignment
LBST 2214
Spring 2022

Leading Cause of Death
Leading Cause of Death: [insert cause here]
Brief Description: [insert brief description here]

Health Disparities
Health Disparity 1: [insert disparity here]
Health Disparity 2: [insert disparity here]

Health Disparity & SDOH (1)
Health Disparity (from previous slide): [restate disparity here]
Related SDOH: [insert first SDOH and brief description of how it contributes to the disparity here]

Health Disparity & SDOH (2)
Health Disparity (from previous slide): [restate disparity here]
Related SDOH: [insert second SDOH and brief description of how it contributes to the disparity here]

Proposed Solution
Proposed Solution: [identify and briefly describe proposed solution here]

Proposed Solution & Bioethical Principle (1)
Bioethical Principle 1: [identify and briefly describe one bioethical principle and how it relates to the proposed solution here]

Proposed Solution & Bioethical Principle (2)
Bioethical Principle 2: [identify and briefly describe second bioethical principle and how it relates to the proposed solution here]

References
[add your APA formatted references here. You may use additional slides if needed]

INTRODUCTION
A playwright, poet and polemicist, August Wilson (1945-2005) rose to
prominence and achieved international acclaim with a cycle of 10
plays, often called the Century Cycle or Pittsburgh Cycle. His plays
powerfully dramatize the pleasures and perils of African-American life,
experience, and history across the 20th century. The plays in the
Century Cycle – Jitney (1982); Ma Rainey’s Black Bottom (1984);
Fences (1987); Joe Turner’s Come and Gone (1988); The Piano Lesson
(1990); Two Trains Running (1991); Seven Guitars (1995); King Hedley
II (1999); Gem of the Ocean (2003); and Radio Golf (2005) – earned
Wilson multiple accolades, including the Tony Award for Best Play
(Fences, 1987), the Olivier Award for Best New Play (Jitney, 2002), and
two Pulitzer Prizes for drama for Fences in 1987, and The Piano Lesson
in 1990). Wilson is considered one of the most significant and
influential artists of the 20th and 21st centuries, often compared with
important writers like Eugene O’Neill (1888-1953). Wilson’s plays
continue to garner numerous productions around the globe annually
and remain among the most studied and written about contemporary
dramatic texts in the US. Several of Wilson’s works have also been
adapted for film, including the 2016 Oscar-nominated movie Fences
starring Denzel Washington and Viola Davis as Troy and Rose Maxson.

DT+ FUNDAMENTALS

A Concise Introduction to:
August Wilson

Isaiah Wooden
American University

Last update: 06/02/2019

HISTORY
Born Frederick August Kittel, Jr. on April 27, 1945, Wilson’s early
upbringing in Pittsburgh, Pennsylvania had an immense impact on his
playwriting. After his mother, Daisy Wilson, an African-American domestic
worker, and father, Frederick August Kittel, a German immigrant and
baker, separated during his childhood, he spent most of his youth with his
maternal family in and around the Hill District, a traditionally African-
American area of Pittsburgh that serves as the setting for nine of the 10
plays in the Century Cycle. As was the case for many African-Americans
living in the US during this era, Wilson’s family faced habitual racism. The
students and teachers at the predominantly white, parochial schools the
young Wilson attended were especially bigoted, bullying the budding
writer for being Black and poor. When a history teacher accused a 15-
year-old Wilson of plagiarising a paper he had meticulously researched
and written on the French military and political leader Napoleon
Bonaparte, the teenager decided to drop out of school, opting instead to
make frequent trips to the library to ‘self-educate.’ It was through this
process of self-education that Wilson began to discover and deepen his
knowledge of the artists and art forms that would become some of his
most significant influences as a writer.

Chief among those influences were blues music, writer Jorge Luis Borges
(1899-1986), visual artist Romare Bearden (1911-1988), and writer-activist
Amiri Baraka, also known as LeRoi Jones (1943-2014). Wilson
affectionately called these “my four Bs,” and would emend the list to
include playwright-essayists James Baldwin (1924-1987) and Ed Bullins
(1935- ). Wilson considered the blues the most important of the “four Bs.”
A musical genre and form that emerged from the work songs, spirituals
and folk traditions of African-Americans living in the rural south of the US
at the end of the 19th century, Wilson recognised in the blues a model
and method for capturing, documenting and expressing the vagaries and
complexities of African-American life. He endeavoured to emulate that
model and method in his own writing. He also attempted to incorporate
elements of Borges, Beardon and Baraka’s singular aesthetics in his
work. Speaking about his influences in a 1999 interview with The Paris
Review, he explained that from Borges, Beardon and Baraka he learned
that he could create stories about a specific time, place and culture and
still have them resonate with universal themes; that it was possible to

render the fullness and richness of everyday life without devolving into
sentimentality; and that all art, even if it does not announce itself as such,
is political.

Interestingly, Wilson did not start out as a playwright but as a poet.
Energised by the revolutionary spirit of the Black Arts Movements that
Baraka and Bullins helped pioneer in the 1960s, he joined the Centre
Avenue Poets Theater Workshop in his early 20s, where he met and
collaborated with other Hill District poets, educators, artists and activists
interested in illuminating and commenting on the experiences of African-
Americans in and through their writing. In 1968, he joined forces with
fellow Workshop participant Rob Penny to launch the Black Horizon
Theater, which aimed to use the arts – performance, in particular – to
raise the political consciousness of Pittsburgh’s African-American
residents. While Wilson directed many of the plays the company
produced – and even acted in a few – he resisted writing his own, as he
continued to see himself first and foremost as a poet. He would not write
his first one-act play, Recycle, until 1973. He followed it up in 1976 with
The Homecoming, which Pittsburgh’s Kuntu Theatre produced, and The
Coldest Day of the Year, which did not receive a production until 1989.

Wilson’s career as a playwright began in earnest after he moved to St.
Paul, Minnesota in 1978 to take a job writing scripts for the Science
Museum there. With some encouragement from a friend, director Claude
Purdy, he reworked a series of poems about a character named Black
Bart that he’d started writing in 1977 into a musical satire called Black Bart
and the Sacred Hills. Lou Bellamy, founder and artistic director of
Penumbra Theater, a company launched in 1976 to spotlight African-
American voices within the Minneapolis-St. Paul theatre community,
agreed to grant the work its first professional production in 1981. The
collaborative relationship Wilson forged with Bellamy and Penumbra
would prove to be one of the most important of his career. Penumbra
presented early professional productions of all 10 plays in the Century
Cycle.

Wilson received a crucial break in 1980 when his play Jitney garnered the
Playwrights’ Center of Minneapolis’ Jerome Fellowship. Focusing on a
group of unlicensed African-American cab drivers trying to survive in
1970s Pittsburgh amidst the push for ‘urban renewal,’ the play was

produced by the Allegheny Repertory Theater and Penumbra Theater in
1982. That same year, the National Playwrights’ Conference at the
Eugene O’Neill Theater Center, which had previously rejected Jitney,
Black Bart and the Sacred Hills, and another play Wilson wrote called
Fullerton Street, selected Wilson’s Ma Rainey’s Black Bottom for a
workshop production. It was during his time at the O’Neill that Wilson
began collaborating with Lloyd Richards (1919-2006), who served as the
head of the National Playwrights’ Conference, dean of the Yale School of
Drama, and artistic director of the Yale Repertory Theater.

After Wilson fine-tuned Ma Rainey’s at the O’Neill, Richards produced and
directed the play at Yale Rep and on Broadway in 1984. Richards
subsequently stewarded Wilson’s Fences (1987), Joe Turner’s Come and
Gone (1988), The Piano Lesson (1990), Two Trains Running (1992) and
Seven Guitars (1996) on Broadway. He also directed the 1995 adaptation
of The Piano Lesson for television. Artistic differences about the latter
caused an irreparable rift in their working relationship, thus bringing an
end to their auspicious collaborations. Wilson chose Marion McClinton to
helm King Hedley II (2001) and Kenny Leon to direct Gem of the Ocean
(2004) and Radio Golf (2007) on Broadway, thereby bearing out the call
he made in a 1990 Spin Magazine essay to have Black directors oversee
his work. Wilson did not live to see the latter production or the
subsequent Broadway premiere of Jitney (2016) directed by Ruben
Santiago-Hudson.

Wilson announced that he had liver cancer on August 26, 2005. He died
from the disease on October 2, 2005 at the age of 60. In addition to the
lush representations of African-American life and experience included in
his poetry and plays, he left behind a formidable legacy of advocacy for
Black artists and aesthetic practices. The 1996 speech he delivered at the
Theatre Communications Group national conference, ‘The Ground on
Which I Stand,’ continues to serve as an important manifesto for artists
interested in transforming the professional theatre world by upending the
racial, class and gender asymmetries present throughout it. With his
successes on Broadway and various stages throughout the US and
across the globe, Wilson accrued tremendous influence, which he used
to create opportunities for other African-American artists. There are
countless Black actors, directors, designers and stage managers who got
their starts working on Wilson’s plays. There are also countless African

American playwrights – among them, Marcus Gardley, Tarell Alvin
McCraney, Dominique Morisseau and Lynn Nottage – who have
benefitted from the successful relationships Wilson cultivated with various
theatres in the 1980s and 1990s.

In 2015, Denzel Washington announced that he had entered into an
agreement with HBO to produce films of all 10 plays in the Century Cycle.
In addition to introducing Wilson’s work to new audiences, the films
promise to further highlight the significance of Wilson’s accomplishments.

METHODS

When Wilson began feverishly writing Jitney in a Twin Cities fish and chip
restaurant, he did not intend the play to be part of a larger series of
works. Indeed, it was only after he completed Ma Rainey’s Black Bottom
that he realised that he had written three plays set in three different
decades: Jitney in the 1970s; Fullerton Street in the 1940s; and Ma
Rainey’s in the 1920s. Wilson explains:

“Once I became conscious of that, I realised I was trying to
focus on what I felt were the most important issues
confronting Black Americans for that decade, so ultimately
they could stand as a record of Black experience over the
past hundred years presented in the form of dramatic
literature.” (Powers, 1984, p.52).

Wilson considered the 10-play cycle “a 400-year-old autobiography.” With
the project, he aimed to craft a dynamic portrait of African-American
experience and to represent silenced and suppressed aspects of African-
American history. He was especially interested in exploring the
particularities of life in the Hill District, the backdrop for all the plays in the
cycle except Ma Rainey’s, which unfolds in Chicago.

It took Wilson more than 25 years to complete the Century Cycle, which
he did not write in chronological order. He finished Gem of the Ocean, set
in the 1900s, in 2003; Joe Turner’s Come and Gone, set in the 1910s, in
1988; Ma Rainey’s Black Bottom, set in the 1920s, in 1984; The Piano
Lesson, set in the 1930s, in 1990; Seven Guitars, set in the 1940s, in 1996;
Fences, set in the 1950s, in 1987; Two Trains Running, set in the 1960s, in
1992; Jitney, set in the 1970s, in 2000; King Hedley II, set in the 1980s, in
2001; and, Radio Golf, set in the 1990s, in 2005. Wilson explicitly wrote
the plays to be in conversation with one another. Thus, there are
characters, themes, plotlines and idiomatic expressions that repeat and
resonate across each. Critics have often highlighted this intertextuality as
one of the cycle’s greatest triumphs. They also frequently herald Wilson’s
emphatic embrace of the Black vernacular. Writing for the New York
Times in 2017, Ben Brantley exclaims:

“I can’t think of another American dramatist since
Tennessee Williams who writes with the generous lyricism
of Wilson. It’s almost as much like the tragedies of Ancient
Greece as it is like Shakespeare, or perhaps grand opera,
even though the characters belong to another social
stratum, altogether, from the usual aristocrats of Verdi.
Wilson found the divine in the down home.” (Morris, 2017).

The enthusiasm Brantley expresses for Wilson’s rich language and
dramaturgy is reflected throughout much of the critical writing on the
Century Cycle.

While Wilson’s work generally received high praise from audiences and
critics alike, his forays into cultural commentary tended to spark
controversy. Robert Brustein, scholar, critic and founding artistic director
of Yale Rep and American Repertory Theater, took particular umbrage
with Wilson’s ‘The Ground on Which I Stand’ speech. Wilson called
Brustein, who offered some of the harshest reviews of his earliest work,
“a sniper, naysayer, and cultural imperialist” during the remarks. Brustein
replied in American Theatre Magazine:

“August Wilson is more comfortable writing plays than
apostolic decrees. His speech is melancholy testimony to
the rabid identity politics and poisonous racial
consciousness that have been infecting our country in
recent years. Although Wilson would deny it, such
sentiments represent a reverse form of the old politics of
division, an appeal for socially approved and foundation-
funded separatism.” (Brustein, 1996).

The barbs the pair traded in print ultimately culminated in a 1997 public
town-hall debate moderated by playwright-performer Anna Deavere
Smith in New York City. There was very little during the discussion on
which Wilson and Brustein agreed.

Although Wilson often resisted suggestions that he wrote political plays,
his work, nevertheless, transformed the cultural politics of theatre.
Indeed, like Baldwin, Baraka and Bullins before him, Wilson made a
forceful case with his work for the vitality and necessity of theatre that
explores the human condition through the lens of African-American
history and culture.

FURTHER READING

American Masters. (2017). August Wilson: The Ground on Which I Stand |
Music in August Wilson’s Work | American Masters | PBS. [online]
Available at: http://www.pbs.org/wnet/americanmasters/august-wilson-
the-ground-on-which-i-stand-/ [Accessed 15 August 2017].

Bigsby, C. Ed. (2007). The Cambridge Companion to August Wilson.
Cambridge: Cambridge University Press.

Biography.com. (2017). August Wilson. [online] Available at:
https://www.biography.com/people/august-wilson-9533583 [Accessed 15
August 2017].

Bryer, J. and Hartig, M. (2006). Conversations with August Wilson. Oxford,
MS: University of Mississippi Press.

Elam Jr, H. (2004). The Past as Present in the Drama of August Wilson.
Ann Arbor: University of Michigan Press.

Lyons, B. and Plimpton, G. (1999). An Interview with August Wilson. Paris
Review 41, 153, pp.66-94.

Morris, W. and Brantley, B. (2017). What August Wilson Means Now.
[online] Nytimes.com. Available at:
https://www.nytimes.com/2017/01/11/theater/what-august-wilson-means-
now.html [Accessed 15 August 2017].

Nadel, A. (1993). May All your Fences have Gates: Essays on the Drama of
August Wilson. Iowa City: University of Iowa Press.

Nadel, A. (2010). August Wilson: Completing the Twentieth Century Cycle.
Iowa City: University of Iowa Press.

Powers, K. (1984). An Interview with August Wilson. Theater (16), pp.50-
55.

Shannon, S. (1995). The Dramatic Vision of August Wilson. Washington,
D.C.: Howard University Press.

Shannon, S. ed. (2015). August Wilson’s Pittsburgh Cycle: Critical
Perspectives on the Plays. Jefferson, NC: McFarland Press.

Shannon, S. and Richards, S. eds. (2016). Approaches to Teaching the
Plays of August Wilson. New York: Modern Language Association of
America.

Spin. (2017). August Wilson’s 1990 Spin Essay on Fences: “I Don’t Want to
Hire Nobody Just ‘Cause They’re Black” [online] Available at:
http://www.spin.com/featured/august-wilson-fences-paramount-pictures-
race-essay-october-1990/ [Accessed 15 August 2017].

Williams, D. and Shannon, S. eds. (2011). August Wilson and Black
Aesthetics. New York, NY: Palgrave Macmillan.

Wilson, A. (2007). The August Wilson Century Cycle. New York: Theatre
Communications Group.

Wilson, A. (2016). The Ground on Which I Stand. [online] American
Theatre. Available at: http://www.americantheatre.org/2016/06/20/the-
ground-on-which-i-stand/ [Accessed 15 August 2017].

Wilson, A. and Brustein, R. (1996). Subsidized Separatism: Responses to
‘The Ground on Which I Stand’. [online] American Theatre. Available at:
http://www.americantheatre.org/1996/10/01/subsidized-separatism-
responses-to-the-ground-on-which-i-stand/ [Accessed 15 August 2017].

COVID-19and Health Disparities in the United States
Version: June 16, 2020

The COVID-19 pandemic has resulted in more than 2.1 million cases and more than 116,127
deaths in the United States as of June 16.i While the pandemic has touched every community in our
country, it has revealed the striking socioeconomic and healthcare inequities in the U.S. that
disproportionately impact African Americans, Latinx and Native Americans in addition to underserved
communities such as individuals in correctional facilities, rural and immigrant populations, people with
disabilities and individuals experiencing homelessness.

The Infectious Diseases Society of America and its HIV Medicine Association represent more than 12,000
infectious diseases and HIV physicians and other health care providers, public health practitioners and
scientists committed to ending the health disparities that have historically impacted the lives of black
and brown and other underserved Americans and that have been exacerbated by COVID-19. Uniform
racial and ethnic data for COVID-19 cases and outcomes continue to be limited but below are some of
the available statistics:

• In the 40 states reporting deaths by race and ethnicity, the mortality rate for African Americans
is 2.4 times as high as the rate for Whites.ii Another analysis found that Latinx individuals are
more than 2 times likely to die than Whites.iii

• According to CDC’s COVIDView, Non-Hispanic Black and Non-Hispanic American Indian/Alaska
Native populations have a hospitalization rate approximately 4.5 times that of non-Hispanic
Whites, while Hispanic/Latinos have a rate approximately 3.5 times that of Non-Hispanic
Whites.iv

• Data points for Native Americans nationwide are limited but the Navajo Nation and Hopi
Reservation have reported one of the highest per capita case rates in the U.S. of over 2,500 per
100,000 people.v

While the African American, Latinx and Native American communities face unique challenges, these
three specific populations share the following:

• Are disproportionately impacted by structural racism and socioeconomic factors.vivii

• Are more likely to be uninsured,viii

• Experience higher rates of pre-existing and underlying health conditions,ix and
Are more likely to be low wage frontline workers.x

While more limited data analysis is available on COVID-19 in rural populations, analysis by the Kaiser
Family Foundation in May 2020 found that non-metro areas were experiencing faster growth rates in
cases and death rates.xi Underserved populations in rural areas also have high rates of pre-existing and
underlying conditions and work in low wage jobs without the ability to work remotely. In addition, the
healthcare infrastructure in rural communities is ill equipped to respond to the pandemic due to rural
hospital closures and a lack of Medicaid expansion in states with large rural areas.xii

According to the CDC, “people with disabilities may not be inherently at higher risk for COVID-19, but
some people with disabilities may be at higher risk if they have underlying chronic conditions. Adults
with disabilities are three times more likely than adults without disabilities to have heart disease,
strokes, diabetes, or cancer.”xiii Additionally, people with disabilities may find wearing masks, self-
isolation, and hand-washing challenging without assistance from personal attendants that may not be
accessible because of social distancing measures or staffing shortages. Further, treatment guidelines in
some states may explicitly or implicitly deny or limit COVID-19 treatment to people with disabilities.xiv

This policy brief and the companion series that will include a brief addressing each population
individually, highlight issues contributing to the health disparities related to COVID-19 specific to each of
these unique and vulnerable communities, as well as policy recommendations for addressing them.

CALL TO ACTION

Policy interventions are urgently needed to improve health outcomes and mitigate the impact of COVID-
19 on African American, Latinx, Native American and other higher risk communities. General policy
recommendations are summarized below but are detailed in the separate policy briefs developed for
each specific population.

Improve Access to Healthcare Coverage and Healthcare Services

The uninsured rate among African Americans is 1.5 times higher than White Americans and among the
Latinx community is 2.5 times higher than White Americans. The uninsured rate among Native
Americans and Alaskan Natives is the highest of any group at more than 21%.xv Rural populations also
have higher uninsured rates (12.3%) than mostly urban areas (10.1%).xvi The Medicaid program is a
lifeline for low income individuals and individuals with chronic conditions. To help address disparities
and prevent the erosion of Medicaid eligibility and services during this national health crisis, Congress
should:

• Offer incentives for the 14 states that have not expanded Medicaid to do so.

• Further increase the federal matching rate for state Medicaid programs to prevent eligibility and
coverage restrictions due to increased demands and strains on state budgets.xvii

• Authorize a national special enrollment period for Affordable Care Act plans.

• Increase funding for safety-net providers, including community health centers and safety-net
hospitals including rural hospitals, which are playing a critical role in COVID-19 testing, care and
treatment for the African American and Latinx communitiesxviii and other high risk populations
and communities.

Ensure the Collection of COVID-19 Data by Race, Ethnicity, and Disability by Zip Code

High quality data on COVID-19 are essential to identify and address disparities and to evaluate and
refine our responses. States should collect and publicly report data in a uniform, rigorous manner. Data
on race, ethnicity, and disability by zip code and institutional and community settings are critical to
understand and track how specific populations and communities are being impacted by COVID-19 and to
target response efforts.

Health department reporting must be uniform across states and include race, ethnicity, and disability by
zip code for every COVID-19 case. The reporting of serology or antibody testing must be separate from

PCR or diagnostic testing and should include the number of tests performed as well as the positivity
rate. Uniform reporting that includes race, ethnicity, and disability also should be required for
hospitalizations and deaths due to COVID-19. Information regarding testing, cases, and deaths in
institutional and community settings is important for collecting and reporting accurate data on people
with disabilities.xix

Provide Access to Affordable, COVID-19 Testing, Prevention, Care and Treatment

As part of a national COVID-19 testing strategy for COVID-19, testing and contact tracing should be
ramped up in the communities impacted by COVID-19 and should be easily accessible within the
community including at walk up testing sites. Safety-net hospitals including those in rural areas should
be prioritized for treatments and clinical trials as they become available.

Ensure the availability of masks, hand sanitizer and enhanced educational outreach for communities and
populations at higher risk for COVID-19.

Protections should be in place to ensure that COVID-19 diagnostics, vaccines, and treatment are
affordable, available and accessible in all communities with a focus on communities that have
disproportionately been impacted by COVID-19.

The programs created by Congress to support testing, care and treatment for individuals who are
uninsured, including the HRSA COVID-19 Reimbursement programxx and the CARES Act Provider Relief
fund should be sustained to ensure that individuals have access to the healthcare services they need
regardless of their ability to pay.

Protect Frontline Workers

Certain racial and ethnic populations, including African Americans, Latinx and Native Americans, are
overrepresented in the lower wage frontline workforce that includes positions in home-health care,
grocery stores and food service, public service, transportation, and in the meat packing industry.xxi Due
to the limited ability to social distance in these positions and increased exposure to the public, these
essential workers are at heightened risk for COVID-19. With federal support, we urge companies that
employ frontline workers be required to provide appropriate personal protective equipment and access
to COVID-19 testing at no charge to employees in addition to providing paid emergency and sick leave
and up to three months of paid family leave. Subsidized childcare also should be available to frontline
line workers.

Address Social and Economic Determinants of Health

Significant structural changes are needed to address the social and economic determinants of health
that are disproportionately harming the well-being of African American, Latinx and Native American
communities in addition to other higher risk communities, including rural populations. Over the long-
term, systemic changes are needed to promote economic stability, healthy neighborhoods, education,
food security and access to culturally competent healthcare in addition to ending structural racism
throughout these systems.xxii In the short-term, the following should be considered:

• Increase funding for the Federal Communications Commission’s Lifeline program to support
unlimited minutes and Internet access for low income individuals and families to stay connected

to health care and educational programs.xxiii This is particularly important in sustaining
telehealth access in communities with limited access to healthcare and transportation to
healthcare facilities.

• Provide a 15% increase in the Supplemental Nutrition Assistance Program maximum benefit
level to provide additional resources to low income household to purchase food.xxiv

• Continue the moratorium on evictions for failure to pay rent.

• Increase the availability of housing assistance and temporary housing for individuals
experiencing homeless and those living in shared housing with a large or extended family to
quarantine.

i Johns Hopkins University. COVID-19 Dashboard by the Center for Systems Science and Engineering (CSSE). Online
at: https://www.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd40299423467b48e9ecf6. Accessed
June 16, 2020.
ii APM Research Lab. The Color of Coronavirus: Covid-19 Deaths By Race and Ethnicity in the U.S. Online
at: https://www.apmresearchlab.org/covid/deaths-by-race. Accessed June 8, 2020.
iii Gross CP, et al. Racial and Ethnic Disparities in Population Level Covid-19 Mortality. medRxiv.
doi: https://doi.org/10.1101/2020.05.07.20094250.
iv Centers for Disease Control and Prevention. COVIDView. Ma 23, 2020. Online at:
https://www.cdc.gov/coronavirus/2019-ncov/covid-data/pdf/covidview-05-29-2020 . Accessed June 3, 2020.
v Statista. Navajo Nation Hit Hard by COVID-19. June 3, 2020. Online at:
https://www.statista.com/chart/21691/native-americans-covid-impact/. Accessed June 9, 2020.
vi Artiga S. Health Disparities are a Symptom of Broader Social and Economic Inequities. Kaiser Family Foundation.
June 1, 2020. Online at: https://www.kff.org/coronavirus-policy-watch/health-disparities-symptom-broader-
social-economic-inequities/. Accessed June 9, 2020.
vii Bailey ZD, Krieger N, Z Agénor M, et al. Structural racism and health inequities in the USA: evidence and
interventions. Lancet 2017; 389: 1453–63.
viii Artiga, S., et al. Changes in Health Coverage by Race and Ethnicity since the ACA, 2010-2018. Kaiser Family
Foundation. March 5, 2020.
ix Artiga S, Garfield R, Orgera K. Communities of Color at Higher Risk for Health and Economic Challenges due to
COVID-19. Kaiser Family Foundation. April 7, 2020. Online at: https://www.kff.org/coronavirus-covid-19/issue-
brief/communities-of-color-at-higher-risk-for-health-and-economic-challenges-due-to-covid-19/. Accessed June 9,
2020.
x Blau FD, Koebe J, Meyerhofer PA. Essential and Frontline Workers in the COVID-19 Crisis. Econofact. April 30,
2020. Online at: https://econofact.org/essential-and-frontline-workers-in-the-covid-19-crisis. Accessed June 9,
2020.
xi KFF. COVID-19 in Metropolitan and Non-Metropolitan Counties. May 21, 2020.
xii National Health Law Program. The COVID-19 Pandemic Will Cause Deep cuts to Rural America. May 20, 2020.
https://healthlaw.org/the-covid-19-pandemic-will-cause-deep-cuts-to-rural-america/.
xiii https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-disabilities.html
xiv http://www.c-c-d.org/fichiers/COVID-disability-data-collection-letter-2020-4-27
xv IBID. Artiga, S., et al.
xvi United States Census Bureau. Health Insurance in Rural America. April 2019.
https://www.census.gov/library/stories/2019/04/health-insurance-rural-america.html.
xvii Musumeci, MB. Key Questions About the New Increase in Federal Medicaid Matching Funds for COVID-19.
KFF. May 4, 2020. Online at: https://www.kff.org/coronavirus-covid-19/issue-brief/key-questions-about-the-new-
increase-in-federal-medicaid-matching-funds-for-covid-19/. Accessed June 9, 2020.

https://www.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd40299423467b48e9ecf6

https://www.apmresearchlab.org/covid/deaths-by-race

https://www.cdc.gov/coronavirus/2019-ncov/covid-data/pdf/covidview-05-29-2020

https://www.statista.com/chart/21691/native-americans-covid-impact/

https://www.kff.org/coronavirus-policy-watch/health-disparities-symptom-broader-social-economic-inequities/

https://www.hivlawandpolicy.org/sites/default/files/Structural%20racism%20and%20health%20inequities%20in%20the%20USA_Evidence%20and%20interventions

https://www.kff.org/disparities-policy/issue-brief/changes-in-health-coverage-by-race-and-ethnicity-since-the-aca-2010-2018/

Communities of Color at Higher Risk for Health and Economic Challenges due to COVID-19

Essential and Frontline Workers in the COVID-19 Crisis (Updated)

The COVID-19 Pandemic Will Cause Deep Cuts to Rural America

https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-disabilities.html

http://www.c-c-d.org/fichiers/COVID-disability-data-collection-letter-2020-4-27

https://www.census.gov/library/stories/2019/04/health-insurance-rural-america.html

Key Questions About the New Increase in Federal Medicaid Matching Funds for COVID-19

xviii Corallo B, Tolbert J. Impact of Coronavirus on Community Health Centers. KFF. May 20, 2020. Online at:
https://www.kff.org/coronavirus-covid-19/issue-brief/impact-of-coronavirus-on-community-health-centers/. June
9, 2020.
xix http://www.c-c-d.org/fichiers/COVID-disability-data-collection-letter-2020-4-27
xxHealth Resources and Services Administration. COVID-19 Claims Reimbursement to Health Care Providers and
Facilities for Testing and Treatment of the Uninsured. Online at:
https://www.hrsa.gov/CovidUninsuredClaim#:~:text=For%20dates%20of%20service%20or,with%20a%20COVID%2
D19%20diagnosis.&text=Specimen%20collection%2C%20diagnostic%20and%20antibody%20testing. Accessed
June 8, 2020.
xxi IBID. Blau FD, Koebe J, Meyerhofer PA.
xxii IBID. Artiga S. June 1, 2020.
xxiii FCC. Lifeline Program for Low-Income Consumers. Online at:https://www.fcc.gov/general/lifeline-program-low-
income-consumers. Accessed June 3, 2020.
xxiv Center on Budget and Policy Priorities. April 29, 2020. Available at: https://www.cbpp.org/research/poverty-
and-inequality/boost-the-safety-net-to-help-people-with-fewest-resources-pay-for

Impact of Coronavirus on Community Health Centers

http://www.c-c-d.org/fichiers/COVID-disability-data-collection-letter-2020-4-27

https://www.hrsa.gov/CovidUninsuredClaim#:~:text=For%20dates%20of%20service%20or,with%20a%20COVID%2D19%20diagnosis.&text=Specimen%20collection%2C%20diagnostic%20and%20antibody%20testing.

https://www.fcc.gov/general/lifeline-program-low-income-consumers

https://www.cbpp.org/research/poverty-and-inequality/boost-the-safety-net-to-help-people-with-fewest-resources-pay-for

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The WHO Regional
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SOCIAL
DETERMINANTS

OF HEALTH

Poorer people live shorter lives and are more often ill than
the rich. This disparity has drawn attention to the remarkable
sensitivity of health to the social environment.

This second edition relies on the most up-to-date sources in
its selection and description of the main social determinants
of health in our society today. Key research sources are
given for each: stress, early life, social exclusion, working
conditions, unemployment, social support, addiction, healthy
food and transport policy.

Policy and action for health need to address the social
determinants of health, attacking the causes of ill health
before they can lead to problems. This is a challenging
task for both decision-makers and public health actors and
advocates. This publication provides the facts and the policy
options that will enable them to act.

ISBN 92 89

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SOCIAL
DE TER MI NANTS

OF HEALTH

Edited by

Richard Wilkinson and Michael Marmot

SECOND EDITION

THETHE
SOLIDSOLID
FACTSFACTS

WHO Library Cataloguing in Publication Data

Social determinants of health: the solid facts. 2nd edition / edited by
Richard Wilkinson and Michael Marmot.

1.Socioeconomic factors 2.Social environment 3.Social support
4.Health behavior 5.Health status

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8.Europe I.Wilkinson, Richard II.Marmot, Michael.

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ISBN 92 890 1371

Foreword

Contributors

Introduction

1. The social gradient

2. Stress

3. Early life 1

4. Social exclusion

5. Work

6. Unemployment

7. Social support

8. Addiction

9. Food

10. Transport

WHO and other important sources

C O N T E N T S

The World Health Organization was established in 1948
as a specialized agency of the United Nations serving as
the directing and coordinating authority for international
health matters and public health. One of WHO’s
constitutional functions is to provide objective and reliable
information and advice in the field of human health, a
responsibility that it fulfils in part through its publications
programmes. Through its publications, the Organization
seeks to support national health strategies and address the
most pressing public health concerns.

The WHO Regional Office for Europe is one of six
regional offices throughout the world, each with its own
programme geared to the particular health problems of
the countries it serves. The European Region embraces
some 870 million people living in an area stretching from
Greenland in the north and the Mediterranean in the
south to the Pacific shores of the Russian Federation.
The European programme of WHO therefore concentrates
both on the problems associated with industrial and
post-industrial society and on those faced by the emerging
democracies of central and eastern Europe and the former
USSR.

To ensure the widest possible availability of authoritative
information and guidance on health matters, WHO
secures broad international distribution of its publications
and encourages their translation and adaptation. By
helping to promote and protect health and prevent and
control disease, WHO’s books contribute to achieving the
Organization’s principal objective – the attainment by all
people of the highest possible level of health.

WHO Centre for Urban Health

This publication is an initiative of the Centre for Urban
Health, at the WHO Regional Office for Europe. The
technical focus of the work of the Centre is on developing
tools and resource materials in the areas of health
policy, integrated planning for health and sustainable
development, urban planning, governance and social
support. The Centre is responsible for the Healthy Cities
and urban governance programme.

The need and demand for clear scientific
evidence to inform and support the health policy-
making process are greater than ever. The field
of the social determinants of health is perhaps
the most complex and challenging of all. It is
concerned with key aspects of people’s living and
working circumstances and with their lifestyles.
It is concerned with the health implications of
economic and social policies, as well as with the
benefits that investing in health policies can bring.
In the past five years, since the publication of the
first edition of Social determinants of health. The
solid facts in 1998, new and stronger scientific
evidence has been developed. This second edition
integrates the new evidence and is enriched with
graphs, further reading and recommended web
sites.

Our goal is to promote awareness, informed
debate and, above all, action. We want to build
on the success of the first edition, which was
translated into 25 languages and used by decision-
makers at all levels, public health professionals
and academics throughout the European Region
and beyond. The good news is that an increasing
number of Member States today are developing
policies and programmes that explicitly address the
root causes of ill health, health inequalities and the
needs of those who are affected by poverty and
social disadvantage.

This publication was achieved through close
partnership between the WHO Centre for Urban
Health and the International Centre for Health
and Society, University College London, United
Kingdom. I should like to express my gratitude
to Professor Richard Wilkinson and Professor
Sir Michael Marmot, who edited the publication,
and to thank all the members of the scientific team
who contributed to this important piece of work.
I am convinced that it will be a valuable tool for
broadening the understanding of and stimulating
debate and action on the social determinants of
health.

Agis D. Tsouros

Head, Centre for Urban Health
WHO Regional Offi ce for Europe

F O R E W O R D

Professor Mel Bartley, University College London,
United Kingdom

Dr David Blane, Imperial College London, United
Kingdom

Dr Eric Brunner, International Centre for Health and
Society, University College London, United Kingdom

Professor Danny Dorling, School of Geography,
University of Leeds, United Kingdom

Dr Jane Ferrie, University College London, United
Kingdom

Professor Martin Jarvis, Cancer Research UK, Health
Behaviour Unit, University College London, United
Kingdom

Professor Sir Michael Marmot, Department of
Epidemiology and Public Health and International
Centre for Health and Society, University College
London, United Kingdom

Professor Mark McCarthy, University College London,
United Kingdom

Dr Mary Shaw, Department of Social Medicine, Bristol
University, United Kingdom

Professor Aubrey Sheiham, International Centre for
Health and Society, University College London, United
Kingdom

Professor Stephen Stansfeld, Barts and The London,
Queen Mary’s School of Medicine and Dentistry,
London

Professor Mike Wadsworth, Medical Research Council,
National Survey of Health and Development, University
College London, United Kingdom

Professor Richard Wilkinson, University of Nottingham,
United Kingdom

C O N T R I B U T O R S

I N T R O D U C T I O N

Even in the most affluent countries, people
who are less well off have substantially shorter
life expectancies and more illnesses than the
rich. Not only are these differences in health an
important social injustice, they have also drawn
scientific attention to some of the most powerful
determinants of health standards in modern
societies. They have led in particular to a growing
understanding of the remarkable sensitivity of
health to the social environment and to what
have become known as the social determinants of
health.

This publication outlines the most important parts
of this new knowledge as it relates to areas of
public policy. The ten topics covered include the
lifelong importance of health determinants in
early childhood, and the effects of poverty, drugs,
working conditions, unemployment, social support,
good food and transport policy. To provide the
background, we start with a discussion of the social
gradient in health, followed by an explanation
of how psychological and social influences affect
physical health and longevity.

In each case, the focus is on the role that public
policy can play in shaping the social environment
in ways conducive to better health: that focus is
maintained whether we are looking at behavioural
factors, such as the quality of parenting, nutrition,
exercise and substance abuse, or at more structural
issues such as unemployment, poverty and the
experience of work. Each of the chapters contains
a brief summary of what has been most reliably
established by research, followed by a list of
implications for public policy. A few key references
to the research are listed at the end of each
chapter, but a fuller discussion of the evidence

can be found in Social determinants of health
(Marmot M, Wilkinson RG, eds. Oxford, Oxford
University Press, 1999), which was prepared to
accompany the first edition of Social determinants
of health. The solid facts. For both publications,
we are indebted to researchers in the forefront
of their fields, most of whom are associated with
the International Centre for Health and Society at
University College London. They have given their
time and expertise to draft the different chapters
of both these publications.

Health policy was once thought to be about little
more than the provision and funding of medical
care: the social determinants of health were
discussed only among academics. This is now
changing. While medical care can prolong survival
and improve prognosis after some serious diseases,
more important for the health of the population
as a whole are the social and economic conditions
that make people ill and in need of medical
care in the first place. Nevertheless, universal
access to medical care is clearly one of the social
determinants of health.

Why also, in a new publication on the determinants
of health, is there nothing about genes? The
new discoveries on the human genome are
exciting in the promise they hold for advances
in the understanding and treatment of specific
diseases. But however important individual genetic
susceptibilities to disease may be, the common
causes of the ill health that affects populations are
environmental: they come and go far more quickly
than the slow pace of genetic change because they
reflect the changes in the way we live. This is why
life expectancy has improved so dramatically over
recent generations; it is also why some European

countries have improved their health while others
have not, and it is why health differences between
different social groups have widened or narrowed
as social and economic conditions have changed.

The evidence on which this publication is based
comes from very large numbers of research
reports – many thousands in all. Some of the
studies have used prospective methods, sometimes
following tens of thousands of people over

decades – sometimes from birth. Others have
used cross-sectional methods and have studied
individual, area, national or international data.
Difficulties that have sometimes arisen (perhaps
despite follow-up studies) in determining causality
have been overcome by using evidence from
intervention studies, from so-called natural
experiments, and occasionally from studies of
other primate species. Nevertheless, as both health
and the major influences on it vary substantially

People’s
lifestyles and
the conditions
in which
they live and
work strongly
influence their
health.

E
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H

Y
C

IT
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R

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O

according to levels of economic development, the
reader should keep in mind that the bulk of the
evidence on which this publication is based comes
from rich developed countries and its relevance to
less developed countries may be limited.

Our intention has been to ensure that policy at
all levels – in government, public and private
institutions, workplaces and the community – takes
proper account of recent evidence suggesting a
wider responsibility for creating healthy societies.
But a publication as short as this cannot provide
a comprehensive guide to determinants of public
health. Several areas of health policy, such as
the need to safeguard people from exposure to
toxic materials at work, are left out because they
are well known (though often not adequately
enforced). As exhortations to individual behaviour
change are also a well established approach to
health promotion, and the evidence suggests they
may sometimes have limited effect, there is little
about what individuals can do to improve their
own health. We do, however, emphasize the need
to understand how behaviour is shaped by the
environment and, consistent with approaching
health through its social determinants, recommend
environmental changes that would lead to
healthier behaviour.

Given that this publication was put together from
the contributions of acknowledged experts in
each field, what is striking is the extent to which
the sections converge on the need for a more
just and caring society – both economically and
socially. Combining economics, sociology and
psychology with neurobiology and medicine, it
looks as if much depends on understanding the
interaction between material disadvantage and its

social meanings. It is not simply that poor material
circumstances are harmful to health; the social
meaning of being poor, unemployed, socially
excluded, or otherwise stigmatized also matters.
As social beings, we need not only good material
conditions but, from early childhood onwards,
we need to feel valued and appreciated. We need
friends, we need more sociable societies, we need
to feel useful, and we need to exercise a significant
degree of control over meaningful work. Without
these we become more prone to depression, drug
use, anxiety, hostility and feelings of hopelessness,
which all rebound on physical health.

We hope that by tackling some of the material
and social injustices, policy will not only improve
health and well-being, but may also reduce a range
of other social problems that flourish alongside
ill health and are rooted in some of the same
socioeconomic processes.

Richard Wilkinson and Michael Marmot

Life expectancy is shorter and most diseases are
more common further down the social ladder in
each society. Health policy must tackle the social
and economic determinants of health.

What is known

Poor social and economic circumstances affect
health throughout life. People further down the
social ladder usually run at least twice the risk of
serious illness and premature death as those near
the top. Nor are the effects confined to the poor:
the social gradient in health runs right across
society, so that even among middle-class office
workers, lower ranking staff suffer much more
disease and earlier death than higher ranking staff
(Fig. 1).

Both material and psychosocial causes contribute to
these differences and their effects extend to most
diseases and causes of death.

Disadvantage has many forms and may be absolute
or relative. It can include having few family assets,
having a poorer education during adolescence,
having insecure employment, becoming stuck in a
hazardous or dead-end job, living in poor housing,
trying to bring up a family in difficult circumstances
and living on an inadequate retirement pension.

These disadvantages tend to concentrate among
the same people, and their effects on health
accumulate during life. The longer people live in
stressful economic and social circumstances, the
greater the physiological wear and tear they suffer,
and the less likely they are to enjoy a healthy old
age.

Policy implications

If policy fails to address these facts, it not only
ignores the most powerful determinants of health
standards in modern societies, it also ignores one
of the most important social justice issues facing
modern societies.

• Life contains a series of critical transitions:
emotional and material changes in early
childhood, the move from primary to secondary
education, starting work, leaving home and
starting a family, changing jobs and facing
possible redundancy, and eventually retirement.
Each of these changes can affect health by
pushing people onto a more or less advantaged
path. Because people who have been
disadvantaged in the past are at the greatest risk
in each subsequent transition, welfare policies
need to provide not only safety nets but also
springboards to offset earlier disadvantage.

Professional

Skilled non-
manual

Managerial
and technical

64
LIFE EXPECTANCY (YEARS)

Skilled
manual

Partly skilled
manual

Unskilled
manual

Men Women

66 68 70 72 74 76 78 80 82 84

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N

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C
LA

1 . T H E S O C I A L G R A D I E N T

Fig. 1. Occupational class differences in life
expectancy, England and Wales, 1997–1999

KEY SOURCES

Bartley M, Plewis I. Accumulated labour market disadvantage and
limiting long-term illness. International Journal of Epidemiology,
2002, 31:336–341.

Mitchell R, Blane D, Bartley M. Elevated risk of high blood pressure:
climate and the inverse housing law. International Journal of
Epidemiology, 2002, 31:831–838.

Montgomery SM, Berney LR, Blane D. Prepubertal stature and
blood pressure in early old age. Archives of Disease in Childhood,
2000, 82:358–363.

Morris JN et al. A minimum income for healthy living. Journal of
Epidemiology and Community Health, 2000, 54:885–889.

• Good health involves
reducing levels of
educational failure,
reducing insecurity
and unemployment
and improving housing
standards. Societies that
enable all citizens to play
a full and useful role
in the social, economic
and cultural life of their
society will be healthier
than those where people
face insecurity, exclusion
and deprivation.

• Other chapters of this
publication cover specific
policy areas and suggest
ways of improving health
that will also reduce the
social gradient in health.

Programme Committee on Socio-economic Inequalities in Health
(SEGV-II). Reducing socio-economic inequalities in health. The
Hague, Ministry of Health, Welfare and Sport, 2001.

van de Mheen H et al. Role of childhood health in the explanation
of socioeconomic inequalities in early adult health. Journal of
Epidemiology and Community Health, 1998, 52:15–19.

Source of Fig. 1: Donkin A, Goldblatt P, Lynch K. Inequalities in life
expectancy by social class 1972–1999. Health Statistics Quarterly,
2002, 15:5–15.

Poor social and economic circumstances affect health throughout life.

O
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Stressful circumstances, making people feel
worried, anxious and unable to cope, are
damaging to health and may lead to premature
death.

What is known

Social and psychological circumstances can cause
long-term stress. Continuing anxiety, insecurity,
low self-esteem, social isolation and lack of control
over work and home life, have powerful effects on
health. Such psychosocial risks accumulate during
life and increase the chances of poor mental health
and premature death. Long periods of anxiety and

insecurity and the lack of supportive friendships
are damaging in whatever area of life they arise.
The lower people are in the social hierarchy of
industrialized countries, the more common these
problems become.

Why do these psychosocial factors affect physical
health? In emergencies, our hormones and nervous
system prepare us to deal with an immediate
physical threat by triggering the fight or flight
response: raising the heart rate, mobilizing stored
energy, diverting blood to muscles and increasing
alertness. Although the stresses of modern urban
life rarely demand strenuous or even moderate

Lack of control
over work and
home can have
powerful effects
on health.

IK
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2 . S T R E S S

KEY SOURCES

Brunner EJ. Stress and the biology of inequality. British Medical
Journal, 1997, 314:1472–1476.

Brunner EJ et al. Adrenocortical, autonomic and inflammatory
causes of the metabolic syndrome. Circulation, 2002, 106:
2659–2665.

Kivimaki M et al. Work stress and risk of cardiovascular
mortality: prospective cohort study of industrial employees.
British Medical Journal, 2002, 325:857–860.

Marmot MG, Stansfeld SA. Stress and heart disease. London,
BMJ Books, 2002.

Marmot MG et al. Contribution of job control and other risk
factors to social variations in coronary heart disease incidence.
Lancet, 1997, 350:235–239.

physical activity, turning on the stress response
diverts energy and resources away from many
physiological processes important to long-term
health maintenance. Both the cardiovascular and
immune systems are affected. For brief periods, this
does not matter; but if people feel tense too often
or the tension goes on for too long, they become
more vulnerable to a wide range of conditions
including infections, diabetes, high blood pressure,
heart attack, stroke, depression and aggression.

Policy implications

Although a medical response to the biological
changes that come with stress may be to try to
control them with drugs, attention should be
focused upstream, on reducing the major causes of
chronic stress.

• In schools, workplaces and other institutions, the
quality of the social environment and material
security are often as important to health as
the physical environment. Institutions that can
give people a sense of belonging, participating
and being valued are likely to be healthier
places than those where people feel excluded,
disregarded and used.

• Governments should recognize that welfare
programmes need to address both psychosocial
and material needs: both are sources of anxiety
and insecurity. In particular, governments should
support families with young children, encourage
community activity, combat social isolation,
reduce material and financial insecurity,
and promote coping skills in education and
rehabilitation.

Important foundations of adult health are laid in early childhood.

IN
N

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D
SE

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O
LF

O
T

A good start in life means supporting mothers
and young children: the health impact of early
development and education lasts a lifetime.

What is known

Observational research and intervention studies
show that the foundations of adult health are laid
in early childhood and before birth. Slow growth
and poor emotional support raise the lifetime
risk of poor physical health and reduce physical,
cognitive and emotional functioning in adulthood.
Poor early experience and slow growth become
embedded in biology during the processes of
development, and form the basis of the individual’s

health because of the continued malleability of
biological systems. As cognitive, emotional and
sensory inputs programme the brain’s responses,
insecure emotional attachment and poor
stimulation can lead to reduced readiness for
school, low educational attainment, and problem
behaviour, and the risk of social marginalization
in adulthood. Good health-related habits, such as
eating sensibly, exercising and not smoking, are
associated with parental and peer group examples,
and with good education. Slow or retarded physical
growth in infancy is associated with reduced
cardiovascular, respiratory, pancreatic and kidney
development and function, which increase the risk
of illness in adulthood.

3 . E A R L Y L I F E

biological and human
capital, which affects
health throughout
life.

Poor circumstances
during pregnancy
can lead to less
than optimal fetal
development via
a chain that may
include deficiencies
in nutrition during
pregnancy, maternal
stress, a greater
likelihood of maternal
smoking and misuse
of drugs and alcohol,
insufficient exercise
and inadequate
prenatal care. Poor
fetal development is a
risk for health in later
life (Fig. 2).

Infant experience is
important to later

Policy implications

These risks to the developing child are significantly
greater among those in poor socioeconomic
circumstances, and they can best be reduced
through improved preventive health care before
the first pregnancy and for mothers and babies in
pre- and postnatal, infant welfare and school clinics,
and through improvements in the educational levels
of parents and children. Such health and education
programmes have direct benefits. They increase
parents’ awareness of their children’s needs and
their receptivity to information about health and
development, and they increase parental confidence
in their own effectiveness.

KEY SOURCES

Barker DJP. Mothers, babies and disease in later life, 2nd ed.
Edinburgh, Churchill Livingstone, 1998.

Keating DP, Hertzman C, eds. Developmental health and the
wealth of nations. New York, NY, Guilford Press, 1999.

Mehrotra S, Jolly R, eds. Development with a human face.
Oxford, Oxford University Press, 2000.

Rutter M, Rutter M. Developing minds: challenge and
continuity across the life span. London, Penguin Books, 1993.

Wallace HM, Giri K, Serrano CV, eds. Health care of women and
children in developing countries, 2nd ed. Santa Monica, CA,
Third Party Publishing, 1995.

Source of Fig. 2: Barker DJP. Mothers, babies and disease in
later life, 2nd ed. Edinburgh, Churchill Livingstone, 1998.

Policies for improving health in early life should
aim to:

• increase the general level of education
and provide equal opportunity of access to
education, to improve the health of mothers
and babies in the long run;

• provide good nutrition, health education,
and health and preventive care facilities, and
adequate social and economic resources, before
first pregnancies, during pregnancy, and in
infancy, to improve growth and development
before birth and throughout infancy, and
reduce the risk of disease and malnutrition in
infancy; and

• ensure that parent–child relations are
supported from birth, ideally through home
visiting and the encouragement of good
parental relations with schools, to increase
parental knowledge of children’s emotional
and cognitive needs, to stimulate cognitive
development and pro-social behaviour in the
child, and to prevent child abuse.

7
6
5
4
3
2
1
0

R
IS

K
O

F
D

IA
B

T
E
S

(

W
IT

H
B

R
T

H
W

E
IG

H
T

4
.3

K
G

E
T
A

T
1

)

BIRTH WEIGHT (KG)

<2.5 2.5–2.9 3.0–3.4 3.5–3.9 4.0–4.3 >4.3

Fig. 2. Risk of diabetes in men aged 64 years by
birth weight
Adjusted for body mass index

Life is short where its quality is poor. By causing
hardship and resentment, poverty, social exclusion
and discrimination cost lives.

What is known

Poverty, relative deprivation and social exclusion
have a major impact on health and premature
death, and the chances of living in poverty are
loaded heavily against some social groups.

Absolute poverty – a lack of the basic material
necessities of life – continues to exist, even in the
richest countries of Europe. The unemployed, many
ethnic minority groups, guest workers, disabled
people, refugees and homeless people are at

4 . S O C I A L E X C L U S I O N

particular risk. Those living on the streets suffer the
highest rates of premature death.

Relative poverty means being much poorer than
most people in society and is often defined as living
on less than 60% of the national median income. It
denies people access to decent housing, education,
transport and other factors vital to full participation
in life. Being excluded from the life of society and
treated as less than equal leads to worse health
and greater risks of premature death. The stresses
of living in poverty are particularly harmful during
pregnancy, to babies, children and old people. In
some countries, as much as one quarter of the total
population – and a higher proportion of children
– live in relative poverty (Fig. 3).

People living on the streets suffer the highest rates
of premature death.

G
R

A
R

U
P
/P

O
LF

O
T
O

Social exclusion also results from racism,
discrimination, stigmatization, hostility and
unemployment. These processes prevent
people from participating in education or
training, and gaining access to services and
citizenship activities. They are socially and
psychologically damaging, materially costly,
and harmful to health. People who live in,
or have left, institutions, such as prisons,
children’s homes and psychiatric hospitals,
are particularly vulnerable.

The greater the length of time that people
live in disadvantaged circumstances, the
more likely they are to suffer from a range of
health problems, particularly cardiovascular
disease. People move in and out of poverty
during their lives, so the number of people
who experience poverty and social exclusion
during their lifetime is far higher than the
current number of socially excluded people.

Poverty and social exclusion increase the
risks of divorce and separation, disability,
illness, addiction and social isolation and

vice versa, forming vicious circles that deepen the
predicament people face.

As well as the direct effects of being poor, health
can also be compromised indirectly by living in
neighbourhoods blighted by concentrations of
deprivation, high unemployment, poor quality
housing, limited access to services and a poor
quality environment.

Policy implications

Through policies on taxes, benefits, employment,
education, economic management, and many
other areas of activity, no government can avoid
having a major impact on the distribution of
income. The indisputable evidence of the effects of

such policies on rates of death and disease imposes
a public duty to eliminate absolute poverty and
reduce material inequalities.

• All citizens should be protected by minimum
income guarantees, minimum wages legislation
and access to services.

• Interventions to reduce poverty and social
exclusion are needed at both the individual and
the neighbourhood levels.

• Legislation can help protect minority and
vulnerable groups from discrimination and social
exclusion.

• Public health policies should remove barriers
to health care, social services and affordable
housing.

• Labour market, education and family welfare
policies should aim to reduce social stratification.

Fig. 3. Proportion of children living in poor
households (below 50% of the national average
income)

KEY SOURCES

Claussen B, Davey Smith G, Thelle D. Impact of childhood
and adulthood socio-economic position on cause specific
mortality: the Oslo Mortality Study. Journal of Epidemiology
and Community Health, 2003, 57:40–45.

Kawachi I, Berkman L, eds. Neighborhoods and health. Oxford,
Oxford University Press, 2003.

Mackenbach J, Bakker M, eds. Reducing inequalities in health:
a European perspective. London, Routledge, 2002.

Shaw M, Dorling D, Brimblecombe N. Life chances in Britain by
housing wealth and for the homeless and vulnerably housed.
Environment and Planning A,1999, 31:2239–2248.

Townsend P, Gordon D. World poverty: new policies to defeat
an old enemy. Bristol, The Policy Press, 2002.

Source of Fig. 3: Bradshaw J. Child poverty in comparative
perspective. In: Gordon D, Townsend P. Breadline Europe: the
measurement of poverty. Bristol, The Policy Press, 2000.

C
ze

ch
R

ep
ub

lic

Sl
ov

ak
ia

Fi
nl

an
d

Sw
ed

N
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w
ay

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m

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en

m
ar

N
et

he
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nd
s

H
un

ga
ry

G
er

m
an

It
al

Is
ra

C
an

ad
a

Sp
ai

Po
la

U
ni

te
d

Ki
ng

do
m

Ru
ss

ia
n

Fe
de

ra
tio

U
SA

P
R

O
P
O

R
T
IO
N

(
%

)
30

20
15
10
5
0

Stress in the workplace increases the risk of
disease. People who have more control over their
work have better health.

What is known

In general, having a job is better for health than
having no job. But the social organization of work,
management styles and social relationships in the
workplace all matter for health. Evidence shows
that stress at work plays an important role in
contributing to the large social status differences
in health, sickness absence and premature death.
Several European workplace studies show that
health suffers when people have little opportunity
to use their skills and low decision-making
authority.

Having little control over one’s work is particularly
strongly related to an increased risk of low
back pain, sickness absence and cardiovascular
disease (Fig. 4). These risks have been found to be
independent of the psychological characteristics
of the people studied. In short, they seem to be
related to the work environment.

Studies have also examined the role of work
demands. Some show an interaction between
demands and control. Jobs with both high demand
and low control carry special risk. Some evidence
indicates that social support in the workplace may
be protective.

Further, receiving inadequate rewards for the
effort put into work has been found to be
associated with increased cardiovascular risk.
Rewards can take the form of money, status and
self-esteem. Current changes in the labour market
may change the opportunity structure, and make it
harder for people to get appropriate rewards.

These results show that the psychosocial
environment at work is an important determinant
of health and contributor to the social gradient in
ill health.

Policy implications

• There is no trade-off between health and
productivity at work. A virtuous circle can be
established: improved conditions of work will
lead to a healthier work force, which will lead
to improved productivity, and hence to the
opportunity to create a still healthier, more
productive workplace.

• Appropriate involvement in decision-making
is likely to benefit employees at all levels of an
organization. Mechanisms should therefore
be developed to allow people to influence
the design and improvement of their work

Fig. 4. Self-reported level of job control and
incidence of coronary heart disease in men and
women

5 . W O R K

Adjusted for
age, sex, length
of follow-up,
effort/reward
imbalance,
employment
grade, coronary
risk factors
and negative
psychological
disposition

R
IS
K
O

F
C

O
R

O
N
A
R

Y
H

EA
R

T
D

IS
EA

SE
(W

IT
H

H
IG

H
J

O
B

C
O

N
TR

O
L

SE
T

A
T

1.
0)

2.5

2.0

1.5

1.0

JOB CONTROL

High Intermediate Low

Jobs with both high
demand and low control
carry special risk. © F

IR
ST

L
IG

H
T
KEY SOURCES

Bosma H et al. Two alternative job stress models and risk of
coronary heart disease. American Journal of Public Health, 1998,
88:68–74.

Hemingway H, Kuper K, Marmot MG. Psychosocial factors in the
primary and secondary prevention of coronary heart disease: an
updated systematic review of prospective cohort studies. In:
Yusuf S et al., eds. Evidence-based cardiology, 2nd ed. London,
BMJ Books, 2003:181–217.

Marmot MG et al. Contribution of job control to social gradient in
coronary heart disease incidence. Lancet, 1997, 350:235–240.

Peter R et al. and the SHEEP Study Group. Psychosocial work
environment and myocardial infarction: improving risk estimation

• Good management involves ensuring
appropriate rewards – in terms of money, status
and self-esteem – for all employees.

by combining two complementary job stress models in the SHEEP
Study. Journal of Epidemiology and Community Health, 2002,
56(4):294–300.

Schnall P et al. Why the workplace and cardiovascular disease?
Occupational Medicine, State of the Art Reviews, 2000, 15:126.

Theorell T, Karasek R. The demand-control-support model and CVD.
In: Schnall PL et al., eds. The workplace and cardiovascular disease.
Occupational medicine. Philadelphia, Hanley and Belfus Inc., 2000:
78–83.

Source of Fig. 4: Bosma H et al. Two alternative job stress models
and risk of coronary heart disease. American Journal of Public
Health, 1998, 88:68–74.

environment, thus enabling employees to
have more control, greater variety and more
opportunities for development at work.

• To reduce the burden
of musculoskeletal
disorders, workplaces
must be ergonomically
appropriate.

• As well as requiring an
effective infrastructure
with legal controls and
powers of inspection,
workplace health
protection should also
include workplace health
services with people
trained in the early
detection of mental health
problems and appropriate
interventions.

6 . U N E M P L O Y M E N T

Job security increases health, well-being and job
satisfaction. Higher rates of unemployment cause
more illness and premature death.

What is known

Unemployment puts health at risk, and the risk
is higher in regions where unemployment is
widespread. Evidence from a number of countries
shows that, even after allowing for other factors,
unemployed people and their families suffer a
substantially increased risk of premature death.
The health effects of unemployment are linked
to both its psychological consequences and

effects on mental health (particularly anxiety and
depression), self-reported ill health, heart disease
and risk factors for heart disease. Because very
unsatisfactory or insecure jobs can be as harmful as
unemployment, merely having a job will not always
protect physical and mental health: job quality is
also important (Fig. 5).

During the 1990s, changes in the economies and
labour markets of many industrialized countries
increased feelings of job insecurity. As job
insecurity continues, it acts as a chronic stressor
whose effects grow with the length of exposure; it
increases sickness absence and health service use.

Unemployed
people and their
families suffer a
much higher risk
of premature
death. © R

E
U

T
E
R

/P
O
LF
O
T
O

the financial
problems it brings
– especially debt.

The health effects
start when people
first feel their jobs
are threatened,
even before they
actually become
unemployed. This
shows that anxiety
about insecurity is
also detrimental
to health. Job
insecurity has
been shown
to increase

KEY SOURCES

Beale N, Nethercott S. Job-loss and family morbidity: a study
of a factory closure. Journal of the Royal College of General
Practitioners, 1985, 35:510–514.

Bethune A. Unemployment and mortality. In: Drever F,
Whitehead M, eds. Health inequalities. London, H.M.
Stationery Office, 1997.

Burchell, B. The effects of labour market position, job
insecurity, and unemployment on psychological health.
In: Gallie D, Marsh C, Vogler C, eds. Social change and the
experience of unemployment. Oxford, Oxford University Press,
1994:188–212.

Ferrie J et al., eds. Labour market changes and job insecurity:
a challenge for social welfare and health promotion.
Copenhagen, WHO Regional Office for Europe, 1999 (WHO
Regional Publications, European Series, No. 81) (http:
//www.euro.who.int/document/e66205 , accessed 15
August 2003).

Iversen L et al. Unemployment and mortality in Denmark.
British Medical Journal, 1987, 295:879–884.

Source of Fig. 5: Ferrie JE et al. Employment status and health
after privatisation in white collar civil servants: prospective
cohort study. British Medical Journal, 2001, 322:647–651.

Fig. 5. Effect of job insecurity and unemployment
on health

Policy implications

Policy should have three goals: to prevent
unemployment and job insecurity; to reduce the
hardship suffered by the unemployed; and to
restore people to secure jobs.

• Government management of the economy to
reduce the highs and lows of the business cycle
can make an important contribution to job
security and the reduction of unemployment.

• Limitations on working hours may also be
beneficial when pursued alongside job security
and satisfaction.

Unemployed

R
IS
K
O

F
IL

L
H

E
A
LT
H

(
W

IT
H

S
E
C

U
R

E
LY

E
M

P
LO

Y
E
D

S
E
T
A
T
1

0
0
)

Long-standing illness

Poor mental health

EMPLOYMENT STATUS

Securely
employed

Insecurely
employed

300

200

150

100

50
0

• To equip people for the work available, high
standards of education and good retraining
schemes are important.

• For those out of work, unemployment benefits
set at a higher proportion of wages are likely to
have a protective effect.

• Credit unions may be beneficial by reducing
debts and increasing social networks.

Friendship, good social relations and strong
supportive networks improve health at home, at
work and in the community.

What is known

Social support and good social relations make an
important contribution to health. Social support
helps give people the emotional and practical
resources they need. Belonging to a social network
of communication and mutual obligation makes
people feel cared for, loved, esteemed and valued.
This has a powerful protective effect on health.
Supportive relationships may also encourage
healthier behaviour patterns.

Support operates on the levels both of the
individual and of society. Social isolation and
exclusion are associated with increased rates of

7 . S O C I A L S U P P O R T

premature death and poorer chances of survival
after a heart attack (Fig. 6). People who get
less social and emotional support from others
are more likely to experience less well-being,
more depression, a greater risk of pregnancy
complications and higher levels of disability
from chronic diseases. In addition, bad close
relationships can lead to poor mental and physical
health.

The amount of emotional and practical social
support people get varies by social and economic
status. Poverty can contribute to social exclusion
and isolation.

Social cohesion – defined as the quality of social
relationships and the existence of trust, mutual
obligations and respect in communities or in the
wider society – helps to protect people and their

health. Inequality is corrosive of good social
relations. Societies with high levels of income
inequality tend to have less social cohesion
and more violent crime. High levels of
mutual support will protect health while the
breakdown of social relations, sometimes
following greater inequality, reduces trust
and increases levels of violence. A study of a
community with initially high levels of social
cohesion showed low rates of coronary heart
disease. When social cohesion declined, heart
disease rates rose.

Policy implications

Experiments suggest that good social
relations can reduce the physiological
response to stress. Intervention studies have
shown that providing social support can
improve patient recovery rates from several
different conditions. It can also improve
pregnancy outcome in vulnerable groups of
women.Belonging to a social network makes people feel cared for.

O
K

H
R

O
N

IK
A

/P
O
LF
O
T
O

Eastern Finland

A
G

E
-A

D
JU

ST
E
D

M
O

R
TA

LI
T
Y

R
A

T
E

Females Males

LEVEL OF SOCIAL INTEGRATION LEVEL OF SOCIAL INTEGRATIONLow

Evans County, USA (blacks)

Evans
County,
USA (whites)

Gothenburg, Sweden

Tecumseh, USA

Evans County, USA (whites)

Alameda County,
USA

Eastern Finland
Evans County, USA (blacks)
Alameda County,
USA
Tecumseh, USA

High Low High

0.5

0.4

0.3

0.2

0.1

0
KEY SOURCES

Fig. 6. Level of social integration and mortality in five prospective studies

• Reducing social and economic inequalities and
reducing social exclusion can lead to greater social
cohesiveness and better standards of health.

• Improving the social environment in schools, in
the workplace and in the community more widely,
will help people feel valued and supported in
more areas of their lives and will contribute to
their health, especially their mental health.

• Designing facilities to encourage meeting and
social interaction in communities could improve
mental health.

• In all areas of both personal and institutional
life, practices that cast some as socially inferior or
less valuable should be avoided because they are
socially divisive.

Berkman LF, Syme SL. Social networks, host resistance and
mortality: a nine year follow-up of Alameda County residents.
American Journal of Epidemiology, 1979, 109:186–204.

Hsieh CC, Pugh MD. Poverty, income inequality, and violent crime:
a meta-analysis of recent aggregate data studies. Criminal Justice
Review, 1993, 18:182–202.

Kaplan GA et al. Social connections and mortality from all causes
and from cardiovascular disease: prospective evidence from
eastern Finland. American Journal of Epidemiology, 1988, 128:
370–380.

Kawachi I et al. A prospective study of social networks in relation to
total mortality and cardiovascular disease in men in the USA. Journal
of Epidemiology and Community Health, 1996, 50(3):245–251.

Oxman TE et al. Social support and depressive symptoms in the
elderly. American Journal of Epidemiology, 1992, 135:356–368.

Sampson RJ, Raudenbush SW, Earls F. Neighborhoods and violent
crime: a multilevel study of collective efficacy. Science, 1997, 277:
918–924.

Source of Fig. 6: House JS, Landis KR, Umberson D. Social
relationships and health. Science, 1988, 241:540–545.

0.5
0.4
0.3
0.2
0.1
0

The irony is that, apart from a temporary release
from reality, alcohol intensifies the factors that led
to its use in the first place.

The same is true of tobacco. Social deprivation
– whether measured by poor housing, low income,
lone parenthood, unemployment or homelessness
– is associated with high rates of smoking and very
low rates of quitting. Smoking is a major drain
on poor people’s incomes and a huge cause of ill
health and premature death. But nicotine offers no
real relief from stress or improvement in mood.

The use of alcohol, tobacco and illicit drugs is
fostered by aggressive marketing and promotion
by major transnational companies and by
organized crime. Their activities are a major barrier
to policy initiatives to reduce use among young
people; and their connivance with smuggling,

8 . A D D I C T I O N

Individuals turn to alcohol, drugs and tobacco and
suffer from their use, but use is influenced by the
wider social setting.

What is known

Drug use is both a response to social breakdown
and an important factor in worsening the resulting
inequalities in health. It offers users a mirage of
escape from adversity and stress, but only makes
their problems worse.

Alcohol dependence, illicit drug use and cigarette
smoking are all closely associated with markers
of social and economic disadvantage (Fig. 7). In
some of the transition economies of central and
eastern Europe, for example, the past decade has
been a time of great social upheaval. Consequently,
deaths linked to alcohol use – such as accidents,

E
IT

H
O

R
N

B
A

K
/P

O
LF
O
T
O

violence, poisoning,
injury and suicide – have
risen sharply. Alcohol
dependence is associated
with violent death in other
countries too.

The causal pathway
probably runs both ways.
People turn to alcohol to
numb the pain of harsh
economic and social
conditions, and alcohol
dependence leads to
downward social mobility.

KEY SOURCES
25

Fig. 7. Socioeconomic deprivation and risk of
dependence on alcohol, nicotine and drugs, Great
Britain, 1993

Bobak M et al. Poverty and smoking. In: Jha P, Chaloupka F, eds.
Tobacco control in developing countries. Oxford, Oxford University
Press, 2000:41–61.

Makela P, Valkonen T, Martelin T. Contribution of deaths related to
alcohol use of socioeconomic variation in mortality: register based
follow-up study. British Medical Journal 1997, 315:211–216

Marsh A, McKay S. Poor smokers. London, Policy Studies Institute,
1994.

especially in the case of tobacco, has hampered
efforts by governments to use price mechanisms to
limit consumption.

Policy implications

• Work to deal with problems of both legal and
illicit drug use needs not only to support and
treat people who have developed addictive
patterns of use, but also to address the patterns
of social deprivation in which the problems are
rooted.

• Policies need to regulate availability through
pricing and licensing, and to inform people
about less harmful forms of use, to use health
education to reduce recruitment of young
people and to provide effective treatment
services for addicts.

• None of these will succeed if the social factors
that breed drug use are left unchanged. Trying
to shift the whole responsibility on to the user is
clearly an inadequate response. This blames the
victim, rather than addressing the complexities
of the social circumstances that generate drug
use. Effective drug policy must therefore be
supported by the broad framework of social and
economic policy.

Meltzer H. Economic activity and social functioning of residents with
psychiatric disorders. London, H.M. Stationery Office, 1996 (OPCS
Surveys of Psychiatric Morbidity in Great Britain, Report 6).

Ryan, M. Alcoholism and rising mortality in the Russian Federation.
British Medical Journal, 1995, 310:646–648.

Source of Fig. 7: Wardle J et al., eds. Smoking, drinking, physical
activity and screening uptake and health inequalities. In: Gordon D
et al, eds. Inequalities in health. Bristol, The Policy Press, 1999:
213–239.

DEPRIVATION SCORE

R
IS
K
O
F
D

E
P
E
N

D
E
N

C
E
(

W
IT

H
M

O
ST

A
FF

LU
E
N

T
S

E
T
A
T
1
)

Most
affluent

Most
deprived

10
9
8
7
6
5
4
3
2
1

0
0 1 2 3 4

Alcohol

Nicotine

Drugs

Because global market forces control the food
supply, healthy food is a political issue.

What is known

A good diet and adequate food supply are central
for promoting health and well-being. A shortage
of food and lack of variety cause malnutrition
and deficiency diseases. Excess intake (also a form
of malnutrition) contributes to cardiovascular
diseases, diabetes, cancer, degenerative eye
diseases, obesity and dental caries. Food poverty
exists side by side with food plenty. The important
public health issue is the availability and cost of
healthy, nutritious food (Fig. 8). Access to good,
affordable food makes more difference to what

Social and economic conditions result in a social
gradient in diet quality that contributes to health
inequalities. The main dietary difference between
social classes is the source of nutrients. In many
countries, the poor tend to substitute cheaper
processed foods for fresh food. High fat intakes
often occur in all social groups. People on low
incomes, such as young families, elderly people and
the unemployed, are least able to eat well.

Dietary goals to prevent chronic diseases
emphasize eating more fresh vegetables, fruits and
pulses (legumes) and more minimally processed
starchy foods, but less animal fat, refined sugars
and salt. Over 100 expert committees have agreed
on these dietary goals.

9 . F O O D

Local production for local consumption.

IL
E
E
N

R
O

B
E
R

T
SO

N
/W

H
O

people eat than health education.

Economic growth and improvements in
housing and sanitation brought with
them the epidemiological transition from
infectious to chronic diseases – including
heart disease, stroke and cancer. With it
came a nutritional transition, when diets,
particularly in western Europe, changed to
overconsumption of energy-dense fats and
sugars, producing more obesity. At the same
time, obesity became more common among
the poor than the rich.

World food trade is now big business. The
General Agreement on Tariffs and Trade
and the Common Agricultural Policy of the
European Union allow global market forces
to shape the food supply. International
committees such as Codex Alimentarius,
which determine food quality and safety
standards, lack public health representatives,
and food industry interests are strong. Local
food production can be more sustainable,
more accessible and support the local
economy.

KEY SOURCES

Fig. 8. Mortality from coronary heart disease in
relation to fruit and vegetable supply in selected
European countries

Diet, nutrition and the prevention of chronic diseases. Report
of a Joint WHO/FAO Expert Consultation. Geneva, World
Health Organization, 2003 (WHO Technical Report Series, No.
916) (http://www.who.int/hpr/NPH/docs/who_fao_expert_
report , accessed 14 August 2003)

First Action Plan for Food and Nutrition Policy [web pages].
Copenhagen, WHO Regional Office for Europe, 2000 (http:
//www.euro.who.int/nutrition/ActionPlan/20020729_1,
accessed 14 August 2003).

Roos G et al. Disparities in vegetable and fruit consumption:
European cases from the north to the south. Public Health
Nutrition, 2001, 4:35–43

Systematic reviews in nutrition. Transforming the evidence on
nutrition and health into knowledge [web site]. London,
University College London, 2003 (http://
www.nutritionreviews.org/, accessed 14 August 2003).

World Cancer Research Fund. Food, nutrition and the
prevention of cancer: a global perspective. Washington,
DC, American Institute for Cancer Research, 1997 (http:
//www.aicr.org/exreport.html, accessed 14 August 2003).

Source of Fig. 8: FAOSTAT (Food balance sheets) [database
online]. Rome, Food and Agriculture Organization of the United
Nations, 25 September 2003.

WHO mortality database [database online]. Geneva, World
Health Organization, 25 September 2003.

Health for all database [database online]. Copenhagen, WHO
Regional Office for Europe, 25 September 2003.

Policy implications

Local, national and international government
agencies, nongovernmental organizations and the
food industry should ensure:

• the integration of public health perspectives
into the food system to provide affordable and
nutritious fresh food for all, especially the most
vulnerable;

• democratic, transparent decision-making and
accountability in all food regulation matters,
with participation by all stakeholders, including
consumers;

• support for sustainable agriculture and food
production methods that conserve natural
resources and the environment;

• a stronger food culture for health, especially
through school education, to foster people’s

900

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100 150 200 250 300 350 400 450

Greece
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E
-S

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D

IZ
E
D

D
E
A

T
H
R
A
T
E
S

P
E
R

1
0
0
0

0
0
M

E
N

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5
–7

SUPPLY OF FRUIT AND VEGETABLES (KG/PERSON/YEAR)

Ukraine
Russian Federation
Lithuania
Poland

Germany

France
Spain

Belarus

knowledge of food and nutrition, cooking skills,
growing food and the social value of preparing
food and eating together;

• the availability of useful information about food,
diet and health, especially aimed at children;

• the use of scientifically based nutrient reference
values and food-based dietary guidelines to
facilitate the development and implementation
of policies on food and nutrition.

United Kingdom
Italy

Roads should give precedence to cycling.

1 0 . T R A N S P O R T

Healthy transport means less driving and more
walking and cycling, backed up by better public
transport.

What is known

Cycling, walking and the use of public transport
promote health in four ways. They provide exercise,
reduce fatal accidents, increase social contact and
reduce air pollution.

Because mechanization has reduced the exercise
involved in jobs and house work and added to
the growing epidemic of obesity, people need to
find new ways of building exercise into their lives.
Transport policy can play a key role in combating
sedentary lifestyles by reducing reliance on cars,
increasing walking and cycling, and expanding
public transport. Regular exercise protects against
heart disease and, by limiting obesity, reduces the
onset of diabetes. It promotes a sense of well-being
and protects older people from depression.

Reducing road traffic would also reduce the toll
of road deaths and serious accidents. Although
accidents involving cars also injure cyclists and
pedestrians, those involving cyclists injure relatively
few people. Well planned urban environments,
which separate cyclists and pedestrians from car
traffic, increase the safety of cycling and walking.

In contrast to cars, which insulate people from
each other, cycling, walking and public transport
stimulate social interaction on the streets. Road
traffic cuts communities in two and divides one
side of the street from the other. With fewer
pedestrians, streets cease to be social spaces and
isolated pedestrians may fear attack. Further,
suburbs that depend on cars for access isolate
people without cars – particularly the young
and old. Social isolation and lack of community
interaction are strongly associated with poorer
health.

Reduced road traffic decreases harmful pollution
from exhaust. Walking and cycling make minimal
use of non-renewable fuels and do not lead to
global warming. They do not create disease from air
pollution, make little noise and are preferable for
the ecologically compact cities of the future.

Policy implications

The 21st century must see a reduction in people’s
dependence on cars. Despite their health-damaging

KEY SOURCES

Davies A. Road transport and health. London, British Medical
Association, 1997.

Fletcher T, McMichael AJ, eds. Health at the crossroads:
transport policy and urban health. New York, NY, Wiley, 1996.

Making the connections: transport and social exclusion.
London, Social Exclusion Unit, Office of the Deputy Prime
Minister, 2003 (http://www.socialexclusionunit.gov.uk/
published.htm, accessed 14 August 2003).

McCarthy M. Transport and health. In: Marmot MG,
Wilkinson R, eds. The social determinants of health. Oxford,
Oxford University Press, 1999:132–154.

Transport, environment and health in Europe: evidence,
initiatives and examples. Copenhagen, WHO Regional Office
for Europe, 2001 (http://www.euro.who.int/eprise/main/who/
progs/hcp/UrbanHealthTopics/20011207_1, accessed 14
August 2003).

Source of Fig. 9:Transport trends 2002: articles (Section 2:
personal travel by mode). London, Department for Transport,
2002 (http://www.dft.gov.uk/stellent/groups/dft_transstats/
documents/page/dft_transstats_506978.hcsp, accessed 18
September 2003).

effects, however, journeys by car are rising rapidly
in all European countries and journeys by foot
or bicycle are falling (Fig. 9). National and local
public policies must reverse these trends. Yet
transport lobbies have strong vested interests.
Many industries – oil, rubber, road building, car
manufacturing, sales and repairs, and advertising
– benefit from the use of cars.

• Roads should give precedence to cycling and
walking for short journeys, especially in towns.

• Public transport should be improved for longer
journeys, with regular and frequent connections
for rural areas.

• Incentives need to be changed, for example,
by reducing state subsidies for road building,
increasing financial support for public transport,
creating tax disincentives for the business use

Car Train Bus Foot Cycle

Fig. 9. Distance travelled per person by mode of
transport, Great Britain, 1985 and

2000

D
IS

TA
N
C
E
(

K
M

)

MODE OF TRANSPORT

10000

8000

6000

4000

2000
0

1985 2000

of cars and increasing the costs and penalties of
parking.

• Changes in land use are also needed, such
as converting road space into green spaces,
removing car parking spaces, dedicating roads to
the use of pedestrians and cyclists, increasing bus
and cycle lanes, and stopping the growth of low-
density suburbs and out-of-town supermarkets,
which increase the use of cars.

• Increasingly, the evidence suggests that building
more roads encourages more car use, while
traffic restrictions may, contrary to expectations,
reduce congestion.

W H O A N D O T H E R I M P O R T A N T S O U R C E S

Stress

The world health report 2001. Mental health: new
understanding, new hope. Geneva, World Health
Organization, 2001 (http://www.who.int/whr2001/
2001/, accessed 14 August 2003).

World report on violence and health. Geneva,
World Health Organization, 2002 (http:
//www.who.int/violence_injury_prevention/
violence/world_report/wrvh1/en/, accessed 14
August 2003).

Early life

A critical link – interventions for physical growth
and psychosocial development: a review.
Geneva, World Health Organization, 1999 (http:
//whqlibdoc.who.int/hq/1999/WHO_CHS_CAH_
99.3 , accessed 14 August 2003).

Macroeconomics and health: investing in health
for economic development. Report of the
Commission on Macroeconomics and Health.
Geneva, World Health Organization, 2001 (http:
//www3.who.int/whosis/menu.cfm?path=cmh&
language=english, accessed 14 August 2003).

Social exclusion

Ziglio E et al., eds. Health systems confront
poverty. Copenhagen, WHO Regional Office for
Europe, 2003 (Public Health Case Studies, No. 1)
(http://www.euro.who.int/document/e80225 ,
accessed 14 August 2003).

Addiction
Framework Convention on Tobacco Control [web
pages]. Geneva, World Health Organization, 2003
(http://www.who.int/gb/fctc/, accessed 14 August
2003).

Global status report on alcohol. Geneva, World
Health Organization, 1999 (http://www.who.int/
substance_abuse/pubs_alcohol.htm, accessed 14
August 2003).

The European report on tobacco control policy.
Review of implementation of the Third Action Plan
for a Tobacco-free Europe 1997–2001. Copenhagen,
WHO Regional Office for Europe, 2002 (http:
//www.euro.who.int/document/tob/tobconf2002/
edoc8 , accessed 14 August 2003).

Food

Global strategy for infant and young child feeding
[web pages]. Geneva, World Health Organization,
2002 (http://www.who.int/child-adolescent-health/
NUTRITION/global_strategy.htm, accessed 15
August 2003).

Globalization, diets and noncommunicable
diseases. Geneva, World Health Organization, 2002
(http://www.who.int/hpr/NPH/docs/globalization.
diet.and.ncds , accessed 15 August 2003).

WHO Global Strategy on Diet, Physical Activity
and Health [web pages]. Geneva, World Health
Organization, 2003 (http://www.who.int/hpr/
global.strategy.shtml, accessed 15 August 2003).

Transport

A physically active life through everyday transport
with a special focus on children and older people
and examples and approaches from Europe.
Copenhagen, WHO Regional Office for Europe,
2002 (http://www.euro.who.int/document/
e75662 , accessed on 15 August 2003).

Charter on Transport, Environment and Health.
Copenhagen, WHO Regional Office for Europe,
1999 (EUR/ICP/EHCO 02 02 05/9 Rev.4) (http:
//www.euro.who.int/document/peh-ehp/charter_
transporte , accessed on 15 August 2003).

Dora C, Phillips M, eds. Transport, environment
and health. Copenhagen, WHO Regional
Office for Europe, 2000 (WHO Regional
Publications, European Series, No. 89) (http:
//www.euro.who.int/document/e72015 ,
accessed on 15 August 2003).

Transport, Health and Environment Pan-European
Programme (THE PEP) [web pages]. Geneva,
United Nations Economic Commission for Europe,
2003 (http://www.unece.org/the-pep/new/en/
welcome.htm, accessed 15 August 2003).

Member States
Albania
Andorra
Armenia
Austria
Azerbaijan
Belarus
Belgium
Bosnia and Herzegovina
Bulgaria
Croatia
Cyprus
Czech Republic
Denmark
Estonia
Finland
France
Georgia
Germany
Greece
Hungary
Iceland
Ireland
Israel
Italy
Kazakhstan
Kyrgyzstan
Latvia
Lithuania
Luxembourg
Malta
Monaco
Netherlands
Norway
Poland
Portugal
Republic of Moldova
Romania
Russian Federation
San Marino
Serbia and Montenegro
Slovakia
Slovenia
Spain
Sweden
Switzerland
Tajikistan
The former Yugoslav
Republic of Macedonia
Turkey
Turkmenistan
Ukraine
United Kingdom
Uzbekistan

The WHO Regional
Offi ce for Europe
The World Health
Organization (WHO) is
a specialized agency
of the United Nations
created in 1948 with
primary responsibility
for international
health matters and
public health. The WHO
Regional Offi ce for
Europe is one of
six regional offi ces
throughout the world,
each with its own
programme geared to
the particular health
conditions of the
countries it serves.
International
Centre for
Health and
Society
SOCIAL
DETERMINANTS

OF HEALTH
Poorer people live shorter lives and are more often ill than
the rich. This disparity has drawn attention to the remarkable
sensitivity of health to the social environment.

This publication examines this social gradient in health,
and explains how psychological and social infl uences affect
physical health and longevity. It then looks at what is known
about the most important social determinants of health
today, and the role that public policy can play in shaping a
social environment that is more conducive to better health.
This second edition relies on the most up-to-date sources in
its selection and description of the main social determinants
of health in our society today. Key research sources are
given for each: stress, early life, social exclusion, working
conditions, unemployment, social support, addiction, healthy
food and transport policy.
Policy and action for health need to address the social
determinants of health, attacking the causes of ill health
before they can lead to problems. This is a challenging
task for both decision-makers and public health actors and
advocates. This publication provides the facts and the policy
options that will enable them to act.

ISBN 92 890 1371 0

SOCIAL DETERMINANTS OF HEALTH SECOND EDITION THE SOLID FACTS

C O N T E N T S
F O R E W O R D
C O N T R I B U T O R S
I N T R O D U C T I O N

1 . T H E S O C I A L G R A D I E N T
2 . S T R E S S
3 . E A R LY L I F E
4 . S O C I A L E X C L U S I O N
5 . W O R K
6 . U N E M P L O Y M E N T
7 . S O C I A L S U P P O R T
8 . A D D I C T I O N
9 . F O O D
1 0 . T R A N S P O R T
W H O A N D O T H E R I M P O R TA N T S O U R C E S

Norm T. Niner
Course Introduction Assignment

LBST 2214
Spring 2021

Leading Cause of Death

• Leading Cause of Death: COVID-19 was responsible for 370,871 deaths in 2020
(Centers for Disease Control and Prevention, 2021)

• Brief Description: COVID-19 is a communicable disease that can cause a range of
reactions from mild sickness to death (Centers for Disease Control and
Prevention, 2020). It is spread through respiratory droplets in the air from an
infected individual with the virus to a healthy individual (Centers for Disease
Control and Prevention, 2020). People can experience symptoms like fever,
shortness of breath, loss of taste or smell, headaches, or fatigue (Centers for
Disease Control and Prevention, 2020).

Health Disparities

• Health Disparity 1: One health disparity for COVID-19 deaths is based on race.
African American people experience 2.4 times the mortality rate compared to
White people (ISDA, 2020).

• Health Disparity 2: Another health disparity for COVID-19 is based on geography.
Counties across the United States that were within 25 miles of an airport had 1.5
times the mortality rate compared to counties that were further than 50 miles
from an airport (Gaskin, Zare & Delamarte, 2020).

Health Disparity & SDOH (1)

• Health Disparity (from previous slide): African American people experience 2.4
times the mortality rate compared to White people (ISDA, 2020).

• Related SDOH: Social Gradient. According to Wilkinson and Marmot (2003)
social and economic conditions have serious implications on health. African
American people are more likely to be low wage frontline workers who face
frequent exposure to COVID-19 (ISDA, 2020). In North Carolina, African American
people represent 40.5% of service positions which is two times higher than the
proportion of the general population (Pryor & Tomaskovic-Devy).

Health Disparity & SDOH (2)

• Health Disparity (from previous slide): African American people experience 2.4
times the mortality rate compared to White people (ISDA, 2020).

• Related SDOH: Social exclusion: Social exclusion, connected to poverty, plays a
role in limiting access to health services (Wilkinson & Marmot, 2003). The
likelihood of African American people being uninsured is 1.5 times higher than
that of white people (ISDA, 2020). Insurance increases healthcare seeking
behavior that can help prevent underlying conditions associated with COVID-19
death (Robyn, 2012; Centers for Disease Control, 2020)

Proposed Solution

• Proposed Solution: Protections to ensure testing and vaccines remain affordable,
available and accessible with special focus toward communities that have been
disproportionately affected (ISDA, 2020). By distributing to frontline workers
there are benefits in reducing the disproportionate mortality rate as well as
limiting disease vectors.

• Making testing and vaccines affordable and accessible addresses the SDOH of
Social Gradient, as this is related to socioeconomic status and type of
employment. African American people are more likely to be low wage frontline
workers who face frequent exposure to COVID-19 (ISDA, 2020), who otherwise
may not be able to access testing and vaccines.

Proposed Solution & Bioethical Principle (1)

• Bioethical Principle 1: Justice refers to fairness (McCormick, n.a). According to
McCormick (n.a) distributive justice refers to creating a fair system of distribution
to a limited supply. applies to the proposed solution because ensuring equitable
distribution of the COVID vaccine addresses the health disparities given. Because
frontline workers face increased risk for contracting COVID-19, allocating
resources to increase vaccination and testing in this population helps create
fairness in risk distribution.

Proposed Solution & Bioethical Principle (2)

• Bioethical Principle 2: Beneficence is defined as a duty to maximize benefit to
society (McCormick, n.a). Testing and vaccination is a limited resource. Allocating
resources to higher risk communities not only benefits the specific population
but has added benefit to society in reducing the vectors of disease caused by
frontline work. This method of resource allocation is more effective than giving
to low risk populations first.

References
Centers for Disease Control and Prevention. (2020). Symptoms of Coronavirus. https://www.cdc.gov/coronavirus/2019-
ncov/symptoms-testing/symptoms.html

Centers for Disease Control and Prevention. (2021). Provisional Death Counts for Coronavirus Disease 2019 (COVID-19).
https://www.cdc.gov/nchs/nvss/vsrr/covid19/index.htm

Gaskin, D., Zare, H., & Delarmente, B. A. (2020). Geographic disparities in COVID-19 infections and deaths: The role of transportation.
Transport Policy, 102. 35-46. https://doi.org/10.1016/j.tranpol.2020.12.001

IDSA. (2020). COVID-19 and health disparities in the United States. https://www.idsociety.org/globalassets/idsa/public-health/covid-
19/covid19-health-disparities

McCormick,T. (n.a). Principles of Bioethics. University of Washington. https://depts.washington.edu/bhdept/ethics-
medicine/bioethics-topics/articles/principles-bioethics

Pryor, C., Tomaskovic-Devy, D.. How COVID exposes healthcare deficits for black workers. University of Massachusetts.
https://www.umass.edu/employmentequity/how-covid-exposes-healthcare-deficits-black-workers

Robyn, F. (2012). Health insurance and health-seeking behavior: Evidence from a randomized community-based insurance rollout in
rural Burkina Faso. Social Science & Medicine (1982), 75(4), 595–603. https://doi.org/10.1016/j.socscimed.2011.12.018

Wilkinson, R., Marmot, M., & Marmot, M. (2003). Social determinants of health : the solid facts (2nd ed.). WHO Regional Office for
Europe

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