Public Health

Social determinants of health inequalities

Michael Marmot Lancet 2005; 365: 1099–104
See Comment page 1005
The gross inequalities in health that we see within and between countries present a challenge to the world. That there International Centre for Health
should be a spread of life expectancy of 48 years among countries and 20 years or more within countries is not and Society, University College
London, 1–19 Torrington Place,
inevitable. A burgeoning volume of research identifies social factors at the root of much of these inequalities in health.
London WC1E 6BT, UK
Social determinants are relevant to communicable and non-communicable disease alike. Health status, therefore, (Prof Sir M Marmot)
should be of concern to policy makers in every sector, not solely those involved in health policy. As a response to this [email protected]
global challenge, WHO is launching a Commission on Social Determinants of Health, which will review the evidence,
raise societal debate, and recommend policies with the goal of improving health of the world’s most vulnerable
people. A major thrust of the Commission is turning public-health knowledge into political action.

There are gross inequalities in health between the major infectious diseases linked with poverty of
countries. Life expectancy at birth, to take one material conditions but also non-communicable
measure, ranges from 34 years in Sierra Leone to diseases—both physical and mental—and violent
81·9 years in Japan.1 Within countries, too, there are deaths that form the major burden of disease and death
large inequalities—a 20-year gap in life expectancy in every region of the world outside Africa and add
between the most and least advantaged populations in substantially to the burden of communicable disease in
the USA, for example.2 One welcome response to these sub-Saharan Africa.
health inequalities is to put more effort into the control To understand the social determinants of health,
of major diseases that kill and to improve health how they operate, and how they can be changed to
systems.3,4 improve health and reduce health inequalities, WHO
A second belated response is to deal with poverty. is setting up an independent Commission on Social
This issue is the thrust of the Millennium Determinants of Health, with the mission to link
Development Goals.5,6 These goals challenge the world knowledge with action (panel 1). Public policy—both
community to tackle poverty in the world’s poorest national and global—should change to take into
countries. Included in these goals is reduction of child account the evidence on social determinants of health
mortality, the health outcome most sensitive to the and interventions and policies that will address them.
effects of absolute material deprivation. This introduction to the Commission’s task lays out
To reduce inequalities in health across the world there the problems of inequalities in health that the
is need for a third major thrust that is complementary to Commission will address and the approach that it will
development of health systems and relief of poverty: to take. This report will argue that health status should be
take action on the social determinants of health. Such of concern to all policy makers, not merely those
action will include relief of poverty but it will have the within the health sector. If health of a population
broader aim of improving the circumstances in which suffers it is an indicator that the set of social
people live and work. It will, therefore, address not only arrangements needs to change. Simply, the
Commission will seek to have public policy based on a
vision of the world where people matter and social
Panel 1: The Commission on Social Determinants of Health
justice is paramount.
The Commission will not only review existing knowledge but
also raise societal debate and promote uptake of policies that Inequalities in health between and within
will reduce inequalities in health within and between countries: poverty and inequality
countries. A catastrophe on the scale of the Indian Ocean
The Commission’s aim is, within 3 years, to set solid tsunami rightly focuses attention on the susceptibility
foundations for its vision: the societal relations and factors of poor and vulnerable populations to natural disasters.
that influence health and health systems will be visible, It is no less important to keep on the agenda the more
understood, and recognised as important. On this basis, the enduring problem of inequalities in health among
opportunities for policy and action and the costs of not countries.
acting on these social dimensions will be widely known and
debated. Success will be achieved if institutions working in Children
health at local, national, and global level will be using this Under-5 mortality varies from 316 per 1000 livebirths
knowledge to set and implement relevant public policy in Sierra Leone to 3 per 1000 livebirths in Iceland,
affecting health. The Commission will contribute to a 4 per 1000 livebirths in Finland, and 5 per 1000
long-term process of incorporating social determinants of livebirths in Japan.1 In 16 countries (12 in Africa), child
health into planning, policy and technical work at WHO. mortality rose in the 1990s,7 by 43% in Zimbabwe, 52%
in Botswana, and 75% in Iraq.8

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 Public Health

between age 15 and 60 years by region of the world

160 Poorest fifth between 1970 and 2002.7 Mortality rose in Africa and in
2nd poorest fifth
140 Middle fifth the countries of central and eastern Europe whereas it
120
2nd richest fifth declined in the world as a whole. By 2002, for example,
Richest fifth
Under-5 mortality per 1000

men in the high mortality countries of Europe had

100 more than 40% probability of death between age 15
80 and 60 years compared to a 25% probability in
60
southeast Asia. These data are for regions. Among
countries, the differences are even more dramatic. The
40 probability of a man dying between age 15 and 60 years
20 is 8·3% in Sweden, 82·1% in Zimbabwe, and 90·2%
0
in Lesotho.7
Indonesia Brazil India Kenya A particularly telling example of health inequalities
Country
within countries is the 20-year gap in life expectancy
between Australian Aboriginal and Torres Strait
Figure 1: Under-5 mortality rates per 1000 livebirths by socioeconomic Islander peoples—life expectancy is 56·3 years for
quintile of household men and 62·8 years for women—and the Australian
Reprinted from reference 9 with permission of Elsevier.
average.10 The men in this population would look
unhealthy in India (male life expectancy 60·1 years)
Figure 1 shows under-5 mortality rates for four whereas Australian life expectancy is among the
countries with households classified according to highest in the world, marginally behind Iceland,
socioeconomic quintile. Child mortality varies among Sweden, and Japan. The poor health of Aboriginal and
countries.9 Within countries, not only is child mortality Torres Strait Islander peoples is not the result of a high
highest among the poorest households but also there is rate of child deaths. Infant mortality is 12·7 per
a social gradient: the higher the socioeconomic level of 1000 livebirths. This figure is high by Australian
the household the lower the mortality rate. standards, but on a scale from Iceland to Sierra Leone,
it is much closer to Iceland than to Sierra Leone. The
Adults shortened life expectancy of Aboriginal and Torres
Differences in adult mortality among countries are Strait Islander peoples results from mortality in adults
large and growing. Figure 2 shows probability of death from non-communicable disease and injury. In this
sense, the population is typical of the world health
600 Women picture. Of the 45 million deaths among adults age
15 years and older in 2002, 32 million were due to non-
Africa–very high adult mortality
communicable disease and a further 4·5 million to
Probability of death between 15 and 60 years of age per 1000 population

400 violent causes.7

Africa–high adult mortality
Aboriginal and Torres Strait Islander peoples are a
socially excluded minority within their country. But
Southeast Asia–low adult mortality poor health is not confined to poor populations or
200 World
Europe–high adult mortality those who are socially excluded. As with child
Western Pacific–low adult mortality
mortality, there is a socioeconomic gradient in adult
0
mortality rates within countries. Figure 3 shows that in
1970 1980 1990 2000 Bangladesh, adult mortality rates vary inversely with
Year
level of education.11 This gradient in mortality is quite
600 Men Africa–very high adult mortality
remarkable. Within rich countries, with strikingly
different material conditions from Bangladesh, there is
Africa–high adult mortality a social gradient in mortality prompting consideration
Europe–high adult mortality
400
of the causal links between status and health.12
Whether the social gradient in poor countries can be
Southeast Asia–low adult mortality
World attributed to the same causal pathways is an urgent
200 Western Pacific–low adult mortality task for review. It is especially important because, in
many countries, inequalities in health have been
increasing.13–15 In Russia for example, where life
0
1970 1980 1990 2000
expectancy is low, social inequalities have grown
Year (figure 4).16
Mortality statistics are readily available. They should
Figure 2: Trends in adult mortality by sex in regions of the world, 1970–2002
The graphs show the probability of death between 15 and 60 years of age per 1000 population. Reprinted from not, however, lead to ignorance of the burden of non-
reference 7 with permission of the World Health Organization. fatal disease. In particular, mental illness causes much

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 Public Health

1·05 65 Primary
1·00 High school
50 University
0·95
Mortality rate ratio

0·90
40
0·85

Mortality per 1000

0·80
30
0·75
0·70 20
0·65
0·00 10
No education Koranic 1–4 years’ ⭓5 years’
education formal formal
0
education education
1980s 1990s
Education Period

Figure 3: Mortality and education in men aged 45–90 years in Matlab, Figure 4: Increase in educational differentials in mortality between the
Bangladesh, 1982–9811 1980s and 1990s in St Petersburg men16

suffering but its effect is not clear by inspection of poor countries.19 Recognising the health effects of
mortality data. Worldwide, the second highest cause of poverty is one thing. Taking action to relieve its effects
disease burden among adults age 15–59 years is entails a richer understanding of the health effects of
unipolar depressive disorder.7 social and economic policies.
Dirty water, lack of calories, and poor antenatal care
The ageing of the world’s population cannot account for the 20-year deficit in life expectancy
It is convenient, but quite wrong, to think that the of Australian Aboriginal and Torres Strait Islander
greying of the world’s population is an issue only for peoples. On a world scale, their infant mortality rate, at
the rich countries. Figure 5 shows the projected 12·7 per 1000 livebirths, is low. Their high rate of adult
increase between 2000 and 2030 in the population mortality is from cardiovascular diseases, cancers,
older than 65 years in selected countries.17 The fastest endocrine nutritional and metabolic diseases
rates of increase are in countries at an intermediate (including diabetes), external causes (violence),
level of human development, starting from a low base. respiratory disorders, and digestive diseases.10 This fact
The social determinants of the health of older people is not to deny that poverty is important. But the form
claim attention alongside those of health at younger that poverty takes and its health consequences are
ages. quite different when considering chronic disease and
violent deaths in adults, compared to deaths from
Social determinants: poverty, inequality, and
the causes of the causes 300
In consulting widely in developing the plan for the
Commission on Social Determinants of Health, a
250
common question was: “What’s new? We know that
poverty is bad for health. Does that need a
Commission?” 200
It is not difficult to understand how poverty in the
Increase (%)

form of material deprivation—dirty water, poor

150
nutrition—allied to lack of quality medical care can
account for the tragically foreshortened lives of people
in Sierra Leone. Such understanding is insufficient in 100
two important ways. First, it fails properly to take into
account that relief of such material deprivation is not
50
simply a technical matter of providing clean water or
better medical care. Who gets these resources is
socially determined.18 Second, and related, 0
Malaysia
Mexico
Chile
India
China
USA
UK
Japan
Italy

international policies have not been pursued as if they

had people’s basic needs in mind. The critics of the Country
policies pursued by the International Monetary Fund
in the global South have argued eloquently that the
Figure 5: Projected percentage increase in the elderly population (older than
economic policies pursued under structural 65 years) from 2000 to 2030 in selected countries
adjustment have not benefited disadvantaged people in Adapted from reference 17 with permission of the US Census Bureau.

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 Public Health

subgroups within countries. It is well known that

Panel 2: The Solid Facts among rich countries, there is little correlation
Because the causes of the causes are not obvious, the WHO between gross national product (GNP) per person and
Regional Office for Europe asked a group at University life expectancy. Greece for example, with a GNP at
College London to summarise the evidence on the social purchasing power parities of just more than
determinants of health, published as The Solid Facts.22 It had US$17 000, has a life expectancy of 78·1 years; the
ten messages on the social determinants of health based on: USA, with a GNP of more than $34 000, has a life
● the social gradient expectancy of 76·9 years. Costa Rica and Cuba stand
● stress out as countries with GNPs less than $10 000 and yet
● early life life expectancies of 77·9 years and 76·5 years.23
● social exclusion There are many examples of relatively poor
● work populations with similar incomes but strikingly
● unemployment different health records.8 Kerala and China, famously,
● social support have good health, despite low incomes.24 The social
● addiction processes that lead to this beneficial state of health
● food need not wait for the world order to be changed to
● transport relieve poverty in the worst-off countries. A social
As an indication that there was a ready audience for these determinants perspective is crucial. It is also important
messages, in the first 12 months after publication of the to enquire whether the action that is taking place to
second edition it was downloaded from the internet 218 000 relieve poverty is having the desired effect not only on
times. average incomes but also on income distribution and
The Solid Facts reviewed evidence from Europe, aimed mainly hence on the poorest people.
at reducing inequalities in health within countries. The task of The social gradient in health is a particular challenge.
the Commission will be to review evidence on the social Where material deprivation is severe, a social gradient
determinants of health that are relevant to global health: in mortality could arise from degrees of absolute
inequalities among countries and within. deprivation. In rich countries with low levels of material
deprivation the gradient changes the focus from
absolute to relative deprivation.25 Relative deprivation
infectious disease in children. It entails a richer relates to a broader approach to social functioning and
understanding of the social determinants of health. meeting of human needs12—capabilities in the words of
The health experience of Aboriginal and Torres Strait Amartya Sen,26 spiritual resources to use Robert Fogel’s
Islander peoples has relevance for the health of term.27 It is likely that both material or physical needs
disadvantaged people worldwide. While in Africa the and capability, spiritual, or psychosocial needs are
major contributor to premature mortality is important to the gradient in health, which will,
communicable disease, in every other region of the therefore, be an important focus.
world it is non-communicable disease.1 Careful A focus on material conditions and control of
analysis of the global burden of disease has pointed to infectious disease must not be to the exclusion of social
the importance of risk factors, such as being determinants. The circumstances in which people live
overweight, smoking, alcohol, and poor diet.20 These and work are as important for communicable as they
are indeed potent causes. But would it be helpful to go are for non-communicable disease. Social conditions
into a deprived Australian Aboriginal population and powerfully influence both the onset and response to
point out that they should really take better care of treatment of the major infectious diseases that kill.28,29
themselves—that their smoking and obesity were The Commission on Social Determinants of Health
killing them; and if they must drink, please do so in will need to have in its sights poverty of the sub-
moderation? Unlikely. To borrow Geoffrey Rose’s Saharan African sort and the social determinants that
term, we need to examine the causes of the causes:21 account for Bolivia having 14 fewer years of life
the social conditions that give rise to high risk of non- expectancy than Costa Rica or Aboriginal and Torres
communicable disease whether acting through Strait Islander peoples having 20 years fewer than
unhealthy behaviours or through the effects of other Australians. As these examples illustrate, it will
impossibly stressful lives12 (panel 2). examine inequalities in health between countries and
A further answer to the what’s new question: inequalities within.
although it might be obvious that poverty is at the root
of much of the problem of infectious disease, and Action is possible and necessary
needs to be solved, it is less obvious how to break the A review of policies in European countries identified
link between poverty and disease. Income poverty several that took action on the social determinants of
provides, at best, an incomplete explanation of health.30 Although the reason for the policies was not
differences in mortality among countries or among necessarily to improve health they were nevertheless

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 Public Health

relevant to health: taxation and tax credits, old-age has moved in a direction of meeting human needs.37
pensions, sickness or rehabilitation benefits, maternity There is a great deal of dogmatic dispute about the
or child benefits, unemployment benefits, housing rights and wrongs of economic and social policies.
policies, labour markets, communities, and care People use labels—globalisation, neoliberal economic
facilities. policies—as badges of allegiance and terms of abuse.
In Sweden, the new strategy for public health is “to The Commission will have one basic dogma: policies
create social conditions that will ensure good health for that harm human health need to be identified and,
the entire population”.31 Of 11 policy domains, five where possible, changed. From this perspective,
relate to social determinants: participation in society, globalisation and markets are good or bad in so far as
economic and social security, conditions in childhood the way they are operated affects health.
and adolescence, healthier working life, and environ- Inequalities in health between and within countries
ment and products. These are in addition to health are avoidable.38 There is no necessary biological reason
promoting medical care and the usual health why life expectancy should be 48 years longer in Japan
behaviours. The UK set reduction of health inequalities than in Sierra Leone or 20 years shorter in Australian
as a key aim of health policy. It assembled evidence Aboriginal and Torres Strait Islander peoples than in
and expert judgments on areas suitable for policy other Australians. Reducing these social inequalities in
development.32 These then formed the basis of a plan health, and thus meeting human needs, is an issue of
of action to reduce health inequalities.33 social justice.
These are examples from rich countries. There are Conflict of interest statement
further encouraging examples. Familias en Accion in Michael Marmot is chairman of the Commission on Social
Colombia transfers cash to poor families. To qualify, Determinants of Health.
families must ensure their children receive preventive Acknowledgments
health care, enrol in school, and attend classes. The Grateful thanks to Ruth Bell, Hilary Brown, Tim Evans, Alec Irwin,
Rene Loewenson, Nicole Valentine, Jeanette Vega, and members of
results are encouraging: favourable growth of children the WHO Equity team who have worked to develop the Commission
and fewer episodes of diarrhoea.34 The Oportunidades and the ideas in this report.
programme in Mexico had somewhat similar aims References
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