Social Environment

Dr Michael Marmot, Chair of the WHO Commission on the Social Determinants of Health, highlights the importance of thinking about equity and health in the context of an increasing elderly population around the world.

There are common problems in high, middle and low income countries with respect to the health of the aged. In addition, when we think about inequities in the health and the functioning of elderly people, we need to examine how this plays out through the whole life course.

While scientific advances have had an enormous positive impact on human well-being, other factors also determine our health.  Where we live and work, our level of income and education, access to water, housing and health facilities all affect our health. Known as social determinants of health, a broader awareness of these issues is important so that health interventions at individual, family, municipal, national and global levels work more effectively.

Social determinants are intrinsically linked to inequities in health. They help to explain why poor and marginalized people get sick and die sooner than people in better social positions. They are a significant reason behind the world’s vast disparities in average life expectancy, ranging from 34 years in Sierra Leone (lowest in the world) to 81.9 in Japan (highest in the world).

Social determinants also account for the majority of health inequities within countries. In Indonesia, under-five mortality is nearly four times higher in the poorest fifth of the population than in the richest fifth. In England and Wales, the latest data shows a 7.4 year gap in life expectancy between men in professional occupations and men in unskilled manual occupations (1997-1999 figures).

In response to this, the World Health Organization launched in 2005 the Commission on Social Determinants of Health to collect the evidence needed to tackle the ’causes of the causes’ of ill-health. It announces its final recommendations in 2008.

Poverty, social exclusion, poor housing and poor health systems are among the main social causes of ill-health.

The conditions in which people live and work can help to create or destroy their health – lack of income, inappropriate housing, unsafe workplaces, and lack of access to health systems are some of the social determinants of health leading to inequalities within and between countries.

Social determinants of health in ageing

Social inclusion (and exclusion) is one such social determinant. Support from families, friends and communities is associated with better health. The caring and respect that occurs in social relationships, and the resulting sense of satisfaction and well-being, seem to act as a buffer against health problems.

Research has suggested that the health effects of social relationships may be as important as risk factors such as smoking, physical activity, obesity and high blood pressure.

Socially disadvantaged people and socially isolated people continue to be at increased risk for negative health outcomes.

The Japanese centenarians profiled in this e-case study all indicate that the feeling of being part of a community made them cherish their lives.

Research has also shown how a lack of social engagement for older men over a prolonged period of time can have a negative impact on cognitive skills. The conclusion is simple: stay active and engaged if you want to be both physically and mentally healthy.


Source: Bassuk SS, Glass TA, Berkman LF (1999). Social disengagement and incidence of cognitive decline. Annals of Internal Medicine 131(3):165-73.

Income and its effect on health outcomes

One of the world’s biggest killers and greatest causes of ill-health and suffering across the globe is listed almost at the end of the International Classification of Diseases. It is given the code Z.59.5 – “Extreme poverty” – a lack of the basic material necessities of life including food, clothing, shelter and safe drinking wate and defined by the World Bank in 2001 as living below $1 per day, is found in many developing countries.

In developed countries, poverty also exists both as “absolute poverty” – for example, the percentage of the population eating less food than is required to sustain the human body – and as “relative poverty”, referring to people who are much poorer than most others in their society, depending on the threshold set by each country, known as the “poverty line”. This is often defined as living on less than around 50% of the average income.

Relative poverty too can deny 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 Japan, a highly visible example of people living in poverty is homeless people, many of whom are older men.

The most recent WHO World Health Statistics highlight the relationship between income and longevity, which contribute to population ageing. For instance, in 2006 over 20% of the population in the high income group are over 60 years of age. This compares with 6% in the low income group. Simply put, the wealthy live longer.

Source: WHO. World Health Statistics 2008.

Level of education and health outcomes

Education contributes to health and prosperity by equipping people with knowledge and skills for problem solving, and helps provide a sense of control and mastery over life circumstances. It increases opportunities for job and income security and it improves people’s ability to access and understand information to help keep them healthy.

Educational attainment has also been inversely associated with physical disability in older age.

Other major social determinants of health

This list is not exhaustive, but other social determinants of health include:

- Urbanization
- Working conditions and unemployment
- Environment
- Stress
- Early child development
- Biological and genetic endowment

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

For more information:

Commission on the Social Determinants of Health