A health crisis is a social crisis

Marmot, Michael

doi:10.1136/bmj.l2278

Cited by 6 publications

(10 citation statements)

References 6 publications

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“…It has been highlighted that reductions in life expectancy are more marked among poorer socioeconomic groups. [16][17][18] We also found an association between multimorbidity and adult socioeconomic status, indicating this group may contribute toward inequalities in life expectancy reductions.…”

Section: Open Accesssupporting

confidence: 53%

“…Drivers for this are complex and multifactorial (with government austerity measures and rising inequality described cited as possible factors). [16][17][18][19] Our results highlight that younger adults with multimorbidity represent an important group at risk of premature mortality. It has been highlighted that reductions in life expectancy are more marked among poorer socioeconomic groups.…”

Section: Open Accessmentioning

confidence: 60%

“…Open access countries has stalled and in some cases reversed. [16][17][18][19] Further to this, non-communicable diseases are a significant source of premature mortality, 15 17 indicating that exploration of this for multimorbidity is important.…”

Section: Introductionmentioning

confidence: 99%

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Prevalence of secondary care multimorbidity in mid-life and its association with premature mortality in a large longitudinal cohort study

et al. 2020

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ObjectivesMultimorbidity is the coexistence of two or more health conditions in an individual. Multimorbidity in younger adults is increasingly recognised as an important challenge. We assessed the prevalence of secondary care multimorbidity in mid-life and its association with premature mortality over 15 years of follow-up, in the Aberdeen Children of the 1950s (ACONF) cohort.MethodA prospective cohort study using linked electronic health and mortality records. Scottish ACONF participants were linked to their Scottish Morbidity Record hospital episode data and mortality records. Multimorbidity was defined as two or more conditions and was assessed using healthcare records in 2001 when the participants were aged between 45 and 51 years. The association between multimorbidity and mortality over 15 years of follow-up (to ages 60–66 years) was assessed using Cox proportional hazards regression. There was also adjustment for key covariates: age, gender, social class at birth, intelligence at age 7, secondary school type, educational attainment, alcohol, smoking, body mass index and adult social class.ResultsOf 9625 participants (51% males), 3% had multimorbidity. The death rate per 1000 person-years was 28.4 (95% CI 23.2 to 34.8) in those with multimorbidity and 5.7 (95% CI 5.3 to 6.1) in those without. In relation to the reference group of those with no multimorbidity, those with multimorbidity had a mortality HR of 4.5 (95% CI 3.4 to 6.0) over 15 years and this association remained when fully adjusted for the covariates (HR 2.5 (95% CI 1.5 to 4.0)).ConclusionMultimorbidity prevalence was 3% in mid-life when measured using secondary care administrative data. Multimorbidity in mid-life was associated with premature mortality.

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Section: Open Accesssupporting

confidence: 53%

Section: Open Accessmentioning

confidence: 60%

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Prevalence of secondary care multimorbidity in mid-life and its association with premature mortality in a large longitudinal cohort study

et al. 2020

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“…Our friends were rendered "structurally vulnerable" to violence from the social and economic forces that create average levels of violence many dozens of times higher in poor non-white neighborhoods compared to affluent white areas just a few miles away [16]. These "social determinants" play an outsized role in shaping the economic and health outcomes available to residents of our field site [20,49]. Nevertheless, through contextualizing these disparities in a mixed-methods assessment of both structural and cultural factors, we see that to understand patterns of violence we need to employ an intersectional analysis involving not only economic drivers but also racial dynamics, spatial segregation patterns, and the individual-level experiences of these forces [50].…”

Section: Documenting and Humanizing Inner-city Violence With Mixed Methods Researchmentioning

confidence: 99%

Structural vulnerability to narcotics-driven firearm violence: An ethnographic and epidemiological study of Philadelphia’s Puerto Rican inner-city

et al. 2019

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BackgroundThe United States is experiencing a continuing crisis of gun violence, and economically marginalized and racially segregated inner-city areas are among the most affected. To decrease this violence, public health interventions must engage with the complex social factors and structural drivers—especially with regard to the clandestine sale of narcotics—that have turned the neighborhood streets of specific vulnerable subgroups into concrete killing fields. Here we present a mixed-methods ethnographic and epidemiological assessment of narcotics-driven firearm violence in Philadelphia’s impoverished, majority Puerto Rican neighborhoods.MethodsUsing an exploratory sequential study design, we formulated hypotheses about ethnic/racial vulnerability to violence, based on half a dozen years of intensive participant-observation ethnographic fieldwork. We subsequently tested them statistically, by combining geo-referenced incidents of narcotics- and firearm-related crime from the Philadelphia police department with census information representing race and poverty levels. We explored the racialized relationships between poverty, narcotics, and violence, melding ethnography, graphing, and Poisson regression.FindingsEven controlling for poverty levels, impoverished majority-Puerto Rican areas in Philadelphia are exposed to significantly higher levels of gun violence than majority-white or black neighborhoods. Our mixed methods data suggest that this reflects the unique social position of these neighborhoods as a racial meeting ground in deeply segregated Philadelphia, which has converted them into a retail endpoint for the sale of astronomical levels of narcotics.ImplicationsWe document racial/ethnic and economic disparities in exposure to firearm violence and contextualize them ethnographically in the lived experience of community members. The exceptionally concentrated and high-volume retail narcotics trade, and the violence it generates in Philadelphia’s poor Puerto Rican neighborhoods, reflect unique structural vulnerability and cultural factors. For most young people in these areas, the narcotics economy is the most readily accessible form of employment and social mobility. The performance of violence is an implicit part of survival in these lucrative, illegal narcotics markets, as well as in the overcrowded jails and prisons through which entry-level sellers cycle chronically. To address the structural drivers of violence, an inner-city Marshall Plan is needed that should include well-funded formal employment programs, gun control, re-training police officers to curb the routinization of brutality, reform of criminal justice to prioritize rehabilitation over punishment, and decriminalization of narcotics possession and low-level sales.

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“…Tracking these inequalities has been adopted as a core dimension of population and public health surveillance efforts [7]. More recently, there has also been interest in understanding health inequalities as a barometer of underlying societal problems; that is, that socioeconomic disparities in health may widen in response to damaging social or political change [8]. Ongoing monitoring of health inequalities, particularly in terms of how they change over time, thus offers considerable insight regarding the health and social conditions of a given population.…”

Section: Introductionmentioning

confidence: 99%

Changing relative and absolute socioeconomic health inequalities in Ontario, Canada: A population-based cohort study of adult premature mortality, 1992 to 2017

et al. 2020

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Background This study aimed to characterize trends in absolute and relative socioeconomic inequalities in adult premature mortality between 1992 and 2017, in the context of declining populationwide mortality rates. We conducted a population-based cohort study of all adult premature deaths in Ontario, Canada using provincial vital statistics data linked to census-based, arealevel deprivation indices for socioeconomic status. Methods The cohort included all individuals eligible for Ontario's single-payer health insurance system at any time between January 1, 1992 and December 31, 2017 with a recorded Ontario place of residence and valid socioeconomic status information (N = 820,370). Deaths between ages 18 and 74 were used to calculate adult premature mortality rates per 1000, stratified by provincial quintile of material deprivation. Relative inequalities were measured using Relative Index of Inequality (RII) measures. Absolute inequalities were estimated using Slope Index of Inequality (SII) measures. All outcome measures were calculated as sex-specific, annual measures for each year from 1992 to 2017. Results Premature mortality rates declined in all socioeconomic groups between 1992 and 2017. Relative inequalities in premature mortality increased over the same period. Absolute inequalities were mostly stable between 1992 and 2007, but increased dramatically between 2008 and 2017, with larger increases to absolute inequalities seen in females than in males.

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A health crisis is a social crisis

Abstract: Falling life expectancy and rising inequality are twin indicators of a society in trouble

Cited by 6 publications

References 6 publications

Prevalence of secondary care multimorbidity in mid-life and its association with premature mortality in a large longitudinal cohort study

Prevalence of secondary care multimorbidity in mid-life and its association with premature mortality in a large longitudinal cohort study

Structural vulnerability to narcotics-driven firearm violence: An ethnographic and epidemiological study of Philadelphia’s Puerto Rican inner-city

Changing relative and absolute socioeconomic health inequalities in Ontario, Canada: A population-based cohort study of adult premature mortality, 1992 to 2017

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