Addressing the 21st century determinants of health and wellbeing

Addressing the 21st century determinants of health and wellbeing Professor Ilona Kickbusch Global Health Programme Graduate Ins>tute Geneva Kickbusch 2012 Health promo>on •  OCawa Ac>on Areas •  Determinants: •  Health public policy •  Suppor>ve Environments •  Community ac>on •  Personal skills •  Reorient health systems • 
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Poli>cal Social Commercial Environmental Behavioral •  (gene>c) Kickbusch 2012 Context •  Radically changing socie>es: • 
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Globaliza>on Urbaniza>on Individualiza>on Virtual connectedness Commercializa>on Demography Kickbusch 2012 Two major strands of public health George Rosen (1910‐1977) •  As inequali+es increase the health debate changes: the medical and technical development dimension of public health is increasingly overlaid by a debate on the social, poli>cal and economic/commercial factors that determine health. •  In the 19th and early 20th century the focus of public health was mainly na>onal, social and poli>cal. •  in the course of the 20th century it moved to being na>onal, medical and technical, •  in the late 20th and very early 21st century to being global, economic and technical. •  Today the focus is increasingly global, social and poli+cal – powered by developments in informa+on technology which were not at our disposal even 10 years ago. (Kickbusch 2012) Kickbusch 2012 New dynamics of health • 
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Development and sustainable economic growth requires healthy popula>ons ‐ NCDs challenge this for developed and developing countries ‐a major dimension of the seminal demographic change. In many developed countries health/medical care now cons>tutes 10‐15% of GNP and 10 – 15% of the work force – many emerging economies are making major investments in health and medical care Health/medical care is a major business sector, a major employer, part the economic compe>>on between countries, the import and export of goods and services and of foreign policy ‐ Health damaging products are a major business sector – economic crisis is affec>ng both •  A new dynamics how a range of governmental sectors and processes contribute to health and how health contributes to societal and economic development require a new posi+oning of health within government and society. Kickbusch 2012 Poli>cal determinants of health •  Health has moved up in the poli>cal agenda in countries, in development policies and in global agreements precisely because of its relevance both to the economy, poli>cal ideology and legi>macy and to the expecta>ons of ci>zens. •  It is of a highly poli>cal and symbolic nature: it concerns defini>ons of the common good, the role of the state, markets and individuals, as well as the interests of many stake holders. Is health and wellbeing something that „we collec'vely strive to pursue” (Sandel 2009) in a world of globaliza>on, individualiza>on and commercializa>on? Kickbusch 2012 Poli'cal determinants of health •  Three overarching recommenda>ons of the CSDH: tackle the inequitable distribu'on of power, money and resources. But this is a societal – not a professional challenge. •  Health promo>on is a social science and – as Rudolf Virchow 1821‐1902 stated for medicine – “it has the obliga'on to point out problems and to a>empt their theore'cal solu'on”. We must not forget though – as he also said – that it is for the poli+cian to find the means for their actual solu+on. Kickbusch 2012 Consumerism – constant choice It has become common prac/ce to turn health issues into a fundamental debate about individual freedom and choice. Kickbusch 2012 Value health •  Because health is at the intersec>on of values and ideology, between market forces and “the state” it is becoming essen>al that parliamentarians – who make many of the laws that impact on health ‐ are fully aware of the (health and other) consequences of their decisions and non‐decisions. •  While NGOs are cri>cal watchdogs and advocates we must ensure that our democra+c ins+tu+ons value health. We must invest in the health literacy of parliamentarians and of the ci>zens who elect them. Kickbusch 2012 CommiCment to health and wellbeing as a public good •  The success of socie>es must be measured differently: •  “The 'me is ripe for our measurement system to shiA emphasis from measuring economic produc'on to measuring people’s well‐being. And measures of well‐
being should be put in a context of sustainability.” • 
Recommenda>on of the Commission on the Measurement of Economic Performance and Social Progress (chaired by Joseph S>glitz) 2010. •  This takes us back to the concept of health as wellbeing in the WHO Cons+tu+on. Kickbusch 2012 Challenge: Building a bridge between the health promo>on and the sustainable development agenda In many cases, the best choices for health are also the best choices for the planet; and the most ethical and environmental choices are also good for health. •  Equity •  Obesogenic environments Kickbusch 2012 Focus: Wellbeing The S>glitz Commission (2010) underlines that well‐being is mul>‐
dimensional and its various dimensions should be considered simultaneously . Quality of life depends on •  people’s health and educa>on, •  their everyday ac>vi>es (which include the right to a decent job and housing), •  their par>cipa>on in the poli>cal process, •  the social and natural environment in which they live, and •  the factors shaping their personal and economic security. Advocates for the social determinants of health could not have said it beHer. Kickbusch 2012 Challenge: Personal and economic security. •  How is health promo>on posi>oned in rela>on to the social processes and rela>onships reshaping our socie>es ? How do we achieve to achieve social sustainability and connec>vity? •  Today most of the social risks fall on young cohorts, irrespec've of their educa'onal status, as 40% youth unemployment in Southern Europe indicates. •  The “new” social risks include rapid skill deple/on, reconciling work and family life, caring for frail rela/ves and inadequate social security and health coverage. •  Can health promo+on help mi+gate such risks through resilience? Are there new models of health promo+on financing in +mes of reduced public budgets? How is public sector investment best combined with social investment by other actors? Kickbusch 2012 Challenge: Mobility and the flow of people •  The total number of interna>onal migrants has increased over the last 10 years from an es>mated 150 million in 2000 to 214 million persons today; some 42.3 million people are displaced globally as a result of conflict. •  We do not yet grasp the impact of this phenomenon which includes tourism, migra'on, mobility and displacement on the health of individuals – but it also stands in the way of accurate assessment of the public health burden of the disease and its distribu>on. Kickbusch 2012 Challenge: SPEED – Time Pressure •  The hurry virus: Urbaniza>on, modern media, new forms of work, women’s entry into the employment market – all have contributed to >me pressure and increased stress, anxiety and depression. They also impact on poor diets and a lack of physical ac>vity. •  “The feeling of constantly having to rush (the hurry virus) is a serious health issue, affec'ng not only adults, but also children.” (Tranter 2010, 2012) Kickbusch 2012 Example: Mental health issues – sleep deficiency Kickbusch 2012 Example: Cybermobbing – new „addic>ons“ Kickbusch 2012 Example: Forgeong •  If no cure is found, the number of demen>a cases worldwide will triple from 36 million today to more than 115 million by 2050 as a result of rising life expectancy. The UKs demen>a crisis Kickbusch 2012 A “radical shake up” of public health and health promo>on •  “Marmot’s focus on the social determinants of health needs to be matched with an equal concern for the commercial determinants of health” (Has>ngs 2012) •  And it needs to be matched with a concern for the poli>cal determinants of health – and above all the interface between these determinants and their impact on how health is created in the context of our everyday lives. Kickbusch 2012 Commercial determinants of health •  “Lifestyles” ‐ The power of markets and business, in par>cular transna>onal companies and their marke>ng has led to “industrial” and “communicated” epidemics based on encouraging unhealthy consump>on. Kickbusch 2012 Expansion of Commerializa>on Kickbusch 2012 Food system as a prism The promo>on of a more sustainable, healthier, and more equitable food system is a primary public health goal and key to the environmental agenda. From a public health and health promo>on perspec>ve, the long standing concern with nutri>on and diet must be widened to an approach that is concerned with the food system in its many dimensions City of Vancouver, 2009 Kickbusch 2012 New challenges demand new responses Lifestyles? Kickbusch 2012 Regula>on: Tax low nutri>onal value Kickbusch 2012 Regula>on: Taxes Nutella is 17 percent palm oil and 55 percent sugar. Gram for gram, it packs 76 percent more calories than a cheeseburger, according to Le Monde. •  The Nutella tax in France is aimed at palm oil. •  By quadrupling the tax on palm oil, the government hopes to force food companies to switch to healthier ingredients. •  It is meant to reduce French obesity and other health risks. Kickbusch 2012 Regula>on: set standards cafeterias Kickbusch 2012 Regula>on: change environments Kickbusch 2012 Regula>on: limit size Kickbusch 2012 Persuasion: NUDGE •  “An addi>onal tool to complement regula>on by moving society incrementally in a direc>on that might benefit all of us.“ •  In all cases, the goal is simple: increase the likelihood that kids will choose healthier op>ons by making them salient and/or seong them as the default. Kickbusch 2012 Persuasion: Voluntary agreements •  Former President Bill Clinton, center, is joined by Dr. Clyde Yancy, les, president of the American Heart Associa>on, as Susan Neely, president and CEO of the American Beverage Associa>on holds up a hand held device used by sos drink delivery drivers programmed to only allow orders of products permiCed to be sold in schools during a news conference. Kickbusch 2012 Persuasion: scare people Kickbusch 2012 Regula+on and persuasion: Supplies to schools dropped by 72% •  US Congress is now regula>ng the types of drinks allowed in school vending machines in an aCempt to reduce childhood obesity. Although state and local restric>ons are responsible for a good por>on of the declines, voluntary guidelines adopted by the beverage companies and their boClers in 2006 have also been a factor. Coca–Cola, PepsiCo and Dr. Pepper Snapple Group pledged to eliminate the supply of full calorie sos drinks to schools by the 2009–10 school year, replacing them with lower calorie, healthier op>ons in smaller packaging. (Keybridge Research LLC on behalf of the American Beverage Associa>on) Kickbusch 2012 HIAP Contradic>ons •  Farm subsidies that push •  The 42 million Americans down the price of high‐
receiving federal food fructose corn syrup add stamps use those benefits about US$100 million a to buy US$4 billion of sos year to the boCom line of drink every year, soda makers, according to according to the Centre a 2009 analysis from Tuss for Science in the Public University researchers. Interest. Those subsidies make soda cheaper. Kickbusch 2012 Everyday ac>vi>es: “Unsustainable lifestyles” •  The obesity epidemic ‐ and the global system of food produc>on, distribu>on, consump>on and waste ‐ is one of the most obvious symptoms of “unsustainable lifestyles” and unsustainable produc>on and consump>on paCerns. It reflects paradigma+cally the global flow of ways of life, ideas and products and the global dimension of health promo+on = global health promo+on Kickbusch 2012 Ecological footprints – health footprints • 
Global meat produc>on tripled from around 200 billion pounds in 1971 to around 600 billion pounds in 2010, while world popula>on grew by just 81 percent. At this rate, produc>on will double by 2050 to approximately 1.2 trillion pounds of meat per year, requiring more water, land, fuel, pes>cides and fer>lizer and causing significant damage to the planet and global health. Kickbusch 2012 Poli>cal determinants: Overcome Equa>on of market behaviour with democracy •  consumer •  ci>zen Hamilton 2010 Barber 2007 Kickbusch 2012 Poli>cal determinants: CommiCment to Ci>zens‘/peoples‘ empowerment Kickbusch 2012 Key ques>ons we need to consider for NCD agenda and SDGs •  1) how can joint policy goals be developed so that health promo>on can contribute to addressing major challenges facing humankind such as food, water, fuel, changing consump>on paCerns, climate change and the environment? •  2) through which strategies can a high level of complementarity and integra>on(co benefits) be achieved between health and the environmental, economic and social impacts? •  3) what conceptual framing and common language can help move a shared agenda that addresses poli>cal and commercial determiniants forward? Kickbusch 2012