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Minutes: Sixteenth Meeting: December 11, 2009


Secretary’s Advisory Committee on 
National Health Promotion and Disease Prevention Objectives for 2020

Social and Physical Environmental Determinants, Committee Work in the Coming Year
Via WebEx

Sixteenth Meeting: December 11, 2009

Committee Recommendations (Approved by Vote)

  • No formal votes were taken during the meeting.

Next Steps

  • Dr. Marmot indicated that, within the limits of his available time, he would be willing to review a Committee document on social determinants of health.
  • ODPHP requested the Committee’s guidance in identifying criteria that could be used to select social determinants of health measures for inclusion in a set of Leading Health Indicators (LHIs).
  • The Subcommittee on Priorities will produce materials on how to use factors, such as preventable burden, preventable fraction, preventable years of life lost, to identify priorities.
  • The Committee may produce a derivative paper based on the priority-setting materials that are submitted by the Subcommittee on Priorities.
  • The Subcommittees will continue to provide guidance to the HHS Secretary in the coming months in response to the following specific questions/charges.
    • Subcommittee on Communications: How should the public be educated about the importance of inequalities in social determinants of health?
    • Subcommittee on Implementation: How can an ecological approach to health improvement be operationalized?
    • Subcommittee on Priorities: What guidance should be used to select measures, particularly LHIs?
    • Subcommittee on Data and IT: Offer guidance on development of the relational database.
    • Ad Hoc Group on Social Determinants: What examples can be used to illustrate the social determinants of health? How can the pubic be educated about this approach? How should objectives related to social determinants of health be selected?
    • Subcommittee on Evidence: How should evidence-based action steps to achieve targets for objectives be selected?
  • Subcommittees will complete their draft recommendations for review and voting at the next meeting.
  • NORC will follow-up with Committee members to schedule upcoming subcommittee and Web-based Committee meetings; a meeting of the full Committee is planned for March of 2010.

I. Welcome and Desired Outcomes of the Meeting

Dr. Jonathan Fielding, Chair of the Secretary’s Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2020 (the Committee), welcomed participants. He thanked Sir Michael Marmot, professor of Epidemiology and Public Health at University College London, for taking time to speak with the Committee. Dr. Fielding explained that the primary focus of the meeting would be on social determinants of health. The Committee would discuss how this approach can be operationalized and integrated into Healthy People 2020. The meeting would also cover logistical issues and an update on HHS progress in developing Healthy People objectives. The Committee would talk about recent progress and challenges in the subcommittees’ work, as well as a list of tasks feasible to accomplish in the coming months.

II. Social Determinants of Health

Dr. Fielding introduced Dr. Marmot, whose expertise as the Chair of the World Health Organization (WHO) Commission on Social Determinants of Health would be very useful to the Committee. Dr. Fielding explained that the Committee had been discussing the central role of social determinants of health for the past two years. Recently, the Committee had explored the question of how to help the U.S. Department of Health and Human Services (HHS) offer concrete guidance to users of Healthy People 2020 on taking action to address social determinants of health.

Dr. Marmot said that, in 2003, the World Health Organization (WHO) was active in disease control programs and health systems, but was not taking action on social determinants of health. Then-Director-General J.W. Lee accepted that social determinants of health were important to an equity perspective on health; he established the WHO Commission on Social Determinants of Health (chaired by Dr. Marmot). The Commission had a clear set of values that began with social justice; they argued on moral, not economic, grounds for taking action on social determinants of health. The Commission emphasized: the conditions in which people are born, grow, live, work and age; structural drivers of those conditions at the global, national, and local levels; and the importance of monitoring, training, research of capacity development. Their report included recommendations on early child development in education, healthy places, employment and social protection. Health care was addressed as only one of several vitally important influences on health.

Addressing uses of Health Impact Assessment (HIA), Dr. Marmot said the Commission has emphasized conducting not just HIA, but health equity impact assessment. HIA often looks at population averages, but even if average health status improves over time, the distribution of health may not. The Commission has emphasized health equity and determinants. The Commission published a paper comparing medical care expenditures in the U.S. and the U.K.; the U.S. spends two and a half times as much per capita on health care. Yet, comparing seven health conditions in both countries, the U.S. had more disease. These differences were not due to access to medical care.

Dr. Marmot’s second message was that health inequities are about not just the poor, but the social gradient. He showed U.S. data looking at life expectancy at age 25 by education. Those with more years of education have a longer life expectancy. Policy-makers often focus resources where the problem is greatest—with the poorest populations. He argued that health disparities cannot be effectively addressed in this way, due to the social gradient: those in the second tertile from the bottom have worse health than those in the third tertile from the bottom. It is possible to change the slope of the gradient, but doing so requires concerted action.

Dr. Marmot discussed strategies to persuade elected officials of the importance of social determinants of health. At an international meeting in London to launch the WHO report, Prime Minister Gordon Brown had announced that Dr. Marmot would undertake a similar review of health inequality in England to recommend strategies for tackling health inequalities. Dr. Marmot met with the Secretary of State for Health about this review and said to the health minister that he would need to reach out to other cabinet secretaries to address health inequities; he had an important role to play in providing leadership at the cabinet level.