Access <strong>to</strong> <strong>health</strong>employment conditions like income, job security, flexibility inworking hours, job <strong>and</strong> task control, <strong>and</strong> employment-relatedmigration.The effectiveness of regula<strong>to</strong>ry <strong>measures</strong>, employment <strong>and</strong>industrial relations policy, <strong>and</strong> worker safety legal frameworks– structural interventions that seek <strong>to</strong> prevent <strong>and</strong> mitigate <strong>the</strong>effects of employment <strong>and</strong> working conditions – should bemapped <strong>and</strong> analyzed 27 .The rapidly changing living environment: urban settingsThe rapid process of urbanization has seen an explosion of“slums” worldwide <strong>and</strong> more generally urban conditions oftennot conducive <strong>to</strong> <strong>health</strong>y living, ei<strong>the</strong>r through <strong>the</strong> physical,<strong>social</strong> or economic environment generated in such settings.Urban slums are characterized as unplanned informalsettlements where access <strong>to</strong> services is minimal-<strong>to</strong>nonexistent<strong>and</strong> where overcrowding is <strong>the</strong> norm. Urbansettings <strong>and</strong> in particular <strong>the</strong> <strong>health</strong> challenges of slumdwellersconstitute a vast <strong>and</strong> growing challenge, particularlyfor developing countries.Urban development has his<strong>to</strong>rically been seen as both acause <strong>and</strong> solution for <strong>social</strong> inequalities in <strong>health</strong>. However,<strong>social</strong> gradients in <strong>health</strong> within urban areas occureverywhere <strong>and</strong> are resistant <strong>to</strong> change. Urban environments,<strong>and</strong> <strong>the</strong>ir effect on <strong>health</strong>, are influenced by <strong>the</strong> degree <strong>and</strong>type of industrialization, availability of sanitary conditions,quality of housing, accessibility of green spaces <strong>and</strong> bytransport, an increasing concern. The urban setting is a lensthat magnifies or diminishes o<strong>the</strong>r <strong>social</strong> determinants of<strong>health</strong> <strong>and</strong> exposes different population groups in differentways <strong>to</strong> a whole variety of fac<strong>to</strong>rs conducive or o<strong>the</strong>rwise <strong>to</strong><strong>health</strong>. Interventions in <strong>the</strong> urban setting <strong>the</strong>refore imply <strong>the</strong>integration of actions simultaneously addressing a range of<strong>health</strong> determinants. Slum upgrading is an often-usedintervention <strong>to</strong> improve <strong>social</strong> <strong>and</strong> environmentaldeterminants of <strong>the</strong> urban poor. This usually includes:physical upgrading of housing, water <strong>and</strong> sanitation,infrastructure, <strong>and</strong> <strong>the</strong> environment; <strong>social</strong> upgrading throughimproved education; violence reduction programmes; betteraccess <strong>to</strong> <strong>and</strong> improved <strong>health</strong> services; governanceupgrading through participa<strong>to</strong>ry processes; communityleadership <strong>and</strong> empowering civil society through knowledge<strong>and</strong> information 27 .Globalization in <strong>the</strong> 21st centuryThe processes, <strong>and</strong> nature, of globalization may be regardedas <strong>the</strong> underpinning structural <strong>social</strong> determinant of <strong>health</strong><strong>and</strong> <strong>health</strong> equity. Global processes exert a powerful impactat all levels of <strong>the</strong> <strong>social</strong> production of <strong>health</strong>: on <strong>the</strong> evolutionof sociopolitical contexts in countries; on <strong>the</strong> nature <strong>and</strong>magnitude of <strong>social</strong> stratification; <strong>and</strong> on <strong>the</strong> configuration ofvarious specific determinants (e.g. working conditions, foodavailability). We see <strong>the</strong> global influence within countriesoperating both formally: multilateral institutions <strong>and</strong>processes of engagement, multilateral binding <strong>and</strong> nonbindingtreaties <strong>and</strong> agreements; <strong>and</strong> informally: culturalproduction, media <strong>and</strong> <strong>the</strong> collapse of “cognitive distance”between global population groups. Among <strong>the</strong> most relevantaspects of globalization on inequalities on <strong>health</strong>, withpotential for intervention, are: market access, trade barriers<strong>and</strong> liberalization, integration of production of goods,commercialization <strong>and</strong> privatization of public services, <strong>and</strong>changing lifestyle patterns.While recent years have seen a rapid expansion of interestin globalization <strong>and</strong> <strong>health</strong>, numerous important questionsremain inadequately explored. There is a need <strong>to</strong> identify <strong>and</strong>evaluate policy options through which national policy-makerscan respond <strong>to</strong> <strong>the</strong> challenges posed by globalization <strong>and</strong> alsocapitalize on its opportunities in a <strong>health</strong>-promoting way. It isnecessary <strong>to</strong> identify <strong>and</strong> characterize <strong>the</strong> degree of negativeor positive <strong>health</strong> impact of globalization in specific cases: no<strong>to</strong>nly <strong>to</strong> clarify relevant causal processes, but as a contribution<strong>to</strong> evaluating <strong>the</strong> impact of interventions <strong>and</strong> policies on o<strong>the</strong>r<strong>social</strong> determinants of <strong>health</strong> 27 .In conclusion, if <strong>the</strong> major determinants of <strong>health</strong> <strong>and</strong><strong>health</strong> equity are <strong>social</strong>, so must be <strong>the</strong> solutions. Areasrequiring research <strong>the</strong>n should be ones which address <strong>the</strong><strong>social</strong> fac<strong>to</strong>rs which influence <strong>the</strong> global inequities in <strong>health</strong>.Each of <strong>the</strong> nine <strong>the</strong>matic areas for research <strong>and</strong>intervention, identified by <strong>the</strong> Commission on SocialDeterminants of Health, is relevant in all countries. Suchresearch should seek <strong>to</strong> highlight <strong>the</strong> transferability ofknowledge, elucidate <strong>the</strong> conditions, processes <strong>and</strong> ac<strong>to</strong>rsnecessary for effective intervention, <strong>and</strong> in a systematicmanner compile a knowledge base which will underpinaction <strong>to</strong> improve <strong>health</strong>, reduce <strong>the</strong> <strong>health</strong> gap <strong>and</strong> redress<strong>the</strong> <strong>health</strong> gradient. ❏Sharon Friel is a <strong>social</strong> <strong>and</strong> nutritional epidemiologist <strong>and</strong> hasworked in <strong>the</strong> area of public <strong>health</strong> nutrition <strong>and</strong> inequalities in<strong>health</strong> since 1992. She is currently <strong>the</strong> Principal Research Fellowfor <strong>the</strong> global Commission on Social Determinants of Health, basedat <strong>the</strong> International Institute for Society <strong>and</strong> Health, UniversityCollege London. She is also a Fellow at <strong>the</strong> National Centre forEpidemiology <strong>and</strong> Population Health, Australian NationalUniversity, Canberra, Australia, where she is currently working asconsultant <strong>to</strong> <strong>the</strong> World Cancer Research Fund diet <strong>and</strong> cancerpolicy report. Prior <strong>to</strong> this Dr Friel worked for many years in <strong>the</strong>Department of Health Promotion, National University of Irel<strong>and</strong>,Galway, as well as being Chair of <strong>the</strong> Irish Health PromotionAssociation for four years. Much of her work is concerned with <strong>the</strong>interface between research, policy <strong>and</strong> practice in matters relating<strong>to</strong> international <strong>and</strong> national level <strong>social</strong> determinants ofinequalities in <strong>health</strong>, in particular those relating <strong>to</strong> diet.Ruth Bell is a Senior Research Fellow in <strong>the</strong> Department ofEpidemiology <strong>and</strong> Public Health at University College London, workingwith <strong>the</strong> global Commission on Social Determinants of Health. Shehas previously worked as a consultant <strong>to</strong> <strong>the</strong> Nuffield Foundation <strong>and</strong><strong>the</strong> King’s Fund. Dr Bell’s early research career at <strong>the</strong> University ofFreiburg, Germany <strong>and</strong> <strong>the</strong> Institute of Cancer Research, RoyalMarsden Hospital, London was in <strong>the</strong> area of cancer causation.Tanja AJ Houweling is a <strong>social</strong> epidemiologist (MSc) <strong>and</strong> medicalanthropologist/sociologist (MA) <strong>and</strong> has worked in <strong>the</strong> area of<strong>social</strong> inequalities in <strong>health</strong> since 2000. Currently, she works as052 ✜ Global Forum Update on Research for Health Volume 4
Access <strong>to</strong> <strong>health</strong>Senior Research Fellow for <strong>the</strong> global Commission on SocialDeterminants of Health, based at <strong>the</strong> International Institute forSociety <strong>and</strong> Health, University College London. Prior <strong>to</strong> this, DrHouweling worked at <strong>the</strong> Department of Public Health atErasmusMC University Medical Center Rotterdam, <strong>the</strong> Ne<strong>the</strong>rl<strong>and</strong>s,where she did research on socio-economic inequalities in <strong>health</strong>, inparticular in low- <strong>and</strong> middle-income countries. She was alsoinvolved in a study on <strong>health</strong> inequalities for <strong>the</strong> World Bank <strong>and</strong> ina technical consultation on <strong>health</strong> inequalities at World HealthOrganization (WHO) Geneva, Switzerl<strong>and</strong>. She obtained her PhDdegree in September 2007 at Erasmus University Rotterdam, on astudy on socio-economic inequalities in childhood mortality in low<strong>and</strong>middle-income countries.Sebastian Taylor is a Senior Research Fellow for <strong>the</strong> globalCommission on Social Determinants of Health, based at <strong>the</strong>Institute for International Society <strong>and</strong> Health, University CollegeLondon. Since 1992, much of his work has been in designing,managing <strong>and</strong> evaluating complex humanitarian <strong>and</strong>developmental programmes. He has worked extensively in China,Laos, India, Pakistan, Nigeria, Egypt <strong>and</strong> Somalia. With a growingfocus on <strong>health</strong> action in resource-poor settings, Dr Taylor workedwith <strong>the</strong> Polio Eradication Initiative from 2002 <strong>to</strong> 2004, <strong>and</strong>retains strong research interests in both <strong>the</strong> politics of large-scale<strong>health</strong> interventions, <strong>and</strong> <strong>the</strong> political economy of policy-making inglobal <strong>and</strong> multilateral aid agencies.References1.Sachs J. Macroeconomics <strong>and</strong> Health: Investing in Health for EconomicDevelopment, 2001. Commission on Macroeconomics <strong>and</strong> Health.Geneva: World Health Organization.2.Dwyer J. Global <strong>health</strong> <strong>and</strong> justice. Bioethics, 2005, 19 (5-6): 460-75.3.Global Forum for Health Research. The 10/90 Report on Health Research2003–2004, 2004. Geneva: Global Forum for Health Research.4.Labonte R, Schrecker T, Gupta A. Health for some: death, disease <strong>and</strong>disparity in a globalising era, 2005. Toron<strong>to</strong>: Centre for Social Justice.5.Baum F. Who cares about <strong>health</strong> for all in <strong>the</strong> 21st century? Journal ofEpidemiology <strong>and</strong> Community Health, 59 (9): 714-715, 2005.6.Wilkinson R, Pickett K. Income inequality <strong>and</strong> <strong>health</strong>: a review <strong>and</strong>explanation of <strong>the</strong> evidence, 2005.7.Ebrahim S, Smeeth L. Non-communicable diseases in low <strong>and</strong> middleincomecountries: a priority or a distraction? International Journal ofEpidemiology, 2005, 34 (5): 961-966.8.Choi BCK et al. Diseases of comfort: primary cause of death in <strong>the</strong> 22ndcentury. Journal of Epidemiology <strong>and</strong> Community Health, 2005, 59 (12):1030-1034.9.Ezzati M et al. Comparative Quantification of Health Risks: Global <strong>and</strong>Regional Burden of Disease Attributable <strong>to</strong> Selected Major Risk Fac<strong>to</strong>rs,2004. Geneva: World Health Organization.10.Gwatkin D, Wagstaff A, Yazbeck A. Reaching <strong>the</strong> poor with <strong>health</strong>,nutrition <strong>and</strong> population services, 2005. Washing<strong>to</strong>n DC: The WorldBank.11.Global Fund. The Global Fund <strong>to</strong> fight AIDS, tuberculosis <strong>and</strong> malaria.12.WHO. WHO 3 by 5 initiative.13.WHO. Roll back malaria partnership.14.United Nations. Millennium Development Goals, 2000.15.Monden C. Current <strong>and</strong> lifetime exposure <strong>to</strong> working conditions. Do <strong>the</strong>yexplain educational differences in subjective <strong>health</strong>? Social Science &Medicine, 2005, 60: 2465-2476.16.Bartley M. Job insecurity <strong>and</strong> its effect on <strong>health</strong>. Journal of Epidemiology<strong>and</strong> Community Health, 2005, 59 (9): 718-719.17.Marmot M, Brunner E. Cohort Profile: The Whitehall II study.International Journal of Epidemiology, 2005, 34 (2): 251-256.18.Christensen C. World hunger: A structural approach. InternationalOrganization, 2002, 32 (3): 745-774.19.Marmot MG. Tackling <strong>health</strong> inequalities since <strong>the</strong> Acheson Inquiry. JEpidemiol Community Health 58 (4): 262-263, 2004.20.Alvarez-Dardet C, Ash<strong>to</strong>n JR. Inequalities goes global. Journal ofEpidemiology <strong>and</strong> Community Health, 2004, 58 (4): 261-.21.Ostlin P, Braveman P, Dachs N. Priorities for research <strong>to</strong> take forward <strong>the</strong><strong>health</strong> equity policy agenda. Bulletin of <strong>the</strong> World Health Organization,2005, 83 (12): 948-53.22.Marmot M, Wilkinson R. Social Determinants of Health (2nd ed.), 2005.Oxford: Oxford University Press.23.Marmot M. Social determinants of <strong>health</strong> inequalities. The Lancet, 2005,365: 1099-1104.24.Jong-wook L. Public <strong>health</strong> is a <strong>social</strong> issue. The Lancet, 2005, 365:1005-1006.25.Pang T. Filling <strong>the</strong> gap between knowing <strong>and</strong> doing. Nature, 2003,426:383.26.Pang T, Gray M, Evans T. A 15th gr<strong>and</strong> challenge for global public <strong>health</strong>.The Lancet, 2006, 367 (9507): 284-286.27.Solar O, Irwin A. Towards a Conceptual Framework for Analysis <strong>and</strong>Action on <strong>the</strong> Social Determinants of Health, 2005. Geneva:Commission on <strong>the</strong> Social Determinants of Health.Global Forum Update on Research for Health Volume 4 ✜ 053
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