Health Protection Inequalities:

A European Perspective

Jan C. SemenzaEuropean Centre for Disease Prevention and Control

Social inequalities in health

Source: National strategy to reduce social inequalities in health, Norwegian Ministry of Health and Care Services, 2007

Susceptible

Population

(S)

Infected

Population

(I)

Deaths

Recovered

Population

(R)

The impact of economic crises on communicable disease control

Infection Rate

Removal Rate

Determinants

Suhrcke M, et al., PLoS ONE. 2011; 6(6): e20724

Susceptible

Population

(S)

Infected

Population

(I)

Deaths

Recovered

Population

(R)

The impact of economic crises on communicable disease control

Infection RateDirect•Person to person•Overcrowding (prisons) •Mixing environments (shelters)•High risk pop (homeless)

Indirect•Common Vehicle•Infrastructure breakdown (water treatment)•Vector •Contact rates (TBE)•Vector pop (rodent and mosquitoes)

Removal Rate

•Treatment•Doctors •Access to drugs

•Nutrition•Immunitysystem•Immunization coverage

Determinants

Suhrcke M, et al., PLoS ONE. 2011; 6(6): e20724

Tuberculosis control and economic recession

Reeves A, Bulletin of the World Health Organization. 2015;93(6):369-79

Intervening on health inequalities of infectious diseases

Three intervention approaches:

1) The population-at-risk approach

2) The population-based approach

3) The vulnerable population approach

1) The population-at-risk approach

Public health interventions should focus on that segment of the population with the highest level of risk exposure as indicated by health risk behaviorsor biological markers.

For example, the homeless, a group at very high risk for TB.

Lalonde MA. A new perspective on the health of Canadians, 1974.

1) The population-at-risk approach

Semenza JC. Euro Surveill. 2010;15(27):32-9.

Mean effect Level of (single) risk

Afterintervention

Benefits after intervention

Beforeintervention

Intervening on TB

Inequality gradient of tuberculosis in the EU

20

TB p

reva

lence

/100,0

00 p

opula

tion

140

120

100

80

60

40

2,000 6,000 10,0000 14,000

R2 = 0.69

Public wealth index: GDP/income inequality

≤ 10%

25%

50%

75%

100%

Percentage of national TB cases that were foreign-born is related to the size of the circle

Suk JE et al., Emerg Infect Dis. 2009;15(11):1812-4.

2) The population-based approach

Mass environmental control methods and interventions that attempt to alter some of society’s norms.

For example, public smoking bans; water treatment and distribution systems; safe sex education; or cervical cancer screening.

Rose G. The strategy for preventive medicine. Oxford, 1992

2) The population-based approach

Mean effect Level of risks

Beforeintervention

Afterintervention

Semenza JC. Euro Surveill. 2010;15(27):32-9.

2) Socio-economic indicators and cervical cancer

Human Development Index

SD

R c

erv

ical ca

nce

rw

om

en <

64 y

rs

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

0.800 0.820 0.840 0.860 0.880 0.900 0.920 0.940 0.960 0.980

Franceschi S, et al., Int J Cancer. 2011;128(12):2765-74

2) Socio-economic indicators, cervical cancer and HPV vaccination

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

0.800 0.850 0.900 0.950 1.000

Human Development Index

SD

R c

erv

ical ca

nce

rw

om

en <

64 y

rs

HPV programme not implemented HPV programme implemented

Franceschi S, et al., Int J Cancer. 2011;128(12):2765-74

2) The population-based approach

Mean effect Level of risks

Beforeintervention

Afterintervention

Concentration of risksConcentration of

benefits

Semenza JC. Euro Surveill. 2010;15(27):32-9.

3) The vulnerable population approach

Vulnerable groups share social characteristics that put them at risk for multiple risks. Because of their position in the social strata they are commonly exposed to contextual conditions that distinguish them from the rest of the population.

Low socio economic status is the risk that generates the exposure to other risks, such as smoking, drug use, high risk sexual behavior, etc.

For example, occupational training and educational opportunities for the unemployed

Frohlich KL, Potvin L, AJPH 2008; 98(2):216-221

Afterintervention

3) The vulnerable population approach

Mean effect Level of (multiple) risks

Beforeintervention

BenefitsMinimal benefits

Semenza JC. Euro Surveill. 2010;15(27):32-9.

3) The vulnerable population approach

EmploymentWages,

unemployment

Faith or religion

Guiding, ruling

EconomicsCommunity,

personal

Family structuresFunctional,

dysfunctional

Support networksFriends, family

CultureValues,

traditions

Social factorsCommunity expectations

Social structures

Laws, politics

Social relationships

Relating to others,peer influence

Social view of health

Adapted from: Mosel-Williams L. Health, Life and Living: Book Two. Harcourt Education Australia, 1999.

Reeves et al., Lancet Infect Dis. 2014;14(11):1105-12

Reeves et al., Lancet Infect Dis. 2014;14(11):1105-12

Social protection spending and TB

Reeves et al., Lancet Infect Dis. 2014;14(11):1105-12

Social protection spending and TB

Reeves et al., Lancet Infect Dis. 2014;14(11):1105-12

Social protection spending and TB

Reeves et al., Lancet Infect Dis. 2014;14(11):1105-12

Summary

• Certain high-risk groups in society, including the poor, migrants, homeless persons, and prison populations suffer disproportionally from infectious diseases in Europe.

• This situation is exacerbated during situations of economic duress.

• Comprehensive interventions should be devised to reduce health inequalities and to avoid unintended consequences.

Jan.Semenza@ecdc.europa.eu