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Analysis Solutions for Prevention and Control of Non-communicable Diseases

Social determinants and non-communicable diseases: time for integrated action

BMJ 2019; 364 doi: (Published 28 January 2019) Cite this as: BMJ 2019;364:l251
  1. Michael Marmot, professor,
  2. Ruth Bell, principal research fellow
  1. Institute of Health Equity, University College London, London, UK
  1. Correspondence to M Marmot m.marmot{at}

A whole systems approach that integrates action on the social determinants of health is essential to reduce the burden of non-communicable disease, argue Michael Marmot and Ruth Bell

In high income countries, life expectancy and healthy life expectancy are linked in a graded way with measures of socioeconomic disadvantage.1 The major contributors to the social gradient in health outcomes are non-communicable diseases (NCDs). Increasingly, in middle income countries, evidence shows that NCDs follow the same gradient of higher risk in people of lower socioeconomic status.234 The example of obesity suggests that as low income countries develop, NCDs will follow the social gradient seen in middle and high income countries.56

Control of NCDs requires integrated action across all major areas of society that influence health. Yet system-wide efforts to improve the social determinants of health, such as early childhood education and parenting skills, education and lifelong learning, working and employment conditions, poverty reduction and ensuring a healthy standard of living, housing and the environment, and prevention of ill health, are yet to take root in many parts of the world.

The argument for integrated action rests on evidence compiled by the World Health Organization Commission on Social Determinants of Health. Social determinants are responsible for the pattern of distribution of disability and mortality from NCDs.7 Simply stated, social determinants encompass the “causes of the causes” of health inequality: the unequal conditions in which people are born, grow, live, work, and age; and the inequities in power, money, and resources that give rise to them.7 These unequal conditions depend on dimensions of social stratification, including socioeconomic status, gender, ethnicity, and disability.

Pathways of action

This article focuses predominantly on risks targeted by the WHO NCD prevention strategy and shows how social determinants shape the prevalence and distribution …

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