by Marion Nestle
Mar 2 2017

Don’t we need a millennium development goal for social rank?

Yes, says Martin Tobias’s must-read commentary in The Lancet.

The commentary cites a paper in the same issue arguing that low social rank, meaning “powerless to determine your own destiny, deprived of material resources, and limited in the opportunities open to you,” has a profound effect on lifestyle and life chances.  Its authors base these views on a study of 1·7 million adults followed up for mortality (all cause and by cause) for an average of 13 years.

Even with use of a crude categorisation of social rank based on occupation (professional, intermediate, and unskilled), the study was able to quantify the social gradient in mortality: an approximately 20% increase in risk per unit decrease in rank.

Tobias’ commentary recommends evidence-based strategies to minimize the impact of social hierarchy on health:

Invest in children

  • Early childhood development enrichment programs

  • Intensive parent support (home visiting) programs

  • Enrollment of all children in early childhood education

Get the welfare mix right

  • Regulate markets as necessary

  • Implement income transfer policies that redistribute resources (ie, progressive tax and benefit regimes)

  • Optimize balance between targeted and universal social protection policies through benefit design that minimizes both undercoverage and leakage

  • Eliminate child poverty through monetary and non-monetary support for families with dependent children

Provide a safety net

  • Provide income support or tax credits

  • Provide social housing

  • Subsidize childcare

  • Provide free access to health care (especially preventive services)

Implement active labor market policies

  • Provide job enrichment programs

  • Democratize the workplace (involve employees in decision making)

  • Provide career development and on-the-job training

  • Provide fair financial compensation and intrinsic rewards

  • Promote job security

  • Discourage casualization of the workforce

Strengthen local communities

  • Foster regional economic development

  • Promote community development and empowerment

  • Encourage civic participation

  • Create mixed communities with health-enhancing facilities

Provide wrap-around services for the multiply disadvantaged

  • Coordinate services across government and NGOs

  • Provide intensive case management when necessary

  • Foster engagement of the targeted families and individuals

Promote healthy lifestyles

  • Strengthen tobacco control and addiction services

  • Improve the diet of poor families (eg, through subsidizing fruit and vegetables, community gardens, purchasing co-ops, school meals)

  • Provide green space and subsidized sport and recreation facilities

Ensure universal access to high quality primary health care

  • Subsidize practices serving high need populations

  • Provide additional nursing and social worker support for practices in disadvantaged areas

  • Assist patients with clinic transport and childcare

  • Provide services free at point of use

  • Provide conditional cash transfers (to increase demand for clinical preventive services)

The paper is open access.  Spread it around.  Pick the recommendation you think most important, and get to work!

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