The Social Medicine Portal

Unofficial Synopsis of the Social Determinants of Health Report

A number of people have requested a brief synopsis of the final report by the WHO Commission on the Social Determinants of Health (discussed in our posting of 9/1/2008). David Woodward (formerly with the New Economics Foundation) has prepared an unofficial synopsis that is shorter and, he promises us, more interesting that the Executive Summary (we agree). We reproduce his synopsis in this posting.

We also note that the report has been the subject of editorials in the British Medical Journal and the Lancet. It was not mentioned in 8/27 and 9/3/08 editions of JAMA or in the 8/28 and 9/4/08 editions of the New England Journal of Medicine.

From: “David Woodward” <David.Woodward@neweconomics.org>
Subject: Commission on Social Determinants of Health - a Golden Opportunity!

As is well known by now, the Commission on Social Determinants of Health has finally published its report, which can be downloaded at http://www.who.int/social_determinants/final_report/csdh_finalreport_2008.pdf. There is a great deal of very valuable material in it not only on health systems and policies, but also on economic policies, globalisation and global governance. Unfortunately, this is played down in the Executive Summary, limited in the recommendations it makes, and virtually absent from the official WHO press release - and consequently from all of the media coverage we’ve seen so far.

To redress the balance, we are attaching a (wholly unofficial) “synopsis”, drawing together and summarising what the main text of the report says in a number of key areas. (Take it from us, it is much more interesting than the Executive Summary!) Anything anyone can do to highlight these aspects of the report would be invaluable - it has some of the best ammunition we’ve had for years!

Part 1: What the Report of the Commission on Social Determinants of Health says about:

Health Care

Other Health-Related Services

Economic Models of Development

Markets and the Corporate Sector

Employment and Livelihoods

Social Protection

While the Commission makes a number of specific recommendations, these are constrained by its mandate, and as a result do not include many suggestions and proposals included in the body of the report, or address specific issues which are clearly identified as necessary if the Commission’s objective of “closing the gap in a generation” is to be fulfilled. At the same time, because of the very complex and inter-connected nature of influences on the social determinants of health, material relevant to a number of key issues is spread across several sections of the report. The following is an attempt to draw the material in the report together, in summary form, under a number of thematic headings, highlighting the Commission’s suggestions and proposals, and the specific needs it identifies, as well as its formal recommendations.

It should be emphasized that this synopsis has no official status, that it has been compiled entirely independently of the Commission and its secretariat, and that it should in no way be attributed to them. While the contents are intended to reflect what the report says on each subject, some selectivity has been inevitable, and the emphasis undoubtedly reflects the priorities of the writer.

Health Care

The Commission is strongly critical of recent health-sector reforms, which it sees as a product of broader economic influences and driven by international agencies, commercial actors, and medical groups. These reforms have resulted in health care becoming increasingly commodified, commercialised and fragmented, and promoted a narrow technical/medical focus. This has undermined the development of comprehensive primary health care, and generated a stark and growing divide between over- and under-consumption of health-care services between the rich and the poor worldwide.

Health-care systems should be designed and financed to ensure equitable, universal coverage and access, allowing everyone who needs health services to use quality services, with adequate human resources. Health systems should be based on the primary health-care model, combining locally organised action on the social determinants of health with strengthened primary care, and should focus at least as much on prevention and health promotion as on treatment. Where universal services cannot be achieved immediately, services disproportionately benefiting disadvantaged groups may be prioritised in the short term. User charges for health services are unacceptable, and health care should be financed from general taxation or mandatory insurance, minimising out-of pocket spending. Intended beneficiary groups should be included in all aspects of policy and programme development, implementation, and evaluation.

The report also criticises the IMF’s Medium-Term Expenditure Framework (MTEF) as prioritising very low inflation and conservative fiscal policy over poverty and health needs, leading to underinvestment in the human capacity critical for health-care systems; and it warns that global health initiatives may skew priorities and exacerbate human resource scarcity. Investment in medical and health personnel should be increased, and efforts made to balance health-worker density in rural and urban areas, for example, through use of community health workers.

Other Health-Related Services

Education, quality housing, clean water and sanitation, as well as health and health-care, are human rights. The report condemns commercialisation of health services and education, which should be governed by the public sector. The state also has a clear responsibility to ensure access to water and sanitation, which is essential to life, and wholesesale privatisation of water should be discouraged. Access to clean water should not be limited by ability to pay, and cross-subsidies should be used where cost recovery is necessary.

Economic Models of Development

The development model pursued since the 1980s has been the target of a great deal of deserved criticism. Structural adjustment had a severe adverse impact on key social determinants of health across most participating countries; and market-oriented economic policies have contributed to the dispersion of regional performances in life expectancy. It is not clear that such policies produced the anticipated benefits, or that the health and social costs were justified. The over-reliance of these programmes on markets to solve social problems has proved damaging; and they have limited investment in infrastructure and human resources, reducing state capacity. There is growing demand for a new approach to social development, moving beyond an overriding focus on economic growth to look at building well-being through a combination of growth and empowerment.

The Commission finds that the relationships among globalisation, growth, and poverty reduction are deeply problematic, noting widespread challenges to he view that economic growth alone can provide a solution to global poverty, and the decline in the income share of the poorest 20% of the population in many countries over the last 15 years. Without appropriate social policies, economic growth brings little benefit to health or health equity. Progress towards health equity requires addressing economic inequality, including inequity in public financing, and the evidence suggests that income redistribution is a more efficient means of reducing poverty. Systems should be built to ensure that no-one’s income falls below a minimum healthy level.

The role of governments through public sector action is fundamental to health equity, and the State has a responsibility to guarantee a comprehensive set of rights and ensure fair distribution among population groups. An empowered public sector, based on principles of justice, participation and inter-sectoral collaboration, is needed to underpin action on the social determinants of health and health equity. This requires strengthening the core functions of government and public institutions, nationally and sub-nationally.

Policy coherence and inter-sectoral action for health - “health in all policies” - are essential, and renewed government leadership is urgently needed to balance public and private sector interests.

Markets and the Corporate Sector

While recognising the potential benefits of markets to health, the Commission also highlights their adverse effects, including economic inequality, resource depletion, pollution, unhealthy working conditions, and increased consumption of dangerous and unhealthy goods. Even where goods and services can be efficiently and equitably provided through the private sector, government regulation is vital, and efforts are needed to ensure that private sector activities and services (eg production and patenting of medicines, and health insurance) contribute to health equity rather than undermining it.

The impact of voluntary initiatives on corporate behaviour is inevitably limited, and “corporate responsibility” is often little more than cosmetic, lacks enforcement, and entails little evaluation. Corporate *accountability*may provide a better means of ensuring positive effects of business activities. The Commission suggests disclosure standards for companies on where products have been produced and with what employment standards. Consideration could also be given to internationally coordinated changes to company law, to require publicly quoted companies to pursue a broader set of social and environmental objectives rather than maximising shareholder value.

Employment and Livelihoods

The Commission condemns inequitable, exploitative, unhealthy and dangerous working conditions, and calls for employment conditions conducive to well-being, including safe, secure and fairly paid work, year-round work opportunities, and healthy work-life balance for all, with effective worker protection and measures to reduce stress and exposure to material hazards.

Fair employment and decent work should be a central focus of development strategies, and economic and social policies should provide secure work and a living wage, taking in line with the cost of health needs. Full employment requires integrated economic and social policies, including employment generation, eg through public works, local procurement policies, income-generation and support to small, medium and micro enterprises.

The Commission calls for progressive fulfillment of global labour standards. While standards should be graduated, recognising the lower standards developing countries are able to achieve, there should be progressive upward convergence of standards over time. The starting point should be the four core principles - freedom of association and the right to collective bargaining; freedom from forced labour; the effective abolition of child labour; and non-discrimination in employment. Child labour can be reduced by increasing poor households’ income and ensuring quality schooling. The state should guarantee the right to collective action among formal and informal workers.

The Commission supports progressive development and implementation of binding codes of practice in relation to labour and occupational health and safety (OHS). Mechanisms should also be explored to create cross-country wage agreements, initially at a regional level.

Government policy and legislative support are required to rebalance work and private life, providing parents the right to time to look after children, access to childcare regardless of ability to pay, flexible working hours, paid holidays, parental leave, job share, and long-service leave. Encouragement could be given to shorter working hours in high-income countries. Government policy and legislation are also needed to create more security in different working arrangements.

Efforts should be made to improve working conditions in the informal sector as part of a coherent economic and social policy including social protection, education, and public sector strengthening. OHS policy and programmes should be applied to all workers, and should be extended to include work-related stress and harmful behaviours. OHS components should be included in employment creation programmes, and in regulation of subcontracting and outsourcing.

The Commission emphasises that changes in the operation of the global economy are necessary for its recommendations on employment to be implemented. (See *Globalisation* in part 2.)

Social Protection

Social protection should be provided to all people across the lifecourse, and should include unemployment, sickness, and disability benefits and social pensions. Universal (rather than targeted) approaches are important for dignity and self-respect, can enhance social cohesion and social inclusion, and may be more politically acceptable. Governments should build towards universal social protection systems, increasing the generosity of benefits over time towards a level that is sufficient for healthy living, and gradually protecting against a more comprehensive set of risks. Targeting should be used only as a back-up for those who slip through the net of universal systems.

A concerted effort is needed to develop realistic solutions to social protection of migrants, asylum seekers and refugees. Attention should also be given to the needs of people with disabilities, including fighting discrimination by employers

In developing countries, social protection should be embedded in Poverty Reduction Strategies. Social protection systems can be developed gradually through pilot projects, successful pilots being rolled out nationally, starting with the most deprived regions. Donors and international organisations have an important role to play in building capacity for social protection.

As for employment, the Commission emphasises that changes in the operation of the global economy are necessary for its recommendations on social protection to be implemented. (See Globalisation in part 2.)

Part 2: What the Report of the Commission on Social Determinants of Health says
about:

Financing
Globalisation
Global Governance

While the Commission makes a number of specific recommendations, these are constrained by its mandate, and as a result do not include many suggestions and proposals included in the body of the report, or address specific issues which are clearly identified as necessary if the Commission’s objective of “closing the gap in a generation” is to be fulfilled. At the same time, because of the very complex and inter-connected nature of influences on the social determinants of health, material relevant to a number of key issues is spread across several sections of the report. The following is an attempt to draw the material in the report together, in summary form, under a number of thematic headings, highlighting the Commission’s suggestions and proposals, and the specific needs it identifies, as well as its formal recommendations.

It should be emphasized that this synopsis has no official status, that it has been compiled entirely independently of the Commission and its secretariat, and that it should in no way be attributed to them. While the contents are intended to reflect what the report says on each subject, some selectivity has been inevitable, and the emphasis undoubtedly reflects the priorities of the writer.

Financing

The Commission calls for increased public finance for programmes and policies to support the social determinants of health, including child development, education, improved living and working conditions and health care, recognising the failure of markets to supply vital goods and services equitably. It also calls for a fair allocation of the costs of action on the social determinants of health, both geographically and across social groups, through progressive taxation at the national level, a major increase in aid, improved aid quality and greater debt cancellation.

Tax systems should be progressive, and focus on direct rather than indirect taxation; and mechanisms should be established to ensure that available tax funding is allocated between populations and areas according to need. This requires strengthening tax systems and capacities in many developing countries.

The Commission finds current levels of aid “grossly inadequate”, and the net financial outflow from many developing countries to richer countries “alarming”. It identifies a “trust deficit” between donors and recipients, leading to multiple and onerous conditions which increase transaction costs, strain recipient countries’ often weak administrative capacity, and constrain their freedom to determine their own developmental and financing priorities. It also highlights problems arising from the volatility and unpredictability of aid flows.

It calls on donor countries to honour existing commitments by increasing aid to 0.7% of GDP, to establish predictable long-term funding mechanisms, to increase aid quality, to reduce tied aid, to increase budgetary support, to align aid with recipient countries’ own development plans, to increase aid for health (particularly the social determinants of health), and to coordinate aid use through a social determinants of health framework

The Commission identifies a need for new multilateral institutions for an expanded, reliable and more coherent system of global aid. Greater emphasis should be placed on globally pooled funds, multilaterally managed and transparently governed, multi-year stability of donor inputs, and the determination of recipients’ eligibility and allocations according to agreed needs and developmental objectives.

The PRSP process has been “something of a missed opportunity”, and appears to have had an adverse impact on national policy space and public spending on education and health care. The PRSP process should emphasise more explicitly that it is a process of national cross-sectoral coherence in decision-making. Donors and national governments should provide more funding for cross-sectoral work on the social determinants of health; more support should be provided to Health Ministries in their engagement with Ministries of Finance; and Medium-Term Expenditure Frameworks should be more flexible, to allow key recurrent costs to be met.

An urgent need exists for more debt relief, deployed more effectively in support of social determinants of health, as the considerable weight of remaining debt continues to draw public resources away from developmental investments. The Multilateral Debt Relief Initiative should be strengthened and extended; and there have been calls for a more balanced approach to debt cancellation and independent arbitration. Consideration of indebtedness should expand the focus from narrow indicators of economic sustainability towards a broader concept of ‘debt responsibility’, including broader measures of economic vulnerability, and legislative scrutiny of government borrowing and lending.

Efforts should be made to ensure that increases in aid and debt relief support coherent policy-making and action by recipient governments on the social determinants of health, and performance indicators of health equity and social determinants of health should be core conditions of recipient accountability.

Globalisation

While the Commission sees potential benefits in globalisation, the process has been inherently disequalising, concentrating benefits among the better off and negative effects among the poor. It criticises various aspects of the recent process of globalisation, market integration and liberalization throughout the report as increasing inequity in health between and within countries; increasing the cost of life-saving drugs; damaging food security; undermining the ability of governments to collect taxes though tariff reduction and tax competition; adversely affecting labour and working conditions and increasing job insecurity; contributing to the double burden on women of paid and domestic work; increasing the frequency of financial crises; intensifying the commodification and commercialisation of water, health care, and electrical power; severely diminishing the role of the public sector in regulation for health; increasing the availability and consumption of health-damaging products; and encouraging unhealthy diets.

The Commission emphasises the necessity of changes in the operation of the global economy and international institutions, including WTO, IMF and World Bank, for its recommendations on employment and social protection to be implemented. While it notes that the the design of a new international economic order is beyond its mandate, it stresses the need for urgency and innovation to integrate health, development and environmental concerns.

The Commission sees an urgent need for a global economic system which supports renewed government leadership to balance public and private sector interests, and identifies quantifying the impact of supra-national political, economic, and social systems on health and health inequities within and between countries as an important research need. It also proposes that international legislative standards for rich country business relations with low- and middle-income trading partners should be increased.

The Commission notes that the global financial architecture may have more influence on health than international assistance for health care, contributing to large net outflows of resources from poor to rich countries and increasingly frequent financial crises.

It calls for better international coordination of tax policy and the establishment of an International Tax Organisation, and highlights the need for a globally enforceable framework to reduce international tax avoidance and capital flight, calling for measures to combat the use of offshore financial centres and curb tax avoidance. It also stressses the need for effective taxation of transnational corporations, including the avoidance of tax incentives for export-processing zones. It proposes requirements for disclosure by companies of all tax, royalty and other payments to governments and other public entities. It calls on all governments to ratify and implement the UN Convention against Corruption rapidly.

The Commission also calls for the development of new national and global public finance mechanisms, ensuring that the resources generated are genuinely additional to development assistance. It sees a strong argument in favour of the development of a system of global taxation, possibly including a tax or solidarity levy on currency transactions.

Health impact assessments are required before international agreements or policy commitments on trade and investment are finalised. Countries considering such commitments should exercise due caution. WHO should re-affirm its global health leadership by initiating a review of trade and investment agreements, in collaboration with other multilateral agencies, with a view to institutionalising health equity impact assessment as a standard part of all future agreements. The flexibility of trade agreements should be increased to allow signatory countries, after signing, to mitigate unforeseen negative impacts on health and health equity, possibly including opt-out provisions where domestic conditions suggest this is necessary.

Implementation of the Commission’s recommendations on empoyment requires improved terms in WTO Agreements, more development-friendly trade policies in developed countries, reduced dependence on external capital and export markets in developing countries, and more intra-regional trade. High- and middle-income countries should not demand further tariff reductions in bilateral, regional, and world trade negotiations with low-income countries which still depend on tariffs for public revenue; and low-income countries should be extremely cautious in agreeing to reduce tariffs before creating alternative revenue streams to replace them. The report also indicates support for the development of preferential trade agreements offering protection to countries attempting to build the capacity to engage viably in the global marketplace.

While it supports the inclusion of occupational health and safety provisions in trade agreements, the Commission highlights the need for caution in seeking to use ’social clauses’ in trade agreements to enforce international labour standards, which may have counterproductive effects, urging instead the strengthening of the International Labour Organisation, the UN Environment Programme, the Food and Agriculture Organisation and WHO.

Countries should avoid making any commitments in binding trade treaties (eg the WTO’s General Agreement on Trade in Services) which affect their ability to regulate health services effectively until they have demonstrated that they can regulate private health services in ways that increase health equity. It is not clear that any country has yet done so.

Food-related trade agreements should concentrate on the three key aspects of nutrition and health equity - availability, accessibility and acceptability. Trade policy that actively encourages the production and consumption of foods high in fats and sugars to the detriment of fruit and vegetable production is contradictory to health policy. It is important to ensure that local agriculture is not threatened by international trade agreements and agriculture protection in rich countries. National and local government policies and programmes should focus on agricultural development and fairness in international trade arrangements, and protect the livelihoods of farming communities exposed to cost and competition pressures through agricultural trade agreements.

The Commission calls on international agencies, donors and national governments to address the “brain drain” of health human resources, focusing on investment in increasing health human resources, and bilateral agreements to regulate gains and losses. It also calls for more effective policy and financing mechanisms to support refugees and internally displaced populations; and greater global cooperation on the establishment of ‘portable rights’ accruing to all cross-border migrants, to be honoured by all host countries.

Global Governance

The nature of global systems and the requirements of good global governance have changed considerably since the current multilateral system was established some 60 years ago. Poor democratic function and inequality of influence are widely prevalent. The institutional processes and democratic credentials of the World Bank and IMF are questionable; trade and investment agreements have often been characterised by asymmetrical participation and inequalities in bargaining power among signatory countries; and participation and representation on the Codex Alimentarius Commission are inequitable and biased, resulting in an imbalance between the goals of trade and consumer protection. Agreements are often entered into without adequate assessment of the full scale of the social risks; and the profound disempowerment of some countries through their lack of resources and unequal capacity leads to treaties and agreements that do not necessarily serve their best interests.

The Commission argues for stronger global management of integrated economic activity and social development as a more coherent way to ensure fairer distribution of globalisation’s costs and benefits. It sees the entrenched interests of some social groups and countries as “barriers to common global flourishing”, and expresses concern about the increasing influence of transnational companies, which it argues should be accountable to the public good as well as to private profit.

The Commission highlights the need for new, strengthened and more democratic forms of global governance, considering it imperative that the international community recommit to a multilateral system in which all countries have an equitable voice. A system of global governance which places fairness in health at the heart of the development agenda and genuine equity of influence in the centre of its decision-making is indispensable to the realisation of the right to health. The Commission calls for reform of Security Council, for example through strengthened regional representation; and for support to governments and other stakeholders to allow their equitable participation in global policy-making fora.

Multilateral agencies should work more coherently to a common set of overarching objectives, underpinned by a common vision of issues to be addressed, and shared indicators by which to measure the impact of their actions. Representation of public health in domestic and international economic policy negotiations should be ensured and strengthened; and the public sector should take a leadership role in national and international regulation to protect health and reduce health inequities.

The ‘thick’ global governance on economic, trade, finance and investment relations, is in marked contrast with ‘thin’ governance on health and social equity, and global roles relating to social determinants of health are fragmented between numerous competing actors. The Commission proposes revising existing global development frameworks to incorporate health equity and social determinants of health indicators more coherently, and the adopting health equity as a core global development goal, with appropriate indicators to monitor progress both within and between countries. The MDGs should be reconsidered, advancing equity as a core marker of achievement,

The Commission strongly supports WHO in renewing its leadership in global health and its stewardship role across the multilateral system, and urges an increase in WHO’s capacity, and its institutional renewal through the establishment of a social determinants of health approach across its programmes and departments. It also proposes the creation of inter-agency thematic working groups on different aspects of the social determinants of health, the appointment of a Special Envoy for Global Health Equity, and a Permanent Special Rapporteur on the Right to Health.

David Woodward

“The People’s Misery: Mother of Diseases”: Johann Peter Frank (1790)

With the publication last week of the final report of the WHO Commission on the Social Determinants of Health (see our posting), it may be pertinent to recall a bit of history. The concern over social determinants of health - and what to do about them - has a very long and rich tradition from which we might profitably learn.

Johann Peter Frank (1745-1821) was one of the leading German physicians of his time and a founding figure in social medicine and public health. He is best known for his System einer vollständigen medicinischen Polizey (A complete system of medical police), a multi-volume work published throughout his lifetime. The term “medical police” is bit off-putting to modern ears. Essentially Frank set out an extraordinarily detailed system for regulating and promoting hygiene throughout Germany.

In 1790 Frank gave a graduation lecture at Pavia entitled De populorum miseria: morborum genitrice (The People’s Misery: Mother of Diseases). This talk was translated from the original Latin by Henry Sigerist and published in the Bulletin of the History of Medicine in 1941. Sigerist was a leading figure in the American health left of the mid-20^th century, a group that was severely hit by the post-WWII red witch hunt. (The Sigerist Circle was formed in 1990 by a group of critical medical historians.)

Sigerist notes that Frank “approached the problem [of poverty] as a physician.” But what is striking about his approach is that (again quoting Sigerist): “As a public health officer of vision, he was a statesman also and saw very clearly that the health problem was merely one aspect of a much broader social and economic problem.”

Frank’s lecture is devoted to a discussion of how poverty causes ill health. He attributes poverty to social conditions, noting that:

“Every social group has its own type of health and diseases, determined by mode of living. They are different for the courtiers and nobleman, for the soldiers and scholars. The artisans have various diseases peculiar to them, some of which have been specially investigated by physicians. The diseases caused by the poverty of the people and by lack of all the goods of life, however, are so exceedingly numerous that in a brief address they can be discussed only in outline.”

Frank organizes this outline by tracing the human lifecycle:

• We begin with the embryo: “Sewn in exhausted soil, the fetus has hardly drawn the first juices through the animal roots of the placenta when, without resistance, it already is shaken and torn as a result of the awful physical labor imposed upon the ill-nourished mother.”
• The birth: “Exhausted from lack of food and hard work, wearily [the mother] gets ready for the great task. In the hands of a drunken or ignorant midwife she has no advice, no assistance, no sympathy.”
• The infant: “If the mother does not sell her breasts to foreign mouths, the scarcity of milk - consumed by excessive labor - or her own frequent separation from the child will force her after a few months to prepare coarser food for the babe.”
• The adolescent: “The sons of destitution have hardly reached boyhood when they are compelled by their parent’s poverty to get ready for too hard labors. They are forced to lose in perspiration the nutritional juices destined for the future development of the body. Hence the lack of slenderness, symmetry and natural perfection.”
• The workers: “Everybody must admit from his own experience that the human machine must break down in a very short time if food of the right kind and quantity does not replace what labor has used up every day and sweats have consumed. Slave people are cachectic people.“
• The dying man: “He enters a hospital if there is one, but he is hardly there before the funeral separates him from his family. He may possibly seek this refuge sooner, but in most hospitals you find so much danger of contagion and such a cruel neglect of the poor that the hospital mortality rate is considerably higher than the general rate.”

The essay offers an interesting early example of using statistical data to explore the social origins of disease:

“For many years the midwives of the Principality of Spires submitted to me accurate reports on abortions and premature births. In comparing figures I was struck by the fact that in certain districts their incidence every year was much higher than in other localities of the same jurisdiction. Investigating the cause of such an unfortunate condition I soon found that it lay in servitude. The husbands are very often kept busy with statute labor and are thus forced to leave not only their household duties but also the agricultural work in the fields and meadows - rather difficult and abundant in those districts - to their wives until the last months of pregnancy.”

Frank also notes the protective effect of social class:

“Physicians, surgeons, military commanders, or priests may be living in the corrupt atmosphere of the sick, coming in close touch with them, and yet they are less frequently affected by contagion than the poor, emaciated and depressed citizens and soldiers.”

Frank was not a revolutionary. Rather he was a believer in an enlightened despotism as exemplified by Emperor Joseph II. Frank supported Joseph’s reforms, including the abolition of serfdom. Joseph II had died shortly before this speech was given and his reforms were under attack. This, then, was the political context for Frank’s conclusion:

“This is the influence of extreme misery on the people. This is the influence of luxury collected from everywhere, of officials who do not care enough for the welfare of the most useful citizens. If the government really wishes an increase in population, it must see to it that parents and children feel secure of their subsistence. It must not let the prices of vital commodities rise beyond what labor and sweat can pay. It must abolish servitude which is a disgrace to mankind…”

Posted by Matt Anderson

WHO’s Commission on Social Determinants of Health: Inequities are Killing People on a Grand Scale

On Thursday, August 28^th the WHO’s Commission on the Social Determinants of Health issued its final report: Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health. The Commission concluded that the “toxic combination of bad policies, economics, and politics is, in large measure, responsible for the fact that a majority of people in the world do not enjoy the good health that is biologically possible.” The report challenges the world community to achieve global health equity “with a generation” a goal that “is achievable, it is the right thing to do, and now is the right time to do it.” [The report is available on the Commission's website and comes in two versions: an executive summary, and the full 256 report. The website has a variety of other materials including presentations, background papers and pictures.]

The report has received virtually no press coverage in the US. On the morning of its release, Dr. Dennis Raphael searched Google News and found no US reporting on the work of the Commission. We did a similar search on 8/31 and found only 3 US sources about the Commission’s report: WebMD, Time Magazine and Voice of America.

Background to the Commission and its Report

September 2008 will mark the 30^th anniversary of the Alma Ata conference where the call for “Health for All” by the year 2000 was made. The WHO is marking this anniversary, in part, by the publication of the Commission’s report and by focusing its annual World Health Report on Primary Health Care. The Commission was established in 2005 by the late Dr. J.W. Lee, then Director General of the WHO. It was mandated to “investigate and report on evidence to guide action on social determinants of health to reduce health inequities.” The Commission was composed of a diverse group of 20 members, including three from the US (David Sachter, Gail Wilensky and William H. Foege).

The Commission was chaired by Professor Sir Michael Marmot, known for his role as director of the Whitehall Studies. These were two large cohort studies of British Civil Servants. They demonstrated that workers in the lower levels of the Civil Service had worse health and higher mortality than those at higher levels. Only part of this difference was explained by traditional risk factors. One of several implications of these studies was that social differences in health persisted even among people who were not poor and even in a country with a strong national health system. Given this conclusion it was logical that British health researchers began to look outside the health care system for solutions to health inequities.

Organization of the Commission

The Commission adopted a particularly open structure in preparing its report. It worked with four “streams:

Knowledge networks: These were nine international groups charged with producing technical reports on: Early Childhood Development; Employment Conditions; Globalization; Social Exclusion; Health Systems; Measurement and Evidence; Priority Public Health Conditions; Women and Gender Equity; and Urban Settings. Each Network produced a report which is available online.

Country partners: A number of countries subscribed to the Commission’s vision and collaborated with it. These included Brazil, Canada, Chile, Islamic Republic of Iran, Kenya, Mozambique, Sri Lanka, Sweden, and the United Kingdom.

The Commission invited input from Civil Society organizations which conducted consultations in Asia, Africa, Latin America, and the Eastern Mediterranean Region. Their final report is available online and a shortened version was published in our journal Social Medicine. The inclusion of civil society reflected a commitment to democratic governance on the part of the commission; this commitment was also reflected in the report’s recommendations.

The World Health Organization was considered the fourth stream in the Commission’s work.

General Recommendations of the Report.

In support of the goal of eliminating health inequities within a generation, the Commission made three general recommendations:

“Improve Daily Living Conditions

Improve the well-being of girls and women and the circumstances in which their children are born, put major emphasis on early child development and education for girls and boys, improve living and working conditions and create social protection policy supportive of all, and create conditions for a flourishing older life. Policies to achieve these goals will involve civil society, governments, and global institutions.

“Tackle the Inequitable Distribution of Power, Money, and Resources

In order to address health inequities, and inequitable conditions of daily living, it is necessary to address inequities -such as those between men and women - in the way society is organized. This requires a strong public sector that is committed, capable, and adequately financed. To achieve that requires more than strengthened government - it requires strengthened governance: legitimacy, space, and support for civil society, for an accountable private sector, and for people across society to agree public interests and reinvest in the value of collective action. In a globalized world, the need for governance dedicated to equity applies equally from the community level to global institutions.

“Measure and Understand the Problem and Assess the Impact of Action

Acknowledging that there is a problem, and ensuring that health inequity is measured - within countries and globally - is a vital platform for action. National governments and international organizations, supported by WHO, should set up national and global health equity surveillance systems for routine monitoring of health inequity and the social determinants of health and should evaluate the health equity impact of policy and action. Creating the organizational space and capacity to act effectively on health inequity requires investment in training of policy-makers and health practitioners and public understanding of social determinants of health. It also requires a stronger focus on social determinants in public health research.”

Commentary:

The Commission’s report (and the extensive preparation for it) clearly represents an important and very rich source of information on global health inequities and their structural bases. The Commission’s comprehensive documentation of how structural changes can quickly lead to improvements in health provides compelling evidence for such structural changes. And the Commission’s overall vision of making health equity and social justice global goals is a needed one in the current political context. We are glad that the WHO is cognizant of its historical mission as the defenders of the public’s health.

Nonetheless it is worth noting that on the 30^th anniversary of Alma Ata we do not have “Health for All.” What we will have are two reports, albeit important, from the WHO.

We are struck by a comment from the Civil Society report:

“As the Commission embarks on its mission to, once again, construct such a strategy [to improve health outcomes globally], we must step back and ponder over two issues. The first, to recapitulate on the global vision that arose from the Alma Ata Declaration of 1978, that explicitly located itself in a social determinants led view of Health. Second, to examine the dominant cause for the failure and virtual abandonment of the vision in the Alma Ata Declaration and the Primary Health Care concept.”

This second comment seems particularly telling. Why did Alma Ata fail? Why does its vision seem so far away? What lessons from this experience might inform current efforts to provide health to all?

These questions raise the issue of what might be called the social determinants of the social determinants of health. In other words, who are the people setting the global health agenda and what are their priorities? How likely are these people to be swayed by the evidence and the arguments for social justice put forth by the Commission? Why are they the ones making the decisions? Why, for example, does the World Bank fund more health programs than the WHO? How could we assure a true participation of civil society in the halls of power?

These are burning issues in the US right now. The Commission’s report comes in the middle of a Presidential campaign and the Commission generously included 3 US members (of a total of 20). And yet the report has been virtually ignored in the US press. The Commission calls for universal access to health care regardless of ability to pay. For us, the simplest, best-evidenced option for this would be a Canadian style national system, an option that has broad public and professional support. And yet, this option is not even up for debate in the United States. The political class in the US has decided that any health reform not based on private insurance is politically unacceptable. This decision is not based on any evidence nor on considerations of social justice. It is based on the economic and political power of the insurance industry.

At least within our local context it does not seem that more evidence is needed. What seems needed are a clearer political analysis, strategy and organization. To develop that strategy we need to answer the question posed by the Civil Society report (speaking of Alma Ata):

“The principal issue, then, that we need to first address is: what prevented us - at a

global, national or sub-national level - from harnessing such compelling evidence

into a cogent and comprehensive strategy for improving Health outcomes at a global

level.”

Here is a summary of the full report:

The Final Report of the Commission on Social Determinants of Health sets out key areas of daily living conditions and of the underlying structural drivers that influence them in which action is needed. It provides analysis of social determinants of health and concrete examples of types of action that have proven effective in improving health and health equity in countries at all levels of socioeconomic development.

Part 1 sets the scene, laying out the rationale for a global movement to advance health equity through action on the social determinants of health. It illustrates the extent of the problem between and within countries, describes what the Commission believes the causes of health inequities are, and points to where solutions may lie.

Part 2 outlines the approach the Commission took to evidence, and to the indispensable value of acknowledging and using the rich diversity of different types of knowledge. It describes the rationale that was applied in selecting social determinants for investigation and suggests, by means of a conceptual framework, how these may interact with one another.

Parts 3, 4, and 5 set out in more detail the Commission s findings and recommendations. The chapters in Part 3 deal with the conditions of daily living the more easily visible aspects of birth, growth, and education; of living and working; and of using health care. The chapters in Part 4 look at more structural conditions social and economic policies that shape growing, living, and working; the relative roles of state and market in providing for good and equitable health; and the wide international and global conditions that can help or hinder national and local action for health equity. Part 5 focuses on the critical importance of data not simply conventional research, but living evidence of progress or deterioration in the quality of people s lives and health that can only be attained through commitment to and capacity in health equity surveillance and monitoring.

Part 6, finally, reprises the global networks the regional connections to civil society worldwide, the growing caucus of country partners taking the social determinants of health agenda forward, the vital research agendas, and the opportunities for change at the level of global governance and global institutions that the Commission has built and on which the future of a global movement for health equity will depend….”

Posted by Matt Anderson, MD

Sydney Principles: Reducing Commercial Promotion of Foods and Beverages to Children

Following our posting last week regarding the American Academy of Pediatrics and Baby Formula, our friend Claudio Schuftan emailed us about an initiative by the International Obesity Task Force to reduce the commercial promotion of foods and beverages to children.

In 2006, the IOTF elaborated a draft set of principles to address this issue, called the Sydney Principles. These were subjected to public criticism and a revised, final set of principles was adopted in 2007. The final principles are available on the IOTF website and were published in article from in Public Health Nutrition in May of 2008. Since this article cannot be downloaded for free, you may want to write the lead author, Boyd Swinburn, for a reprint. These principles were developed in collaboration with the WHO Collaborating Centre for Obesity Prevention.

Here are the seven principles:

The Sydney Principles

Actions to reduce commercial promotions to children should:

1. SUPPORT THE RIGHTS OF CHILDREN.

Regulations need to align with and support the United Nations Convention on the Rights of the Child and the Rome Declaration on World Food Security which endorse the rights of children to adequate, safe and nutritious food.

2. AFFORD SUBSTANTIAL PROTECTION TO CHILDREN.

Children are particularly vulnerable to commercial exploitation, and regulations need to be sufficiently powerful to provide them with a high level of protection. Child protection is the responsibility of every section of society - parents, governments, civil society, and the private sector.

3. BE STATUTORY IN NATURE.

Only legally-enforceable regulations have sufficient authority to ensure a high level of protection for children from targeted marketing and the negative impact that this has on their diets. Industry self-regulation is not designed to achieve this goal.

4. TAKE A WIDE DEFINITION OF COMMERCIAL PROMOTIONS.

Regulations need to encompass all types of commercial targeting of children (e.g. television advertising, print, sponsorships, competitions, loyalty schemes, product placements, relationship marketing, Internet) and be sufficiently flexible to include new marketing methods as they develop.

5. GUARANTEE COMMERCIAL-FREE CHILDHOOD SETTINGS. Regulations need to ensure that childhood settings such as schools, child care, and early childhood education facilities are free from commercial promotions that specifically target children.

6. INCLUDE CROSS BORDER MEDIA.

International agreements need to regulate cross-border media such as Internet, satellite and cable television, and free-to-air television broadcast from neighbouring countries.

7. BE EVALUATED, MONITORED AND ENFORCED.

The regulations need to be evaluated to ensure the expected effects are achieved, independently monitored to ensure compliance, and fully enforced.

Some thoughts:

It is interesting to use these principles as a benchmark to see how far commercial promotion to children has penetrated our society, particularly into the commercial-free childhood settings mentioned in the principles.

In 2003, New York City signed an agreement with Snapple Beverages, making Snapple “the exclusive provider via vending machines of water and fruit juices in the City’s 1,200 schools” and New York City’s official beverage. One wonders why New York City needed an official beverage. In addition:

As a part of its commitment to schools, Snapple has entered into a five-year agreement to exclusively vend bottled spring water and 100 per cent juices in all schools. Snapple, in cooperation with the Department of Education, will develop new products that meet the City’s strict nutrition guidelines. Snapple’s new product line ‘100% Juiced!’ will include four flavors, Green Apple, Orange Mango, Grape and Fruit Punch, with Vitamins A, C, D and Calcium.

I suppose this is an attempt to show that Snapple is promoting nutrition. But bottled water is not necessarily safer than public water, it is more expensive than tap water, and is much less ecologicaly friendly. Many of us feel that juice drinking is part of the obesity problem, not part of its solution. In short, this type of marketing gives a stamp of nutritional approval to corporate-friendly diets. When kids are thirsty, shouldn’t they be going to the drinking fountain?

And, of course, there is the promotion of food to children in healthcare settings. Perhaps the extreme form of this has been the placing of McDonald’s Restaurants in New York City Hospitals.

For background to this issue, the IOTF webpage offers several detailed reports.

Posted by Matt Anderson

Class and Health

Social Medicine had its birth during the Industrial Revolution in Europe as health statistics (a relatively new tool) made clear that disease and death were linked to poverty and exploitation.

One of the first empiric studies examining this question was done in the 1820’s by the French physician Louis Rene Villerme. Villerme looked at mortality statistics in Paris and noted marked differences in death rates between one section of the city and another. After considering several possible explanations, he concluded that poverty was the main determinant of differentials in death rates. We are fortunate that his original publication from 1830 is available online at the French National Library. We have discussed Villerme’s paper in greater detail in an article entitled “Social Medicine 101.”

Twenty years later Friederich Engel’s impassioned The Condition of the Working Class in England, described in detail the devastating health impact of the Industrial Revolution on workers and their families.

Two centuries later these problems are very much with us. As Vicente Navarro pointed out in a 2004 Monthly Review article entitled “Inequality is Unhealthy“, a member of the corporate class in Europe lives some 7 years longer than an unskilled worker who is chronically unemployed; in the US, the gap is 14 years.

The debate over health inequalities in the English-speaking world was revitalized by Sir Douglas Black’s 1980 report on inequalities and health (most of which is available on the website of the Socialist Health Association). The Black Report is a very rich document born out of the flowering of Social Medicine in England after World War II. Later Allison Quick and Richard Wilkinson introduced the idea that mortality depends upon the degree of inequality in a society, irrespective of the absolute wealth of the country.

In the United States we are told there is no social class and the Federal government does not routinely collect statistics on class and health. Class issues are often discussed in racial terms or in terms of “inequality”. Inequality.org provides an introduction from a US perspective. The New York City-based Russell Sage Foundation has published a number of interesting social critiques, which are available on their website. There are several papers on the topic of inequality and health. See The Social Dimensions of Inequality, a literature review of the Foundation.

Matt Anderson

Using Google Earth as an Innovative Tool for Community Mapping

We wanted to share an article we just published in Public Health Reports on using Google Earth for community mapping. We have found Google Earth a very useful tool that allows non-experts to make maps illustrating the community context for health problems. This post contains two of the maps created by our residents and medical students.

Using Google Earth as an Innovative Tool for Community Mapping

SYNOPSIS

Maps are used to track diseases and illustrate the social context of health problems. However, commercial mapping software requires special training. This article illustrates how nonspecialists used Google Earth^TM, a free program, to create community maps. The Bronx, New York, is characterized by high levels of obesity and diabetes. Residents and medical students measured the variety and quality of food and exercise sources around a residency training clinic and a student-run free clinic, using Google Earth to create maps with minimal assistance. Locations were identified using street addresses or simply by pointing to them on a map. Maps can be shared via e-mail, viewed online with Google Earth or Google Maps, and the data can be incorporated into other mapping software.

Authors: Theodore B. Lefer, Matthew R. Anderson, Alice Fornari, Anastasia Lambert, Jason Fletcher and Maria Baquero

Source: Public Health Reports, July-August 2008, 123: 474-480, Available at www.publichealthreports.org

Sources of Food and Exercise around the Montefiore Comprehensive Health Care Center; Legend: Red cross = Comprehensive Health Care Center; Grocery cart = Grocery Store (n =10); Fork and Knife = Restaurants (n=16); Red dot = Fast Food outlet (n=32); Yellow dot = Bodegas (small variety stores, n=44); Green tree = Exercise site (n=11). Note the old Yankee stadium on the lower left of the map.

Food stores around ECHO Free Clinic, ranked by variety and quality of produce for sale; Legend: Red Cross = ECHO Free Clinic; Small red icon of shopping cart = “no variety” (n=33) ; Yellow cart = “Poor variety” (n=67); Blue cart = “Limited variety” (n=50); Darker green cart = “Better variety” (n=11); Larger, lighter green cart = “Good variety” (n=15) ; Blue -shaded area = Study area

If you are interested, you can also download the original KMZ file.

posted by: Matt Anderson

Former WHO Director Halfdan Mahler on Alma Ata, May 2008

Distinguished audience,

My remarks will focus on “Why Alma-Ata in 1978 and Whither the Health for All Vision and Primary Health Care Strategy”.

Milan Kundera wrote in one of his books: “The struggle against human oppression is the struggle between memory and forgetfulness.” So allow me to remind all of us today, of the transcendental beauty and significance of the definition of health in WHO’s Constitution: “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”

This definition is immediately followed by: “The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.” Most importantly, the very first constitutional function of WHO reads: “To act as the directing and coordinating authority on international health work.” Please do note that the Constitution says “the” and not “a” directing and coordinating authority.

So please, allow this old man in front of you to insist that unless we all become partisans in renewed local and global battles for social and economic equity in the spirit of distributive justice, we shall indeed betray the future of our children and grandchildren.

My memory tells me that the World Health Assembly had this in mind when, in 1977, it decided that the main social target for governments and WHO in the coming decades should be the attainment of what is known as “Health for All”.

And, the Health Assembly described that as a level of health that will permit all the people of the world to lead socially and economically productive lives. The Health Assembly did not consider health as an end in itself, but rather as a means to an end.

That is, I believe as it should be.

When people are mere pawns in an economic and profit growth game, that game is mostly lost for the underprivileged.

Let me postulate that if we could imagine a tabula rasa in health without having to deal with the constraints - tyranny if you wish - of the existing medical consumer industry, we would hardly go about dealing with health as we do now in the beginning of the 21st century.

To make real progress we must, therefore, stop seeing the world through our medically tainted glasses. Discoveries on the multifactoral causation of disease, have for a long time, called attention to the association between health problems of great importance to man and social, economic and other environmental factors. Yet, considering the tremendous political, social, technical and economic implications of such a multidimensional awareness of health problems I still find most of today’s so-called health professions very conventional, indeed.

It is, therefore, high time that we realize, in concept and in practice, that a knowledge of a strategy of initiating social change is as potent a tool in promoting health, as knowledge of medical technology.

Primary health care is indeed conditioned by its holistic framework and as such, may use different expressions. For example, in some countries health management has to be considered along with such things as producing more or better food, improving irrigation, marketing products, etc. It is not that people consider health services as unimportant, but there are things like getting food, or a piece of land, or house or an accessible source of water which are more of a life and death nature and must, in the wisdom of the people, come first to make other things meaningful. We have rarely considered these needs as falling within our expressed policies for health development and therefore, we risk being restricted, unilateral and ineffective in our action.

Again, I am afraid that conventional or medical wisdom has done very little to provide scientific and political credibility to the alleged importance of individual, family and community participation in health promotion.

These concerns, to which I have just alluded prompted an organizational study on “Methods of promoting the development of basic health services” by WHO’s Executive Board in 1973 in which it is bluntly stated that:

“There appears to be widespread dissatisfaction of population about their health services for varying reasons. Such dissatisfaction occurs in the developed as well as in the Third World. The causes can be summarized as a failure to meet the expectations of the populations; an inability of the health services to deliver a level of national coverage adequate to meet the stated demands and the changing needs of different societies; a wide gap (which is not closing) in health status between countries, and between different groups within countries; rapidly rising costs without a visible and meaningful improvement in service; and a feeling of helplessness on the part of the consumer who feels (rightly or wrongly) that the health services and the personnel within them are progressing along an uncontrollable path of their own which may be satisfying to the health professionals but which is not what is most wanted by the consumer”.

It was this organizational study by WHO’s Executive Board that led to the decision by WHO in co-sponsorship with UNICEF to convene “The International Conference on Primary Health Care” in the city of Alma-Ata in 1978.

Let me then repeat with awe and admiration, the consensus concept of primary health care as contained in the Declaration of Alma-Ata 1978:

“Primary Health Care is essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and the country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination. It forms an integral part, both of the country’s health system, of which it is the central function and main focus, and of the overall social and economic development of the community.

“It is the first level of contact of individuals, the family and community with the national health system bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process.”

Let me also quote from the Declaration of Alma-Ata, that primary health care includes at least: education concerning prevailing health problems and the methods of preventing and controlling them; promotion of food supply and proper nutrition; an adequate supply of safe water and basic sanitation; maternal and child health care, including family planning; immunization against the major infectious diseases; prevention and control of locally endemic diseases; appropriate treatment of common diseases and injuries; and provision of essential drugs. In my opinion, an admirable summation of key priorities.

Are you ready to address yourselves seriously to the existing gap between the health “haves” and the health “have-nots” and to adopt concrete measures to reduce it?

Are you ready to ensure the proper planning and implementation of primary health care in coordinated efforts with other relevant sectors, in order to promote health as an indispensable contribution to the improvement of the quality of life of every individual, family and community as part of overall socio-economic development?

Are you ready to make preferential allocations of health resources to the social periphery as an absolute priority?

Are you ready to mobilize and enlighten individuals, families and communities in order to ensure their full identification with primary health care, their participation in its planning and management and their contribution to its application?

Are you ready to introduce the reforms required to ensure the availability of relevant human resources and technology, sufficient to cover the whole country with primary health care within the next two decades at a cost you can afford?

Are you ready to introduce, if necessary, radical changes in the existing health delivery system so that it properly supports primary health care as the overriding health priority?

Are you ready to fight the political and technical battles required to overcome any social and economic obstacles and professional resistance to the universal introduction of primary health care?

Are you ready to make unequivocal commitments to adopt primary health care and to mobilize international solidarity to attain the objective of health for all by the year 2000?

Alma-Ata was, in my biased opinion, one of the rare occasions where a sublime consensus between the haves and the have-nots in local and global health emerged in the spirit of a famous definition of consensus: “I am not trying to convince my adversaries that they are wrong, quite to the contrary, I am trying to unite with them, but at a higher level of insight.”

The Alma-Ata primary health care consensus also reflects a famous truism: “The Health Universe is only complete for those who see it in a complete light, it remains fragmented for those who see it in fragmented light!”

In conclusion, my personal view is that the Alma-Ata primary health care consensus has had major inspirational and operational impacts in many countries having a critical mass of political and professional leadership combined with adequate human and financial resources to test its adaptability and applicability within the local realities through a heavy dose of systems and operations research.

Mind you, it is much easier to be rational, audacious and innovative when your are rich! But, please, let us not forget that the inspirational energies and the evidence base came from the developing countries themselves, be they governmental or non-governmental sources.

For a majority of these countries, financial support from so-called donors was essential to carry out a broad array of studies, in appropriate technology, human resources development, infrastructure development, social participation, financing etc. in order to integrate the Alma-Ata vision into heavily constrained local contexts.

Most donors, after an initial outburst of enthusiasm quickly lost interest or distorted the very essence of the Alma-Ata Health for All Vision and Primary Health Care Strategy under the ominous name of selective primary health care which broadly reflected the biases of national and international donors and not the needs and demands of developing countries.

But in spite of these brutal impediments many developing countries have shown, before and after the Alma-Ata happening, courageous adhesion to its health message of equity in local and global health. Civil society movements have also been prime shakers and movers in these admirable efforts.

And so, being an inveterate optimist I do believe that the struggle between memory and forgetfulness can be won in favour of the Alma-Ata Health for All Vision and its related Primary Health Care Strategy. Let us not forget that visionaries have been the realists in human progression.

And so, distinguished audience, let us use the complete light generated by WHO’s Constitution and the Alma-Ata Health for All Vision and Primary Health Care Strategy to guide us along the bumpy, local and global health development road.

Thank you.

Global Health Watch: The Alternative Health Report

Global Health Watch is one of several civil society initiatives set up after the international community failed to reach the goal of “Health for All” in the year 2000. It is a “broad collaboration of public health experts, non-governmental organisations, civil society activists, community groups, health workers and academics” which attempts to produce an alternative health report. GHW was started by the People’s Health Movement, Global Equity Gauge Alliance and Medact.

GHW published its first report in 2005-2006 and it is available for free at this link. The report covers a broad variety of topics within contemporary global health. The 360 page report provides essential reading on globalization, health care systems, medications, the crisis in global health care workers, sexual and reproductive health, gene technology, indigenous health, disabled people, climate, water, food, education, war, the WHO, UNICEF, World Bank/IMF, big business, international AID, debt relief, and essential health research.

Work is currently ongoing on the production of GHW 2007-2008. One can also subscribe to the GHW monthly newsletter.

Here is the introduction to GHW 2005-2006:

“Today’s global health crisis reflects widening inequalities within and between countries. As the rich get richer and the poor get poorer, advances in science and technology are securing better health and longer lives for a small fraction of the world’s population. Meanwhile children die of diarrhoea for want of clean water, people with AIDS die for want of affordable medicines, and poor people in all regions are increasingly cut off from the political, social and economic tools they can use to create their own health and well-being.

“The real scandal is that the world lacks neither funds nor expertise to solve most of these problems. Yet the predominance of conservative thinking and neoliberal economics has led the institutions that were established to promote social justice into imposing policies and practices that achieve just the opposite. They police an unjust global trade regime with a doctrinaire insistence on privatization of public services, and preside over the failure to curb disease by tackling the poverty that enables it to flourish. Global Health Watch 2005–2006 is a collaboration of leading popular movements and non-governmental organizations comprising civil society activists, community groups, health workers and academics. It has compiled this alternative world health report – a hard-hitting, evidence-based analysis of the political economy of health and health care – as a challenge to the major global bodies that influence health. Its monitoring of institutions including the World Bank, the World Health Organization and UNICEF reveals that while some important initiatives are being taken, much more needs to be done to have any hope of meeting the UN’s health-related Millennium Development Goals.

“The report also offers a comprehensive survey of current knowledge and thinking in the key areas that influence health, focusing throughout on the health and welfare of poor and vulnerable groups in all countries. These issues range from climate change, water and nutrition to national health services and the brain drain of health professionals from South to North.

“Global Health Watch 2005–2006 is above all a call for action, written in a clear, accessible style to appeal to grass-roots health workers and activists worldwide, as well as to international policy-makers and national decisionmakers. Its resource sections advocate actions everyone can take, while its recommendations show how better global health governance and practice could work for Health for All rather than health for the privileged few.”

Social Determinants of Health

The study of the social roots of disease began in earnest during the Industrial Revolution and is exemplified in the works of writers like the French physician Louis Rene Villerme (see Social Medicine 101) and the German physician/politician/anthropologist Rudolf Virchow (see Howard Waitzkin’s article in volume 1, number 1 of Social Medicine). With the development of microbiology in the late 19th century, it seemed that “the” true cause of disease had been found and social explanations were seen as somewhat quaint. However, social explanations for disease have never truly gone out of fashion. As Christopher Hamlin has noted, despite the microbiologic revolution many diseases - even infectious ones - continue to kill people at high rates. Some infectious diseases clearly require social interventions (such as improvements in diet and water supply). Even in infectious diseases, the sole presence of a pathogen is rarely able to explain the patterns of disease prevalence and natural history. Finally, many of the health issues facing us today - such as diabetes and smoking - are not uni-causal. As a consequence, we have seen a flourishing of interest recently in the social determinants of health.

The British Medical Journal maintains a collection of articles related to the socio-economic determinants of health. Many of the most important themes in the field are debated in these articles, so they are well worth a look.

The Canadian Center for Social Justice (CSJ) has posted abstracts from their 2002 conference on “Social Determinants of Health across the Life Span”. The conference produced the Toronto Charter (PDF), a program to improve Canadians’ health through strengthening the social determinants of health.

From York University in Canada is the Social Determinants of Health list serve, run by Dennis Raphael.  In 2006 Dr. Raphael published a overview of “theory and research concerning social determinants of health that is available on-line: “Social Determinants of Health: Present Status, Unanswered Questions, and Future Directions.”

MacArthur Research network on Socioeconomic Status (SES) and Health. The overall goal of the network is to identify the mechanisms by which socioeconomic status affects health status. The Social Environment Notebook contains chapters on measurement of income inequality, educational status, and overviews of environmental conditions affecting health in both work and home settings. In addition the Social Environment Notebook includes a Sociodemographic Questionnaire developed by the Network, which includes questions to assess educational, economic and occupational status.

Population Health Forum. Population health looks at the most important factors that determine the health of nations and parts of nations. Why is the USA less healthy than pretty well all the other rich countries and a few poor ones, despite spending almost half of the world’s health care bill? The Population Health Forum’s website addresses these issues.

Finally, the website of the World Health Organization’s Commission on the Social Determinants of Health has a wide variety of reports - some for general audiences and some quite detailed. It is well worth perusing these materials.