March 2009

“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 inequities in health both within and between countries are caused by “… the unequal distribution of power, income, goods, and services, globally and nationally…” Those were some of the profound conclusions of the WHO Commission on Social Determinants of Health (CSDH). The CSDH provides very convincing evidence that the structural determinants and conditions of daily life, the social determinants, are the major determinants of health and inequalities in health. Social determinants “… are responsible for the major part of health inequities between and within countries.” The CSDH calls for a new approach to economic and social development that involves the whole of government, civil society and local business, global and international agencies to tackle the upstream determinants. It challenges the dominant types of economic growth that currently does not include fairness in how benefits are distributed. Without equitable distribution of benefits, economic growth can exacerbate inequities in health. The major conclusions of the CSDH are a wake-up call to all health professionals, policy makers and politicians. They herald a large shift in thinking about policies on promoting health. Indeed the report of the 2008 Commission on Social Determinants of Health is a significant successor to the 1978 WHO Alma Ata Declaration which drew attention to the fact that intersectoral policies were vital for improvements in health and that health policy was not the sole responsibility of the health ministry. Alma Ata stressed that community participation and health promotion should be a central lever of policy. Alma Ata was adopted by most governments and had an important impact on health policies and was followed by the Ottawa Declaration where the term ‘healthy public policy’ was coined to emphasize that ministries, be they economic, agriculture, education or transport, should always consider the health impacts of their policies. And now we have the 2008 CSDH that goes further than the Alma Ata Declaration to promote health equity. CSDH analyses the causes of ill health and the causes of the causes. The then Director General of the WHO Dr Lee Jong-wook, who set up the CSDH at the WHO World Health Assembly in 2004, said that: “The goal is not an academic exercise, but to marshal scientific evidence as a lever for policy change - aiming toward practical uptake among policymakers and stakeholders in countries”. The core values underlying the work of the CSDH were “The development of a society, rich or poor, can be judged by the quality of its population’s health, the fair distribution of health across the social spectrum, and the degree of protection provided from disadvantage due to ill-health.” Systematic differences that are avoidable by reasonable action are unjust and labeled health inequity. CSDH considers that most inequalities in health are avoidable and, hence, inequitable; that addressing health inequity is a matter of social justice and that health equity is a goal within countries and between them. The strong concern about injustice of inequalities in the CSDH were succinctly expressed by the WHO Director-General, Dr Margaret Chan. She said: “No one should be denied access to life-saving or health-promoting interventions for unfair reasons, including those with economic or social causes … When health is concerned, equity really is a matter of life and death.” The power of the CSDH report derives from the stark figures on the existing large inequalities in health and life expectancies. Why should a child born in several African countries have a life expectancy of 42 years less than one in Japan? Such inequalities are neither random events nor merely related to biological differences. They are influenced by behaviours. Those behaviours are socially determined. So to change the behaviours we need to change the environment. The report rightly frequently emphasizes social justice. For the inequalities in health are unjust. The time has come to focus on the determinants of the gross differences in health both within and between countries. With so much information on inequalities in health (and oral health) the usefulness of more surveys on inequalities is questionable. CSDH takes a human rights based approach to health and emphasises social action needed to guarantee individual freedoms. It links health with human dignity, equity and justice. Vulnerability to illhealth can be reduced through realization of human rights - the right to education, to water and to food. They should be available, accessible, acceptable and of good quality (AAAQ). Moreover, CSDH goes some way beyond medical care and individual responsibility as the solutions to inequality in health. The recommendations imply a shift to human entitlements to the conditions for good health and considers that empowerment, agency and participation are key elements in policy. “Change the social determinants of health and there will be dramatic improvements in health equity.” The new global agenda should focus on changing unequal living conditions and life chances and the structural and political ways in which societies are organized.