From the Social Medicine Portal
WHO's Commission on Social Determinants of Health: Inequities are Killing People on a Grand
Scale<http://www.socialmedicine.org/2008/09/01/globalization-and-health/whos-commission-on-social-determinants-of-health-inequities-are-killing-people-on-a-grand-scale/>
excerpts
On Thursday, August 28th the WHO's Commission on the Social Determinants of Health <http://www.who.int/social_determinants/en/> 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<http://www.who.int/social_determinants/en/>and comes in two
versions: an executive summary<http://www.who.int/entity/social_determinants/final_report/csdh_finalreport_2008_execsumm.pdf>, and the full 256
report<http://www.who.int/entity/social_determinants/final_report/csdh_finalreport_2008.pdf>\. 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 <Communications & Public Affairs | York University 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<Health Insurance Center: Your Guide to the Affordable Care Act, Time Magazine<http://www.time.com/time/health/article/0,8599,1836907,00.html?imw=Y>and Voice of America <http://voanews.com/english/2008-08-29-voa36.cfm>\.
Organization of the Commission
The Commission adopted a particularly open structure in preparing its report. It worked with four "streams:
Knowledge networks<http://www.who.int/social_determinants/knowledge_networks/en/index.html>: These were nine international groups charged with producing nine different technical reports. Each Network produced a report which is available online<http://www.who.int/social_determinants/knowledge_networks/en/index.html>
.
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<http://www.who.int/social_determinants/resources/cso_finalreport_2007.pdf>and a shortened version was published in our journal Social Medicine<View of Civil Society Report to the Commission on Social Determinants of Health.
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"
"Tackle the Inequitable Distribution of Power, Money, and Resources" and
"Measure and Understand the Problem and Assess the Impact of Action"
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 WHO is cognizant of its historical mission as the defenders of the public's health.
Nonetheless it is worth noting that on the 30th anniversary of Alma Ata we do not have "Health for All." What we will have are two reports, albeit important, from 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 calledthe 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 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."
Posted by Matt Anderson, MD
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