Closing the gap in a generation is a rousing call.1 Did
the World Health Organization’s Commission on Social Determinants of
Health (CSDH) really believe it to be possible? Technically, certainly.
Yes, there is a greater than 40-year spread in life expectancy among
countries and dramatic social gradients in health within countries. But
the evidence suggests that we can make great progress towards closing
the health gap by improving, as the CSDH put it, the conditions in which
people are born, grow, live, work and age. These include ensuring:
equity for every child from the start, healthier environments, fair
employment and decent work, social protection across the life course and
universal health care. To make such progress, we must also deal with
inequity in power, money and resources – the social injustice that is
killing on a grand scale. At a more fundamental level, our vision is to
create the conditions so that every person may enjoy the freedoms that
lead to improved health – what we call empowerment.
In the three years since Closing the gap in a generation was
published, there is no question that there is much to make us gloomy:
the global financial crisis and the steps put in place to deal with it
have worse impacts on the poor and relatively disadvantaged; the
persistence of bad governance nationally and globally; climate change
and inequitable measures for mitigation and adaptation and, in many
countries, an increase in health inequity.
On
the positive side, however, much has happened to support my claim that I
am an evidence-based optimist. First at the World Health Organization
(WHO) itself, the doubting voices (what do social determinants have to
do with a disease control organization?) were countered by the argument
that WHO could not possibly ignore what the CSDH called “the causes of
the causes” of ill-health. Specialists across WHO, who formed the CSDH’s
knowledge network on priority public health conditions, showed that
action on social determinants of health was fundamental to disease
control programmes.2 Importantly,
a resolution was passed at the World Health Assembly in 2009 that
called on WHO and all Member States to take action on the social
determinants.
Each
of the WHO Regions has expressed interest in this issue. The WHO
Regional Office for the Americas will make social determinants a theme
for its publication Health in the Americas 2012,
has developed training courses and has been promoting health equity in
the region. Zsuzsanna Jakab, WHO Regional Director for Europe, thought
it essential that work be done to adapt the CSDH findings to the diverse
countries that make up the WHO European Region. She therefore invited
me to lead the European Review of Social Determinants and the Health
Divide. The recommendations from this review will feed in to Europe’s
new public health strategy, Health 2020. WHO, with the government of
Brazil, is organizing the World Conference on Social Determinants of
Health in Rio de Janeiro.
Several
countries have explicitly taken on the social determinants of health
agenda. Brazil, Denmark, England, Norway, Scotland and Slovenia are
among many countries that have commissioned reviews and/or produced
strategies for action on this subject. In other countries such as
Argentina, Chile, Costa Rica and Sri Lanka, there is much focus on and
concern about the social determinants of health and a variety of actions
have been taken. The state of South Australia has made the Health in
All Policies approach a central plank of government action. India, while
not explicitly addressing the social determinants of health has,
nevertheless, pursued policy initiatives that will have important impact
on health equity. These include: rural employment guarantees, food
security, universal health care, social security for informal workers,
education, housing and rights of tribal and forest dwellers. These new
policies and programmes are all welcome but the proof will come from
monitoring their effect on social determinants and health outcomes.
The review of health inequalities in England, published as Fair society, healthy lives,3 adapted
the CSDH recommendations into six domains: (i) give every child the
best start in life, (ii) improve education and life-long learning,
(iii) create fair employment and jobs, (iv) ensure a minimum income for a
healthy standard of living, (v) build healthy and sustainable
communities, and (vi) apply a social determinants’ approach to
prevention. In the wake of this review there are encouraging signs of
impact on policy and practice at national and local level in the United
Kingdom of Great Britain and Northern Ireland.
The
ambition of the CSDH was to create a global movement for social
determinants and health equity. As the global community gathers in Rio
de Janeiro in October for the conference on social determinants of
health, we are at a crucial juncture. Will the call for social justice
and the need to formulate all policies to benefit health equity remain
something, at best, honoured in speech alone? Or will the global
community recognize that action on social determinants of health is not
only vital for health equity but has other highly desirable societal
outcomes including social cohesion, reduction of crime and civil unrest,
a more educated workforce and the freedom for people to lead lives they
have reason to value.4
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