PHA-Exchange> WHO's Commission on the social determinants of health: News Release (2)

[claudio at hcmc.netnam.vn]

WHO's Commission off to a poor start?

1. Make them healthy but keep them poor! 

There is a fundamental problem with the rationale behind the press release. It 
suggests that we can protect or even improve poor people's health while they 
remain in poverty. This is of course the flaw of "pro-poor policies" in 
general.  They can only have short term, cosmetic effects on either health or 
poverty. 

 

Dr Lee states "This commission will assist countries to implement strategies 
that will help people who are poor and marginalized to live longer, healthier 
lives".

Dr Marmot states "We will arm policy makers with the best evidence to ensure 
that poverty does not sentence a person to a shorter, unhealthy life". 

 

There is a significant difference between approaches to health which are anti-
poverty and those which are "pro-poor".  The first addresses root causes of 
health problems: structural poverty and structural violence and the second 
addresses health problems within the context of structural poverty and 
structural violence. Needless to say, the second is favoured under a 
neoliberal regime because it poses no threat to the status quo of the powerful 
while it creates the illusion that international health authorities are 
seriously addressing both poverty and health significantly and sustainably. 
They are doing neither.  

 

As the PHM stands for, poverty is the disease.  The aim therefore is poverty 
eradication.  It is not to make health somehow compatible with poverty, or to 
make health something that can be achieved despite poverty. Not only is this 
logically impossible, it is a historical nonsense. The classic public health 
lessons all show that poverty - as characterized by miserable living 
conditions - must be eradicated in order to achieve significant and 
sustainable improvements in the health status of populations.  We know that 
relatively poor countries or states (Cuba, Kerala) can achieve excellent 
health outcomes but we must remember that with their modest resources, they 
have addressed basic needs, miserable living conditions and social 
inequalities.   

 

2. What about food and water? 

 
There is a striking omission in the list of "causes behind the causes", namely 
lack of food and water. Together these "social" determinants are responsible 
for well over 60% of avoidable disease and death - according to WHO's own 
figures. Why then are they left off the list of the "causes behind the 
causes"? 

 

Equally striking is the odd inclusion under social determinants of "unsafe 
employment conditions" rather than lack of employment or a means of support 
and survival at all. This is reminiscent of the interest in food safety rather 
than food as a determinant of health.       

 

Perhaps we should have paid attention to the terminology long ago. We should 
have been alerted by use of the term "social" rather than "social and 
economic" to the possibility that this WHO Commission would (once more) ignore 
the most fundamental "causes behind the causes" which are, of course, economic 
determinants.  According to the WHO press release "Social standing plays a big 
part in whether people will live to be 40 or 80".  Are we to understand that 
massive health deficits and health inequalities between and within countries 
are due to differential social standing of individuals? Or might it be helpful 
to take a look at the international economic order which facilitates 
exploitation of entire communities of people (nations even) and their 
maintenance in conditions of gross material deprivation so that their basic 
needs for health remain unmet?    

 

3. Health Action Zones replace Health for All

 
The press release cites examples of "innovative health programmes that address 
social determinants" which use targeting, means testing and conditionalities - 
all mechanisms which have been tried, tested . . . . . and found wanting.

 

We learn of "social welfare programmes with benefits conditional on children's 
school attendance, regular medical checkups and other health promoting 
actions". Oh dear, conditionalities now on individuals such as desperately 
poor single mothers who will now have to prove that their children are worthy 
of health care. No matter that those most in need are also those for whom 
such "conditionalities" pose most difficulties or are materially impossible. 
The working poor in the USA need as many as 3 different jobs merely to pay the 
rent on a caravan and buy (some) food for their children.  These examples from 
developed countries are unlikely to inspire hope in developing countries.    

 

V. Navarro and others have presented ample evidence on the superiority of 
universalist and redistributive policies.  Targeting benefits through means 
testing or individual conditionalities is the antithesis of this approach.  
Health as a human right is not going to be achieved through subjecting 
individuals in deprived communities to impossible tests and rationing health 
benefits accordingly. This is paternalism and victim blaming at its most 
ludicrous. 

 

And . . . the whole point of the Commission on Social Determinants is to 
address the non-health sector determinants of health responsible for most 
disease and death (as a corrective to the Sachs Report). So whatever is done 
through health programmes can only achieve limited improvements in overall 
health status of populations.  So much for intersectoral approaches. Only when 
intersectoral is correctly interpreted to include macroeconomic and political 
measures such as land reform, trade justice, debt cancellation and self 
determination of peoples and nations without interference (violent or 
otherwise), will the huge burden of disease in poor countries start to come 
down.   

 

4. Addressing global health inequalities through national health policies?

 

Referring to developing country policies to be identified and promoted by the 
Commission, the press release claims that "overcoming these social barriers 
represents a prime opportunity to reduce global health inequalities".  How 
will health programmes and policies implemented in individual developing 
countries affect global health inequalities which are themselves the result of 
global economic structures and arrangements which have been accelerating 
poverty, inequality and consequently, miserable living conditions responsible 
for avoidable disease and death, for the past 25 years?  Global inequality can 
only be tackled at the global level. 

 

The reversals of logic are astounding. The triumphant concluding sentence of 
the press release reads as follows: "The MDGs recognize the interdependence of 
health and other social conditions and present an opportunity to promote 
health policies that tackle the social roots of unfair and avoidable human 
suffering".  Health policies, understood to mean measures designed to be 
implemented within the health sector, cannot tackle social roots of suffering 
as these lie outside the health sector.  However if health policies are 
predicated on a fair and rational international economic order, then the 
social roots of human suffering will indeed be addressed.

 

This was of course the raison d'être of Alma Ata born 1978; died 1980.  
Revived 2005 ? 

 

Note: If this press release is an unfair representation of WHO's Commission on 
Social Determinants, we will all be relieved. If not, civil society - meaning 
public interest NGOs, trade unions, and people's movements for social justice 
need to urge WHO in the strongest possible terms to keep the Commission's work 
close to WHO's constitutional mandate and to Health for All values and 
principles.  

 AK

Comments to the list are welcome.
Claudio

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