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

Mon Apr 4 07:43:58 PDT 2005

Dear Claudio,

I really appreciated your thought-provoking critique of the WHO's
Commission on the social determinants of health's news release. Sharp as
ever, your analysis shows it is necessary to read this kind of
statements carefully and not take anything at face value. I definitely
agree with the gist of your message.

Please allow me, however, to point out one inconsistency. You
convincingly show how the press release argues we should make the people
healthy while keeping them poor. I agree it's not exactly what we
advocate. As an alternative for this "pro-poor" approach, you advocate
an approach that is anti-poverty and mention "poverty eradication" as
the main aim. I'm afraid this argument is suffering from the same kind
of reductionism as Dr. Lee's target of the "healthy poor." All too
often, the international discourse has now shifted to "poverty
reduction" whereas before "development" was the ultimate objective.
Instead of aiming for comprehensive social, cultural, economic and
political development, we are now supposed to be satisfied if we can
lift the poorest above a certain poverty threshold. The MDGs are a case
in point.

The examples you mention, Cuba and Kerala, show indeed that good health
is actually possible among populations that are poor by conventional
standards. They have achieved this level of good health not because they
employed pro-poor health policies as the WHO seems to imply, but neither
because they have worked on 'poverty eradication'. Their achievements
are the result of a comprehensive development policy. 

Likewise PHM's main aim, as I understand it, is not "poverty
eradication" as a basis for better health. When I checked the People's
Charter for Health I was reassured: "Health is a social, economic and
political issue and above all a fundamental human right. Inequality,
poverty, exploitation, violence and injustice are at the root of
ill-health and the deaths of poor and marginalised people. Health for
all means that powerful interests have to be challenged, that
globalisation has to be opposed, and that political and economic
priorities have to be drastically changed." I'm sure this is also what
you had in mind but let's avoid the trap of supplanting the development
discouse with the reductionist language of 'poverty reductionism.'

In solidarity, 

Wim

On Fri, 2005-04-01 at 17:34, claudio at hcmc.netnam.vn wrote:

> 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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