PHA-Exch> WHO press release: Inequities are killing people on a "grand scale"

[Claudio Schuftan]

Inequities are killing people on a "grand scale" reports WHO's Commission
http://www.who.int/social_determinants/final_report/en/index.html

Press release
28 August 2008

28 August 2008 | GENEVA -- A child born in a Glasgow, Scotland suburb can
expect a life 28 years shorter than another living only 13 kilometres away.
A girl in Lesotho is likely to live 42 years less than another in Japan. In
Sweden, the risk of a woman dying during pregnancy and childbirth is 1 in 17
400; in Afghanistan, the odds are 1 in 8. Biology does not explain any of
this. Instead, the differences between - and within - countries result from
the social environment where people are born, live, grow, work and age.

These "social determinants of health" have been the focus of a three-year
investigation by an eminent group of policy makers, academics, former heads
of state and former ministers of health. Together, they comprise the World
Health Organization's Commission on the Social Determinants of Health.
Today, the Commission presents its findings to the WHO Director-General Dr
Margaret Chan.

"(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
Commissioners write in Closing the Gap in a Generation: Health Equity
through Action on the Social Determinants of Health. "Social injustice is
killing people on a grand scale."

"Health inequity really is a matter of life and death," said Dr Chan today
while welcoming the Report and congratulating the Commission. "But health
systems will not naturally gravitate towards equity. Unprecedented
leadership is needed that compels all actors, including those beyond the
health sector, to examine their impact on health. Primary health care, which
integrates health in all of government's policies, is the best framework for
doing so."

Sir Michael Marmot, Commission Chair said: "Central to the Commission's
recommendations is creating the conditions for people to be empowered, to
have freedom to lead flourishing lives. Nowhere is lack of empowerment more
obvious than in the plight of women in many parts of the world. Health
suffers as a result. Following our recommendations would dramatically
improve the health and life chances of billions of people."

Inequities within countries

Health inequities – unfair, unjust and avoidable causes of ill health – have
long been measured between countries but the Commission documents "health
gradients" within countries as well. For example:

   * Life expectancy for Indigenous Australian males is shorter by 17 years
than all other Australian males.
   * Maternal mortality is 3–4 times higher among the poor compared to the
rich in Indonesia. The difference in adult mortality between least and most
deprived neighbourhoods in the UK is more than 2.5 times.
   * Child mortality in the slums of Nairobi is 2.5 times higher than in
other parts of the city. A baby born to a Bolivian mother with no education
has 10% chance of dying, while one born to a woman with at least secondary
education has a 0.4% chance.
   * In the United States, 886 202 deaths would have been averted between
1991 and 2000 if mortality rates between white and African Americans were
equalized. (This contrasts to 176 633 lives saved in the US by medical
advances in the same period.)
   * In Uganda the death rate of children under 5 years in the richest fifth
of households is 106 per 1000 live births but in the poorest fifth of
households in Uganda it is even worse – 192 deaths per 1000 live births –
that is nearly a fifth of all babies born alive to the poorest households
destined to die before they reach their fifth birthday. Set this against an
average death rate for under fives in high income countries of 7 deaths per
1000.

The Commission found evidence that demonstrates in general the poor are
worse off than those less deprived, but they also found that the less
deprived are in turn worse than those with average incomes, and so on. This
slope linking income and health is the social gradient, and is seen
everywhere – not just in developing countries, but all countries, including
the richest. The slope may be more or less steep in different countries, but
the phenomenon is universal.

Wealth is not necessarily a determinant

Economic growth is raising incomes in many countries but increasing national
wealth alone does not necessarily increase national health. Without
equitable distribution of benefits, national growth can even exacerbate
inequities.

While there has been enormous increase in global wealth, technology and
living standards in recent years, the key question is how it is used for
fair distribution of services and institution-building especially in
low-income countries. In 1980, the richest countries with 10% of the
population had a gross national income 60 times that of the poorest
countries with 10% of the world's population. After 25 years of
globalization, this difference increased to 122, reports the Commission.
Worse, in the last 15 years, the poorest quintile in many low-income
countries have shown a declining share in national consumption.

Wealth alone does not have to determine the health of a nation's population.
Some low-income countries such as Cuba, Costa Rica, China, state of Kerala
in India and Sri Lanka have achieved levels of good health despite
relatively low national incomes. But, the Commission points out, wealth can
be wisely used. Nordic countries, for example, have followed policies that
encouraged equality of benefits and services, full employment, gender equity
and low levels of social exclusion. This, said the Commission, is an
outstanding example of what needs to be done everywhere.

Solutions from beyond the health sector

Much of the work to redress health inequities lies beyond the health sector.
According to the Commission's report, "Water-borne diseases are not caused
by a lack of antibiotics but by dirty water, and by the political, social,
and economic forces that fail to make clean water available to all; heart
disease is caused not by a lack of coronary care units but by lives people
lead, which are shaped by the environments in which they live; obesity is
not caused by moral failure on the part of individuals but by the excess
availability of high-fat and high-sugar foods." Consequently, the health
sector – globally and nationally – needs to focus attention on addressing
the root causes of inequities in health.

"We rely too much on medical interventions as a way of increasing life
expectancy" explained Sir Michael. "A more effective way of increasing life
expectancy and improving health would be for every government policy and
programme to be assessed for its impact on health and health equity; to make
health and health equity a marker for government performance."

Recommendations

Based on this compelling evidence, the Commission makes three overarching
recommendations to tackle the "corrosive effects of inequality of life
chances":

   * Improve daily living conditions, including the circumstances in which
people are born, grow, live, work and age.
   * Tackle the inequitable distribution of power, money and resources – the
structural drivers of those conditions – globally, nationally and locally.
   * Measure and understand the problem and assess the impact of action.

Recommendations for daily living

Improving daily living conditions begins at the start of life. The
Commission recommends that countries set up an interagency mechanism to
ensure effective collaboration and coherent policy between all sectors for
early childhood development, and aim to provide early childhood services to
all of their young citizens. Investing in early childhood development
provides one of the best ways to reduce health inequities. Evidence shows
that investment in the education of women pays for itself many times over.

Billions of people live without adequate shelter and clean water. The
Commission's report pays particular attention to the increasing numbers of
people who live in urban slums, and the impact of urban governance on
health. The Commission joins other voices in calling for a renewed effort to
ensure water, sanitation and electricity for all, as well as better urban
planning to address the epidemic of chronic disease.

Health systems also have an important role to play. While the Commission
report shows how the health sector can not reduce health inequities on its
own, providing universal coverage and ensuring a focus on equity throughout
health systems are important steps.

The report also highlights how over 100 million people are impoverished due
to paying for health care – a key contributor to health inequity. The
Commission thus calls for health systems to be based on principles of
equity, disease prevention and health promotion with universal coverage,
based on primary health care.

Distribution of resources

Enacting the recommendations of the Commission to improve daily living
conditions will also require tackling the inequitable distribution of
resources. This requires far-reaching and systematic action.

The report foregrounds a range of recommendations aimed at ensuring fair
financing, corporate social responsibility, gender equity and better
governance. These include using health equity as an indicator of government
performance and overall social development, the widespread use of health
equity impact assessments, ensuring that rich countries honour their
commitment to provide 0.7% of their GNP as aid, strengthening legislation to
prohibit discrimination by gender and improving the capacity for all groups
in society to participate in policy-making with space for civil society to
work unencumbered to promote and protect political and social rights. At the
global level, the Commission recommends that health equity should be a core
development goal and that a social determinants of health framework should
be used to monitor progress.

The Commission also highlights how implementing any of the above
recommendations requires measurement of the existing problem of health
inequity (where in many countries adequate data does not exist) and then
monitoring the impact on health equity of the proposed interventions. To do
this will require firstly investing in basic vital registration systems
which have seen limited progress in the last thirty years. There is also a
great need for training of policy-makers, health workers and workers in
other sectors to understand the need for and how to act on the social
determinants of health.

While more research is needed, enough is known for policy makers to initiate
action. The feasibility of action is indicated in the change that is already
occurring. Egypt has shown a remarkable drop in child mortality from 235 to
33 per 1000 in 30 years. Greece and Portugal reduced their child mortality
from 50 per 1000 births to levels nearly as low as Japan, Sweden, and
Iceland. Cuba achieved more than 99% coverage of its child development
services in 2000. But trends showing improved health are not foreordained.
In fact, without attention health can decline rapidly.

Is this feasible?

The Commission has already inspired and supported action in many parts of
the world. Brazil, Canada, Chile, Iran, Kenya, Mozambique, Sri Lanka,
Sweden, and the UK have become 'country partners' on the basis of their
commitment to make progress on the social determinants of health equity and
are already developing policies across governments to tackle them. These
examples show that change is possible through political will. There is a
long way to go, but the direction is set, say the Commissioners, the path
clear.

WHO will now make the report available to Member States which will determine
how the health agency is to respond.

Comments from the Commissioners

Fran Baum, Head of Department and Professor of Public Health at Flinders
University, Foundation Director of the South Australian Community Health
Research Unit and Co-Chair of the Global Coordinating Council of the
People's Health Movement: "It is wonderful to have global endorsement of the
Australian Closing the Gap campaign from the CSDH established by the WHO.
The CSDH sets Closing the Gap as a goal for the whole world and produces the
evidence on how health inequities are a reflection of the way we organize
society and distribute power and resources. The good news from the CSDH for
Australia is that it provides plenty of ideas on how to set an agenda that
will tackle the underlying determinants of health and create a healthier
Australia for all of us"

Monique Begin, Professor at the School of Management, University of Ottawa,
Canada, twice-appointed Minister of National Health and Welfare and the
first woman from Quebec elected to the House of Commons: "Canada likes to
brag that for seven years in a row the United Nations voted us "the best
country in the world in which to live". Do all Canadians share equally in
that great quality of life? No they don't. The truth is that our country is
so wealthy that it manages to mask the reality of food banks in our cities,
of unacceptable housing (1 in 5), of young Inuit adults very high suicide
rates. This report is a wake up call for action towards truly living up to
our reputation."

Giovanni Berlinguer, Member of the European Parliament, member of the
International Bioethics Committee of UNESCO (2001–2007) and rapporteur of
the project Universal Declaration on Bioethics: "A fairer world will be a
healthier world. A health service and medical interventions are just one of
the factors that influence population health. The growth of inequalities and
the phenomena of increased injustice in health is present in low and middle
income countries as well as across Europe. It would be a crime not to take
every action possible to reduce them."

Mirai Chatterjee, Coordinator of Social Security for India's Self-Employed
Women's Association, a trade union of over 900 000 self-employed women and
recently appointed to the National Advisory Council and the National
Commission for the Unorganised Sector: "The report suggests avenues for
action from the local to national and global levels. It has been eagerly
awaited by policy-makers, health officials, grassroot activists and their
community-based organizations. Much of the research and evidence is of
particular relevance to the South-East Asian region, where too many people
struggle daily for justice and equity in health. The report will inspire the
region to act and develop new policies and programmes."

Yan Guo, Professor of Public Health and Vice-President of the Peking
University Health Science Centre, Vice-Chairman of the Chinese Rural Health
Association and Vice-Director of the China Academy of Health Policy: "A man
should not be concerned with whether he has enough possessions but whether
possessions have been equally distributed", this is a time-honored teaching
in China. Constructing a harmonious society is our shared aspiration, and
equity, including health equity, composes the prerequisite for a harmonious
development. Eliminating determinants that are adverse to health under the
efforts from all of the society, promoting social justice, and advancing
human health are our shared goals. Let's join our hands in this grand
course!"

Kiyoshi Kurokawa, Professor at the National Graduate Institute for Policy
Studies, Tokyo, Member of the Science and Technology Policy Committee of the
Cabinet Office, formerly President of the Science Council of Japan and the
Pacific Science Association: "The WHO Commission addresses one of the major
issues of our global world - health inequity. The report's recommendations
will be perceived, utilized and implemented as a major policy agenda at
national and global levels. The issue will increase in importance as the
general public become more engaged via civil society movements and
multi-stakeholder involvement."

Alireza Marandi, Professor of Pediatrics at Shaheed Beheshti University,
Islamic Republic of Iran, former two-term Minister of Health and Medical
Education, former Deputy Minister and Advisor to the Minister and recently
elected to be a member of the Iranian Parliament: "According to the Islamic
ideology, social justice became a priority, when the Islamic revolution
materialized in Iran. Establishing a solid Primary Health Care network in
our country, not only improved our health statistics, but it was an
excellent vehicle to move towards health equity. Now through the final
report of the CSDH and implementing its recommendations we need to move much
faster in our own country toward health equity."

Pascoal Mocumbi, High Representative of the European and Developing
Countries Clinical Trials Partnership, former Prime Minister of the Republic
of Mozambique, former head of the Ministry of Foreign Affairs and the
Ministry of Health: "The Commission on Social Determinants of Health report
will help African leaders adapt their national development strategies to
address the challenges to health. These are derived from the current
systemic changes taking place in the global economy that affects heavily on
the poorest segments of Africa's population."

Amartya Sen, Lamont University Professor and Professor of Economics and
Philosophy at Harvard University, awarded the Nobel Prize in Economics in
1998: "The primary object of development - for any country and for the world
as a whole - is the elimination of 'unfreedoms' that reduce and impoverish
the lives of people. Central to human deprivation is the failure of the
capability to live long and healthy lives. This is much more than a medical
problem. It relates to handicaps that have deep social roots. Under Michael
Marmot's leadership, this WHO Commission has concentrated on the badly
neglected causal linkages that have to be adequately understood and
remedied. A fuller understanding is also a call for action."

David Satcher, Director of the Center of Excellence on Health Disparities
and the Satcher Health Leadership Institute Initiative, formerly the United
States Surgeon General and Assistant Secretary for Health and also Director
of the Centers for Disease Control and Prevention: "The United States of
America spends more on health care than any other country in the world, yet
it ranks 41st in terms of life expectancy. New Orleans and its experience
with Hurricane Katrina illustrate why we need to target social determinants
of health (SDH) ­ including housing, education, working and learning
conditions, and whether people are exposed to toxins­better than any place I
can think of right now. By targeting the SDH, we can rapidly move towards
closing the gap that unfairly and avoidably separates the health status of
groups of different socio-economic status, social exclusion experience, and
educational background."

Anna Tibaijuka, Executive Director of UN-HABITAT and founding Chairperson of
the independent Tanzanian National Women's Council: "Health delivery is not
possible for people living in squalor, in dehumanizing pathetic conditions
prevailing in the ever growing slum settlements of cities and towns in
developing countries. Investment in basic services such as water and
education will always remain constrained if not wasted unless accompanied by
requisite investment in decent housing with basic sanitation."

Denny Vågerö, Professor of Medical Sociology, Director of CHESS (Centre for
Health Equity Studies) in Sweden, member of the Royal Swedish Academy of
Sciences and of its Standing Committee on Health: "Countries of the world
are presently growing apart in health terms. This is very worrying. In many
countries in the world social differences in health are also growing, and
this is true in Europe. We have been one-sidedly focused on economic growth,
disregarding negative consequences for health and climate. We need to think
differently about development."

Gail Wilensky, Senior Fellow at Project HOPE, an international health
education foundation. Previously she directed the Medicare and Medicaid
programmes in the United States and also chaired two commissions that advise
the United States Congress on Medicare: "What this report makes clear is
that improving health and health outcomes and reducing avoidable health
differences­goals of all countries-- involves far more than just improving
the health care system. Basic living conditions, employment, early childhood
education, treatment of women and poverty all impact on health outcomes and
incorporating their effects on health outcomes needs to become an important
part of public policymaking. This is as true for wealthy countries like the
United States as it is for many of the emerging countries of the world,
where large numbers of people live on less than $2 per day."
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