PHM-Exch> Determinants of disease, health and well-being Rights, equity, justice: Rumpus in Rio de Janeiro

Tue Nov 1 12:35:12 PDT 2011

 Determinants of disease, health and well-being Rights, equity, justice:
Rumpus in Rio

We report on dramatic scenes in Rio de Janeiro. All who see that public
health nutrition is a branch of public health will do well to study the
products of the World Conference on the Social Determinants of Health. This
was held in Rio between 19-21 October, immediately following the Valparaiso
summit <http://www.wphna.org/2011_nov_hp1_un_summit.htm> reported on in
this issue. The conference revealed vivid and sharply polarised ideologies.
Interesting times

The expected division would have been between officials from UN agencies
and national governments, on the one hand, and representatives of public
interest civil society organisations and universities, on the other hand.

But this is not how things turned out. Certainly, the genuine civil society
organisations, of which the *People's Health Movement* was the most vocal
and effective, severely criticised and even denounced the
offi<http://www.wphna.org/downloadsnov2011/11-10-21%20WCSDH%20Political%20Declaration.pdf>cial
Political Declaration issued at the conference. As it turned out, their
views were evidently recognised and respected by many official delegates
from national governments and UN agencies. Indeed, key delegates, including
those given time to speak who are quoted below, clearly sympathised with or
agreed with the People's Health Movement position. Judging from what she
said, quoted here, these include current WHO director-general Margaret
Chan.

The official Declaration is a statement of good and worthy principles, but
it identifies improvement of social and other inequities as largely a
technical issue to be fixed by experts and with money. As pessimists
predicted, the fire, energy and purpose of the 2008 report of the
Commission on the Social Determinants of
Health<http://en.wikipedia.org/wiki/People%27s_Health_Movement#Social_Determinants_of_Health>has
been filleted out. Cynics believe that technocrats within the UN
system
encouraged the Rio conference as a way to neutralise uncomfortable aspects
of the Commission's work. These go against what is now the utterly
disgraced and discredited but still dominant 'free market' red in tooth and
claw capitalism, which became known as 'the Washington
Consensus<http://en.wikipedia.org/wiki/Washington_Consensus>',
put in place beginning in the 1980s.

Return to Alma Ata

With remarkable enterprise and initiative, the People's Health Movement
team, pictured above (left) with other colleagues from social movements,
produced and circulated its unofficial
Declaration<http://www.wphna.org/downloadsnov2011/11-10-20%20WCSDH%20Civil%20society%20Declaration.pdf>.
This identifies the true 'causes of the causes' of disease, health and
well-being. These include the systematic and deliberate hollowing out of
the South by the already wealthy countries of the North, and by the global
financial, economic and trade organisations they control. Cynics pointed
out that some senior people in government and the UN system may find future
careers in 'the private sector', or working for the 'new philanthropies' or
for US-based aid, trade or research organisations.

With great significance, the unofficial Declaration is signed by a large
number of organisations. It is also signed by a large number of people, of
whom the first is Halfdan
Mahler<http://en.wikipedia.org/wiki/Halfdan_Mahler>who, when
director-general of WHO from 1973 to 1988, enabled the Alma
Ata Health For All
Declaration<http://en.wikipedia.org/wiki/Alma_Ata_Declaration>.

Who let the PHM in?

Who accepted so many people from the People's Health Movement into the
by-invitation-only conference? Why was Association member David Sanders,
whose views are well-known, given a key position in the programme as a
final commentator on the conference and its significance and failures? Was
this the decision of the head of the WHO conference secretariat Rüdiger
Krech, whose WHO post is as head of Ethics, Equity, Trade and Human Rights?
Maybe: he is understood to be in favor of public-private partnerships which
the PHM is not. It seems likely that the decision was influenced by the
local Brazilian host and mastermind Paulo Buss. He is the dynamic and
charismatic former president of the progressive Oswaldo Cruz (Fiocruz)
foundation in Rio. This is the branch of the Brazilian health ministry
responsible for public health, which is now taking a special interest in
public health nutrition.
Margaret Chan
Director-general, World Health Organization

Margaret Chan opened the conference. Here follows a shortened version of
her address. Hers is a progressive and even radical voice within her own
organisation. One of her points is that public health, including population
food and nutrition adequacy, security and equity, is a political issue. She
began by stressing the need for strong and persistent civil society
organisations, vital to any responsive democracy. She has said on other
occasions that the current dominant systems of political and economic
governance have failed.

Brazil is the ideal place to host the first event of this kind. This
country has long enjoyed a strong civil society movement pushing for health
reforms and health equity. These reforms have recognised health as more
than a biomedical entity.

Improvements in key indicators of health in any country are the proof of
what can be achieved when social equity is embedded in minds and policies.
As we open this conference, lives hang in the balance. Lives cut short
because the right policies are not in place. Social cohesion, stability and
security are at stake, in individual nations and internationally.

Governments have responsibility towards people and their health. But people
are pushed into poverty due to catastrophic medical bills, and many
governments are not preventing this. Progress in a civilised world should
mean more than simply making more and more money.

Globalisation was set to be the rising tide that would lift all boats, but
this never happened. It lifted the big boats, but sunk many of the small
ones. Globalisation creates benefits, sometimes big ones, but has no rules
that ensure the distribution of those benefits.

Things are getting worse

The world now is highly interconnected, but the goal right now is to fulfil
the economic benefits and not to distribute them fairly or evenly. As a
result differences in income, access to care, and health outcomes, are
greater today than in any time in history. As a consequence, the world is
not safe or secure.

This year of 2011 is a year that has witnessed many disasters and social
turmoil, but also two very important events. The first one is the Middle
East uprising demanding democratic reforms and human rights, which include
the right to health. This uprising has been at times inspiring and at times
worrying.

Just as with the financial crisis in 2008, these protests seemed to be a
surprise. But there are root causes that make them understandable and even
predictable. These include inequality in income and access to services.
Greater social equity must be the new political and economic imperative for
a safer world. Health services have to be delivered according to the
values, principles and practices of primary health care.

A second key event in 2011 has been the High-Level Meeting on
non-communicable diseases, held during the UN General Assembly last month
in September. These diseases are driven by powerful universal forces, like
rapid urbanisation and the globalisation of unhealthy lifestyles. They
undermine development and growth, they break the bank.

Studies estimate that in the next 20 years these diseases will cost the
global economy more than $US 30 trillion. The majority of the costs for the
care of these diseases are met through out-of-pocket payments, which lead
people into poverty. Therefore these diseases are a two-punch blow to
development: loss of national income and an increase in the number of poor
people.

The junk food menace

Prevention is by far the best option, and it is entirely feasible and
affordable in any resource setting. But nearly all the risk factors lie out
of the control of the health sector. These include junk food, tobacco,
alcohol and sedentary lives. Prevention measures lie as well outside the
health sector, and public health loses power in this fight. We need the
right policies in place in all sectors of government.

Vast collateral damage to health is being caused by policies made in other
sectors and in the international system. Good policies are known and well
studied, but putting them in place is an enormous challenge. It means
pushing against powerful and pervasive commercial interests.

Every corner of the world is fighting against obesity and overweight, which
is rising particularly in children. This is not a failure of individual
willpower, but a failure of political will at the highest level. Kids in
the whole world watch cartoon characters who tell them what to eat and
drink. Two weeks ago, France passed a 'fat tax' on sugary drinks, and was
immediately threatened by a company producing such drinks. It is very hard
for any country to bear the financial burden of this kind of litigation,
especially for small countries.

These are some of the forces undermining health that are being addressed in
this conference. Will governments now put the health of people before the
health of corporations? We know enough to act and we have extremely good
reasons to do so, including economic ones. We need to change the rules of
this world and to implement policies that work. We need greater social
cohesion, security and stability. This is the price worth fighting for in
health and in multiple other sectors.

The loss of equity in China

China is a great success in terms of economic growth, but now health and
education have to be reformed and the government is now clear on this.
Before the opening up, health was equitable and accessible. Then it moved
on a fee for service model, driving people into poverty. People say it's
difficult to see a doctor and extremely costly as well, people are unhappy
and angry and that has pushed health reforms.

Now there are multiple mechanisms in place, including social insurance.
Universal coverage is so important because it's going back to the basic
principle of social protection, social justice and fair distribution.
Health is political.

 [The above is extracted from Margaret Chan's opening statement].

David Sanders
University of the Western Cape, South Africa
Speaking from the People's Health Movement

His intervention in the closing ceremony received a standing ovation. This
came not only from genuine civil society representatives present. As the
applause continued, more and more politicians, civil servants and UN
representatives also rose to their feet, demonstrating the divide between
them and the officials who remained sitting, hands in laps. Association
member David Sanders was the conscience of the conference.

I want to focus on mothers and children in particular. There is an
unacceptable gap between rich and poor. A woman in a poor country has a one
in ten chance of dying in childbirth. A total of 35 per cent of deaths of
children in the world are due to malnutrition.

Big Snack immiserates populations and causes obesity

What are we doing about this? Very little. Trade is sadly not mentioned in
the Rio Declaration<http://www.wphna.org/downloadsnov2011/11-10-21%20WCSDH%20Political%20Declaration.pdf>.
Undernutrition is related to free trade agreements. Northern countries
subsidise their agriculture and export food to impoverished countries,
flooding their markets. For example, Japan subsidises its dairy industry to
the tune of $US 2,600 a year per cow. Why should a Japanese cow enjoy an
annual 'income' of five times that of an African citizen who earns on
average $US 500 a year? And this leads to food insecurity. Why are we not
talking about these things?

What is UNICEF doing about this? It is flying
Plumpy'nut™<http://en.wikipedia.org/wiki/Plumpy%27nut>from France into
Africa to treat malnutrition. This medicalises the problem
and draws attention away from the fact that African countries import food
and sell land to transnational food companies. Ethopia, the largest
recipient of Plumpy'nut, also receives 700,000 tonnes of food aid a year.
It has just sold 3 million hectares of prime land to a food transnational
corporation.

This is the context of the problem and we are not addressing it. Looking at
non-communicable diseases, again trade is the issue. South Africa is the
third fattest country in the world; and the importation and production of
processed food products, and of whey, an ingredient of snacks, has gone up
exponentially. How are we going to control malnutrition without regulating
trade?

Also, there is no reference in the Rio Declaration to the unfair trade of
health personnel. Africa and Asia have been stripped of health personnel
and that is very unequal trade, contributing to an increase in maternal
mortality among other things, since skilled health personnel are crucial to
reducing this tragedy.

It was estimated several years ago by UNCTAD (the UN Conference on Trade
and Development) that the US saves $US 184,000 in training costs for each
imported professional. Totalled up, this translates into hundreds of
billions of dollars. Again here is the South subsidising the North. We need
compensation for what African ministers of health a few years ago called
brain robbery – not a voluntary code, like the present WHO code on
recruitment, which has no teeth to enforce it.

The new philanthropies and the food crisis

I am also member of the People's Health Movement, a global movement active
in about 70 countries, with several affiliated organisations. We have a
position in PHM of unconditional but critical support of the UN agencies.
Although they are imperfect, they represent the views of the member states.
However, they have been weakened substantially because countries are not
funding them as they should. They should also be strengthened and they
should be bolder. But private initiatives such as the Gates Foundation are
major funders and they are influencing these agencies to a great extent.

As Bob Dylan said, money doesn't talk, it swears. We need to speak about
the financial crisis, a food crisis and a climate crisis (and climate is
not mentioned in the Rio Declaration). The financial crisis is a crisis of
capitalism. There is an alternative Rio
Declaration<http://www.wphna.org/downloadsnov2011/11-10-20%20WCSDH%20Civil%20society%20Declaration.pdf>put
up by civil society, with ten very clear demands, including a Tobin
tax <http://en.wikipedia.org/wiki/Tobin_tax>. Why aren't United Nations
agencies calling for this? This is not a radical thing, it's a tax on the
casino economy. Now poor people everywhere, including in SoutherN Europe,
are paying for the crisis. We should stand up for them
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