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<P class=MsoNormal style="MARGIN: 0in 0in 0pt; mso-layout-grid-align: none"><B
style="mso-bidi-font-weight: normal"><SPAN lang=EN-AU
style="FONT-SIZE: 9pt; FONT-FAMILY: AdvPA0C4; mso-bidi-font-family: AdvPA0C4"><FONT
face="Times New Roman">Journal of Epidemiology and Community Health
</FONT></SPAN></B><B style="mso-bidi-font-weight: normal"><SPAN lang=EN-AU
style="FONT-SIZE: 10pt; FONT-FAMILY: Arial">2005;59;714-715<?xml:namespace
prefix = o ns = "urn:schemas-microsoft-com:office:office"
/><o:p></o:p></SPAN></B></P>
<P class=MsoNormal
style="MARGIN: 0in 0in 0pt; mso-layout-grid-align: none"><SPAN lang=EN-AU
style="FONT-SIZE: 9pt; FONT-FAMILY: AdvPA0C4; mso-bidi-font-family: AdvPA0C4"><o:p><FONT
face="Times New Roman"> </FONT></o:p></SPAN></P>
<P class=MsoNormal
style="MARGIN: 0in 0in 0pt; mso-layout-grid-align: none"><SPAN lang=EN-AU
style="FONT-SIZE: 9pt; FONT-FAMILY: AdvPA0C4; mso-bidi-font-family: AdvPA0C4"><FONT
face="Times New Roman">Equity and health<o:p></o:p></FONT></SPAN></P>
<P class=MsoNormal
style="MARGIN: 0in 0in 0pt; mso-layout-grid-align: none"><SPAN lang=EN-AU
style="FONT-SIZE: 7.5pt; FONT-FAMILY: AdvTimes; mso-bidi-font-family: AdvTimes"><FONT
face="Times New Roman">. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . .<o:p></o:p></FONT></SPAN></P>
<P class=MsoNormal
style="MARGIN: 0in 0in 0pt; mso-layout-grid-align: none"><FONT
face="Times New Roman"><SPAN lang=EN-AU
style="FONT-SIZE: 14pt; FONT-FAMILY: AdvPA0C4; mso-bidi-font-family: AdvPA0C4">Who
cares about health for all in the 21st century</SPAN><SPAN lang=EN-AU
style="FONT-SIZE: 14pt; FONT-FAMILY: AdvP2A83; mso-bidi-font-family: AdvP2A83">?
</SPAN><SPAN lang=EN-AU
style="FONT-SIZE: 19pt; FONT-FAMILY: AdvP2A83; mso-bidi-font-family: AdvP2A83"><SPAN
style="mso-spacerun: yes"> </SPAN></SPAN><SPAN lang=EN-AU
style="FONT-SIZE: 11.5pt; FONT-FAMILY: AdvPA0C8; mso-bidi-font-family: AdvPA0C8">Fran
Baum *<o:p></o:p></SPAN></FONT></P>
<P class=MsoNormal
style="MARGIN: 0in 0in 0pt; mso-layout-grid-align: none"><SPAN lang=EN-AU
style="FONT-SIZE: 7.5pt; FONT-FAMILY: AdvPA0C8; mso-bidi-font-family: AdvPA0C8"><FONT
face="Times New Roman">. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . .<o:p></o:p></FONT></SPAN></P>
<P class=MsoNormal
style="MARGIN: 0in 0in 0pt; mso-layout-grid-align: none"><SPAN lang=EN-AU
style="FONT-SIZE: 11.5pt"><FONT face="Times New Roman">This paper regrets the
retreat in the 1990s from a focus on health as a social good that results from
good social policy. It highlights the importance of the People’s Health Movement
and the WHO Commission on the Social Determinants of Health as offering a chance
to return to a more socially just quest for equity and
health.<o:p></o:p></FONT></SPAN></P>
<P class=MsoNormal
style="MARGIN: 0in 0in 0pt; mso-layout-grid-align: none"><SPAN
lang=EN-AU><o:p><FONT face="Times New Roman"
size=3> </FONT></o:p></SPAN></P>
<P class=MsoNormal
style="MARGIN: 0in 0in 0pt; mso-layout-grid-align: none"><FONT size=3><FONT
face="Times New Roman"><SPAN lang=EN-AU>It’s been a peculiar century so far. It
started off with the great and lofty thoughts that accompany centennial change.
Millennium summits, domes, and plans for a peaceful century in which human
health and wellbeing blossomed. With amazing rapidity, in the wake of
</SPAN><?xml:namespace prefix = st1 ns =
"urn:schemas-microsoft-com:office:smarttags" /><st1:date Year="2001" Day="11"
Month="9"><SPAN lang=EN-AU>11 September 2001</SPAN></st1:date><SPAN lang=EN-AU>,
it deteriorated into a century of fundamentalisms, acute fear of terrorism, and
an unprovoked attack on a sovereign state that was not backed by the United
Nations or the majority of citizens of the countries going to war. The aftermath
of the war in </SPAN><st1:country-region><st1:place><SPAN
lang=EN-AU>Iraq</SPAN></st1:place></st1:country-region><SPAN lang=EN-AU> has
become a public health nightmare and there are few signs of the flourishing of
democracy that was meant to justify the war .Meanwhile the deeper causes of
global instability persist and the </SPAN><st1:country-region><st1:place><SPAN
lang=EN-AU>USA</SPAN></st1:place></st1:country-region><SPAN lang=EN-AU> spends
more on war than it does on tackling extreme poverty. Sachs estimates that eight
million people die each year because they are too poor to stay alive. The 21st
century, then, is proving to be a disaster for Africa and many other
postcolonial states who face economic disaster under the burden of crippling
debt and the onslaught of both old (such as malaria) and new infectious diseases
(most notably HIV/AIDS). Life expectancy in </SPAN><st1:place><SPAN
lang=EN-AU>Africa</SPAN></st1:place><SPAN lang=EN-AU> is going backwards for the
first time in over a century. Meanwhile the populations of OECD countries are
experiencing growth in wealth and prosperity, albeit with increasing inequities
between the rich and poor.<o:p></o:p></SPAN></FONT></FONT></P>
<P class=MsoNormal
style="MARGIN: 0in 0in 0pt; mso-layout-grid-align: none"><SPAN
lang=EN-AU><o:p><FONT face="Times New Roman"
size=3> </FONT></o:p></SPAN></P>
<P class=MsoNormal
style="MARGIN: 0in 0in 0pt; mso-layout-grid-align: none"><SPAN lang=EN-AU><FONT
size=3><FONT face="Times New Roman">IMPORTANCE OF VISIONARY
LEADERSHIP<o:p></o:p></FONT></FONT></SPAN></P>
<P class=MsoNormal
style="MARGIN: 0in 0in 0pt; mso-layout-grid-align: none"><SPAN
lang=EN-AU><o:p><FONT face="Times New Roman"
size=3> </FONT></o:p></SPAN></P>
<P class=MsoNormal
style="MARGIN: 0in 0in 0pt; mso-layout-grid-align: none"><FONT size=3><FONT
face="Times New Roman"><SPAN lang=EN-AU>It is against this background that I
pose the question: who cares about Health for All in this century? The answer
would have been easier if we had gone back 25 years to the period around 1980.
The World Health Organisation under the charismatic leadership of Dr Halfdan
Mahler had launched the Health for All by the Year 2000 campaign and the target
seemed a real possibility. WHO was widely respected as a lead organisation in
global health with a leader who was visionary and inspiring. Many public health
doctors now in their 50s and 60s remember with affection the great inspiration
they received from the HFA2000 strategy. Mahler’s leadership lasted through to
the 1980s when the Ottawa Charter for Health Promotion inspired more people to
adopt a comprehensive model of promoting health that did not blame individuals
but rather focused on creating environments and making policies in which people
could flourish and make easy, healthy choices. I remember my own excitement on
reading the Ottawa Charter and seeing that it could move health promotion beyond
simple ineffective behaviour change strategies to whole of community approaches
to improving wellbeing. There was a buzz in public health then, a palpable
feeling that we were on the right track with Healthy Cities, Healthy Schools,
and other such initiatives, comprehensive primary health care plans, community
involvement, and a growing (if fragile) commitment to equity in health. Sadly,
much of this idealism was lost in the 1990s. WHO lost its ability to inspire and
seemed to give up its leadership in global health to the World Bank. This was
most obvious in 1993 with the publication of the World Bank’s Investing in
Health. This report saw health as a crucial part of economic development but did
not see health as a human right. This approach was consolidated with the notion
of disability adjusted life years (DALYs) that privileged the value of lives of
those who were young and without disability. These approaches to health were
very much in line with the zeitgeist of neoliberalism that led to the
devastating economic prescription of structural adjustment throughout the
developing world—completely without an evidence base or sound justification. The
WHO did nothing to challenge this neoliberalism and seemed to endorse the
general direction with its Commission on Macro-economics and Health. In fact the
main challenge within public health came from outside governments and
international agencies. It came from grass roots and activist movements who
despaired at the direction of global health and came together in December 2000
in Savar </SPAN><st1:country-region><st1:place><SPAN
lang=EN-AU>Bangladesh</SPAN></st1:place></st1:country-region><SPAN lang=EN-AU>
at the People’s Health Assembly. <o:p></o:p></SPAN></FONT></FONT></P>
<P class=MsoNormal
style="MARGIN: 0in 0in 0pt; mso-layout-grid-align: none"><SPAN
lang=EN-AU><o:p><FONT face="Times New Roman"
size=3> </FONT></o:p></SPAN></P>
<P class=MsoNormal
style="MARGIN: 0in 0in 0pt; mso-layout-grid-align: none"><SPAN lang=EN-AU><FONT
size=3><FONT face="Times New Roman">FIRST PEOPLE’S HEALTH ASSEMBLY AND PEOPLE’S
HEALTH MOVEMENT<o:p></o:p></FONT></FONT></SPAN></P>
<P class=MsoNormal
style="MARGIN: 0in 0in 0pt; mso-layout-grid-align: none"><SPAN
lang=EN-AU><o:p><FONT face="Times New Roman"
size=3> </FONT></o:p></SPAN></P>
<P class=MsoNormal
style="MARGIN: 0in 0in 0pt; mso-layout-grid-align: none"><SPAN lang=EN-AU><FONT
size=3><FONT face="Times New Roman">This was truly a civil society movement that
had roots in popular people’s organisations from around the
globe.<o:p></o:p></FONT></FONT></SPAN></P>
<P class=MsoNormal
style="MARGIN: 0in 0in 0pt; mso-layout-grid-align: none"><FONT size=3><FONT
face="Times New Roman"><SPAN lang=EN-AU>At this assembly the 1500 people
attending provided testimonies of the impact of neoliberalism on their lives,
health, and wellbeing. These testimonies were combined with analysis of the
global economic trends and the role of major public health institutions such as
the WHO and World Bank. Topics discussed included: the ways in which the
international regime that governs global trade is fundamentally unfair and
biased against poor countries; the impact of unsustainable environmental
practices; and the need for a return to people centred primary health care that
focuses on the development needs of communities and not on disease focus
strategies imposed from outside. The People’s Health Movement emerged from this
event. Its philosophy and approach to global health is laid out in the People’s
Health Charter, which has been translated into 42 languages. In July 2005 the
Second People’s Health Assembly took place in </SPAN><st1:place><st1:City><SPAN
lang=EN-AU>Cuenca</SPAN></st1:City><SPAN lang=EN-AU>,
</SPAN><st1:country-region><SPAN
lang=EN-AU>Ecuador</SPAN></st1:country-region></st1:place><SPAN lang=EN-AU> and
was a major milestone in the road back to a public health based on the needs of
ordinary people rather than on the demands of a neoliberal economic
fundamentalism. The catchcry of the Second People’s Health Assembly was ‘‘The
Voices of the Earth are Calling!’’ This captures the grass roots nature of the
movement. The health of the world’s indigenous people received special focus at
the assembly. In so many ways indigenous people highlight what is wrong with our
approach to health. </SPAN><st1:country-region><st1:place><SPAN
lang=EN-AU>Australia</SPAN></st1:place></st1:country-region><SPAN lang=EN-AU>
exemplifies this well. It is one of the world’s richest countries yet the life
expectancy of its indigenous peoples is 20 years less than non-indigenous
Australians. Instead of being celebrated as the first peoples of the land and
given special status, colonial and racist ideas have led to systematic policies
that have seen indigenous people deprived of their land and culture, stolen from
their families, excluded from the economic benefits of the mainstream, and then
blamed and vilified when their health suffered as a<SPAN
style="mso-spacerun: yes"> </SPAN><SPAN style="COLOR: black">result of the
cruel and inhuman policies. Blatant injustices such as this provide the fuel and
passion for the People’s Health
Movement.<o:p></o:p></SPAN></SPAN></FONT></FONT></P>
<P class=MsoNormal
style="MARGIN: 0in 0in 0pt; mso-layout-grid-align: none"><SPAN lang=EN-AU
style="COLOR: black"><o:p><FONT face="Times New Roman"
size=3> </FONT></o:p></SPAN></P>
<P class=MsoNormal
style="MARGIN: 0in 0in 0pt; mso-layout-grid-align: none"><SPAN lang=EN-AU
style="COLOR: black"><FONT size=3><FONT face="Times New Roman">GLOBAL CIVIL
SOCIETY CARES<o:p></o:p></FONT></FONT></SPAN></P>
<P class=MsoNormal
style="MARGIN: 0in 0in 0pt; mso-layout-grid-align: none"><SPAN lang=EN-AU
style="COLOR: black"><o:p><FONT face="Times New Roman"
size=3> </FONT></o:p></SPAN></P>
<P class=MsoNormal
style="MARGIN: 0in 0in 0pt; mso-layout-grid-align: none"><SPAN lang=EN-AU
style="COLOR: black"><FONT size=3><FONT face="Times New Roman">The other signs
of caring about achieving health for all in the 21st century come from the
‘‘Make Poverty History’’ campaign with the goals of ‘‘trade justice, drop the
debt, more and better aid’’. The campaign focuses on the 2.8 billion people
(nearly half the world’s population) who live on less than US$2 per day. It is
driven by a range of non-government organisations and global campaigners such as
Sir Bob Geldof and calls directly on the G8 countries to drop debt for the most
heavily indebted nations and for aid to be increased to 0.7% of GDP as
recommended by the UN Millennium Summit. Achievement of these aims has the
potential to make our world healthier and more equitable. But this will only
happen if what follows is an approach to health and wellbeing that builds on the
early, visionary history of the WHO that recognised that health is not just
about the absence of disease but about improving the quality of everyday life in
terms of our relationships with each other, the safety of and satisfaction with
our schools and workplaces, the quality and sustainability of transport and
housing, the availability of education, sustainability of the environment, and
freedom from violence and war. So often those who want to do good do not act on
this knowledge. Rather they focus on the diseases and believe that tackling them
will do the job of creating more health and equity. So we have seen the
flourishing of bodies such as the Global Fund and Gates Foundation that, with
the best of intentions, set out to tackle a range of infectious diseases. Yet
they do very little to tackle the broad social and economic determinants of
health that dictate who gets what disease. Healthy people are mainly healthy,
not primarily because they have access to good health services (although this
helps), but because they have good food, comfortably homes, live in a peaceful
environment, have good social support, adequate income, and a satisfying job.
The global public health community has to understand and act on this crucial
knowledge about what creates health. Are there any signs this may be
happening?<o:p></o:p></FONT></FONT></SPAN></P>
<P class=MsoNormal
style="MARGIN: 0in 0in 0pt; mso-layout-grid-align: none"><SPAN lang=EN-AU
style="COLOR: black"><o:p><FONT face="Times New Roman"
size=3> </FONT></o:p></SPAN></P>
<P class=MsoNormal
style="MARGIN: 0in 0in 0pt; mso-layout-grid-align: none"><SPAN lang=EN-AU
style="COLOR: black"><FONT size=3><FONT face="Times New Roman">SIGNS OF HOPE:
SECOND PEOPLE’S HEALTH ASSEMBLY AND WHO COMMISSION ON THE SOCIAL DETERMINANTS OF
HEALTH<o:p></o:p></FONT></FONT></SPAN></P>
<P class=MsoNormal
style="MARGIN: 0in 0in 0pt; mso-layout-grid-align: none"><SPAN lang=EN-AU
style="COLOR: black"><o:p><FONT face="Times New Roman"
size=3> </FONT></o:p></SPAN></P>
<P class=MsoNormal
style="MARGIN: 0in 0in 0pt; mso-layout-grid-align: none"><SPAN lang=EN-AU
style="COLOR: black"><FONT size=3><FONT face="Times New Roman">It just could be
that 2005 may be remembered as the year the social and economic determinants of
health began to be taken really seriously globally, nationally, regionally, and
locally. In July 2005 the Second People’s Health Assembly took this knowledge as
central to its deliberations about how to make the world healthier and more
equitable. In March 2005 the WHO launched its own Commission on the Social
Determinants of Health (CSDH). This commission will place a primary emphasis on
the underlying factors that determine how healthy populations are and how
equitably health is distributed within populations. It will emphasise that
health services, while crucial, are only one of the determinants of health and
that most health gain will come from going<o:p></o:p></FONT></FONT></SPAN></P>
<P class=MsoNormal
style="MARGIN: 0in 0in 0pt; mso-layout-grid-align: none"><SPAN lang=EN-AU
style="COLOR: black"><FONT size=3><FONT face="Times New Roman">upstream to focus
on those factors such as employment, housing, quality of living environments,
social relationships, and education that are the main determinants of how
healthy we are. The commission works on the assumption that creating healthy
societies and individuals largely results from action outside the health
sector.<o:p></o:p></FONT></FONT></SPAN></P>
<P class=MsoNormal
style="MARGIN: 0in 0in 0pt; mso-layout-grid-align: none"><SPAN lang=EN-AU
style="COLOR: black"><FONT size=3><FONT face="Times New Roman">The CSDH will use
three key strategies to achieve its aims. Firstly, it will establish knowledge
networks preliminarily entitled: Priority Public Health Diseases; Child Health
and Education; Financing; Human Settlements; Social Exclusion; Employment;
Globalisation; Health Systems, Measurement, Gender and Women’s <SPAN
style="mso-spacerun: yes"> </SPAN>Empowerment. Secondly, it will work with
countries to ensure action on the social and economic determinants of health.
Thirdly, it will work to reform the WHO by ensuring that awareness of the
importance of the social and economic determinants of health informs all its
work and becomes evident in its response to health
issues.<o:p></o:p></FONT></FONT></SPAN></P>
<P class=MsoNormal
style="MARGIN: 0in 0in 0pt; mso-layout-grid-align: none"><SPAN lang=EN-AU
style="COLOR: black"><FONT size=3><FONT face="Times New Roman">The commission
has great potential to assist Dr J W Lee, the current director general, to leave
as his legacy a reformed WHO that is imbued with a strong understanding and
determination to act on the social and economic determinants of health and a
public health community that accepts the inevitable logic and sense of designing
all interventions based on this
understanding.<o:p></o:p></FONT></FONT></SPAN></P>
<P class=MsoNormal
style="MARGIN: 0in 0in 0pt; mso-layout-grid-align: none"><SPAN lang=EN-AU
style="COLOR: black"><o:p><FONT face="Times New Roman"
size=3> </FONT></o:p></SPAN></P>
<P class=MsoNormal
style="MARGIN: 0in 0in 0pt; mso-layout-grid-align: none"><SPAN lang=EN-AU
style="COLOR: black"><FONT size=3><FONT face="Times New Roman">MAKING SOCIAL
DETERMINANTS OF HEALTH CENTRAL<o:p></o:p></FONT></FONT></SPAN></P>
<P class=MsoNormal
style="MARGIN: 0in 0in 0pt; mso-layout-grid-align: none"><SPAN lang=EN-AU
style="COLOR: black"><o:p><FONT face="Times New Roman"
size=3> </FONT></o:p></SPAN></P>
<P class=MsoNormal
style="MARGIN: 0in 0in 0pt; mso-layout-grid-align: none"><SPAN lang=EN-AU
style="COLOR: black"><FONT size=3><FONT face="Times New Roman">The path taken by
the People’s Health Movement and the CSDH is not going to be easy. While more
funding has gone into global health in recent years the overwhelming amount of
it has gone into disease initiatives that do not tackle the underlying social
and economic determinants of health. However, if the People’s Health Movement
and the CSDH are successful in picking up the baton from the earlier Health for
All 2000 movement they may form the vanguard of a successful movement for a
socially just and healthier world in which policy decisions are driven primarily
by this vision rather than by decisions that maximise profit for a small elite.
If the public health community does care about health for all in this century
then it must put its full support behind the People’s Health Movement and the
Commission on the Social Determinants of Health.
<o:p></o:p></FONT></FONT></SPAN></P>
<P class=MsoNormal
style="MARGIN: 0in 0in 0pt; mso-layout-grid-align: none"><SPAN lang=EN-AU
style="COLOR: black; FONT-FAMILY: AdvPED1282; mso-bidi-font-family: AdvPED1282"><o:p><FONT
face="Times New Roman" size=3> </FONT></o:p></SPAN></P>
<P class=MsoNormal
style="MARGIN: 0in 0in 0pt; mso-layout-grid-align: none"><FONT
face="Times New Roman"><SPAN lang=EN-AU
style="FONT-SIZE: 10pt; COLOR: black">Correspondence to: </SPAN><SPAN lang=ES
style="FONT-SIZE: 10pt; COLOR: black; mso-ansi-language: ES">fran.baum@flinders.edu.au<o:p></o:p></SPAN></FONT></P>
<P class=MsoNormal
style="MARGIN: 0in 0in 0pt; mso-layout-grid-align: none"><FONT
face="Times New Roman"><SPAN lang=EN-AU style="COLOR: black"><FONT size=3>(*):
</FONT></SPAN><SPAN lang=EN-AU style="FONT-SIZE: 10pt; COLOR: black">Fran Baum
has been a member of the Global Steering Group of the People’s Health Movement
since 2000 and was appointed as a Commissioner on the WHO Commission on the
Social Determinants of Health in March 2005.</SPAN></FONT><SPAN lang=EN-AU
style="COLOR: black"><o:p></o:p></SPAN></P></FONT></DIV></BODY></HTML>