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The Commission on Social Determinants of Health sets out its vision and goals
This week the Commission on Social Determinants of Health (CSDH), established in 2005 by the then director general of the World Health Organization (WHO), the late Lee Jong-Wook—has released an interim statement.1 It sets out a new vision to achieve what it calls worldwide “health equity”—fairness of opportunity to achieve and maintain good health. The intention is to kickstart a global movement to tackle, at all levels and in all sectors, the social, environmental, economic, and political factors that underpin inequities in health—the so called “causes of the causes” of ill health.
Nearly 30 years ago, WHO brought the community of nations together to issue a call for “health for all by the year 2000.” The Declaration of Alma Ata2 focused on accessible and affordable primary health care worldwide, and on tackling the social and economic causes of ill health. It affirmed that health is a fundamental human right. And it called on governments, international organisations, and the world community to create the opportunity for everyone to attain a level of health that would enable them to lead socially and economically productive lives. Alma Ata was a seminal moment in the history of global public health.
Thirty years on, the world is a very different place. Increased urbanisation, larger trading blocks, increased globalisation, massive aid programmes, deforestation, climate change, international terrorism, cheap air travel, the internet, the collapse of the Soviet Union, the rise of rapidly emerging “tiger” economies, sweatshop working conditions, and low pay have all contributed to major shifts in the world order, and to fundamental changes in the health of the world's peoples.
The commission's interim statement has four main elements. Firstly, it outlines the philosophy and principles behind the new movement—strengthening health equity by seeking to rebalance the socially determined conditions in which people grow, live, work, and age. Secondly, it provides overviews of some of the problems that need to be dealt with, such as differences in life expectancy, health, and wellbeing between different countries and regions, and between people of different sexes, ethnic groups, classes, occupations, and other forms of social stratification. Thirdly, it looks at the main ways in which these gaps can be minimised—the big levers for change. And lastly, it outlines how the commission is amassing the evidence and engaging governments, international organisations, civil societies, and other global big players in driving the messages home.
To pull together the evidence, the commission has established nine “knowledge networks.” It has collected, collated, analysed, and synthesised a vast body of information on a wide range of themes—globalisation, health systems, urban settings, employment and working conditions, early child development, social exclusion, women and equity between the sexes, measurement and evidence, and priority public health conditions. The quest is to identify the most important causal relations, the key areas for action, and the most effective interventions to tackle socially determined inequities worldwide.
Poverty is usually the ultimate cause of inequity. But the commission looks beyond poverty, at the many factors that enmesh people in a poverty trap—from drought and war to sex bias, religious castes, language barriers, unemployment, corruption, lack of investment, and sheer bad government. How can the world community help to ameliorate some of these influences?
The commission admits it has no magic wand. But what it does have—and what has previously been lacking—is a thorough understanding of the links between the various social determinants and the types of ill health they can lead to, and a much better evidence base of how they can be tackled. The statement looks in depth at three case studies. Firstly, a union of female street vendors in India which has set up a wholesale service, crèche facilities, a cooperative bank, and an insurance scheme. Secondly, a state run welfare scheme for poor families in Brazil, with cash grants to mothers, linked to child immunisation and better education. Lastly, a two pronged programme to increase employment and promote cardiovascular health in an economically depressed part of northern Sweden. All three schemes are making a big difference and are sustainable.
The other weapon in the commission's armoury is the mechanism it has set up to engage with the world's movers and shakers. Part of this comes from the high level influence of its 19 prestigious members—from ex-heads of state to world renowned academics, and from senior ministers to leaders of international organisations—and part from the expanding family of “partner countries” who signed up to the process and who are cascading the principles and practice through their own internal networks.
Given that the biggest gains are likely to be made outside the healthcare system, what part can health professionals play in all this? The answer is potentially a very large part. Health networks are among the most firmly established and extensive in the world. As the recent Crisp Report has urged,3 we have powerful means for sharing our knowledge, skills, and expertise with communities and nations who could most benefit from them.
Next year, 30 years after Alma Ata, the Commission will launch its final report with detailed recommendations. But this interim statement initiates the tasks of building a wider and more solid consensus, adding direct experience to the knowledge base, and developing and testing the levers for change. The vision is clear, stark, and unambiguous—health equity is a fundamental human right, a matter of social justice. No self respecting nation should tolerate the persistence of such colossal unfairness and disadvantage. The Commission on Social Determinants of Health seeks not only to open our eyes to this injustice, but to galvanise us all, wherever we are, into doing something about it.
This article was posted on bmj.com on 6 September 2007: http://bmj.com/cgi/doi/10.1136/bmj.39328.478044.80
Competing interests: AM-D is a member of a Department of Health technical group considering the CSDH statement.
Provenance and peer review: Commissioned; not externally peer reviewed.