From the workshop "Closing the Gap in OUR Generation: Reducing health inequities through action on the global and local determinants of health" held last March 5-9, 2013 in Baltimore, Maryland, USA during the 62nd General Assembly March Meeting of the International Federation of Medical Students' Associations (IFMSA). Brought to you by the IFMSA Global Health Equity Initiative (http://www.ifmsa.org/Activities/Initiatives/The-IFMSA-Global-Health-Equity-Initiative). For more information about the workshop, visit http://www.scribd.com/doc/131377723/Closing-the-Gap-in-OUR-Generation-PreGA-Final

1. Global Health Equity and the
Social Determinants of
Health
Ramon Lorenzo Luis Rosa Guinto, MD
Liaison Officer to the World Health Organization and
Founding Coordinator, Global Health Equity Initiative
International Federation of Medical Students‟ Associations (IFMSA)
Youth Commissioner, Lancet-University of Oslo
Commission on Global Governance for Health

2. Alma Ata, 1978
The International Conference on Primary
Health Care calls for urgent action by all
governments, all health and development
workers, and the world community to protect
and promote the health of all the people of
the world by the year 2000.

3. From Beaglehole and Bonita, 2012

4. Life expectancy at birth (men)
Glasgow, Scotland (deprived suburb) 54
India 61
Philippines 65
Korea 65
Lithuania 66
Poland 71
Mexico 72
Cuba 75
US 75
UK 76
Glasgow, Scotland (affluent suburb) 82
(WHO World Health Report 2006; Hanlon,P.,Walsh,D. & Whyte,B.,2006)

8. Source: Dr. Ramon Paterno, University of the Philippines

9. Mortality over 25 years according to level in the
occupational hierarchy: Whitehall Study
(Marmot & Shipley, BMJ, 1996)

10. Life expectancy and disability-free life expectancy at birth
by neighbourhood income deprivation, 1999-2003

13. Angola

14. Brazil

15. Burkina Faso

16. European Union

17. The Jubilee Line of Health Inequality
Travelling east from Westminster, each tube stop represents
up to one year of male life expectancy lost at birth (2002-06)
Male Life
Expectancy Male Life
78.6 (CI 76.0-81.2) Expectancy
Canning Town 72.8 (CI 71.1-74.6)
Female Life Expectancy
84.6 (CI 82.5-86.7) Female Life
Expectancy
81.4 (CI 79.3-83.6)
Westminster
Canary
London Bridge Wharf
River Thames Canada North
Bermondsey Water Greenwich
Waterloo
Southwark
Electoral wards just a few miles apart geographically have life
expectancy spans varying by years. For instance, there
are eight stops between Westminster and Canning Town
London Underground Jubilee Line on the Jubilee Line – so as one travels east, each stop, on
average, marks up a year of shortened lifespan. 1
1 Source: Analysis by London Health Observatory using Office for National Statistics data revised for 2002-06. Diagram produced by Department of Health

18. Definitions
• Inequalities/Disparities in health – „differences‟ in
health across individuals / population groups
• Inequities in health – avoidable differences
• „Where systematic differences in health are judged to be
avoidable by reasonable action they are, quite simply,
unfair. It is this that we label health inequity.‟ WHO
Commission on Social Determinants of Health (2008)
From Mike Rowson, 2011

19. Definitions
• Horizontal equity – equal access for equal needs
• Vertical equity – unequal access for unequal needs
From Mike Rowson, 2011

22. Elaboration of disparities in wealth
• The world‟s richest 1% receive income = to the poorest
57%
• The income of the world‟s richest 5% = 114 X that of the
poorest 5%
» UN Human Development Report 2002

23. Champagne Glass

24. Social Production of Disease
Do we not always
find the diseases of
the populace
traceable to defects
in society?
Dr. Rudolf Virchow
Father of Social Medicine

25. Source: Ravi Narayan, SOCHARA, India

26. Source: Ravi Narayan, SOCHARA, India

27. Source: Ravi Narayan, SOCHARA, India

28. Source: Ravi Narayan, SOCHARA, India

29. Source: Ravi Narayan, SOCHARA, India

30. Rudolf Virchow
remedy for
epidemics was:
“prosperity, education
& liberty”
Doctor, Pathologist, Biologist, Politician: first to recognize
Leukemia, elucidated embolism, founded “Social Medicine”
founded discipline of Anthropology,

31. The Constitution of WHO, 1948
“Health is a state of complete physical,
mental, and social well-being and not
merely the absence of disease or
infirmity… a fundamental human right”

32. Alma Ata Declaration
“Economic and social
development… is of basic
importance to the fullest
attainment of health for all and
to the reduction of the gap
between the health status of
the developing and developed
countries.”

33. Alma Ata Declaration
“Involves, in addition to the
health sector, all related
sectors and aspects of national
and community development,
in particular agriculture, animal
husbandry, food, industry,
education, housing, public
works, communications and
other sectors…”

34. Ottawa Charter
• The Ottawa Charter for Health
Promotion (WHO 1986)
identified 8 key determinants
(prerequisites) of health:
• peace, shelter, education, food,
income, a stable eco-system,
sustainable resources, social
justice, and equity.

35. McKeown‟s Thesis

36. Tuberculosis
TB deaths in England
4.5
4 BCG Vaccination
3.5
3
2.5
2 Streptomycin
1.5
1
0.5
0
1838 1860 1880 1900 1920 1940 1960
TB deaths
* David Werner, Questioning the Solution: The Politics of Primary Health Care and Child Survival,
Healthwrights, 1997, p. 76. (cited also in WHO SDH Background papers)

40. Source: Ravi Narayan, SOCHARA, India

41. Source: David Sanders, South Africa

42. Social Determinants
of Health
• Conditions in the
social, physical, and economic
environment in which people are
born, grow, live, work, and
age, including access to health care
• Policies, programs, and institutions
• Social structure, community factors

46. Dahlgren and Whitehead, 1991

48. From Fran Baum

49. Epidemiology of Inequality

53. “Unequal distribution of health-damaging
experiences is not in any sense a „natural'
phenomenon, but is a result of the toxic
combination of poor
social policies and
programs, unfair
economic arrangements
and bad politics.”
WHO Commission on Social
Determinants of Health, 2008

54. Commission on Social
Determinants of Health
1. Improve Daily Living Conditions
2. Tackle the Inequitable Distribution
of Power, Money, and Resources
3. Measure and Understand the
Problem and Assess the Impact of
Action.

55. CSDH Report: Action Areas
• Equity from the start
Daily Living Conditions
• Healthy places- healthy people
• Fair employment –decent work
• Social protection across the life course
• Universal health care
• Health Equity in All Policies
Power, Money and • Fair financing
Resources • Market responsibility
• Gender equity
• Political empowerment – inclusion and voice
• Good global governance
Knowledge, Monitoring • Monitoring, research, training
and Skills • Building a global movement
Full report downloadable at http://www.who.int/social_determinants/en/
Source: Fran Baum, Flinders University

56. Basic question: What good does it do to treat people‟s
Illnesses …
only to send them back to the conditions
that made them sick?

58. The new physician as champion of social
determinants approach to health

61. From Fran Baum

62. The Power of Medicine
"Medicine… has the
obligation to point out
problems and to attempt
their theoretical
solution…The physicians
are the natural attorneys
of the poor…”
Dr. Rudolf Virchow
Father of Social Medicine

63. Health for All!
Alma Ata, USSR, 1978 Almaty, Kazakhstan, 2008
Thank You Very Much!