Lecture given during the pre-APRM workshop on Social Determinants of Health and Global Health Equity, September 11, 2012, Hospital Universiti Kebangsaan Malaysia, Kuala Lumpur

1. Social Determinants of
Health Inequities
Ramon Lorenzo Luis Rosa Guinto, MD
Regional Coordinator for the Asia-Pacific 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. Source: Ravi Narayan, SOCHARA, India

3. Source: Ravi Narayan, SOCHARA, India

4. Source: Ravi Narayan, SOCHARA, India

5. Source: Ravi Narayan, SOCHARA, India

6. Source: Ravi Narayan, SOCHARA, India

7. 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

8. 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,

9. 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”

10. 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.”

11. 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…”

12. 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.

13. McKeown’s Thesis

14. 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)

18. Source: Ravi Narayan, SOCHARA, India

19. Source: David Sanders, South Africa

20. 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

24. Dahlgren and Whitehead, 1991

26. From Fran Baum

27. From Fran Baum

29. Commissioners
• Sir Michael Marmot (Chair)
• 18 others representing academics, politicians,
civil society, senior public health bureaucrats

31. “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

33. 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.

34. 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

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

36. World Conference on SDH
“To engage high level political support to make
progress on national policies to address social
determinants of health to reduce health inequities”

38. Five Thematic Areas
• Adopt better governance
• Promote participation
• Reorient the health sector
• Strengthen global cooperation
• Monitor progress and increase accountability

39. Major Achievements
• Revival of the Alma Ata spirit
• Governments start speaking the SDH language
• WHO engagement with civil society

40. The New “Alma Ata”?
• It needed to be said again.
• We know a great deal more than we did.
• The CSDH gave practical direction to realize
Alma Ata.

43. Major Criticisms
• Avoided the crucial questions – structural
determinants of health
• Lack of coherence with other pressing global
issues
• Rio Declaration drafted behind closed doors –
lack of ambition

45. 1 billion undernourished people
in the developing world
IFPRI, Global Hunger Index 2010

46. two billion people are overweight

47. 3 drivers of dietary change
1. Liberalisation of international food trade
2. Increased foreign direct investment
3. Globalised advertising and marketing
Source: Sharon Friel, Australia

48. Top 10 manufacturers of packaged foods
Three quarters of world food sales involve
processed foods, for which the largest
manufacturers hold over a third of the global
market.
Stuckler et al (2012) Manufacturing Epidemics: The Role of Global Producers in Increased Consumption of Unhealthy Commodities Including
Processed Foods, Alcohol, and Tobacco. PLoS Med 9(6): e1001235. doi:10.1371/journal.pmed.1001235

49. CALL TO ACTION

50. POOR GLOBAL HEALTH
SICK WORLD
HEALTH INEQUITY
within and among nations
SOCIAL, POLITICAL, ECONOMIC,
CULTURAL, AND ENVIRONMENTAL
Determinants of Health

51. SDH to shape the post-MDG world
eradicate extreme improve maternal
poverty and health
hunger
achieve universal combat HIV/AIDS,
primary malaria and other
education diseases
promote gender equality ensure environmental
and empower women sustainability
reduce child develop a global
mortality partnership for
development

53. The Global Health
System and the
link to other
Sectors

54. Revitalize the SDH movement and
enhance capacity for SDH action
at national and sub-national levels

56. Transformative scale-up of medical
education – integrate SDH thinking

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. The Power of Young People
“The youth are
the hope of the
Fatherland.”
Dr. Jose Rizal
National Hero of the Philippines

64. Fathers of Social Medicine

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