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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
Source: Ravi Narayan, SOCHARA, India
Source: Ravi Narayan, SOCHARA, India
Source: Ravi Narayan, SOCHARA, India
Source: Ravi Narayan, SOCHARA, India
Source: Ravi Narayan, SOCHARA, India
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
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,
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”
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.”
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…”
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.
McKeown’s Thesis
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)
Source: Ravi Narayan, SOCHARA, India
Source: David Sanders, South Africa
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
Dahlgren and Whitehead, 1991
From Fran Baum
From Fran Baum
Commissioners
• Sir Michael Marmot (Chair)
• 18 others representing academics, politicians,
  civil society, senior public health bureaucrats
“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
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.
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
Basic question: What good does it do to treat people’s
                      Illnesses …




only to send them back to the conditions
          that made them sick?
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”
Five Thematic Areas

•   Adopt better governance
•   Promote participation
•   Reorient the health sector
•   Strengthen global cooperation
•   Monitor progress and increase accountability
Major Achievements

• Revival of the Alma Ata spirit
• Governments start speaking the SDH language
• WHO engagement with civil society
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.
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
1 billion undernourished people
                                            in the developing world




IFPRI, Global Hunger Index 2010
two billion people are overweight
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
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
CALL TO ACTION
POOR GLOBAL HEALTH
      SICK WORLD



      HEALTH INEQUITY
   within and among nations




 SOCIAL, POLITICAL, ECONOMIC,
CULTURAL, AND ENVIRONMENTAL
     Determinants of Health
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
The Global Health
 System and the
  link to other
     Sectors
Revitalize the SDH movement and
 enhance capacity for SDH action
at national and sub-national levels
Transformative scale-up of medical
education – integrate SDH thinking
The new physician as champion of social
       determinants approach to health
From Fran Baum
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
The Power of Young People

“The youth are
the hope of the
  Fatherland.”

     Dr. Jose Rizal
 National Hero of the Philippines
Fathers of Social Medicine
Health for All!




Alma Ata, USSR, 1978   Almaty, Kazakhstan, 2008


         Thank You Very Much!

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Social Determinants of Health Inequities Explained

  • 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.
  • 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)
  • 15.
  • 16.
  • 17.
  • 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
  • 21.
  • 22.
  • 23.
  • 25.
  • 28.
  • 29. Commissioners • Sir Michael Marmot (Chair) • 18 others representing academics, politicians, civil society, senior public health bureaucrats
  • 30.
  • 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
  • 32.
  • 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”
  • 37.
  • 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.
  • 41.
  • 42.
  • 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
  • 44.
  • 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
  • 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
  • 52.
  • 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
  • 55.
  • 56. Transformative scale-up of medical education – integrate SDH thinking
  • 57.
  • 58. The new physician as champion of social determinants approach to health
  • 59.
  • 60.
  • 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!