The World Health Organisation that carried out a three-year analysis of the ‘social determinants’ of health concludes that “social injustice is killing people on a grand scale”

Life expectancy of children in India is better than those in deprived suburbs of Glasgow, and a man in India lives longer than a black man living in Washington DC, says a latest report from the World Health Organisation (WHO).

The reasons are almost entirely social, like those that ensure that the Japanese and Swedes live longer than the Ukrainians, and why aborigines in Australia, on average, die 17 years earlier than non-aborigines.

After a three-year analysis, a panel of experts forming the WHO’s Commission on the Social Determinants of Health are convinced that social factors, rather than genetics, are responsible for huge variations in ill-health and life expectancy around the world.

Citing an example, they say a boy living in the Glasgow suburb of Calton is expected to live to 54, 28 years less than a boy born in affluent Lenzie nearby. That same child from Calton will typically have a shorter life than a child born in India, where life expectancy is 62.

Government policies that contribute to the gap between rich and poor, and wider social injustices are “killing people on a grand scale” in almost all countries around the world, say the experts.

Millions of people die globally due to lack of healthcare facilities. “A toxic combination of bad policies, economics and politics is largely responsible for a majority of people in the world being deprived of good health that is biologically possible,” says the report.

Titled ‘Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health’, the report, presented to WHO Director General Dr Margaret Chan in Geneva on August 28, claims that health inequities -- unfair, unjust and avoidable causes of ill health -- have long been measured between countries.

The commission brought together an international team of academics, politicians and medical experts from around the world, including two former heads of state (a president of Chile and a prime minister of Mozambique) and two former directors of the US Centres for Disease Control and Prevention. It also included Nobel laureate Amartya Sen.

The team of commissioners combed through health data from around the world and, based on the evidence, drew up recommendations to narrow the inequalities of circumstance and opportunity that affect health.

It found evidence to suggest that, in general, poor people are worse off than those less deprived. It also found that the less deprived are in turn worse than those with average incomes, and so on.

“This slope, linking income and health, is the social gradient, and is seen everywhere -- not just in developing countries but all countries including the richest. This slope may be more or less steep in different countries, but the phenomenon is universal,” says the report.

While there has been an enormous increase in global wealth, technology and living standards, in recent years, the distribution of services and institution-building, especially in low-income countries, is unfair.

However, wealth alone does not determine the health of a nation’s population. Some low-income countries such as Cuba, Costa Rica, China, Sri Lanka and the state of Kerala in India have achieved levels of good health despite relatively low national income.

But, the commission points out, wealth could be wisely used. Much of the work to redress health inequities lies beyond the health sector. According to the report, waterborne diseases are not caused by lack of antibiotics but by dirty water and by the political, social and economic forces that fail to make clean water available to all.

“We rely too much on medical intervention as a way of increasing life expectancy. A more effective way of increasing life expectancy and improving health would be for every government policy and programme to be assessed for its impact on health and health equity.”

Sir Michael Marmot, chairman of the 19-member commission and professor of epidemiology and public health at University College London, says there was evidence from around the world of successful interventions on the social determinants of health.

The commission makes three recommendations to tackle the “corrosive effects of inequality of life chances”. These are: improving daily living conditions, including the circumstances in which people are born, grow, live and work; tackling the inequitable distribution of power, money and resources -- the structural drivers of these conditions; and measuring and understanding the problem to assess the impact of action.

“We do have the knowledge which, if applied today, could really make a difference to inequities in health between and within countries,” he said. “Differences in health between groups that are avoidable and could be avoided by social action are quite simply unfair.”

Inequities within countries:

• Life expectancy for indigenous Australian males is shorter by 17 years than all other Australian males.
• Maternal mortality is three to four times higher among the poor compared to the rich in Indonesia. The difference in adult mortality between least and most deprived neighbourhoods in the UK is more than 2.5 times.
• Child mortality in the slums of Nairobi is 2.5 times higher than in other parts of the city. A baby born to a Bolivian mother with no education has a 10% chance of dying, while one born to a woman with at least secondary education has a 0.4% chance.
• In the United States, 886,202 deaths would have been averted between 1991 and 2000 if mortality rates between white and African Americans were equalised. (This contrasts with 176,633 lives saved in the US by medical advances in the same period.)
• In Uganda, the death rate of children under five years in the richest fifth of households is 106 per 1,000 live births, but in the poorest fifth of households in Uganda it is worse -- 192 deaths per 1,000 live births. That is, nearly a fifth of all babies born alive to the poorest households are destined to die before they reach their fifth birthday. Set this against an average death rate for under-fives in high-income countries of seven deaths per 1,000.

The commission recommends that countries set up an inter-agency mechanism to ensure effective collaboration and coherent policy between all sectors for early childhood development, and aim to provide early childhood services to all young citizens. Investing in early childhood development provides one of the best ways to reduce health inequities. Evidence shows that investment in the education of women pays for itself many times over.

Billions of people live without adequate shelter and clean water. The commission’s report pays particular attention to the increasing numbers of people who live in urban slums, and the impact of urban governance on health. The commission joins other voices in calling for a renewed effort to ensure water, sanitation and electricity for all, as well as better urban planning to address the epidemic of chronic disease.

Health systems also have an important role to play. While the commission report shows how the health sector cannot reduce health inequities on its own, providing universal coverage and ensuring a focus on equity throughout health systems are important steps.

The report highlights how over 100 million people are impoverished due to paying for healthcare -- a key contributor to health inequity. The commission thus calls for health systems to be based on principles of equity, disease prevention and health promotion, with universal coverage, based on primary healthcare.

The feasibility of action is indicated in the change that is already occurring. Egypt has shown a remarkable drop in child mortality from 235 to 33 per 1,000 in 30 years. Greece and Portugal reduced their child mortality from 50 per 1,000 births to levels nearly as low as Japan, Sweden and Iceland. Cuba achieved more than 99% coverage of its child development services in 2000. But trends showing improved health are not pre-ordained. In fact, without attention health can decline rapidly.

The WHO will now make the report available to member states which will determine how the health agency is to respond. And the key may just be political will.

Any government official -- or doctor, for that matter -- who tries to improve population health has basically just two options. One is to push the frontiers constantly, improving basic health knowledge and medical technology. The other is to work with existing knowledge and technology, but to concentrate on allocating it efficiently.

Almost all the WHO’s recommendations fall into the latter category, and the commissioners are convinced that focusing on the social determinants of health will save both lives and cash in the long run. That’s not to say that lab breakthroughs won’t bring all kinds of new health benefits in the decades to come. “But we don’t need to wait for those new breakthroughs to make enormous differences,” says Marmot.

Source: The Hindu, September 2, 2008
             PTI, August 29, 2008
             http://www.ft.com, September 2008
             http://www.time.com, September 2008
             http://www.who.int/en/, September 2008