Health is social, not medical

December 16, 2008

     By Duncan Green     

It is often argued that municipal sanitation, rather than doctors, ended the periodic scourges of cholera and other disease that afflicted Victorian Britain (e.g. see here). Now the World Health Organization has adopted an even broader version of the argument in the new report of its Commission on Social Determinants of Health. It marks a significant shift in WHO thinking.

Chaired by British public health guru Sir Michael Marmot, and including Amartya Sen among its members, the Commission broke new ground on both process and content. On process, it brought together a global network of policy makers, researchers and civil society organizations, explicitly aiming to ‘foster a global movement’ that will endure after the report’s publication.

On content, the commission to some extent went back to earlier debates in the 1970s, with an emphasis on primary health care, systems and equity, rather than high tech magic bullets. As the Commission’s name implies, it focussed on the social origins of ill health, arguing that ‘the high burden of illness responsible for appalling premature loss of life arises in large part because of the conditions in which people are born, grow, live, work and age’. Its radical proposals are based on the need to seek ‘social justice’ in order to ‘tackle the inequitable distribution of power, money and resources’.

Some of the stats linking equity and health are striking – in the US, nearly 900,000 deaths would have been averted from 1991-2000 if mortality rates between white and African Americans were equalised. A boy born in the poor suburb of Calton, Glasgow has a life expectancy of 54, less than the average for a child born in India and 28 years lower than a child born a few miles in a more affluent part of the Scottish city.

The Commission sets out three principles for action:

1. Improve the conditions of daily life, covering everything from comprehensive provision of essential services during early life (particularly important in determining a lifetime’s good/ill health); a focus on health equity in urban planning and labour policies, and a commitment to universal social protection

2. Tackle the inequitable distribution of power, money and resources, based on ‘strong public sector leadership and adequate public expenditure. This in turn implies progressive taxation.’ The Commission is sceptical on privatization and ‘commercialization of vital social goods.’

3. Improve measurement, train workers and raise public awareness. This begins with the most elementary information – globally, 36% of births are not even registered, leaving the authorities with only the most patchy knowledge of health inequalities.

The WHO’s message contrasts with a growing number of reports linked to groups such as the World Bank’s International Finance Corporation, the Global Fund to Fight Aids, Tuberculosis and Malaria, and the Gates Foundation, on the failure of public systems and the ability of the private sector to deliver health services for poor people effectively. Interestingly, all three are linked by one thread: the IFC report on the Business of Health in Africa, sponsored by the Gates Foundation, was researched and produced by McKinsey and Co. whose former MD, Rajat Gupta is now Chair of the Global Fund.

But the WHO’s approach fits well with the messages of Oxfam in general, and From Poverty to Power in particular. Our most recent overview on essential services also argued for what the Commission calls the ‘primary role of the state in the provision of basic services.’ More broadly, the Commission argues for a combination of active citizens and effective states as crucial in tackling deep social and economic inequalities that underpin global ill health. Music to my ears.


December 16, 2008
Duncan Green