A new report from the World Health Organization suggests that the reason most people in the world do not enjoy the good health that their bodies potentially offer from a biological perspective is due to a “toxic combination of policies, economics, and politics” and if this is to change, the world must unite to put equity at the centre of the agenda for human health and development.

The report reveals stark contrasts within and between countries. For example, a child born in a suburb of Scotland’s city of Glasgow has a life expectancy that is 28 years shorter than one living only 13 kilometers away. And a girl in Lesotho, a country landlocked and surrounded by the Republic of South Africa, can expect to live 42 years less than one in Japan. In Afghanistan 1 out of every 8 pregnant women dies either during pregnancy or giving birth compared to 1 in 17,400 in Sweden.

An eminent group of policy makers, academics, former heads of state and former ministers of health have been working for three years to put the report together under the auspices of the World Health Organization’s Commission on the Social Determinants of Health and present its findings to Dr Margaret Chan, Director-General of the WHO.

Their conclusion is:

“Social injustice is killing people on a grand scale.”

Chan welcomed the report, saying that “unprecedented leadership” was now needed to galvanise action and compel all actors, including those not directly involved in health, to examine their impact on it.

“Primary health care, which integrates health in all of government’s policies, is the best framework for doing so,” said Chan.

Chair of the Commission, Sir Michael Marmot, said:

“Central to the Commission’s recommendations is creating the conditions for people to be empowered, to have freedom to lead flourishing lives.”

He highlighted the plight of women and their lack of empowerment, which results in poor health for many.

“Following our recommendations would dramatically improve the health and life chances of billions of people,” he added.

Some of the the “health gradients” revealed by the report include:

  • Life expectancy for indigenous Australian men is 17 years shorter than all other Australian men.
  • In Indonesia, poor women are 3 to 4 times more likely to die in pregnancy or childbirth than rich women.
  • 1 in 10 babies born in Bolivia to mothers with no education die, while this figure is less than 1 in 200 for babies born to educated mothers.
  • In the UK adult mortality is 2.5 times higher in the most compared to the least deprived neighbourhoods.
  • If mortality rates between white and African Americans were equalized, 886,202 fewer people would have died between 1991 and 2000.
  • This is over four times the number of deaths averted by medical advances over the same period (176,633).
  • In high income countries the average death rate for children under 5 years old is 7 per 1,000 live births. In Uganda it ranges from 106 per 1,000 live births in the poorest, to 192 in the richest households.

The Commission found that while economic growth is raising incomes in many countries, it is not enough to increase national health: there has to be equal access to benefits as well, and in some cases, national growth can widen the gap between those who have access and those who have not. Fair distribution of the increasingly sophisticated and technologically advanced services is the key issue, which means more institution and infrastructure building, especially in low income nations.

In 1980, countries with the richest 10 per cent of the world’s population had a gross national income that was 60 times that of the countries with the poorest 10 per cent of people. Today that figure has widened to 122 said the Commission, pointing out that the situation is even worse than that because the poorest 20 per cent of people in many low income countries are actually experiencing a decline in their share of national consumption.

It is not wealth that ensures a nation’s health, said the report, giving examples like China, Costa Rica, Cuba, the state of Kerala in India and Sri Lanka, whose people have secured good levels of health despite living in countries of low national income. They also pointed to the success of Nordic countries that use their wealth wisely and promote strong equity policies such as equality of access to benefits and jobs, gender equity and low social exclusion. These are outstanding examples, said the Commission.

The Commission also pointed to solutions that lie beyond the health sector such as sanitation, lifestyle, environment, and food availability. As Sir Michael explained:

“We rely too much on medical interventions 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; to make health and health equity a marker for government performance,” he added.

The Commission makes three recommendations:

  1. Improve daily living conditions, including the circumstances in which people are born, grow, live, work and age.
  2. Tackle the inequitable distribution of power, money and resources — the structural drivers of those conditions — globally, nationally and locally.
  3. Measure and understand the problem and assess the impact of action.

The lead Editorial in this week’s Lancet is timed to coincide with the release of the WHO Commission’s report. The journal has been linked to the work of the Commission from the start, when it supported the launch of the initiative in March 2005, and has been involved in various other ways since then.

The Editorial said that the Commission’s most refreshing conclusion is that optimism, vigour and “muscular policy” can overcome “hopelessness, impotence, and paralysis”.

The Editorial concludes that:

“After 3 years of gathering evidence, the Commission on Social Determinants of Health has performed an invaluable service in making the health case for a fairer society. It is a case that deserves the full support of health professionals and policymakers in all countries. At last equity is taking its rightful place at the centre of public debate about health. The Commission’s report is a fitting tribute to Dr J W Lee, WHO’s late Director-General who initially commissioned this brave project.”

“Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health.”
Commission on Social Determinants of Health – Final Report.
World Health Organization, 28 August 2008.

Click here for the full report (10.31 MB), a summary (5.34 MB), or to order a hard copy.

Sources:WHO, The Lancet.

Written by: Catharine Paddock, PhD