So says a report from the World Health Organization (WHO) titled Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health. Actually, their language is even stronger: inequities are killing people on a grand scale. As the press release states,
"A child born in a Glasgow, Scotland suburb can expect a life 28 years shorter than another living only 13 kilometres away. A girl in Lesotho is likely to live 42 years less than another in Japan. In Sweden, the risk of a woman dying during pregnancy and childbirth is 1 in 17 400; in Afghanistan, the odds are 1 in 8. Biology does not explain any of this. Instead, the differences between – and within – countries result from the social environment where people are born, live, grow, work and age."
The report investigates precisely these social determinants of health, especially health inequities defined as "unfair, unjust and avoidable causes of ill health." The report not only examines health inequities between countries but also what it calls health gradients, that is, health inequities within countries:
- Life expectancy for Indigenous Australian males is shorter by 17 years than all other Australian males.
- Maternal mortality is 3–4 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 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 equalized. (This contrasts to 176 633 lives saved in the US by medical advances in the same period.)
- In Uganda the death rate of children under 5 years in the richest fifth of households is 106 per 1000 live births but in the poorest fifth of households in Uganda it is even worse – 192 deaths per 1000 live births – that is nearly a fifth of all babies born alive to the poorest households destined to die before they reach their fifth birthday. Set this against an average death rate for under fives in high income countries of 7 deaths per 1000.
These health gradients are in turn related to social gradients: the poor are worse off than the less deprived, the less deprived are worse off than the average income earners, etc. These social gradients are found in all countries, from the poorest to the richest.
Another important point noted in the report is that wealth or economic growth are not the major factors in reducing health inequities. Mechanisms of redistribution work better:
"Economic growth is raising incomes in many countries but increasing national wealth alone does not necessarily increase national health. Without equitable distribution of benefits, national growth can even exacerbate inequities. (…)
Wealth alone does not have to determine the health of a nation’s population. Some low-income countries such as Cuba, Costa Rica, China, state of Kerala in India and Sri Lanka have achieved levels of good health despite relatively low national incomes. But, the Commission points out, wealth can be wisely used. Nordic countries, for example, have followed policies that encouraged equality of benefits and services, full employment, gender equity and low levels of social exclusion. This, said the Commission, is an outstanding example of what needs to be done everywhere."
In other words, and unsurprisingly, social democratic models tend to work best rather than leaving it more or less to market mechanisms.
The report also notes that solutions to many of these problems are social and not to be narrowly confined in the health sector:
"Much of the work to redress health inequities lies beyond the health sector. According to the Commission’s report, "Water-borne diseases are not caused by a lack of antibiotics but by dirty water, and by the political, social, and economic forces that fail to make clean water available to all; heart disease is caused not by a lack of coronary care units but by lives people lead, which are shaped by the environments in which they live; obesity is not caused by moral failure on the part of individuals but by the excess availability of high-fat and high-sugar foods." Consequently, the health sector – globally and nationally – needs to focus attention on addressing the root causes of inequities in health."
It is therefore the job of governments to provide the social conditions that promote health and healthy lifestyle rather than just medical interventions. This is a very activist stance and a very liberal one (not very surprising considering the presence of Amartya Sen – Wikipedia page – on the committee). So what are the committee’s recommendations?
"Based on this compelling evidence, the Commission makes three overarching recommendations to tackle the "corrosive effects of inequality of life chances":
- Improve daily living conditions, including the circumstances in which people are born, grow, live, work and age.
- Tackle the inequitable distribution of power, money and resources – the structural drivers of those conditions – globally, nationally and locally.
Note the Weberian reference to life chances and the thoroughly sociological perspective.
In addition to these three overarching recommendations, the committee has more specific ones, as noted by Rachel Stevenson in the Guardian:
- Quality care for all mothers and children from the child’s birth.
- Compulsory primary and secondary education for all children, regardless of ability to pay.
- Improved living conditions, such as water, sanitation, paved roads and affordable housing for all.
- Health equity at the centre of all urban planning, for example, using designs that promote physical activity.
- Full and fair employment, with improved working conditions and wages that take into account the real cost of living.
- Universal welfare programmes that ensure everyone has the level of income needed for healthy living.
- Universal health care provision.
- The highest level of government taking responsibility for action on health, and all government policies being assessed for their impact on health equity.
- Increase public spending on tackling the social determinants of health.
- Ensure rich countries honour their commitments to increase aid and debt relief to poorer countries.
- Ensure international finance institutions use transparent terms and conditions for international borrowing and lending.
- Reinforce the role of the state in providing basic services such as water/sanitation and regulating goods such as tobacco, alcohol, and food.
- Address gender biases through anti-discrimination laws, providing equal opportunities and pay for men and women.
- Establish national and global surveillance systems for routine monitoring of health inequity and the social determinants of health, such as the compulsory registering of all births, free of charge to the parents/carers.
- Make health equity a global development goal, and strengthen multilateral action.
- Measure and understand the problem and assess the impact of action.
Again, these involve a very specific and interventionist policy framework. The question, as usual, will be how much of this will be payed lip service to, while more or less ignored.