About the Social Determinant of Health

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November blog                                                                                           

  Claudio Schuftan

This is a bit belated report from the Rio World Conference on the Social Determinants of Health. The conference was convened by the World Health Organization together with the government of Brazil, to whom many thanks, for their enabling many colleagues from the People’s Health Movement to attend.

The conference was billed as the way to advance the cause of Closing The Gap in a Generation (1), the report of the WHO Commission on the Social Determinants of Health. Cynics had a feeling that it would be nothing of the kind, and once again, the facts supported cynicism, I am sorry to say. Preparations for the conference turned out to be a case study of what is now amounting to a kind of ‘war of the words’. This is being fought between all those in the UN system and member states who believe in public health and public goods, and those who remain committed to ‘business as usual’ at the time when the world’s financial institutions and banks are collapsing under the weight of their own greed.

Successive drafts of the final conference’s Political Declaration were covered in crossed-out and bracketed clauses and phrases, as the wealthy nations got to work, ‘toning down’ and eliminating almost all traces of real quantifiable concrete measurable and accountable progress on behalf of the majority of people in the world whose suffering increases.

As battle-scarred public health warriors expected, the powerful nations won most of the battles. But not all.  We did not come or go quietly, and it became apparent in the conference that more and more key people in the UN system and national governments have also concluded that the current systems of political, financial and social governance are broken. In clear interventions, WHO director-general Margaret Chan indicated this almost in so many words. But UN agencies are choked with executives who believe in alliances with the transnational corporations that with its allies are wrecking our world. Some of these executives will perhaps be working for such corporations in due course. That’s where the stock options and nice pensions are.

The frustration in the conference halls was so intense that no less than three alternative declarations were circulated. One of them came from the organisation of which I am a member, the People’s Health Movement; one from the Latin American Association of Social Medicine (www.alames.org ); and one from the International Federation of Medical Students’ Associations (www.ifmsa.org ). Revealing too was the fact that the representative of civil society in the panel in the closing ceremony, our PHM colleague David Sanders, was the one person during the three days to receive a standing ovation from the floor. He made comments fully in line with what I say here below.




Sir Michael Marmot, chair of the WHO Social Determinants Commission, was at the centre of the Rio conference. We believe he is as frustrated as we are. Here is what he said in a recent issue of the WHO Bulletin (2). I insert my own comments.

‘Closing the Gap in a Generation is a rousing call. Did the World Health Organization’s Commission on Social Determinants of Health really believe it to be possible? Technically, certainly’. (This is a telling word. It’s code for saying that there is pressure to take the politics out of policy issues and reduce them to technical ‘fixes’)

‘Yes, there is a greater than 40-year spread in life expectancy among countries and dramatic social gradients in health within countries. But the evidence suggests that we can make great progress towards closing the health gap by improving, as the Commission put it, the conditions in which people are born, grow, live, work and age.  These include ensuring: equity for every child from the start, healthier environments, fair employment and decent work, social protection across the life course and universal health care. To make such progress, we must also deal with inequalities in power, money and resources – the social injustice that is killing on a grand scale. At a more fundamental level, our vision is to create the conditions so that every person may enjoy the freedoms that lead to improved health – what we call empowerment’. (And does he believe that this now is really happening? Read on…)

In the three years since Closing the Gap in a Generation was published, there is no question that there is much to make us gloomy: the global financial crisis and the steps put in place to deal with it have worse impacts on the poor and relatively disadvantaged; the persistence of bad governance nationally and globally; climate change and inequitable measures for mitigation and adaptation and, in many countries, an increase in health inequalities’. (Quite. Exactly. He then goes on to make some rather vague positive points. But the signal is clear. The only conference that could start to make a real difference in favour of rights, equity and justice would be one that resulted in a Declaration that acknowledged the outrageous misery and poverty that has been and is being accelerated by the present dominant systems of governance. Did that happen? No, it did not. Did Michael Marmot expect this would happen? I have not asked him).






                                                                              Rudolf Virchow



The People’s Health Movement was invited by the WHO Commission on the Social Determinants of Health to give evidence, and to contribute to the Commission’s report which was published in 2008 (1).This we did. Since then it has become increasingly evident to us that the most powerful WHO member states – that is, national governments – are reluctant to redress, or even to discuss or acknowledge, the power politics that year in, year out, worsen health inequities.


Constantly, states of health and disease of populations are being reduced to technical issues, whereas in truth, these are political. This was understood during the Industrial Revolution, as the quotation from the great epidemiologist, pathologist and reformer Rudolf Virchow makes clear. Health inequities are determined by the social conditions in which people are born, grow, live, work, and age. This has always been well-known by those prepared to see what is in front of their eyes and to face these facts. Public health pioneers, such as Rudolf Virchow saw this. Robert Koch devoted a key part of his Nobel laureate speech in 1905 to the issue. Brock Chisholm, the first director-general of the World Health Organization, said in 1949 that ‘the death rate from pulmonary tuberculosis is now everywhere accepted as a sensitive index to the social state of a community’.


Margaret Chan, the current WHO director-general, also understands this, as well she might. In her opening address to the Rio conference she said: ‘Governments have responsibility towards people and their health… People are pushed into poverty due to catastrophic medical bills, and many governments are not preventing that. Progress in a civilised world should mean more than simply making more and more money. Globalisation was set to be the rising tide that would lift all boats, this never happened. It lifted the big boats but tended to sink many of the small ones. Globalisation creates benefits, sometimes big ones, but has no rules that ensure the distribution of those benefits. The world now is highly interconnected, but the prevailing goal remains to fulfil economic benefits and not to distribute them fairly or evenly. As a result differences in income, access to care, health outcomes are greater today than in any time in history’. Well said, but it would have been nice if  Dr Chan stayed until the last day when the Political Declaration was presented. Instead, she left the night before the Conference ended. Is there a hint here?


Public health is not technical, it is political


The social determinants of health cannot be addressed by fixes that address policy coherence and inter-sectoral action in health, as is being called for. Platitudes like ‘inter-sectoral action’ and ‘policy coherence across sectors’ do nothing to address the continuing violation of the right to health. It is not policy incoherence that causes the negative impact of dominant macro-economic policies on health. Actually there is significant policy coherence across sectors, including the health sector. But these policies have been greatly influenced by the currently dominant political and economic ideology. This is the issue. It has promoted a ‘market’ approach that in effect privatises public health.


Why is this continually glossed over? Why are the features of what is a reckless and ruthless not recognised? Corporations remaining free to do whatever they want to protect their bottom line. Capital flight, and a continued unfair regime of patents especially of medicines are all widening health inequities in health, across the world. This is why obesity and diabetes have become not merely epidemic, but pandemic.


For us at the People’s Health Movement, comprehensive primary health care is the backbone of any equitable health system, but it cannot be supported without active community involvement. The same is true for nutrition.


Primary health care needs publicly provided, publicly accountable health care services, working in partnership with the communities from which the people who become patients live. It involves working with community networks and organisations and engaging with communities. This can never be properly provided by private systems whether or not these are supported by health insurance schemes. Health care provision has been increasingly privatised over the last three decades. Indeed, Big Pharma has become less and less regulated. Poor social policies and programmes, unfair economic arrangements, and bad politics, are robbing an increasing proportion of populations all over the world of the opportunity to lead healthy lives. Reduction of public health and nutrition inequities depends on reform of the global economy and of geopolitics generally.


The evil of ‘trade-offs’


Taking an non-political approach to such issues by saying, as we constantly hear,  that conflicts and trade-offs between the interests of different sectors are inevitable, or that taking necessary actions will result in some negative impacts or costs for some groups, is mistaken. Differences among countries, between social classes, between men and women, between corporations and communities, can be reduced. These all are caused by the power politics that determine which actions will be taken and which will not, on the social determinants of health and nutrition. Willingness to transfer real power to communities is the key.


This is what we in the People’s Health Movement reminded delegates, in our own statements made before and during the Rio conference. But relentless pressures from the US and Europe continue to force governments of vulnerable and impoverished countries to sign up to basically unfair free trade agreements. These agreements force weak government to open their markets to – among many other items – the ultra-processed food and drink products that enrich and further empower transnational corporations. Reform of the global agricultural trade regime has continued to stall for years. Food systems thus become increasingly insecure and fragile.


The combination of the opening up of markets to the transnationals, massive subsidies to agribusiness in the North, and intellectual property rights that unfairly protect big business, gives increasing power to the transnational seeds, agribusiness and food and drink corporations, and undermines national food sovereignty. This process continues to accelerate. Thus between 1990 and 2001, foreign sales of the biggest food-related transnational corporations rose from $US 88.8 billion to $US 234.1 billion, with total foreign assets rising from $US 34.0 billion to $US 257.7 billion. These corporations increasingly dominate the global food supply system, which includes seeds, fertilisers and pesticides, the production, processing and manufacturing of food and drink products, and how these are marketed to consumers.


This trend, together with factors like speculation that creates chaos in food prices, the increasing proportion of US corn being used for bio-fuels, and the impact of industry-generated climate change, is primarily responsible for the recent critical food shortages in many impoverished countries. Food price increases and fluctuations in the last few years have done enormous damage to the reductions achieved in poverty and hunger in the past two decades. Such food insecurity has contributed to continuing widespread malnutrition, as evidenced by high stunting rates and micronutrient malnutrition, with an estimated 854 million undernourished people worldwide in 2001-2003. The UN Food and Agriculture Organizations estimates that food price rises alone have caused at least 50 million more people becoming hungry. At the same time, supplies of degraded ultra-processed snack products, sugared drinks and other degraded edible substances continue to erode and destroy previously established rational food systems, and are causing rocketing rates of obesity, diabetes and other chronic disease. Unless unfair social, economic and political regimes are successfully challenged, these pandemics will get worse. ESTIMATES THAT FOOD PRICE RISES HAVE RESULTED IN AT LEAST 50 Gender issues are not ‘one of those things’


The global distribution of child and maternal malnutrition and mortality illustrate the significance of unequal power relations. Unequal gender relations are not easy to change. An important first step is to acknowledge that these exist and that they are maintained by prevailing political and economic policies. Practical steps towards women’s equality and empowerment must be taken.


Examining of the processes that led to the Rio conference, it was hard to believe these steps were really serious. They mostly evaded analysis or even acknowledgement of the power relations which maintain health and gender inequalities. People are poor because they live within unjust societies.


Now, after the Rio conference, let me acknowledge and highlight the commitment of so many representatives of the Brazilian government and civil society, in supporting and inspiring us in the People’s Health Movement. Interventions in Rio, from that of the Minister of Health to those of Brazilian grassroots organisation representatives, resonated with us. Other ministers of health from Latin America resisted the dilution of statements in successive drafts of the Political Declaration. In the final Declaration it was evident that they had lost some, but also that they won some.


The corporations, governments and other institutions that perpetuate the new world must be confronted. The mandate of WHO includes assistance to member states in addressing the ‘causes of the causes’ of malnutrition in all its forms. The rights-based approach to health equity provides WHO with a strong mandate to direct and coordinate realisation of equitable universal primary health care coverage. The right to health is enshrined in the constitution of WHO and in that of over 130 national constitutions. This needs to be used as a powerful tool for legalisation, enforceability and implementation of policies very urgently needed to enhance equity between and within nations.








The planners of the Rio conference on the social determinants of health constantly stated that its emphasis should be on practical initiatives designed to address inequity. These are conspicuous by their absence in the conference’s final Political Declaration. 


Yet there are many practical examples of courageous countries and communities finding ways of managing national and international economic relations equitably. There is much to learn from such examples.


Confronting the power of transnational corporations in areas most relevant to global and national states of health is within the mandate of WHO. Thus, WHO has led the way in developing a global regulatory regime for tobacco control. After Big Tobacco, the next targets for rational and equitable regulation must be Big Booze and Big Snack.


Due to the economic crisis that impoverished countries did nothing to cause, there are now 200 million more people living on less than US$ 2 a day, existing in distress, malnutrition and ill-health. The international bankers and their representative organisations must be held accountable. They must contribute to addressing the vast resource gap in health, for example by paying a Tobin Tax on financial transactions. WHO member states should champion such an approach, which after all is in their own interests.


The danger now is that some countries may face the issues of the social determinants of health, but do so in a medicalised and individualistic way, by focusing on ‘risk factors’ and ‘individuals’ lifestyles’. But the real challenge is to renew relatively equitable politics and economics that truly will go towards ‘closing the gap’. We in the nutrition, public health and medical sectors are the professionals who patch up sick societies. There is ultimately not much we can do, unless we also engage politically.


The People’s Health Movement was present in force in Rio. We are thankful and feel this is a good sign. There, we were able to speak out what we believe in. We distributed our unofficial Political Declaration, which has been and evidently is being studied avidly by people in the UN system and national governments. And we have now launched our  fresh-off-the-press third report, Global Health Watch 3 (www.ghwatch.org ). We believe we are making our mark. The change will come. It must come.





1                Commission on the Social Determinants of Health. Closing the Gap in a

            Generation. Health Equity Through Action on the Social Determinants of Health.

            Geneva: WHO, 2008.

2                Marmot M. Closing the gap in a generation. Bulletin of the World Health

            Organization 2011; 89, 702.



Please cite as: Schuftan C. The Rio Social Determinants Conference [Column] Website of the World Public Health Nutrition Association, November 2011. Obtainable at www.wphna.org










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