Journal of Epidemiology and Community Health 2005;59;714-715

 Equity and health

Who cares about health for all in the 21st century?  Fran Baum *

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This paper regrets the retreat in the 1990s from a focus on health as a
social good that results from good social policy. It highlights the
importance of the People’s Health Movement and the WHO Commission on the
Social Determinants of Health as offering a chance to return to a more
socially just quest for equity and health.

 It’s been a peculiar century so far. It started off with the great and
lofty thoughts that accompany centennial change. Millennium summits, domes,
and plans for a peaceful century in which human health and wellbeing
blossomed. With amazing rapidity, in the wake of 11 September 2001, it
deteriorated into a century of fundamentalisms, acute fear of terrorism,
and an unprovoked attack on a sovereign state that was not backed by the
United Nations or the majority of citizens of the countries going to war.
The aftermath of the war in Iraq has become a public health nightmare and
there are few signs of the flourishing of democracy that was meant to
justify the war .Meanwhile the deeper causes of global instability persist
and the USA spends more on war than it does on tackling extreme poverty.
Sachs estimates that eight million people die each year because they are
too poor to stay alive. The 21st century, then, is proving to be a disaster
for Africa and many other postcolonial states who face economic disaster
under the burden of crippling debt and the onslaught of both old (such as
malaria) and new infectious diseases (most notably HIV/AIDS). Life
expectancy in Africa is going backwards for the first time in over a
century. Meanwhile the populations of OECD countries are experiencing
growth in wealth and prosperity, albeit with increasing inequities between
the rich and poor.

 IMPORTANCE OF VISIONARY LEADERSHIP

 It is against this background that I pose the question: who cares about
Health for All in this century? The answer would have been easier if we had
gone back 25 years to the period around 1980. The World Health Organisation
under the charismatic leadership of Dr Halfdan Mahler had launched the
Health for All by the Year 2000 campaign and the target seemed a real
possibility. WHO was widely respected as a lead organisation in global
health with a leader who was visionary and inspiring. Many public health
doctors now in their 50s and 60s remember with affection the great
inspiration they received from the HFA2000 strategy. Mahler’s leadership
lasted through to the 1980s when the Ottawa Charter for Health Promotion
inspired more people to adopt a comprehensive model of promoting health
that did not blame individuals but rather focused on creating environments
and making policies in which people could flourish and make easy, healthy
choices. I remember my own excitement on reading the Ottawa Charter and
seeing that it could move health promotion beyond  simple ineffective
behaviour change strategies to whole of community approaches to improving
wellbeing. There was a buzz in public health then, a palpable feeling that
we were on the right track with Healthy Cities, Healthy Schools, and other
such initiatives, comprehensive primary health care plans, community
involvement, and a growing (if fragile) commitment to equity in health.
Sadly, much of this idealism was lost in the 1990s. WHO lost its ability to
inspire and seemed to give up its leadership in global health to the World
Bank. This was most obvious in 1993 with the publication of the World
Bank’s Investing in Health. This report saw health as a crucial part of
economic development but did not see health as a human right. This approach
was consolidated with the notion of disability adjusted life years (DALYs)
that privileged the value of lives of those who were young and without
disability. These approaches to health were very much in line with the
zeitgeist of neoliberalism that led to the devastating economic
prescription of structural adjustment throughout the developing
world—completely without an evidence base or sound justification. The WHO
did nothing to challenge this neoliberalism and seemed to endorse the
general direction with its Commission on Macro-economics and Health. In
fact the main challenge within public health came from outside governments
and international agencies. It came from grass roots and activist movements
who despaired at the direction of global health and came together in
December 2000 in Savar Bangladesh at the People’s Health Assembly.

 FIRST PEOPLE’S HEALTH ASSEMBLY AND PEOPLE’S HEALTH MOVEMENT

 This was truly a civil society movement that had roots in popular people’s
organisations from around the globe.

At this assembly the 1500 people attending provided testimonies of the
impact of neoliberalism on their lives, health, and wellbeing. These
testimonies were combined with analysis of the global economic trends and
the role of major public health institutions such as the WHO and World
Bank. Topics discussed included: the ways in which the international regime
that governs global trade is fundamentally unfair and biased against poor
countries; the impact of unsustainable environmental practices; and the
need for a return to people centred primary health care that focuses on the
development needs of communities and not on disease focus strategies
imposed from outside. The People’s Health Movement emerged from this event.
Its philosophy and approach to global health is laid out in the People’s
Health Charter, which has been translated into 42 languages. In July 2005
the Second People’s Health Assembly took place in Cuenca, Ecuador and was a
major milestone in the road back to a public health based on the needs of
ordinary people rather than on the demands of a neoliberal economic
fundamentalism. The catchcry of the Second People’s Health Assembly was
‘‘The Voices of the Earth are Calling!’’ This captures the grass roots
nature of the movement. The health of the world’s indigenous people
received special focus at the assembly. In so many ways indigenous people
highlight what is wrong with our approach to health. Australia exemplifies
this well. It is one of the world’s richest countries yet the life
expectancy of its indigenous peoples is 20 years less than non-indigenous
Australians. Instead of being celebrated as the first peoples of the land
and given special status, colonial and racist ideas have led to systematic
policies that have seen indigenous people deprived of their land and
culture, stolen from  their families, excluded from the economic benefits
of the mainstream, and then blamed and vilified when their health suffered
as a  result of the cruel and inhuman policies. Blatant injustices such as
this provide the fuel and passion for the People’s Health Movement.

 GLOBAL CIVIL SOCIETY CARES

 The other signs of caring about achieving health for all in the 21st
century come from the ‘‘Make Poverty History’’ campaign with the goals of
‘‘trade justice, drop the debt, more and better aid’’. The campaign focuses
on the 2.8 billion people (nearly half the world’s population) who live on
less than US$2 per day. It is driven by a range of non-government
organisations and global campaigners such as Sir Bob Geldof and calls
directly on the G8 countries to drop debt for the most heavily indebted
nations and for aid to be increased to 0.7% of GDP as recommended by the UN
Millennium Summit. Achievement of these aims has the potential to make our
world healthier and more equitable. But this will only happen if what
follows is an approach to health and wellbeing that builds on the early,
visionary history of the WHO that recognised that health is not just about
the absence of disease but about improving the quality of everyday life in
terms of our relationships with each other, the safety of and satisfaction
with our schools and workplaces, the quality and sustainability of
transport and housing, the availability of education, sustainability of the
environment, and freedom from violence and war. So often those who want to
do good do not act on this knowledge. Rather they focus on the diseases and
believe that tackling them will do the job of creating more health and
equity. So we have seen the flourishing of bodies such as the Global Fund
and Gates Foundation that, with the best of intentions, set out to tackle a
range of infectious diseases. Yet they do very little to tackle the broad
social and economic determinants of health that dictate who gets what
disease. Healthy people are mainly healthy, not primarily because they have
access to good health services (although this helps), but because they have
good food, comfortably homes, live in a peaceful environment, have good
social support, adequate income, and a satisfying job. The global public
health community has to understand and act on this crucial knowledge about
what creates health. Are there any signs this may be happening?

 SIGNS OF HOPE: SECOND PEOPLE’S HEALTH ASSEMBLY AND WHO COMMISSION ON THE
SOCIAL DETERMINANTS OF HEALTH

 It just could be that 2005 may be remembered as the year the social and
economic determinants of health began to be taken really seriously
globally, nationally, regionally, and locally. In July 2005 the Second
People’s Health Assembly took this knowledge as central to its
deliberations about how to make the world healthier and more equitable. In
March 2005 the WHO launched its own Commission on the Social Determinants
of Health (CSDH). This commission will place a primary emphasis on the
underlying factors that determine how healthy populations are and how
equitably health is distributed within populations. It will emphasise that
health services, while crucial, are only one of the determinants of health
and that most health gain will come from going

upstream to focus on those factors such as employment, housing, quality of
living environments, social relationships, and education that are the main
determinants of how  healthy we are. The commission works on the assumption
that creating healthy societies and individuals largely results from action
outside the health sector.

The CSDH will use three key strategies to achieve its aims. Firstly, it
will establish knowledge networks preliminarily entitled: Priority Public
Health Diseases; Child Health and Education; Financing; Human Settlements;
Social Exclusion; Employment; Globalisation; Health Systems, Measurement,
Gender and Women’s  Empowerment. Secondly, it will work with countries to
ensure action on the social and economic determinants of health. Thirdly,
it will work to reform the WHO by ensuring that awareness of the importance
of the social and economic determinants of health informs all its work and
becomes evident in its response to health issues.

The commission has great potential to assist Dr J W Lee, the current
director general, to leave as his legacy a reformed WHO that is imbued with
a strong understanding and determination to act on the social and economic
determinants of health and a public health community that accepts the
inevitable logic and sense of designing all interventions based on this
understanding.

 MAKING SOCIAL DETERMINANTS OF HEALTH CENTRAL

 The path taken by the People’s Health Movement and the CSDH is not going
to be easy. While more funding has gone into global health in recent years
the overwhelming amount of it has gone into disease initiatives that do not
tackle the underlying social and economic determinants of health. However,
if the People’s Health Movement and the CSDH are successful in picking up
the baton from the earlier Health for All 2000 movement they may form the
vanguard of a successful movement for a socially just and healthier world
in which policy decisions are driven primarily by this vision rather than
by decisions that maximise profit for a small elite. If the public health
community does care about health for all in this century then it must put
its full support behind the People’s Health Movement and the Commission on
the Social Determinants of Health.

 Correspondence to: [log in to unmask]

(*): Fran Baum has been a member of the Global Steering Group of the
People’s Health Movement since 2000 and was appointed as a Commissioner on
the WHO Commission on the Social Determinants of Health in March 2005.