Amen, Dennis.  
The Commission was flawed from the get-go by being named 'Social Determinants' when it could have been 'Societal Determinants'---as we have discussed before.  It is not a trivial distinction!

Barbara

Barbara

-----Original Message-----
From: Social Determinants of Health [mailto:[log in to unmask]] On Behalf Of Dennis Raphael
Sent: Thursday, April 14, 2005 9:52 AM
To: [log in to unmask]
Subject: [SDOH] WHO Commission off on wrong start...?

This interesting analysis comes from
[log in to unmask]

Subject: WHO's Commission on the social determinants of health: News
Release

WHO's Commission off to a poor start?

1. Make them healthy but keep them poor!

There is a fundamental problem with the rationale behind the press release.
It suggests that we can protect or even improve poor people's health while
they remain in poverty. This is of course the flaw of "pro-poor policies"
in general.  They can only have short term, cosmetic effects on either
health or poverty.

Dr Lee states "This commission will assist countries to implement
strategies that will help people who are poor and marginalized to live
longer, healthier lives".

Dr Marmot states "We will arm policy makers with the best evidence to
ensure that poverty does not sentence a person to a shorter, unhealthy
life".

There is a significant difference between approaches to health which are
anti-poverty and those which are "pro-poor".  The first addresses root
causes of health problems: structural poverty and structural violence and
the second addresses health problems within the context of structural
poverty and structural violence. Needless to say, the second is favoured
under a neoliberal regime because it poses no threat to the status quo of
the powerful while it creates the illusion that international health
authorities are seriously addressing both poverty and health significantly
and sustainably. They are doing neither.

As the PHM stands for, poverty is the disease.  The aim therefore is
poverty eradication.  It is not to make health somehow compatible with
poverty, or to make health something that can be achieved despite poverty.
Not only is this logically impossible, it is a historical nonsense. The
classic public health lessons all show that poverty - as characterized by
miserable living conditions - must be eradicated in order to achieve
significant and sustainable improvements in the health status of
populations.  We know that relatively poor countries or states (Cuba,
Kerala) can
achieve excellent health outcomes but we must remember that with their
modest resources, they have addressed basic needs, miserable living
conditions and social inequalities.

2. What about food and water?

There is a striking omission in the list of "causes behind the causes",
namely lack of food and water. Together these "social" determinants are
responsible for well over 60% of avoidable disease and death - according to
WHO's own figures. Why then are they left off the list of the "causes
behind the causes"?

Equally striking is the odd inclusion under social determinants of "unsafe
employment conditions" rather than lack of employment or a means of support
and survival at all. This is reminiscent of the interest in food safety
rather than food as a determinant of health.

Perhaps we should have paid attention to the terminology long ago. We
should have been alerted by use of the term "social" rather than "social
and economic" to the possibility that this WHO Commission would (once more)
ignore the most  fundamental "causes behind the causes" which are, of
course, economic determinants.  According to the WHO press release "Social
standing plays a big part in whether people will live to be 40 or 80".  Are
we to understand that massive health deficits and health inequalities
between and within countries are due to differential social standing of
individuals? Or might it be helpful to take a look at the international
economic order which facilitates exploitation of entire communities of
people (nations even) and their maintenance in conditions of gross material
deprivation so that their basic
needs for health remain unmet?

3. Health Action Zones replace Health for All

The press release cites examples of "innovative health programmes that
address social determinants" which use targeting, means testing and
conditionalities - all mechanisms which have been tried, tested . . . . .
and found wanting.

We learn of "social welfare programmes with benefits conditional on
children's school attendance, regular medical checkups and other health
promoting actions". Oh dear, conditionalities now on individuals such as
desperately poor single mothers who will now have to prove that their
children are worthy of health care. No matter that those most in need are
also those for whom such "conditionalities" pose most difficulties or are
materially impossible. The working poor in the USA need as many as 3
different jobs merely to pay the rent on a caravan and buy (some) food for
their children. These examples from developed countries are unlikely to
inspire hope in developing countries.

V. Navarro and others have presented ample evidence on the superiority of
universalist and redistributive policies.  Targeting benefits through means
testing or individual conditionalities is the antithesis of this approach.
Health as a human right is not going to be achieved through subjecting
individuals in deprived communities to impossible tests and rationing
health benefits accordingly. This is paternalism and victim blaming at its
most ludicrous.

And . . . the whole point of the Commission on Social Determinants is to
address the non-health sector determinants of health responsible for most
disease and death (as a corrective to the Sachs Report). So whatever is
done through health programmes can only achieve limited improvements in
overall health status of populations.  So much for intersectoral
approaches. Only when intersectoral is correctly interpreted to include
macroeconomic and political measures such as land reform, trade justice,
debt
cancellation and self determination of peoples and nations without
interference (violent or otherwise), will the huge burden of disease in
poor countries start to come
down.

4. Addressing global health inequalities through national health policies?

Referring to developing country policies to be identified and promoted by
the Commission, the press release claims that "overcoming these social
barriers represents a prime opportunity to reduce global health
inequalities".  How will health programmes and policies implemented in
individual developing countries affect global health inequalities which are
themselves the result of global economic structures and arrangements which
have been accelerating poverty, inequality and consequently, miserable
living conditions responsible for avoidable disease and death, for the past
25 years? Global inequality can only be tackled at the global level.

The reversals of logic are astounding. The triumphant concluding sentence
of the press release reads as follows: "The MDGs recognize the
interdependence of
health and other social conditions and present an opportunity to promote
health policies that tackle the social roots of unfair and avoidable human
suffering".  Health policies, understood to mean measures designed to be
implemented within the health sector, cannot tackle social roots of
suffering as these lie outside the health sector. However if health
policies are predicated on a fair and rational international economic
order, then the social roots of human suffering will indeed be addressed.

This was of course the raison d'être of Alma Ata born 1978; died 1980.
Revived 2005?

Note: If this press release is an unfair representation of WHO's Commission
on Social Determinants, we will all be relieved. If not, civil society -
meaning public interest NGOs, trade unions, and people's movements for
social justice need to urge WHO in the strongest possible terms to keep the
Commission's work close to WHO's  constitutional mandate and to Health for
All values and principles.

AK

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