Build back fairer: achieving health equity in the Eastern Mediterranean region of WHO

Abstract

The Eastern Mediterranean region of WHO stretches from Morocco in the west to Pakistan in the east. This region's 22 countries and territories contain great contrasts. Life expectancy in Kuwait—84 years for women, 79 years for men—is 25 years longer than in Somalia.1WHOGlobal Health Observatory data repository. Life expectancy and healthy life expectancy data by country.apps.who.int/gho/data/view.main.SDG2016LEXv?lang=enDate: Dec 4, 2020Date accessed: March 12, 2021Google Scholar The region contains among the richest countries in the world, measured by income per person (Kuwait, Qatar, and United Arab Emirates), and among the poorest (Afghanistan, Djibouti, and Yemen).2UN Development ProgrammeHuman Development Report 2020. The next frontier Human development and the Anthropocene. UN Development Programme, New York2020Crossref Google Scholar Similar to other regions, non-communicable diseases are a major burden, and ischaemic heart disease is the leading cause of premature mortality in the region.3Institute for Health Metrics and EvaluationEastern Mediterranean region profile.http://www.healthdata.org/sites/default/files/files/EMR%20Profile_final_4_0.pdfDate accessed: March 25, 2021Google Scholar Unlike other regions, deaths related to conflict are increasing in the Eastern Mediterranean region. There have been more than 100 000 conflict-related deaths per year since 2014 in this region, and most such deaths in the world occur in the Eastern Mediterranean region.4Institute for Health Metrics and EvaluationGBD results tool.http://ghdx.healthdata.org/gbd-results-toolDate accessed: March 25, 2021Google Scholar Linked to conflict is massive displacement of people. By 2019, an estimated 6·7 million people had left Syria and 6·2 million had been internally displaced.5UNHCRGlobal trends forced displacement in 2018.https://www.unhcr.org/5d08d7ee7.pdfDate: 2018Date accessed: March 25, 2021Google Scholar In Yemen and Iraq, the numbers of displaced people are in the millions.6UNHCRYemen sees fresh displacement after five years of conflict.https://www.unhcr.org/uk/news/latest/2020/3/5e7dba1e4/yemen-sees-fresh-displacement-five-years-conflict.html#:~:text=They%20made%20the%20harrowing%20trek,near%20the%20city%20of%20MaribDate: March 27, 2020Date accessed: March 25, 2021Google Scholar, 7Chamie J Desperate migration in the Middle East. Yale Global Online.https://yaleglobal.yale.edu/content/desperate-migration-middle-eastDate: July 9, 2015Date accessed: March 25, 2021Google Scholar Looking more generally at migrants, large numbers are received by Iran, Jordan, Lebanon, Pakistan, and Saudi Arabia.8UN Population DivisionInternational migrant stock.https://www.un.org/en/development/desa/population/migration/data/estimates2/estimates19.aspDate: 2019Date accessed: March 12, 2021Google Scholar Conflict and COVID-19 both expose and amplify existing inequities in society. Inequities in health can be linked to poverty and income inequality; inequities in social conditions through the life course; gender inequities; problems related to extremes of weather, made worse by climate change; and land degradation with impacts on supplies of food and water. Against this background, the Commission on Social Determinants of Health in the Eastern Mediterranean was charged with assembling the evidence on social determinants of health and on inequities in health within and between countries and to make recommendations. The Commission was convened in 2019 by the WHO Regional Office for the Eastern Mediterranean in collaboration with the Institute of Health Equity at University College London and the Alliance for Health Policy and Systems Research, Geneva. The Commission's report Build Back Fairer: Achieving Health Equity in the Eastern Mediterranean Region was published on March 31, 2021.9Commission on the Social Determinants of Health in the Eastern Mediterranean RegionBuild back fairer: achieving health equity in the Eastern Mediterranean region. World Health Organization Regional Office for the Eastern Mediterranean, Cairo2021http://www.emro.who.int/media/news/report-of-the-commission-on-social-determinants-of-health-in-the-eastern-mediterranean-region.htmlDate accessed: March 31, 2021Google Scholar The Build Back Fairer title was chosen as a deliberate echo of a 2020 report on COVID-19 and socioeconomic and health inequalities in England.10Marmot M Allen J Goldblatt P Herd E Morrison J Build back fairer: the COVID-19 Marmot review. The pandemic, socioeconomic and health inequalities in England. Institute of Health Equity, London2020Google Scholar Emerging from the COVID-19 pandemic, with its large impacts on society, is an opportunity to ask how, based on the best evidence, societies and health systems can be rebuilt in a way that benefits all people. Doing so will be a major step to building greater health equity. A theme of this Commission on Social Determinants of Health in the Eastern Mediterranean, as of a previous Commission for the Americas,11Commission of the Pan American Health Organization on Equity and Health Inequalities in the AmericasJust societies: health equity and dignified lives. Report of the Commission of the Pan American Health Organization on Equity and Health Inequalities in the Americas. Pan American Health Organization, Washington, DC2019Google Scholar is to pursue policies that enable people to lead lives of dignity. Better health, and greater health equity, will be the results. In making its recommendations, the Commission adopted the approach of do something, do more, do better, which recognises the diversity of countries in the region and the health inequities within countries. For countries or population groups with shortages of the basic necessities of life—food, water, sanitation, and shelter—do something; it will make a difference. When these basic needs are met, do more: create the conditions for people to lead lives of dignity and purpose. For rich countries of the region, where there have been improvements in health over recent years, set your sights on achieving parity with other countries in the highly developed UN Development Programme group, and improve education and health commensurate with income. Doing better for rich countries should also entail committing 0·7% of the gross national income to development assistance for poorer countries in the region. The aim should be to do something, do more, do better at the same time rather than in sequence. People with insufficient nutrition need to educate their children and have lives of dignity. An important question the Commissioners (appendix) asked at the beginning of our work was: why is a Commission on Social Determinants of Health the appropriate mechanism? Our conceptual framework includes political economy, culture and religion, and climate change as structural drivers of inequities in the conditions in which people are born, grow, live, work, and age. Conflict in the region is related to global political and economic interests as well as religious frictions. There are health problems caused by displacement of people, by sanctions, and by occupation. Present and looming health inequities associated with the climate crisis have to be addressed in a region that derives much of its wealth from the production and consumption of fossil fuels. Could a WHO Commission really contribute to the relief of these large problems? Our starting and finishing point, and our modus operandi, is health equity. Our approach is at once moral and scientific. Our position is that the reason for taking action on these complex political, economic, and environmental issues is because the evidence shows how important they are for health equity. Improving the health of populations and advancing health equity should be central to the political debate. The question of what to do is answered by the evidence presented in the Commission's report. The question of why to do it is captured by the quote from the earlier WHO Commission on Social Determinants of Health: social injustice is killing on a grand scale.12Commission on the Social Determinants of HealthClosing the gap in a generation. Health equity through action on the social determinants of health. World Health Organization, Geneva2008Google Scholar MM is Chair of the Commission on Social Determinants of Health in the Eastern Mediterranean and the Director of the Institute of Health Equity University College London. AA-M is the WHO Regional Director for the Eastern Mediterranean. AG is the Executive Director of the Alliance for Health Policy and Systems Research. ME-A is Director of Healthier Populations, RH is Director of Programme Management, and WK is Regional Advisor Health Promotion and Social Determinants of Health at the WHO Regional Office for the Eastern Mediterranean. JA is the Deputy Director of the Institute of Health Equity, University College London. We declare no other competing interests. Download .pdf (.06 MB) Help with pdf files Supplementary appendix