Social determinants of health: practical solutions to deal with a well-recognized issue

Abstract

The call on governments to address the major challenge of health inequities which are determined by the social conditions in which people are born, grow, live, work, and age, is not new. The Commission on Social Determinants of Health worked on this. Its report re-enforces the message from the Ottawa Charter for Health Promotion, which itself was strongly rooted in the commitments made at the International Conference on Primary Health Care in Alma-Ata in 1978.1,2 The thinking behind the Alma-Ata Declaration, of course, dates back much further. Public health pioneers, such as Rudolf Virchow, Robert Koch and Oswaldo Cruz, had an in-depth knowledge of how social inequities relate to health outcomes.3 Robert Koch, for instance, devoted a key part of his Nobel Laureate speech in 1905 to the issue.4 And Brock Chisholm, the first Director-General of the World Health Organization, asserted in 1949 that “the death rate from pulmonary tuberculosis is now everywhere accepted as a sensitive index to the social state of a community.”5 Today, we know that this statement is not only true for tuberculosis but also for noncommunicable diseases, HIV/AIDS, malaria and other diseases. Reflecting that socio-cultural context is key to public health, the mandate for the World Health Organization to assist Member States in addressing the “causes of the causes” of ill-health is firmly rooted in its constitution.4 So why, one might ask, is it important to hold a world conference on social determinants of health in Rio de Janeiro in October 2011, bringing together Heads of State, Ministers of Health and other social sectors, the most distinguished experts and the world's leading civil society organizations working in the field? The short answer to this is: addressing social determinants of health is a matter of social justice and, looking at current social unrest, we can no longer procrastinate. And there is increasing knowledge about how to do it. Thus, this conference will focus on providing innovative solutions on the “how-to.” Noncommunicable diseases, in particular, cannot be addressed effectively without action on social determinants of health and obesity provides a good example for this. Since 1980, obesity rates have more than doubled in the world. This is due to an increased intake of energy-dense foods that are high in fat, salt and sugars but low in vitamins, minerals and other micronutrients. The problem is not only rooted in people's lifestyle choices and eating habits but also in the lack of availability of healthy, affordable food or – as Michelle Obama has put it – the existence of “food deserts,” especially in urban poor areas. So, in addition to the social gradient in health that runs from top to bottom of the socioeconomic spectrum, we can identify a “food gradient.” This gradient shows both a lack of affordable healthy food and an over-exposure to unhealthy and processed food in the geographical areas which have the highest disease burden. I am convinced that the political leaders coming together for the world conference are determined that more needs to be done to address the societal conditions for people and turn them into environments that are conducive to health. Coming back to the example of obesity, the food industry can play a significant role in promoting healthy diets by reducing the fat, sugar and salt content of processed foods. It can practice responsible marketing and change its strategy (as American retailer Walmart has announced)6 so that healthy and nutritious choices are available and affordable to all consumers. If health as a societal goal is taken up by other governmental and policy sectors, it will contribute to improving equity and economic development and tackling social and environmental challenges. There are impressive examples from Australia, Chile, India and Scotland in this issue. The conference will focus on five building blocks that have proven to be essential for effective action on social determinants of health: governance, participation, the changing role of the health sector, the need for global action and how to monitor progress. Key recommendations are suggested for action in each of the building blocks. We know the “what and the why” of social determinants and we are getting closer to understanding the “how-to.” The Rio Declaration on the Social Determinants of Health as the main outcome of the conference will provide high-level political support for action. Success in implementation will then depend on the will, the powers and the political economy – the political determinants of health.