Social determinants of health: social justice and vested interests

Abstract

I commend Kumanan Rasanathan (Oct 6, 2018, p 1176)1Rasanathan K 10 years after the Commission on Social Determinants of Health: social injustice is still killing on a grand scale.Lancet. 2018; 392: 1176-1177Google Scholar for stressing the enduring inertia against efforts to tackle social injustice, despite it killing people on a grand scale. However, this inertia has not existed for a decade, but for more than half a century. In 1984, Marmot2Marmot MG Shipley MJ Rose G Inequalities in death—specific explanations of a general pattern?.Lancet. 1984; 323: 1003-1006Google Scholar showed that individuals in the lowest socioeconomic status group were three times more likely to die of cardiovascular diseases than individuals in the highest socioeconomic group. This finding did not preclude the Progression of Early Subclinical Atherosclerosis study3Fernández-Friera L Fuster V López-Melgar B et al.Normal LDL-cholesterol levels are associated with subclinical atherosclerosis in the absence of risk factors.J Am Coll Cardiol. 2017; 70: 2979-2991Google Scholar from investigating subclinical atherosclerosis (imaging, biomarkers, and genetics) in employees of a major bank headquarters in Madrid, Spain. It excluded the most at risk in Spain, such as the unemployed, smokers, consumers of alcohol, and obese individuals, despite the fact that unemployment (17·6% in 2017) is three times the Organisation for Economic Co-operation and Development (OECD) mean, daily smoking, alcohol consumption, and obesity are higher than the OECD mean, and expenditure on health has been decreasing since 2008 to 9·0% of gross domestic product in 2014. Worse, detection of subclinical atherosclerosis is an old concept intended to individualise treatment decisions in at-risk individuals, and, since 1993, no clinical trial has shown that it improves clinical outcomes.4Simon A Levenson J Early detection of subclinical atherosclerosis in asymptomatic subjects at high risk for cardiovascular disease.Clin Exp Hypertens. 1993; 15: 1069-1076Google Scholar Concerns about social injustice must not mask the fact that tobacco, alcohol, and processed foods are industrial products causing modern epidemics and killing people on a grand scale. These epidemics are spawned by industry, but social determinants (environmental factors or risk factors, such as poverty and education) also affect their spread. Public policies do not target these issues and protect vested industrial interests rather than citizens' health. Concerns for social justice should help children first because they are the future of our societies, but inequities are growing in several high-income countries, such as in the UK, where child poverty has increased in absolute terms.5Wickham S Anwar E Barr B Law C Taylor-Robinson D Poverty and child health in the UK: using evidence for action.Arch Dis Child. 2016; 101: 759-766Google Scholar I declare no competing interests. 10 years after the Commission on Social Determinants of Health: social injustice is still killing on a grand scaleIn 2008, WHO launched the final report of the Commission on Social Determinants of Health (CSDH) that concluded “social injustice is killing people on a grand scale”.1 A decade later, how should we judge the CSDH's impact? A Google search for the CSDH yields 156 000 results and the accompanying Lancet paper has had 932 citations.2 The CSDH led to two World Health Assembly resolutions and more than 100 countries adopted the Rio Political Declaration on Social Determinants of Health in 2011.3 The CSDH's report has become a foundational text for how crucial social determinants are to health and health equity. Full-Text PDF