I first heard about historical trauma, as an explanatory concept, about 10 years ago in my role as an academic.  Without knowing the term, I had seen and experienced it playing out in those I knew or loved; nursed; or partnered in research with; and even in myself during my ‘more than a few’ decades on this earth.  Historical trauma as a concept has been applied to groups such as those surviving the Holocaust and their descendants, as well as to the Japanese who suffered internment camps in the US during World War ll and their descendants.  For American Indians, “historical trauma is defined as cumulative trauma over both the life span and across generations that results from massive cataclysmic events such as the Wounded Knee Massacre.”  In fact, historical trauma has been used to describe an American Indian holocaust by Braveheart and others (1998). The Lakota researcher also defines it as unresolved historical grief across generations.

I have described in previous postings on my own blog how federal policy periods, specifically aimed at American Indians, were carried out that resulted in loss of life, culture, language, place, sovereignty and family structure.  This list of losses is far from comprehensive.  Some of the more detrimental eras were named:  removal (1825-1850); reservation (1850-1887); allotment and assimilation (1887-1934); and termination (1940s-1961).  I maintain that historical trauma ultimately affects health.  As an American Indian nurse, I am fortunate to be able to combine paradigms in that both groups see health as holistic.  Health in the holistic view includes: physical, mental, emotional and spiritual domains of the person.  Much of the early work on historical trauma focused almost solely on non-physical domains, i.e. grief, stress, post-traumatic stress-like symptoms, etc.

The stunning health differences that are seen between American Indians and either Whites or ‘all races’ as reported by the Indian Health Service in ‘Trends in Indian Health’ (2002-3) can be found on their website: www.ihs.gov .  The Indian Health Service is a national health agency under the US Public Health Service charged with the health care of members of the 565 federally recognized tribes.  Some of the differences as noted in their report includes: 1) tuberculosis 533 percent greater; 2) alcoholism 526 percent greater; 3) diabetes mellitus 208 percent greater; 4) unintentional injuries 150 percent greater; 5) homicide 87 percent greater; 6) suicide 60 percent greater; 7) pneumonia and influenza 42 percent greater, and; 8 ) firearm injury 26 percent greater.

One difference noted between Holocaust, other trauma survivors, and American Indians is that for American Indians “[t]here has been no ‘safe place’ to begin again”. In other words, catastrophic group traumas such as the Holocaust, had a beginning and an end.  The survivors and descendants are dealing with the repercussions.  However, for many in Indian Country, historical and contemporaneous group and individual trauma continues.  There has been no end wherein now healing can begin.  That is an important distinction. The investigators found that historicalin the case of American Indians may have to refer to its beginnings in the past as opposed to a distinct historic block of time.

This sustained, persistent trauma- both current (see statistics above on homicide, suicide, injuries and firearms) and historically invoked but persisting today- grief- has most likely impacted the inability to make real strides today in raising the health status of American Indians.  Admittedly this is a quite heterogeneous group with variations in lifespan and disease prevalence.  Some of the numbers look close to those for US numbers broadly.  However, when drilling down to some specific groups one finds huge differences.  For instance, the average life expectancy of a male born today on the Pine Ridge Reservation is in the 40s; diabetes rates can be as high as 10 times that of the White or ‘all races’ rates.  There are explanations beyond genetics and socioeconomic circumstances.  One of these is likely the health manifestation of historical grief and trauma coupled with individual current trauma.  And it is the persistence of the stress and crushing burden that feeds into these numbers.

In my own family, I had three Native brothers and sisters.  Two grew up with me, 1 did not. They have all died with an average age of 40.  Between the families was a variance of socioeconomic standing, economic ‘class’, education and reservation vs. suburban upbringing.  It did not matter in the end.

Margaret Sanger, an American sex educator, nurse, and legendary birth control activist once said that “No woman can call herself free who does not own and control her body.  No woman can call herself free until she can choose consciously whether she will or will not be a mother.”  Nowadays, these words are true as ever and encapsulate the main premise behind a recent joint publication by the UN Population Fund (UNPF) and the Center for Reproductive Rights (CRR) – that the right to contraception is a human right.

Michele Bachmann’s recent foray into damning a public HPV vaccination program for potentially harming ‘innocent girls’ shows how much politicians can get away with when it comes to reproductive health. When have you last heard anyone complaining about polio vaccinations? Oh right, it’s not a sexually transmitted disease…

It would have probably been even worse today if not for The Programme of Action from the 1994 Cairo International Conference on Population and Development (tellingly rejected by the Vatican). This document was an important milestone in changing the perception about reproductive health which is no longer a shameful issue to be dealt with in secrecy, but an important public health concern and a domain in which states should work to improve their citizens’ quality of life. Therefore, the current perception of the importance of contraceptives in particular and reproductive rights and health in general should not be taken for granted. Most governments nevertheless still hate mentioning anything that can be interpreted to even mildly refer to sex about as much as they dread the thought of having to raise taxes 6 months before a major election. However, the The Programme of Action has made its mark. Importantly, it was also the first to suggest that access to contraceptives is a human right.

You may be thinking “What? I can’t remember condoms and the Pill being mentioned anywhere in the Universal Deceleration of Human Rights (UDHR)?!” You’re right – it isn’t explicitly mentioned (in the UDHR at least).  However, the issue is a little bit more complicated than that, but really pretty straightforward.

Let’s deal with the more complicated things first (and not to worry, they really aren’t that difficult to grasp). As I mentioned in my previous post, the UDHR is not the only ‘UN-approved’ human rights document out there. There are actually a number of declarations (non-binding) and covenants and conventions (binding) which are part of the human rights legal framework and include, for example, the International Covenant on Economic, Social and Cultural Rights (ICESCR) and the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW). When stating that access to contraception is a human right, UNPF and CRR drew on all these documents and did not limit their analysis to the UDHR.

And now for the straightforward part, in which we will see that access to contraceptives really is a human right – one grounded in the basic principles behind the very notion of human rights. Women’s right to contraceptive information and services is, in fact, an element of a number of key basic human rights such as the right to life, the right to the highest attainable standard of health, the right to decide the number and spacing of one’s children, the right to privacy, the right to information, and the right to equality and non-discrimination. Not only is guaranteeing access to contraception an integral part of these rights, but it is also a means to securing their fulfilment.

Moreover, guaranteeing access to available, acceptable, and good quality contraceptive information and services free from coercion, discrimination, and violence is critical for achieving gender equality and ensuring that women can participate as full members of society.  The importance of contraceptives is highlighted by the fact that a range of them is included in the World Health Organization (WHO) Model List of Essential Medicines. UN bodies (such as the Committee on Economic, Social and Cultural Rights) have indicated that provision of the drugs on this list is a core minimum obligation of states in realizing the right to health. Importantly, the obligation to provide contraceptives is classified as “immediate” – often also called the “minimum core obligations” – meaning that this obligation is not dependent on the socioeconomic context and thus should be fulfilled immediately.

A rights-based approach (RBA) to the provision of reproductive healthcare and contraceptive information and services can guarantee the fulfilment of states’ obligation and the concomitant realization of women’s fundamental human rights. And it’s really crucial to understand that access to contraception is mostly about preventing unwanted pregnancies in the developed North, but in the global South it really is a life-and-death matter. While the life-quality enhancement and human rights fulfilment related to the provision of appropriate family planning is difficult to overestimate, the tragic and potentially life-threatening consequences of restricting access to contraceptives may result in devastating social, economic, and public health consequences. For example, of the approximately 80 million women who annually experience unintended pregnancies, 45 million have abortions. As a result, approximately 68,000 women die from botched back-alley abortions each year and complications from unsafe procedures are a leading cause of maternal morbidity.  Research has shown that satisfying the current unmet need for contraceptives could prevent roughly 150,000 maternal deaths and 25 million induced abortions worldwide annually.

It really is a no-brainer – preventing unwanted pregnancies allows women and families to lead a measurably better life and prevents deaths (of mothers as well as children). Access to contraceptives is a human right and it’s important to keep that in mind, when we veer towards perceiving it as a privilege of the richer or better educated.

One of the biggest health related actions of the Movement took place on October 26^th when Healthcare for the 99% (a coalition of physician unions, nurses unions, and various healthcare campaign groups) organized a march in New York City against the for-profit health insurance industry. Just yesterday, a group of health advocates in Boston organized a Health Justice Day of Action where in addition to a variety of health focused events, a team of volunteers dispensed free flu shots. In the UK, protesters in Cambridge occupied the offices of the Healthcare firm Atos, and on Twitter, the hashtags  #occupyhealthcare and #occupyhealth document  that more and more people are making the link between economic inequalities and healthcare related concerns.

Less visible in the Movement are messages about the social determinants of health (SDOH).  The need for better integration of SDOH messages have been noted by blogger Nate Osit, who emphasizes the need for a more global SDOH outlook in occupying efforts, and blogger Vinu Ilakkuvan, who has written about the need to move ‘beyond healthcare’ and highlighted examples of successful efforts toward this end. However, SDOH concerns aren’t completely absent from the Movement. The People’s Health Movement has stepped up to endorse the Occupy Wall Street Movement, directing attention to the importance of SDOH and urging its affiliates to “participate in this movement to overcome ill-health caused by social, political and economic systems that reproduce inequality and social injustice”. Moreover, “a group of (mostly) San Francisco Bay Area health professionals, providers, students, and advocates” have developed an Occupy Public Health site which includes, among other great resources, a lesson plan for teaching occupiers about the SDOH.

In an effort to support occupying actions directed at the social determinants of health, Healthy Policies will be hosting a Twitter chat tomorrow (Monday November 14th) on how SDOH messages can be better integrated into the Occupy Healthcare movement.  This chat is part of a larger effort organized by the IMAXI group, who are coordinating a series of social media events to bring people together to discuss the state of the world’s health every Monday, from the 14th of November until Human Rights Day a month later.

The Twitter chat will begin at 3PMEST/20hGMT and last for 30 minutes. To view the chat search Twitter for #SDOHchat; to participate, tweet your thoughts, adding  ‘#SDOHchat’ to your tweet.  A transcript of the chat will be made available shortly afterwards.

This post is the second half of a two-part series by guest blogger Kate Thomson which explores proposed changes to the National Health Service in England. The first post provides useful background information (particularly for those living outside the UK) on these proposed changes. In this post, Kate explains in greater detail the areas of reform which are of greatest contention. Kate is a Senior Lecturer in the Department of Public Health at Birmingham City University and is currently researching health reforms in the Russian Federation.

In a previous post, I outlined some of the major changes taking place within the English health service (NHS) via the Health and Social Care Bill. Here, I go into more detail on some of the main areas of contention.

Who are the providers? Competition and ‘choice’

The extent to which NHS services will be opened up to the private sector is one of the battleground areas in debates about the Bill. Government contends that ‘competition’ between providers incentivises quality improvement. Opponents suggest that increasing private sector involvement is an ideologically-informed step by a government that is inclined to be ‘on the side’ of big business. The link between provider competition (regardless of whether or not private sector providers are involved) and quality has been questioned. Key evidence cited by the Prime Minister as supporting this link has been subject to critical appraisal by a number of scholars who question its conclusions.

The term, ‘any qualified provider,’ is used in the Health and Social Care Bill to emphasise that healthcare services should be commissioned(purchased) via a competitive process. NHS providers, in other words, will not automatically be preferred over new and/or private sector organisations.  As well as ‘qualifying’ on grounds of quality and capacity, it seems that there will also, in practice, be financial criteria: is the company /enterprise solvent enough to bear the ‘risk’ of providing such services?

An unintended consequence may be tension with another much lauded principle of public sector reform – the Big Society, an idea which promotes extended involvement by charities and ‘social enterprises’ in providing public services.Such organisations are meant to be able to act more flexibly and be more in touch with needs ‘on the ground’ than state bodies. However, there is evidence that they may be ‘squeezed out’ of competitive tendering processes.All this adds up to what commentators have called an ‘intrinsic bias’ in the commissioning processes towards private, for-profit bidders.

Objections to private sector involvement go beyond the ideological (principled resistance to the idea of public money going ‘outside’ the system and into the pockets of shareholders). It is likely that there will be less competition to provide services in the most difficult and complex areas of care (e.g.intensive care), than in areas with relatively predictable costs and outcomes (such as non-urgent surgery). This could make it difficult for NHS hospitals that provide a range of interventions to compete in the local market; will a district hospital, for example, be allowed to ‘fail’?

Evidence is already emerging that newly formed clinical commissioning groups (CCGs) are directing GPs in what are effectively rationing decisions (e.g. relating to overall number of referrals to hospital; or access to specific interventions). This does not appear to fit with the model of shared decision making between practitioner and patient (‘nothing about me without me’), touted in government rhetoric. Nor does it entirely match the notion of clinically-led decision making about appropriate treatment  and availability (as opposed to decisions made by ‘bureaucrats’).  Such developments raise serious questions about equity and appropriateness in access to care.

Beyond problems around equity and consistency of ‘rationing’ decisions, CCG responsibilities raise the possibility of conflicts of interest. To a greater degree than in the past, ‘commissioners’ (CCGs) will be able to both plan (purchase) and provide services (i.e. they may ‘commission’ from their own members, such as GP practices or ‘spin-off’ enterprises). They will also be in a position to explicitly ration (limit access to certain treatments ‘on the NHS’) while offering themselves to patients  as willing providers of a fee-paying service.

The rhetoric of reform links competition with ‘choice’ for patients/consumers. ‘Personalisation’ is a health policy buzzword. Health and social care services are to be tailored to individual needs, with increasing individual choice about what, where, how and by whom care is provided. One of the mechanisms for this is the ‘personal budget’ – a direct payment, initially for patients with long-term conditions, to spend on an individually-determined package of services. Undoubtedly there are benefits from self-determination – an empowered service user getting the services they desire. Demand for under-resourced services may stimulate supply (and quality improvements).  However, there are also potential difficulties, such as the burden of administering such budgets; the negotiation of boundaries between personally budgeted care and access to commissioned services; and the possibility that less popular, yet important, services, could be undermined.  Personalisation and choice also need to be fully realised principles within the entirety of the system, rather than becoming ways of describing mechanisms for choosing services.

Public Health

In parallel with these changes there are proposed changes to the provision and structure of Public Health (which had its own White Paper in late 2010). The headline change was a move of public health responsibilities from within the NHS, to local authorities. This offers the opportunity for public health concerns to be effectively ‘joined up’ with the very wide range of policy decisions and service provisions offered by local authorities (the generation of ‘healthy public policy’ at the local level). However many public health practitioners fear dilution of expertise and reductions in clout and budgets to act. Amendments to the Health and Social Care Bill emphasised CCGs’ responsibilities for health improvement and public health; and for the health of all in their geographical area (not just ‘their’ patients). However, the demarcation of responsibilities in practice, between health care commissioners and local authority public health bodies, is yet to be clarified. There are certainly grave concerns about the impact of restructuring and other elements of the Bill, among many public health specialists.

Bureaucracy

Finally, it is worth questioning the extent to which the reforms will reduce ‘bureaucracy’ in the NHS. The Bill was promoted as a way of creating a leaner health service, that operated closer to the patients and their clinical needs.  However, as the Bill has developed, proposed CCG roles have changed such that these will now be quite large organisations with a layered structure, and with a duty to consult with experts and the public, to inform their decision making. This is actually a rather different model to the original vision of GPs (primary care physicians) making decisions as a collective. Doctors are concerned about how far the burden of ‘bureaucracy’ for these organisations, will fall upon them. Perhaps an additional layer of oversight or management will be brought in – however this moves closer to our starting structure of Primary Care Trusts and Strategic Health Authorities.

Internal contradictions within health policy are nothing new to the NHS. Tensions, for example, between devolution of decision-making and imposition of national standards; and between the ‘choice’ agenda and the requirement to spend budgets in the most rational and equitable way, were features of the previous government’s approach too. We will discover whether the current reforms spell ‘the end’ of the NHS, or a more efficient and ‘modern’ reconfiguration, as the changes bed down over the coming months and years.

In the first of a two-part series, guest blogger Kate Thomson  provides helpful background on the proposed reforms to the NHS, as embodied in the Health and Social Care Bill. Also outlined are the major concerns and debates surrounding the Bill. Kate is a Senior Lecturer in the Department of Public Health at Birmingham City University and is currently researching health reforms in the Russian Federation.

What’s going on with the English National Health Service (NHS)? If you’re based outside of the UK but follow health policy discussions on social media, you may well have noticed that major changes are afoot, in the  shape of the Health and Social Care Bill.

The NHS’s origins in the immediate aftermath of  World War 2, have generated a fierce sense of loyalty, or at least, ownership, among the population over successive generations. It was said that even the most forthright and radical of Prime Ministers, Margaret Thatcher, declined to make significant changes to it, understanding that politicians ‘meddle with the NHS’ at their peril.  In fact the system has changed in many ways over the past 60 or so years, and perhaps most dramatically within the past 15 years, during the term of the Labour administration (1997-2010).

The most significant change made by the Labour government was structural: a radical extension of the ‘purchaser –provider’ split introduced in the early 1990s. What came to be called Primary Care Trusts (PCTs) handled the NHS budget for each locality. They planned and bought (‘commissioned’) services appropriate for their populations –including hospital services. Combined with stronger entitlements for patients to choose where they had treatment, this generated an ever more competitive environment- crudely put, hospitals had to compete for patients by demonstrating good outcomes and satisfaction levels. Services could be commissioned from the private sector (e.g. private hospitals) too. Health policy making powers were devolved to the constituent parts of the UK; the NHS in Scotland, Northern Ireland and Wales started pursuing and structuring services in different ways.

Equity & Excellence

In May 2010 a Conservative – Liberal Democrat Coalition government was formed. July of that year saw publication of White Paper, Equity and Excellence: Liberating the NHS. Major re-organisation of NHS services in England was proposed.  This caused some disgruntlement given that pre-election promises had included ‘no top-down reorganisation’ of the NHS.

Of particular note were the proposals to abolish Primary Care Trusts (PCTs) and move to a system of commissioning care based around ‘consortia’ of General Practitioners. GPs are primary care physicians and usually the first point of  contact with the health system. The ten Strategic Health Authorities (which oversee the NHS in regions) were also to go, to be replaced eventually (2013) by a single Commissioning Board. Over the following months, NHS organisations started gearing up for these changes, with some PCTs divesting themselves of resources and merging with others. GP practices started forming groups with other local practices to ultimately form Consortia. Some had already been involved in planning and commissioning services as a result of the ‘practice-based commissioning’ policy, but this principle was to be rolled out on a much greater scale.

The White Paper formed the basis of the Health and Social Care Bill which was presented to Parliament in January 2011. Rumblings of discontent from professional groups and other commentators, about the direction and speed of the proposed changes, led to the announcement of a ‘pause’ in the progress of the Bill. This prompted a ‘listening exercise’ – an extended consultation period, led by the NHS Future Forum, which reported back to the Department of Health in June.  After the listening exercise, amendments were made to the bill (some of which are outlined below), and it progressed through the House of Commons (lower chamber) in September.

Post ‘listening exercise’, the new commissioning bodies are now called ‘clinical commissioning groups’ (CCGs), rather than ‘GP’ consortia. This is to emphasise the involvement of other members of clinical teams-not just doctors- in providing expertise to, and making decisions within, CCGs. CCGs now have to have at least one nurse representative and must also consult with a range of other experts in making their decisions. ‘Pathway’ CCGs have been identified to try out the mechanisms.  Other amendments include tweaks to terminology (e.g. from ‘any willing’ to ‘any qualified’ provider); some clarifications about roles and responsibilities (e.g. the national Commissioning Board); and alterations to the timeline for implementation.

In October, the Health and Social Care Bill had a second reading in the House of Lords (the upper chamber). Unions and others had campaigned to persuade members of the Lords to reject the Bill.  However, this motion, and another to refer it to a Select Committee (which would significantly delay its progress as well as making significant amendments likely), were defeated. At the time of writing, the Bill is progressing through the ‘Committee stage’ in the Lords, which involves very close scrutiny of the details in the legislation.

Reaction and debates

There has been considerable resistance to the proposed changes from professional and public sector groups. The Keep Our NHS Public campaign (a public organisation); the British Medical Association (representing doctors), Royal College of Nursing ,Royal College of GPs and a collective of public health specialists, among others, have written very considered and constructive, yet in places quite damning responses.  Some summaries of professionals’ and academics’ responses to the Bill are available here and here.

Major concerns and debates around the bill include:

• the extent of market competition – the role of the private sector, impact on NHS services and smaller-scale providers (charities, social enterprises);
• vulnerability of services (or even population groups) not regarded as priorities by commissioners;
• the blurring of roles (especially for GPs) leading to potential conflict of interests, and to reduced time caring for patients;
• extent to which the proposed changes will really reduce ‘bureaucracy’;
• cost of implementing the changes in a time of financial austerity;
• perceived fragmentation of the NHS as a national institution; and withdrawal of ultimate responsibility of ‘state’ to provide health services;
• the place of public health responsibilities within the new structures.

Some of these issues are going to be discussed in greater detail in my next blog post.

1. British Medical Association (2011) BMA Statement on the Health and Social Care Bill, 20 July 2011 http://www.bma.org.uk/healthcare_policy/nhs_white_paper/latestnhsreformstatement.jsp    [accessed 17 October 2011]
2. Royal College of Nursing (2011) RCN Briefing on the Health and Social Care Bill, October 2011 http://www.rcn.org.uk/__data/assets/pdf_file/0003/408351/Health_and_Social_Care_Bill_Update.pdf [accessed 17 October 2011]
3. Beckford, M. (2011) Nearly 400 public health experts warn Lords to reject NHS reforms, 3 October 2011 http://www.telegraph.co.uk/health/healthnews/8804619/Nearly-400-public-health-experts-warn-Lords-to-reject-NHS-reforms.html [accessed 17 October 2011]

In the context of the recent World Conference on Social Determinants of Health, guest blogger Amir Attaran discusses the role of governance in improving the health of societies. Amir Attaran is a professor and Canada Research Chair in Law, Population Health and Global Development Policy at the University of Ottawa.

(Originally published in Portuguese in O Globo (Rio de Janeiro) on 19 October 2011)

If you are over 40 years old and reading this, consider yourself lucky, because historically you should be dead. Just two centuries ago, and for millennia before that, human life expectancy was half of what it is today. For doubling our lives, we must thank medical and public health science, and the legal and economic governance of modern, liberal societies.

But medicine and public health science are now close to a plateau, where life expectancy increases more slowly, at greater expense. As people live longer, lifestyle choices—diet, exercise—produce obesity, cardiovascular disease, diabetes, and cancer. In an ageing population, long life increasingly is not healthy life.

These transformations demand us to reevaluate the methods of using science and medicine to cure disease, and instead to ask how the governance of societies can prevent disease. Well before 2050, when the most typical Brazilian will be a woman over 80 years of age, societies must reorganize themselves so all their members can lead healthy lives. That means the governance of liberal societies, which formerly improved our health, now must adapt not to destroy our health.

This week in Rio, the World Health Organization is holding the World Conference on Social Determinants of Health, hosted by the Government of Brazil. It is a very important event: the first of its kind. Appropriately the agenda emphasizes governance over science or medicine. Governments need persuading that health is a good reason to use the controls of law and taxation –controls all governments possess to nudge society’s direction justly and not tyrannically –both to improve absolute health outcomes of all society, and relative health outcomes between the powerful and weak.

Not all governments accept this version of liberalism, and worse, many use the controls to destroy health rather than to improve it. Governments legislate agricultural subsidies of fast food (so a fatty burger and a sugary cookie are cheap) but do not legislate agricultural subsidies of slow food (so comida caseira and fruit are expensive). Or governments invest in highways to vast suburbs where the relatively wealthy must drive, but not safe downtowns where all of us can walk safely. What to legislate or what to tax are difficult choices, but with governance like this, is it any wonder that more people suffer obesity and hypertension which can kill them?

What worries me most, as a professor in both science and law, is that the unsurpassable influence of governance on health is either appreciated by too few, or too frightening to many. In many countries, even rich ones with universal health care systems like the UK, a distance of 10 kilometers or less separates neighbourhoods where for social reasons lifespan differs by 10-20 years (in Rio, 12.8 years). Yet governments avoid using the legal and economic controls. Even the WHO, which should know better, avoided mentioning “law” or “tax” once on the official agenda. Instead its agenda touts fuzzy goals like “Promoting participation and community leadership” – an irony because at WHO headquarters in Geneva, even NGOs which are officially recognized by WHO are not allowed participation in working groups. Thus even the WHO is not setting a good didactic example or leading by example.

Brazil has many social problems, but is trying hard and setting a better example that many so-called “advanced” countries. Recently in the British medical journal, The Lancet, our research team pointed to laws in Brazil which help procure cheaper medical supplies—a law that even Canada, my country, lacks. Good governance in Brazil means social services are increasing and income inequality is declining, while in Canada social services are declining and income inequality is exploding. It is not only symbolic that Brazil’s Vice-President and two Ministers will attend the conference, but Canada sent no Minister and only bureaucrats without authority.

Roughly 1000 members of national delegations, experts identified by  the World Health Organization (full disclosure: I was one of these) and civil society representatives converged on Rio de Janeiro for the World Conference on Social Determinants of Health, hosted by the Government of Brazil on October 19-21 at the picturesque Forte de Copacabana. Key background documents can be downloaded from the WHO web site, and a valuable blow-by-blow description of the conference events was provided by Canadian Jim Chauvin, president-elect of the World Federation of Public Health Associations.  WHO’s current director-general, Margaret Chan, opened the first day (really half a day) with a powerful speech that began: “Lives hang in the balance, many millions of them.  These are lives cut short, much too early, because the right policies were not in place.”  Much of the following day, which consisted of morning and afternoon parallel sessions on five areas identified in a discussion paper prepared by the WHO secretariat in advance of the conference, was anticlimactic.  The third day (again, really a half-day) was dominated by a panel that featured powerful presentations by Finland’s new Minister of Health and Social Services, Maria Guzenina-Richardson, and Zimbabwean pediatrician David Sanders, a long-time primary health care activist described as the “star of the day” in The Guardian.

Unlike the scientific conferences with which many of us are more familiar but in keeping with the standard for diplomatic events, most of the Rio meeting was tightly scripted.  (The “annotated session plan” of the parallel session for which I was a rapporteur ran to five single-spaced pages.)  The only concrete output from the conference was the aspirational Rio Political Declaration on Social Determinants of Health.  As usual with such documents, especially when a unanimity rule is involved, drafting began months in advance, with a first draft circulated to WHO member states in August and subsequent drafting sessions in Geneva starting in September.   Details were finalized during a day-long drafting session in Rio, operating in parallel with the conference but open only to the representatives of national delegations.

The Declaration is surprisingly strong in several ways.  For example it recognizes the potential of the current economic crisis to undermine health (¶9), and governments “pledge to adopt coherent policy approaches that are based on the right to the enjoyment of the highest attainable standard of health” (reference to such rights-based approaches has long been anathema to the United States), including such measures as social protection floors (¶14).  On the other hand, it contains neither new commitments of resources nor any formal mechanisms for monitoring and accountability.

Other omissions were highlighted by civil society participants in the conference, and by Dr. Sanders in his remarks on the last day.  For example, the Declaration includes no mention of trade and health; no reference to the ongoing problem of ‘brain drain’ of health professionals from low- and middle-income countries; and the conference as a whole paid little attention to capital flight, which drains capital from low- and middle-income countries in amounts far larger than the annual value of development assistance.  The lack of specifics would seem to underscore the concern expressed by Sir Michael Marmot and colleagues, in a commentary published at the start of the conference, that “social determinants of health have barely penetrated the global agenda … and the default position of people in the health sector is to focus on health services and prevention of specific diseases.”   Reflecting a similar concern, the People’s Health Movement – a multinational coalition of advocacy organizations – circulated at the conference an alternative declaration based on a more explicit analysis of how the global economic system generates health inequities.

A useful comparison can be drawn between the 2011 Declaration and the similarly aspirational 1978 Alma Ata commitment to achieve Health for All in the year 2000. Inthe event, the Alma Ata vision was thwarted by several elements of the political environment, notably resistance from the multilateral financial institutions that were emerging as key players in development policy for health.  “The Rio summit offers the opportunity to ensure that failure to implement a widely supported agenda does not happen again,” wrote Prof. Marmot and colleagues.

How realistic is this hope?  Despite the Rio Declaration’s omissions and lack of specifics, I am less sceptical about its value than many colleagues.  It offers an unequivocal affirmation that reducing health disparities by way of social and economic policy and the design of policy-making institutions is both scientifically sound and ethically imperative.  Unfortunately, these points remain bitterly contested in the quotidian work experience of many of us, and no international agreement can substitute for the myriad initiatives within national borders that will be needed to advance the science and politics of social determinants of health.   The view from Forte de Copacabana is very different from that from Rio’s favelas, about which amnesia seemed to be the rule during the conference.   Even in countries like Brazil that have achieved major reductions in economic and health inequalities, through programs such as the bolsa família cash transfer program and  extensive health sector reform, neither the strength of domestic opposition to redistributive policies nor the constraints created by the global political-economic system should be underestimated.   In less hospitable contexts, political battles are likely to be even more difficult.

Nowhere is this more true than with respect to WHO itself.  The organization is beset by financial difficulties, increasingly driven by the priorities of discretionary funders, and in the throes of a ‘reform’ process that may actually exacerbate those problems.   My own observations dating back to 2005 and some conference corridor talk suggest that in the absence of decisive pressure from member states, WHO’s Geneva-based management will regard the Rio conference as an endpoint of the social determinants of health agenda and the detour that it represented from business as usual.  Sarah Bosely concluded her Guardian coverage of the Rio conference, one of the few mentions it received in English-language media, by saying that social determinants of health are “one genie that looks unlikely to go back in the bottle”.  Maybe so, but keeping the genie out and active will require a lot of hard work and bloody-minded resistance to opponents that are both well-funded (think about industry responses even to the cautious agenda of the recent UN Summit on non-communicable diseases) and intellectually dishonest.

In the early 1990s the late Jonathan Mann and Daniel Tarantola left the WHO Global Program on AIDS. They helped establish the unit just a few years before, however they now felt they disagreed with the way the program was run and the philosophy that motivated its actions. Tarantola and Mann found academic “refuge” at Harvard and began thinking about the most effective framework for dealing with the AIDS epidemic. The epidemic is now known as the one “that changed public health forever”. One of factors behind this dramatic sea change was the framework Mann and Tarantola developed.  Although they were both qualified physicians, it didn’t take long for them to realize that HIV/AIDS needs to be treated with new drugs, but equally importantly the patients need to be guaranteed respectful treatment and honoured of their dignity as human beings.  After some trial and error Mann and Tarantola decided that the Universal Declaration of Human Rights (UDHR) is the best theoretical basis for an effective fight against AIDS forward.

And so the discipline of health and human rights was born. Today it is a thriving area of research and clinical as well as legal practice with increasing numbers of institutions and countries incorporating a rights-based approach to health.

The core idea behind health and human rights is that the best public health programs respect the human rights of the population involved. Unfortunately, I do not have the space here to go into too many details, but the WHO provides a good introduction for those who may want to know more.  In just a few words, incorporating a rights-based approach to health means treating patients with the dignity they deserve and respect for their choices and decisions. I’ll take a closer look at this now, with the example of a rights-based approach to reproductive rights and health.

It is important to realize that these concepts are not just subjects of academic discussion and taglines from WHO leaflets. They are the forces driving policies and ultimately the healthcare we are delivered in the doctor’s office. This may be hard to believe: probably the first things that come to mind when discussing human rights violations in the context of reproductive rights are coercive reproductive policies such as China’s one-child rule.  Governments which force citizens into unwanted abortions are obviously violating a number of human rights. Similarly, it is clear to most of us that countries which delegalize homosexuality or criminalize it are also guilty of human rights violations. But the situation really isn’t always that obvious. What about governments which delegalize abortion (e.g. Malta)? And governments which do not provide access to evidence-based sexual education (e.g. Poland but also the US)? Governments which force mandatory HIV/AIDS status tests on sex workers (discussed in a number of countries and regions)? What about doctors who do not want to prescribe contraceptives to under-18s (again, many places around the world)? Or on a more personal level, has any doctor ever performed an examination – including (for those readers who have given birth) a vaginal examination during delivery – without your explicit informed consent?  All these are in fact human rights violations according to a number of binding human rights instruments (the UDHR is not the only basic human rights document, although it is the only one with the term ‘human rights’ explicitly embedded in it – a full list of the important international documents can be found here).

We tend to imagine that breaking human rights involves wars, refugee camps, power-obsessed dictators and lunatic warlords. In fact, human rights violations may be happening in your oby/gyn office or at the GPs. For example, The Convention on the Elimination of All Forms of Discrimination against Women (CEDAW), adopted in 1979 by the UN General Assembly, clearly states that access to evidence-based sexual education and contraception is a basic human right. CEDAW should be informing policy-makers around the world. However, as is too often the case we lag far behind the ideal. I’ve recently written about the pretty bad condition Polish citizens’ reproductive rights are in. But we needn’t look to emerging post-communist countries to find examples of human rights violations in regards to reproductive health. For example, the U.S. Department of Health and Human Services announced only last month that insurance will now have to cover several women’s preventive services, including birth control and voluntary sterilization. Prior to that contraceptives required a considerable co-pay, which barred many lower income women from accessing them. Moreover, according to the leading reproductive health research body The Guttmacher Institute: A total of 36 states require that sex education include abstinence, while only thirteen states require that the information presented in sex education classes be medically accurate and factual. And just a reminder: access to contraception and evidence-based information about sex is considered a human right according to CEDAW!

In this (very brief) outline I hope to have communicated that human rights really aren’t a bunch of idealistic phrases written down for the benefit of victims of violent conflicts. Human rights come into every aspect of our lives and definitely with regards to health – particularly an issue as intimate and politically charged as reproductive health. The take-home message really is this: the human rights framework guarantees that we should be the ones making choices, and they should be informed ones. The role of the state is to aid us in this and not encroach on our decisions about our sexuality and reproductive activity.

One of the movement’s fundamental concerns, excessive levels of income inequality, is a major determinant of health. In 2007, the top 1% of U.S. earners  owned 34.6% of the wealth. In 2009, CEOs of major U.S. corporations took home 263 times the average compensation of American workers. It is now well established (see here, here, and here) that in places where income inequality is greater, population health is worse. It has recently been reported that the combined impact of poverty and income inequality was responsible for 291,000 US deaths in the year 2000 alone.

States with the highest income inequality are also less likely to invest in human capital and provide far less generous social safety nets. This is because income inequality also undermines civil society, erodes political participation and in turn, determines the type of policies government chooses to (and not to) pursue—all with important implications for the opportunities people have to lead a healthy life.

But the Occupy Wall Street protesters aren’t just demanding a redistribution of income–there is a far superior recognition within the movement. Protesters recognize that social ills, like income inequality, are a consequence of deliberate actions by individuals and groups who impart undue influence on the government. This is important because it is ultimately this undue influence which threatens the quality, availability and distribution of resources important for health. Resources like income, employment, food, healthcare, housing, education, and the environment. By demanding sweeping reform of an entrenched system, protesters are thus taking aim at the ultimate determinants of health. Take a look at the Declaration of the Occupation of New York City for an idea of how protesters have related corporate influence to a range of these resources. Moreover, see this report by the World Health Organization which outlines how these resources in turn influence health.

There are many reasons why the  Occupy Wall Street movement should be supported.  For those concerned with the public’s health the call to action should be answered without hesitation.

The contemporary uptake of this idea can be found in the increasingly popular concept of ‘social determinants of health’ (SDOH).  Introduced in the 1970s, SDOH theory arose as a critical response to a public health agenda narrowly focused on an individualized and bio-medical understanding of health.  Popularized in the 1990s, SDOH seem to be of increasing concern nowadays and are generally understood to represent the resources by which people control the conditions of their life. These resources include things like food, housing, income, education, employment, our physical environments, as well as their distribution across society.

But should all social determinants be treated with equal concern? In other words, are certain determinants more important than others in influencing the health of populations?

In 1995, researchers Link and Phelan introduced a distinction which begins to answer this question.  Highlighting the importance of SDOH (without explicit reference to the concept), Link and Phelan distinguish between SDOH which ‘contextualize risk factors’ and those which represent the fundamental determinants of health. Whereas the former explain “how people come to be exposed to individually-based risk factors such as poor diet, cholesterol, lack of exercise, or high blood pressure” (p81),the latter are broadly conceptualized to include things like “money, knowledge, power, prestige, and the kinds of interpersonal resources embodied in the concepts of social support and social networks”(p87).

The main point of this distinction is that even if we change the contexts within which people are exposed to individually based risk factors (things like access to parks, healthy foods, and health care), unless we address the fundamental determinants of health, the link between socio-economic status and health will continue to shape population health profiles. This is because fundamental causes are associated with multiple risk factors as well as multiple health outcomes. Moreover, we live in a dynamic world system where new diseases and risk factors are always emerging and those with greater access to resources will always be better positioned to respond to them.

A SDOH distinction advanced by researches more recently, distinguishes between the structural determinants of health, factors related to social positioning, and the social processes responsible for the distribution of these determinants (sometimes termed the social determinants of health inequalities).  By positioning social processes further upstream, this distinction, like Link and Phelan’s fundamental cause theory, gives strength to the idea that not all social determinants of health should be treated with equal concern.

With even greater discernment of the various ways in which SDOH can be understood, recent work by Dennis Raphael identifies seven unique SDOH discourses, each with divergent policy implications (see the SDOH discourse table below). Raphael uses the term ‘discourse’ to differentiate the various ways researchers talk about SDOH since these different approaches “appear to direct the kinds of research and professional activities that are deemed acceptable” and thus, like the Foucaultian concept of discourse, “involve issues of legitimation, power, and coercion” (p223).

SDOH Discourses

Source: Raphael, D. (2011). A discourse analysis of the social determinants of health, Critical Public Health, 21:2, 221-236

Aside from gaining insight into the type of policy implications associated with each of these discourses, from Raphael’s outline it becomes clear which type of SDOH discourses merely contextualize risk factors (discourses 1 through 3) versus those which address the fundamental determinants of health (discourses 4 through 7).  We are also able to set aside those which focus mainly on the structural determinants of health (discourses 1 through 4), and those which direct attention to the processes responsible for the distribution of these determinants (and thus also responsible for health inequalities) (discourses 5-7). Most importantly however, we are directed to the ultimate determinants of health (discourse 7): “the individuals and groups who through their undue influence upon governments create and benefit from social and health inequalities—and in the process threaten the quality of the SDH to which individuals are exposed and skew their distribution” (p229).

While SDOH theory arose as a critical response to the preponderance of individually and healthcare-based responses to disease, with Raphael’s discourse analysis, we are forced to question how far the SDOH concept has actually begun to address this concern—especially given the respectively diminishing attention directed towards the fundamental determinants of health, the policies responsible for their distribution, and the ultimate drivers of these policies: those who benefit from their disequalizing  consequences.