Social Determinants of Health: Life after Rio

In this guest post, Ted Schrecker offers an overview of the recent World Conference on Social Determinants of Health. Ted discusses the Conference’s ‘Rio Declaration’, highlighting both its strengths and weaknesses, as well what it will take to keep the SDOH agenda moving forward. Ted is an associate Professor in the University of Ottawa’s Department of Epidemiology and Community Medicine, and a principal scientist at the University’s Institute of Population Health.

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.

Human Rights and Reproductive Health: A primer

In this guest post Maria Pawlowska presents the story and ideals behind the use of a human rights framework in health.  Maria establishes the importance of using a human rights framework to guide reproductive health policies by tracing its implications from the global to the individual level.

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.

Why Occupying Wall Street can make the U.S. Healthier

Occupy Wall Street protests are taking hold in a growing number of US cities. These protests seek to draw attention to extreme corporate influence which leaves no part of the county’s social, political  nor economic infrastructure untouched. Growing commentary has covered much ground on the causes, faults, and promise of the movement. However, a stone that has yet to be overturned is  one that should have public health professionals, as well as anyone who cares about the health of their community, taking to the streets. While protesters are no doubt occupying Wall Street for a variety of reasons, in the process they are also confronting some of the most important determinants of health.

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.

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From the Social to the Ultimate Determinants of Health

The notion that health is influenced by society, and the politics governing it, has been around for generations. Rudolf Virchow, known for his advancement of public health, is quoted famously for his 1841 declaration that “medicine is a social science, and politics is nothing else but medicine on a large scale”.

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.

 

WHO Reform: Background notes, Broader context, Directions for advocacy

In this guest post, David Legge directs us to his work at the WHO Watch where he provides insightful background on the upcoming WHO reform talks, set to take place this November. Advanced is an analysis of global health governance which positions the social determinants of health, and health system development, within a dynamic interplay of policy paradigms, donor practices and corporate power. David also offers thoughtful insight into key issues facing the WHO and possible directions for advocacy efforts. David is a teacher of public health at La Trobe University in Melbourne.  He is also very much involved with the international People’s Health Movement.

The WHO is in crisis. It is in debt and its agenda is increasingly dictated by donors rather than member states. The Director General has initiated a reform process which will come to a head in November 2011. There are powerful pressures at work which are directed to restricting WHO to a purely technical role and towards closer relationships (‘partnerships’) with private corporations and private foundations (in particular the Gates Foundation).

This paper provides background to the WHO Reform process, contextualises the reform initiatives within the wider global health governance scene and provides a starting point for consideration of possible advocacy messages.

Read more at: http://www.ghwatch.org/sites/www.ghwatch.org/files/Legge110909_WHOReformBackgroundOptions.pdf

Reasons For and Benefits From Community Participation in Public Health

In this guest post, Lauri Andress continues her series on community participation and public health. In order to bring more clarity to the concept of community participation, Lauri provides a framework that
attempts to discern a range of benefits that stem from community participation.
She argues that some justifications for community participation are more likely to benefit the community than others. Also outlined are various mechanisms through which these benefits impact population health. Lauri is a public health policy analyst at Andress & Associates where she advises US public health departments on policies, programs, and competencies related to health inequities.

Community participation has been elevated to a list of “must-have” elements in government, university, and research institutions. However, while described as delivering a myriad of benefits, it seems that we still know little of the extent to which these benefits are in fact delivered, to whom the benefits inure, and the mechanisms by which the benefits are conveyed.

In fact, a systematic review of community engagement studies involving community redevelopment initiatives by Burton et al. (2004) reported either evidence of negative impacts or difficulty in deciphering what the objectives of the interventions were, let alone their impact.

Without a reasonable degree of conceptual clarity about community participation, any projects and subsequent practical measures have been and continue to be built on shaky foundations.  Seeking to begin to address this inadequacy, part two of this series critiquing the use of community participatory methods in public health examines the benefits of and reasons for community participation and explores the possible means by which these benefits are conveyed.

Richardson (1983) provides a helpful framework for understanding the commonly touted benefits of community participation.  She distinguishes between the developmental benefits that attach mainly to the individuals who participate and the instrumental benefits associated with the institutions/systems, and/or decisions and policies made as a result of community participation.

Webler et al. (1995) presents three instrumental reasons for stakeholder and public participation.

  • First, when expert knowledge is scrutinized in public the relevance, scope, and proficiency of the final decision may be increased by the inclusion of local knowledge;
  • Second, the legitimacy of the final outcome (policy, program, project) may be increased when effected stakeholders have the opportunity to state their own case and influence the outcome (i.e., a due process argument–the process was fair); and
  • Third, there is a widespread belief  and dictum among parliamentary democracies and other representative systems of government that above and beyond the opportunity to vote on national, regional and local governments, citizens should be allowed and encouraged to participate more directly in decisions that affect them (Beetham, 1994).

What is most striking about these examples of and reasons for instrumental community participation is how the benefits to the community are more distant and have a lower chance of transpiring.

First, in instrumental community participation the purpose is meant to fulfill the requirements of a system or institution that it consult with and /or provide an opportunity for the community to offer their views on some action.

Inherent in the idea of instrumental community participation is the explicit rationalization of the effort based on procedural reasons where the citizen involvement is satisfied by the simple existence of a course of action grounded in principles of due process.  In this case, everyone is entitled to a process or rather a means by which a person may or may not interface with a program, system, policy, or decision-making procedure.

Accordingly, instrumental community involvement may be seen as a right to be satisfied or violated by the absence or meager presence of opportunities for community members to be engaged.

Next, at the end of the day or closing of the community engagement process, it is not clear that the community’s voice, votes, vision, or ideas will be taken up by the system or institution.  However, it is clear that the obligation to include the community has –according to the regulation, policy, or law- been fulfilled.

Under instrumental community participation neither the quality of the process nor the creation of outcomes that have a chance of benefiting the citizens is scrutinized.   In the end the benefits have a greater chance of flowing in one direction – toward the system and away from the community.

To Webler’s three instrumental benefits I would add a fourth reason for public participation which also adheres to Richardson’s (1983) framework where developmental benefits attach mainly to the individuals who participate.  In this rationale for community participation, the benefits have a greater chance of flowing to the community because the interest lies in the political dimension of people’s experience.  Central to the idea of developmental community participation is the idea that civically skilled citizens will become engaged individually and collectively in acts requiring greater autonomy, collective will making, and  social engagement.  These are outcomes that have worth to the citizens whether the system acknowledges the community’s participation or not.

By what mechanism does community participation deliver these developmental benefits to the individual?  In other words, how does community participation get under the skin to influence health?

Current thinking posits the use of secondary routes where community participation influences health indirectly through several intermediate mechanisms.[1]

Evidence demonstrates, that in the end, developmental benefits of public participation that impact population health -particularly for marginalized groups include: greater social inclusion, decreased feelings of alienation, anxiety and exclusion, and an increased sense of autonomy, social capital, social cohesion, sense of control over decisions affecting their lives, and collective self-efficacy.

In other words, community engagement approaches that involve communities as equal partners or give some or total control are thought to lead to positive health outcomes.

Richardson (1983) advanced five developmental benefits from community participation that may be seen as intermediate, mechanistic outcomes that lead to long term health benefits.

First, participation may be a means to acquire, retain, or enhance our dignity and self-esteem where involvement in decisions about matters that affect our own lives confirms that we are valuable and valued members of society with something worthwhile to contribute.

The second and third benefit lies in the educative role played by participation. By participating in one aspect of public life, we become more self-confident in our ability to take greater control over other aspects of our lives.  As participating citizens we increase our sense of autonomy as we learn how to think publicly.

The third developmental benefit with an educative element says that participating in public discussions and decision-making engenders more thoughtfulness about our preferences and priorities and about our values and beliefs.  Further, we evolve a more complete understanding of our own real interests leading to a decrease in a sense of passiveness where we are prey to others saying what is best for us.

Richardson’s fourth benefit relates to identity and expression where participation provides an opportunity for us to give expression to relevant aspects of our identity for example, as green radicals, as independents or conservatives.

The final developmental benefit claims that by participating we become more sociable and at the same time contribute to a greater sense of social integration, social cohesion, or social solidarity.

The non-specific, undefined use of community participation is problematic and adversely affects public health research, practice, and causal accountability.  By examining the reasons for and benefits from community participation we can get closer to creating authentic opportunities for citizen engagement that will benefit both the community and the institutions and systems that seek out these interactions.


[1]   Attree P., French, B., (2007) Testing theories of change associated with community engagement in health improvement and health inequalities reduction. Report prepared for NICE.

Poland vs. Malta – or a beginner’s guide to strict anti-abortion policies

In this post, guest blogger Maria Pawlowska discusses anti-abortion policies in Malta, drawing comparisons to her previous post on Poland and relating the harmful repercussions of these policies to the influence of the Catholic Church, social conservatism, and gender inequality.  Maria is a healthcare analyst with a passion for reproductive health and gender issues in health care provision. Maria has a PhD from Cambridge, where she was a Gates scholar, and has worked with the Global Poverty Project and RESULTS UK.

In my previous post I wrote about how the political transformation in Poland had a detrimental effect on reproductive rights. Now, I would like to take a closer look at Malta – where abortion is completely illegal – and investigate the political and social climate in which women’s lives are valued less than those of the foetuses they carry.

Being a pregnant woman in Malta can be dangerous – abortions are completely illegal even if they endanger the pregnant woman’s life. As a result, a doctor who removes a pregnancy to save the life of the woman is banned from the profession and can be sentenced to up to four years in jail. This law potentially puts pregnant Maltanese women in extreme danger. However, those who are responsible for providing their medical care support the current legislation. In an interview for the Times of Malta, Donald Felice, president of the Malta College of Obstetricians and Gynaecologists, says that throughout his 40 years of experience he never witnessed any “dramatic” cases where a woman’s life depended on an abortion – and that’s jolly nice, but does not in any way make pregnant women safer! He continues – “If a woman needs treatment, like chemotherapy, we will administer it and let the baby take its chances, even if it is likely that the unborn child could die as a secondary effect.” Therefore, according to doctor Felice, having women go through the trauma of a serious illness and additionally a likely stillbirth or miscarriage is the preferred option. Moreover, he simply chooses to ignore pregnancies which result from crime, pregnancies which endanger the mother’s life (such as ectopic pregnancies) and diseases which can become fatal if the patient is pregnant. Ectopic pregnancies for example occur in about 11-16 pregnancies per 1000. According to the Maltanese Statistics Office there were 4143 births in Malta in 2009 – therefore, statistically speaking at least 4 women had seriously life-endangering pregnancies, which were unlikely to resolve safely.

It was hoped that a recent ruling in which The European Court of Human Rights found that a sick woman’s human rights were breached when she sought an abortion in Ireland but was forced to go to the UK instead, might lead to the Maltanese government to reconsider its abortion policies. However, analysis of the verdict and the political situation in Malta suggest this is highly unlikely. According to Judge Bonello, one of the judges deciding on this case, the Irish state’s fault was failing to provide legal and practical structures through which a woman could make use of her legally recognized right to abortion if her life was in danger. Therefore, the verdict of the European Court of Human Rights does not force countries to provide their citizens with means of obtaining an abortion (in which case it would have an impact on the situation in Malta). It simply states, that if a country decides abortion is legal in some circumstances, women must be able to access it – this hadn’t happened in Ireland. Maltanese law clearly states that abortion is illegal and therefore the government is under no obligation whatsoever to provide any – even potentially life-saving – abortion services.

Polish “pro-life” groups were actually hoping to catch up with Malta in this respect – a law which would completely delegalize abortion had made it through a first hearing in the Parliament.  Luckily for Polish women, however, last week the Polish Parliamentary Commission on Social Politics and Family voted to give no further consideration to this bill. However, the fact the bill made it all the way to the parliamentary commission is a clear sign that the influence of the “pro-life” movement is steadily increasing.

The fact that such strict anti-abortion laws are considered in places like Poland, and are legal reality in places like Malta, has little to do with bioethics and everything to do with a similar political backdrop in which the Catholic Church has a huge say.  In Malta, for example, divorce will only become an option this October – previously the Catholic Church blocked any debates of this issue. In Poland, on the other hand, crosses hang in all public institutions, Catholic religion is taught in state schools and Church officials very actively and openly take part in political debates. Of course, this influence can be seen most clearly when it comes to reproductive rights. Don’t get me wrong – I firmly believe that views to the effect that life should be “protected from conception” – should have the right to be expressed by religious authorities. That’s exactly what free speech is for. However, when they become the law of the land they break the human rights of that country’s citizens and put their lives at stake.

Moreover, there is a clear link between social conservatism, women’s roles in society and anti-abortion laws. According to socially conservative views of gender roles, a woman’s primary duty to the family and state is bearing and raising children and all her other talents, ambitions and needs should be secondary to motherhood. When women are valued primarily as “home-makers” and their main role in society is seen as nurtures of the family, strict anti-abortion laws “aid and enhance” the fulfilment of women’s function in society. Consequently, if women are seen chiefly as child-bearers, it is easier for the lawmaker to justify sacrificing women’s life in relation to pregnancy (although I do not think it is inconsequential that in these countries the vast majority of parliamentarians and government members are men).  Women’s devaluing to primarily the role of de facto incubators is highlighted by the term “pro-life legislation”. Even though the strictest anti-abortion (and therefore most “pro-life”) laws may result in a doubling of preventable casualties the term does not ring hallow to a majority of its supporters. This is because they are clear on which life is important – the foetus’; a pregnant women is simply a means of getting the foetus into the world.

There is little doubt that anti-abortion laws are as much about sex equality as they are about anything else. In Poland and Malta the anti-abortion laws are symptomatic of deeper inequalities and the harshness of the anti-abortion law seems correlated to the level of discrimination. Consequently, in the 2010 Global Gender Gap report Poland is 43rd and Malta 83rd  most unequal country (out of 134 listed country). It isn’t a coincidence that Iceland – number 1 in the report – has legal abortion. Over 40 years ago the Icelandic government gave its female citizens the full right to decide about their bodies and confirmed the importance of self-determination irrespective of gender. Poland and Malta still aren’t there.

Tackling Health Inequalities: restructured into a luxury?

In this guest post, Kate Thomson discusses the elimination of a national taskforce proven to reduce health inequalities in England. She asks whether the shift of responsibility to local authorities will render health equity concerns into unaffordable luxuries. 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.

Earlier this month, it was reported that a taskforce that supported English primary care trusts and local authorities in tackling health inequalities and other public health issues, had been ‘quietly abolished’. Prime Minister, David Cameron, has been insistent about the government’s commitment to address health inequalities – so how can we interpret this decision, and what is the outlook for sustaining ‘healthy policies’?

The ‘taskforce’ in question combined ten Public Health National Support Teams (NSTs), established in 2006. Each NST provided expertise on a specific issue, for example, Health Inequalities; Tobacco Control and Teenage Pregnancy. They analysed the performance of localities in improving health outcomes and offered tailored advice and toolkits, with a particular focus on supporting areas with the worst outcomes. The involvement was intensive and sought to engage local partnerships and communities. The NSTs’ final report indicates that areas they had visited showed greater improvements in relevant indicators than others; in other words there appears to have been real impact.

This news comes at a fraught time for public health, health and other public services in England.   Serious cuts to local budgets are beginning to take effect, ostensibly as a response to wider economic crisis and state debt. Major restructuring of the National Health Service (NHS) is underway via the Health and Social Care Bill . General practitioners (GPs) are to take a more central role in deciding upon and budgeting for the services that are available in their local area – including preventive health services- within new ‘clinical commissioning groups’ (CCGs).   Some professional organisations and campaigners have expressed disquiet about the impact of these changes, including their implications for public health.

At the same time, public health structures are being dismantled and reshaped so that they become absorbed into local authorities, rather than existing as separate entities. This is a great opportunity to ensure ‘healthy policies’ as there is potential for public health practitioners’ closer involvement with all areas of local decision making (planning, transport, housing, education, etc.). However there is concern about a loss of authority, as well as about budgets – how will ‘ring-fencing’ public health budgets work out within a context of wider cuts in services? A recent public consultation response did not entirely clear up these questions.

Let us take as an example the issue of teenage pregnancy, which had its own NST and has been a priority over the last decade (in policy terms and in terms of media coverage). The teenage pregnancy NST identified localities that most needed support in meeting targets, provided analysis and detailed tools to help them achieve it; effective practice was also disseminated. Critical debates about the overall (as opposed to symbolic) importance of teenage pregnancy as indicator of an (un)healthy society are important (see this insightful example) – there is an element of moral panic in public discourse on this issue.  However, there is also persuasive evidence about the inter-generational impact of health disadvantage, which suggests that both preventive and supportive interventions are necessary in the area of teenage parenthood. There is already concern that general government spending cuts will inevitably hit services that have achieved impact in reducing teenage pregnancy rates and supporting young mothers. How will work in this area be sustained and supported after the loss of taskforce expertise, and in the wake of reorganisations and budget cuts?

The GP Online report that broke this story quoted the head of the Health Inequalities NST as saying that he and others from the team had set up their own consulting company to provide support to local health authorities (commissioning groups).  Expertise will therefore continue to be available for localities that choose to spend from their budget: good news that the insight and support will not disappear entirely. This reflects wider shifts in the health and public services landscape in England.  There is strong encouragement of entrepreneurship, social enterprises, involvement of private sector and ultimately, competition between providers. From the government’s perspective, stimulating a diversity of provider models will lead to quality improvements, greater choice and the possibility of tailoring services to local needs. These moves are viewed with great concern by those who regard it as a ‘privatisation’ of their beloved NHS; there is also scepticism about the sustainability of an ‘enterprise’ based model.

I am going to sidestep the debate about privatisation, plurality, competition and quality, although it is an important one both nationally and globally. For now let us just acknowledge some practical implications of this specific situation. The NST’s own final report indicates that not all localities they identified as having a need, were committed to working with them. The report talks of lengthy preliminary discussions / correspondence to ‘engage’ the relevant people gain access to work. Under the new regime localities (local authorities and clinical commissioning groups) will presumably no longer be under pressure to allow consultants (e.g. those emerging from NSTs) in. A new Public Health Outcomes Framework will be in place, although its mechanisms (and the sharpness of its ‘teeth’) are yet to be finally defined.

It seems evident that if concerted and sustained action to address complex public health problems and health inequalities is no longer required, and the ‘assistance’ to do so not imposed, some localities will choose to spend their money in other areas. Many aspects of health spending have ‘results’ attached that are far more tangible and easy for local residents to engage with.  Traditionally, GPs (who will be closely involved in commissioning local services) have a keen sense of the wider health needs of their constituencies and have long been engaged in preventive and public health measures. However when very large budgets are at stake, is it inevitable that monies might be tracked more readily into more tangible aspects of health and healthcare such as hospital treatment and management of long term conditions?

The tension between ‘localism’ and standard expectations (or ‘bureaucracy’) is acute here. It is very difficult to sustain a claimed commitment to addressing inequalities in health (whose roots after all, are not only ‘local’), while at the same time devolving responsibility for how (and whether) to tackle them, to local organisations. Let us hope that tackling knotty public health issues will not turn into a luxury that areas feel they are unable to afford or support.

 

Social Determinants of Health: Resuscitating the Agenda in Rio

In this guest post, Ted Schrecker offers a commentary on how the 2011 World Conference on Social Determinants of Health might restore an otherwise ailing SDOH agenda. Ted is an associate Professor in the University of Ottawa’s Department of Epidemiology and Community Medicine, and a principal scientist at the University’s Institute of Population Health.

The final report of the WHO Commission on Social Determinants of Health, published three years ago, should have represented a milestone in the quest to achieve the goal of Health for All articulated at Alma-Ata in 1978. Based on a synthesis of available evidence that was unprecedented in its scale, the Commission identified conditions of life and work that deny literally billions of people the opportunities for a long and healthful life as “the result of a toxic combination of poor social policies and programmes, unfair economic arrangements, and bad politics.” It went on to identify “changes in the functioning of the global economy” as critical to its objective of closing the health gaps between rich and poor in a generation. The Economist, in a generally laudatory review, said that the Commission was “baying at the moon.” Two months later, after a financial crisis had spread across the world, the Commission appeared remarkably prescient.

So what happened? Despite its heightened relevance post-2008, three years later the social determinants of health (SDH) agenda is in peril, although it could bring major benefits to the majority of the world’s population living in low- and middle-income countries (LMICs) and drive integration of health concerns into debates about how to distribute the pain of post-crisis austerity in high-income economies. The Commission may inadvertently have contributed to the problem by saying little about implementation beyond calling for a global social movement. Beset by budgetary constraints even more acute than usual, and by intense opposition to the agenda from elements of the medical profession both outside and (one suspects) within the organization, WHO is ill equipped to carry the agenda forward. The World Conference on Social Determinants of Health, to be held in Brazil in October 2011, appears directionless and sometimes seems nothing more than a ritual response to a generic World Health Assembly resolution responding to the Commission’s report .

The SDH agenda, and those who could benefit from its aggressive uptake, deserve better.  What to do?  The Global Fund to Fight HIV-AIDS, Tuberculosis and Malaria, now a decade old, provides a promising model. The Fund was established at the initiative of G7 governments convinced of the urgency of improving global health. They, the United States in particular, were also reluctant to commit billions of dollars for disbursement through UN system agencies that often were, and are, politics-driven rather than results-driven. The Global Fund is far from perfect; critiques of its emphasis on specific diseases rather than on strengthening health systems must be heeded. At the same time, the Fund has shown willingness to respond, and core elements of its organizational design – donor commitments of funds not tied to any specific project or beneficiary; independent scientific review; reliance on recipient-originated proposals as an indication of commitment; and rigorous auditing of both financial management and achievement of objectives – have survived the test of a decade well enough to deserve emulation.

Thus, a modest proposal for two initiatives to be taken forward by committed national governments at the October conference.

A Global Fund on Social Determinants of Health could be modeled closely on the existing Global Fund. It might more actively seek proposals from sub-national governments and civil society organizations in LMICs, subject only to assurance from the national government in question that it would not obstruct the initiatives for which funding was proposed. Proposals could range from pilot projects to national scale-ups of policies that had already demonstrated their effectiveness.  Funding criteria would give preference to policies and interventions that do not primarily involve health care providers and to support for intersectoral action.

A second fund, with a subtly different remit, could address governance issues central to SDH. This proposal recognizes the oft-neglected connections between SDH and broader issues of democratic governance (including governance of the global economic system), accountability, and human rights. For example, the annual value of illicit capital flight (a subset of the total) from sub-Saharan countries in the first decade of this century has been estimated at twice the value of the 2005 Gleneagles development assistance commitments, underscoring a major limitation of current initiatives to improve development assistance effectiveness. And the international human rights law framework offers important potential for reducing health inequity in areas ranging from access to essential medicines to protecting against forced evictions that benefit only a wealthy minority of domestic consumers and foreign investors. Thus, eligible proposals for purposes of this Fund might involve efforts as diverse as cross-border collaborations between civil society organizations and national or multilateral agencies to track and repatriate illicit flight capital, and provincial or local efforts to provide legal advocacy in support of economic and social rights.

These proposals are obviously presented in preliminary form, intended to stimulate further intensive discussion (and elicit better ideas) within a short time frame. Although the need for substantial new transfers to LMICs cannot be ignored, the two Funds proposed could probably be financed in their first few years with minimal new net expenditure by OECD development assistance providers, through redirecting part of the existing budgets of national aid agencies and major foundations.  In a “looking-glass world” of trillion dollar war budgets and bank bailouts, this argument is morally troubling.  Practically, making-do with existing resources would probably suffice to provide proof of concept; new commitments, whether by high-income countries with a history of innovation or by LMICs that have emerged as leaders in South-South cooperation, would strengthen the proposals from the start, and will be critical for longer term success. The challenge for the World Conference will be relentlessly to foreground the moral imperative of reducing health inequity, mobilizing resources that are abundant by any reasonable definition, while at the same time protecting the prospect of agreement on concrete proposals to restore momentum that has dissipated since 2008.

Community Participatory Methods : Positive, Negative or Negligible Benefits for the Community

This guest post is the first in a series of posts which will critique the use of community participatory methods in public health. The author of this series, Lauri Andress, is a public health policy analyst at Andress & Associates where she advises US public health departments on policies, programs, and competencies related to health inequities. In this introductory piece, Lauri introduces the idea of community involvement and demonstrates its alignment with a social determinants of health perspective.

Public health, medicine, and especially the growing literature on social determinants of health, routinely invoke the idea of “community involvement”– a universal term meant to capture efforts by groups external to the community who seek to integrate citizens or community members in a project, intervention, or event.

In the late 1970s, following Canada’s lead, the World Health Organization broadened its definition of health to account for the fact that health is much more than the absence of disease.  This broader definition embraces the notion that only 25% of our health status comes from health care while the rest comes from the effects of other social determinants of health (SDOH), distributed on the basis of social position.

With this orientation in mind and a framework that expands notions about the factors that make up health, the field of public health has looked more broadly at how to get at these non-medical, contextual factors that are external to the individual and the body.  One essential idea is that to mitigate the social and economic issues that impact groups based on social position, interventions must transform institutions, systems, organizations and the public policies that emanate from these arrangements.

At this point we arrive at the need for community participation.  In a democratic system, we rely on the active participation of our citizens in relation to each other and elected officials to govern society; to create, change, and monitor systems and policies; and to balance out the effects of inequality.

To demonstrate the connection between the social determinants of health and community involvement, the remainder of this series will introduce and draw upon an ecosocial perspective to illustrate how notions of community involvement get caught in the middle of problematic efforts to satisfy the procedural goals of researchers and government health organizations — surprisingly embraced by both biomedical and social determinist frameworks—with cursory attention to community benefits.

Over the next few months, I will argue that the non-specific and undefined conceptualization of community involvement is problematic and adversely affects public health research, practice, and causal accountability.  At issue are distortions created by confusing different types of community involvement and a lack of clarity on aims, goals, and measurable outcomes.  Eventually I will propose the use of specific methods for community involvement based on explicit goals and the use of identifiable outcomes accompanied by explicit measures.

More posts in the series