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.