Wednesday, October 08, 2008

Social Determinants of Health

By Alberto G. Romualdez, M.D.
Malaya, Tuesday, 7 October 2008

In 2005, the late Director-General of the World Health Organization, Dr. Lee Jun-Wok, set up the Commission on the Social Determinants of Health. Its job was to marshal evidence on what could be done to promote health equity. Last month, after working for three years, the Commission issued its final report entitled “Closing the Gap in a Generation – Health Equity through Action on the Social Determinants of Health”.

Chaired by a well-respected epidemiologist, Professor Michael Marmot of the United Kingdom, the Commission’s members were a diverse group ranging from a former president of Chile to health ministers and health experts to a Nobel laureate in economics. But despite their different backgrounds, the Chairman noted that “everyone connected to the Commission were united in three concerns: a passion for social justice, a respect for evidence, and a frustration that there appeared to be far too little action on the social determinants of health.”

“Closing the Gap” did not reveal any startlingly new findings about the relationships between social status and health. However, its methodical exposition of the evidence on these relationships and how widespread they were across the globe provides documentation that should initiate action by responsible authorities not only in the health sector but at all levels and areas.

For the Philippines, the findings of the Commission underscored the fact that, as repeatedly asserted in past forums, our country situation mirrors the global situation in almost all aspects especially in the disgraceful health inequities between the rich minority and the poor majority of Filipinos.

The recommendations on the approaches to reducing health inequities are also very much applicable to our situation. These approaches are based on an all-encompassing concern for social justice which, the report asserts, “is a matter of life and death. It affects the way people live, their consequent chance of illness, and their risk of premature death.”

The Commission proposes three overarching recommendations for dealing with inequities in health. It is obvious from these that reforming the health sector to deal with inequality cannot be the business of the health sector alone because not all the factors that promote inequity are within its sphere.

The first of these is to improve living conditions for all because “the inequities in how society is organized mean that the freedom to lead a flourishing life and to enjoy good health is unequally distributed between and within societies. This inequity is seen in the conditions of early childhood and schooling, the nature of employment and working conditions, the physical form of the built environment, and the quality of the natural environment.”

The second overarching recommendation is to tackle the inequitable distribution of power, money, and resources because “inequity in the conditions of daily living is shaped by deeper social structures and processes. The inequity is systematic, produced by social norms, policies, and practices that tolerate or actually promote unfair distribution of and access to power, wealth, and other necessary social resources.”

The third recommendation is to measure and understand the problem and to assess the impact of action because “the world is changing fast and often it is unclear the impact that social, economic, and political change will have on health in general and on health inequities in particular. Action on the social determinants of health will be more effective if basic data systems, including vital registration and routine monitoring of health inequity and the social determinants of health are in place.”

“Closing the Gap in a Generation” is a very important document that will help to understand the underpinnings of health inequity. It should be required reading for individuals who have any interest in trying to remedy the problem of inequity in the Philippine health system. The document provides materials to support the argument that it is time to elevate the level of politicization of health from that of parochial self-interests and petty patronage to a national issue of common concern.

Unfortunately, despite the fact that polls show that health is a priority issue for most Filipinos, politicians’ have for the most part shown a rather shallow appreciation of the issues. It is for this reason that political campaigns for any post always feature medical missions and distributions of medicines (mostly unnecessary). The most common promise of politicians to their constituents is to build yet another hospital or health center or health station.

Hopefully, the publication of “Closing the Gap in a Generation” coupled with the promotion of the attainment of the millennium development goals will encourage deeper thinking about the situation of health in the Philippines. Perhaps a true concern for the health of poor Filipinos will also convince some of the more conservative religious groups to reconsider their stance on reproductive health, information and services which will empower poor couples to become responsible couples, allow them to pay more attention to their family needs, and avoid the many health risks associated with reproductive ignorance.

The initial confusion and delays in the response of Philippine health authorities to the melamine contaminated food products from China reflects the inherent weaknesses of the food and drug regulatory system now in place. It turns out that this problem came at a very awkward time for the Bureau of Food and Drugs. Its Deputy Director, who was effectively the agency’s main trouble-shooter, had just resigned. There had just been a reshuffle of division chiefs that had cause a level of demoralization because it had been done to appease a powerful multinational food company at the behest of the Department of Trade and Industry. Hopefully, after things settle back to normal following this melamine affair, the story behind the turmoil of the country’s food and drug safety agency can be told as one of the basis for reforms of food and drug regulations expected with the passage of a pending BFAD strengthening law.
(Dr. Romualdez’ e-mail address is: