April 23, 2005

Social Determinants of Health

New WHO commission examines more than biology

by Andrea Smith

The Dominion - http://www.dominionpaper.ca

Although it has received little fanfare, public health advocates are hopeful that a new World Health Organization (WHO) Commission on Social Determinants of Health will act to improve people's health around the world. Inequalities in health have been deepening–both within countries and between them–and a growing body of research suggests that these inequalities are not the result of individuals' biology or health choices, but the result of the social conditions in which people live and work.

The WHO convened the Commission to recommend interventions and policies to reduce disparities in health status resulting from social determinants. Social determinants such as poverty, literacy, and employment affect the health of populations, leading some people to be healthier than others. Key amongst these factors are conditions of material deprivation, such as lack of income, but some propose that the gap between rich and poor itself accounts for people's health. For example, countries with less social inequality (such as Cuba) contain lower mortality rates than do the wealthiest classes in societies where large gaps between the rich and poor exist (such as the United States).

A vast body of research on these determinants has accumulated and according to the Commission, it is now time to put that knowledge into action. Canadian Minister of State for Public Health, Dr. Carolyn Bennett, who attended the formal launching of the WHO Commission, agrees: "Finding strategies to improve these social determinants is equally, and in some cases more, important than medical care and improving personal health behaviours."

Two Canadians, Monique Bégin and Stephen Lewis, will sit on the panel. Lewis is currently UN Special Envoy for HIV/AIDS in Africa and Bégin served as Minister of National Health and Welfare during the implementation of the Canada Health Act. Canada's representation on the Commission is fitting given that Canada has been at the forefront of research on the social determinants of health. Canadian researchers have come up with a list of eleven social determinants, which include not only medical services, early education, education and employment, but also social exclusion and income distribution.

"It is about opportunities in life and control over one's life, in addition to social conditions that shape the physical environment one lives in," says Michael Marmot, Commission chair and Director of the International Centre for Health and Society. Writing in the British medical journal The Lancet, Marmot says that "the Commission will seek to have public policy based on a vision of the world where people matter and social justice is paramount."

While the aims of the Commission resonate with the values of social justice, some are skeptical. The Commission points to interventions such as nutrition programs in Latin American schools as examples of successful strategies. By providing families with subsidies to enable their children to attend nutrition clinics and enroll in school, the children are able to stay in school and pay attention. However, programs like these are unlikely to address the facts of poverty, especially income inequality between countries.

Addressing the roots of social injustice will require substantial reform, and will likely be resisted by economic forces, and the Commission's proposals will likely face formidable obstacles in some areas. Anticipating this opposition, Marmot's team intends to focus its efforts within "a group of countries where there is commitment to rapid action to overcome the social barriers to health among political leaders, health officials, civil society groups and other stakeholders." The Commission is to operate until March 2008. Only time will tell if the Commission will have the support it needs to turn its talk on health inequality into action.

UPDATE: EPA Cancels Childhood Environmental Exposure Research Study

On April 8th, 2005, the US EPA announced it was canceling the Children's Health Environmental Exposure Research Study (CHEERS). According to Stephen Johnson, Acting Administrator of the EPA, the study was axed due to misrepresentation and controversy. Critics were concerned about CHEER's ethical implications, particularly the risk of families increasing their use of household chemical hazards in order to qualify for the study so they could receive compensation which included $970 and a video camera. Questions of ethics were compounded when it became known that the American Chemical Council, the chemical industry's trade group, provided $2.1 million to the study. Initially the EPA had halted the study and sent it for an independent review, but Johnson said, "the study cannot go forward, regardless of the outcome of the independent review. EPA must conduct quality, credible research in an atmosphere absent of gross misrepresentation and controversy."