Addressing the social causes of illness

Stephen Dale

Why do some people live long lives, punctuated by only short periods of illness, while others die young after struggling with chronically poor health?

That question was posed to an audience at a recent panel discussion hosted by Canada’s International Development Research Centre (IDRC). International health experts are convinced that they’ve found the answer. In both rich and poor countries, longevity and susceptibility to disease often have less to do with germs and genetics than with the so-called “social determinants of health” — factors such as income, education, occupation, and access to services, good medical treatment, and decent housing. Several exhaustive studies show that scoring well on the checklist of social indicators means one will likely live a long and healthy life, while deprivation is just as sure a predictor of increased illness and fewer years.


Looking beyond genes and germs

Yet the question remains: “What to do?”

That’s the practical puzzle facing the blue-ribbon Commission on Social Determinants of Health (CSDH), convened in 2005 by the World Health Organization (WHO).

In her opening remarks to the 13 April 2006 panel discussion, IDRC president Maureen O’Neil remarked that the Commission’s central mandate “is to inform and energize national and global action, to overcome the persisting social barriers that defeat equal access to good health.” To that end, the WHO has assembled, in Ms O’Neil’s words, “20 exceptionally accomplished and gifted policymakers, practitioners, scholars, and civil society leaders” to guide the Commission’s work.

Prestigious panel

Indeed, two of the three panelists (Nobel prize-winning economist Amartya Sen, and former Canadian health minister Monique Bégin) were drawn from the CSDH’s 20 members. The other panelist was Dr John Frank, founding Scientific Director of Canada’s Institute of Population and Public Health, and the moderator was Canadian writer and broadcaster Evan Solomon. Amartya Sen situated the new Commission’s work within the evolving global understanding of the relationship between income-generating activities and the health and well-being of populations. This focus on social links to health, it seems, signifies a gradual but major shift in the outlook of international organizations.


An evolving outlook

Professor Sen recounted that in the late 1940s, with the creation of the Bretton Woods system (which includes the World Bank and the International Monetary Fund), these new institutions focused almost solely on income-generation, to allow former colonial nations to prosper and European powers to rebuild after the devastation of World War II. Yet gradually, this view of income creation as a paramount good — the ultimate goal of development — became tempered by the creeping realization “that income is not really what we are seeking, that it is merely useful as a means to something else, to enable us to live a good life.”

Charting the paths to that better life required a more textured, multidimensional means of measuring countries’ social and economic progress. Enter the celebrated Pakistani economist Mahbub ul Haq who (with assistance from his friend, Professor Sen) devised the United Nation’s Development Programme’s Human Development Index (HDI). The HDI presents composite portraits of national well-being by meshing purely economic indicators with other crucial factors such as life expectancy, literacy, and enrolment in education.

Health and economics after Sachs

Professor Sen cited the work of the 2001 Commission on Macroeconomics and Health, chaired by Professor Jeffery Sachs, as another example of the international community’s efforts to come to terms with the complex interrelationships between economic achievements, social investments, and health outcomes. The Sachs Commission, which helped spur a global wave of reinvestment in health care, was largely concerned with the impact of poor health on countries’ economic status. “It brought to light that people cannot generate income when they are not healthy enough to hold a job,” recalled Professor Sen.


“But the Sachs Commission,” he continued, “was also supposed to look at how economics can help health care — which is the reverse issue.” This is where the new CSDH comes in. With its mandate to explore “the idea that living a deprived life means you are unhealthy,” it can be seen as taking on the unfinished business of the Sachs Commission — looking at ways that economics can promote better health, rather than how good health boosts economic output.

Aiming for real change

All three panelists remarked on the unusually practical orientation of the CSDH. It will be free to concentrate on the concrete measures that countries and global agencies can take, since many of the theoretical questions underlying the social determinants of health have already been resolved.

Dr John Frank suggested that the “Eureka moment” that launched this area of inquiry was the release of a seminal study conducted in Scotland between 1980 and 1985. It showed that for each gradient up or down in social and economic standing, there was a corresponding and equivalent positive or negative movement in health status and life expectancy. “That result has been replicated in virtually every country,” he said. The only major exception to this pattern comes from data produced in the United States, where changes in health status seem to occur much more dramatically as one becomes very rich or very poor. The unresolved, practical dilemma posed by that discrepancy is whether it is better to concentrate resources on the poorest of society where the need is severe, or to distribute those resources more widely to improve the health of greater numbers of people.

Budgeting for better health

Dr Frank added that one of the most striking messages from cross-national studies is that the countries that best succeeded in improving the health of seniors, children, and the socially marginalized, are those that have used “taxation and transfer policies” to flatten social and economic disparities (most notably the Nordic countries).

One of the biggest challenges of the new CSDH, therefore, will be to convince the officials who write national budgets that their decisions will have critical ramifications for citizens’ health. “The Commission’s job is to challenge the hegemony of straight economics,” stated Dr Frank. “Normally, decisions about taxes and transfer payments are made without regard for any public health consequences. They are all made by economists who can’t even read the health literature, and with no discussion about the health and functional implications for the population.”

Monique Bégin remarked that one of the most encouraging aspects of the CSDH’s early work is that several countries have already made the social determinants of health a cornerstone domestic policy issue — for instance, by creating their own national commissions. Work that is catalyzed at the national level, Ms Bégin believes, may wind up being a major outgrowth of the CSDH’s work — alongside whatever overarching recommendations the commission produces.


Some countries are energized

“In addition to dreaming of a report that makes a big splash,” she says, “there is the hope that countries would have already engaged in integrated programs addressing many of the social determinants of health. In Chile, for example, [several] ministries are working together . .. working in housing, employment, training, etc.. . What’s refreshing to see is that in some countries equity is a political value on which it is possible to win elections.”

Amartya Sen pointed out that particular challenges will be determined largely by structural and political considerations within individual countries. In China, for example, the health care system was privatized by decree in the 1970s, leading to large numbers of people no longer being properly insured. As a result, the drastic improvements in life expectancy that had been experienced in China slowed to a snail’s pace. Professor Sen noted that this outcome would likely not have arisen had there been a process for broad social consultation within China.

Even within countries, conditions vary. Professor Sen also noted that in many Indian states, health care service is poor because there is no functional public health service to compete with private health care providers. In the state of Kerala, by contrast, functional public clinics mean that private providers are kept in line, since patients can get a second opinion from a public health doctor with no interest in selling the patient more services.

The Nobel economics laureate also urged that there be much more creative and far-ranging thinking about how the health and well-being of humankind can be improved, particularly on the part of his fellow economists. “Economics,” he told the Ottawa audience, “is a much broader topic than the one we have boxed ourselves into.”

Stephen Dale is a writer with IDRC's Communications Division