A child born in a Glasgow suburb can expect a life 28 years shorter than another living only 13 kilometers away. A girl in Lesotho is likely to live 42 years less than another in Japan. In Sweden, the risk of a woman dying during pregnancy and childbirth is 1 in 17,400; in Afghanistan, the odds are 1 in 8.
The differences between — and within — countries result from the social environment where people are born, live, grow, work and age. These "social determinants of health" have been the focus of a three-year investigation by an eminent group of policy makers, academics, former heads of state and former ministers of health who comprise the World Health Organization's Commission on the Social Determinants of Health.
"(The) toxic combination of bad policies, economics, and politics is, in large measure, responsible for the fact that a majority of people in the world do not enjoy the good health that is biologically possible," the Commissioners write in their report.
"Health inequity really is a matter of life and death," said WHO Director-General Dr Margaret Chan.
"But health systems will not naturally gravitate towards equity. Unprecedented leadership is needed that compels all actors, including those beyond the health sector, to examine their impact on health. Primary health care, which integrates health in all of government's policies, is the best framework for doing so."
Health inequities – unfair, unjust and avoidable causes of ill health – have long been measured between countries but the Commission documents "health gradients" within countries as well.
Wealth is not necessarily a determinant
Economic growth is raising incomes in many countries but increasing national wealth alone does not necessarily increase national health. Without equitable distribution of benefits, national growth can even exacerbate inequities.
In 1980, the richest countries with 10% of the population had a gross national income 60 times that of the poorest countries with 10% of the world's population. After 25 years of globalization, this difference increased to 122, reports the Commission.
Wealth alone does not have to determine the health of a nation's population. Some low-income countries such as Cuba, Costa Rica, China, state of Kerala in India and Sri Lanka have achieved levels of good health despite relatively low national incomes.
Nordic countries have followed policies that encouraged equality of benefits and services, full employment, gender equity and low levels of social exclusion. This, said the Commission, is an outstanding example of what needs to be done everywhere.
Solutions from beyond the health sector
According to the Commission's report, "Water-borne diseases are not caused by a lack of antibiotics but by dirty water, and by the political, social, and economic forces that fail to make clean water available to all; heart disease is caused not by a lack of coronary care units but by lives people lead, which are shaped by the environments in which they live; obesity is not caused by moral failure on the part of individuals but by the excess availability of high-fat and high-sugar foods."
"We rely too much on medical interventions as a way of increasing life expectancy," the Commission concluded. "A more effective way of increasing life expectancy and improving health would be for every government policy and programme to be assessed for its impact on health and health equity; to make health and health equity a marker for government performance."
The Commission makes three overarching recommendations to tackle the "corrosive effects of inequality of life chances":
Improve daily living conditions, including the circumstances in which people are born, grow, live, work and age;
Tackle the inequitable distribution of power, money and resources – the structural drivers of those conditions – globally, nationally and locally;
Measure and understand the problem and assess the impact of action.
The Commission recommends that investing in early childhood development provides one of the best ways to reduce health inequities. Evidence shows that investment in the education of women pays for itself many times over.
While more research is needed, enough is known for policy makers to initiate action. The feasibility of action is indicated in the change that is already occurring. Egypt has shown a remarkable drop in child mortality from 235 to 33 per 1000 in 30 years. Greece and Portugal reduced their child mortality from 50 per 1000 births to levels nearly as low as Japan, Sweden, and Iceland. Cuba achieved more than 99% coverage of its child development services in 2000. But trends showing improved health are not foreordained.
