I am a woman with two university degrees who went to a private though free school. My family did not receive means-tested benefits. Had I grown up where I live now, in the Borough of Southwark, London, my privileged start into life would put my life-expectancy up to seven years ahead of those who are at the bottom end of the social scale. Similarly, in Guatemala, the maternal mortality ratio among indigenous women is up to three times higher than for the rest of the population.
From the safety of our birth through to education, from the environment we live in to how fair our employment conditions are and what level of health care we are offered within our means - all are factors that influence our health over the life-course. These so-called social determinants of health are largely responsible for the inequalities in health status that exist within and between countries. But they are not factors that are set in stone or natural. Rather a much deeper level of structural causes, which is more difficult to change, underlies them: the World Health Organisation's Commission on the Social Determinants of Health summarises this as the distribution of money, power and resources at global, national and local levels. Globalised value chains that exploit the poorest's desperate need for an income, trade systems that favour pharmaceutical companies' intellectual property rights over access to affordable medicines, or the racism and discrimination that prevents indigenous mothers from seeking skilled assistance during birth complications are such structural social determinants of health.
At one of the largest global health conferences since the Alma Ata Conference on Primary Health Care in 1978, health ministers, government health officials and civil society representatives came together in Rio de Janeiro last week to tackle the social determinants of health and the inequities caused by them. This raised high hopes among health activists that the recommendations of the Commission on the Social Determinants of Health to improve daily living conditions, to tackle the inequitable distribution of power, money and resources, and to measure and understand the problem and assess the impact of action may finally find their way into mainstream health policies.
Instead the recommendation on the redistribution of power in particular was largely buried, in the words of Professor of Public Health Fran Baum from Flinders University in Australia, one of the members of the Commission speaking in Rio. In her analysis of the conference she said: "Perhaps this is not surprising as addressing these factors (which include trade policy and the need to redistribute wealth more fairly) would directly challenge the global status quo of power and resources."
The South African paediatrician and public health professor David Sanders' break with government sweet-talk was thus loudly greeted with standing ovations when he also pointed out that the economic context of trade, food systems or the "brain-robbery" of African health workers by Western health systems had been omitted by the final Rio Political Declaration. He put it in the words of Bob Dylon: "While money doesn't talk, it swears."
On the eve of the Conference, public interest civil society organisations and social movements such as the People's Health Movement had detailed the required changes to address the challenge of health inequities in an Alternative Declaration on "Protecting the Right to Health through Action on the Social Determinants of Health". Action items that campaigners wanted to be introduced into the official declaration include the use of progressive taxation, wealth taxes and the elimination of tax evasion; regulate and protect populations from health hazards emanating from commercial activities, such as those created by the tobacco, alcohol, breast-milk substitutes, high fat and sugar processed food; or to provide equitable universal health care coverage including high quality promotive, preventive, curative and rehabilitative health services throughout the life cycle.
As Remco van de Pas from Wemos in The Netherlands notes: "There is a strong voice here to enforce corporate social accountability; not merely by big commercial actors, but similarly via advocating parliamentarians and governments that they have the obligation to respect their citizens' rights above the drive for unsustainable economic growth."
This is just one challenge the Rio Political Declaration has missed to meet. Eradicating the shocking health inequalities within and between countries remains the overarching one and governments must now go beyond their declaration to show they are serious about it.