Health as if everybody counted blog
The road to (and from) Rio
The title of this blog is inspired by former police reporter Michael Connelly's novels about homicide detective Hieronymus (Harry) Bosch. Raised in foster homes and orphanages after his mother was murdered when he was 12, Bosch is a relentless loner with a strong egalitarian streak, reacting to a Los Angeles Police Department bureaucracy that devotes far more attention to some deaths than to others with the axiom that "everybody counts or nobody counts." "Everyone counts" was also the theme of the United Nations Population Fund's World Population Day 2010, which emphasized the way in which a variety of social arrangements devalue the lives of women and girls.
Everywhere in the world, achieving health equity requires equality of opportunities to lead a healthy life. We must never forget that the lifetime risk of dying in pregnancy or childbirth for women in Canada is one in 5,600 while in sub-Saharan Africa, the world's poorest region, it is one in 31. Closer to home, in 2010 more than 400,000 Ontarians a month were turning to food banks, and in mid-2011 more than 150,000 Ontarians were on waiting lists for affordable housing. Housing and nutrition are among the most basic social determinants of health, and we are far from providing such equality of opportunity. For the moment, not everybody counts. Like the fictional Detective Bosch, those of us working in health equity are trying to change that. The purpose of this blog is to provide resources for bringing about that change, and a forum for discussing cutting-edge research and best practices.
The road to (and from) Rio
On a global scale, that kind of change was a central theme of the World Conference on Social Determinants of Health, hosted by the Government of Brazil and held October 19-21 at the picturesque Forte de Copacabana in Rio de Janeiro. The conference was a milestone in a process that began in 2005 when the previous director-general of the World Health Organization appointed a Commission on Social Determinants of Health, chaired by Sir Michael Marmot. The Commission's report, released in August 2008, began with the observation that "social injustice is killing people on a grand scale" – not the kind of language we are used to encountering in UN system documents. Some of the activities that followed the release of the report will be the subject of later postings. The Rio conference represented a specific response by WHO to a 2009 resolution (WHA62.14) of the World Health Assembly, WHO's governing body, calling for action on the Commission's report.
Roughly 1000 members of national delegations, experts identified by WHO, and civil society representatives converged on Rio for the conference. Key background documents can be downloaded from the WHO web site, and a valuable blow-by-blow description of the conference events was provided by Jim Chauvin of the Canadian Public Health Association, who is also president-elect of the World Federation of Public Health Associations. WHO's current director, Margaret Chan, opened the first day (really half a day) with a powerful speech that began: "Lives hang in the balance, many millions of them. These are lives cut short, much too early, because the right policies were not in place." She was followed by a panel of UN agency officials and government representatives including Kathleen Sebelius, US Secretary of Health and Human Services. Perplexingly, Ms Sibelius lauded the US for its steps to expand health care coverage, making no mention of the fact that countries like Canada come far closer to providing universal coverage (at lower cost) than the 90 percent she said the United States would be glad to achieve.
The second day consisted of morning and afternoon parallel sessions corresponding to five action areas identified in a discussion paper prepared by the WHO secretariat in Geneva in advance of the conference. Although these sessions were webcast live, unfortunately at the time of writing they do not appear to be available for viewing or downloading after the fact. The third day (again, really a half-day) was dominated by a panel that featured powerful presentations by Finland's new Minister of Health and Social Services, Maria Guzenina-Richardson, and Zimbabwean pediatrician David Sanders, a long-time primary health care activist described as the "star of the day" in The Guardian.
What are such conferences good for?
Unlike the scientific conferences with which many of us are more familiar but in keeping with the standard for diplomatic events, most of the Rio meeting was tightly scripted. (The "annotated session plan" of the parallel session for which I was a rapporteur ran to five single-spaced pages.) The only concrete output from the conference was the aspirational Rio Political Declaration on Social Determinants of Health, endorsed by all WHO member states participating in the conference. As usual with such documents, drafting the declaration began months in advance, with a first draft circulated to WHO member states in August and subsequent drafting sessions in Geneva starting in September. The details were finalized during a day-long drafting session in Rio, operating in parallel with the conference but open only to the representatives of national delegations.
The Declaration was developed using a unanimity rule, meaning there is nothing in it to which any government involved strongly objected. It is nevertheless surprisingly strong in several ways. For example it recognizes the potential of the current economic crisis to undermine health, and governments "pledge to adopt coherent policy approaches that are based on the right to the enjoyment of the highest attainable standard of health" (reference to such rights-based approaches has long been anathema to the United States), including such measures as social protection floors. On the other hand, it contains neither new commitments of resources nor any formal mechanisms for monitoring and accountability. Other omissions were highlighted by civil society participants in the conference, and by Dr. Sanders in his remarks on the last day. For example, the Declaration includes no mention of trade and health; no reference to the ongoing problem of 'brain drain' of health professionals from low- and middle-income countries; and the conference as a whole paid little attention to capital flight, which drains capital from low- and middle-income countries in amounts far larger than the annual value of development assistance. The lack of specifics would seem to underscore the concern expressed by Sir Michael Marmot and colleagues, in a commentary published at the start of the conference, that "social determinants of health have barely penetrated the global agenda ... and the default position of people in the health sector is to focus on health services and prevention of specific diseases."
What does it mean for Canada?
The Declaration is not a treaty; it does not bind WHO member states. Of course, the treaty status of an international agreement is no guarantee of effective implementation, as we know from the history of Canada's commitments under the UN Framework Convention on Climate Change. A useful comparison can be drawn between the 2011 declaration and the similarly aspirational 1978 Alma Ata commitment to achieve Health for All in the year 2000. In the event, the Alma Ata vision was thwarted by several elements of the political environment, notably resistance from the multilateral financial institutions that were emerging as key players in development policy for health. "The Rio summit offers the opportunity to ensure that failure to implement a widely supported agenda does not happen again," wrote Prof. Marmot and colleagues. Despite the lack of specifics, the Rio declaration provides an unequivocal affirmation that an agenda of reducing health disparities by way of social and economic policy and the design of policy-making institutions is both scientifically sound and ethically imperative. Unfortunately, these points remain contested in the quotidian work experience of many of us, and no international agreement can substitute for the myriad initiatives at local, provincial and national levels that will be needed to advance the science and politics of social determinants of health. Sarah Bosely concluded her Guardian coverage, one of the few English-language media mentions of the conference, by saying that "this is one genie that looks unlikely to go back in the bottle". In the Rio declaration, those of us working in the field as researchers, practitioners and advocates have a valuable resource for keeping the genie out and active. More about this in subsequent postings.