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‘Social injustice is killing people on a grand scale’

Why do aboriginal Australian males live 17 years less than all other Australian males? Men in the Calton neighbourhood of Glasgow live on average 28 years less than that of men in Lenzie, a few kilometres away. Why is it that a girl in Lesotho lives on average 42 years less than another in Japan? Biology does not explain any of these differences. Instead, the differences between - and within - countries result from the social environment where people are born, live, grow, work and age. So says a ground-breaking Report of the World Health Organization (WHO) released on 28 of August 2008 titled ‘Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health’.

Sri Lanka was given high praise by Sir Michael Marmot, Professor of Epidemiology and Public Health, University College London who chaired the Commission. He says that Sri Lanka is among the countries that have better health facilities than some other countries with higher incomes. "Health in Sri Lanka for example is considerably better than it is in Russia, despite considerably higher incomes in Russia than in Sri Lanka." said Michael Marmot.

What are the findings of the report that are relevant to us?

The rport is relevant to Sri Lanka because it recommends a new approach to health improvement of populations. The thrust is that health is determined more by social factors, rather than by hospitals or clinics. Humans need the latter mostly when they are ill, but our common goal ought to be to remain healthy for as long as biologically possible. Even within the health care sector, the Reports reiterates its faith in Primary Health Care, a model practiced by the Ministry of Health and the Department of Health Services in Sri Lanka (yet another feather in the cap for our community health physicians who have defended this system for decades).

As noted in the opening paragraph, some population groups live healthy lives longer while others live miserably unhealthy lives and die prematurely. This observation has been the focus of much research. The Report presents further evidence that there is a ‘gradient in health’. This means, in general the poor are worse off than those less deprived, and the less deprived are in turn worse off than those with average incomes, and so on. This slope linking income and health is the social gradient, and is seen everywhere, in developing countries, as well as the richer countries. Though Sri Lanka has on average a better health than other equally poor countries, one can observe this gradient in health. Though more research is needed, it appears that the wealthiest have the best of health, while the middle classes would do less well and the disadvantaged rural villagers, the urban poor, and some estate populations fair worst.

The commission report suggests that much of the work to redress health inequities and the ‘gradient in health’ lies beyond the health sector. The social environment shapes our behaviour, the way we live, work, fall ill and die. "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." Therefore, the health sector needs to focus attention on addressing the root causes of inequities in health. "We rely too much on medical interventions as a way of increasing life expectancy" explained Sir Michael. According to the large body of research evidence collated by the commission, it is the social (and physical) environment we live and work which have a very strong influence on our life span and the ‘healthiness’ of our existence.

The Commission makes several recommendations to tackle the gradient in health and health inequalities.

A few points are relevant to Sri Lanka.

Health

For example, in the health sector the commission strongly comes out in favour of the Sri Lankan model of a universal ‘free health service’ and its Primary Health Care model. "Access to and utilization of health care is vital to good and equitable health. Without healthcare, many of the opportunities for fundamental health improvement are lost. Upwards of 100 million people are pushed into poverty each year through catastrophic household health costs. The Commission calls for healthcare systems to be based on principles of equity, disease prevention, and health promotion with universal coverage, focusing on primary health care, regardless of ability to pay".

The commission strongly supports all activities that improve early child development, compulsory quality primary and secondary education and programmes that support all children, mothers and caregivers. The Ministries of Health and Education have already embarked on several policies to combat childhood malnutrition and support early childhood development.

There are several important recommendations on sectors ‘outside’ the health care services that are relevant to Sri Lanka. In the area of Housing, the commission states that ‘access to quality housing and clean water and sanitation are human rights’ and calls for:

* Greater availability of affordable housing by investing in urban slum upgrading including, as a priority, provision of water, sanitation and electricity;

* Healthy and safe behaviours to be promoted equitably, including promotion of physical activity, encouraging healthy eating and reducing violence and crime through good environmental design and regulatory controls, including control of alcohol outlets;

* Sustained investment in rural development’

Though more needs to be done, the traditions set by many Sri Lankan governments are praiseworthy. For example, programmes to uplift rural masses (e.g. the current government’s ‘Gamin-Gamata Programme and the previous ‘Gam Udaawa’ programme), the ‘Mathata-thitha’ programme (for curtailment of alcohol consumptions) and the late-President Premadasa’s Million-Houses programmes, all find resonance with these recommendations. In this context, the Ministry of Health’s legislation to control tobacco and alcohol too are laudable pieces of legislation that would improve the health of Sri Lankans.

Fair employment and decent work

The Labour Unions and particularly some of the leftist parties in Sri Lanka should hail the following: ‘Employment and working conditions have powerful effects on health equity. When these are good, they can provide financial security, social status, personal development, social relations and self-esteem, and protection from physical and psychosocial illness’. The commission goes on to recommend:

* Full and fair employment and decent work, to be a central goal of national and international social and economic policy-making;

* Economic and social policies that ensure secure work for men and women with a living wage that takes into account the real and current cost of healthy living; (Thus the constant battle by trade unions for a minimum wage in Sri Lanka have important health implications).

* All workers to be protected through international core labour standards and policies; and

* Improved working conditions for all workers.

Regulation of foreign migrant workers and opening insurance policies for Sri Lankan migrating workers is a small step in the right direction, but more needs to be done, especially in the informal sector. The latter includes our farmers, domestic helpers, casual workers and those working in small enterprises.

Social protection throughout life

Sri Lanka lacks an effective system where society protects people at times of need (i.e. a system where citizens receive an affordable sum of money or assistance at times of dire need such as severe illness or disablement). Currently, it is the families thathave been to care for the ill and the disabled (and the elderly). This situation is becoming increasingly difficult, as families become smaller (i.e. less siblings), females seek employment (because most carers are females) and the proportion of elderly and chronically ill increase. (We have one of the fastest growths in the proportion of elderly in the world and our rates of chronic diseases like diabetes are skyrocketing). The commission calls for extending "social protection to all people, within countries and globally" and "ensuring social protection systems include those who are in precarious work, including informal work and household or care work".

Health an issue of social justice

The commission also comments on tackling the inequitable distribution of power, money, and resources. Social activists would be pleased to note that the report strongly favours empowerment and considers equitable health as an issue of Social Justice. There is a call for civil society to act by participating actively in policy, planning and programmes; and evaluation and monitoring of performance of governments and non-state actors.

Conclusion

The WHO’s Commission on Social Determinants of Health seeks to give a fresh perspective of population health. Its recommendations are groundbreaking and should create an intense public debate in Sri Lanka and abroad. We are now in a unique position to strengthen its public and social policies for two reasons. First, Sri Lanka is the only country in Asia to be a ‘Country Partner’ that enables us to work closely with the WHO. Second, we now have the benefit of a vast knowledge base from the research collated by the Commission that supports some of our policies that are under constant scrutiny by some of the lending organizations. Sri Lanka should be steadfast, and continue to become an example in the field of health and in some areas of social development.

More information is available at www.who.int/social_determinants

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