Social Determinants of Health

An IFMSA Primer


Prepared by
Ramon Lorenzo Luis R. Guinto, Nilofer Khan Habibullah, Josephine Mak, Deborah Bloch,
Taavi Tillman, and the IFMSA Small Working Group on Health Inequities

How sick is the world today?

The existing gross inequality in the health status of the people particularly between developed
and developing countries as well as within countries is politically, socially and economically
unacceptable and is, therefore, of common concern to all countries. 1972 Alma Ata Declaration
on Primary Health Care

More than 10 years ago, Member States of the United Nations signed the Millennium Declaration,
articulating a bold pledge to rid the world from extreme poverty, hunger, illiteracy, and disease by 2015.
For more than a decade now, the Millennium Development Goals have shaped global and national
priorities, heralding inspiring strides in human development. For example, an estimated 1.1 billion
people in urban areas and 723 million people in rural areas gained access to clean and potable water
over the period 1990-2008. Some of the poorest regions, such as Sub-Saharan Africa, made marked
improvements in basic primary education.

Although remarkable progress has been made, existing disparities between and within countries remain
daunting, especially in the arena of health. Life expectancy, for example, ranges from 82 years in Japan
to 34 years in Sierra Leone. Looking at maternal mortality rate, which is a widely-used indicator of
population health and one of the MDG indicators, 170 for every 1,000 mothers die of unnecessary
deaths and preventable causes in the Philippines, while in Thailand the rate is already 36, while only 8
die in Japan.

Health inequity is also present within countries. For instance, in the Philippines, maternal mortality rate
is already 15 for every 1,000 mothers in urban centers such as Manila. However, this value is increased
tenfold 150 in the poorest areas of the archipelago. The same is true even in developed countries a
20-year gap looms between life expectancies of the most and the least advantaged populations even in
the United States the wealthiest country in the world. In a rich city such as Glasgow, there is a 30-year
gap in life expectancy between the richest and the poorest populations.

Inequities in health are made even more complicated by the rapidly changing burden of disease
worldwide. Not just industrialized countries but also developing societies grapple with non-
communicable illnesses like hypertension and diabetes, while they still strive to eradicate infectious
diseases like tuberculosis and malaria that have been plaguing their populations for millennia. In
addition, emerging diseases intensified by forces of globalization such as SARS and Avian flu, as well as
diseases brought about by climate change and disasters add to the already-formidable equation of
global health.

Global recommendations call for intensified and customized approaches to target the hardest to reach
out: the marginalized, those disadvantaged due to their sex, age, or ethnicity, the poorest sections of
our society, and those persecuted by oppressive regimes or due to religious grounds. Despite numerous
efforts from various global health actors, many of our fellow humans are still left behind, especially in
terms of health conditions. We need to do more and better.




Why do health inequities exist?

The great gaps in health outcomes are not random. Much of the blame for the essentially unfair
way our world works rests at the policy level. Dr. Margaret Chan, at the 62nd World Health
Assembly, May 2009

This ends the debate decisively. Health care is an important determinant of health. Lifestyles are
important determinants of health. But it is factors in the social environment that determine
access to health services and influence lifestyle choices in the first place. Dr. Margaret Chan, at
the launch of the CSDH Final Report in Geneva, 28th August 2008

Inequalities in health, which refer to measurable variations in health status, are inevitable, as each
person has her own genetic make-up that may predispose her to certain diseases. However, more than
the genes, it is the conditions in which a person lives, grows, works, and ages that greatly influence the
way she is exposed to certain disease risk factors, or that shape her behaviors and daily activities leading
to lifestyle diseases. These social determinants of health bring about inequities in health, which are
defined as inequalities in health that are deemed to be unfair or stemming from some form of
injustice. And since they are products of social injustice and cannot be explained by any biological
reason, these inequities are certainly avoidable and unacceptable.

Health equity is about the resources, capacities, and power people need to act upon the circumstances
of their lives that determine their health. People live in different communities, each having its own
distinct characteristics and governed by its own leaders, structures, and policies. Because of these
differences, some people might have closer access to healthy food than others, or a subdivision may
have safer roads than a village in the outskirts. These differences are shaped by social, economic, and
political forces that work in the municipal, national, or international level, and these are the forces that
we must address through collective action across all sectors.

How long a person lives, or how one overcomes an illness, is largely dependent on a persons access to
power, money, and resources, which unfortunately are unequally distributed within and between
societies. For example, a 2005 United Nations Human Development Report exposed that the annual
ow of income of the richest 500 people in the world exceeds that of the poorest 416 million. More
appallingly, it also estimated the cost of ending extreme poverty at $300 billion, which equates to less
than 2% of the income of the richest 10% of the worlds population.

Health equity is also about enabling people to have equitable access to services on the basis of need.
Health care, unfortunately, is not a birth right like Martin Luther King Jr. said it should be, but rather
depends on which part of the world one is born. Health systems in most countries fail to respond to the
basic health needs of people, especially the poor and the marginalized. The way health services are
financed, or the distribution of health workers, for example, are just some of the potential ways health
systems can bring about widening of health inequities.

Having understood how external forces lead to health equity, we are now convinced that it is not
enough to target those that are left behind by society, to reach out to the poor, the marginalized, the
vulnerable, and the underserved. In order to sustain the health of populations in all places and at all
times, we need to root out the causes of the causes these are the social determinants of health.
What are social determinants of health?

If medicine is to fulfill her great task, then she must enter the political and social life. Do we not
always find the diseases of the populace traceable to defects in society? Rudolf Virchow

Unequal distribution of health-damaging experiences is not in any sense a natural'
phenomenon, but is a result of the toxic combination of poor social policies and programs,
unfair economic arrangements and bad politics. Commission on Social Determinants of Health

First, what is a determinant of health? Determinants of health refer to factors or characteristics that
bring about change in health, either for the better or for the worse characteristics that define those
groups that are more likely to become sick or to die. Determinants of health are usually categorized into
three the biological and genetic determinants, the environmental determinants, and the social
determinants.

Now, what are social determinants of health? According to WHO, social determinants of health are the
conditions in which people are born, grow, live, work and age, including the health system. These
circumstances are shaped by the distribution of money, power and resources at global, national and
local levels, which are themselves influenced by policy choices. The social determinants of health are
mostly responsible for health inequities - the unfair and avoidable differences in health status seen
within and between countries. In short, social determinants are health determinants attributable to the
structure and functioning of society.


Illustration from Dahlgren, G. and Whitehead, M. (1991). Policies and Strategies to Promote Social Equity
in Health. Stockholm: Institute for Futures Studies.



According to to Keheler and Murphy, social determinants of health are often divided into:
Downstream or proximal factors are those at micro level including treatment systems, disease
management, and investment in clinical research.
Midstream factors are those at the intermediate level including lifestyle, behavioral, and
individual prevention programs.
Upstream or distal factors are at the macro level including government policies, global trade
agreements, and investment in population health research.

Social determinants of health act by stratifying members of society into different groups and levels, and
this social stratification leads to inequalities in power, prestige, income, and wealth. Stratification
engenders:
Differential exposure to health-damaging conditions and risk factors (Example: poor riverside
dwellers being more exposed to chemicals released by factories into the river)
Differential vulnerability, in terms of health conditions and material resource availability
(Example: One WHO report showed that tobacco use is highest among the worlds poorest.)
Differential access to resources for preventing or treating disease (Example: lack of health care
facility that can deliver basic health services in a rural province)
Differential outcomes as manifested through disease and mortality (Example: greater
prevalence of
Differential consequences of ill health for more and less advantaged groups (Ex: further
financial hardship among families with sick members, and therefore less financial risk protection
when another illness strikes the family)

























What is the guiding philosophy behind action on social determinants?

Of all forms of inequality, injustice in health care is the most shocking and inhumane. Dr. Martin
Luther King, Jr.

Health has been long recognized as a fundamental human right, being one the articles in the Universal
Declaration of Human Rights and also stated in the Preamble to the WHO Constitution. In 1948, the
WHO defined health as "a state of complete physical, mental and social well-being and not merely the
absence of disease." Given, then, that inequities in health arise from inequalities in the conditions of
daily life and their fundamental drivers such as inequities in the distribution of power, money and
resources the social determinants of health it becomes a matter of justice that we act on these
factors in order to achieve health and health equity for all people, at all times, in all places.

In 1978, the Declaration of Alma Ata reaffirmed the concept of health as a basic human right. The
Declaration also recognized gross inequalities in health status between people as politically, socially and
economically unacceptable and should be a common concern of all countries and all sectors, not just the
health sector or the ministry of health. Health for all by year 2000 has been the clarion call since Alma
Ata, but more than three decades since the conference, while considerable progress has been made,
we still grapple with significant inequities which, we need to remember, are avoidable.

Thirty years after Alma Ata, the message still remains the same. The report of the WHO Commission on
Social Determinants of Health (CSDH) once again reminded the world that reducing health inequalities
by addressing the social determinants of health is a moral imperative. The Commission summarized a
wealth of evidence to illustrate how social determinants impact human health. It showed, for example,
how the social gradient widens inequities in health - that is, the lower a person's socioeconomic status,
the worse their health status becomes. The Report went on by saying that these disparities in health are
the result of a toxic combination of poor social policies and programs, unfair economic arrangements,
and bad politics.

Simply put, inequities kill people. Yet, they are avoidable. In addressing the social determinants of
health, we not only better the health of people we also help address the conditions that cause ill
health and human misery. More importantly, we also empower people to take control of their health
and their lives. In doing so, we do not only make an impact on individual lives we improve society as a
whole.










How can social determinants of health be addressed?

The message of the WHO Commission on Social Determinants of Health is clear: it is through action on
social determinants of health that health equity can be truly achieved. The next question is more
challenging to answer how can we do it?

In 2008, through the report Closing the Gap in a Generation, the Commission laid out three
overarching recommendations for action:
1. the improvement of daily living conditions;
2. tackling the inequitable distribution of money, power, and resources; and
3. measuring and understanding the problem and assessing the impact of action.

Social determinants of health are the very circumstances of society in which we live, as well as the
social, economic and political forces which shape them. Therefore, reducing health inequities within and
between countries should be the collective work of all sectors government, NGOs, private enterprises,
academia at all levels global, national and local. A global coalition for health equity must be formed
in order to move the agenda forward and to build a constituency that will hold accountable most
especially governments.

Dr. K. Srinath Reddy asked in one article, Shouldnt every Minister be a Health Minister? Sir Michael
Marmot also rephrased this: Every sector is a health sector. Addressing social determinants by
Member States require the adoption of a whole-of-government approach, wherein all ministries, not
just the Ministry of Health, recognize health as a shared societal goal. Governments need to assess the
impact of every sector, from transport to education, on the health of people; this is what popularly
referred to as a health in all policies approach.

Coherence in governance results in policies, systems and programs that complement each other to
produce health and health equity. It is ineffective to have, for example, a trade policy encouraging
production, trade and consumption of high-fat high-sugar foods as it contradicts any health policy that
encourages low consumption of such foods and high consumption of fruit and vegetables (Elinder,
2005).

Because there are so many factors at play, it may be the case that country, society or cultural specific
practices may be overlooked in developing principles to address SDH. Therefore, there is a need to
develop country- and even area-specific policies on SDH, such as those that specifically aims to protect
marginalized groups in an area such as ethnic minorities. While general principles of action should be
provided by central bodies, local area bodies may prefer to develop their own targeted interventions.
Indeed, in action on social determinants, there is no "one-size-fits-all" approach.

The healthcare sector plays a crucial part in leading the movement to address social determinants and
reduce health inequities. Healthcare like power, money and other resources is often inequitably
distributed, and not all can afford the often high price of medical attention. The Commission
recommends universal health care as the health systems approach to addressing health inequity. It also
supports the renewal of primary health care, which has a strong emphasis on community participation,
health promotion and disease prevention. The Commission particularly calls for the alignment of work
on social determinants with the renewal of primary health care as a

In addition, public health programs must be evaluated based on their ability to consider and tackle the
social determinants of the public health issues they aim to address. For example, HIV/AIDS programs
should not focus alone on the provision of anti-retrovirals but also in identifying the barriers to access to
medicine and even healthy information about the disease, its prevention and treatment. Using the SDH
lens in public health programs will greatly advance the progress in our combat against specific diseases
that cannot be attacked by conventional public health mindset anymore.

In action on social determinants, members of the community should be actually engaged in the process.
Empowerment of communities is a central theme of the Commissions recommendations. Community
ownership of programs can lead to more sustained results. Such empowerment also allows individuals
and communities to take control of their own lives, and may also give them the ability to hold
governments accountable for their actions in addressing the SDH.

Civil society groups that work for health equity should be included in the global discussion. For many
years, the voice of civil society has been ignored, especially in the crafting of policies and
implementation of programs at all levels. Many of these groups have longstanding experience in closely
working with communities and governments in reducing health inequities worldwide. Academic
institutions that also create evidence on the magnitude of health inequity and its social determinants
should also be engaged in the design of solutions.

The issue of health equity should be interlinked with other pressing global issues of our time. Climate
change, for example, has the potential to create more inequities in health, as well as complicate existing
health inequities within and between nations. Solutions to the social determinants of health inequities
also have co-benefits for climate change mitigation and adaptation, and vice versa. Therefore, advocates
for both climate change and health equity should work hand in hand in pushing governments to
designate these two issues as national priorities for action.

Finally, progress in the reduction of health inequities and in action on social determinants must undergo
close monitoring and comprehensive evaluation. Novel indicators that capture the breadth of social
determinants, in addition to existing ones such as the Human Development Index, must be developed.
Such common indicators can ensure global coherence in policy making, implementation, and
monitoring. Through constant evaluation, policies and programs may be altered to adapt to changing
needs of the community.










What is the role of IFMSA and medical students in addressing social
determinants and reducing health inequity?

The physicians are the natural attorneys of the poor, and social problems fall to a large extent
within their jurisdiction. Rudolf Virchow

Recently, within the IFMSA, there has been an increasing awareness of gross inequities in health, as well
as recognition of social determinants that worsen inequities. Last March 2011, during the 60th March
Meeting in Jakarta, Indonesia, the plenary passed a Policy Statement on Health Inequities and Social
Determinants of Health. This pioneering statement pledged to launch a federation-wide movement or
campaign that will champion health equity and will mobilize members to combat the social determinants
leading to ill health and to participate in activities awareness-building, research, service, etc. that
aim to close the health gap and address the social determinants of health.

Considered the biggest student organization in the world, the International Federation of Medical
Students Associations has the capacity as well as the responsibility to champion the fight against global
health inequities and the addressing of social determinants worldwide. Its approximately 1.3 million
medical students from around 100 countries can lead in spreading the health for all spirit, not just in
medical schools and hospitals, but also in far-flung communities, town squares, city streets, and
government halls. In addition, as soon-to-be physicians, who will also become the worlds educators,
managers, researchers, and community leaders, it is unacceptable for medical students to keep silent
and to just watch things unfold. Medical students, particularly IFMSA, should challenge the status quo
and start reshaping the vision of medicine and public health for this century.

This worldwide campaign Root Out, Reach Out calls on every medical student to speak for health
equity anywhere, all the time. Health equity is not just an issue we want to solve it is a global vision we
want to achieve. IFMSA, as the global Federation of medical students, will serve as the guiding light of all
medical students and young health professionals in moving this campaign forward. As the Federation
celebrates its 60
th
anniversary in 2011, it is our hope that solving health inequity through action on social
determinants of health will be at the center of IFMSAs vision for the world in the next 60 years.

The campaign does not expect all medical students and doctors to work in public health settings.
However, what is expected is that all of us, whether as a clinician, a public health practitioner, a
laboratory researcher, or a medical school professor, do not contribute to the widening of health
inequities, but rather advocate for their immediate reduction and further elimination.

The IFMSA envisions the Week of Global Action on Social Determinants of Health this October as a
launching pad of more efforts for global health equity that cut across all Standing Committees, NMOs,
and other units of the IFMSA. For the coming months and years, the Federation will lead in advocating
for the full incorporation of a social determinants view of health in the education of medical students
and other health professionals. In addition, it will continuously call other actors in global health to
address the global determinants of health such as international trade policies and unsustainable
environmental practices. Finally, the Federation will constantly push for global health equity as a
universal societal goal.

Again, as future medical doctors and healers of the world, it is our duty to bring the issue of social
determinants and health inequity to the table of global discussion and to the arena of public awareness,
so that more people will choose to stand against those who violate our rights to health and to initiate
positive action to close the gap in our generation as the Commission Report says. It has been a decade
since the promise of Alma Ata was left unfulfilled. This vision may be too ambitious and visionary and
maybe even imaginary, but IFMSA has no doubt in the capacity of medical students and of humanity at
large in making this world a more just, equitable, and healthy place to live in.
































Why commemorate the Week of Global Action on SDH?

As medical students committed to sharing your knowledge and skills internationally, you are a
powerful source of hope for the future. I commend your determination to use your medical
training to benefit all members of society. Kofi Annan

The Small Working Group on Health Inequities, which was organized last year by the Standing
Committee on Public Health, accepted the challenge of leading the Federation in the massive effort to
spread the awareness of social determinants, to understand the roots of health inequity, and to explore
the role of medical students, particularly IFMSA, in addressing these shared global health challenges. For
the past months, members of the SWG recalled existing efforts and envisioned new ones, with the hope
of realizing the vision of the Policy Statement and the dream of health for all sooner rather than later.

As a response to the Commissions Report, WHO and the Government of Brazil will be organizing the
World Conference on Social Determinants of Health this coming October 19-21, 2011 in Rio de Janeiro.
This high-level meeting aims to bring Member States and other actors together to build political support
and to make progress on national policies in addressing social determinants of health to reduce health
inequities.

For the past 60 years, IFMSA used to send delegations to high-level conferences in an attempt to
channel the voice of medical students worldwide on global health matters. For this timely and urgent
concern, however, the Small Working Group on Health Inequities proposed that IFMSA maximize the
timing of the world conference to launch a global campaign for action on social determinants of health
by designating the week of October 17-23, 2011 as IFMSA Week of Global Action on Social
Determinants of Health.

During this week, while in Rio the world leaders are discussing global health policy and debating about
action on social determinants, medical students from all over the world will be doing real, tangible
actions big or small, showing leaders the road to global health equity. NMOs will participate in this
global campaign, beginning with educating local NMO members on the issues of global health equity
and social determinants of health through interactive events as well as educational materials. Actions at
the NMO level range from public fora and round table discussions with stakeholders, to street
mobilizations and social media campaigns, to community-based development projects that target
vulnerable groups. NMOs are also encouraged to conduct analysis of social determinants in their
respective countries, with the guide of analytical tools to be provided by the Small Working Group. This
global initiative will culminate in a strong IFMSA presence at the World Conference itself.








A Call to Action: Root Out, Reach Out!

In his lecture during the 60th anniversary conference in Copenhagen, Sir Michael Marmot, the head of
the WHO Commission on Social Determinants of Health, said that the Commissions vision is a world
where social justice is taken seriously. In response, we, the IFMSA, have committed that we will
transform into a Federation that takes social justice seriously. The WOA-SDH is the first crucial step
towards achieving this goal.

Let us root out the causes of inequity, and let us reach out to the poor, the marginalized, the vulnerable,
and the underserved! Rooting out and reaching out are what medical students and IFMSA as a whole
can do, here and now.




References

62
nd
World Health Assembly. Reducing health inequities through action on the social determinants of health.
Resolution 62.14, Geneva; World Health Organization, 2009. Available from
http://apps.who.int/gb/ebwha/pdf_files/A62/A62_R14-en.pdf

Commission on Social Determinants of Health. CSDH nal report: Closing the gap in a generation: health equity
through action on the social determinants of health. Geneva: World Health Organization, 2008. Available from
http://www.who.int/social_determinants/thecommission/en/

International Federation of Medical Students' Associations. Policy Statement on Health Inequity and the Social
Determinants of Health. Jakarta, Indonesia: The 60th March General Assembly of the International Federation of
Medical Students' Associations; 2011.

Keleher, Helen and Berni Murphy, ed. Understanding Health: A Determinants Approach. Melbourne: Oxford
University Press, 2004.

Solar O, Irwin A. A conceptual framework for action on the social determinants of health. Social Determinants of
Health Discussion Paper 2 (Policy and Practice). Geneva; World Health Organization, 2010.



IFMSA Week of Global Action on the Social Determinants of Health (Oct 17-23rd 2011) by IFMSA Small
Working Group on Health Inequity is licensed under a Creative Commons Attribution-NonCommercial-
NoDerivs 3.0 Unported License.