WHO Commission on the social determinants of health: a bold new venture

Abstract

There was a time, not long ago, when scientists working on social determinants of health ended every paper with a reverential bow to policy with a weak comment about the relevance of their results for policymakers. This was especially true for social epidemiologists who often had high hopes of contributing to the policy debates about health equity. Most of these comments were very naïve from a policy perspective albeit well intentioned. In the policy world, there was often a parallel nod to building the evidence base from which one could make sound policy or even political decisions. Again, policymakers had a slim grasp of what constituted strong evidence from a scientific perspective. We know that changes in policies are based on much more than evidence alone, but history has also taught us that strong science can ultimately influence political debates and policy implementation. We have only to look at the recent tobacco policies sweeping North America and now much of Europe to see that we can have an impact on public policy. The WHO Commission on Social Determinants (CSDH) has done what few WHO reports do—that is to open a dialogue between scientists and policymakers to pave the way for introducing evidence into the politics and pathways of policymaking.1 With the CSDH, the two worlds of science and policy have collided in an exceptionally productive way. The Commission's searchlight has been sweeping. With the conclusion of the Commission, we now have assembled, under one single umbrella, a massive amount of epidemiological and social science evidence and at the same time a long list of relevant recommendations for action from around the world that informs us about what we can do to improve health equity across the globe. The Commission has the potential to help countries throughout the world address health inequities related to social and environmental causes. The CSDH covered areas related to early child development, globalization, health systems, urbanization, employment conditions, women and gender equity, measurement and evidence and social exclusion. The topical reports leading up to the main document describe what we know about the social determinants of health and what we can do to improve health and reduce health inequities across not only economic divides but also those based on racial and ethnic differences, gender and social participation. The final report calls for us to close the gap in a generation by implementing policies that will improve daily living conditions, tackle the inequitable distribution of power, money and resources, and measure and understand the problem and assess the impact of action. This is truly a call to action. The CSDH frames new strategies for international, national and even local stakeholders so as to reach out to create coalitions and collaborations at multiple levels—among governmental agencies, NGO's and world bodies including the WHO, IMF, World Bank, etc. It also emphasizes the critical role of public action and civil society empowerment in encouraging truly decentralized health equity oriented programs based on authority and accountability from the local to the national level. The report is remarkable in many ways but three features are particularly noteworthy. Until the CSDH report, research on social determinants of health was most often studied in the context of highly industrialized countries. One of the major accomplishments of the report is to embed the ideas of social determinants in a global context by comparing both within and across countries. It makes a forceful case for the importance, even primacy of social determinants of health in developing countries. The second remarkable concern which permeates the report and many of the recommendations relates to gender equity. Here again, we see the way in which economic conditions interact with gender to produce profound inequities and social exclusion. Third, the report deserves praise for it breadth and lack of ‘dichotomous thinking’ in which policies, for instance, need to be based on reducing inequalities in either material conditions or psychological, social and behavioral resources. The way forward? It has become increasingly popular to say that social and economic policies in addition to those related to health systems hold the potential to improve both population health and to reduce health disparities. Nevertheless, we are still left at the end of this report with a limited number of policies that we can be confident will achieve the desired results. Evidence-based policy analysis and implementation is still in its infancy and it is worthwhile noting that much more effective work can be done in this arena if we subject policies to rigorous evaluation. Thus, the last set of recommendations on surveillance, sharing of evidence and training are particularly important from a public health standpoint. With these approaches, we can identify the consequences of specific policies—both intended and unintended. The CSDH creates a pathway by which to improve health for all citizens of the world by integrating the worlds in which policy makers live with those of workers in population health. The agenda is clear, we now need to start.

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