The crusade for health equity

BMJ 2012; 344 doi: http://dx.doi.org/10.1136/bmj.e4414 (Published 27 June 2012) Cite this as: BMJ 2012;344:e4414
  1. Tessa Richards, assistant editor, BMJ
  1. trichards{at}bmj.com

The financial crisis makes it increasingly urgent for countries to protect the most vulnerable people, and social movements are setting the pace

Is the economic crisis marching us towards Armageddon? If so, what’s driving us? Is it a limited understanding of the political and economic forces that are widening wealth and health divides, catalysing civil unrest, stoking climate change, and damaging the environment—or a reluctance to counter those forces?

Four years ago the World Health Organization’s Commission on the Social Determinants of Health said that “social injustice is killing people on a grand scale.” It recommended tackling the inequitable distribution of power, money, and resources within and between countries and implementing cross sector policies to improve the conditions in which people are born, grow, live, work, and age.1

Over the past year the “Occupy” movement has taken up the baton in the protest against corporate capitalism and its imperative that 99% of the population “pay for the sins” of the wealthy 1%. Some criticise the movement’s idealism as fluffy, but even the elite that meets each year at Davos in Switzerland now admits that too much inequality may be bad for growth as well as for society.

When the Alma Ata declaration on primary healthcare for all was signed in 1978,2 most people who lacked access to healthcare or who risked impoverishment by paying for it lived in developing countries. Now nearly three quarters of the “new bottom billion” live in middle income countries. The financial crisis in Europe has brought poverty to its front door.

Many countries have seen progressive cutbacks in health and welfare services and an increase in cost shifting to patients. In the most indebted, austerity measures have resulted in draconian reforms. In Spain, for example, measures have been criticised as undemocratic and inequitable.3 In Greece their effects have been linked to rising rates of depression, suicide, and HIV infection.4

“People are angry about the barbarously unequal society we are living in,” Alexis Benos, professor of primary care at Thessaloniki medical school, told the BMJ. “The unemployed [25% of the population] have lost social security benefits, and many can’t afford care, as the copayments levied are high. Last year 300 people went on a hunger strike about this. In response we have set up social solidarity health centres across the country, manned by doctors who provide free services. Essential drugs have been obtained by putting out a call to people to hand in unused medicines.”

Benos is a member of PHM, the People’s Health Movement (www.phmovement.org), an international network of health professionals, non-governmental organisations, community advocacy groups, academics, and activists whose European members have just signed a “Right to health” charter.

Since its inception in Bangladesh in 2000, the profile and influence of PHM has grown. It has an active presence at the World Health Assembly, and its Global Health Watch reports are widely used in public health education programmes.5

These reports don’t hold back. They criticise the organisations involved in global health governance for lacking a coherent agenda for developing health systems, WHO for allowing policy to be shaped by rich donors, global trade regimes, transnational corporations, privatisation of healthcare, rich countries for their failure to provide enough debt relief and aid to poor countries, and poor countries for not doing enough to protect their citizens’ health.

Next week PHM is holding its third global assembly in Cape Town (www.phmovement.org/en/pha3) and, in response to concern about the NHS reforms in England, a parallel meeting in Nottingham (www.phm-uk.org.uk).

The Cape Town meeting has been organised by David Sanders, a paediatrician and longstanding PHM member. His powerful advocacy for an “alternative Rio declaration,” which includes a recommendation for progressive taxation to fund action on the social determinants of health, attracted much support at WHO’s 2011 meeting in Rio de Janeiro.6 7 His fire against the official declaration was directed at its failure to mention the impact of free trade agreements on undernutrition and obesity, climate change, or the financial crisis—which, he said in his closing speech at Rio, was “a crisis of capitalism for which the poor, including those in southern Europe, are paying the price.”

Evidence from an interim report of a review of health inequalities in Europe conducted by Michael Marmot, who chaired the 2008 WHO commission on social determinants of health and now heads the UK Centre for Heath Equity, certainly backs the view that the social gradient in health is getting steeper and that gaps in life expectancy and health outcomes are widening.

These trends, Marmot argued, make it urgent for Europe’s politicians to “get serious” about adopting a cross sector and whole government approach to reducing health inequity, as Norway, Finland, Canada, Australia, and Brazil have done. Although he does not endorse the view that capitalism is the root of all evil or that the food industry is the biggest threat to health, he agreed, when we talked last week, that PHM’s voice is an important one to listen to.

Outside Europe, countries such as Thailand, Brazil, and Vietnam have been lauded for their progress in establishing equitable, publicly funded universal healthcare services, having seen the value of eliciting and responding to the health concerns expressed by public and social movements. Progress in India, the economist Amartya Sen has underlined, has come from public discussion—and agitation.8

Policy makers in Europe could learn from the approach of these countries,6 and health professionals could learn from absorbing the passion and following the debates in Cape Town and Nottingham.


Cite this as: BMJ 2012;344:e4414