Intended for healthcare professionals


Tackling health inequities

BMJ 2008; 337 doi: (Published 03 September 2008) Cite this as: BMJ 2008;337:a1526
  1. George Davey Smith, professor of clinical epidemiology1,
  2. Nancy Krieger, professor2
  1. 1Department of Epidemiology and Public Health, Social Medicine, University of Bristol, Bristol BS8 2PR
  2. 2Department of Society, Human Development, and Health, Harvard School of Public Health, Boston, MA 02115, USA
  1. George.Davey-Smith{at}

    WHO report calls for global action to ensure health equity within and between countries

    Finally, an official report on health inequity has been published that has the honesty and courage to say that “social injustice is killing people on a grand scale.”1 The report of the World Health Organization’s Commission on Social Determinants of Health synthesises evidence from a large and disparate range of sources, while recognising that what constitutes evidence is itself contested and not value free.2 It presents a wealth of data to show the unquestionable link between economic, social, and bodily wellbeing—within and across countries. In the case of life expectancy, these embodied facts of social inequity3 can span the equivalent of a lifetime: women born in Botswana can anticipate living an average of 43 years, half that of the 86 years for women in Japan; between the poorest and most affluent parts of Glasgow life expectancy in men ranges from 54 to 82 years.

    Many official reports have documented social inequalities in health over the past 170 years, from Chadwick4 to Sachs.5 Yet, in contrast to these reports, which subtly (and not so subtly) emphasised the detrimental effects of poor health induced by poverty on economic performance,6 the commission firmly draws the arrow of causality from impoverished environments to ill health, something that is clear to most of the world’s population (if not to some economists).

    The ability of this report to make these conclusions rests on its unprecedented broad scope—unlike many other reports that have focused on one country or on groups of countries at similar economic levels, the commission has produced a global picture of economic and social deprivation that makes it impossible not to recognise the importance of economic redistribution, health care, and the direct material consequences of poverty and social inequality across the life course on health.

    Once it is acknowledged that poverty, exploitation, oppression, and injustice damage health, the question is clearly what should be done and by whom? The commission offers three overarching recommendations (table 1). Firstly, improving the conditions of daily living from before birth to old age will alleviate the health consequences of inequality. Secondly, although the commission accepts that it “was beyond the[ir] remit, and competence . . . to design a new international economic order that balances the needs of social and economic development of the whole global population, health equity, and the urgency of dealing with global warming,” it appropriately identifies the inequitable distribution of power, money, and resources as underlying poor health. Finally, to galvanise action and ensure accountability, it recommends global, national, and local monitoring of health inequities; the assessment of the impact of policies aimed at the alleviation of these inequalities; and the training of all health professionals in the social determinants of health.

    WHO Commission on Social Determinants of Health’s recommendations

    View this table:

    Wisely advocating a “both and” rather than a divisive “either or” approach, the commission calls for “bottom-up” and “top-down” action, both within and outside the health sector. Declaring that “health is not a tradable commodity,” it boldly asserts that “certain goods and services such as basic human and societal needs—access to clean water, for example—and health care” must be “made available universally regardless of ability to pay.”

    The report’s inclusion of both social and health system policies as social determinants of health follows others7 in moving on from debates that narrowly pit one against the other.Throughout, the report usefully provides diverse concrete examples showing how health equity can be advanced by intersectoral action from grassroots organisations, national and local government, multilateral agencies (including WHO itself), the private sector, and research and teaching institutions. Observing that governments obviously are “not always benign,” the commission underscores the “clear links between a ‘rights’ approach to health and the social determinants approach to health equity.” Highlighting the harmful effects of gender inequity, discrimination, and social exclusion on health (including the health of indigenous populations), it calls for democratic and participatory approaches as the essential glue for integrating multisectoral multiagency activity and making sure this work has an effect. Indeed, as advocated 65 years ago by Morris, the leading health inequalities researcher of the 20th century,8 the need to include community based, participatory approaches to evaluation and monitoring—often seen to be the domain of “experts”—is as crucial as grassroots involvement.

    Equally telling, the commission eviscerates the platitude that economic growth and reliance on markets are sufficient for improving health.9 10 Pointing to the harmful health consequences of the “market oriented economic policies” pursued since the 1980s that have led to a “significant reduction in the role of the state and levels of public spending and investment,” the report provides evidence that equity oriented growth can produce the health gains of development without the adverse effects of growth that favours the “interests of a rich and powerful minority over the interests of a disempowered majority.” As the report clearly notes, although markets can “bring health benefits in the form of new technologies, goods and services, and improved standard of living,” this is not the full story, because “the marketplace can also generate negative conditions for health, in the form of economic inequalities, resource depletion, environmental pollution, unhealthy working conditions, and the circulation of dangerous and unhealthy goods,” such as tobacco.

    The commission accordingly forcefully argues that work on health inequities is blocked not by a lack of resources, but by a lack of political will. Noting that the budget of the Gates foundation has at times exceeded WHO’s core budget; that the annual cost of bringing the 40% of the world’s population currently living below $2 (£0.55; €0.68) a day up to this level would be $300 billion—less than 1% of the gross national income of the high income countries; and that many countries spend more on the military than on health, the report makes it clear the problem is not money itself but rather how “money is used for fair distribution of goods and services and building institutions within low income countries.”

    To return to the question of what is to be done the report clarifies that just as cynicism and inaction are not an option, neither is there one master plan to be dictated from above. Instead, health professionals have clear and plentiful work to do within the many systems in which we work, together with every other sector of society. By placing health equity as a crucial goal and as the standard for accountability, and by recognising that social justice is the foundation of public health,11 we stand a better chance at rectifying current inequities and playing our part in establishing a more just and sustainable world.


    Cite this as: BMJ 2008;337:a1526


    • Competing interests: None declared.

    • Provenance and peer review: Commissioned; not externally peer reviewed.


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