Monday, 2 March 2015

Social Determinants in a Post-Conflict Colombia

An attractive proposition?

Taking a social determinants approach to planning for a “new” peaceful society? How could it not be attractive. We have been arguing that health and health inequities tell us how we are doing as a society. It follows that planning for a new society should have social determinants of health at its heart. Hence the invitation to come to Colombia and be part of that discussion was irresistible.

There was a second reason I had to go to Bogota, and it relates to our social movement. We, IHE colleagues Jessica Allen, Ruth Bell and I, conducted a workshop for the Inter Academy Medical Panel on social determinants of health in Trieste Italy in summer of 2014. I said at the end of the workshop that there were senior representatives of Academies of Medical Science from 22 countries represented here; if only two of them went home and got active on social determinants of health I would consider the workshop a success; if three… a bonus; any more … I would be in heaven.

So far we seem to have three: South Africa, Morocco, and Colombia, with Tanzania in the wings. Prof Luis Alejandro Barrera Avellaneda of Pontificia Universidad Javeriana in Bogota, who had been at the workshop, said that they were planning for a post-conflict Colombia, would I come and address their new inter-sectoral commission on public health, meet ministers, have an exchange with some of their university professors, and participate in a day-long conference on social determinants of health.

He, and Professor Francisco Jose Yepes Lujan, co-hosted my visit with generous hospitality. Significantly, the Minister of Health was present at the dinner at which the University rector presided. It suggests a good channel of communication. I found the Minister open, engaging and willing to discuss social determinants of health. Some of the Twitter commentariat suggested otherwise. I do not know what that is about.

Post-conflict Colombia? Any outsider who claims to understand Colombia’s recent history is not concentrating. People were born liberal or conservative, or socially excluded. In Britain these partisan differences are debated with childish insults, in Colombia with deadly weapons. A civil war in the late 1940s that led to a military dictatorship was followed, in 1957, by sixteen years of Liberals and Conservatives agreeing to take it in turn to lead the government. It was something that could not last. And indeed it did not. Marxist guerrillas, private armies of the right (the paramilitaries), the infamous drug cartels with their own armies – it is hard to keep track of all the violence. Arguably, with political assassinations and kidnapping, the cartels overreached themselves, and were smashed. There is still a drug trade in cocaine – it partly funds the guerillas. But the drug-related violence between rival gangs seems to have moved to Mexico.

Emerging from all of this violence, the government is in the process of signing an agreement with FARC the leading rebel group. It is a fragile peace, watched with suspicion by many. More than 200,000 people, mostly civilians, have been killed in the fighting, and 7 million people, out of a population of 48 million, have registered with the government’s victims unit as having been internally displaced by the violence, or kidnapped, injured or otherwise affected. Whew! How to row back from such pain.

I made a presentation to the Intersectoral commission on health, chaired by the minister of health and with representation from 9 ministries. As background to our discussions I had been sent an excellent report documenting health and their approach to social determinants of health in Colombia (see link below). We will, of course, have to see what happens but the existence of this intersectoral group led by ministers who in their speeches show a keen understanding that key determinants of health lie outside the health care system is hugely encouraging.

The next day, the conference itself at Javeriana University was hugely oversubscribed. I took this great level of interest as an expression that our social movement on social determinants is alive and well. The Minister of Health followed the University Rector (President) in opening the conference. I have notionally shared platforms with Ministers of Health in many countries. But the ministers almost always – Sweden was an exception – make their speech, and leave before any of the substantive presentations. I don’t take it personally (perhaps I should?). Here the Minister stayed and personally made commitments to me to send me examples of their cross-sectoral action.

A lively discussion included a challenge from the left. Have we any examples, I was asked, of successful action to diminish health inequities. Presumably not, because the problem is capitalism, which inevitably increases inequalities, and there is nothing that can be done. It is a point of view we had heard while conducting the Commission on Social Determinants of Health. Nothing that can be done? All of our recommendations useless? To me, it is a counsel of despair.

I had four responses to this challenge. First, I am arguing that social determinants implies addressing the causes of the causes. My interlocutor wants to address the political causes of the causes of the causes. Go for it. Do it, by all means. I wish him luck.

Second, the country with the best health in the world, and relatively narrow health inequalities, is Japan, a successful capitalist country; followed by the Nordic countries, also successful capitalist countries. In fact all the countries with the best health are capitalist countries. The question is not whether we want to reconstruct a better version of the Soviet Union or North Korea, but how, as Thomas Piketty argues in his Capital in the Twenty first Century, to construct capitalist societies that are fairer, more just, and less unequal.

Third, it is not true that the evidence shows that until we smash capitalism we can not make progress. There are two ways to gauge success: health of the most disadvantaged, and the health gradient. There are examples from all over the world of the health of the most disadvantage improving – a major societal success. But, in many countries they have not been improving as rapidly as the better off. It remains a major challenge to address the social gradient in health. That is why we are in business.

Fourth, there are examples of reducing the slope of the health gradient, from Peru, Brazil, Bangladesh. It is simply not true that we cannot make progress on addressing the causes of the causes, without removing capitalism. That said, as we argued in the CSDH, commitment from the top of government is vital in addition to mobilisation of social movements from society.

In Colombia, itself, there has been considerable progress in reducing poverty, but poverty is still at very high level with strikingly high levels of inequality. There is much to be done. An intersectoral commission to improve health inequity is an important step in building a post-conflict Colombia.

Tuesday, 24 February 2015

Is it not better to light a lamp than curse the darkness?

A question we have been asking for at least the last five years: what can doctors do on social determinants of health? Not least, I posed this question when accepting election as President-elect of the World Medical Association. I finished my speech with a quote from Ghandi. Dr Jitendra Patel, (now immediate past-) President of the Indian Medical Association, said: I will start a hunger strike and won’t finish until you come to Ahmedabad. We will take you to a tribal area and show you what we are doing to improve the lives and the health of tribal people. People, that is, who have been socially excluded from the mainstream of Indian society and live in great poverty.

I had to go to check on Dr Patel’s state of nutrition. Indian hospitality certainly enhanced mine.

Gujarat is not one of the most populous Indian states – population “only” 60 million; Uttar Pradesh is 200 million. About a three hour drive from the big city of Ahmedabad, near the Pakistan border, is the Virampur area of the Banaskantha District. Getting there was an ordeal of embarrassment and gracious hospitality. At four stops organised by local branches of the Indian Medical Association we were greeted by dancers, drums, pipes and banners saying: Welcome to President-elect of the WMA. There followed garlands of flowers, shawls draped round the neck, and a slight sense of disbelief on my part that this could be happening.

At Virampur, we were part of a ceremony of opening a new multipurpose facility to aid the work of the Samvedana Trust  in improving the lives and the health of tribal people in the area.

The work began when Ketan Desai, also based in Ahmedabad, was President of the Indian Medical Association at the beginning of the century. He proclaimed the Ghandian slogan: let’s go back to the villages. Dr Jitendra Patel picked up the challenge and began with medical camps ‘under the Banyan tree’ in the tribal area of Virampur. He and his willing colleagues voluntarily treated the illnesses of tribal people from 42 villages in the area. What began with medical camps and on the spot treatment of disease grew. Over a ten year period from 2004, more than 40,000 tribal, and other poor, patients were treated – not at their expense – including over 11,000 operations at a nearby hospital, or in Ahmedabad.

Medical care to the under-served is vital and filling a gap, but as we said on the CSDH: what good does it do to treat people and send them back to the conditions that made them sick.

Note the goat sharing this woman’s front room.

These doctors went further and established the Samvedana Trust. A key figure is Dr Jitendra Patel’s older brother, Hasmukh Patel, social worker, social activist, and all-round good person. He lives simply in the tribal area on the site of the new building.

One among the many reasons, including prejudice and discrimination, for the marginal existence of the tribal groups here was the dry parched nature of the landscape. Hasmukh Patel, and the Samvedana Trust, were instrumental in establishing a system of 90 ‘check-dams’ to capture the water from the surrounding hills. With irrigation, agriculture is being transformed and migration to seek work has been reduced.

The Trust is actively involved in education, in helping gifted children to go on to further training, in promoting handicraft production as a commercial activity, and in generally promoting community development.

One of the lessons I have been taught in India is that government activity is central to improving the lot of the vast population of the nation’s poor. But so, too, is civil society. With an Indian population of 1.2 billion (in the 2011 Census) it is hard for any government to reach into the remoter corners of tribal areas, quite apart from issues of endemic corruption. An inspired and inspirational civil society organisation such as the Samvedana Trust can be transformational.

Working together to improve lives

I was back in Gujarat last weekend visiting street vendors who are members of SEWA – the Self Employed Women’s Association. It was nearly ten years since I visited with the WHO Commission on Social Determinants of Health (CSDH). After that visit I wrote:

I can picture the lives of the vegetable sellers of Ahmedabad from the outside, as they sit on the streets of the market area in the sun and the monsoon rains, with a small pile of vegetables on the rag in front. I cannot begin to understand how it feels from the inside to live the life of one of the poorest, most marginalised women in India. You start with some significant social impediments: you are poor, from a scheduled caste, you had no chance of education, and you are female. The only employment you can envisage is what your mother did: become a vegetable seller. This means you have to borrow money at usurious interest rates to buy your vegetables, pay inflated prices to the middle man in the wholesale market, deal with police harassment as you sit on the road side, and worry what to do with the children while you earn your few rupees. On the morning of my visit an elephant swaying through the market was simply one more hazard.

On this latest visit, Mirai Chaterjee, a leader of SEWA and a member of the CSDH, took me back. The street vendors in this area, the women at least, are members of the union, SEWA. Mirai introduced me to the local leader. She said (in Guajarati) that she remembered me from ten years earlier. Goodness. How come? This is not exactly a tourist attraction, and they don’t get so many outsiders come to visit.

Mirai is the one on the right

This woman was a street vendor as was her daughter. But the next generation? They are getting educated and do not want to go into the vegetable market. It is tempting to believe that the childcare SEWA provides is a significant step towards education. We know from evidence elsewhere in the world that enrolment in pre-school education is a significant predictor of educational success.

Interesting. These women are Dalit, outcastes. They have presumably married other Dalit for generations. But caste is not destiny, or should not be. Give the children the opportunity to be educated and they seize it and, presumably, flourish.

There are many other ways that SEWA has been active in improving the lot of its members. The wholesale vegetable market is a prime example. The wholesalers were forcing small farmers to sell at low rates and passing produce on to the retailers at high rates. Large profit for them; hardship for the street vendors. SEWA, against opposition from the, largely  male, wholesalers, set up as middlewomen: buying from growers at reasonable prices and selling to retailers with modest profit.

SEWA Bank is an important part of the jigsaw – small loans to street vendors without extortionate interest rates. Health care, insurance, legal representation, housing are all active areas for SEWA and its members.

Inspiring stuff. SEWA shows how collective action by civil society can transform lives.

Monday, 24 November 2014

We opened our minds. More important we opened our hearts.

Who do you imagine might say something like that? A social worker? A new age traveller? A cleric of one or other faith?
How about a Deputy Chief Fire Officer at West Midlands Fire Service. He was launching their report “Improving Lives to Save Lives – the role of West Midlands Fire Service in contributing to Marmot objectives”.
He said that they opened their minds to the Marmot Review, Fair Society Healthy Lives, and they opened their hearts to what they could do to help the poor and the needy in the communities they serve and of which they form an important part.
Their principles are Prevention, Protection, and Response. They have given an undertaking to respond within five minutes to a call for a fire. They spend between 6 and 10% of their time responding to fires. With training, shifts, and preparation that comes to about half their time. They have been innovative, creative, and committed in using the other half of their time to enhance the communities they serve. They quote us in pointing out that both health and fires follow the social gradient. Prevention of one is likely to help in preventing the other.

One important principle is Making Every Contact Count (MECC). A fire fighter goes into a home to check fire risks and talk about making the home safer. He sees hoarding, which contributes to risk, deprivation, isolation of an elderly person. He doesn’t then say, bad luck. He either works on the problem himself or works with colleagues to figure out who they should be working with. If the fire fighter has reason to suspect domestic violence, for example, he contacts the relevant experts.

They have ‘Marmot Ambassadors’ who are the front line staff whose role is acting on the six domains of recommendations in our Review. They call them the Marmot Six (sounds like a miscarriage of justice – one better than the Birmingham five).

Certainly, they inspired me.
We heard moving case studies. A fire in a house led to discovery of an octogenarian, ‘David’, who was burning rubbish in his living room to stay warm – his gas had been cut off. It took a fire officer three weeks of coaxing for David to let her in the door. Turns out he didn’t “do” anything. He didn’t watch TV because his electricity had been cut off 26 years ago. The Fire Officer brought him clothes, Xmas dinner, located his sister, and finally got him on needed medication and into sheltered accommodation. He was in a good deal better state than when they found him.

Each case study was more moving than the last. The fire officers give of their time and effort beyond the call of duty. They are worried that when someone discovers the inspiring work they are doing in preventing fires and improving health and well-being their funding will be cut. It would be a catastrophe if it were.

Wednesday, 12 November 2014

The Social Movement is Alive

Without missing a beat, or even slowing down, the man said: “42nd street that way, (right arm pointing), 41st that way, (left arm).” I smiled intermittently for the rest of the day. I liked to think that this was a typical New York interaction, brisk, business-like but good-natured and well intentioned. My Samaritan, in a flash, and before I needed to say anything, diagnosed that I had emerged blinking and disoriented from the 42nd subway station into one of the ornate corridors of Grand Central Station, looking for inspiration. Equally quickly, no fuss, he solved it. Gratefully, I headed south.

Solving the NY subway, and eschewing taxis, was a means not an end. The ends were engaging first with the New York City Commission of Health and Mental Hygiene (quaint name), then with the New York Academy of Medicine – each headed by an impressive woman.

The Mayor of New York, Bill de Blasio, has social justice and equity at the heart of his concerns. This seems a good moment for New York to get active on social determinants of health. The Health Commissioner, Mary Bassett, had invited to me have lunch with her and fifteen or so of her senior staff, and then give a talk on ‘implementing the Marmot Review’ to those and another hundred staff. There is enthusiasm there. The one doctor in New York who contracted Ebola after his work with MSF in West Africa has diverted the Commissioner and staff in a major way, given the public fear of the issue. Their handling of the issue seems to have gone well. I did wonder, though, if some part of the tens of millions of dollars that New York spent on Ebola had been spent in West Africa…

City level of government may well be the most appropriate level for action on social determinants of health in the US, given the policy immobility of Washington. I was in New York the day after the mid-term elections revealed that with a Democratic President, and Republicans in control of the Senate and the House, who knew what would happen next at Federal level. There is real interest in the NY Health Commission in working across the organs of City government on social determinants of health. I showed them the work we have been doing on monitoring Social Determinants of Health and health inequalities. If London can do it, why not New York?
To the New York Academy of Medicine (to receive a public health award) and to, I hope, engage them as partners in potential activities with New York.

I reminded the audience at New York Academy of Medicine that when we launched the CSDH we said we wanted to foster a social movement. The number of people who said that the CSDH report, Closing the Gap, was influencing their work, suggested that the social movement is alive and well. The Acting Commissioner of Health for the State of New York – as distinct from the City – Howard Zucker, says he keeps a copy of the report on his desk.

Unrelated to social movements, a spare hour spent in the Frick Collection in New York is a revelation. It has a small, but astonishing collection: a Rembrandt self-portrait – one of the merciless self-examinations of his later years; three Vermeers; a Titian; Holbeins; two Turners; a couple of Constables; and a whole slew of Gainsboroughs. The next day, by contrast, between day meetings and the evening occasion at NYAM, I managed an hour at the Neue Galerie, with its fine collection of Gustav Klimt and Egon Schiele. Schiele, particularly captures what an edgy time that was to be in Vienna, early 1900s, soon before the whole empire came crashing down. Schiele and his wife both died, within three days of each other, in the pandemic influenza in 1918.

Tuesday, 11 November 2014

"In Sweden we don't do VIP..."

But they do a lot else. Perhaps no trappings, but I have no complaints. What they showed me was gift enough. Goteborg is the third of the three Swedish cities/regions – the others are Malmo and Linkoping – that are doing reviews of social determinants of health. Or, as they put it, Swedish Marmot Reviews. It felt like we were having a conversation.

Apparently at the airport, there is a sign promoting the city:

Goteborg, growth.

One of the local hosts proposed a new sign, sadly not adopted:

Goteborg: reading to children.

Another said that they had recently been to Birmingham on a fact-finding mission, having heard me say, a few years ago, how Birmingham (England) narrowed the gap in early child development between Birmingham and the English average. They were told in Birmingham that the special programmes on Early Child Development were no longer being supported. Disappointing.

The leitmotif of this Goteborg activity is inclusion: 1100 people, mainly employees of the City of Goteborg, came to this conference on socially sustainable Goteborg. I have been to meetings of various kinds in London, but never 1100 people engaging with how to make London a more sustainable place. Per capita, to match Goteborg, such a London meeting would have to have been 11,000.  The day after my visit, 400 of these 1100 were to sit down to work together to plan a more socially sustainable Goteborg, with health equity and sustainable development at its heart.

One of the gifts they gave me was to take me on a quick trip of the city, accompanied by three expert employees of the city. Slightly uncomfortably, I was fitted with a microphone and accompanied by a cameraman. They wanted to capture my reactions (not including post prandial afternoon drowsiness, I hope.) Goteborg “boasts” a nine year gap in life expectancy between small areas. What might that look like on the ground? What I didn’t “see”, but they told me, is that 22% of the population is foreign born, with another 13% or so children of migrants. Sweden had a programme to build a million new homes in the 1960s. In Goteborg, some of these were built in outlying communities that are rather cut off from the city. They are heavily populated by immigrants. These are ‘slums’ done by the Swedes. Apparently well-built, rather neat, five or so storey-blocks of flats, landscaped, no graffiti, no broken glass, but soulless and isolated, cut off from the Central City.

Perhaps linked to this isolation, one of the questions I was asked at the conference was what might they be doing about the fact that the 1100 people attending, overwhelmingly, were white. My response was that I wouldn’t start from here. If immigrant communities were cut off from the main stream, geographically, it was perhaps no surprise that they were underrepresented socially.

Even egalitarian Sweden has inequality issues with which they must grapple. But they are, grappling. Particularly, they liked our European slogan, which we adopted from Swedes: “Do something, do more, do better.” I think it highly likely they are going to do better. I was invited to come back in three years and see.

Tuesday, 21 October 2014

Singing the same song...

... But now others are singing with you, said a WHO official.

I had just addressed a Ministerial meeting of the WHO Eastern Mediterranean Regional Committee, here in Tunis. The Regional Director of EMRO, Ala Alwan, has taken the initiative to put social determinants of health (SDH) on the agenda for EMRO. In introducing the session this morning he reminded Ministers of the five priorities for the Region: health systems strengthening towards universal coverage; non-communicable diseases; communicable diseases, particularly health security; maternal and child health; emergency preparedness and response. He said that each of these require SDH.

I had a few minutes to give it my best.

When we published Closing the Gap, the CSDH Report, in 2008, I came to the EMRO Regional Committee to present the report. The response was tepid. This time the response was summed up by the WHO official I quoted above. She said that she heard me speak before at WHO Geneva, you may be singing the same song, she said, but now others are singing with you.

We had a good response from the Ministers present. My response underlined the points they made and allowed me to emphasise a few things:

  • Haven't we known about SDH since the 1970's? asked a minister. Yes, it was in Alma Ata 1978, but was ignored. WE had the Washington consensus, IMF structural adjustment, but not SDH. Our knowledge on SDH was not acted on.
  • We need evidence and politics. You do the politics, Ministers; we'll do the evidence. We need to work together.
  • How will we deal with high risk groups? Proportionate Universalism (sorry interpreters) - universalist policies with effort proportionate to need.
  • Need commitment of the centre of government, PM or President, but also need local action.
  • Related: need to take the evidence and adapt it to national and local conditions.
  • Thank you for not forgetting Mental Health.
  • Taking action on SDH is especially challenging in countries torn by conflict. Urgent task to work out how to go forward.
Ala Alwan told the Regional Committee he wanted their approval to work on SDH over the coming year which he proposes to do with us, IHE. I think he got it. He seems pleased.