Thursday, 27 October 2011

...this one ended up in Rio

On the first morning of the conference in Rio de Janeiro I commented to Zeinab Badawi (BBC World superstar who was interviewing me) that the fate of most Commission reports is to end up in the dustbin. This one (the Commission on Social Determinants of Health’s) ended up in Rio. Altogether a better option. 

Several people came up to me in Rio and said, metaphorically rubbing their eyes, could you have believed even five years ago, that we would be at The World Conference on Social Determinants of Health – the biggest event WHO has organised since Alma Ata in 1978?

No, me neither.

This was a remarkable event – despite some annoying “airbrushing” (see my blog below on “Who gets the credit”). From the D-G, Margaret Chan’s opening, to the closing, 48 hours later, people talked social determinants of health. It was my turn to rub my eyes. For my whole life, this conversation had been beyond the pale: global health was about disease control or health systems. Nationally, public health was about screening for cancer, smoking clinics, or disposition of health services; not about the issues we covered in the CSDH and the English Reviews: the conditions of daily life and the structural drivers of those conditions. A large proportion of the 60 government ministers who attended spoke at the meeting. Not all showed awareness that social determinants meant anything more than access to health care. One who did was the Finnish Minister who spoke eloquently of the importance of the Finnish Welfare state and education system. The civil society activists understood the issues and were a welcome, and vigorous, presence.

The background: the Commission on Social Determinants of Health had, among its other recommendations, called for a global meeting where all countries reported on what they were doing on social determinants of health and health equity. I never thought I would reach the point in life when I thought that a resolution at the World Health Assembly was important. But the one in 2009 endorsed the CSDH recommendations, including the one for a global summit, and Brazil offered to host it.

There was a rumour that some powerful people didn’t want a big summit, with lots of politicians present. Who would have believed that! Or if there were to be a meeting, it should be a narrow technical meeting. Brazil said “no” and “no”. They argued for a big political meeting with 120 countries represented. Brazil won.

Was the meeting good? Of course, it was good. Not primarily for the good things that happened, nor for the Rio declaration (see the blog below), but because the fact that the meeting happened at all was sensational. The CSDH called for a global movement on social determinants of health. It was evident, in a big way, in Rio de Janeiro. Now, we need to keep up the momentum.

It’s amazing what you can accomplish if you do not care who gets the credit.

My source for this quote was Bill Foege, who as well as being a luminary of global public health, was a member of the CSDH. According to the web, the author of the quote was President Harry Truman – who got quite a lot of credit. It came to mind when several people came up to me in Rio with the observation that the CSDH was being airbrushed out of the World Conference on Social Determinants of Health. Surely not. The CSDH is not in the draft Rio declaration, I was told. And the meeting was presented as if it were a direct follow on from the Ottawa charter of 1986 without the intervening work of the CSDH. Indeed, in the speeches in the opening ceremony, no one referred to the CSDH, and assurance from the Brazilians that I would speak in the opening session, to present the view from the CSDH was countermanded. It was after Margaret Chan finished reading her prepared speech, with its reference to the Ottawa charter, and was being interviewed, that she said: we are here because of the work of the Commission on Social Determinants of Health. Similarly, in the closing session, ADG, Marie-Paul Kierny, referred to the key role of the CSDH.

I know that the CSDH led to this global meeting. As does everyone else who knows about the CSDH. Should I then care at this attempted airbrushing? Or simply remember Harry Truman?

The interesting question is why? Why would anybody want to pretend that this conference on Social Determinants of Health was really the heir to the Ottawa Charter on Health Promotion and not a direct follow on to the CSDH? The word on the street was that there were objections to the Commission’s strong emphasis on inequities in power, money and resources. Trying to convince poor people to eat vegetables is one thing, acceptable and safe; attacking the inequity in power, money and resources is altogether less safe. Hence, portray this meeting as NOT an endorsement of the CSDH recommendations.

The wonderful medical students from IFMSA had it down pat. Here is a quote from their alternative Rio declaration:

“The main problem of the Rio Declaration is that it failed to explicitly tell us how the unfair distribution of power, resources and wealth will be addressed, especially by Member States. The WHO Commission on Social Determinants of Health has been adamant about the need to tackle this lingering issue, as health inequities within and between countries are rooted in power relations and resource maldistribution. We understand that changing the current dynamics of power will not happen overnight. However, we believe that this Declaration could have been the watershed moment for leaders to make a strong commitment in making this world a fairer place.”

This provides a clear explanation of why there was an attempt, ultimately unsuccessful, to remove all mention of the CSDH from the Rio declaration. Too strong for some political stomachs. This attempt also illustrates the difference between intellectual life and political. In intellectual life, to remove all reference to the source of an idea is simply unacceptable. For example, if I wrote a paper and didn’t acknowledge the source of the ideas, such behaviour would be, to put it gently, dishonourable. Apparently, when politics is at stake, normal canons of behaviour do not apply.