Heads of State vow to “achieve social and health equity.” Students respectfully ask for more specifics.
Last week, Heads of State, Ministers, government representatives, and leaders of different sectors met in Rio de Janerio at the WHO World Conference on Social Determinants 
of Health. (Writing and discussions about social determinants of health can often get lost in very academic and sterile sounding language, so it is important to keep it as close to real life as possible.) What is important about the World Conference on Social Determinants of Health (WCSDH) in Rio is that 125 nations pledged their commitment to work to promote awareness, develop policies, and support programs to transform certain social factors that play a significant role in determining whether or not a person will be healthy. The U. S. Centers for Disease Control uses the following words in an attempt to define ‘Social Determinants of Health’, “…complex, integrated, and overlapping social structures, and economic systems that are responsible for…” As you can see, we are already getting off into language that feels far removed from the daily realities of global health disparities like lack of access to care. Of course, all this has to do more with economics, education, and politics than with the common understanding of health and healthcare. And that is exactly the point. The fact that many high level political decision makers were present in Rio gives us some hope that there is a growing realization that health ministers alone cannot address these issues.
The Rio Declaration referenced a similar conference in 1978 that produced The Declaration of Alma Ata, named for the Russian city –then in the USSR, where health was defined as “…a state of complete physical, mental, and social wellbeing, and not merely the absence of disease of infirmity… .” It went on to declare health as “a fundamental human right.” So we have known for a very long time that the goal of health for a nation and for the world is larger than healthcare, at least as we know it in the United States.
More than thirty years later, it is great to see the Spirit of Alma Ata is still alive. For, as economics, politics, and situational specifics change, it is imperative to remember that fundamental values and rights remain constant. It was right for Alma Ata to call for essential primary healthcare for all the world’s population back in 1978, and it is right for Rio to say today that just because we have not yet achieved the promise of Alma Ata does not mean that we should stop trying.
Progress is being made, but there is much more that can be done. That is why it is good to see the fresh eyes of students also present at the Rio conference. The International Federation of Medical Students (IFMSA) sent a delegation of ten medical students to Rio. Their take on the events of the WCSDH can be found on the IFMSA blog. While the IFMSA students don’t have the experience of some of the professionals who have been working at this for several decades, they do bring a fresh perspective and the ability to think more simply, with less jaded minds. In their critique, Renzo Guinto, the leader of the youth delegation, hits the nail on the head by saying: “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.”
Students who participate in any of Child Family Health International’s (CFHI) Global Health Immersion Programs are, in fact, immersed into underserved communities around the world. They are mentored by local healthcare workers who face the challenges of few resources and many patients. Students say that they are deeply impacted as they see dramatic health disparities and the realities of the social determinats of health playing out right in front of their eyes. They become some of the most effective advocates for global health equity because they are eye witnesses to the consequences of inequity. And some of them are moved enough to have the experience directly impact their career plans, like Erin Newton who wrote about her experience on the Great Nonprofits Website. “Having never been exposed to the poverty, illness, and disease that I experienced in India, I learned so much about myself and found that I have a true passion for underserved and rural patient care. I learned that much of it can be prevented and I want to help treat these individuals and educate the rural communities as a future physician.”
Along with his challenges, Mr. Guinto also seems to speak for IFMSA in pledging to “…commit ourselves to continue engaging with all sectors involved in the work towards global health equity, spreading awareness of the social dimensions of health to our fellow young people, mobilizing them to take action in their respective communities and countries, doing our part, little by little, but with courage, constancy, and conviction.” We call on all CFHI alumni, whether they be part of IFMSA, AMSA (America), AMSA (Australia), ASDA, NSNA, SNMA, as well as many other groups, or just individual health science students, to read Mr. Guinto article and find the best way to engage in the great effort to achieve heath equity both at home and abroad.
With additional specific yet respectful challenges, Mr. Guinto offers an important contribution to the dialogues around social determinants of health that may require the veterans of this work to take a step back and refocus for a fresh look at what is taken for granted, or thought to be impossible. For it is only that kind of courage that will produce the bold steps needed to truly transform the status quo and bring about the promise of Alma Ata that is still waiting for us all.
The dichotomy between just talking the talk and actually walking the walk to address global health disparities which arise from power, resource, historical and other inequities is exemplified by the Rio conference and the critical reflection of the IFMSA delegation. I think this dichotomy operates on a variety of levels- from the macro global and national perspective to the level of institutions within countries. These inequities (and the agendas, power structure, funding streams, etc that underlie them) also operate between US institutions- including medical schools, universities and the international institutions and communities they engage with.
Unfortunately while many US academic centers are increasing their global health efforts, they run the risk of siphoning off money, resources, and attention from local health providers, institutions, and national/community efforts. Many US/Canadian universities will be gathering next week at the GHEC/CUGH annual meeting in Montreal. I think it is an apt time to really challenge Western (or Northern as it may be) universities to ensure that their global health efforts are truly contributing to capacity building and improved outcomes in the countries they are working in. In this way- are our global health efforts socially-accountable?
US/Canadian personnel are much more expensive to invest in than our counterparts in low/middle income countries, thus investments in Western personnel and projects can be much less cost effective in a strictly monetary sense (and often unsustainable, locally-inappropriate, the potential downfalls are numerous). In addition US institutions run the risk of exporting health care models, research, and drug development agendas which also export the gross inequities in health care outcomes found in the United States (I probably don’t need to remind you that the infant mortality rate in the US for black babies is 13.3/1,000, on par with Thailand and more than double the mortality rate for white babies).
In my experience it has been students, such as those from IFMSA who attended the Rio conference, who tend to ask the difficult questions and try to hold academic institutions and organizations (such as GHEC/CUGH) accountable for their agenda, funding structures, and outcomes. I commend the IFMSA students and encourage students to recognize the powerful position they are in as ‘consumers’ of a costly education system (at least in the US), and as stakeholders who are not beholden to universities as employers (unlike faculty members), jobs producers (unlike states and municipalities), health care providers (unlike patients and community members) or as lifelines (unlike partners in resource-deprived environments).
In addition, I think it is important to recognize institutions who are truly responding to locally-relevant health care inequities, addressing the social determinants of health and training health care providers who are committed to long-term community-engaged health improvements and provision. It is time to recognize that if we train health care providers in environments which minimize or ignore the social determinants of health, then they will perpetuate the status quo. We need to radically change the predominant education and health provision models to truly embrace the importance of social determinants of health and their causes. There are institutions that are already doing this and doing it well. A group of them is represented by THEnet (more info: http://www.healthprofessionals21.org/docs/TransformingMedEd.pdf). These institutions tend to be low in prestige and resources, but high on ideals and action. It’s time to consider what models we are exporting to the rest of the world- are they socially accountable and truly challenging the root causes of health inequities? Or are they perpetuating the status quo while reinforcing power and health disparities?