After Rio, where to?

The IFMSA delegation at the World Conference on Social Determinants of Health

In this commentary, Renzo Guinto analyzes the aftermath of the World Conference on Social Determinants of Health held last October 19-21, 2011 in Rio de Janeiro, Brazil, and reminds all stakeholders, including IFMSA, that we cannot fail the second time around. More articles about “Youth and the Social Determinants of Health” in Medical Students International 25


Ramon Lorenzo Luis R. Guinto

The road, or rather the flight to Rio de Janeiro, Brazil is the longest I ever took. Two days to the destination, two days on the way back, but at the end of the nine-day sojourn, I can say it was all worth it. As someone who lives in Asia, you only get to South America once in a blue moon. I feel blessed because this trip was not just my first to the continent, but the main object was historic and inspirational.

For three days, more than a thousand public health experts coming from governments, UN agencies, academia, and civil society gathered at the World Conference on Social Determinants of Health to discuss how global health equity can be achieved. Unfortunately, the road towards it is not as smooth as my flight to the land of samba.

To illustrate the gravity of the situation, I turned to my reference materials. In Southeast Asia alone, glaring inequalities in maternal mortality rates can be noted: 339 out of 100,000 mothers in Laos, 229 in Indonesia, 84 in the Philippines, and only 16 in Singapore (1). On the other hand, when referring to inequities within countries, the classic example in social determinants literature is that of Glasgow in Scotland. Despite it being a city in a rich industrialized country, there exists a 30-year gap in life expectancy between the city’s most and least advantaged communities (2).

Clearly, there are forces that shape these inequities, and biomedicine realized that genetic and other individual factors have little to do with these gross inequalities at the population level. Two hundred years ago, the German physician Rudolf Virchow (3), who is regarded as the Father of Social Medicine, had already hit the nail at the head when he asked: “Do we not always find the diseases of the populace traceable to defects in society?”

It is therefore with this background that the World Conference was organized, with the intent of engaging “high level political support to make progress on national policies to address social determinants of health to reduce health inequities” (4). Moreover, the conference is an off-shoot of the 2008 report of the World Health Organization (WHO) Commission on Social Determinants of Health (5), which synthesized evidence from around the world illustrating how social determinants of health (SDH) – the conditions in which people are born, grow, live, work and age – bring about avoidable health inequities within and between countries.

The Commission, headed by renowned British social epidemiologist Professor Sir Michael Marmot, also listed down proposals for action on social determinants, which were summarized into three overarching recommendations: 1) the improvement of daily living conditions; 2) tackling the inequitable distribution of money, power, and resources; and 3) measuring and understanding the problem and assessing the impact of action.

Mixed views

The overall outcome of the conference itself can be described as equivocal, as it has drawn mixed views from different sectors. Some saw the conference as a major step towards renewing the global health equity debate, even being tagged as the new “Alma Ata,” in reference to the landmark 1978 Alma Ata Declaration on Primary Health Care (6). Although not explicitly using the phrase “social determinants of health,” the Declaration was the first international document that recognized gross health inequities as “politically, socially, and economically unacceptable” and which had called for intersectoral action and international collaboration towards the achievement of “health for all by the year 2000.”

However, others noted the diminished ambition of this event, especially of its main product – the Rio Political Declaration on Social Determinants of Health (7). This new document laid out commitments and recommendations from the over 100 governments present, capturing the five themes of the conference – governance, participation, the role of the health sector, alignment of global priorities, and monitoring of progress (8). However, other groups, especially civil society, criticized the document as being silent about some fundamental and crucial subjects such as trade as a social determinant of health, the links between social determinants of health, climate change, and sustainable development, and ultimately the redistribution of power, money, and resources, which has been the clarion call of the Commission’s Report since its publication.

Despite the document stepping on middle ground, there are still reasons to celebrate. The World Conference provided a venue for academics and civil society to gather and combine their voices for the revival of the health equity debate. In recent years, especially since the failure of Alma Ata in 2000, international networks such as the People’s Health Movement (9) have created their own platforms for global discussion on health equity and social justice, but none of these are either initiated or actively participated in by the WHO or any other intergovernmental agency.

The Rio conference, on the other hand, was the brainchild of WHO as requested by Member States through a World Health Assembly resolution in 2008 (10). Thus, this event served as an opportunity for meaningful dialogue between governments and UN agencies on one hand and civil society and academia on the other. Civil society groups were even allowed to organize their own side events, which further contributed to the solidifying of existing international and regional networks.

The People’s Health Movement (PHM) in particular also made use of this rare chance to concretize their dismay towards the Rio Political Declaration. Considered as the largest network of health activists calling for the revival of Alma Ata principles and of the vision of “health for all,” PHM came up with its own “Alternative Rio Declaration” (11). In this document, PHM listed down specific and concrete measures to address global health inequities such as the use of progressive taxation, reducing the clout of financial capital, use of health impact assessments in trade agreements, reconceptualization of development aid as an international obligation, and democratization of global governance, to name a few. The group’s statement somehow reflects the dissatisfaction towards the status quo, embodied by the ongoing Occupy protests which have spread from Wall Street to across the globe (12).

PHM and civil society at large even infiltrated the closing panel of the conference in a grand manner. One of its members, Dr. David Sanders from the University of Western Cape in South Africa, lambasted the Rio Declaration’s silence on unfair trade in food production and the “brain robbery” of health workers by Northern countries. Such fearless statements triggered the only standing ovation during the three-day conference.

Speaking the SDH Language

Another positive sign that we have observed during the conference is that some governments are now starting to speak the language of social determinants. Before the World Conference, I have previously attended a few meetings on social determinants. It is evident that despite the publication of the Commission’s Report and the wide availability of resources on social determinants, there remains diversity in understanding of the concept, ranging from promoting healthy lifestyle among local politicians (hoping that their good health will translate into good policies) to addressing global determinants such as climate change and the financial crisis.

In Rio, it seemed that some countries have already grasped the idea, while a few were actually fairly advanced in their understanding and implementation of action on social determinants. For example, South Australia boasts its “Health in all Policies” approach which enables other departments beyond the health sector to apply a “health lens analysis” to their policies and projects (13). Thailand instituted a National Health Assembly in an attempt to democratize health governance and allow participation from all sectors in priority setting and decision making (14). Finland even went on by declaring the welfare state as the best medicine against growing health inequities (15).

Despite this, albeit minor, victory, it is important to keep in mind that no matter what ministers of health declare in international conferences like this, most of the crucial decisions governing social determinants of health are under the jurisdiction of other domestic leaders such as ministers of finance or labor or even the prime ministers and presidents themselves, none of whom are present in the conference (16). The same can be said of the international arena – key actors such as the United Nations, World Bank, and World Trade Organization were also absent in Rio. Expressing a commitment during the World Conference is just half the battle – advocating for action to other sectors at home still remains the major formidable task.

Consistency is key

Even after the World Conference, health equity activists should also keep an eye at the World Health Organization. Observers of global health history clearly understand WHO’s tendency to switch themes from time to time, depending on the tune of some donor countries, influential NGOs and academic think tanks, and even private donors.  If WHO is really serious about “closing the gap in our generation” as the Commission’s Report’s title says, then the organization should remain consistent in its policy pronouncements from the Director-General to its country offices, and the SDH framework should be reflected in all its implemented programs, whether on HIV-AIDS to NCDs.

It is saddening that “social determinants” or “health equity” is not mentioned in the candidature current WHO Director-General Dr. Margaret Chan, who is now seeking another five-year term (17). Surely, as the only candidate for the post, she will be given another chance to lead WHO and to push forward the health equity agenda. Not only will it complement her agenda towards stronger health systems and a reformed WHO, this work on social determinants, and not her present focus on NCDs or any other vertical disease-oriented program, could also become her enduring legacy to global health.

Finally, again speaking of consistency, governments should start realizing – and realizing through the hard way – that business as usual is not an option for our global health future.

Health equity at the heart of IFMSA

Finally, this commentary will not end without looking at the role of the International Federation of Medical Students’ Associations (IFMSA) in this ongoing global debate. In 2011, IFMSA made health equity and social determinants of health a key policy focus (16), commencing with the passing of a policy statement on the matter in Jakarta (18). For months, the Small Working Group on Health Inequities under the Standing Committee on Public Health energized the discussions, both online and in actual meetings and consultations, which then culminated in a magnetic presence in all standing committee and regional sessions, and an overwhelmingly-attended forum with Sir Michael Marmot during our 60th anniversary conference. During that week, “SDH” became the mantra of Copenhagen.

Now, after Rio comes Accra, Ghana, which hosts IFMSA’s March Meeting this 2012, revolving around the theme of social determinants of health. This assembly is accompanied with a pre-General Assembly workshop on SDH and a presentation to the plenary on the proposed Global Health Equity Initiative. All these, I believe, will set the tone for IFMSA’s future.

This “SDH” capital that has been amassed in 2011 should not be put to waste, and I hope the future generations of IFMSA leaders and members will not cease talking about it and doing something about it. I recall someone telling me, “There should be no SDH-related activity in future meetings after Ghana.” I beg to disagree – the discussions should continue beyond Accra – as we already triumphantly did from Jakarta to Copenhagen to Rio.

We should remember that for every missed opportunity to discuss and to act on this crucial issue of our times, someone has to pay the price. Global health equity is not merely a theme for a conference, but a real global challenge that a truly global and truly health-committed organization should tackle in the 21st century.

Our aim is to create a global movement, not to make it a topic for a session. Every General Assembly has a new breed emerging, and therefore every General Assembly should not stop sowing the seeds of health equity into each IFMSA generation.

Medical students as social determinants of health

Looking at particular social determinants, I hope to see IFMSA spark a discussion about the management of human resources for health, including medical students who will soon become physicians, as an important global social determinant of health (19). I already mentioned about the “brain robbery” of health workers by developed countries from developing countries being a hot topic in Rio. It cannot be denied that medical students and young doctors play a vital part in this ongoing process.

As an international federation of medical students, it is our obligation to look into this issue, not just in medical education, which is only one segment of the whole health human resource production process, but also in the recruitment, certification, deployment, quality assurance, and compensation of physicians and health workers. These processes, in turn, are inextricably intertwined with issues concerning global trade, human migration, and global health governance, to name a few.

For example, a closer look into our professional exchange programs would enable us to understand if such programs actually promote global health learning for meeting local needs, or instead lead to global health inequalities by encouraging young physicians to move from their places of origin and training to new locations, which are often more lucrative but where they are needed least. I am sure many of our members will feel uncomfortable about this matter, but if we truly want to close the health gap, this one cannot be ignored.

Time to Become Revolutionary Doctors

Sometimes, no matter how well-informed, updated, and passionate I am about the issue of social determinants and health equity, I feel that I still do not have the exact answers. But also I think what is important now is that we medical students have already started talking about it – that we condemn the inequalities in health, that we understand the root causes of ill health and health inequities, and that we seek for ways to change the status quo. The members of the IFMSA delegation even expressed this desire and optimism in a statement distributed during the final day of the World Conference:

“We medical students 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.” (20)

We therefore invite every member of this Federation to embrace this commitment, now as medical students, and beyond, when we become doctors of the future, until we see the day when, in the words of former UN secretary-general Kofi Anan, “health will finally be seen not as a blessing to be wished for, but as a human right to be fought for.”

This year and beyond, we, IFMSA, must keep reminding the global health world that we, medical students and young people at large, are not mere observers or beneficiaries, but are key players in this global movement. We will inherit this current global health regime sooner rather than later, and so we must exhaust all the platforms within our reach not tomorrow but now.

So, after Rio, where to? For IFMSA and medical students worldwide, it is time to, quoting from a new book entitled Revolutionary Doctors, “combine the humanitarian mission of medicine with the creation of a just society” (21). Realizing this requires an unwavering commitment to social determinants and “health for all.”

About the Author

A final year medical student at the University of the Philippines Manila, Ramon Lorenzo Luis R. Guinto (Renzo) is the facilitator of the SCOPH Small Working Group on Health Inequities and head of the IFMSA delegation in the World Conference on Social Determinants of Health. He is also the Regional Coordinator for the Asia-Pacific of IFMSA and immediate past president of the Asian Medical Students’ Association-Philippines, the IFMSA NMO in the Philippines.




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