A landmark document, the Alma Ata declaration (1978) decreed that ‘Health for All by 2000 AD' was an achievable goal and positive health should be universally recognised as a fundamental right. The document also talked of a “New International Economic Order” that would reduce the gap between the developed and the developing countries.
The declaration was confident that “an acceptable level of health for all the people of the world by the year 2000 can be attained through a fuller and better use of the world's resources, a considerable part of which is now spent on armaments and military conflicts.” It specifically recommended the diversion of resources from such destructive uses to the strengthening of public health services. The basic orientation was state-sponsored health care under the guidance of WHO/UNICEF and with increased funding.
But the irony is that the world kept moving in the direction just opposite to what was set out in the Alma Ata declaration. The rich-poor divide widened, and the global spending on armaments and nuclear weapons increased, taking away more of the much-needed resources from primary health care. International bodies like the World Bank started prodding governments to cut down expenditure on public health services. And the result is there for all to see. ‘Health For All by 2000 AD' is reduced to a footnote in text-books on preventive medicine.
It was in this context that the WHO commissioned a study on social determinants of health and the outcome was a comprehensive document, titled “Closing the Gap in a Generation: Health Equity through Action and Social Determinants of Health 2008” (CSDH). Amartya Sen was one of the Commissioners involved in preparing it. This book is a collection of papers presented at an international conference that critically examined the report.
Asserting that health is “not a tradable commodity,” the CSDH report emphasises that correcting the inequities in public health is a “matter of social justice” and “an ethical imperative.” It is confident that health inequities can be bridged in a generation, if all the stakeholders take it up seriously.
“The central message,” according to Sir Michael Marmot, chairman of the Commission, is that “a toxic combination of poor social policies, unfair economic arrangements and bad politics is responsible for most of the avoidable health equities we see in the world today.”
While Kavitha Ramakrishnan and Rama Baru focus on the role of the state in delivering health equity goals, Kohei Wakimura looks at the report from the perspective of socio-economic history, using the experience of the malaria control programme to support his position.
Particularly interesting is the paper by Anne-Emmanuelle Birn, who draws liberally from the public health efforts in France, Prussia, and England. She proposes a table of alternative milestones in the march towards health equity, which merits serious study.
Simon Szreter traces a common thread in the approaches of the Alma Ata declaration and the CSDH report. His emphasis on “creating free and accessible, safe and secure civil registration systems of identity at birth for the world poor” is of vital importance to the third world countries, many of which do not have a credible registration system.
Cristiana Bastos uses “Brazilian responses to AIDS” to buttress her argument that social awareness and concerted action worldwide are imperative for any effort at reducing global health inequity to succeed.
Francesca Perlman, who explores the causes of health inequity, offers solutions that vary from country to country and discusses their implications for policy-making and monitoring mechanisms.
Andrew Gibbs and Catherine Campbell argue that political will and community empowerment are a must if the committed objectives of the CSDH report are to be fulfilled. The book should serve as a very useful guide to public health activists — planners, strategists, theoreticians, and workers at the grassroots.