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The president of Chile and the WHO director-general launch global commission to tackle the "causes behind the causes of ill-health"

On March 18 the President of the Republic of Chile, His Excellency Mr. Ricardo Lagos Escobar and World Health Organization Director-General, Dr. LEE Jong-wook launched the Commission on Social Determinants of Health, a new body to spearhead action on the social causes behind ill-health.

The new Commission includes leading global experts on health, education, housing and economics. Commissioners will work to recommend the best ways to address health's social determinants and safeguard the health of poor and marginalized populations, and to break the "poverty equals ill-health' cycle.

"Social standing plays a big part in whether people will live to be 40 or 80, whether they will be treated for a curable disease, and whether their children survive their fifth birthday. People should not die young because they are poor. This commission will assist countries, no matter how rich or poor, to implement strategies that will help people who are poor and marginalized live longer, healthier lives," said Dr. Lee at the official launch in Santiago, Chile. "This effectively places the needs of the disadvantaged first on the health agenda in the 21st century."

Social determinants are the conditions in which people live and work. They are the "causes behind the causes" of ill-health. They include poverty, social exclusion, inappropriate housing, shortcomings in safeguarding early childhood development, unsafe employment conditions, and lack of quality health systems.

The core of the Commission's work will be to identify, evaluate, adapt and distribute effective strategies to address social determinants, with the aim of supporting governments to scale-up interventions. The Commission will operate for three years from this month.

"A great share of health problems is attributable to social conditions, and this is why the poor carry the greatest burden of ill-health. On a global scale, we must ensure that health policies move beyond exclusively disease-focused solutions and include the social environment," said Commission Chair Michael Marmot. "I am honored to be working with Commissioners of such a high caliber. We will arm policymakers with the best evidence to ensure that poverty does not sentence a person to a shorter, unhealthy life."

Social determinants are intrinsically linked to inequities in health. They help to explain why poor and marginalized people get sick and die sooner than people in better social positions. They are a significant reason behind the world's vast difference in average life expectancy, which ranges from 34 years in Sierra Leone (lowest in the world) to 81.9 in Japan (highest in the world). Social determinants also account for the majority of health inequities within countries. In Indonesia, under-five mortality is nearly four times higher in the poorest fifth of the population than in the richest fifth. In England and Wales, the latest data shows a 7.4 year gap in life expectancy between men in professional occupations and men in unskilled manual occupations (1997-1999 figures).

Some countries—such as Chile, Sweden, and the United Kingdom—are already advancing innovative health programs that address social determinants through a comprehensive inter-sectoral approach. For instance, social welfare programs with benefits conditional on children's school attendance, regular medical check-ups, and other health-promoting actions are helping to reverse the "poverty equals ill-health" trend. Health inequity assessments resulting in the declaration of "health action zones" and health promotion campaigns targeting disadvantaged people are also safeguarding the health of vulnerable groups.

The Commission will identify successful strategies now underway in countries. It will work with national authorities to determine ways to replicate success in other countries and settings. Whereas, to date, the greatest progress in tackling social determinants has occurred in high-income countries, the Commission will focus especially on identifying and promoting policies applicable in developing countries, where the adverse health effects of social determinants are greatest. Overcoming these social barriers represents a prime opportunity to reduce global health inequalities and ensure that health gains are sustainable over time.

The Commission will focus the attention of the world's top experts and researchers on specific social determinants such as urban settings, social exclusion, and employment conditions. These "Knowledge Networks" will push the limits of current information to better define the links between social determinants and health, particularly in developing countries

The Commission on Social Determinants of Health will work with national authorities to incorporate social determinants approaches into efforts to meet the Millennium Development Goals (MDGs). The MDGs recognize the interdependence of health and other social conditions, and present an opportunity to promote health policies that tackle the social roots of unfair and avoidable human suffering.

Frances Baum: Australia Professor of Public Health, Flinders University, Adelaide; Global Steering Committee, People's Health Movement

Monique Bégin: Canada Professor Emeritus, Faculty of Health Sciences, University of Ottawa; former Canadian Minister of National Health and Welfare

Giovanni Berlinguer: Italy Member of European Parliament; Professor of Hygiene, Occupational Health and of Bioethics (Emeritus), University "La Sapienza", Rome

Mirai Chatterjee: India Coordinator of Social Security, Self-Employed Women's Association (SEWA)

William Foege: USA Emeritus Presidential Distinguished Professor of International Health, Emory University, and Gates Fellow; former Director of the US Centers for Disease Control and Prevention

Alireza Marandi: Iran Professor of Pediatrics at Shaheed Behesti University, Tehran; former Minister of Health and Medical Education, Islamic Republic of Iran

Michael Marmot: UK Commission Chair and Director, International Centre for Health and Society, University College London

Hoda Rashad: Egypt Research Professor and Director, Social Research Centre, American University of Cairo; Member of El Shoura Council of the Senate

Amartya Sen: India 1998 Nobel laureate in economics; Lamont University Professor, Harvard University, Cambridge

David Satcher: USA Interim President of the Morehouse School of Medicine, Atlanta, Georgia; former Surgeon General of the USA

Denny Vagero: Sweden Director of the Centre for Health Equity Studies (CHESS), Stockholm University/ Karolinska Institute

Frances Baum is Head of Department and Professor of Public Health at Flinders University and Foundation Director of the South Australian Community Health Research Unit. She is a past National President of the Public Health Association of Australia. She is the regional representative for the People's Health Movement in Australia and the Pacific, and a member of its Global Steering Committee.

Professor Baum is one of Australia's leading researchers on the social and economic determinants of health. Currently, she is the Lead Investigator on a $2.4 million grant entitled the 'Australian Health Inequities Program' funded by the Australian National Health and Medical Research Council.

Professor Baum's numerous publications relate to social and economic determinants research and evaluation in community health, theories of health promotion, Healthy Cities, social capital and health promotion, and the political economy of health.

Dr. Giovanni Berlinguer is a member of the European Parliament. He serves two Commissions: "Environment and Health" and "Culture, Education and Information".

Dr. Berlinguer was responsible for Italy's first National Health Plan under the Economic Development Programme approved by Parliament (1968). He served in the Chamber of Deputies of Italy (from 1972 to 1983) and in the Senate of the Republic (from 1983 to 1992). In the Italian Parliament, he worked for the Commissions on environment and health.

Dr. Berlinguer is currently a member of the International Bioethics Committee of UNESCO (2001-2007) and rapporteur on the project "Universal Declaration on Bioethics". He is one of the founders of Legambiente (the leading environmental association in Italy), and has worked with Italian and Brazilian unions on the relationship between work, health and security.

His Excellency President Ricardo Lagos Escobar is the President of the Republic of Chile.

Dr. Monique Bégin, PC, FRSC, OC, is Professor Emeritus, Faculty of Health Sciences, and Visiting Professor, School of Management, University of Ottawa.

A sociologist, Dr. Bégin was the first woman from Québec elected to the House of Commons. Re-elected three times, she was twice appointed Minister of National Health and Welfare. She remains best known for the Canada Health Act (1984). An academic since she left politics, Dr. Bégin taught in Women's Studies at Ottawa and Carleton Universities before becoming Dean of the Faculty of Health Sciences at University of Ottawa.

Dr. Bégin co-chaired the Royal Commission on Learning of Ontario and served on the International Independent Commission on Population and Quality of Life. A Fellow of the Royal Society of Canada, she received several honorary doctorates in recognition of her contribution to human rights and to public policies. In 1998, she was invested as Officer of the Order of Canada.

Dr. Mirai Chatterjee is Coordinator of Social Security for India's Self-Employed Women's Association (SEWA) - a trade union of over 200,000 self-employed women. She is responsible for SEWA’s Health Care, Child Care and Insurance programs. Before this, she was General Secretary of SEWA for three years and Coordinator of SEWA Health Team for twelve years.

Dr. Chatterjee is on the boards of several organizations in India, including the Friends of Women’s World Banking (FWWB) and HealthWatch. She has been a member of national task forces on social security, health and poverty reduction. Most recently, she was appointed to the National Advisory Council and the National Commission for the Unorganized Sector.

Dr. Manuel Dayrit is Secretary of Health of the Philippines. He is a physician by profession as well as an epidemiologist and health care manager whose expertise lies in the fields of public health, disease control, primary health care and health communications.

Dr. Dayrit served as Assistant Secretary of Health from 1992 to 1997. Before his appointment, he was Assistant Vice-President of United Laboratories, Inc. as well as Vice-President and General Manager of Health Delivery Systems, Inc. Before that, he was Vice-President for Medical Services of Aetna Health Care, Inc.

Dr. Dayrit is a recipient of numerous grants and awards, among them as British Council Scholar (1981-82) and Outstanding Young Scientist in 1990. Dr. Dayrit has authored and co-authored 40 local and international publications on infectious disease control and community health. He has served as President of the Philippine Society of Epidemiology since 1996.

Dr. William H. Foege is Emeritus Presidential Distinguished Professor of International Health, Emory University, and a Gates Fellow.

Dr. Foege, an epidemiologist, worked in the successful campaign to eradicate smallpox in the 1970s. Dr. Foege became Chief of the CDC Smallpox Eradication Program, and was appointed director of the U.S. Centers for Disease Control and Prevention in 1977. In 1984, Dr. Foege co-founded the Task Force for Child Survival, a working group for WHO, UNICEF, The World Bank, UNDP, and the Rockefeller Foundation.

Dr. Foege served The Carter Center between 1986-1992 as its Executive Director, Fellow for Health Policy and Executive Director of Global 2000. Between 1992-1999, he contributed to the Centre's work as a Fellow and as Executive Director of the Task Force for Child Survival and Development. Between 1999-2001, Dr. Foege served as Senior Medical Advisor for the Bill and Melinda Gates Foundation.

Dr. Kiyoshi Kurokawa is President of the Science Council of Japan and the Pacific Science Association. He is also Adjunct Professor, Research Center for Advanced Science and Technology of the University of Tokyo; Adjunct Professor of the Institute of Medical Sciences of Tokai University; and Professor Emeritus of the University of Tokyo.

Dr. Kurokawa has served in many ministerial committees in Japan. He was Science Advisor for the Ministry of Education, Sciences and Culture. He was also member of the Executive Committee and Chair of the Special Committee for Dr.ug Evaluation of the Ministry of Health and Welfare, and the National Health Policy Council of the Ministry of Health and Welfare. He currently serves as Member of the Science and Technology Policy Committee of the Cabinet Office and in additional committees for the Prime Minister’s office.

Dr. Kurokawa was a recipient of Order of Purple from the Government of Japan for Excellence in Academic Achievements in 1999.

Mr. Stephen Lewis is UN Special Envoy for HIV/AIDS in Africa, appointed by UN Secretary General Kofi Annan in 2001. From 1995 to 1999, Mr. Lewis was Deputy Executive Director of UNICEF in New York. He was first appointed as Special Representative for UNICEF in 1990.

In 1997, in addition to his work at UNICEF, Mr. Lewis was appointed by the Organization of African Unity to a Panel of Eminent Personalities to Investigate the Genocide in Rwanda. The 'Rwanda Report' was issued in June of 2000. In 1993, he became coordinator for the Graca Machel study on the "Consequences of Armed Conflict on Children".

From 1984 through 1988, Stephen Lewis was Canadian Ambassador to the United Nations. In this capacity, he chaired the Committee that Dr.afted the Five-Year UN Programme on African Economic Recovery. He also chaired the first International Conference on Climate Change, which Dr.ew up the first comprehensive policy on global warming.

Dr. Alireza Marandi is Professor of Pediatrics at Shaheed Beheshti University, Islamic Republic of Iran.

Dr. Marandi is former two-term Minister of Health (and Medical Education). During his nine years in office, medical education was integrated with health care delivery. In each of the 29 provinces, one University of Medical Sciences was established, thus making the country self sufficient in health human resources. In addition to being Minister, Dr. Marandi also served as Deputy Minister and Advisory to the Minister.

Dr. Marandi is Chairman of the Iranian Society of Neonatologists; the Board of Directors of the Islamic Republic of Iran Breastfeeding Promotion Society; and the National Committee for the Reduction of Perinatal Mortality and Morbidity. He is also the laureate recipient of the United Nations Population Award (1999) and WHO's Eastern Mediterranean Region's Shousha Award (2000).

Michael Marmot, MBBS, MPH, PhD, FRCP, FFPHM, is Director of the International Centre for Health and Society, and Professor of Epidemiology and Public Health, University College London.

Professor Marmot has been at the forefront of research into health inequalities for the past 20 years, as Principal Investigator of the Whitehall studies of British civil servants, investigating explanations for the striking inverse social gradient in morbidity and mortality. He chairs the Department of Health Scientific Reference Group on tackling health inequalities and chairs the National Institute for Clinical Excellence (NICE) Research and Development Committee. He also chairs committees of the BHF and the Wellcome Trust. He was a member of the Royal Commission on Environmental Pollution for six years.

Professor Marmot is a Vice President of the Academia Europaea; a member of the RAND Health Advisory Board; and a Foreign Associate Member of the Institute of Medicine. He was awarded the Balzan Prize 2004 for Epidemiology and was Knighted by HM the Queen in 2000 for services to epidemiology and understanding health inequalities.

Mrs. Charity Kaluki Ngilu is the Minister of Health of Kenya. Before taking office, she was a member of the National Assembly of Kenya representing the Democratic Party.

Mrs. Ngilu was the Social Democratic candidate for the Presidency of Kenya in the 1997 elections. Since 1989, she has been a leader of the Maenbeleo ya Wanawake organization, the national women’s movement.

Before entering politics, Mrs. Ngilu was Managing-Director of a food-manufacturing company in Nairobi.

Dr. Rashad is Director and Research Professor of the Social Research Center of the American University in Cairo. She is member of the Senate (El Shoura Council), one of the two parliamentary bodies in Egypt. She serves on the National Council for Women, which reports to the President of Egypt and is chaired by the First Lady.

Dr. Rashad is a member of the Higher Council for Policies of the National Party. She is also Chair of the Committee on Women in the Policy Secretariat of the National Party. A resource person and consultant to a number of regional and international organizations, Dr. Rashad is currently a Vice-Chairman of the Dutch Development Assistance Research Council (RAWOO).

In the past, Dr. Rashad served on the governing body of the Global Development Network (GDN), and as a member of the Scientific and Technical Advisory Group of the UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction.

Dr. David Satcher is Interim President of Morehouse School of Medicine, National Centre for Primary Care.

Dr. Satcher served simultaneously as United States Surgeon General and Assistant Secretary for Health from February 1998 through January 2001. While in these posts, he spearheaded the development of Healthy People 2010, which included the elimination of racial and ethnic disparities in health as one of its two goals. He also released 14 Surgeon General’s reports on topics that included tobacco and health; mental health; suicide prevention, oral health; sexual health; youth violence prevention; and overweight and obesity.

From 1993 to 1998, Dr. Satcher served as Director of the Centers for Disease Control and Prevention and Administrator of the Agency for Toxic Substances and Disease Registry. Dr. Satcher is a former Robert Wood Johnson Clinical Scholar and Macy Faculty Fellow. He is the recipient of over 40 honorary degrees and numerous distinguished honors. In 2004, he received the “Voice of Conscience Award” from Aetna for his work toward eliminating health disparities. In 2002, he received the “Rhoda and Bernard Sarnat International Prize in Mental Health” and the “City of Medicine Award.”

Dr. Amartya Sen is Lamont University Professor and Professor of Economics and Philosophy at Harvard University.

Dr. Sen has served as President of the Econometric Society, the Indian Economic Association, the American Economic Association and the International Economic Association. He was formerly Honorary President of OXFAM and is now its Honorary Advisor.

Dr. Sen is a Fellow of the British Academy, Foreign Honorary Member of the American Academy of Arts and Sciences, and a member of the American Philosophical Society. Among the awards he has received are the “Bharat Ratna” (the highest honor awarded by the President of India); the Senator Giovanni Agnelli International Prize in Ethics; the Alan Shawn Feinstein World Hunger Award; the Edinburgh Medal; the Brazilian Ordem do Merito Cientifico (Grã-Cruz); the Presidency of the Italian Republic Medal; the Eisenhower Medal; and Honorary Companion of Honour (U.K.). In 1998, Dr. Sen was awarded the Nobel Prize in Economics.

Mrs. Anna Tibaijuka is Executive Director of UN-HABITAT. During her first two years in office, Mrs. Tibaijuka oversaw major reforms that led the UN General Assembly to upgrade the United Nations Centre for Human Settlements to a fully-fledged UN program.

Mrs. Tibaijuka has spearheaded UN-HABITAT’s main objective of improving the lives of slum dwellers in line with the Millennium Development Goals. UN-HABITAT is responsible for leading the effort on Target 11 of those goals: improving the lives of 100 million slum dwellers by the year 2020.

Apart from her UN-HABITAT activities, Mrs. Tibaijuka is dedicated to the role and rights of women in development. The founding Chairperson of the independent Tanzanian National Women's Council (BAWATA), she is also the founding Chairperson of the Barbro Johansson Girls Education Trust dedicated to promoting high standards of education for girls in Africa.

Dr. Denny Vågerö is Professor of medical sociology and Director of CHESS (Centre for Health Equity Studies), a research institute set up by Stockholm University and the Karolinska Institute. He is a member of the Royal Swedish Academy of Sciences, and of its standing committee on health.

Dr. Vågerö's present research focuses on health inequalities and on how health is determined at different stages of life. The on-going Russian public health crisis, and its historical roots, is another of his research interests. Dr. Vågerö has been a key figure in European health inequalities research and is presently Vice-President of the European Society of Health and Medical Sociology.

Dr. Vågerö was involved in the Swedish Government´s Commission on Work, Environment, and Health, where he wrote its report about “jobs exposed to special health risks” and formulated policies to combat them. He has worked in the Swedish Parliament´s Census Commission and is Scientific Advisor to the Swedish National Board of Health and Welfare.

During the three-year mandate of the Commission, the Scientific Secretariat at the University College London will issue updated facts and figures on topics relevant to social determinants of health.

Mortality among children aged under five ranges from between 316 per 1000 live births in Sierra Leone (highest in the world) to three per 1000 in Iceland (lowest in the world). [1]

Life expectancy at birth ranges from 34 years in Sierra Leone (lowest in the world) to 81.9 in Japan (highest in the world). [1]

The probability of a man dying between ages 15 and 60 is 8.3% in Sweden, 46.4% in Russia, 90.2% in Lesotho. [2]

Births attended by skilled health personnel range from 100% in Sweden to 12% in Bangladesh and 6% in Ethiopia. [3]

In Indonesia, under-five mortality is nearly four times higher in the poorest fifth of the population than in the richest fifth. [4]

In the USA, there is a twenty-year gap in life expectancy between the least and most advantaged. [5]

In England and Wales there was a 7.4 year gap in life expectancy between men in professional occupations and men in unskilled manual occupations (1997-1999 figures). [6]

In Australia, there is a 20-year gap in life expectancy between Australian Aboriginal and Torres Strait Islander peoples and the Australian average (1999 – 2001 figures). [7]

The postneonatal (28 days-11 months) death rate for American Indians and Alaska Native people is almost double that of white Americans. [8]

In Northern Ireland among women, those in the lowest social class are 60% more likely to experience some form of neurotic disorder than those in the highest social class. [9]

[1] World Health Organization. The World Health Report 2004: Changing History. WHO, Geneva.

[4] Victora CG, Wagstaff A, Schellenberg JA, Gwatkin D, Claeson M, Habicht JP. Applying an equity lens to child health and mortality: more of the same is not enough. Lancet 2003; 362:233-41.

[5] Murray, C. J. L., Michaud, C. M., McKenna, M. T., and Marks, J. S. U.S. Patterns of Mortality by County and Race: 1965-94. 1-97. 1998. Cambridge,MA, Harvard Center for Population and Development Studies.

[6] Donkin, A., P. Goldblatt, and K. Lynch. 2002. Inequalities in life expectancy by social class, 1972-1999. Health Statistics Quarterly, no. 15:5-15.

[7] Aboriginal and Torres Strait Commissioner, Statistics, Human Rights and Equal Opportunities Commission. A statistical overview of Aboriginal and Torres Strait Islander peoples in Australia, 2003).

[8] "Health, United States, 2004", US Department of Health and Human Services (2202 Figures).

[9] Ministry for health, social services, and public safety. Investing for Health. Belfast: Northern Ireland Assembly, 2002. http://www.dhsspsni.gov.uk/publications/2002/investforhealth.asp.

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