[Sir Michael's blog] SDH, Structural adjustment and the Zambian Medical Association

One in every 13 Zambian children does not survive to their fifth birthday; in Iceland it is one in 500. Of a population of 14.5 million Zambians, 2 million have no access to sanitation facilities. Practicing medicine under these circumstances is a challenge – not least because of shortage of human resources for health. 

Given this background I was particularly delighted when Dr Mujajati Aaron, President of the Zambia Medical Association, came forward and said he wanted to be part of my call (as President-elect of the World Medical Association, WMA) to National Medical Associations to rise to the challenge of social determinants of health and health equity. Dr Mujajati Aaron invited me to speak at the annual meeting of the Zambia Medical Association – the theme: the role of the Government and Zambia Medical Association in addressing social determinants of health and increasing health equity in Zambia.


Aaron began by asking why this theme? It sounds like social science not medical science. But then he cited figures such as those above and said we cannot solve these problems without action on SDH.

Dr Mzukisi, Chair of the South African Medical Association, said it was a pleasure to come to Zambia not pursued by the South African authorities. He was a great ally when he claimed that the WMA had recognised the importance of shifting from health care to health.

I felt as I do when hearing a much loved piece of music when Jairos Miti discussed early child development. He said we must look at conditions in which parents live as determinants of how parents care for children. Such examination will lead to understanding of children’s health and development.

I was very much taken with the presentation of Gabriel Banda, a former assistant to Kenneth Kaunda, first president of independent Zambia. Again sweet music intellectually, as he talked the language of social determinants of health. He said that basic needs bear closely on people’s health. Basic needs include: water, sanitation, food, shelter, energy, education and learning, livelihood and incomes (of individuals, households, and nations), communication, freedom from violence, safe natural environment and health care. And health can affect basic needs, although he focussed on social causation.

Zambia’s history, he said, is an illustration of what we are seeing in Greece now: of how austerity can damage a country and its population’s health. In his account, Zambia got into financial difficulties that led to a familiar deadly dance with the IMF. In the 1980s if a country was in financial trouble and appealed to the IMF for help with its debts, there was a standard response: we’ll help with debts and you pursue structural adjustment programmes (SAP).

SAP sought to commercialise and marketise provision of goods and services, reduce public spending through spending cuts, removal of subsidies, and increase in tax income, privatisation of public enterprises and liberalisation of finances. Spending cuts involved retirement of workers in the public service and reduction of the retirement age. Institutional memories and capacities declined in health and other fields.

Mr Banda said SAP wanted to make everything business and business everything. By his account, the austerity that SAP brought completely undermined the country’s advances, since independence, in meeting basic needs. The population did not like it. There were riots and people died. In 1987 President Kaunda said: that’s it. No more austerity; we will not continue to implement SAP. But that meant Zambia could not pay its debts. Sounding like Greece? Sanctions brought Zambia to heel and the country was forced to go back to the IMF and World Bank, and continue with liberalisation and diminution of services. Arguably, this hampered the country’s ability to deal with the new HIV/AIDS epidemic.

Given the IMF’s history, as exemplified in Zambia, the fact that the IMF is saying that in Greece, the EC and European Bank are imposing terms that are too tough, tells us either that IMF has learnt something from their grisly record, or that the EC and European Bank have learnt nothing at all from the history of the devastating effects of austerity.

I came away from my meeting with the Zambian Medical Association very encouraged. (But then that is my default state.) They have limited financial resources, the Medical Association has no paid staff, but they would really like to be part of a network of National Medical Associations that are dealing with social determinants of health. They see it as an absolute necessity.

Oh, and Dr Mujajati Aaron said: if you haven’t seen Victoria Falls, you haven’t been to Zambia. I have and I have. Here’s the evidence: 


WMA President-Elect, Professor Sir Michael Marmot is Director of the UCL Institute of Health Equity, which works to reduce health inequities through action on the social determinants of health. He will be inaugurated as WMA President in October 2015. Please visit his blog for more reading!