Adopted by the 62nd WMA General Assembly, Montevideo, Uruguay, October 2011
and the title (Statement to Declaration) changed by the 66th WMA General Assembly, Moscow, Russia, October 2015
The social determinants of health are: the conditions in which people are born, grow, live, work and age; and the societal influences on these conditions. The social determinants of health are major influences on both quality of life, including good health, and length of disability-free life expectancy. While health care will attempt to pick up the pieces and repair the damage caused by premature ill health, it is these social, cultural, environmental, economic and other factors that are the major causes of rates of illness and, in particular, the magnitude of health inequalities.
Historically, the primary role of doctors and other health care professionals has been to treat the sick – a vital and much cherished role in all societies. To a lesser extent, health care professionals have dealt with individual exposures to the causes of disease – smoking, obesity, and alcohol in chronic disease, for example. These familiar aspects of life style can be thought of as ‘proximate’ causes of disease.
The work on social determinants goes far beyond this focus on proximate causes and considers the “causes of the causes”. For example, smoking, obesity, alcohol, sedentary life style are all causes of illness. A social determinants approach addresses the causes of these causes; and in particular how they contribute to social inequalities in health. It focuses not only on individual behaviours but seeks to address the social and economic circumstances that give rise to premature ill health, throughout the life course: early child development, education, work and living conditions, and the structural causes that give rise to these living and working conditions. In many societies, unhealthy behaviours follow the social gradient: the lower people are in the socioeconomic hierarchy, the more they smoke, the worse their diet, and the less physical activity they engage in. A major, but not the only, cause of the social distribution of these causes is level of education. Other specific examples of addressing the causes of the causes: price and availability, which are key drivers of alcohol consumption; taxation, package labeling, bans on advertising, and smoking in public places, which have had demonstrable effects on tobacco consumption. The voice of the medical profession has been most important in these examples of tackling the causes of the causes.
There is a growing movement, globally, that seeks to address gross inequalities in health and length of life through action on the social determinants of health. This movement has involved the World Health Organisation, several national governments, civil society organization, and academics. Solutions are being sought and learning shared. Doctors should be well informed participants in this debate. There is much that can happen within the practice of medicine that can contribute directly and through working with other sectors. The medical profession can be advocates for action on those social conditions that have important effects on health.
The WMA could add significant value to the global efforts to address these social determinants by helping doctors, other health professionals and National Medical Associations understand what the emerging evidence shows and what works, in different circumstances. It could help doctors to lobby more effectively within their countries and across international borders, and ensure that medical knowledge and skills are shared.
The WMA should help to gather data of examples that are working, and help to engage doctors and other health professionals in trying new and innovative solutions. It should work with national associations to educate and inform their members and put pressure on national governments to take the appropriate steps to try to minimise these root causes of premature ill health. In Britain, for example, the national government has issued a public health white paper that has at its heart reduction of health inequalities through action on the social determinants of health; several local areas have drawn up plans of action; there are good examples of general practice that work across sectors improve the quality of people’s lives and hence reduce health inequalities. The WMA should gather examples of good practice from its members and promote further work in this area.