WMA Declaration of Oslo on Social Determinants of Health

Adopted by the 62^nd WMA General Assembly, Montevideo, Uruguay, October 2011,
the title (Statement to Declaration) changed by the 66^th WMA General Assembly, Moscow, Russia, October 2015
Amended by the 71^st WMA General Assembly (online), Cordoba, Spain, October 2020

PREAMBLE

The social determinants of health are the conditions in which people are born, grow, are educated, 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. Social determinants of health also include the impact of racism and discrimination, not just from an individualized or interpersonal perspective, but from structural and institutional perspectives.

While health care aims to cure and restore 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 inequities.

Achieving health equity for all requires strong commitment from governments, the health care sector, health professionals and the international community among others. The UN Sustainable Development Goals (SDG)^[1] specifically aims to ensure healthy lives and promote well-being for all at all ages (goal 3), to ensure inclusive and equitable education and promote lifelong learning opportunities for all (goal 4) and to reduce inequality within and among countries (goal 10). In the WMA Statement on Access to Health Care, the WMA stresses the importance of health care access for all and suggests ways to act on inadequate access and health inequalities. The WMA further supports and promotes the introduction of adequate Universal Health Coverage in all countries. Universal Health Coverage will improve access to appropriate health care for all and thus promote awareness of and action on the social determinants of health.

Historically, the primary role of physicians 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 lifestyle 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 lifestyle are all causes of illness. A social determinants approach addresses the causes of these causes; and in particular how they contribute to social inequities in health. This approach focuses not only on individual behaviors but seeks to address the social and economic circumstances that give rise to premature poor health, throughout the life course. The voice of the medical profession has been and continues to be important in tackling these causes of the causes.

In many societies, unhealthy behaviors follow the social gradient: the lower in the socioeconomic hierarchy, the higher the rate of smoking, the worse the diet, and the less the physical activity. Central to the issue of addressing social determinants of health is the close interrelation between poverty and illness. A major, but not the only, cause of the social distribution of these causes is level of education. Structural inequity can also make access to healthy food difficult.

Specific examples of addressing the causes of the causes are: regulating the price and availability of alcohol, which are key drivers of alcohol consumption; and promoting tobacco taxation, package labeling, bans on advertising and smoking in public places, all of which have had demonstrable effects on tobacco consumption.

There is a growing movement globally that seeks to address gross inequities in health and length of life through action on the social determinants of health. This movement has involved the World Health Organization, several national governments, civil society organizations, and academics. Solutions are being sought and knowledge shared. Physicians need to be well informed about the implications of perpetuating inequalities and be willing to participate in this debate. They can be advocates for action on social conditions that have important effects on health and for strengthening of primary care and public health institutions. The medical profession can contribute significantly to public health, including through working with other sectors to find innovative solutions.

RECOMMENDATIONS

1. The WMA and National Medical Associations should take an active role in combating social and health inequities and barriers to obtaining health care, striving to enable physicians to provide equal, high quality health care to all. Adequate Universal Health Coverage in all countries should be a core objective as it will help reduce health inequity.
2. The WMA can add significant value to the global efforts to address the social determinants of health by helping physicians, other health professionals and National Medical Associations to understand what the emerging evidence shows and what works in different circumstances. WMA can call on physicians to lobby more effectively within their countries and across international borders and ensure that medical knowledge and skills are shared.
3. The WMA should help to gather data on successful initiatives and help to engage physicians and other health professionals in sharing experiences and implementing new and innovative solutions.
4. The WMA should work with National Medical Associations to promote education to medical students and physicians on health inequity and the social determinants of health, and to put pressure on national governments and international bodies to take the appropriate steps to minimise health inequity and these root causes of premature poor health.
5. The WMA and National Medical Associations should encourage governments and international bodies to take action on and implement specific policies and tools addressing health inequity and the social determinants of health. Some governments have taken initial steps to reduce health inequity by taking action on the social determinants of health; local areas have drawn up plans of action; there are good examples of general practice that work across sectors improving the quality of people’s lives and hence reduce health inequity. The WMA should gather examples of good practice from its members and promote further work in this area.

[1] https://www.un.org/sustainabledevelopment/sustainable-development-goals/