Equity – WMA – The World Medical Association

Adopted by the 74th WMA General Assembly, Kigali, Rwanda, October 2023

PREAMBLE

Understanding that early life experiences can impact health in later life and that the major drivers of health lie outside healthcare is essential to direct action to improve health where it is most needed. This is supported by Paragraph 11 of General Comment No. 14 of the Committee on Economic, Social and Cultural Rights, and by Article 24 of the Convention on the Rights of the Child, both of which recognise the importance of the role of the state in providing good living standards and healthy environments for their citizens. The WMA Declaration of Oslo on Social Determinants of Health and WMA Statement on Sustainable Development acknowledge that conditions, including environmental conditions, in which people are born, grow, are educated, live, work and age (sometimes termed “social” or “wider” determinants”) are major influences on healthy life expectancy, quality of life[i] and the magnitude of health inequalities.

Human health is a cardinal component of a society’s ability to prosper; declining human health adversely affects a nation’s productivity, and therefore a nation’s economy, which in turn limits many actions to prevent ill health and deliver healthcare to treat illness.

Therefore, in addition to health practitioners, many actors share in the responsibility to preserve and improve human health. For example, the ability to influence these wider determinants of health are spread across multiple government departments.

A cardinal challenge in striving for improved population health lies in the fact that decision makers tend to focus on short-term economic indicators, such as Gross Domestic Product (GDP)/Gross National Income (GNI), as the primary driver of government policy.

Investment in the health of the population has a long-term positive economic impact, but the focus on GDP/GNI often acts to the detriment of health. Many activities that increase GDP/GNI, such as smoking and the use of fossil fuels, damage health. Conversely, activities such as breastfeeding and parenting, which improve health, are not measured in GDP.

RECOMMENDATIONS

Recognizing this, the World Medical Association and its constituent members on behalf of their physician members, call on Governments to:

Recognise that well-functioning health systems accessible to all are important, but the principal determinants of health and wellbeing lie outside healthcare;
Prioritise population health and wellbeing in government policy decisions and incorporate metrics of population health and wellbeing into measures of national progress and performance;
Acknowledge that securing and safeguarding population health and wellbeing are crucial to a sustainable future;
Promote equity in health and address inequalities in whatever sphere they exist, by supporting actions that address the wider determinants of health.

[i] WMA Declaration of Oslo on Social Determinants of Health – WMA – The World Medical Association

Adopted by the 73^rd WMA General Assembly, Berlin, Germany, October 2022

PREAMBLE

Racism is rooted in the false idea that human beings can be ranked as superior or inferior based on inherited physical traits. This harmful social construct has no basis in biological reality; however, racist policies and ideas have been used throughout history and are still used to perpetuate, justify, and sustain unequal treatment.

Despite the fact that races do not exist in the genetic sense, in some cultures racial categories are used as a form of cultural expression or identity, or a means of reflecting shared historical experiences. This is one aspect of the concepts of “ethnicity” or “ancestry”.

Acknowledging that the words “race” and “racial” have different connotations in different linguistic and cultural contexts, these terms are used throughout this document to denote socially constructed categories and not a biological reality.

While the false conflation of racial categories with inherent biological or genetic traits has no scientific basis, the detrimental impact racial discrimination has on historically marginalized and minoritized communities is well documented. The experience of racism in all its forms – for example, interpersonal, institutional, and systemic – is recognized as a social determinant of health and a driving force behind persistent health inequities, as noted in the WMA Declaration of Oslo on Social Determinants of Health. These inequities can be compounded by other factors like national origin, age, gender, sexual orientation, religion, socioeconomic status, disabilities, and more. Individuals subjected to racism are often also affected negatively by other social determinants of health.

Racially motivated violence and overt bias, housing and employment discrimination, education and health care inequity, environmental injustice, daily microaggressions, pay gaps, and the legacy of intergenerational trauma experienced by those who are subjected to racism are just some of the many factors that may impact health and illustrate why racism poses a serious threat to public health. These and other structural barriers faced by historically marginalized communities can lead to disproportionate rates of infant and maternal mortality and certain illnesses, mental health struggles, poorer health outcomes, as well as shorter life expectancies.

Racism in medicine

With the WMA Declaration of Geneva, the Physician’s Pledge, the physician vows to respect the dignity of all patients, to respect teachers, colleagues, and students, and to “not permit considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social standing or any other factor to intervene between [the physician’s] duty and [the] patient.”

Nonetheless, racism in all its forms also exists in medicine throughout the world and has a direct impact on patients and their health. Systemic racial disparities in access to care and health resources at a global and local scale can translate to disparities in health outcomes.

At the interpersonal level, prejudice and stereotypes held and acted upon by medical professionals can lead them to be reluctant to see patients or dismissive of symptoms from patients from marginalized communities, which can result in suboptimal communication, as well as inappropriate or delayed treatment. Racism can hinder or undermine the foundation of trust that is essential to a successful patient-physician relationship.

Physicians from marginalized communities also face racism from patients, other physicians, and health professionals. This can take the form of bullying, harassment, and professional undermining in the workplace. These distressing experiences may not only impact the physician’s health and well-being, but consequently the physician’s performance. They may also leave marginalized physicians less confident to raise concerns about patient safety for fear of being blamed or suffering adverse consequences. Large and growing racial disparities in adequate professional treatment and advancement opportunities can have an impact on physicians’ career trajectories.

Furthermore, systemic racism can create barriers to entry to the medical profession for certain historically excluded groups, leading to a lack of representation, which may contribute to adverse health outcomes for patients. These barriers are caused by a variety of factors, including implicit and explicit bias in admissions and hiring practices, a dearth in inclusive professional environments, and lifelong racial disparities in educational funding.

A medical profession that is representative of the population is crucial to addressing health disparities among patients.

Racism in medical education

In medical education, implicit and explicit bias not only impact the admissions process, but also the curriculum, faculty development, and how marginalized students are treated and assessed. Non-inclusive and harmful learning environments can leave minoritized students with an increased risk of anxiety and depression. In addition, learning materials and curricula often do not reflect a diversity of experiences, imagery, and disease presentations and fail to address the issue of racism in medicine head-on.

Racism in medical research / medical journals

Structural racism also influences participation and therefore inclusivity in medical research. Historical examples of unethical experimentation or research in the absence of informed consent on marginalized communities have led to a high level of mistrust of the medical establishment. On the other hand, exclusion of marginalized groups from clinical trials results in a lack of data about how certain drugs, treatments, or health conditions might impact individuals in those groups. A lack of racial data transparency can lead to a lack of understanding about how racial disparities lead to health inequities. It can also jeopardize the potential of artificial intelligence to reveal and override biases in medicine. Algorithms are only as inclusive as the health and technology professionals who create them.

Furthermore, medical journals – the gatekeepers of evidence-based research – have generally been remiss in addressing the issue of racism and its impact on health inequities, as well as in addressing underrepresentation among journal decision makers and authors.

DECLARATION

Therefore, the World Medical Association

condemns unequivocally racism in all its forms and wherever and whenever it occurs;
declares racism to be a public health threat;
acknowledges that racism is structural and deeply engrained in health care;
asserts that racism is based on a social construct with no basis in biological reality and that any effort to claim superiority by exploiting racist assumptions is unethical, unjust, and harmful;
recognizes that the experience of racism is a social determinant of health and responsible for persistent health inequities;
commits to actively promote equity and diversity in medicine and to strive for an inclusive and equitable health environment.

RECOMMENDATIONS

The WMA urges its members and all physicians to:

enact the above-mentioned declaration in their own organizations;
acknowledge the harmful impact of racism on the health and well-being of marginalized communities and act upon it;
promote equitable access to health and other societal resources locally, nationally and on a global scale;
commit to actively work to dismantle racist policies and practices in health care and advocate for antiracist policies and practices that support equity in health care and social justice;
implement organizational and institutional changes to foster diversity in the medical profession and the organizations that support it;
support and, where possible, implement admissions and curriculum changes in medical education that promote inclusivity and raise awareness about the harmful impact of racism on health;
promote just and safe learning environments in medical education;
promote equitable access to quality medical and public health education;
center the experiences of physicians from underrepresented communities to ensure the visibility of role models and foster a feeling of inclusivity and empowerment among prospective students from historically marginalized communities;
ensure safe, supportive, and respectful work environments for all physicians, including those from historically marginalized communities;
establish channels for physicians and students of medicine to safely report cases of racially motivated harassment or bias;
enact disciplinary measures against perpetrators of racial harassment or bias in the medical profession and implement measures to prevent such harassment and discrimination, to protect those who suffer from it and to eliminate it from the medical field;
take measures to identify research gaps and promote evidence-based research on the health impact of racism;
encourage medical journals to amplify the voices of medical researchers and health experts from underrepresented and historically excluded communities;
make all efforts to promote representation in ethically conducted clinical trials in accordance with the WMA Declaration of Helsinki as a means of advancing health equity;
promote further research on the impact of racism in the health system.

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

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.
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.
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.
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.
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/