Under-5 mortality varies from 316 per 1000 live births in Sierra Leone to 3 per 1000 livebirths in Iceland and 5 per 1000 in Japan. Differences in adult mortality among countries are large and growing. The probability of a man dying between age 15 and 60 years is 8.3% in Sweden, 82.1% in Zimbabwe, and 90.2% in Lesotho. Health inequalities also exist within countries – there is a 20-year gap in life expectancy between Australian Aborigines and Torres Strait Islander people than in other Australians.
Michael Marmot (University College London, UK) writes that health status should be a concern to all policy makers, not just those within the health sector. Initiatives that focus on addressing poverty and controlling infectious diseases must not ignore the social determinants. The circumstance in which people live and work are as important.
As a response to this challenge WHO is launching an independent Commission on Social Determinants of Health, which will review evidence, raise debate and recommend policies to improve health on a national and global level. The Commission will be chaired by Professor Marmot and includes global experts on health, education, housing and economics.
Professor Marmot concludes: "Inequalities in health between and within countries are avoidable. There is no necessary biological reason why life expectancy should be 48 years longer in Japan than in Sierra Leone or 20 years shorter in Australian Aboriginal and Torres Strait Islander peoples than in other Australians. Reducing these social inequalities in health, and thus meeting human needs, is an issue of social justice."
In an accompanying commentary, which names all the members of the new Commission, Lee Jong-wook (Director-General, World Health Organisation) states: "Some links between poverty and health seem obvious but in practice they can be complex and paradoxical. As Marmot points out, there are countries with a gross national product of US$10,000, which have a higher average life expectancy than others with a gross national product of over $30,000, and some social groups within the same country have a life-expectancy that is 20 years lower then the national average although their infant mortality rates are low. When the specific causes of such anomalies are known, there is a strong basis for corrective action. Health improves when that action is taken, and health systems are run and financed more effectively."
Contact: Professor Sir Michael Marmot, Department of Epidemiology & Public Health, University College London, 1-19 Torrington Place, London, WC1E 6BT, UK.
T) 020 7679 1717
michael@public-health.ucl.ac.uk
Comment: Dr Lee Jong-wook c/o Christine McNab, Office of the Director General, WHO
T) 41-22-791-4688
mcnabc@who.int
Journal
The Lancet