Written by: D.I. Sotomayor-Irizarry
Edited by: Line Bayer (@lbager87)
Topics such as poverty, education, work conditions and infrastructure, among others are roots of multiple social inequalities. These issues are highly political because they can be changed and are the base of everyday political discussions at national and global levels. I find it both interesting and concerning that political stakeholders rarely link the issues that cause social inequities with health inequities, despite the fact that the correlation between both is well acknowledged and understood. Public health evidence has been disregarded in many political contexts and health has been simplified and depoliticized erroneously. I believe it is time that we politicize health to collectively recognize it as a human right obstructed by complex global forces that we should all strive to attain through a global good-governance and stewardship oriented approach.
Bambra et al provide three arguments on why health is political:
- Health is distributed unevenly among and within societies
- Health determinants are dependent on political action (or inaction)
- Health is a critical dimension of human rights
The key message of the first Alternative World Health Report in 2005 supported these arguments and highlighted the need to increase political action on poverty and global health. Later on in 2008, the WHO’s Commission on Social Determinants of Health concluded that health is shaped by “the distribution of money, power and resources at global, national and local levels”, issues that are all tackled from non-health, political sectors. Most recently, the 2014 publication of the Commission on Global Governance for Health emphasized how health inequities between and within countries required global political solutions that transcended national health sectors.
We know very well that our global health field is based on the principle that the social determinants of health play a major role in shaping health outcomes and health inequities and that these patterns of disease are not randomly spread across the population but rather clustered around the most disadvantaged (1). Social inequities lead to unequal experiences and resources, leaving some groups of people more or less vulnerable to poor health. Some of these include schooling, employment and income, working and living conditions, type of housing, sanitary systems and access to clean water, and food, among many others. Ultimately, we know that this social stratification within and among countries defines the access and use of health care and has implications in the inequitable promotion of health and well-being, disease prevention, illness recovery and survival. All in all, the access and distribution of resources that promote or impede health is inherently political.
The launching of the Sustainable Development Goals (SDG’s) last year demonstrates that the world needs a more integrated approach between health, development, economic growth, urbanization, gender equality, and climate action, among others. However, I have the impression that although the majority of the world’s leaders adopted these SDG’s, many governments are still not prioritizing an integrated health agenda that incorporates other seemingly non-health-related political topics. Health and its societal, economic and development implications continue to be very much depoliticized at national and global political contexts. Moreover, discussions on health issues continue to be reduced to technical health care services and systems controlled by physicians, pharmaceutical and insurance companies. Health continues to be a commodity that is produced and delivered by either the market or the health service.
Some authors have suggested that the depolitization of health has occurred as a result of the perception that politics is government, which ultimately creates a divide between individuals with and without political roles and power. However, it is fundamental to recognize that politics does not just take place in government through elite politicians in a top-down approach. Politics it is ubiquitous in society and it encompasses “all the processes of conflict, cooperation and negotiation in taking decisions about how resources are to be owned, used, produced and distributed”. At a broader scale, the transnational activities that globalization has triggered and that involve multiple actors with different interests and degrees of power are also politics and have turned health inequities into a global and political challenge. Whether at national or global levels, all issues are political and everyone can and should engage in a political act.
I believe that this perceived elitism of politics has not only disengaged people from taking part in political processes but has also disengaged and frustrated public health professionals from the advocacy processes regarding the topics in which they are experts. In fact, authors such as Mackenbach are highly critical to public health professionals and their little involvement in politics. He argues that researchers often cite “lack of political will” to explain the failing to deal with factors that affect health; they urge health to be placed higher in the political agenda and continuously emphasize that health policies need to be evidence based without having an understanding the political arena (6). He highlights that it is precisely because of this lack of training in politics, policy making processes and how their complexities function that the work and efforts of public health professionals can sometimes be fragmented or ignored.
I agree with Mackenbach up to some extent because I believe that as professionals that study and tackle social and health issues that are in essence and in practice very much political, we should be more educated and involved in the political processes from which these issues can be changed. Nonetheless, I understand that there are many ways of being politically active and that not everyone has to be in the frontlines of debate and policy creation in order to be an agent of change. I also recognize how time and energy consuming is research, especially when it requires doing fieldwork in countries around the world and that the high quality of evidence that we have today is the result of these investments. However, I do believe that as global health professionals, working for a more equitable society, we should acknowledge and be proud of the variety of our politically charged efforts. By situating global health work within a political context and recognizing that what we do and what we want is political, we would be taking a step forward in pressuring national and global stakeholders to engage in the multiple levels of social change in a way that they connect health with the macro political causes of the major economic, social and health inequalities, such as macroeconomic policy, trade policy, defense policy, foreign policy and international development.
It is unfortunate that social and health inequities continue to be addressed independently and therefore, redundantly. This is especially in light of the fact that the evidence relating the two as well as the know-how to address them in a more effective and sustainable way, already exist and is well documented. The recent adoption of the SDG’s has marked the initiation of the long-due conversation of the interrelatedness and relevance of health with all of the other social, development, economic and political aspects of the global agenda as well as the diversification of the stakeholders involved in the process. Thus, I believe that as global health professionals we have the responsibility of creating political pressure to achieve the SDG’s by 2030 through multi-sectorial civil society, national and transnational initiatives. To achieve this, we need to embrace the politics of health and do a better job in communicating what we study, work and research in our academic circles and institutions to the multiplicity of sectors that can and should foster sustainable change. Let’s recognize how political our work is and let’s voice it for what it is.
The clock is ticking!
1. Merson M, Black R, Mills A. Global Health: Diseases, Programs, Systems and Policies. 3rd edn. Jones & Bartlett Learning ; 2012