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Social Social Determinants of Determinants of Health Health Health as a basic right of Health as a basic right of Filipinos Filipinos Ramon P. Paterno, MD, MPH Ramon P. Paterno, MD, MPH Aug. 15. 2009 Aug. 15. 2009 UPM UPM
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Page 1: Blue  S D H Aug 15 09

Addressing the Social Addressing the Social Determinants of Determinants of

HealthHealthHealth as a basic right of FilipinosHealth as a basic right of Filipinos

Ramon P. Paterno, MD, MPHRamon P. Paterno, MD, MPHAug. 15. 2009Aug. 15. 2009

UPMUPM

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Basic question: What good does it do Basic question: What good does it do to treat people’s Illnesses …to treat people’s Illnesses …

only to send them back to the conditions only to send them back to the conditions that made them sick?that made them sick?

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Objectives:Objectives:At the end of this talk: the participant At the end of this talk: the participant will be able to:will be able to:

1.1. Describe the Social Determinants Describe the Social Determinants Approach to Health.Approach to Health.

2.2. Describe major macro political, Describe major macro political, economic, and cultural factors that economic, and cultural factors that have influenced the health of have influenced the health of populations;populations;

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Definition of Health:Definition of Health:

Health is the absence of diseaseHealth is the absence of disease Health is the state of complete well-Health is the state of complete well-

being – physical, mental, social being – physical, mental, social

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Two approaches to healthTwo approaches to health

If health is just the absence of diseaseIf health is just the absence of disease• Treat the illness – BioMedical technological Treat the illness – BioMedical technological

approachapproach If health and ill health are multifactorialIf health and ill health are multifactorial

Address the factors that affect health – The social Address the factors that affect health – The social conditions in which we live in are the major conditions in which we live in are the major Social Determinants of Health or ill health:Social Determinants of Health or ill health:

Employment or lack of employmentEmployment or lack of employment HousingHousing Food securityFood security Education or lack of itEducation or lack of it Living conditions – sanitation, safe waterLiving conditions – sanitation, safe water

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The Historical contextThe Historical context 1847 Virchow:1847 Virchow:(German)(German) remedy for remedy for

epidemics epidemics was:was:

Doctor, Pathologist, Biologist, Politician: first to recognize Leukemia, elucidated embolism, founded “Social Medicine” founded discipline of Anthropology,

““prosperity, prosperity, education & education & liberty”liberty”

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Ashorn 03/2009

The Historical ContextThe Historical Context

… … Mr. Jagor [German ethnologist … invited me to attend a Mr. Jagor [German ethnologist … invited me to attend a meeting of the Geographic Society and introduced me to meeting of the Geographic Society and introduced me to the most famous professors and scholars … the famous the most famous professors and scholars … the famous Virchow. The scholar told me jestingly that he wished to Virchow. The scholar told me jestingly that he wished to study me ethnographically. I replied that I was willing to study me ethnographically. I replied that I was willing to submit to his study for the love of science … At the table I submit to his study for the love of science … At the table I was seated beside him and he understood my German was seated beside him and he understood my German ______ fairly well.______ fairly well.

Rizal letter to Blumentritt, 12 January 1887, Rizal letter to Blumentritt, 12 January 1887, Jaegerstrasse, Berlin.Jaegerstrasse, Berlin.

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TuberculosisTuberculosisTB deaths in EnglandTB deaths in England

00.5

11.5

22.5

33.5

44.5

1838 1860 1880 1900 1920 1940 1960

TB deaths

Streptomycin

BCG Vaccination

* David Werner, Questioning the Solution: The Politics of Primary Health Care and Child Survival,Healthwrights, 1997, p. 76. (cited also in WHO SDH Background papers)

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Land Reform and TB: JapanLand Reform and TB: Japan

The big health problem in Japan was TB, The big health problem in Japan was TB, the leading cause of death since 1934the leading cause of death since 1934• Mass inocultations led to reduction of Mass inocultations led to reduction of

death rate from 280/100t to 181/100t in death rate from 280/100t to 181/100t in 3 yrs3 yrs

• 70 % of farmers paid 50 – 70% of gross 70 % of farmers paid 50 – 70% of gross farm outputfarm output

• Land reform turned millions of tenant Land reform turned millions of tenant farmers into free landholders; involved farmers into free landholders; involved 30,000,000 tracts of land30,000,000 tracts of land

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The Global Health SituationThe Global Health Situation

Improving health status:Improving health status:• Increasing Life expectancy at birthIncreasing Life expectancy at birth• Improving Infant Mortality rateImproving Infant Mortality rate• Improving Maternal Mortality ratioImproving Maternal Mortality ratio

BUT increasing disparities in BUT increasing disparities in Health among nations and within Health among nations and within nationsnations

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WHO WHOSIS DataWHO WHOSIS Data Table generated http://apps.who.int/whosis/data/Search.jspTable generated http://apps.who.int/whosis/data/Search.jsp

GN Income GN Income per capita ($)per capita ($)

LEB LEB 20062006

MMR MMR 20052005

IMR IMR 20062006

DR CongoDR Congo 270270 4747 11001100 129129

TanzaniaTanzania 980980 5050 950950 7474

PhilippinesPhilippines 3,4303,430 6868 230230 2424

CubaCuba -- 7878 4545 55

ChileChile 11,30011,300 7878 1616 88

FranceFrance 32,24032,240 8181 88 44

FinlandFinland 33,17033,170 7979 77 33

SingaporeSingapore 43,30043,300 8080 1414 33

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Case Study PhilippinesCase Study Philippines

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Economic DeterminantsEconomic Determinants

Globalization - Globalization - Neo Liberalization or “Free Trade”Neo Liberalization or “Free Trade”

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Economic DeterminantsEconomic Determinants

Globalization:Globalization:• One World, One MarketOne World, One Market

Neo Liberalization or “Free Trade”Neo Liberalization or “Free Trade”• Free flow of goods, services & human Free flow of goods, services & human

resourcesresources• Migration – right to travel!Migration – right to travel!• Markets freed from govt interferenceMarkets freed from govt interference• Economic growth key to rapid Economic growth key to rapid

development and better life for all!development and better life for all!

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Does Neo Liberal policies lead to Does Neo Liberal policies lead to the trickle down development?the trickle down development?

19601960 19901990 19971997

Richest Richest countriescountries

3030 6060 7474

Poorest Poorest countriescountries

11 11 11

UN Human Development Report 1999

Equity: Income of the fifth of the world’s population

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Elaboration of disparities in wealthElaboration of disparities in wealth

The world’s richest 1% receive The world’s richest 1% receive income = to that of the poorest 57%income = to that of the poorest 57%

The income of the world’s richest 5% The income of the world’s richest 5% = 114 X that of the poorest 5%= 114 X that of the poorest 5%

UN Human Development Report 2002UN Human Development Report 2002

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How Countries Got Rich;How Countries Got Rich;Why Countries Stay PoorWhy Countries Stay Poor

Countries that industrialize Countries that industrialize became richbecame rich

Countries that remained Countries that remained agricultural remained poor …agricultural remained poor …

Countries developed by Countries developed by government intervention, by government intervention, by protecting their industries,protecting their industries,

These countries did not These countries did not practice Free Trade practice Free Trade

Erick Reinert, Norwegian Historical Economist

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How Countries Got Rich … and How Countries Got Rich … and Why Countries Stay PoorWhy Countries Stay Poor

Free trade when a country’s Free trade when a country’s industries are not ready to compete industries are not ready to compete result in:result in:

De – agriculturalizationDe – agriculturalization De – industrializationDe – industrialization DepopulationDepopulation

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Impact of Globalization - we de-industrialized ..Impact of Globalization - we de-industrialized ..

Philippines: Critical Development Constraints

ADB Dec 2007

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Growth that has no impact on the Growth that has no impact on the poor…poor…

Headline, Philippine Daily Inquirer, June 1, 2006.

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Impact of PovertyImpact of Poverty

Income Income deciledecile

2006 ( in P1000)2006 ( in P1000)IncomeIncome ExpenseExpense SavingsSavings

Nat aveNat ave 172172 147147 2525

11stst 3232 3535 (3)(3)

22ndnd 5151 5252 (2)(2)

33rdrd 6565 6666 (.5)(.5)

44thth 8181 7979 22

55thth 100100 9595 55

10th10th 617617 461461 156156

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0

10

20

30

40

50

60

Poorest Richest

Per

100

0 li

ve b

irth

s

Impact on Health

NDHS 2003

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Can we in Health afford Moderate Can we in Health afford Moderate Greed?Greed?

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Can we in health afford “moderate” Can we in health afford “moderate” greed?greed?

Inquirer Today June 25, 2008

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Impact of Corruption on HealthImpact of Corruption on Health

UNDP report: corruption at least 13% of UNDP report: corruption at least 13% of National BudgetNational Budget

2008 P1.2T budget = P156B enough to 2008 P1.2T budget = P156B enough to initially fund Universal Health Careinitially fund Universal Health Care

How much would UHC cost?How much would UHC cost?• 2005 NSCB National Health Accounts 20052005 NSCB National Health Accounts 2005• Total National Health Expenditure – P200BTotal National Health Expenditure – P200B

Govt National / Local – 29%Govt National / Local – 29% PhilHealth – 11%PhilHealth – 11% Out of Pocket – 49%Out of Pocket – 49%

• 2006 – OOP – 56%2006 – OOP – 56%

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Neri’s “Web of Dysfunction”Neri’s “Web of Dysfunction”

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Crisis fatigue?Crisis fatigue?

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CulturalCultural

A sense of despair – survival modeA sense of despair – survival mode A sense of disempowermentA sense of disempowerment ““Pagod na ang mga tao sa EDSA”Pagod na ang mga tao sa EDSA” And yet in community medicine, one And yet in community medicine, one

of our goals is an empowered of our goals is an empowered community …community …

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Kick Gloria’s Con AssKick Gloria’s Con Ass

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How do we address poverty?How do we address poverty?

Poverty alleviation?Poverty alleviation?• Feeding programsFeeding programs• P500 cash transfersP500 cash transfers

Apparently to be funded by WB loanApparently to be funded by WB loan

• Medical missionsMedical missions• PCSO PCSO

Or Poverty eradication?Or Poverty eradication?

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For genuine growthFor genuine growth

We need to industrializeWe need to industrialize It can not be export orientedIt can not be export oriented Create a domestic market – address the Create a domestic market – address the

poverty of the majority – Land Reformpoverty of the majority – Land Reform Ensure Food Security firstEnsure Food Security first Industrialize initially to support Industrialize initially to support

agriculture and food securityagriculture and food security Not aid nor charity but FAIR tradeNot aid nor charity but FAIR trade

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Alma Ata Primary Health CareAlma Ata Primary Health Care

Health is a Right, health is not just the Health is a Right, health is not just the absence of disease.absence of disease.

Inequities in health are not acceptableInequities in health are not acceptable Inequities in health are rooted in inequities Inequities in health are rooted in inequities

in societyin society Socio-Economic development within a new Socio-Economic development within a new

International Socio-Economic order is International Socio-Economic order is essential for the attainment of Health for essential for the attainment of Health for All. All.

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A New International Socio-A New International Socio-Economic order Economic order

What is it? Who will define it?What is it? Who will define it? The people, not the executives of Financial The people, not the executives of Financial

& Banking institutions& Banking institutions A society with justice and equity with a A society with justice and equity with a

developed economy that can providedeveloped economy that can provide• Work for allWork for all• Housing for allHousing for all• Food for allFood for all• Education for allEducation for all• Health for allHealth for all

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So why did we discuss all these?So why did we discuss all these?

We are a Nation:We are a Nation: Because of our blind adherence to Because of our blind adherence to

Neo Liberal PolicyNeo Liberal Policy Have remained underdeveloped and Have remained underdeveloped and

poorpoor Because we remain poor, we remain Because we remain poor, we remain

unhealthy unhealthy What then is the role of a health What then is the role of a health

student, of UP Manila?student, of UP Manila?

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Role of a health student?Role of a health student?

Study the situation & the social Study the situation & the social determinants of health – the determinants of health – the economy, the politics and the cultureeconomy, the politics and the culture

Health can be used to make people Health can be used to make people accept an unjust societyaccept an unjust society• Medical missions, charity workMedical missions, charity work

Health can be used to empower Health can be used to empower people …people …

Arouse, organize, mobilize …Arouse, organize, mobilize …

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Basic question: What good does it do Basic question: What good does it do to treat people’s Illnesses …to treat people’s Illnesses …

only to send them back to the conditions only to send them back to the conditions that made them sick?that made them sick?

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Thank youThank you