Dr. Oscar Mujica, Washington DC

There are, indeed, many things popping out for closer scrutiny when reading the paper that I am left wondering if my apparent difficulty to extract (and synthesize) the ‘big picture’ here has something to do with an inherent haphazard structure behind the wording of the technical paper itself (other than, of course, my own semiotics limitations –i.e., for decoding the discourse).

I am being candid here but, maybe, that can help in a small way too.

The first thing that really hit me is the heavy rhetoric style of the whole document: unfortunately, this is not in the sense of persuasive or effective argumentation but, disappointingly, as lacking in sincerity or meaningful content. It is prescriptive, as if everything relevant (on how to implement action on social determinants of health to tackle health inequality) is already matter-of-factly known, all the multilevel, multivariable, multisectoral pieces and causal connections in place, and all the evidence so-well known that it became irrelevant to invoke and use them explicitly in the document to support and advance its contentions.

The document claims that it deals with strategies and methodologies for implementing action on SDH but, alas, it seems to me that, in its contents, the accent has been put almost exclusively in the ‘what’ instead of in the ‘how’ (the latter being, precisely, what you expect when dealing with implementation, action, strategy, and methodology); in any case, the claimed presentation of strategies and methodologies is not clearly organized in a systematic, comprehensive, visible, and persuasive way.

It is not clear to me the true meaning of the ubiquitously invoked concept of “policy coherence” in the document, much less so when the document is deprived of a meaningful, critical discussion and positioning with regard to political determinants, including the prevailing global economic order and its pervasive power asymmetries (which were clearly stated in the WHO Commission on the Social Determinants of Health, CSDH, Report, back in 2008). The technical document commits tokenism is this very topic: it makes only a perfunctory effort to analytically touch (not to mention treat) the issue of politics in the big context of social determinants and inequities. Without an explicit and shared political rationale for ‘policy coherence’ in the context of implementing action to SDH, this concept can be plainly regarded as a platitude (i.e., a prosaic, banal statement presented as original and significant).

And that can alienate the whole document and even the strategic positioning of WHO in the discussion on how to implement action on SDH.

A third main point from my reading of the document is what seems to be an ambiguous treatment, i.e., synonymic, interchangeable use, of the concepts of ‘health determinants’, ‘social determinants of health’ and, more worrisome, ‘health inequalities’ (or inequities). These concepts merit in-depth clarification (may be a glossary may help) in the technical document (or an explicit adoption of the CSDH Report terminology).

It should be clear that inasmuch as that in order to improve daily living conditions of the people (including health, the very first recommendation of the CSDH), action should be implemented on the social determinants of health, then in order to tackle health inequalities, action should be implemented on the social determinants of health inequality. Those sets of determinants, under the paradigmatic multilevel model of the determinants of health, are not necessarily the same, nor the action upon one necessarily produces changes in the effects of the other.

This attribute of policy specificity should be unambiguously addressed in the technical document.

With propositive intent, and given the 3-year gap between the release of the CSDH Report and the WCSDH, I believe this technical document will benefit a great deal from what is already discussed and proposed in The Marmot Review 2010 (Fair Society, Healthy Lives, at www.ucl.ac.uk/marmotreview), an independent review commissioned by the UK Government –and chaired by Prof. Marmot– precisely to propose the most effective evidence-based strategies for reducing health inequalities in England from 2010.

With best regards,


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