EDITORIALS
Global action on social determinants of health
Michael Marmot*
Department of Epidemiology and Public Health, University College London, 119 Torrington Place, London, WC1E 6BT, England
Closing the gap in a generation is a rousing call.1 Did the World Health Organization's Commission on Social Determinants of Health (CSDH) really believe it to be possible? Technically, certainly. Yes, there is a greater than 40-year spread in life expectancy among countries and dramatic social gradients in health within countries. But the evidence suggests that we can make great progress towards closing the health gap by improving, as the CSDH put it, the conditions in which people are born, grow, live, work and age. These include ensuring: equity for every child from the start, healthier environments, fair employment and decent work, social protection across the life course and universal health care. To make such progress, we must also deal with inequity in power, money and resources the social injustice that is killing on a grand scale. At a more fundamental level, our vision is to create the conditions so that every person may enjoy the freedoms that lead to improved health what we call empowerment.
In the three years since Closing the gap in a generation was published, there is no question that there is much to make us gloomy: the global financial crisis and the steps put in place to deal with it have worse impacts on the poor and relatively disadvantaged; the persistence of bad governance nationally and globally; cli-mate change and inequitable measures for mitigation and adaptation and, in many countries, an increase in health inequity.
On the positive side, however, much has happened to support my claim that I am an evidence-based optimist. First at the World Health Organization (WHO) itself, the doubting voices (what do social determinants have to do with a disease control organization?) were countered by the argument that WHO could not possibly ignore what the CSDH called "the causes of the causes" of ill-health. Specialists across WHO, who formed the CSDH's knowledge network on priority public health conditions, showed that action on social determinants of health was fundamental to disease control programmes.2 Importantly, a resolution was passed at the World Health Assembly in 2009 that called on WHO and all Member States to take action on the social determinants.
Each of the WHO Regions has expressed interest in this issue. The WHO Regional Office for the Americas will make social determinants a theme for its publication Health in the Americas 2012, has developed training courses and has been promoting health equity in the region. Zsuzsanna Jakab, WHO Regional Director for Europe, thought it essential that work be done to adapt the CSDH findings to the diverse countries that make up the WHO European Region. She therefore invited me to lead the European Review of Social Determinants and the Health Divide. The recommendations from this review will feed in to Europe's new public health strategy, Health 2020. WHO, with the government of Brazil, is organizing the World Conference on Social Determinants of Health in Rio de Janeiro.
Several countries have explicitly taken on the social determinants of health agenda. Brazil, Denmark, England, Norway, Scotland and Slovenia are among many countries that have commissioned reviews and/or produced strategies for action on this subject. In other countries such as Argentina, Chile, Costa Rica and Sri Lanka, there is much focus on and concern about the social determinants of health and a variety of actions have been taken. The state of South Australia has made the Health in All Policies approach a central plank of government action. India, while not explicitly addressing the social determinants of health has, nevertheless, pursued policy initiatives that will have important impact on health equity. These include: rural employment guarantees, food security, universal health care, social security for informal workers, education, housing and rights of tribal and forest dwellers. These new policies and programmes are all welcome but the proof will come from monitoring their effect on social determinants and health outcomes.
The review of health inequalities in England, published as Fair society, healthy lives,3 adapted the CSDH recommendations into six domains: (i) give every child the best start in life, (ii) improve education and life-long learning, (iii) create fair employment and jobs, (iv) ensure a minimum income for a healthy standard of living, (v) build healthy and sustainable communities, and (vi) apply a social determinants' approach to prevention. In the wake of this review there are encouraging signs of impact on policy and practice at national and local level in the United Kingdom of Great Britain and Northern Ireland.
The ambition of the CSDH was to create a global movement for social determinants and health equity. As the global community gathers in Rio de Janeiro in October for the conference on social determinants of health, we are at a crucial juncture. Will the call for social justice and the need to formulate all policies to benefit health equity remain something, at best, honoured in speech alone? Or will the global community recognize that action on social determinants of health is not only vital for health equity but has other highly desirable societal outcomes including social cohesion, reduction of crime and civil unrest, a more educated workforce and the freedom for people to lead lives they have reason to value.4 
References
1. Closing the gap in a generation: health equity through action on the social determinants of health. Geneva: World Health Organization; 2008.
2. Blass E, Kurup AS. Equity, social determinants and public health programmes. Geneva: World Health Organization; 2010.
3. Review M. Fair society, healthy lives: strategic review of health inequalities in England post-2010. London: Marmot Review; 2010.
4. Sen A. Development as freedom. New York: Alfred A Knopf; 1999.
* Correspondence to Michael Marmot (e-mail: m.marmot@ucl.ac.uk)