The World Health Organization commission on social determinants of health emphasizes that health inequalities are manifestations of societal inequalities, and that the increased inequality caused by differences in healthcare and educational attainment adds to longstanding inequalities in other dimensions. Many among us may assume that social inequalities in health result from inequalities in access to care, medical treatments and our lifestyle choices. However, lack of access to medical care only partially explains the difference and therefore, a causal framework is necessary to elucidate the variation.
Countrywide measures of important diseases and mortality patterns in Nepal such as the maternal mortality ratio (MMR), infant mortality rate (IMR) and under five mortality rate (<5 MR) conceal important regional variations that have remained poorly documented. The global nature of health disparities across regions, districts and cities makes this one of the most pressing issues facing science and medicine today.
For example, the recent deaths in Doti district due to cholera outbreak could have been avoided. John Snow’s hypothesis of cholera from the 19th century is still evident: that group differences are a guide to a set of social causes, whereas individual differences are a guide to a different set of causes. The contribution of medical care in this case was primarily to treat illness when it occurred and not to prevent its occurrence. Therefore, differences in the incidence of disease cannot be explained by the provision of medical care alone. More important is to understand what makes these people more susceptible to an exposure.
Many of the major determinants of health inequalities lie outside the health sector and require non-health policies to tackle them. Social policies, politics, economical and cultural factors largely determine the health of our society. Most of the people in Nepal may be unaware of the fact that our health is primarily shaped by the distribution of income and wealth in the country. Widening socioeconomic differences in Nepal have created health inequalities and epidemiological polarization both through their direct effects and through the effect that they have on lifestyle and behavior.
As far back as 1998, Nobel laureate Amartya Sen had strongly argued that mortality should be used as among the most important indicators to measure the quality of life and development, which is relevant even in the case of Nepal. In 2009, the life expectancy of people born in Kathmandu was roughly 74 years and those born in Mugu roughly 44 years. Assuming that the figures have not changed dramatically in the last three years, how are we going to explain this enormous variation of 30 years in life expectancy? The many pathways underlying the observed inequalities in life expectancy are difficult to disentangle; they are like the two strands of DNA’s double helix twisted around each other.
The effects of fetal, infant and child health on adult health further complicate it. The scientific consensus emphasizes providing nutritious food to children during the critical first 1,000 days of life to eliminate the irreversible consequences of under-nutrition and other problems associated with it, but our health workers do not have a say when there are food shortages in the mid- and far-western regions. Since food insecurity directly translates into poor nutrition, are these inequalities to be accepted as natural and inevitable or should they be considered the result of social and economic abhorrence that need to be tackled?
Most health workers and researchers mention “lack of political will” as an obstruction to redressing health inequalities. However, they rarely discuss their own role in stimulating and supporting action, based on the fact that they are employed by the government and choose not to be seen as politically active. The top-down political approach in Nepal has separated politics from the community even when the social relevance of political decisions that impact health has been underscored. The de-politicization of health is partly due to the transfer of power from the public to medical and health professionals and pharmaceutical companies. Thus, health has gained a commodity status.
The definition of health was conventionally operationalized into the absence of disease or a commodity that individuals could access through health systems. Such a one-dimensional focus on individuals as opposed to the society has limited the recognition of the political nature of health and hence, has been less effective for promotion of heath issues in the political arena.
So far, politicians have not displayed the leadership and pragmatism needed to introduce reforms to benefit the marginalized populations. Therefore, a major restructuring of the society with a focus on poverty, living and work conditions, education (especially during earlier years), strengthening health system, and health reforms is required.
As most of the inequalities result from disparities in formative years, it is important that we give a good start to children. Differences in life chances should not depend on factors that are beyond the control of an individual.
The author is a PhD student of preventive medicine and epidemiology at University of Oslo, Norway
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