Unlike ITM at the river Scheldt where the Congo boats moored, Harvard is situated on the banks of Charles River, Boston. And while Boston never had a formal colony, it is the capital of a New England settler state, and its United Fruit Company plantation hospitals were field stations for Harvard students till deep into the 20^th century. Which made the opening remarks of Elizabeth Solomon – one of 80 survivors of the Massachusett Ponkapoag tribe – rather fitting: “Here is where we interacted with the visitors. Here is where those who survived remained (…) But colonization is not limited to centuries ago. The systems of colonization continue, in this place and others (…) Each and every one in this room is a colonist. So please be mindful, introspect, and respect”.

Solomon’s plea did not fall on stony ground. Among others, Anne-Emmanuelle Birn made it clear to everyone in the conference hall that a straight line goes from erstwhile ‘tropical medicine’ – “actually reinforcing the political and social stratification between colonizer and colonized” – to present-day ‘global health’ dominated by “Tata kills, Tata funds” and Davos-style philanthrocapitalism. Yesterday’s colonialism and today’s coloniality have one thing in common – the reinforcement of inequity – and the current mainstream global health is essentially colonial, hence needs to be decolonized. One possible and much needed way of doing so is to decolonize global (and international, and tropical) health syllabi. Which is one of the more immediate aims of the student committee that came up with the great idea to organize this conference. But it is not enough: Harvard scholar Melissa Barber outlined a chain of academic mechanisms maintaining the global health community as it is, and which all need to be redressed – “(1) Gatekeeping for people entering; (2) Selecting of global health frameworks; and (3) Legitimizing mainstream global health initiatives”. Much remains to be done before we arrive at “a vision of global health that is equitable, reflexive, and anti-colonial in both delivery and discourse”.

In the closing plenary, distinguished health and equity champion Mary Travis Bassett pointed out the essence of the way forward for genuine decolonization: “replace the happy handholding of global health partnerships with solidarity, meaning equal value and rights of all humans”. She concluded by asking all of us to “apply the principles of solidarity on the whole globe, not only far away, but also in your own environment”. Which brings me back home, in my own academic environment, at ITM. There is little doubt that our own house needs decolonization too. Are we willing to take on the task?

Prof Bart Criel, the initiator of the symposium, rightly pointed out that the Alma-Ata Declaration is a simple, 3-page document about the unfulfilled right to health and the widening of health inequities, and that it takes a clear stance on how the lack of access to health is morally, socially and politically unacceptable. 40 years after this declaration we find that half the world’s population cannot even obtain essential health services, while year after year 100 million are pushed into extreme poverty due to out-of-pocket healthcare spending, according to a 2017 report by the World Bank and WHO.

In trying to understand why so little has changed, we want to point out a ‘clear and present paradox’ that hovered over the discussions October 23^rd at the ITM – but extends much further than that.

When opening the one-day event, our ITM director brought forward that it should not be forgotten that the first and foremost responsibility of medical doctors is to take care of their patients. The last remark in the panel that brought the day to a close was about how family doctors also need to think about their own wellbeing, given this difficult task. And both were right: patients need healing and relief, and doctors need well-being as much as anyone else. But these messages also highlighted, perhaps unintentionally, the paradox that hinders progress in primary health care (PHC). The crucial issue was – and is – of course what should change to make sure that in 2058 (and hopefully much earlier) more convincing results on achieving ‘health for all’ can be shown.

Overall, the day was filled with in-depth contributions from the field, and proposals on how to renew and take forward PHC. Yet in some of the break-out groups, and in the concluding panel discussion, the paradox was very visible: while health is about so much more than health care, many of us seem to be stuck within healthcare boundaries. It is obvious that improved health requires engineers, law-makers, social activists and many more – including health professionals.

But with whom in the driver’s seat? When it comes to curing patients, (most) health professionals focus on illness and disease rather than on health. Which is good for the excited and enthusiastic social activist hit by a stroke. Should that lead to Kelsey Lucyk’s remark, when referring to Canada’s struggle with social determinants of health: “health has to add its voice, but in a respectful way, and also know when to get out of the way”? Richard Smith goes further when he expresses his concern about the ‘hegemony of the health people’: he is afraid that the “health people will always dominate with their computers, statistics, journals, theories, knowledge, and inability to think beyond the biomedical model and take over”. Perhaps we, the ‘health people’, should raise to the challenge. There are good arguments in what is brought forward by Lucyk and Smith. Both beg the question of a clear division of tasks within the broader health community.

We know that for developing and implementing health policies, health professionals are required. Health issues continuously compete for legitimacy and resources in the policy process, and this ‘agenda setting’ for Global Health has inspired much research. And although the role of many other disciplines is clear, it is never denied that ‘health people’ also have a role to play, and an important one. Within the health workforce there is slow but undeniable progress in recognizing the importance of a multidisciplinary workforce, acknowledging the huge contribution of informal carers/volunteers/social workers/people themselves in PHC, as was the topic of one of the break-out sessions. We may carry that division of mutually recognized tasks further, in order to prevent misunderstanding and improve effectiveness of the role of the ‘health people’ in PHC.

Tackling the infamous ‘medical-doctor perspective’ is important, and can be helped by improving a clear and outspoken relation of interdependency between the different disciplines in our own institution. We may want to show at ITM that it is self-evident that better health for all is built on the interdependency of first-rate biomedical knowledge and first-rate  knowledge of socio-economic-anthropological foundations of public health systems, policy-making and governance. That  may increase the relevance of the voice of ‘health people’ in the PHC debate – without claiming it for ourselves.

It might also help prevent conceptual confusion that can paralyze progress in formulating simple action points – as happened in another outbreak group. There, buzz-words such as sustainability and resilience^, seemed problematic, which could have been solved by including other disciplines.  The time won could have been used to discuss the other elephant in the room, the need for a ‘new economic order’, so central in the Alma-Ata declaration, perhaps echoed by the ‘doughnut framework’ of today’s world.

We have a dream, which we hope you share: before our next Alma-Ata commemoration all of us will have read sections I, II, III, IV, V, VII-1, VII-4, VII-5, VIII and X of the famous 1978 declaration. That should help….we  would, for example, hear no more plea from a closing panel to protect the ‘white privilege’ of western medical doctors to roam about the world to participate in the global health debate. Who knows, we might then already have found more equal ways to exchange knowledge and experience in the world – in order to provide equity and health for all.

Three days earlier, on June 22^nd, the Inter-American Commission on Human Rights (IACHR) presented its report ‘Severe human rights violation in the context of social protests in Nicaragua’ to the permanent council of the Organization of American States. The report – shamelessly turned down by Ortega’s Minister of Foreign Affairs as “subjective, prejudiced and notoriously biased” – gives a detailed account of “the Nicaraguan government’s repressive response”, including “murders, likely extrajudicial executions, mistreatment, likely acts of torture and arbitrary detentions”. It adds one more concern – echoing what Amnesty International already highlighted in its May 29^th report ‘Shoot to kill – Nicaragua’s strategy to repress protest’: “the violation of the right to health and (…) the denial of medical attention”.

There have indeed been numerous testimonies of denial of medical attention to injured civilians in public hospitals. The Minister of Health herself, Dr. Sonia Castro, had threatened the medical staff with expulsion if treatment was provided to students and protesters. Once this became widely known, she of course denied so while still describing the care-seeking of the wounded as “attacks and forceful access to hospitals”, which would hamper medical attention to poor infants with diarrhea. Attacks around hospitals are indeed documented, but by paramilitary forces and against wounded protesters seeking care. The same government-loyal paramilitaries systematically hampered the humanitarian work of Red Cross staff, paramedics, firefighters, doctors, medical students and volunteers. When improvised health posts were set up in houses, schools and churches, volunteers were threatened, and some of them kidnapped. To make the picture of terror complete, Ministry of Health ambulances were used to mobilize shock troops and police forces to attack neighborhoods where roadblocks had been put up by the population for protection. Autopsies have been interfered and corpses with evident signs of torture have been categorized as ´death by natural causes´.

One of the most heartbreaking stories was that of Álvaro Conrado. On April 20^th while carrying water to protesting students, the 15-year old boy was shot in the throat. Bleeding to death – his last words were “It hurts to breathe” – he was denied access to the social security Cruz Azul hospital, administered by a government doctor-politician who is also president of the National Assembly. Then taken to the private Baptist hospital, the boy died while undergoing surgery.

While the death count and the denial of human rights get worse day by day, very little concern and condemnation has been shown by the international community. The Latin American and the Caribbean Medical Confederation (Confemel) and the World Medical Association (WMA) have been the exception. Confemel raised its concern for the “scandalous tolerance of the international community” and the WMA condemned “the collapse of the public health care system in Nicaragua and the breakdown of medical ethics and human rights in the country”.

Adding insult to injury, the Ortega-Murillo regime blatantly denies the on-going human rights violations and maintains its Orwellian discourse of “war is peace, freedom is slavery and ignorance is strength” to convince the handful of Nicaraguans still supporting them.

Our diaspora has started voicing indignation for the indifference of some international entities. Last Tuesday, a man interrupted a PAHO meeting to question its Director Dr. Carissa Etienne’s silence at the crisis that has affected adversely the Nicaraguan health system. But not much has changed. We understand many crises are going on in the world at this moment, but still. How many more deaths do we have to show?

So you, colleagues and friends, will you help us to restore at least our right to health? Or would you rather prefer an ‘I really don’t care’ jacket? Which side are you on?

It all started with the World Development Report 1980, part II: Poverty and Human Development, in which the Bank admitted that poverty could not be comprehensively measured. Unhindered by such wise insight, the document went on advocating for (economic) growth as “vital to reducing all aspects of absolute poverty”. Trickle-down economics pur sang, which – as we know – never materialized. Comes 1990, with a whole World Development Report dedicated to Poverty, and the recognition that “lack of education, landlessness, and acute vulnerability to illness and seasonal hard times” are all “at the core of poverty”. Yet all of a sudden, absolute poverty had become measurable (a dollar a day) and the solution was refined: “the pursuit of a pattern of growth that ensures productive use of the poor’s most abundant asset – labor”. Let them work! Any resemblance to good old English workhouse logic was of course purely coincidental. Agreed, “primary education, primary health care, and family planning” could also be delivered. Who would like many paupers anyway?

By the turn of the century, most experts were aware that poverty is more than an economic condition. The UNDP had defined poverty as “a denial of choices and opportunities for living a tolerable life”. The World Bank itself had run its Voices of the Poor research project and finally reached the insight that poverty was a “multidimensional social phenomenon”, including “lack of voice and power”. Poverty reduction strategies were rolled out in line with an apparently revolutionary strategy summed up in the Bank’s 2000-2001 World Development Report: give the poor chances, empower them, and provide  them with security. Yet choices would again depend on economic growth (which by then everyone knew would not suffice), and empowerment on responsive governance (as if the privileged would be eager to share the helm). Most questionable was the risk management concept on which security should be based: as the poor have nothing to lose, they will be very willing to take risks, so let us teach them how to take risks and “take advantage of emerging market opportunities”. Too good to be true.

Pardon me if I skip the MDG years. You might remember the first one: “Eradicate poverty and extreme hunger”. But poverty did not decrease, and if it did, it did not in absolute numbers. Nor did the poor get more chances (unlike banks receiving bailouts, in 2008), were they empowered or did they feel by any means more secure. We even saw a new class of poor emerging: the working poor. As economists describe it, the labor share of income went down and profit share went up. ‘Flexible’ workers lose, and speculators win. I am lucky enough to live in one of the few countries where this perverse phenomenon is still partly remedied, via social protection.

This is not to say that nothing promising happened after 2000. The WHO put UHC on the agenda and made a call for action on the social determinants of health and for health equity (I leave it up to others to argue how far away we still are from this goal). Even the IMF, in 2014, came to the conclusion that inequality was something like a time bomb and that equitable redistribution was needed for sustainable growth. And we, the world, have the SDGs now, and should “leave nobody behind”. At this very moment in time the World Bank introduces its Changing Nature of Work, a working draft for its World Development Report 2019, presented and discussed at its 2018 Spring Meetings a week ago in Washington. To everybody’s surprise, the draft starts off with a quote of Marx.

I will spare you a discussion on all seven chapters and focus on one only: Social Protection and Labor Market Institutions. After all, next week is May Day, and social protection is what laborers then celebrate (or call for, according to the country you happen to live in). And at first sight, people might be happy with the Bank now putting a guaranteed income at the core of renewed social protection. Only problem, the Bank doesn’t promote guaranteed incomes to empower labor in relation to capital. On the contrary, it considers such basic income not as a right but as a form of social assistance. At the same time, “labor markets can be made more flexible to facilitate work transition” because “high minimum wages, undue restrictions on hiring and firing, strict contract forms, all make workers more expensive vis a vis capital”. I beg your pardon? Duncan Green calls this flexibility-on-speed, Peter Bakvis accuses the Bank of promoting deregulation disguised as a new social contract. I’m afraid they both got it right, but who hears them?

If we really want to leave nobody behind, and do something about poverty and inequity, we might need a renewed social movement for people’s wellbeing – not a new social contract to fit “The Changing Nature of Work”. So, if the World Bank has the guts to start its master plan with a quote from Marx, I might be excused for ending with another one: Workers of the world, unite, before it’s too late. And may you have a happy May Day!

Habitat III is the first UN global summit after the adoption of the 2030 Agenda for Sustainable Development and the Sustainable Development Goals. Augusto Barrera, former mayor of Quito, was the one who came with the idea of hosting Habitat III. The idea was supported throughout Latin America, a region that has witnessed rapid urbanization, rural-urban migration and a concentration of resources and services in the cities. Plans for the conference continued even as the country suffered a massive earthquake measuring 7.4 on the Richter scale less than six months ago.

 “Change comes from the heart of the world” – the Habitat III slogan literally reflects Quito’s geographical location at the center of the world, at latitude zero. The slogan is accompanied by an emphasis on outlining an ‘inclusive’ urban agenda for the next twenty years, an objective which feels slightly ironic when one notices the fenced-off El Arbolito Park where the conference takes place.

Getting there

My journey to Habitat III started in Bolivia on Friday, after the worst trip ever! Twenty four hours and 4 airports later, I finally arrived to the city declared as a UNESCO world heritage site. Beautiful roses, people dressed in traditional outfits and posters greeting the approximately 45,000 participants from around the world.  The city sprouted new road signs, and brand new bike paths along some streets. I had landed in a Quito quite different from the one I had spent the last 20 years living in, I felt.

The atmosphere was a different story. Quito has witnessed several protests in the recent past against the current mayor, Mauricio Rodas, driven by the lack of participatory decision-making in ‘development’ projects such as the new metro system, highways and overpasses – infrastructure which led to the eviction of people in poor neighbourhoods, and reflected the lack of a comprehensive urban mobility plan. Inclusivity and organisation took another hit when I found myself facing a 10-block long queue to enter the conference premises. Five hours under the relentless Quito sun didn’t do much for my enthusiasm. Of course, there was a special queue for international participants – not quite sure if I can say this is ‘equity’.

National president Rafael Correa – also presiding the conference assembly – was quick to deflect the long queues to the UN’s responsibility to arrange logistics. His colleagues in the US Congress would have been proud of him –  Blame the UN if things go wrong!

Habitat III between hope and scepticism

By the time you read this, Habitat III will have culminated with the adoption of the ‘Quito declaration on sustainable cities and human settlements for all’, also known as the ‘New Urban Agenda’. This agenda has raised both hope and scepticism. Most observers hope that the agenda will lead to real political commitment and transformative urban development. Yet quite a few have their doubts. The London-based International Institute for Environment and Development (IIED) – particularly engaged in the urban agenda ever since the preparation of Habitat I in the 1970’s – described the draft New Urban Agenda (June 2016) as one that “lacks both an overarching vision (…) and a consistent approach to implementation”. To correct this, the IIED advocated for “an explicit overarching vision that promotes sustainable and just urbanization (…) This vision has to recognise (…) above all, the systemic conditions that threaten the very possibility of a sustainable future”. Whether that clearer vision emerged during the conference, well…

Even then, scepticism remains. As reported in the Inter Press Service earlier this week, many experts fear that Habitat III “will only pay lip service to commitments that will quickly be forgotten, as occurred after the first Habitat conference (…) and the second”. The Guardian was even more critical and described  “sustainable, inclusive and resilient” as “the conference’s favourite buzzwords”.

From a public health point of view, the meagre attention to health in Habitat III was striking. In the draft New Urban Agenda, health is mentioned 12 times (cities should “allow people to live healthy”) but nowhere developed. Among the hundreds of events on the Habitat III calendar, barely a handful were dedicated to health: a UNFPA session on health and empowerment on the opening day, a WHO session also on Sunday, and two side events on Thursday (I don’t count ‘Implementing urban health and wellbeing by taking a systems approach’, co-organised by an ITM public health unit but cancelled at the last minute). Besides being remarkable, this is a lost opportunity. Whatever ideology people adhere to – like hedonism striving to maximise health and wellbeing, or eudaemonism optimising the path to health and wellbeing – most experts today regard health as a core part of wellbeing. If we want our future cities to be ‘sustainable, inclusive and resilient’, then health and wellbeing are essential ingredients. Yet curiously, the Habitat III jargon got stuck in ‘shared prosperity’, and hardly used the term ‘wellbeing’. A pity.

 “The city that we want or the city that they want?”

During the high-level round table “Leave no one behind” on Monday, speakers addressed the challenges towards the path to ‘shared prosperity’. Poverty reduction and access to basic services were elements common across discussions. Equity and inclusion were indeed the mantra of the conference, yet many groups felt excluded. Jean-Yves Duclos, Canada´s Minister of Families, Children and Social Development highlighted the exclusion of LGTBI groups, particularly criticizing the move to exclude the LGBTI community from urban development plans by 17 countries a few months ago. In the shadow of Habitat III, women, cyclists, pedestrians, indigenous people, students, LGTBI people and evicted locals organised a parallel event, Resistance Habitat III, and planned a march on Thursday (while this blog was being written).

‘People’ were to be at the heart of the new urban agenda. This was one of the key messages of the sessions I attended. I was pondering this when suddenly a caramelera (woman who sells candies and snacks) in the Arbolito park surrounding the venue brought me back to reality. “What is this for?”, she asked, as she struggled with a toddler on her back. I thought of echoing some of the nice slogans I had heard at the Conference, such as ‘diminish poverty’, ‘increase access to services’, ‘decrease inequity’… Then I realized that we cannot achieve this dream of inclusive, safe and sustainable cities, if we remain blind to the ‘invisible’ in our streets. It reminded me of Eduardo Galeano´s poem, The Nobodies:

“…The nobodies: the sons of no one,

the owners of nothing.

The nobodies:  treated as no one,

running after the carrot, dying their lives, fucked,

double-fucked.

Who are not, even when they are.

Who don’t speak languages, but rather dialects.

Who don’t follow religions,

but rather superstitions. 

Who don’t do art, but rather crafts.

Who don’t practice culture, but rather folklore.

Who are not human,

but rather human resources…”

But probably those nobodies will not be invited to the closing cocktail.

There is little doubt that these health disparities should be considered inequitable: social health inequities’  “textbook definition” of being ‘systematic, socially produced, and unfair’ clearly applies to them. All the same, health inequities in India (as elsewhere in the world) are widening. Clearly, there is a need for better understanding of the causal mechanisms of health inequities, and for effective policies to reduce them.

The Institute of Public Health (IPH, Bangalore), in collaboration with the Institute of Tropical Medicine (ITM, Antwerp), has made health equity the central theme of its 3^rd EPHP Conference (Bringing Evidence into Public Health Policy, Bangalore, 7-9 July 2016). In a pre-conference workshop (7 July) cutting-edge concepts and methods for health equity research were presented and discussed. The conference itself (8-9 July), under the banner ‘Equitable India: All for Health and Wellbeing’ makes the point that the road to equity needs a joint effort. As the organizers state in the editorial of the EPHP abstract book, published in BMJ Global Health: “Health cannot be separated from overall wellbeing. If we want to bring health closer to the people, to all of them according to their needs, the policy will have to embrace intersectoral action”.

The two-day Conference will bring together over 300 delegates, including researchers, academics and policy makers, from across the world. Sessions will address a wide range of topics on inequities in maternal care to urban health, and health systems and policy interventions to address inequities.

Narayanan Devadasan, Director IPH

From right to left: Abdul Ghaffar (WHO-Alliance for Health Policy and Systems Research, Geneva), Gita Sen (Ramalingaswami Centre on Equity & Social Determinants of Health, Delhi), Sundari Ravindran (Achutha Menon Centre for Health Science Studies, Werner Soors (Institute of Tropical Medicine, Antwerp)

What receives far too little attention is the fact that the Zika crisis – and the response to it – generates fear, confusion and uncertainty for the poor actually living through it, especially women. Little justice is done to gender, sexual and reproductive health issues, major inequities in the living and sanitary conditions of the poorest and criticism towards mainstream control strategies.

Delaying pregnancies is one containment measure. Several Latin American countries have asked women to delay pregnancies until there is a better understanding of Zika and its relation to microcephaly, and the transmission of the virus in utero. It is good to realise that Latin America is the same region that saw abortion banned in Chile, Surinam, El Salvador, Haiti, Nicaragua and the Dominican Republic, where access to contraceptive methods is generally inadequate, and which already has the highest proportion of unintended pregnancies (56%) in the world. It’s also the region where ‘Christian’ beliefs are most influential in policymaking, and pope Francis’ comment that in times of Zika “avoiding pregnancy is not an absolute evil” caused panic among local church officials .

With Zika being the latest addition to Aedes-spread infections in Latin America (yellow fever, dengue, chikungunya), vector control is key to the public health response. Ever since the construction of the Panamá Canal, chemicals have occupied a central role, either through spatial fumigation or adding them to drinking and non-drinking water storage containers. Most commonly used in the region were organophosphates like Temefos and Malathion, and they keep being used despite well-known harmful effects on humans and ecosystems, and increasing resistance of the mischievous Aedes. A pesticide of more recent use in chemical vector control is pyriproxyfen. In Brazil, where pyriproxyfen was introduced in drinking water in 2014, Abrasco (Associação Brasileira de Saúde Coletiva) made a case for paying more attention to the association between poverty, intensity of chemical disease control and incidence of microcephaly (in a February 2016 Technical Note ). Abrasco’s thoughtful questioning of mainstream disease control was dismissed as a complot theory, the suggestion that pyriproxyfen could be part of the problem debunked as a myth. While indeed the case for a causal link between the Zika virus and microcephaly is getting stronger, defenders of pyriproxyfen have weak arguments. The WHO, in its emergency update ‘No evidence that pyriproxyfen insecticide causes microcephaly’ , bases its claim on 2008 ‘Guidelines for Drinking Water Quality’ . Those guidelines however extrapolated the safety of pyriproxyfen from tests in rats and rabbits only, and clearly state that “this guideline value is not intended to be used when considering the use of pyriproxyfen as a vector control agent”. From a scientific point of view, it is a pity that the mounting evidence against culprit Zika eclipses critical attention for the impact of pesticides. From an ethical point of view, it is a shame.

What is common to most Zika control measures so far  – vector control and others – is a total neglect of the people involved. Women are told to postpone childbearing, but denied family planning. Favela shacks are sprayed without consent, while their inhabitants are denied a life worthwhile living. This is of course nothing new in disease control; it is rather a déjà vu. Nearly 100 years ago, Juan Bautista Justo was one of the first to criticize Rockefeller public health in Latin America for turning a blind eye to the people. What was needed, Justo argued with strong political arguments, was social change for improved health. He was laughed away.

We should be wiser today. On top of the arguments Justo already had, we have a century of failed disease control, including old and new emergencies, and know much more of social and environmental impact than was the case then. For public health to be effective, it should be with the people, not against them.

In this comment, I offer you three things. First, a short explanation of what is meant by social determination (the lexicon part). Second, I argue that the distinction between social determination and social determinants is based on a partial understanding of social determinants. Third, I wonder whether cryptic concepts like social determination are pathognomonic  for the ‘splendid isolation’ of the Latin school of social medicine (the question part).

In their 2013 article ‘Conceptual differences and praxiological implications concerning social determination or social determinants’ (Spanish with English abstract), Morales Borrero and colleagues set the concept of social determination of health apart from that of social determinants of health. In their view, the social determinants approach as adopted by the WHO is the product of “Anglo-Saxon social epidemiology” which “conceptualizes society as the sum of individuals”, “does not call into question the structural causes of health inequities arising from capitalist accumulation” and leads to a focus on individual risk factors and lifestyle. In contrast, the concept of social determination of health emerged as an “alternative to classical epidemiology” within the 20^th century Latin American school of social medicine, which gives society a central place that “cannot be reduced to individual dynamics”, regards health inequities as the “product of inequitable power relations” and leads to a focus on social transformation. In their view, the social determinants approach is, at its core, based on an understanding of health and illness as dichotomic  variables at individual level, whereas social determination considers health and illness as a “dialectic process” embedded in and determined by a social context.

I would argue that the distinction between social determinants and social determination is a false dichotomy in itself. The very delineation of ‘social determination’ as a separate approach is dependent on a rather restrictive interpretation of social determinants framework(s). Admittedly, Anglo-Saxon scholars have contributed a lot to the latter. True also, a mainstream framework is the rainbow model developed by Dahlgren and Whitehead, consisting of a set of concentric arcs around the individual. And indeed, the individual being in the centre of the rainbow might have made it too easy to focus on that level (only) and keep the structural determinants out of sight. Dahlgren and Whitehead themselves never did so, and neither did Marmot, Diderichsen and others in their frameworks. In fact, there is no reason to adapt such a myopic view, except stubborn neoliberalism. Morales Borrero and colleagues (no neoliberals, for sure) are simply wrong: what they call ‘social determination’ perfectly fits within a comprehensive view of social determinants. Worse, they are fighting the wrong enemy: today, when the real challenge is to reach a critical mass of policymakers who can then put our knowledge on social determinants into action, setting up a separate fraction can hardly be considered a masterstroke.

Which leads me to question a key characteristic of the Latin school of social medicine – the repetitive use of unnecessarily complicated vocabulary in search of a unique identity. Let there be no misunderstanding: I have no disagreement with the cause of social medicine and I do think we can all  learn a lot from Latin America. I can also fully appreciate a good piece of Bourdieu after breakfast or one of the ‘Prison Notebooks’ from Gramsci over the weekend. But if I really want to take the cause of social medicine forward, should I then wrap up my thoughts in highbrow lingo? Iriart and colleagues, protagonists of the Latin school of social medicine, rightly note that much of the outputs of their school are hardly known in the English-speaking world. They postulate that “scepticism about research coming from the ‘Third World’” could explain lack of acceptance. Or that English itself would be the main barrier, not allowing “exact transmission, in all its complexity, of the concepts of social medicine”. As if the terms used were Spanish by origin, which is rarely the case. It does not seem to occur to them that mixing ‘praxiology’ with ‘hegemony’, or dropping a bit of Althusser dressing here and warming up some Marx basics there, does not necessarily add to understanding. Not among peers (they usually get tired – how many times have you been yawning reading this piece?), and less still among the obreros and campesinos the school pretends to represent. Which is a pity.

Ever wondered how journalistic writing is totally different from academic writing? Chances are you do when yet another of your policy briefs satisfies the agency that funded your research but doesn’t make any difference in the outer world. Reason to worry, if you pretend to belong to those “switching the poles in international health policies”. But the humble recognition of our limitations doesn’t have to be so dramatic.

When I was asked to write a press release for last week’s  Health Inc conference at ITM, I felt fairly confident. I had been involved in this project on social exclusion in social health protection from the setup to the final stage, so summarizing it in no more than 400 words would be a piece of cake. Let me see – short introduction, some words on methods, a trio of teasing results and a hint on discussion. Would make sense for anybody, wouldn’t it? I could even spice it up with a catchy title and a sexy hook. That’s how I learned to do it decades ago, when still earning my student fees writing for a couple of national newspapers. Moving with the times, I would top it up with a hyperlink or two.

When I presented the press release’s first draft to ITM’s communication officer, I expected no less than approval. A decent cold shower was what I got instead. Didn’t I know that the intro-methods-results sequence worked for bookworms only? Had I never heard of the famous  inverted pyramid rule in journalism, to start with the bottom line before entering into details and background? Of course I had, how could I have forgotten?

My next draft was much better. BLUF (bottom line up front)! The Health Inc project has provided a new tool to the world, called SPEC-by-step: “By making the social, political, economic and cultural dimensions (SPEC) of social exclusion in health financing visible, policymakers now have an instrument to address the phenomenon”. So, journalists of all countries, unite and publish!

Of course they did not. If you know of any journal article based on our press release, please let me know. I would feel so much better. Otherwise, I have no reasons for discontent: the Health Inc conference was well attended, presenters and policymakers engaged in meaningful debates, and contributions of the invited experts added to satisfaction. In short: a success. Moreover, feedback from the audience was overtly positive, including on the SPEC-by-step tool I thought would be a major contribution. Old and young co-alumni of ITM recognized it as a valuable adaptation (in social policy) of good old Maurice Piot’s  model (in disease control). Some even wondered why nobody came up with it earlier. But for nobody it was the centrepiece of our conference.

Everybody agreed that what really made the Health Inc conference stand out was the voice of those who had faced social exclusion themselves: loneliness, the sense of not belonging. It was first present in the songs and poems of Tutti Fratelli, the acclaimed theatre troupe that added lustre to the conference’s inauguration. It was also felt forcefully in the testimony of Danny Trimbos, an invited expert-by-experience in poverty and social exclusion. And it was omnipresent in the Health Inc film footage from Ghana and  Senegal, in which filmmaker Ellen Vermeulen warmheartedly pictured the people our partners had researched.

Not everyday a feeling strikes the privileged more than facts, certainly not the painful feeling of ‘others’. Should we feel proud to have given space to the voices that made this feeling of loneliness tangible?

Possibly yes. After all, social exclusion is not immaterial; it is painfully real.

You will forgive me for not writing about on-going ice bucket challenges this week, none match Laurel and Hardy’s pioneering work anyway. You might also understand that I skip the Gaza ceasefire. However desirable the latter certainly is, it is not yet the end of history and still a long way from peace. So allow me to talk about equity, an all-time favourite of mine.

It will come as no surprise if I tell you that I feel a deep respect for the critical views of Joseph Stiglitz, especially since he left the World Bank in 1999. Even before that, he was one of the first economists exposing market failure as the norm, not the exception. Hats off!

But times are changing fast. Gone are the early days of summer when Stiglitz hailed Piketty’s ‘Capital in the Twenty-First Century’ for providing “an institutional context for understanding the deepening of inequality over time” (July 27 in the New York Times). This week, we were flooded by announcements building up to Stiglitz ´Piketty is Wrong’ in Harper’s Magazine September issue. Bill Moyers reveals part of the upcoming article on his blog and Stiglitz himself tours the world to spread the word: “Inequality does not arise from capitalism” and “inequality has risen by abuse of capitalism, not by capitalism itself” (for those who read Dutch, see here). Nothing wrong with the economic system (of capitalism), but with the politics (of wealth-holders), he argues. Stiglitz’ argument is based on an ideal view of capitalism, quite at odds with his demystification of the market’s “invisible hand” two decades ago. In other words: there is something like good capitalism (in the same vein as sustainable development I guess), and we should go for it.

Sorry, dear Stiglitz, but in the real world economics and politics are hand in glove. As you yourself said before: “Economic inequality translates into political inequality, and political inequality yields economic inequality”. So please keep on fighting inequity, not Piketty.

In this week’s Featured Article, Natalie Eggermont reflects on WHO’s climate change & health conference in Geneva and the WHO Bulletin issue on the same topic from earlier this month.

Enjoy your reading.

Werner Soors (on behalf of the editorial team)