Closing the gap in a generation: Health equity through action on the social determinants of health

Committees often figure in the punch lines of jokes about inefficiency and lack of productivity sometimes for good reason. Ideological stalemates can grind work to a halt, or lack of agreement on substantive items can produce documents that cater only to the very least common denominator. When confronted with ‘Closing the gap in a generation’, produced by a committee appointed by the embattled World Health Organization, a reader might feel authorised to be cynical before even opening it. But the jaded reader is in for a surprise. The Commission on Social Determinants of Health, chaired by Michael Marmot, includes 19 participants from several countries and diverse academic backgrounds, among them heavyweights such as Giovanni Berlinguer, one of the most relevant intellectuals in the international field of public health, and Nobel Prize-winning economist Amartya Sen. Part manual, part manifesto, ‘Closing the gap in a generation’, the product of their collaboration, is a powerful proposal of sound health policies, with a broad, intersectoral approach, founded in solid evidence and pulling no punches in putting forward a very progressive agenda. Incidentally, such characteristics make writing a review about this book quite a challenge; among other aspects, how to summarise something that is already a summary. The key argument of the book is quite straightforward, and could be summarised by its very first sentence: ‘Social justice is a matter of life and death’. Further, ‘inequities in health, avoidable health inequalities, arise because of the circumstances in which people grow, live, work, and age, and the systems put in place to deal with illness. The conditions in which people live and die are, in turn, shaped by political, social, and economic forces’. The action plan is spelled out a couple of paragraphs after that: ‘In the spirit of social justice, the Commission on Social Determinants of Health was set up by the World Health Organization (WHO) in 2005 to marshal the evidence on what can be done to promote health equity, and to foster a global movement to achieve it’. And that, in a nutshell, is exactly what the book is about. It is organised in three parts: an executive summary that presents the overall discussion of the book in synthetic form; 17 chapters contained in six divisions (‘parts’) that flesh out the full argument in detail; and an appendix that lists again all the recommendations. This reiteration of ideas is in line with its dual characteristics of being simultaneously a reference textbook and a guide for political action. In the detailed chapters that form the bulk of the book, the arguments are structured in smaller segments, beginning with a review of pertinent literature, followed by a brief discussion on the problems and ways to face them and ending Global Public Health Vol. 6, No. 1, January 2011, 102 105