On the 19th May, the Universitat Pompeu Fabra (UPF) hosted the 2023 Presentation of the International Journal of Social Determinants of Health and Health Services (IJSDOHS). The event brought together experts in the social determinants of health (SDOH) from across the world to explore and discuss the major questions and future pathways for research, policy and action regarding the SDOH and health services. 

The following article summarises the key issues and discussions that proceeded in Session 4 of the event.

The final session of the day, entitled “Policies and actions for the reduction of health inequities”, was moderated by Keshia Pollack Porter (Johns Hopkins Bloomberg School of Public Health, US). The speakers were Nihaya Daoud (High Committee for Palestinian Health / Public Health Forum for the 1948 Palestinians, Palestine/Israel), Davel Milian Valdés (Faculty of Medicine, Hospital General Calixto Garcia, Cuba) and Bukola Salami (University of Alberta, Canada). 

In the first presentation, Daoud explored Palestinian health and health inequalities from a critical and decolonial perspective, arguing that the healthcare system in Palestine/Israel operates as an arm of Israel’s settler colonial system. She stated that Palestinians have not been recognized as indigenous people despite more than a century of colonialism, and “are denied the collective rights enshrined by the UN Declaration on the Rights of Indigenous Peoples, including the right to health.” Daoud gave various examples of how Israel’s colonial power over the Palestinian population is maintained by structural and institutionalised racism, whereby Palestinians are considered second-class citizens and have a lack of political power. This causes extreme health inequalities between the Jewish Israeli and Palestinian populations, which are visible in health indicators such as life expectancy, causes of mortality and mental health. She identified the creation of the Israeli state as the starting point of these inequalities: "When Israel was created in 1948, separate health care systems were created for Jewish settlers and for Palestinians...at this point we start to see health inequalities growing". She added that although there is technically universal health coverage in Israel, the country’s two-tier system continues to cause major health inequalities: this became explicit during the COVID-19 pandemic, in which mortality was much higher for Palestinians than for Jewish Israelis. Daoud argues that in order to tackle this unjust situation, the international community must recognise Palestinians’ rights as an indigenous people, and adopt the narrative of colonisation in discourses regarding Palestine/Israel, acknowledging the historical injustices and racism that they have suffered. This would change the approach to Palestinian health “from victim-blaming to a more equity-based approach.”

Milian Valdés followed this with a presentation of the Cuban case. He started by providing the historical context of health in Cuba, whereby 60 years ago, life expectancy was 35 years and the maternal mortality rate was 137.8 per 100,000 live births. He contrasted this with the current situation, where life expectancy in 2020 was 78 years and maternal mortality rate was 40 per 100,000 live births, and noted that these improvements have happened despite the country having faced considerable economic hardship, political struggles and ongoing sanctions. Milian Valdés linked these major developments to the importance placed on the social determinants of health by the Cuban government since the 1960s, for example through tackling illiteracy. He described some key events in the recent history of Cuba that transformed its healthcare system, reducing the health inequalities in the country considerably. During the first stage of transformation, in the 1960s, the government implemented a “social medicine service” to provide medical services to the rural parts of the country. It also united the three-tiered public, private and insurance-based healthcare system into one universal, public system. In the second stage, in the 1970s, the government created a multitude of general clinics across the country, with a strong focus on preventative healthcare. In the third stage of transformation in the 1980s, the government implemented the unique family doctor and family nurse model. Under this model, family doctors take on the role of community leader, working towards social transformation and health equality through “identifying and tackling the social determinants of health in their community”. Milian Valdés highlighted that this impressive progress in tackling health inequalities has occurred despite the damaging effect that US sanctions have had on the Cuban economy. 

The final presentation, by Salami, focused on the mental health of black children and youths in Canada. She started by describing the unequal demographic context of Canada, using the metaphor of the “cappuccino effect” whereby the society is “black underneath and white on top”. She noted the large discrepancy between educational attainment and income levels for Black people in Canada: Black people in Canada tend to have higher education than white and indigenous people, due to the high levels of education of Black immigrants. Nevertheless, they have some of the lowest incomes in the country. Salami indicated the health implications of racial inequality, referring to the COVID-19 pandemic, in which Black communities in Canada, the US and the UK suffered from higher mortality rates than white communities. She then presented her research on the mental health of black youths, demonstrating how structural racism and racist attitudes in Canada have a negative impact on Black youths’ mental health. One example is the mental pressure and suffering caused by the fact that “for the Black population, you are guilty until proven innocent”. She described certain formal and informal barriers to Black youths accessing mental health services and care, such as distance to services, lack of finances and lack of representation (formal), and stigma and cultural expectations (informal). In response to these findings, Salami proposed some policies and approaches for tackling the racial inequalities in mental health in Canada. These included diversifying the health workforce, addressing income as a social determinant of health, tackling anti-Black racism, strengthening Black communities and the capacity of community leaders to address mental health, and improving the geographical distribution of mental health services.

The Q&A session that followed included a discussion with the audience on the limitations of implementing progressive public policies within capitalist systems and strategies for overcoming these limitations.