Box 1.2The Multisectoral Determinants of Health

Malnourished children easily acquire diseases, and they easily die from the diseases that they acquire. Dwellings and neighborhoods without sanitation provide fertile environments for transmission of intestinal infections. Cooking with wood and coal results in air dense with particulates and gases, which destroy lungs and lives. Hopeless life circumstances thrust young girls (and boys) into commercial sex work with its attendant risks of violence and sexually transmitted infections, including HIV/AIDS. Manufacturers of tobacco and alcohol profit enormously from advertising and promotion that spread addiction. Rapid growth in vehicular traffic—often with untrained drivers on unsafe roads—generates a rising toll of injury. Poorly designed irrigation creates breeding grounds for vectors of disease. The point is clear: determinants of health are truly multisectoral.

WHO coordinated a group of more than 100 individuals to generate estimates of the percentage of deaths, by region and globally, associated with a range of 26 risk factors (Ezzati and others 2004). Those estimates were revised and updated for the Disease Control Priorities Project. The results give a sense of the extent to which multisectoral factors contributed to mortality and disease burden in low- and middle-income countries in 2001. The following, for example, are estimates of the percentage of disease burden (and, in parentheses, of deaths) in those countries attributable to the indicated risk factors:

  • tobacco smoking—4.7 percent (8.5 percent)
  • indoor air pollution—2.7 percent (3.2 percent) inadequate water and sanitation—3.4 percent (2.8 percent)
  • risky sexual activity—5.3 percent (5.1 percent)
  • alcohol use—3.6 percent (3.4 percent).

Underlying most proximal risks are more general determinants of health, such as education and, to a lesser extent, income. The effects of income and education operate for the most part through influencing risk (and permitting effective use of health services). If an important fraction of ill health results from poverty and low educational levels—or from their consequences in inadequate food or sanitation or other specific risks—then ought the task of the health professional lie principally in addressing these underlying problems? In one sense, the answer is surely yes: the health community should measure the effects on health of actions outside the health sector. It should ensure that these findings are communicated and are considered by those making policy choices. The magnitude of the demonstrated effect of girls' education on health and fertility outcomes, for example, provides one powerful argument for investing in expansion of educational access to girls. Millions of premature deaths, to take another example, could be averted in Africa alone in the next quarter century with appropriate policies toward supply of energy for household use (Bailis, Ezzati, and Kammen 2005). It is essential that the health sector document and advocate opportunities such as these.

The health community has limited capacity for direct action outside the health sector, however. It will make more of a difference if it focuses its energy, expertise, and resources on ensuring that health systems efficiently deliver the powerful interventions provided by modern science.

Source: Author.

Note: The estimates reported here of DALYs and deaths that are attributable to various risk factors come from Ezzati and others (2006).

From: Chapter 1, Investing in Health

Cover of Disease Control Priorities in Developing Countries
Disease Control Priorities in Developing Countries. 2nd edition.
Jamison DT, Breman JG, Measham AR, et al., editors.
Washington (DC): World Bank; 2006.
Copyright © 2006, The International Bank for Reconstruction and Development/The World Bank Group.

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