Page - 316 - in VULNERABLE - The Law, Policy and Ethics of COVID-19

VULNERABLE316 The fair social distribution of valuable health care resources is a coher- ent concern, and speaks to the question of how nations should allocate resources during a pandemic. But concerns about equity or fairness have also been raised regarding the high proportion of deaths among older people and racial and ethnic minorities, the impacts of lock- downs and gender inequalities, and the economic impacts due to loss of incomes and jobs. Beyond the allocation of health care resources, the equity concerns raised by this pandemic go to the very founda- tions of how the 260-plus countries and territories in the world are organized and function. Health Equity and Social Determinants of Health During normal times, the health and well-being of both individu- als and a national population, as well as health inequalities across individuals and social groups, are created overwhelmingly by social determinants. Across all high-, middle-, and low-income countries, social determinants of health are what have been described as “the conditions in which people are born, grow, live, work and age.”3 These conditions include such things as early infant care and stimula- tion, safe and secure employment, housing conditions, discrimination, self-respect, personal relationships, community cohesion, and income inequality, among others. Access to health care for prevention and care is important, but it is only one of the many social determinants of health, illness, impairments, and premature death. Furthermore, these determinants operate at levels ranging from the micro, such as inter- personal interactions affecting neuropsycho-biological pathways, to the meso and macro, such as community cultures, national political regimes, and global processes affecting trade—and, as this pandemic shows, global organizations, governance structures, and norms. Social determinants of health, unlike the proximate determi- nants of individual biology, personal behaviours, and exposure to harmful agents (for example, pathogens) are most often the long chain of causes setting up these proximate determinants. A third key aspect of social determinants of health is that health, with life expectancy 3. WHO Commission on Social Determinants of Health & World Health Organization, “Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health: Final Report of the Commission on Social Determinants of Health” (2008), online (pdf): World  Health  Organization <www. who.int/social_determinants/final_report/csdh_finalreport_2008.pdf>.