[This article was published on Planeta Futuro / El País, on the occasion of World Health Day (7 April), by Clara Pons and P. Efraín Pantoja. Image by ISGlobal]
I am spending a week in the Mozambican capital of Maputo for the first time. A number of my friends and acquaintances have visited the city several times, including Efrain, my companion on this trip. We are both researchers at ISGlobal and Efrain has been living for some time in Manhiça, a district not far from Maputo. He knows the capital well and is familiar with its hidden corners and the markets where you can get the best food. So my visit is a good chance for us to explore the streets of one of the most beautiful and unequal cities in sub-Saharan Africa.
What immediately jumps out at us are the marked contrasts in the economic levels of the street’s inhabitants
We are eager to start our walk. The centre of Maputo is not complicated—just a few long, straight streets laid out in a grid. At the very beginning of our walk, on Avenida 24 de Julho, we pass several bookshops with window displays showcasing the best Mozambican and Portuguese literature. When we turn down Avenida Salvador Allende what immediately jumps out at us are the marked contrasts in the economic levels of the street’s inhabitants.
We take a right turn down Avenida Patrice Lumumba and eventually reach a large central square, the Praça da Independência. At the end of the street is the Franco-Mozambican Cultural Centre, a well-conserved building in the colonial style, frequented mainly by resident and visiting foreigners, whose purchasing power far exceeds that of the mean for Mozambicans. Tonight’s event is a concert with tickets at 500 meticals (a little over 7 euros), in a country where the minimum wage hardly exceeds 8,000 meticals for miners (114 euro) and does not even reach 5,000 (70 euro) for other workers.
Without even crossing the street, we are struck by the juxtaposition of newly built homes protected by electric fencing and a security guard on the door next to an abandoned building where the door is wide open door and the people living there are just about surviving. Side by side we see an imposing bank building, a trendy bar and a municipal theatre. Rain and last night’s fiesta have left their mark in potholes that dot the roadways, sidewalks and corners along the whole route we have walked.
The social perspective and the analysis of inequalities are not systematically included in all health research
Maputo is a city where people from different social classes live cheek by jowl on every street. We did not have to cross many pedestrian crossings to realise that. Inequality in health care is also normalized in this city. It is not unusual to see standing pools of water that can provide a home for mosquito eggs, there are no public baths, and waste management is minimal.
We sit down to rest for a while at a cafe terrace; the city has given us something to think about. The focus of our research is the health of the most vulnerable populations in sub-Saharan Africa, and Mozambique is one of the countries where we have most often worked. However, exploring the streets of Maputo today, we have realised that our scientific training has sometimes blinded us to another standpoint from which one can approach and understand the health of the population.
We already knew about the poverty in Mozambique; the high level of inequality is a less well known fact. After reviewing the scientific literature on the topics related to our work—mainly maternal health—we noticed that the social perspective and the analysis of inequalities are not systematically included in all health research.
Very often, the social inequalities in a country, region or city are what define the health of the population, even more than the global poverty level. In Manhiça, a district in southern Mozambique, almost 40% of the adult population is HIV-positive, but the prevalence is even higher in the population groups with least resources.
It is vital to include the social perspective and a multidimensional and multidisciplinary vision in both current and future science
The same thing occurs with maternal and infant mortality and with the incidence of malaria and tuberculosis. In each one of these cases, and also in a long list of other neglected diseases, depending on the route of transmission, the preventive measures implemented and available treatments are socially determined.
But what can we do to rectify this inequitable situation—this unjust and preventable inequality in health indicators depending on each individual’s social environment? Efrain and I finally decided that the only way something will be done is to first diagnose the problem. We came to the conclusion that it is vital to include the social perspective and a multidimensional and multidisciplinary vision in both current and future science.
The idea is not new, but to what extent has it been put into practice. In 2005, the World Health Organisation (WHO) created a Commission on the Social Determinants of Health. In 2008 this body published a report recommending the measurement and analysis of health inequities and the social determinants of health as an essential prerequisite to reducing such inequality.
Health is not something that should be associated only with hospitals and health centres, it also has a very important social component
Subsequently, other international resolutions and declarations by organisations such as the United Nations have supported the same idea of accelerating the improvement of health globally through multisectoral strategies that take into account the social determinants of health. And today, the Sustainable Development Goals (SDG) are based on the principles of working to achieve equity and leaving no one behind, with a view to achieving the goal of a healthy life for all at all ages.
While it is true that in recent decades the social aspects of health have received more attention in the academic world, a part of the scientific literature still does not take social determinants into account. For Efrain and me, this means starting to include this new perspective in our projects as well as promoting it to encourage more of our colleagues who work in the sciences to take social determinants into account in their work.
The many community studies, epidemiological surveillance systems and clinical trials currently under way in Mozambique and other parts of the world could throw new light on how we can reduce health inequities. Because health is not something that should be associated only with hospitals and health centres, it also has a very important social component, a component rooted on the street and in day to day activities. To be convinced of this, all you have to do is take a stroll through the streets of Maputo.