>> Professor Marmot
Thank you very much indeed, and for leaving a brief moment of time as well. Because I
have to go and catch a plane, so this won't be a very long summing up.
Just one comment, Helen, in relation to what you showed about twin studies. That, I always
feel one needs a certain caution. Twin studies, essentially, [inaudible] a lot of the interesting
environment. For example, twin studies show that obesity is 60 to 80 per cent heritable.
And we know what's happened to obesity over time. We didn't change heritability but it's
increasing its epidemic. So twin studies answer certain type of question, and as you then
made clear in the rest of your talk about the importance of a particular aspect of the
environment, which, given today's meeting, is adverse child experiences.
I was asked, when I met the CMO, Catherine Calderwood, how are we doing in Scotland?
And my first comment was, the fact that this meeting is happening is really very encouraging.
The fact that it's happening and was full, there was a waiting list, so many people wanted
to come. So that's really encouraging. It's on the agenda, people are concerned about
it.
My own view is that if we think that cross government action is vital to take action
on social determinants of health and health equity, then children is a good way in. I
was giving a lecture to the American Public Health Association meeting three years ago
in Boston, 7,000 people in the room. And I showed figures for poverty of children before
and after taxes and transfers. And a slightly different figure to the one I showed then,
but I've used this contrast.
If you compare the US and I chose Australia, because I thought Australia sounds a bit like
Texas, maybe California, you know, Americans would understand that. And if you compare
child poverty, less than 50 per cent median income, in the US, before and after taxes
and transfers, child poverty goes from 24 per cent, less than 50 per cent median income,
to 23 per cent, after taxes and benefits. In Australia, it goes from 29 per cent child
poverty to 11 per cent. And I said to this audience, it shows that government action
can make a difference, and this must be the level of child poverty that you want. You
live in a democracy and you must have voted to have this. I think I'd get lynched in certain
circles now, given what happened on November 9th, the idea that this is the kind of democracy
that the US wants.
But it illustrates that, firstly, what kind of society we live in is important, and the
social action to change the environment in which children are raised, and child poverty
absolutely key. And it relates to the question commonly that gets asked, well, are the poor
to blame for their own poor health, too many fish and chips, lack of interest in their
health, don't go and see the doctor when they need to, and so on.
And I have several responses to that, but one of them is, don't blame the children.
It's not the children's fault for the parents they chose. You may say - I'm not enough of
a biblical scholar to know, but I think it comes from Jeremiah - 'If the parents eat
sour grapes, the children's teeth get put on edge'. You could say, well, it's the parents'
fault for eating sour grapes that the children's teeth are on edge. Yeah, but golly, you're
going to blame the children for their choice of parents? So that seems to be immoral. You
can't say, well, the children just should have been brought up in different families.
We really, as a society, should care about those things.
A second response to, isn't it their own fault. A most recent example was a study in science
that was published last week, looking at rhesus macaque monkeys, the female rhesus monkeys,
where they can manipulate their social status. We don't do it that way, we tend to have life
course effects that continue. But with rhesus, you get a group of high status monkeys, and
second ranking and third ranking and fourth ranking in different groups, so you get high
status from all the different groups. And then the status is highly correlated with
the order in which they enter the new group. So you take Abigail and she's high status,
and you put her in a new group. And then you take Bertha who was high status and put her
in the new group, she tends to be second in the rank. And so on, you take Cordelia and
put her in, and she tends to be third. And you take [inaudible] - or somebody, I can't
make it up quickly enough as you go along - and she tends to be fourth, and so on.
So you can manipulate the status. Well, the monkeys' immune function is determined not
by the status which they had in the past, but the status in the new group. And they
weren't responsible, it was their social situation that actually determined their biological
response. And none of them smokes or eats deep-fried Mars Bars or whatever the thing
is. They don't do any of that stuff, it's related to their social position which has
been manipulated. So simply to blame people for their own misfortune or blame the children
is hugely inappropriate.
And if we're successful in getting cross government buy-in because education, the criminal justice
system, social welfare, environment, housing, as well as health, are all key, then perhaps
we've established the principle of cross government action that would apply to the other key domains
of life.
Again, one of the usual questions is, yeah, yeah, yeah, but politicians only think about
the next election or the one after, or whatever, and they're very short term, et cetera, and
you're talking about a long legacy, how do you get them interested in this? I have an
unusual hypothesis, which is, inside most politicians is a desire to do good. I think
inside most of us is a desire to do good. And we have to tap into that inner good person.
They're in a position to do a whole power of good, and we need to tap into that part
of them that wants to do that. And I think most of them are there for that reason. Other
ghastly things happen when they get there, but most of them really are motivated at some
part of their inner being, they want to do good. And then, of course, we can get short
term markers that show how things are going.
So I think using the fact that almost everybody - I mean, when I said this to this big American
audience and I said this is our children we're talking about, democrat, republican, I couldn't
get care less, it's the future of our children, is there a politician in the land who said
I don't care about our children? And a voice called out, you'd be surprised. Well, I think
most people care about children and it is a way of getting in there.
And I think what we've heard today is that we need action at different levels. I've been
arguing - and it sounds a bit academic and abstract and abstruse - that health and health
inequalities tell us a great deal about the nature of society. I knew that things were
bad in the Former Soviet Union and the communist countries of Central and Eastern Europe, because
health failed to improve. When the Soviet Union collapsed, things got worse in Russia,
the society wasn't working. It got better in the Czech Republic and Poland, and some
of the other countries.
So health tells us a great deal about how well the societies are functioning. And health
inequalities tells us something even more. Now trying to get that argument through to
the decision makers sounds a little bit airy-fairy but saying Scotland's doing well but it could
do better, and then translating it into some things they really do care about. And we said
in the discussion with the CMO this afternoon, I said, if you look at the gradient, for example,
in school performance, the gradient by degrees of deprivation and affluence, and ask, are
we failing our children in England, only 30 per cent in the most deprived deciles get
as many as five Cs as the GCSEs aged 15.
And any expert I've spoken to thinks that means children are not living up to their
potential. And we potentially are giving politicians the opportunity to take action to help all
our children achieve their potential. And that means doing what we can to avoid adverse
child experiences; doing what we can to understand resilience, promote recovery; doing what we
can to improve early child development in general, not just avoid adverse child experiences.
So we need specific action - and we heard a lot about that today - and we need to be
addressing the nature of society.
Next steps. Well, next steps are saying we've heard a great deal of interesting material.
Mark Bellis in Wales gave us a ten-step plan of action at different levels. I said, Mark,
we're going to be watching, we want to know if any of it works. We heard about action
at the very local and specific level, working with individuals. And we need it at all levels.
So we need to get really active to build on the excellent material we've heard today,
and have an evaluative framework. I was saying at lunch, somebody said to me, if you've never
been proved wrong, you're not doing your job properly. So we need to have a self-critical,
self-questioning evaluative framework as we go forward, because we might be wasting our
time. I don't think we're wasting time in recognising the dramatic importance of adverse
child experiences, but we might be wasting time if we're doing things that are not effective
in trying to address the problem.
So continuing the work but doing it in a context of evaluation of knowing how well we're doing,
I think, is absolutely crucial. And you can see the potential benefits. Somebody said,
I think it was Michael, I showed the US figures and you talked about the Glasgow effect. It's
interesting the point that Michael made, those excess causes of death that I showed on the
US figures are exactly the same as the excess in Glasgow. They're all psychosocial, poisonings,
suicide, alcohol related deaths, and other violent deaths. They're all psychosocial and
they all have their origin early in life.
The goal is certainly one worth attaining, to improve health for everybody and reduce
inequalities; to create societies where everyone can achieve their potential. And I go away
from today hugely encouraged, and I want to thank you for that.
[applause]
And thanks to everybody for coming and for organising such a splendid meeting.
[applause]