Dr. Benjamin: Five years ago, we had a speaker come to our fine gathering and talk to us
about the root causes of ill health.
Five years later, we have asked Dr. Sir Michael Marmot to come back and talk with us a bit
about what’s happened these last five years.
Dr. Marmot, you know, is the director of the Institute of Health Equity, also known as
the Marmot Institute.
He is a chair of the European Review on the Social Determinants of Health, or the Health
Divide.
He is the director of the International Institute for Society and Health, and an MRC research
professor of epidemiology and public health, the University College of London.
He is also a good friend, my friend, Sir Michael Marmot.
Dr. Marmot: Look along the row.
Count 10 women.
If we were in Afghanistan, assuming women were allowed in, one of those women would
die during her life from a maternal-related cause – one in 10.
Imagine seven of these vast arenas in the best-off part of Europe.
One woman in 46,500 would die during her life of a maternal-related cause.
That is entirely unnecessary – this enormous toll of women’s lives, of children’s lives,
of people’s lives is an entirely unnecessary.
As I will tell you in a moment, I’ve just completed a European review of Social Determinants
of Health and Health Divide, and I made an unlikely assumption that the United States
of America was a European country.
I should say that the European region of WHO is 53 member states.
It includes the whole of the former Soviet Union, so Kazakhstan and [Kegastan] – it
stretches so far east, you can just about touch Sarah Palin.
You think that’s funny?
I think that’s really scary.
I asked for maternal mortality, how would the United States look?
It turns out 37 countries have lower maternal-mortality ratios than the USA.
You rank just behind Turkey and just ahead of the Ukraine.
Two months ago I spoke to a meeting of the American Gynecological and Obstetrics Society,
and I said “I would be convinced if you told me you provided the best obstetrics care
in the world.
Why do you rank 38th When we reported, we said social injustice
is killing on a grand scale – somewhat unusual for a WHO report to have that on the cover.
Social injustice is killing on a grand scale.
We said that inequities in power, money, and resources are responsible for the inequities
in health that we see around the world – a toxic combination of poor social in Europe?”
If I asked you – who is it who dies?
Write it down on a piece of paper, and you will come up with same answer.
It’s the disadvantaged, the poor, ethnic minorities, the socially excluded.
Much of the discussion in recent months and years in the US has been about healthcare
– has been about healthcare.
But having mentioned maternal mortality, which is healthcare-related, you know as well as
I know that much of the differences in health that we see across the world, the inequalities
between countries and inequalities within countries – there, I will move it on.
The inequalities within and between countries are not due to deficiencies in healthcare.
They are due to the operation of the social determinants of health.
It was precisely for that reason that WHO set up the Global Commission on Social Determinants
of Health.
policies and programs, unfair economic arrangements, and bad governments is responsible for most
of the health inequities that we see.
The question is – is anybody listening?
The answer – my evidence-based answer – is yes.
We said, naïvely perhaps, when we launched the Commission on Social Determinants of Health,
that we wanted to create a social movement.
I think what you’ve heard from Dr. Benjamin, what you represent here is part of that social
movement.
Let me show you some evidence.
In the wake of the global commission, I was commissioned by the British government to
conduct a review of health inequalities in England.
I called my review – and it’s the title I gave my talk today – “Fair Society,
Healthy Lives.”
It was a statement that if we put fairness at the heart of all policymaking, health would
improve; and health inequalities would diminish.
I’m slightly regretful that I gave at that title.
The government in Britain that we have now – the conservative-led coalition government
– uses the word “fairness” as if it has no meaning at all.
They cut the top rate of tax, and they call it fair.
They cut benefits to the poor, and they call it fair.
They cut services to the disadvantaged, and they call it fair.
I call it a grotesque parody of fairness.
I debated with our health minister at British Medical Association House, BMA House, and
I said to him “I use health equity in a technical sense.
The systematic inequalities in health between social groups that are judged to be avoidable
by reasonable means and are not avoided are unfair.”
Therefore any government policies that retard progress toward reduction of these avoidable
health inequalities are unfair.
That’s how we should judge policies across the whole of society.
As I will finish with, I will tell you about our European review of Social Determinants
of Health and the Health Divide that we launched in London last Wednesday.
This was figure one from my English review, and in a way it set the intellectual framework
for everything that followed.
This is every neighborhood in England classified by deprivation.
At the upper and you have the most affluent, and at the other you have the most deprived.
The top graph is life expectancy.
What you can see is that people in neighborhoods near the very top have shorter life expectancies
than those at the top.
Those in the middle have shorter life expectancy than those near the top – and so on, all
the way from top to bottom.
The bottom graph is disability-free life expectancy, and the gradient is steeper.
The gap between top and bottom, which was seven years for life expectancy, is 17 years
or disability-free life expectancy.
That means that people at the top are living 12 years of their life on average with disability,
and people on the bottom – shorter lives, but are living 20 years of their lives with
disability.
I said with the global commission, I said with my English review that it’s about social
justice and fairness.
People have said to me “No government will take you seriously unless you can make the
economic case.”
So I’ve said “Okay, I have a cost-effective intervention to deal with that large gap in
disability – that 20 years of life that with
disability.
Handout free cigarettes the poor.”
You are not applauding.
Of course you are not applauding.
It’s morally corrupt.
We don’t do things just because they are cost-effective and cheap.
We do what’s right.
And you only have to conduct that thought experiment for an instant to know we are driven
by a moral commitment, not simply what’s cheap and effective.
I had six domains of recommendation in my English review.
Every child should have the best start in life.
Education and lifelong learning.
Create fair employment and good work for all.
This fourth one is a really radical one – in a rich society, everyone should have the minimum
income necessary for a healthy life.
That minimum income includes, for example, for people beyond working age having enough
money to buy presents for your grandchildren.
How can you lead a life of dignity if you can’t buy presents for your grandchildren?
That’s what we mean by a healthy life.
The fifth is create and develop healthy and sustainable places and communities, and take
a social-determinants approach to prevention.
As you can see, we think that every sector is a health sector.
I was at a meeting where the Norwegian minister of foreign affairs said “I am a health minister.
Every minister,” he said “is a health minister because what we do in our day job
impacts on health.”
I got a phone call from a senior official in the ministry of health in Norway, and she
said “You know you’ve been quoting our minister of foreign affairs, saying he is
a health minister.
He now is our health minister, and he would like to meet you.”
So I went to Norway, and we had this session of mutual congratulation.
I told him what I had been saying about him all around the world, and he said “I went
to a county in southern Norway, and not the health people but the local government people
showed me their plans and said ‘These have been Marmot-certified.’”