Marmot Makes The Case Yet Again For Social Determinants Of Health As
The “Causes Of The Causes”
Social
Inequalities Drive Health Inequalities
The Australian Broadcasting Corporation’s annual Boyer
Lecture series featured prominent epidemiologist and public health
researcher Sir Michael Marmot this month, delivering four
lectures entitled Fair Australia: Social Inequalities and the
Health Gap. The lectures were based on findings from his work over
the last 30 years on the social determinants of health.
In his first lecture, Marmot makes his case that the
societal inequalities affecting the conditions in which people live,
work and age, drive the health inequalities seen throughout the
world. As an example of the relationship between dramatic health,
social and economic inequalities that exist even within highly
developed countries, Marmot refers to a 20 year difference in life
expectancy between the richest (83 years) and poorest (63 years)
sections of Baltimore Maryland. He points out that the inner city
section with the lowest life expectancy is the very neighborhood where
riots broke out in 2015 in response to the police killing of a black
man. He cites similar gaps in life expectancy found elsewhere such as
London, where similarly a 2011 riot took place in the neighborhood
with the lowest life expectancy and argues that the very same social
conditions that promote civil unrest are significant contributors to
poor health.
While it may seem obvious to many that the poor have
worse health outcomes than the rich, a key finding coming from
Marmot’s research is that health
and life expectancy outcomes exist on a gradient both within and
across all social and income classes. As Marmot puts it, “People in
the middle of the hierarchy have worse health than those above them
and better than those lower than them. It is true in supposedly
egalitarian Australia and it is in class-bound England.” This finding
illustrates the importance of focusing on the social determinants of
health for all people and not just society’s poorest citizens.
Determinants Across
The Life Span
While much of public health research and policy is
devoted to what Marmot refers to as “downstream” factors, behaviors we
know to negatively affect health like smoking or drinking, he suggests
that society must devote more attention to what he calls the
“upstream” factors. These “causes of the causes” determine the
context within which all downstream factors take place, thereby
ultimately influencing how and when behavior choices are made by
individuals. This leads Marmot to suggest that we need to look at the
whole life from early childhood to old age and social inequities that
influence opportunities to grow and thrive.
The second and third lectures in the series continue on
this theme, examining in more detail the influence of social
inequalities on childhood development and our
working
lives and how these affect health in adulthood. Marmot argues that
adverse conditions in childhood lead to fewer opportunities for
meaningful and fulfilling employment in adulthood. In turn this leads
people to lack a feeling of personal empowerment and control over
their lives, which he believes has major negative effects on health
outcomes.
Inequalities Not
Inevitable
Despite the complexity of the issues underlying
inequality, Marmot argues that health inequalities are not inevitable,
pointing to the great variation in health inequality seen across the
globe. In his final lecture, Marmot offers examples of successful
interventions and suggests our efforts should be directed at
minimizing social inequalities that contribute to the health gap.
He begins his fourth lecture stating, “we have in our
heads the knowledge to close the gap in a generation; we have in our
hands the means to close the gap in a generation; the question is what
do we have in our hearts. Do we have the will to close the gap in a
generation?” He argues that both government and community actions are
necessary and cites work on social
determinants of health taking place all around the
world.
On a national
level, Marmot suggests new economic policies are needed to address
rapidly growing income and wealth inequalities. On a local level,
Marmot gives examples of community programs and interventions that
promote education, economic development and cultural continuity,
empowering individuals and giving them more control over their lives.
Despite a long career studying the numerous and powerful social
factors that can lead to poor health, Marmot remains optimistic,
saying “the problems are huge, there is a long, long way to go but
progress can be rapid”. Through efforts to create a more socially just
and equitable society, he believes that we can greatly improve the
health and lives of many of the world’s citizens.
Marmot is currently a professor of Epidemiology and Public Health from
the University College of London, the president of the World Medical
Association and director of the Institute for Health Equity. All four
lectures are available in their entirety for download here:
https://tinyurl.com/z9kbjew
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