We have the knowledge and the means, but do we have the will? That is the question which UK epidemiologist Michael Marmot posed to his audience in a keynote address at the Second Annual Symposium on the Social Determinants of Health sponsored by the Urban Institute at the Johns Hopkins School of Public Health. The theme of the conference was on “Taking Action on the Social Determinants of Health”.

Bold Assertion

Marmot began his talk by recalling the bold assertion made in the title of the landmark WHO Commission report on social determinants of health in 2008 that the gap in health equity could be closed in a generation. He cited a 44-year gap in life expectancy between women in Zimbabwe (LE 42 years) and those in Japan (LE 86 years), and an enormous difference in the risk of dying from maternal related causes of death in Afghanistan (1 in 8 women) versus those in European women (1 in 46,500). The WHO report was in effect stating, said Marmot, that the world has the knowledge and the means to close this gap if it chooses to do so.

Fairness As A Health Intervention

Marmot described how he was invited by authorities in the UK to examine how the findings from the WHO report could be translated into action for one specific country. Marmot and his colleagues issued a UK report entitled “Fair Society, Healthy Lives” which made what he called the “grand claim “ that if fairness became more widespread in British society, then health would improve and health inequities would diminish. In effect, the report conceived of fairness as a health intervention, and made recommendations for actions in early child development, adult education, income, environment, and in prevention and other domains.

Truth To Power

Marmot said he came to regret the use of fairness in the title of the UK report because politicians in the UK at the time were lowering taxes on the rich, removing tax credits and benefits for the poor, and calling these policies fair. He denounced these unfair policies as “a grotesque parody of fairness” and was portrayed as  “political” by the media. Marmot insisted to his audience that he is not political, but as a person with the luxury of being an independent academic, he believes one of his main tasks is to “speak truth to power”.

Rationales

When invited to review the situation on social determinants for the broader European region, Marmot was keen to select social justice and empowerment as the key rationales for addressing social determinants of health. “We take action not for instrumental reasons, but because avoiding health inequities is the right thing to do,” he said. Furthermore, he placed empowerment of people at the center of efforts to reduce inequities. “We want to create the conditions for people to have control of their lives,” he said.

Social Gradient

In discussing social determinants, Marmot took up the important concept of “social gradient” to emphasize that poverty is relative to what individuals can do in the context of their own societies. He noted that 40% of the world population lives for less than $2 per day. In that sense, “persons in the UK and the US would be fantastically wealthy,” he said.

But there are still large gaps in life expectancy between different groups in these countries. He denied the accusation that he would like the rich to have poorer health in order to reduce the inequities, and he called for taking action across all socio-economic groups.  Even in countries like Sweden where the overall health level is high, there are still growing gaps in life expectancy between groups at all income levels, according to Marmot.

Knowledge and Passion

In the follow up question and answer session, Marmot sought to emphasize even further the importance of being committed to a fair society. In seeking to move forward on such a goal, Marmot said he sees two key tasks. First, there is the need to gather evidence of what works and to obtain a sound evidence base. He repeatedly emphasized the importance of having solid facts behind you. Second, there is a need to engage partners in the effort wherever you can find them. He declined to express a preference for working on social determinants at the global, national, state, or local levels, but instead urged his audience to “go where the receptors are!”

Advice

If he had any advice to give young persons, he said it would be “argue while staying as close as possible to solid evidence, and then have the passion to make a difference.”

Videos for Marmot and Amartya Sen

Videos of Marmot’s talk as well as one given at the first annual Hopkins symposium in 2012 by prize winning economist Amartya Sen are available at:

http://tinyurl.com/jvoahgj
and at:
http://tinyurl.com/kdljfpn

No Famines In Democracy

In his earlier address, Sen echoed Marmot in noting the importance of empowerment for health, saying that a station in life which is one of“unfreedom”, of being “sat upon” affects one’s mental configuration, and it has a major impact on mortality. He was much less reluctant than Marmot to acknowledge the important role of political activity in addressing the challenges associated with the social determinants of health, noting that there are no famines in a democracy!

By implication, there should be no equity gaps in free societies if the gaps or the inequities could be publicized by the media as easily and effectively as famines.  Sen stated that the effort on social determinants of health should include political engagement of a much wider kind. Sen also highlighted the importance of the market in supplying the state with the revenue needed for public services.

He closed by reiterating how health is present in every aspect of our lives and is “a quintessentially social subject”. As such, Sen argued, “there is room” for economics and politics in the pursuit of the goals related to social determinants of health.

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