UK epidemiologist Sir Michael Marmot is well-known in epidemiology circles for his work on social determinants of health and for his efforts to promote public health actions linked to those determinants. He was interviewed recently on radio in Australia and offered insights about his quest to achieve greater impact for the evidence on social determinants. Shortly afterwards, he he was in Edmonton Canada attending a conference organized by the Institute of Health Economics. Below are excerpts from the Australian interview with Richard Aedy and quotes from an article in the Edmonton Journal about this talk that will be of special interest to epidemiologists

Selected Excerpts From Australian Radio Interview

Aedy:…All of these factors, from diet and education through to status, are what’s called social determinants. And the man who worked out what impact they have on health is Sir Michael Marmot of University College, London.

So how important are they?

Marmot:  Health inequalities and the social determinants of health are not a footnote to the determinants of health. They are the main issue.

Aedy:  Insofar as this relates to social environment, poverty say, it seems very intuitive. If you’re poor you don’t eat as well, you don’t have access to the best health care or education.

But you have found that there’s more to it. Not only does absolute disadvantage matter – relative disadvantage matters.

Marmot:  Absolutely. And that’s very important because the default position of social policy in certainly the English-speaking world is that we should focus on the worst off.

But what we’ve shown in study after study, in country after country, that there’s a social gradient. And by that I mean the lower you are in the hierarchy, the worse your health, the higher you are, the better your health.

So it’s not just that people with no education have worse health. People with a bit of education at somewhat better, with a lot of education it’s even better. And with even more education it’s better still.

In Sweden, for example, people with PhDs have lower mortality than those with a masters degree. And people with a masters degree or a professional degree are not poor. In fact, those with professional degrees are richer than those with PhDs, and yet the PhDs have lower mortality than those with a professional degree.

So we’re not dealing only with poverty, important as that is. We’re dealing with a social gradient; relative inequalities.

Aedy:  What is the mechanism? I mean, do we know what is happening inside our body?

Marmot:  Now I think there are perhaps three ways to think about it. The first is exposure to environmental hazards. And they may be physical hazards, they may be biological hazards, so maybe pollution, maybe infections - and they tend to follow the social gradient.

The second is lifestyle, that your position in the hierarchy influences your behaviour. So I don’t blame people for smoking when I see a social gradient in smoking. I say we need to understand why is it the lower you are in the hierarchy the more likely you are to smoke. So we need to address the causes of the causes.

And thirdly the most interesting organ - or what Woody Allen called the second most interesting organ - is the brain. And the brain is an important gateway by which the social environment impacts on people’s health through the mind.

There’s good evidence that if people are disempowered - if they have little control over their lives, if they’re socially isolated or unable to participate fully in society - then there are biological effects.

Aedy:  You’ve said that health is a good marker of how society is going. So given the health of indigenous Australians, how is Australia going?

Marmot:  What we see when we compare the health of indigenous Australians with non-indigenous Australians is marked inequalities. And that tells you something about Australia.

Australia is a very healthy country which goes along with the fact that it’s very high on the Human Development Index: high wealth, good levels of education. So Australia ranks right up there, second or third on the Human Development Index.

And indigenous Australians, if you treated them as if they were a separate country, would rank probably about 100^th or below 100.

So you’ve got this incredible inequality, which of course tells you that there are huge social and economic inequalities, that the differences between indigenous and not indigenous Australians can be easily attributed not to differences in their genes, but to differences in the conditions in which they’re born, grow, live, work and age – in other words, to the social determinants of health.

Aedy:  Mmm. That of course has been taken on by governments, especially in the last few years, with this idea of closing the gap in life expectancy. And there has been some progress, I think, not very much, but some in that. How can we do better?

Marmot:  The first thing I would say is that solutions cooked up in Canberra, Sydney or Melbourne will fail, guaranteed. That we cannot decide what’s best for a community several thousand kilometres away and expect that to work, with the best will in the world.

One of the things that we said in the WHO Commission on Social Determinants of Health is that empowerment of individuals and communities is absolutely central. Getting the community involved in organising their own destiny has got to be a key part of it.

Aedy:  But politicians have to work in the here and now more than the future. We’re constrained.

Marmot:  I don’t have to work in the here and now and my job is to produce the best evidence. If the politicians don’t want to listen to it, then we live in a democracy, and they’re politicians we elect and that’s the way it is. But my job is to produce the best evidence and the best arguments based on that evidence.

Aedy:  You have always been very careful not to be political. But it must be frustrating sometimes when you present evidence which an enormous amount of work has gone into obtaining, and the decision makers mostly don’t do very much with it.

Marmot:  Well, I think the aim of doing the kind of work I do and bringing the evidence to bear is to become part of the discourse. One does not see, or very rarely does one see a one-to-one link between a review of the evidence and policies to address it.

My experience of trying to influence policy makers, the first time I put evidence in front of them and they didn’t do it I thought, this is terrible! How can they ignore the evidence?

Now I think my job is to continue to produce the evidence, to put it before them, to try and influence policy makers. But our elected politicians do what they judge is the right thing to do. And if we disagree then I’ll show them the evidence of why I disagree.

Aedy:  You are able to do that more and more now. I mean, you’re very much the leader in this field. You’re world-renowned, your research, and the tide is with you, if I could put it that way. But it wasn’t always like that. I mean, you spent years really swimming upstream. I’m wondering, what sustained you in that time?

Marmot:  Well, it’s interesting. In Britain for eighteen years from the time Mrs Thatcher was elected ’til the time Tony Blair was elected, for eighteen years the government of the day said, ‘we do not want to know about health inequalities’. So what I was doing was pure research. There were no applications of the research.

So what sustained me was the fun, I mean the sheer intellectual joy of doing research, which I did a lot of during that time, published lots of papers, got lots of research grants, talked to interesting colleagues. You know, the academic life is wonderful. That’s why people love to do research. And I loved it, it was great.

And then the government changed. And from one day to the next yesterday’s pure research became today’s applied research. Suddenly they were asking: what if we took this seriously?

Some of the things that sustained me is that when I was commissioned - the Marmot Review in England - when I was commissioned to do that by a Labour government it was reasonable to speculate - and a lot of people did speculate - that we’d have the same experience as happened way back in 1979 when Mrs Thatcher got elected and said, I don’t want to know anything about health inequalities, and suppressed what was called the Black Report on health inequalities. And people said Marmot would go the way of Black.

But my report did not. A Conservative led government said, we will not try and sweep health inequalities under the carpet. We’ll try and address them. Now I’m somewhat critical of the degree to which they’re doing it, but they didn’t try and sweep it under the carpet.

So to come back to your question, I was sustained by the sheer fun, joy of doing research, the intellectual inquiry, and now the challenge of trying to formulate policy.

Selected Quotes From Edmonton Newspaper

“We don’t do things because they’re cheap. We do them because they’re right.”

“Social injustice is killing on a grand scale. Inequalities in power, money, and resources are the key drivers of inequities in health.”

“Its social circumstances that determine health, not health that determines social circumstances…and its not just about the money. It has more to do with social position than money.”

“We need to create conditions for people to take control of their lives.”

“Focusing solely on the most disadvantaged will not be sufficient. A health system for the poor is a poor health system.”

“Every minister is a health minister and every sector is a health sector. If we put fairness at the heart of all policies, health would improve.”