Pursuing health equity with Professor Sir Michael Marmot

[Opening music…]

Gretchen Miller: Hello again, you are with Prevention Works, the podcast of The Australian Prevention Partnership Centre, recorded here on Gadigal Land with me, Gretchen Miller. Now, of course, all our guests are special, but today’s is particularly so. We are joined by the renowned epidemiologist Professor Sir Michael Marmot, what a treat. Sir Michael is Professor of Epidemiology at the University College London. He is the Director of the University’s Institute of Health Equity, and past President of the World Medical Association. He is also the author of The Health Gap: The Challenge of an Unequal World, published by Bloomsbury in 2015, and he has 20 honorary doctorates from universities across the world. More recently, he is the author of Build Back Fairer: The COVID-19 Marmot Review, and this is the theme of his visit to Australia, hosted by the Health and Social Care Unit of Monash University. The notion of fairness and equity forms the core of our conversation today, so let’s get to it. I started by asking Sir Michael a rather basic question about this very complex area, how do you define health equity and equality, and how do we even start to measure this?

Sir Michael Marmot: Well, the functional definition for me is that inequalities in health between social groups that are judged to be avoidable by reasonable means, and are not avoided, are unfair, hence inequitable. So, it is a rather technical definition of health equity, it is the systematic inequalities between social groups that are judged to be avoidable by reasonable means and are not avoided, hence unfair. A classic economic viewpoint is inequality is individual differences, but no, I talk about the inequalities between social groups.

Gretchen Miller: Yes, as an epidemiologist that makes perfect sense. How do we even start to measure health inequities?

Sir Michael Marmot: Well, it is pretty straightforward, take two issues of health inequity that have been concerning me. The first, is socioeconomic inequalities, which measure people’s education, income, wealth, the level of deprivation of the area in which they live, and then take a simple measure like mortality rate or life expectancy, voila, you’ve got inequalities. That doesn’t tell you how much is avoidable, the inequitable part, but we can then make an assumption that may be incorrect, but let’s make an assumption that all of it’s avoidable, that everybody could have the same good health as people at the top, and let’s work on that assumption, and then all the excess mortality or shorter life expectancy for people below the top is unfair, inequitable. Now if you say but you don’t really know that, okay, well that’s why we need a good research base, but it is not as difficult as it sounds, there is a simple starting position from which one can retreat and say, well, it is not all avoidable.

And the difference between social groups is important because if it were the differences between individuals, well yes, some of that will be genetic, Winston Churchill drank a bottle of cognac or whatever it was, smoked cigars, and fine, he had genes that led to his long survival, but between social groups it’s a reasonable assumption that this is not inevitable. So as a starting assumption, let’s talk about the inequalities and assume they’re avoidable. And once again, you have to make an assumption of how much of those differences are avoidable, but why not have a starting assumption that there should be no health differences between different groups, and if it turns out we’re wrong, okay, but at least we’ve erred in a good direction.

Gretchen Miller: Your recent thinking has occurred around a fairly major global health event, the COVID-19 pandemic, and I wanted to give our listeners a little bit of a background on your work, Sir Michael. As you point out, ‘building back better’ has been a post-COVID mantra we’ve heard across the western world, and there’s nothing like a nice bit of alliteration, but you questioned that mantra, and at the beginning of 2020 you put out a report, the 10-year update on a strategic review commissioned by the British government in 2010 called Fair Society, Healthy Lives, which you had in fact written. Not even a year later you had written another review, because COVID had I think, widened the cracks that were already crazing through the British health system, and that report was called, Build Back Fairer: The COVID-19 Marmot Review. So, I wondered if you could paint us a picture of the once-renowned British health system just before COVID hit, and then we’ll have a look at what the COVID years have been like for you personally as an epidemiologist. When you came to write the report at the beginning of 2020, what had you been observing happen to the British health system at that time?

Sir Michael Marmot: Well, when people talk about the health system they usually mean the healthcare system, and when you ask what’s been happening to the British health system, well the healthcare system is just about to fall over because of systematic underfunding, neglect, underinvestment, whether it’s brutal incompetence or worse than that, a systematic undermining, is difficult to say, but clearly it has been mismanagement. We can see that funding in real terms, adjusted for population size and ageing of the population, from 1997, New Labour, to 2010 increased at about 4.4 percent a year, and from 2010 on, in real terms, it increased at not 0.4 percent a year. Wow.

Gretchen Miller: So, it was a dire situation, right?

Sir Michael Marmot: I don’t think what I documented in my February 2020 report was due to the failings of the healthcare system, bad as they are, because inequalities in access to healthcare are not the key determinant of inequalities in health, and what I documented in February 2020 was that the rate of improvement of life expectancy had slowed dramatically. Life expectancy had been improving about one year every four years for women and men for a century, and that (beginning in 2010/11) slowed dramatically. The social gradient in life expectancy, the poorer you are, the shorter the life expectancy, that social gradient got steeper, and for people in the most deprived decile outside London, life expectancy went down, health got worse for poor people, and that wasn’t primarily due to lack of access to healthcare, that was due to inequalities in society. The fact that the social and economic conditions did not improve, and the inequalities increased and for poorer people they got worse over the decade. That is not just the healthcare system, it is saying health is a reflection of how we organise our affairs in society, and inequalities, inequities in health, reflect inequities in social and economic arrangements, and those inequities increased over the decade from 2010.

Gretchen Miller: Less than a month after that report came out COVID-19 swept across the globe, what was 2020 like for you, personally, as a researcher and a scholar and an epidemiologist observing all of this, how did you feel as a human watching it all unfold?

Sir Michael Marmot: Well, there are a couple of things. Firstly, my colleagues and I said at the beginning of the pandemic, when people said the pandemic would be a great leveller, we said no it won’t, it never is, it will expose the underlying inequalities in society and amplify them, and I watched as a citizen and a member of communities as people who could work from home, who had white collar jobs and they could sit at home and work, kept their incomes, were relatively safe, could keep working. I was working harder, in one sense, because in the past, pre-COVID, if I gave a lecture in Peru I’d have to fly to Peru, spend two or three days, give your lecture, fly home, it’d be four days minimum, whereas now it would be an hour, and that means I could give a lecture in Hong Kong, another one in Peru, on the same day, and do a seminar in London. So I was working harder, there was no drop in my income, I was still working full-time, and I could do all this from my desk in North London, and then have the privilege of going for a daily walk in a nice park. I was very conscious every single day of that privilege. We clapped for the nurses on Thursday evening, but what about the delivery drivers, the refuse collectors, the people who worked in the supermarkets, they kept society running, and these people have been traditionally, which is why I wanted to ‘Build Back Fairer’, and still are undervalued by society, and I thought, if the pandemic is going to teach us anything it’s going to teach us who keeps the wheels of society turning, and it is the delivery drivers and the refuse collectors and the supermarket checkout clerk. Nobody clapped for bankers on a Thursday evening, there were no hedge-fund managers who became the heroes, but the food workers became heroes, and the delivery driver, well they should have, let alone the nurses and the doctors and the ambulance drivers, and they were the ones who were most exposed or laid off. Hospitality workers were in shattered industries and got laid off, and it was very welcomed that there was a furlough scheme, but they paid up to 80 percent of previous salary. It means if you are at the poverty line, you are now getting 80 percent of your previous salary, it was very clear as a researcher, but also just as a person, that these inequalities were being exaggerated and people were being exposed to the virus.  That’s why we did the COVID-19 Marmot review only 10 months after we did Health Equity in England: The Marmot Review 10 Years On, because we then documented that it was precisely those occupations which were the ones that were at high risk. Now, what we saw is the social gradient in COVID-19 mortality looked rather similar to the social gradient in all-cause mortality, in other words, the inequalities that affect health more generally were affecting COVID-19, but it was steeper for COVID. The most deprived two or three deciles contained people living in overcrowded accommodation, working in frontline occupations, and hence, being more exposed to the virus.

Gretchen Miller: And then, of course, COVID went on and on across another two years, and it is still discussed whether we are quite out of the pandemic phase. Was there anything that surprised you to come out of this period of time in the way that emergency responses came into play in the UK?

Sir Michael Marmot: Well, firstly, what surprised me was the brilliance of the researchers who developed the vaccine in seconds flat, brilliant, and that’s very important, because they’d done the basic science before the pandemic, they were ready to go, and they began the day after the Chinese published the genome of the virus, and brilliant, absolutely brilliant, and I was surprised at how quickly everything moved. The second thing that surprised me, in a positive way, was how good the British Office of National Statistics was in producing evidence on a very timely basis, almost in real time. They were astonishingly good, you could talk to 10 people, 100 people, 1000 people, you have got to be a bit of a nerd to say the Office for National Statistics did a brilliant job, but they did. We had the data in no time at all, so we knew as much as could be known. The things that surprised me, in a negative way, is how incompetent the government was in setting up a test-and-trace operation. Everybody who understood, and I am not a communicable disease epidemiologist, so this is not my special area, but everybody who did understand communicable disease said test, trace, and isolate. Test, test, test. The WHO said test, test, test. Everybody who understood this said test, test, test, and the British government said, test, no, don’t bother.

Gretchen Miller: We were doing a lot of that here, a lot of testing and yes, it was quite an extraordinary time. Looking back on it, I think Australia, and in a way, we are all still reeling from the social impacts of the appropriate heaviness of the lockdowns here.

Sir Michael Marmot: Well, Australia did pretty well at handling the pandemic.

Gretchen Miller: Yes.

Sir Michael Marmot: I mean, it was difficult for everybody to take, but Australia did pretty well and Britain did not do well, so we didn’t test. We privatised the tracing operation, and it was a colossal failure, we wasted, I don’t know…£35 billion on privatising testing? Why would you not give it to local public health to do? If you can spend £35 or £37 billion on setting up an incompetent operation that didn’t work, why not give it to the public sector, the public health doctors who are employed?

Gretchen Miller: Yes, there were incredible things going on there. I want to go back to right at the front of your review, the Build Back Fairer review, where you drew the connection between health inequality, social inequality, planetary inequality. Perhaps we could call it anthropocentrism, the centring of humans at the expense of all other earth inhabitants, but what is revealing itself as a theme for Prevention Works at the moment is co-benefits, the co-benefits of healthcare. I wondered if you could speak to those connections that you draw out and the co-benefits of making healthcare more fair across the population?

Sir Michael Marmot: Well, I will again make the distinction between health and healthcare. I would say that investing in the social determinants of health produces a better society, it has co-benefits indeed. So, for example, invest in early child development, and you will improve reduction in mental illness and physical health. The evidence suggests fewer young people will end up in a life of crime if you invest in a good early child development and education, there will be less mental illness and less interaction with the criminal justice system, so there will be less incarceration. Invest in early childhood development and education and you are likely to have a more productive workforce, you will have a more educated population, which will have real benefits. So, it is not just about co-benefits of healthcare, it’s the co-benefits of action on the social determinants of health, which will create a better, fairer society.

Gretchen Miller: And would you draw into that the better, fairer society on a planetary level, as we look down the barrel of the climate crisis?

Sir Michael Marmot: Well, I’ve said more recently, and I should have been saying it more strongly right from the beginning, we have to address the climate emergency and health equity together, they are twin challenges that affect the planet, and health equity. When you asked me about health equity right at the beginning of the conversation, I was replying as if it was a problem within countries, but it’s obviously the same mode of thinking applies to health inequities between countries, and the climate emergency exaggerates the inequalities, both within and between countries, and we have to pursue those agendas together of creating greater health equity and dealing with the climate emergency at the same time.

Gretchen Miller: Yes, so a healthy planet is something that benefits us all.

Sir Michael Marmot: And it is crucial for the next generation. What kind of world are we bequeathing our children and our grandchildren? And both of those agendas, there is a health equity agenda and the climate crisis, if they apply to equity in the current generation, they apply even more so to succeeding generations.

Gretchen Miller: There is much more to speak about, but before we finish up, in your 2020 report you observed that the New Zealand Treasury, just across the ditch here in the Southern Hemisphere, put wellbeing as a measure of its success, because as has become abundantly clear, prioritising the economy above all else doesn’t work. Now, I can’t tell you right now how New Zealand has gone with that in the years following your report and your observation, but how do you see that pivot to wellbeing becoming embedded in our systems, how is that playing out?

Sir Michael Marmot: Well, two weeks ago I was at a WHO European meeting on the Wellbeing Economy, and the World Health Organization regional office for Europe is taking the lead, so countries like Finland and others in Europe, like New Zealand did, put wellbeing at the heart of their social and economic planning.

Gretchen Miller: We’re at the beginning of that, aren’t we? I mean, we haven’t worked out quite how to make that meaningful, I sense?

Sir Michael Marmot: If you are going to put wellbeing at the heart of your social and economic planning, that means putting health equity there as well. You can’t have wellbeing if you have poor health and greater inequities in health. So, it is very encouraging the fact that other countries, New Zealand and Finland were the first ones, but others are now picking this up and saying, what do we have to do this? Very encouraging. Unfortunately, there is very little sign of it in the UK at the moment, but change will happen.

Gretchen Miller: Change has to happen. Before we go, I would like to point out to audiences that we will have a link to both of those reviews on the website, but in brief, your recommendations about how we bring about change? I know you have short-term, medium-term, and long-term actions that need to occur, but in short, what would you say we need to do to bring about the kind of changes that are necessary, quite urgently, really?

Sir Michael Marmot: Well, I had six domains of recommendations in my original English review, building on the WHO Commission on Social Determinants of Health, and the six were to give every child the best start in life, education and lifelong learning, number three, employment and working conditions, number four, everyone should have at least the minimum income necessary for a healthy life, number five, healthy and sustainable places in which to live and work, and number six, taking a social determinants approach to prevention. I have now added two more: tackle racism, discrimination, and their consequences and the one we have just been discussing, pursue the climate agenda and health equity together.

Now, drawing from that at a higher level, we also need to address the structural drivers, the larger inequities in society, a set of values, and what we have just been talking about with the wellbeing economy, what is your value as a society? Is it to get more economic growth or is it to create greater equity of health and wellbeing for the society? So, we need to address those conditions of daily life, those eight recommendations that I just spelled out, but we also need to look at, as it were, at a higher level, the structural drivers, macroeconomic arrangements, the set of values, the political aspect of how we organise our affairs. So yes, I would say we know what to do, starting tomorrow morning, maybe this evening, the time to start building on the medium and longer-term objectives is right now.

Gretchen Miller: Professor Sir Michael Marmot, it has been such a honour to have you on the program. I really appreciate your time during this very busy visit. I hope you have a lovely evening. Thank you.

Sir Michael Marmot: Thank you.

Gretchen Miller: Professor Sir Michael Marmot here on Prevention Works with me, Gretchen Miller. As always, the Prevention Centre will pop details of his publications on the podcast webpage, and we would love you to leave us a review. Let us know what you think. See you next time.

[End of recording – 24:58]