The Health Gap: The Challenges of an Unequal World

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The Health Gap: The Challenges of an Unequal World

Published:

Thu, 28/07/2016 - 10:44

By:

paul
The Health Gap: The Challenges of an Unequal World
Published: 
28 July, 2016
by JEAN GRAY

EVERY morning Sir Michael Marmot cycles from his home in Hamp­stead to University College London where he is Professor of Epidemi­ology and Public Health. The journey covers only four miles and yet it illus­trates the same gap in life expectancy you would find when comparing countries as economically diverse as the UK and Belize. 

“If you live in Somers Town your life expectancy is 11 years shorter than if you live in Hampstead,” he explained when I spoke to him at UCL’s Institute of Health Equity. “This can’t be blamed on lack of healthcare or differential access in the London Borough of Camden, an area that is comparatively well served by the NHS.”

Professor Marmot has spent most of his working life investigating such stark inequalities and famously concludes that in every country health is directly related to degrees of social advantage, with the emphasis on degrees. 

There is no clear line between rich and poor, but a “social gradient” in health. Those in the middle of the social hierarchy, while they may be better off than those lower down, are still at greater risk of suicide, heart disease, lung disease, obesity and diabetes than those at the top. 

The world’s leading expert on health inequal­ity, Professor Marmot is best known for heading up high-powered national and international commis­sions. His 2010 review Fair Society, Healthy Lives, is now the corner­stone for public health policy across England. 

But his latest book is aimed at a rather different audience, one he describes as “the non-specialist, an educated reader who takes an interest in the world”. The Health Gap is a call to action. This very readable – some would even say entertaining – book looks to spark an urgent, global social movement. 

A professor of epidemiology may not seem the obvious candidate to lead such a force, but the name Marmot is already being linked to community actions around the country. According to Professor Marmot, his 2010 review offered people a way to organise and deliver change. One example is the West Midlands fire service, which now has a number of “Marmot Ambassadors”, frontline firefighters who work beyond their traditional role, recognising that fires, like health, follow the social gradient. By helping people improve their circumstances, firefighters are also helping to prevent fires. 

The Health Gap gives the self-help tradition a very wide berth. Professor Marmot believes there is little the individual can do about their own health, in spite of “worthy, well-meaning”’ government advice that he says is unlikely to make much difference. For example, in 1999 England’s Chief Medical Officer published 10 tips for staying healthy, including: “Don’t smoke. If you can, stop, or if you can’t cut down. Follow a balanced diet. Keep physically active. Drink only in moderation.” 

Professor Marmot presents an alternative list, devised by Bristol University, which advises: “Don’t be poor. If you can, stop, if you can’t try not to be poor for too long. Don’t live in a deprived area. If you do, move. Don’t be disabled or have a disabled child.”

Reading to children at bedtime, known to help their development, is one example of how healthy behaviour is affected by people’s living conditions, he says. 

“If you can’t pay the rent, are worried about the children getting into trouble because of the kind of neighbourhood you live in, there is little space to think about bed time.”

In the Marmot model, government must create conditions that enable individuals to make healthy choices and to support the creation of resilient communities. 

Tackling the social gradient demands what Professor Marmot calls “proportionate universalism”, an ugly phrase perhaps but one that well describes a more inclusive benefits system. “It recognises that we need to provide some support for everyone, except those at the top. If we target only the most deprived it increases admin costs and ends up labelling people.”

He cites the gover­nment’s Sure Start policy for early child develop­ment, which was initially to be confined to deprived areas. It was changed after he demonstrated that children’s reading skills become increasingly worse by comparison with Sweden and Japan as we move down the social hierarchy in Britain.

At the heart of the book is a genuine belief that we are “all in it together”, another benefit of the universal approach to welfare, much closer to the Scandinavian model and more successful in ensuring healthier populations. 

Marmot confesses that he maintains a fiction of not being political – he likes the evidence to speak for itself. But inevitably health inequal­ity is political and he is convinced that austerity measures are damaging.

On a global level he wants to see a change in  how countries measure success – the current Gross Domestic Product captures only economic perfor­mance and there needs to be a measure that gets closer to people’s lives and what they value – health is high on that list. 

“Health equity should be at the heart of all decisions and policies,” he argues, pointing out that there have been occasions recently when the government had to back down on changes to welfare rights. 

The Health Gap may make you angry, but it is also inspiring and full of hope, with extensive use of individuals’ stories from the UK and around the world to illustrate how the unjust distribution of wealth harms people – and what is being done about it. 

Few government reports begin with poetry, but the Marmot Review was an exception, quot­ing the Chilean poet Pablo Neruda. Professor Marmot repeats these words in The Health Gap, urging readers to join him and “Rise up... against the organisation of misery.”

• The Health Gap: The Challenges of an Unequal World. By Michael Marmot, Bloomsbury, £10.99 euchre

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