Dr. Marmot said the review of health inequities in England (Fair Society, Healthy Lives) would be published on February 11, 2010. (See: http://www.ucl.ac.uk/gheg/marmotreview). Its seeks to identify evidence, underpin future policy and action, show how evidence can be translated into practice, advise on possible objectives and measures, and build on experience with the current Public Service Agreement target on infant mortality and life expectancy. The report argues that health inequities can be narrowed if a fairer society is achieved.
Addressing the role of government in dealing with health inequities, Dr. Marmot described six policy objectives and a framework for monitoring them that would be presented in the report. Dr. Marmot has met with government ministers and senior civil servants in departments overseeing each of these areas, as well as politicians from both parties. With an election scheduled for the coming year, he hoped that the incoming administration would find this issue important if the government changes hands. Dr. Marmot has also met with the mayor of London, who agreed to partner with the Commission to create the London Health Inequities Strategy, which is intended to make London a healthier community for all. The Commission has also partnered with the northwest region of England, including Liverpool and Manchester.
III. Q&A and Discussion
Dr. Fielding thanked Dr. Marmot for his informative presentation and invited questions. He asked how Dr. Marmot has been able to convince politicians to take a long-term view when many focus on short-term issues, such as being re-elected. Dr. Marmot said that, in one case, a key official had a background of privation and understood health inequity from personal experience. Dr. Marmot approaches his discussions with officials from the standpoint of asking, “Why would you want to be in government if you didn’t want to make things better?” He then explains what the evidence suggests they need to do to make things better.
Dr. Shiriki Kumanyika said there are those who stand to lose if society is fairer; she asked Dr. Marmot to discuss whether he has overt opponents. He replied, “We do, and we don’t.” In Britain, an established Labor Party argument has been that one doesn’t need to worry how much richer the rich are, as long as the poor have enough. Opposition is not about health or a desire for poor people to be unhealthy. Rather, it is driven by the desire to “reward success” and “create incentives” to foster economic growth. He said the argument is, “Don’t stop the wealth producers; don’t stop economic growth in the interest of equity.”
Dr. Marmot discussed the results of public opinion surveys showing support for more equity in society. The public recognizes the fairness of differences in earnings for workers with different levels of responsibility, but they believe the extent of differences in income is excessive. When asked about the proposition that a fair society is one that creates the same opportunities for everybody to get ahead, 90 percent agree. They also agree that children of richer families have different opportunities to get ahead than children of poorer families. Putting these three findings together, the public endorses the propositions that: fairness means equality of opportunity, there is not equality of opportunity because of inequalities in income, and inequalities in income have gone too far. When speaking with elected officials, Dr. Marmot uses evidence of public opinion to support his arguments. Other Committee questions included:
- How can empowerment strategies be used to advance the concept of fair communities?
- How has your work been received by colleagues in the healthcare community?
- How is work on developing and producing evidence for interventions proceeding?
Responding to work on health equity, opposition politicians have asked where personal responsibility fits in. Dr. Marmot has said personal responsibility is at the center. The goal is to create conditions where people can take control of their own lives; they do not currently have those conditions. Empowerment is not just about the individual, but comes from creating the right social conditions and giving every child the best start in life. Empowerment at the individual and community levels means recognizing the social gradient in early child development. Evidence shows that the lower a child is in the hierarchy the less likely that child is to have an ideal environment or to achieve his or her physical, cognitive, social, and emotional potential. Community empowerment can mean that people want to make their own solutions. He has asked, “Even if you have no evidence that (your solutions) are effective? How do you know you are doing any good?” Communities can choose how they want to do things, but they should be informed by evidence of what is likely to work.
Dr. Marmot noted an unfortunate divide between those who think health care is everything and those who are perceived to believe that health care is nothing. When people think about health, they mainly think about health care, and the organization and funding of healthcare. It is important to advance understanding that health is not the same thing as health care. The climate of understanding on the importance of health inequalities has changed, as evidenced by Dr. Marmot’s recent appointment as President-elect of the British Medical Association. When he was asked to do this he noted that he was an odd choice, as he does not work in the healthcare system and talks about the wider determinants of health. But they asked him to do it.
Dr. Fielding thanked Dr. Marmot, and asked if he would be willing to review a document on the social determinants of health once the Committee has prepared one. Dr. Marmot would be pleased to do this, within his physical limitations. After his departure, Dr. Kumanyika said subcommittees may be able to follow-up on some of the themes that Dr. Marmot raised. She highlighted four areas: 1) There is opportunity to train public health stakeholders to make these arguments with the other sectors. 2) Even though there may be a moral argument, it is important to be concrete (e.g., how does mixed land use relate to health, or how does air quality relate to specific health problems or zoning). 3) The Commission has selected six policy areas; this group could also agree on key indicators, and then articulate specific strategies to work those pathways. 4) The Health in all Policies approach requires looking at policies that other sectors are trying to influence.
One area where this comes together is “sustainability,” now an area of focus for several sectors. The Committee should articulate that the overlap and mutuality between public health and environmental issues. She suggested that the Committee discuss how to operationalize some of Dr. Marmot’s ideas when they thinking about next steps for the subcommittees. Dr. Fielding added that until there is better public understanding that we can’t have better health and reduce inequalities without focusing on the social and physical determinants, we can’t move ahead. He emphasized the need for metrics to see where we’re going, and for analytics to help project reasonable outcomes. Such tools can help to convince politicians that, even though they may not be in office in 20 years, this could make a big difference and leave an important legacy.