“Fair society, healthy lives”

Michael Marmot,
Director of the Institute of Health Equityof of the University College London (UCL)

Based on your policy work, what mechanisms connect social inequalities and health outcomes? What role can early child development play in reducing health inequalities based on social class?

Our WHO Commission Report on Social Determinants of Health says that inequalities in health arise from the conditions in which people are born, grow, live, work and age. Inequities in power, money and resources give rise to these inequities in the conditions of daily life. Our approach was to look at the conditions of daily life through the life course. But we also looked at the drivers of these inequities in power, money and re­sources. I would not look at early child de­velopment without also looking at the social and economic policies relating to inequalities in early child development. What inequalities in early child development lead to in terms of inequalities in education, job type, income, place of residence.

Evidence across Europe appears to show that countries that spend more generously on benefits and welfare have better health outcomes and narrower inequalities. These countries also offer better employment conditions, so what implications must this have with regards to future work on health inequalities?

My starting position is: inequalities in health between social groups, that are judged to be avoidable by reasonable means and are not avoided, are unfair, hence inequitable. So the question is: what can societies do? And the evidence suggests: a great deal. At the societal level, they can be generous in welfare spend­ing, for example. What we see across Europe is, the more generous the welfare spending, the better the health outcomes, and the narrower the health inequalities, as a general rule. It’s difficult to say if this is cause and effect, because many other things may have an influence. Many people think that if un­employment benefits are too generous, people won’t want to work. However, that’s not what the evidence shows. It shows that countries with more generous unemployment benefits actually have lower rates of unemployment.

One of your social policy recommendations is to adopt a living wage to release people from poverty, a measure you see as a significant factor for improving health outcomes. Can you give us evidence that the living wage helps eradicate or reduce inequalities?

The evidence for a living wage is indirect but quite powerful. A question I have struggled with for a long time relates to absolute ine­qualities and relative inequalities. In Western Europe, in the European Community, no­body really has lack of shelter or not enough calories to eat, so in that sense, absolute dep­rivation has been tackled. However, people on low incomes need to go to food banks to feed their children. So they can bring home calories, but there is a threat to dignity.

In Britain, for example, most housing benefit goes to people who are in work but are not paid enough to cover the private rental, so they need housing subsidies. This is some­where in between absolute and relative ine­qualities. It’s absolute because you don’t have enough money to live, but relative in that it’s not the destitution seen in low-income coun­tries. It’s a threat to dignity and self-esteem. It threatens what you can give your children, or how you relate to your family, things which are vitally important. In Britain, for exam­ple, over the next five years, the family type that will have an income furthest below the minimum income threshold which is need­ed for healthy living is a single mother with children, followed by two parents with two children. So single people with no children will get closest to the threshold, but families with children and particularly single mothers will be the furthest below it. Predictably there will be families with children who won’t have enough for a healthy life. Indirect evidence shows that this will damage their health, starting with the quality of early child devel­opment, then quality of food, how you relate to people, and so on.

You also recommend addressing avoidable mortality in relation to wealth. In “Fair Society, Healthy Lives”, the so-called Marmot Review of 2010, the study found that people living in the poorest neighbourhoods will, on average, die seven years earlier than people in the richest neighbourhoods in Great Britain. Can you elaborate on that and assess the problems of European governments in recent years with regard to the Marmot Review?

One of my key insights is that health ine­qualities are not confined to “poor health for the poor and good health for everybody else”, but follow a gradient. Our data classifies every neighbourhood in England by degree of deprivation. The more affluent the neigh­bourhood, the longer people’s life expectancy. The gap between the 5th centile and the 95th centile stood at seven years.

Inequalities in health refer not just to length of life but to quality of life, where the inequal­ities are even greater. We see this gradient phenomenon – the higher you are, the better your health, the lower you are the worse your health – right across Europe, without ques­tion, but with varying magnitude.

If you look by education, the difference between people with a university education and those with only primary education is quite small: in Sweden and also Norway, Italy, Malta. But if you go east, to Estonia, Hungary, Rumania or Bulgaria, with a lower average and a steep gradient, there is a huge gap be­tween the same two groups. There will always be inequalities in society, and inequalities in health will follow social inequalities, but the magnitude can change, and it can change be­tween societies. This should be encouraging: it suggests that there are things we can do to address the situation. 

The European region has seen remarkable health gains in populations, after experiencing progressive improvements in the conditions in which people are born, grown, live and work. Spain is an example. But curiously, inequalities persist. What factors do you think determine the persistence of those inequalities? And, what would your recommendations be? 

In my English review, the so-called Marmot Review, there were six domains of recom­mendations, which feature in our European Review as well: Early child development; Education and lifelong learning; Employ­ment and working conditions. The fourth, as already mentioned, is: Everyone should have the minimum income necessary for a healthy life. The fifth is: Healthy and sustainable plac­es in which to live and work. And the sixth is: Taking a social determinants approach to prevention. So instead of just saying: “Don’t smoke”, you deal with the drivers of why there’s a social gradient in smoking. You don’t just say “Don’t eat so much” or “Don’t be fat” but you deal with the fact that obesity follows the social gradient. Looking internationally, I would also add the inequities in power, mon­ey and resources that give rise to inequities in these six conditions of daily life. So I believe there is a great deal we can do.

In your research you distinguish between global, country-level and local-level actions to diminish health inequalities. Can you provide some specific examples of these different policies at different levels of government?

One example is the English city of Coventry. Its leaders have declared it a Marmot City. They took my six recommendations and said: “In Coventry, we are going to do it.” That action was taken by the local government, not the health authorities, and that’s good. But we need national action too. Let me illustrate that with early childhood. There is quite clear evidence that parenting makes a difference to the quality of early child development. In­put from parents: cuddling, talking, singing, playing... all of these things matter. Children who get more of these things develop better cognitively, linguistically, socially, emotional­ly and behaviourally. Their social conditions are partly affected by local policy: whether local government has policies for housing. Does it make good housing available, particu­larly for families with young children? But they are also affected by national policy. We did a comparison of child poverty in different countries, in which child poverty is a relative measure: less than 60% of median income, before and after transfers. It showed dramatic differences. Sweden, for example, has a child poverty level, before taxes and transfers, of about 32%, not very different from Latvia. Af­ter taxes and transfers, Sweden’s child poverty drops from 32% to 12%. Latvia’s only drops from 32% to 25%. In other words, Sweden is saying it doesn’t want child poverty, that it’s a bad thing, and that it will use its tax and benefits system to reduce it. 

To reduce health inequalities it would be necessary to focus on six types of policies: 

1. Provide all children with better starting conditions.

2. Allow all children, young people and adults to maximise their capabilities and control their own lives.

3. Create a fair labour framework and offer the whole population quality employment.

4. Guarantee a healthy standard of living for everyone.

5. Create and develop healthy and sustainable environments and communities.

6. Promote health prevention and consolidate its achievements. 

Marmot Review of 2010

In terms of the household level: What would be the main features of a type of good parenting that could influence health outcomes for children?

Good parenting involves, of course, the supply of nutrition and stability first of all. But it involves two things in my opinion: the presence of the good and the absence of the bad. And they are different. What do I mean? I described good parenting in terms of reading to children, talking to children, cuddling children, singing, playing, talking... basically input. Loving, and all the things that go with loving. Regrettably, we find that this tends to follow the social gradient. The lower people’s income, the less likely they are to do all these good parenting things and, I would say, at least partly, because of the pressures upon them. The other part of good parenting is the absence of the bad. A body of evidence exists about adverse child experiences. They take various forms, including physical abuse, psychological abuse, sexual abuse and family disruption.

What do you think will be the short-term and long-term effects of the economic crisis on health? Can we prevent them? How are different socioeconomic groups affected?

The short-term effects that we see relate to mental illness and suicide. Data across Europe show that, on average, a 3% rise in unemployment is associated with a 3% rise in suicides if there is no expenditure on social protection in the country. However, the more generous a country’s expenditure on social protection, the less the rise in suicides. So in Western Europe, where countries are quite generous in terms of social protection, a 3% rise in unemployment is a less than 1% rise in suicide, whereas in countries of Central and Eastern Europe, it is closer to a 2-3% rise in suicide. When the economy turns down, unemployment doesn’t strike at random: the more years of education people have, the less likely they are to become unemployed, and vice versa. Looking at the indignados on the streets of Madrid and with over 50% youth unemployment – which may include hidden employment, the grey economy, etc., but still reflects high levels of youth unemployment – I would say they are right to be indignant and angry, because the implied promise of: “work hard, study, and then you’ll have a job and good conditions”, has been broken.

How should the health agenda and the economic and social agenda work together in Europe?

My argument is that the magnitude of health inequalities tells us a great deal about how we are doing as a society. Look at the changes in Spain. It went from being a rather primitive fascist country to a liberal democracy, despite its ups and downs. It reduced poverty and improved conditions, and health improved. Those improvements in health told us a great deal about what was going on socially. On the other side of Europe, in the communist countries, health is doing very badly. With the collapse of communism, there has been a mixed picture. Countries such as the Czech Republic and Poland have had dramatic improvements in health but also an increase in inequalities. The former Soviet Union has not done so well. It’s had a very rocky health trajectory, but I think that’s partly because of social breakdown. Instead of replacing com­munism with something that functioned well, they replaced it with something rather dys­functional. So social improvement and health improvement go hand in hand. We don’t just need investment in the health care sector, but also in education, social protection, early child development: they are all vital. Look at climate change. There is good reason to be­lieve that environmental impacts affect social groups differentially. With climate change, mitigation and adaptation, if not done care­fully, will increase inequalities. We must take that route, but we should always bear in mind the equity dimension. 

Interview by Joan Costa-i-Font, Associate Professor of Political Economy  

London School of Economics (LSE).

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