The health gap: the challenge of an unequal world, by Sir Michael Marmot, hardback, 387 pages, ISBN 978-1-4088-5799-1, Bloomsbury, 2015, £20. Kindle edition available, paperback edition due in May 2016.
Sir Michael Marmot is Professor of Epidemiology and Public Health at University College London and President-elect of the World Medical Association. In this essential book, which sums up a lifetime’s research into the causes of ill health, he asks why some people live longer than others.
His answer is that people at relative social disadvantage suffer worse health and live shorter lives. All of us except the very richest are less healthy than we might be. We should level up to the highest standards to improve conditions and health for everyone.
Early development
Marmot spells out how early child development matters hugely for subsequent health and health equity. Good early child development is shaped by the environment in which children grow. Educating girls is the single best contributor to improving the health of women and their children. A local authority centre in Newham charged £850 a month for child care. By contrast, in Sweden, where child care is subsidised, the most you pay a month is £113.
For child well-being in rich countries, Britain comes 16th out of 21. The USA is 21st. 62 countries have lower lifetime risks of maternal deaths than the USA. The USA provides no state-guaranteed paid maternity leave, along with Papua New Guinea and Surinam. Every other country does. On one measure of child poverty in 35 countries Romania is the worst of 35 countries, the USA is the second worst.
‘Some countries achieve better health by specific, identifiable actions.’
Some countries achieve better health than others by specific, identifiable actions. For example, by giving everybody access to high-quality medical care regardless of ability to pay. Another way is to promote early child development and education, good working conditions, good conditions for older people and resilient communities. Societies that ensure these things have good health and health equity.
The Nordic countries achieve high levels of good health because they have: universal social policies not targeted, means-tested selective policies; welfare state redistribution policies; relatively narrow income inequalities; a stress on equality of opportunity and outcomes according to class and gender and for socially excluded groups; a broad scope of public services with services provided mainly by the public sector at local level; social spending and social protection; which all add up to a set of policies across the life course, each with its specific effects.
Social spending
Marmot sums up, “The more generous the social spending of a country, and the more universal, the lower is the national mortality rate.” His evidence is that worse welfare spending means making people’s health worse, even killing people.
In the 1980s the International Monetary Fund (IMF) enforced spending cuts, privatisation and deregulation. The Lancet-University of Oslo Commission on Global Governance for Health concluded, “these programmes have been disastrous for public health…structural adjustment programmes undermined the health of poor people in sub-Saharan Africa through effects on employment, incomes, prices, public expenditure, taxation, and access to credit, which in turn translated into negative health outcomes through effects on food security, nutrition, living and working environments, access to health services, education.”
‘Enforced spending cuts, privatisation and deregulation are disastrous for public health.’
Marmot observes, “The idea that unbridled free markets in everything (the so-called Washington Consensus) is the way for countries to grow, develop and ensure better health and greater health equity is contradicted by the evidence.”
Even the IMF now says that unemployment is bad for people. In every social class, those unemployed had a 20 per cent higher death rate than those employed. Job insecurity also damages health, particularly mental health.
Price of unemployment
Norman Lamont Chancellor of the Exchequer from 1990 to 1993 said, “Rising unemployment and the [1991] recession have been the price that we have had to pay to get inflation down. That price is well worth paying.” Marmot notes that he could have said, but didn’t, “Rising unemployment and the consequent damage to people’s health have been the price that we have had to pay to get inflation down. That price is well worth paying.”
The IMF now says that, other things being equal, austerity slows growth. We need to grow to cut the debt not cut the debt to grow. Real wages in Britain in 2013 were 7 per cent lower than they were in 2007 – the worst performance of any rich country over that period.
Marmot argues for evidence-based politics. We need the best evidence that will help us to make society more just. Research papers usually end, “more research is needed”; that’s often true, but more action is needed too. The strength of this book is that it looks at actions that can be shown to have positive results.
Injustice
He admits to an ideology: avoidable health inequalities are wrong: “avoidable health inequality, health inequity, was the deepest injustice in our society.” Inequities in power, money and resources cause that health inequity.
Medicine, doctors, all of us, should deal with the conditions that make people sick. To improve health, we have to reduce the inequities in power, money and resources caused by those unbridled free markets. We have to reorder society so that the drive for profit does not override every human need.
Putting it another way, Marmot notes, “There is a serious failure of global financial governance when the interests of hedge funds, legally if not morally, trump the ability of nations to decide their own future.” That is, capitalism overrides national sovereignty and democracy. So it would seem that to make their people healthy, nations need to control and develop their own resources, overriding capitalism’s demands. But the health equity we need won’t happen without the working class taking responsibility for running society.