Tackling social factors to improve health
The Bulletin interview with Professor Sir Michael Marmot.
Professor Sir Michael Marmot was born in London. He earned his MD in 1968 at the University of Sydney, Australia, and a PhD in epidemiology from the University of California, Berkeley, United States. He started his career as a doctor at the Royal Prince Alfred Hospital, University of Sydney in 1969. Marmot has been at the forefront of research in health inequalities for the past 20 years, most famously as Principal Investigator of the Whitehall studies of British civil servants. He is Professor of Epidemiology and Public Health at University College London (UCL) and Director of the UCL International Institute for Society and Health, which he set up in 2005. Marmot was appointed Chair of WHO’s Commission on the Social Determinants of Health in 2005.
Many governments recognize that factors such as status, education and employment have an impact on people’s health, but few have tackled these social determinants head on. WHO established a commission in March 2005 to come up with recommendations on how countries can address these. One year later, the Commission’s chair Professor Sir Michael Marmot tells the Bulletin how WHO’s Commission on the Social Determinants of Health is helping governments tackle underlying factors to improve the health and well-being particularly of disadvantaged populations.
Q: What is the Commission’s goal?
A: The goal is to reduce inequalities in health within countries and among countries. For example, under-five child mortality in some sub-Saharan countries is greater than 300 per 1000 live births and in Iceland, it is three per 1000 live births: there is no good biological reason for this. If we had the means and will to tackle this, we could prevent it. Within countries, we see remarkable differences in health, life expectancy, and mortality among social groups. The focus of the Commission is primarily on lower- and middle-income countries, but rich countries also have a problem of great inequalities in health. For example, there is a 20-year gap in male life expectancy between men living in downtown Washington DC and those living in suburban Maryland.
Q: What are your core activities?
A: We have several strands to our work taking place simultaneously. We have a remarkable group of Commissioners; we have set in place a number of knowledge networks to review what can be done in a number of key areas; we are working with country partners; we engage with civil society organizations; and we are planning how to engage with other international organizations. It is, of course, vital that the social determinants agenda be taken forward by WHO itself. To that end, we have been actively engaged with WHO staff since the Commission was planned.
Q: Are there success stories which the Commission can draw upon?
A: Yes, it is important to learn from the success stories. We have a group of experts from the Nordic countries, funded by the Swedish Government, looking at how these countries went from having a great deal of ill-health to having good health in a short space of time. The Japanese Government has a small group of academics, initially to advise our Japanese commissioner. We are helping them set up an Asian group to look at the reasons for the astonishing health success of Asian countries that went from being developing countries with poor health to affluent countries with remarkably good health.
Q: What have you achieved so far beyond four meetings in partner countries?
A: Chile is working hard to look at how various government programmes affect the social determinants of health. There is active discussion with India, Iran and Kenya as to how they might do this. Sweden, Britain and Canada are all signed up to be partners of the Commission. We are raising awareness by working with groups that have influence.
Q: How will you measure your success after the three years are up?
A: Three years is too short a time to be able to say health inequalities have reduced. It’s unrealistic to think we will see that a partner country has improved its health record, compared to countries that did not work with us. If countries establish mechanisms for regular reporting on these determinants, that will be an indicator of success.
Q: How many countries are putting such mechanisms in place?
A: Between six and 10 of the partner countries we are working with. Ideally, others will catch the bug and start doing it too. Inspired by the work of the Commission, Brazil, a partner country, has set up its own regional Commission on the Social Determinants of Health. We hope it will be a focus for other activities in the region involving other Mercosur countries.
Q. Manual workers are more exposed to job insecurity and the hazard of injury, but someone has to do this work?
A: One doesn’t have to accept as inevitable the physical and job security hazards associated with manual work. It’s possible to have regulations for better working conditions. Employers often say they can’t afford better working conditions, that they can’t compete that way. It’s false economics. There are a lot of rich countries with safe working places, and it doesn’t seem to have harmed their economies.
Q: The Commission’s area of responsibility overlaps with other areas of public life? How easy is collaboration?
A: Yes, of course, an important theme of our work is that ministries of health have to get out of their straitjackets and understand that what happens across the whole of government affects public health. Other government departments need to appreciate that what they do has an impact on health. Yes, the social determinants of health overlap with everything government does. All government actions should be evaluated for their impact on health and health inequality, the overlap is good thing.
Q: Is the WHO Commission competing with other organizations that work on similar issues, such as the World Bank?
A: The more the Commission’s work overlaps with the work of other agencies and organizations the better. We — on the Commission — don’t want an agenda on health that is different to what others are doing, we want the World Bank and all other international organizations to be aligned with us, and to think about the impact of what they do on people’s well being.
Q: Some people object to the choice of Commissioners, particularly one from Iran as a barrier to tackling social determinants, such as women’s and human rights? How much can the Commission achieve with its 20 commissioners?
A: All of the commissioners, without exception, have a fundamental ethical, moral and practical commitment to improving health and reducing health inequalities, regardless of national and religious background, or the political complexion of the government of the country in which they work. We are concerned with the health of people and, particularly of the disadvantaged within and among countries. Without such commitment it is hard to see things improving, or a real partnership with the Commission. We hope that, in time, all governments will share that commitment.
Q: How can WHO promote equity without sounding as if it is trying to be everything to everyone?
A: I would put it another way: how can WHO control major killer diseases without paying attention to the social determinants of health and dealing with the greater ill-health of the disadvantaged? WHO can do its job better if pays attention to the social determinants of health and if it can work with countries that are doing that better.
Q: Why are countries not doing this?
A: The poor suffer, partly because nobody cares, and key actors pursue economic, political, and social ends regardless of the effect on the poor and underprivileged; and partly because of malign intent. We see this with ethnic conflicts, where one group sets out to kill or disenfranchise another. The poor also suffer, because, despite good intentions, governments don’t know what to do to improve the situation. You can have a healthier more flourishing population if you pay attention to these issues. Social and economic success go together: improve health and you may improve the economy; improve the economy and you may improve health.