Tuesday, 7 November 2017

NCDS, health equity and social determinants of health

Remarks in opening expert plenary session at NCD conference in Montevideo
18 October 2017

Michael Marmot
UCL Institute of Health Equity

NCDs are a global health problem. One purpose of our meeting here in Montevideo is to plan for an NCD summit to be held in at the UN in New York in September 2018. If you attend that summit and, while there, go to Central Park for a little exercise in green space – good for mental as well as physical health –  you may find your life at risk. Mown down by hordes of high-income joggers.

Much as I applaud people taking responsibility for their health, these high-income New Yorkers are atypical. Globally, the burden of NCDs is in middle-income and, increasingly, low-income countries. Within countries, the so-called diseases of affluence are no longer; the lower people are in the social hierarchy, the higher the risk of NCDs. We cannot deal with NCDS, without dealing with the social determinants of health inequities.

There is a rumour going around that poor people are poor because they make poor choices; and that poor people are unhealthy because they make unhealthy choices. This rumour is a myth. It has the causal connection backwards. More accurately, it is not mythical that the rumour exists – I read it in the press nearly daily – but the evidence points the other way. It is not poor choices that lead to poverty, but poverty that leads to poor choices. An Indian villager is more likely to invest in longer term strategies if the harvest has been good. If it has been poor, he will focus on how to get calories for his family tomorrow, not on strategies for future prosperity. A single mother may respond to the admonition to read bed time stories to her children – it’s good for their long-term future – that she would if she could be sure that they would have a bed, let alone a book.

So it is with healthy choices. Change circumstances and people of low income are more likely to adopt the choices that are good for health. Having time to think about exercise is a luxury that people at the economic margins may not have, quite apart from lack of amenities; healthy food may be beyond a household budget. The stress of marginal employment would be happily forgone if better jobs were available.

Globally, to take effective action on NCDs, we need to address inequities in NCDs, and this entails action on the social determinants of health. What can we do?

In the wake of the WHO Commission on Social Determinants of Health, I was invited by the British Government to conduct a review to answer a question: how can we apply the findings of your global Commission to one country, England. In the Marmot Review, Fair Society Healthy Lives, we identified six domains of recommendations necessary for reducing avoidable health inequalities, promoting health equity:

·         Give every child the best start in life
·         Education and life-long learning
·         Employment and working conditions
·         Minimum income for healthy living – every one should have at least the minimum income that would enable them to live a healthy life
·         Healthy and sustainable places and environments in which to live and work
·         Taking a social determinants approach to prevention. Not just looking at smoking and unhealthy diet, for example, but looking at the causes of the social distribution in these behaviours – the causes of the causes.

As I have but a few minutes I encourage you to read the Marmot Review, or my book, The Health Gap. I will, though, touch on how these six are relevant to prevention of NCDS.

Early child development sets a basis for everything that follows in the life course. Good early child development, leads on to better educational outcomes, better jobs on graduation, more income, better living conditions, and longer lives. People in these favoured conditions are more empowered to make the healthy choices that will reduce the burden of NCDs.

Education is a step on this life-course journey. There has been emphasis on health literacy, very welcome, but we should not forget literacy, more generally. Better educational outcomes give people the life skills not just to negotiate the health system but to negotiate life.

Employment and working conditions are vital not just because work earns money that enables other things to happen. But conditions at work may influence stress pathways that change NCD risk, in addition to influence on healthy behaviours.

Minimum income for healthy living. Universal basic income is on the agenda. It is a health issue. Do I need to make the case for why people need enough money to live healthy lives? The Minister of Finance may have more influence on health equity than the Minister of Health.

Healthy environments. Housing, of course. Working conditions, too. But we now have estimates for the millions of deaths globally caused by air pollution, respiratory and cardiovascular deaths principal among them. Increasingly, environmental pollution is an equity issue.

Social Determinants and prevention. Alcohol is a good example. We know, in general, that the higher the mean alcohol consumption of a country, the greater the frequency of alcohol-associated problems. One strategy, then, must be to aim for lower mean consumption in the population. It is often said that we should find ways to collaborate with the private sector. But we are on a collision course with industry. The brewers don’t want to reduce mean consumption.

When we turn to inequalities and alcohol, we need a further strategy. In the UK, and other countries, the higher the socioeconomic position of people the higher their mean alcohol consumption. Harm goes the other way. The lower the socioeconomic position, the higher the risk of alcohol-related hospital admissions and alcohol-associated deaths. We need, then, to address the social causes that put people at progressively higher risk the lower they are in the social hierarchy; as well as pursuing the first strategy of reducing population mean consumption.

Increasingly health inequity means inequity in the burden of NCDs. Therefore, to address NCDs, we must address health inequity, and that means concerted action on the social determinants of health. Cross government action is a priority.

Friday, 21 July 2017

The rise of life expectancy in the UK is slowing

19 July 2017

There is cause for alarm. Something has happened to slow health improvement in the UK. It is entirely reasonable to think that health just gets better and better. Indeed, over the last century, in the UK, life expectancy showed a steady increase: about 1 year every 3.5 years in men; about 1 year every 5 years in women. As you think about it, such improvement is quite remarkable: every 24 hours male life expectancy increased nearly 7 hours. Since 2010, this rate of increase has halved. Indeed, the increase has more or less ground to a halt.

What’s going on? The first thing to say is that we have not reached peak life expectancy. A levelling off is not inevitable. In the Nordic countries, in Japan, in Hong Kong, life expectancy is greater than ours and continues to increase. There must, inevitably, come a point where levelling off occurs, but we are not there yet

In considering reasons for this stalling, there is another part of the picture that claims attention: inequality. Since we published Fair Society Healthy Lives, the Marmot Review, in 2010 we have been monitoring health inequalities and their social determinants. In our July 2017 publication, we showed the longest life expectancy in the country was in the richest borough, Kensington and Chelsea: 83 for men and 86 for women. By contrast, the lowest life expectancy was in the North: Blackpool, 74 for men; Manchester, 79 for women.

Even more dramatic than these regional inequalities are the inequalities within local areas. In Kensington and Chelsea, life expectancy was 14 years shorter among the most disadvantaged compared to the best off. Alarming, but perhaps not surprising. Kensington and Chelsea may be the richest local area in the country, it is also the most unequal economically. The average salary in Kensington and Chelsea is £123,000. But the median is £32,700; i.e half the earners have £32,700 or less. There are some very high earners in the borough. Parenthetically, no prize for guessing correctly that Grenfell Tower, the tower block that went up in flames, is in the poor part of the borough.

In the Marmot Review, we identified six domains that cause health inequalities and where action is required to reduce them: early child development, education, employment and working conditions, minimum income for healthy living, healthy and sustainable places to live and work, and taking a social determinants approach to prevention.

Each of these raises cause for concern. To illustrate, our fourth recommendation was that in a rich country such as Britain everyone should have at least the minimum income necessary for a healthy life. The Joseph Rowntree Foundation monitors the minimum income standard – akin to our minimum income for healthy living. In 2008/9 about 25% of people lived in households with incomes below the minimum income standard. By 2014/15 this had risen to 30%. Not just the very poor, but the just about managing simply do not have sufficient income to lead a healthy life.

Inequalities in these social determinants provide potential explanations for a slowing of improvement. It is worth, though, thinking about the elderly, specifically.

The majority of deaths occur after age 75. Here, as well as effects from earlier in life, it is possible that spending on social care and health care could have much more immediate effects. Spending on adult social care has been reduced by more than 6%, since 2009/10 at a time when the population aged 65 and over increased by a sixth. Given that we show a big increase in deaths with dementia written on the certificate, and given the growth in the number of people aged 85+, there will be an increase in the need for social care. With cuts in funding, it is likely that there are unmet needs.

Similarly, funding of the NHS, which historically increased at about 3.8% a year since the late ‘70s, has, since 2010 been increasing at about 1.1%. And the spending per person is projected to go down.

It is tempting to link policies of austerity since 2010 to the slowing in increase in life expectancy since 2010. So far, I have resisted that temptation. What I would conclude, though, is that less generous spending on social care and health will have adverse impacts on quality of life of the elderly. It is urgent to determine whether austerity also shortens lives.

Professor Sir Michael Marmot is Director of the UCL Institute of Health Equity www.instituteofhealthequity.org and author of The Health Gap: The Challenge of an Unequal World

Thursday, 1 December 2016

Universities in a post-fact political world

One of my colleagues in Trondheim admitted that as he gets older the tears seem to come more readily. They did on Friday 18 November. Perhaps I should explain.

NTNU, Norwegian University of Science and Technology, in Trondheim awarded me a doctorate honoris causa, their 91st. The ceremony was a wonderful mixture of Nordic pomp, clockwork precision and Norwegian informality. Apart from two honorary doctors, twice a year approximately 150 students get their doctorates. Impressive.

Like all graduations it was a moving occasion. Certainly, I was moved. My short acceptance speech was along the following lines:

I love graduations. You, dear doctoral graduates, have worked so hard and now you are to be rewarded. You will go out into the world and use your knowledge and skills to make the world a better place.

I find this this graduation occasion special for three reasons. The first, not so important, is that it makes us happy. I work at UCL. The auto-icon of Jeremy Bentham sits in box outside the office of the University President and Provost. Bentham emphasised that social progress should aim at the greatest good for the greatest number. By each of us graduates being happy we add to the world’s utility. But I am not really a Benthamite.

A second more important reason why today is special is because it is a wonderful celebration of what we do in Universities like this one. It stands in stark contrast with what is going on in the world of politics at the moment. With Brexit, far right parties in Norway, Sweden, Denmark and across Europe, the US election, some politicians have declared war on truth, logic, consistency, reason and social justice; not to mention the assault on statistics. What we stand for in universities is all those things: truth, logic, consistency, reason and social justice. We have a vital role to play in standing up for these civilised and civilising values.

The third reason for my valuing this occasion so highly is because I take the award to me as an award to the field in which I work: social justice and health. What I do relies on evidence-based policies and social justice. I am chairing a new Commission on Equity and Health Inequalities in the Americas. At a recent meeting in Washington DC I walked in the Mall and found myself in the area devoted to Martin Luther King Jr. Dr King said:

Injustice anywhere is a threat to justice everywhere. We are caught in an inescapable network of mutuality, tied in a single garment of destiny. Whatever affects one directly affects all indirectly.

The world’s problems are our problems, your problems, my dear new doctors.

My colleagues here in Trondheim asked me if I am optimistic, given all the bad things happening in the world, as I have just laid out. Yes, I am optimistic because I do believe that evidence-based policies and social justice will win out. Martin Luther King said it better.

I believe that unarmed truth and unconditional love will have the final word in reality. This why right, temporarily defeated, is stronger than evil triumphant.

Another Norwegian professor, as if accounting for his colleague’s tendency to shed a tear, said: you spoke from your heart to our hearts. I shed a tear.

Wednesday, 26 October 2016

World Medical Association General Assembly, Taipei 2016

Welcome Message: Michael Marmot

It is my special pleasure and privilege to welcome you to our WMA General Assembly Taipei 2016 and 204th/205th Council Sessions. And to thank our hosts in Taiwan for their gracious hospitality and splendid arrangements.

It is tempting to say that this has been a tumultuous year – when were they ever different? There is, though, evidence to support this contention. The Global Peace Index looks at three broad themes: level of safety and security in society; the extent of domestic or international conflict; and the degree of militarisation.

2016 shows the level of peace in the world to be declining and the gap between the most and least peaceful countries continues to widen. Not just peace, but economics, too. Inequalities of income have been increasing in many if not most countries. Globally the gap in wealth is enormous. Oxfam reported this year that the richest 62 billionaires have the same wealth as the poorest half of the global population. The 62 could just about fit into a red London double decker bus. Not so the 3.5 billion people with the same cumulative wealth.

Added to concerns of security and economic inequality there is the slow burn of climate change that threatens major changes to way of life, particularly in low income countries. All three of these – conflict, economic insecurity and climate events such as floods, drought and famine – drive migration. According to the UNHCR we are now witnessing an unprecedented number of people driven from their homes – 65 million worldwide. Among them are over 21 million refugees, half of whom are under the age of 18. The top hosting countries for displaced people are Turkey, Pakistan, Lebanon Iran, Ethiopia and Jordan, but there are big impacts in Europe, Africa, the Americas, and Asia and the Pacific.

Each of these dramatic trends affects us as medical professionals. We deal with the health consequences of conflict and insecurity, economic inequality, climate events and large scale displacement of people. Our freedom to deliver medical care to the needy has, in some countries, been compromised unconscionably. And, at our best, we are active in addressing the causes of these challenges to the health or our patients and the communities of which we are part.

As we come together to debate these big issues we, representing doctors from all parts of the world, bring the highest ethical principles and commitment to the health of our populations. We have important roles to play within the World Medical Association, our National Medical Associations, and in the society at large.

More, we enjoy the company of colleagues from round the world. What we share is so much bigger and more important than what divides us. We gain so much from each other. A heartfelt thank you to all.

Michael Marmot
World Medical Association

Monday, 19 September 2016

Hope among the melee

It is easy to find accounts of Australian aboriginal health – strictly Aborigines and Torres Strait Islanders – that are lacking in hope. The standard narrative is that $billions have been spent, but aboriginal families are characterised by violence, alcohol, drugs, worklessness and high rates of crime.

Billions have been spent and aboriginal health is bad compared to the non-indigenous population – 11 years shorter life expectancy for men and just under 10 years for women. But a different account says that when people’s lives are characterised by betrayal of trust and systematic destruction of identity and self-worth leading to powerlessness perhaps it is no surprise that this Spiritual Sickness can lead to destructive behaviours. Money spent is not irrelevant. But the psychosocial issues are central. My starting position is that if communities and individuals are empowered it is more likely that money spent will lead to progress.

On my recent trip to Sydney to give the first Boyer Lecture for the ABC, the Australian Medical Association wrote to ask how could they help. I said I would like to see examples of doctors in action on social determinants of health. Prof Brad Frankum, President, and Fiona Davies, Chief Executive of the New South Wales Branch of AMA took me to Tharawal Community Centre in Campbelltown, a suburb 50 km South-West of Sydney. Sydney spreads and spreads and spreads...

(the photos from the Tharawal Aboriginal Corporation)

As I understand it, the two names are emblematic of Australian history. The Tharawal people were the original Aboriginal residents of the area. The Colonial Administration established a settlement named after the Governor Macquarie’s wife, Elizabeth Campbell. Indigenous people make up just over 3% of the Campbelltown population, compared to 1.2% of greater Sydney.

The Centre was an inspiration. I was shown around by two enthusiasts, aboriginal women, who were key in the administration. I was also greeted by one of the doctors, Tim Senior, with a sign:

The evening before, on ABC Television’s national discussion programme, QandA, I had talked of a fairer distribution of power, money and resources, and was told I was in Fantasy Land. This aboriginal centre was making a difference. It was making fantasy a reality.

Among its many roles is providing medical care:

But it is a prime example of what we mean by doctors working in partnership. As I went round the Centre, I was shown where the ante-natal classes took place, and activities at every stage of the life course: from early childhood

to older age:

“Bringing them home” is significant. A psychologist at the Centre told me that she works with the psychological consequences for children and the family of a child’s removal from home. I asked if she was talking about the stolen generations – Aboriginal children taken from their families between the 1890s and 1970s with the presumed intent of destroying aboriginal culture. The psychologist said that it is still going on. Children are removed because of family disruption but the consequences are severe.

 There is also a variety of services that deal with the reality of people’s needs:

Not to mention subsidised fruit and vegetables to make healthy eating more of a possibility:

We then came to the part of the Centre that dealt with drug and alcohol problems:

I said to the woman in charge: you must have the toughest job in this whole centre.
No, she said, I have the most rewarding job.

She showed me a painting on the wall. The man who painted this had come to the centre with huge problems of drugs, alcohol and domestic violence. By the time he left, the centre had made a step difference to him. He came back with this painting to say thank you.

I hold no illusions. There are deep-seated structural problems that account for the dramatic life expectancy gap between indigenous and non-indigenous Australians. But I challenge anyone to come away from a visit to Tharawal and say it is all hopeless. I saw evidence of community empowerment: a community controlling the services needed for its population. To repeat, funding for services is vital, as are good schools and job opportunities. But here was a centre dedicated to improving things for its own community. Inspiring, indeed.

Thursday, 11 August 2016

Canal and the Rest

Word Association game. Panama…Papers. There is, though, a canal. Actually, the Canal. A rather important canal that antedated the Panama Papers. It is hard not to think Panama Papers as you fly in to the city and see the remarkable cluster of tall buildings. Where did the money come from for these buildings? The Canal, in part, but money dirty and clean, or making the transition from the one to the other clearly plays a part. Panama’s economy is now 75% Service.

I last visited Panama in 1975 as a young doctor just completing his PhD in epidemiology at UC Berkeley. Stony Stallones, Dean of the School of Public Health in Houston, had called me and asked if I would like to spend 6 weeks leading a field trip to measure blood pressures in villages along the Caribbean coast of Panama, and in the city of Colon. A few Spanish 1 classes at Berkeley and off went Alexi and I. One way of learning how to conduct a field epidemiology study is to lead one.

In 41 years Panama made the transition from poor country with poor health to upper middle income country, per capita Gross National Income $18,200 at PPP, with life expectancy of 77.8 years. I look at the life expectancy statistics and decide that the salad is safe to eat. Not so, 41 years ago.

Panama may have got richer but it a fair bet that a country that is growing rich from its financial dealings and its Canal revenues will have big inequalities. The 80:20 ratio of earnings (the share of total income enjoyed by top 20% compared with the bottom 20%) is 18 in Panama. By contrast it is 13 in Costa Rica and Chile, 9.8 in the US, 7.6 in the UK, 4.0 in Norway and 3.6 in Sweden.

My visit started with an invited address to the National Assembly – the Congress. My challenge was to see if I could get the elected delegates to stop using their smart phones and listen. I did, more or less. I started with my visit of 41 years ago and commented on the remarkable and welcome improvement in income and health since then. But, and it is a big “but”, next door neighbour Costa Rica has national income of $13,000 (at PPP) but life expectancy that is 1.5 years longer. Further, it is highly likely that the big inequalities in income are correlated with big inequalities in health, but there are almost no data on health inequalities.

I know there is real concern with the rate of violent crime in Panama. I made the case to the Congress that ill-health and crime cluster geographically and socially. Action on the social determinants of health will likely have the benefit of reducing violent crime. (It may do nothing for white collar crime – but that is another question, see above and below). My parting message was that we need cross-government action on social determinants of health. I reminded them what we said on the cover of the CSDH report: social injustice is killing on a grand scale.

The President of the Assembly listened. When he opened the Public Health Congress the next evening, he said that social injustice kills. That is a start to cross-government action.

It had been arranged for me to meet the Canal Minister. I was keen to hear more about the Canal but made sure I told him about SDH. He said that the health minister should hear this and he fixed it. When I met the health minister, he said that the Vice-Minister of Social Development should hear this, and they both (Health Minister and Social Development Vice-Minister) came for lunch the next day. I was getting a feel for how the political hierarchy works.

The Canal represents about 9% of Panama’s GDP, so the Canal Minister is important. They just spent around $5.5billion putting a third lane in. Panamax is the largest size of vessel that could go through the existing Canal. NeoPanamax is the larger size that can go through the new larger channel. I had a guided tour of the new facility that opened only a month ago. Impressive.

There is a real concern among Panamanian colleagues that “health” in Panama has meant building hospitals. Primary care is under-developed and is much needed.

Among the many questions, I was asked by one Panamanian: what about corruption? My response: when we began the CSDH, I said that if governments were inactive or worse then we were sunk. Mirai Chatterji, with her experience of the Self Employed Women’s Association in Gujerat said: absolutely not. If governments won’t do it, civil society can and should. It is the power of social organisation. Then shame government into action.

Through all my various lectures and meetings in Panama I had the sense of a great deal of good will and commitment to social determinants of health and health equity. An important step forward is to develop monitoring systems and then to put in place cross-government action. We will watch this space with great interest.

Social Determinants of Health in Trinidad and Tobago

“If the house began as a shack on vacant land and grew from there, what evidence does he have that his house is his?” I asked Father Harvey. The Padre asked him.

“My life,” said his parishioner, a wiry 60 something year old. “I was born there, lived there all my life, it’s mine.” All said with a toothy grin. He had had dental work, a little too obviously.

“If there is no official land tenure,” I asked the Padre, “what happens when someone dies? Who gets the house?”

“It goes to the children but it can be problem,” said the Padre. “There was a lady who had a job as a laundress who earned enough to improve her house with the help of family and neighbours. That one over there,” pointing to a two story weatherboard house perched on the hill side, painted bright pink, “when she died one of her sons, addled by drugs and mental illness, was causing great problems for the others. Another son, bigger and stronger, had to be firm. He sat on him,” metaphorically, if not literally.

Laventille grew up as a typical squatter settlement on a hill with a panoramic view of Port-of-Spain and the Caribbean beyond. As with the favelas of Rio de Janeiro, Laventille confounds the more usual pattern of wealthy communities having the altitude and the view. Many people from other islands, coming to Trinidad because of its oil wealth, with no home or connections in Port of Spain, found themselves in Laventille. The settlement shows its past. Makeshift shacks, survivors of the old days, are in odd apposition with improved dwellings. The whole is an improvised higglediggy-pigglediggy cluster of dwellings making its way sinuously up the hill, via the “palace” of the steel band, to the church at the top. Snaking its way down midst the uphill ladders is the drain, unseemly, unsightly, and unhygienic, especially when blocked with rubbish when the rains come. Interesting to know whether, in the real life social “game”, the downwards snakes or the upward ladders predominate. My guess is that many of the residents would say there is a floor effect – life can only get better. There is no way but up.

I had asked my host in Trinidad and Tobago, Dr Solamain Juman, President of the Commonwealth Medical Association, if it was possible to visit the informal settlement. He lives in Port-of-Spain close to Laventille, but has never been there. With its justly won reputation for violence, it is not safe for outsiders. But he asked Father Harvey, the Catholic priest whose parish is in Laventille to take us there. (“Stick with me, Solly,” I said, “and I’ll show you Port of Spain.”)

Father Harvey is an understated hero. He leads a community development centre in Laventille and wherever we go he knows someone. The morning began in downtown Port of Spain with a man picking himself up from the street to chat to Father Harvey. The chat began with the Padre’s asking after the man’s health and well-being and ended with the priest giving him some money. I cannot imagine that the priest’s charity is the way to solve the problem, but it was an expression of the feelings of the man. In one city block we walked past three men sleeping on the street at 7.30 in the morning. Apparently there is simply no political will to solve the problem of homelessness. Laventille had been a solution in the past.

Physically, the problems of Laventille could be solved. The houses are being converted from shacks to something more substantial before our eyes. There are connections to the electricity grid and a water supply, intermittent though it may be. It would not take too much to fix the drain and put in proper sewage.

Socially, it is another matter entirely. Each block of the area is controlled by a gang chieftain. Although “block” implies something readily discernible – not quite so obvious in this maze. A former prime minister had the entirely commendable idea of creating employment for the residents of Laventille. The implementation was not good. He gave control of the jobs to the chieftains. It became their power base. I’ll give you a job if you give me 20%. Some of the gang leaders became quite rich. Then, of course, there was the issue of drug distribution, again controlled by rival gangs. Hence a great deal of gang warfare with cycles of revenge killings. And, of course, no one was prepared to come forward as a witness. One man was grateful to the priest for helping having him jailed. The man is convinced that the protection of prison saved his life.

Controlling the violence is a major challenge. Each gang is likely to have a police officer in their employ. In addition, T and T is a major route for drugs from Colombia via Venezuela to the US and Europe. The cartels, with tentacles that stretch to Europe, are much involved in this international traffic. The local gang leaders may well be offshoots of this global network. Now, we are talking about serious money and power.

I have pointed to the conjunction of crime and ill-health, both socially determined. Here was the crime playing out. Unfortunately, Trinidad and Tobago has a rather dysfunctional statistical system and we simply do not have the data on geographical distribution of mortality rates or life expectancy. No one, though, seemed in any doubt that the people of Laventille would be less healthy than the average.

When the Minister of Health heard that I was going to visit Laventille he was keen for me to visit the district of “Bangladesh” in his Port of Spain constituency. I had wondered if he was trying to make an issue of ethnic differences. Laventille is Afro-Caribbean, and I assumed that Bangladesh was East Indian – these are the two big ethnic groups in Trinidad and Tobago. But although the two big ethnic groups are, in general, geographically separate, Bangladesh is mixed. It is altogether a more benign affair, smaller in scale and a lay out that approximately resembles city blocks. Again, the issue is more social than physical.

I did the rounds in Port of Spain. The Trinidad and Tobago Medical Association were marvellous hosts and organised a two day meeting to review the evidence on social determinants of health with a second day on what can be done, involving much of the health and social community. I did two Television slots, talked to the faculty of the Medical School, had meetings with the Minister of Health and senior officials at the Health Ministry, did a Webinar for the United Nations, talked to the American Chamber of Commerce – a challenge to them and me both. Finally I crawled on to an early morning flight to Panama, there to raise the health inequalities flag once more.

The Minister of Health said publicly: I am a Minister of Health Care. But I want my legacy to be that I become a Minister of Health. He will be the champion in government for social determinants of health.