Tuesday, 22 March 2016

Celebrations and health equity in Ghent

Can we justify the kind of celebrations accompanying an honorary doctorate? Putting on funny gowns and hats, having bands and choirs, and walking through the streets in procession? Not to mention the lectures and dinners that accompany such an occasion. We can indeed. Not for the first time this year – see Bangkok – I have had occasion to reflect that such celebrations are a wonderful testament to scholarship. They take us out of the everyday political concerns of austerity and cuts, the human concerns of war and refugees, the economic concerns of global slow downs and market uncertainty and allow space to reflect on what universities can contribute to our civilisation. Five of us received honorary doctorates from Gent University – it has no “h” in Flemish, but seems to have gained one in English – a statistician from Sydney, an expert in fire safety now in Brisbane, an animal physiologist from Pennsylvania, a Belgian choreographer and me.

The diversity made the occasion even more special. I can illustrate. Several years ago a visiting American colleague gave me a copy of A Civil Action by Jonathan Harr. When my guest left I glanced at the book. Then something happened that has only one or two precedents in my life – I read through the night, literally. (If I recall, TS Eliot read through the night and went south in winter. I stayed put with the book.) It is a story of a small cluster of childhood leukaemia cases in a town north of Boston. A local factory was pumping so much chemical into the water that it was coloured. The question was whether the chemical was causing the leukaemia. Difficult scientific question. Reading the book, riveted by the book, I was convinced that a legal process is not the best way to settle scientific questions of cause and effect. Louise Ryan, now a statistics professor back in her native Australia, had had some involvement in this fascinating question while at Harvard. In case you are wondering, the legal case did not resolve it satisfactorily.

Next up, I remembered a typical long article in the New Yorker. A man in Texas was executed for murdering his children. There had been a fire in his house, the children died and he was accused of arson and hence murder. A fire expert said that the pattern of the fire was typical of arson and that clinched the man’s guilt, despite his repeated professions of innocence. Later expertise, too late, questioned the conventional wisdom and showed it to be false. It turned out that the pattern of the fire was NOT typical of arson and should not have been incriminating. Professor Jose Torrero from the School of Engineering in Brisbane had been important in bringing real science to the question and revising understanding.

My ‘promotor’ was Jan de Maeseneer who built up the Department of Family Medicine and Primary Health Care of Universiteit Gent. They had been part of the knowledge network on health systems of the Commission on Social Determinants of Health. Now, under Professor Sara Willems, social determinants of health is an important theme of their department. To that end they take students out into the community to experience the reality of people’s lives and encourage their feelings of empathy and their understanding of social determinants of health.

Another theme running through each of the honorary doctorates is the importance of networks and human relations in academic life. Though their countries of work are spread,  each of the honorary graduands, now graduates, had close intellectual and personal links with their promotor at Gent. There is a global community contributing to knowledge and understanding. That surely is ample reason to have a day of celebration.

…and my experience was captured on Flemish TV

Wednesday, 16 March 2016

Treating people with dignity not as instruments

I began my book, The Health Gap, with the line: What good does it do to treat people and send them back to the conditions that made them sick. I did not have in mind the current crisis of mass refugees in Europe, but it brings home the question in a starkly tragic way.

Some politicians take the view that if refugees are treated well, it will only encourage others to follow. My response to that is twofold. First, you would have to treat refugees particularly badly to make things worse than the conditions in Syria, for example, from which the refugees fled; quite apart from the hazards of the journey. Ghastly idea.

Second, and more fundamentally, medicine can lead by example in the ethical treatment of refugees. Doctors treat individuals who need care regardless of who they are and what made them sick. Each individual has the right to be treated with dignity. It is a core ethical concern for doctors. If someone is lying in the gutter with a broken head, the doctor does not say: I smell alcohol, I won’t treat him. The doctor delivers the best care (s)he can. So should it be with refugees. Treating people badly so as to discourage others from coming means that people have become instruments of political policy. It goes against the core ethical principles of medicine. To repeat, individuals have a right to be treated with dignity not as an instrument of someone else’s policy.

We should extend this ethical approach to the conditions in which refugees are eking out an existence: apply the social determinants of health principle. Treat the sick and be advocates for dealing with the conditions that made them sick. And that means addressing the appalling conditions in which refugees find themselves, as well as doctors speaking up for peace in the areas of conflict.

All this came to mind at the conference on War, Migration and Health, convened by the Turkish Medical Association and the World Medical Association in Istanbul, 25-27 Feb, 2016. The Turkish Medical Association had prepared an excellent report on the Turkish experience. Official figures suggest that there are between 2.5 and 3 million Syrian refugees in Turkey. The real figures are probably higher. Such numbers put enormous strain on a country’s resources – economic, social and political.

In Turkey’s case it comes with the background of the long-standing tension between the government and the Kurds and tensions over degrees of Islamisation. The Turkish Medical Association stands tall. By delivering medical care to all it has earned the opprobrium of government, but they have strong support from the World Medical Association. The declaration from the conference states this clearly.

My frustration at visiting cities and seeing little was eased by being shown something of Istanbul by our hosts. One has the feeling that the bridge over The Bosporus is the link between secular, modern, Europeanised Istanbul and traditional, more Muslim, conservative Asia. It is a tension that is playing out on the larger political stage. The secular republic of Ataturk is being challenged by the present government.

Wednesday, 10 February 2016

Prince Mahidol and Social Determinants of Health - Speech

Prince Mahidol and Social Determinants of Health

Michael Marmot
UCL Institute of Health Equity

A recent report from Oxfam showed that just 62 billionaires have the same wealth as the poorest half of the global population. With a bit of a squeeze all 62 could fit into one London double-decker bus. Not so the other 3.6 billion people. Within most countries, too, inequalities of income and wealth have been growing. Should we care?

We should for three reasons. First, as Sir Tony Atkinson highlights in his recent book, Inequality, surveys find that the population in the US and Europe identify inequality as the number one problem in the world. People feel it that is just plain wrong, unfair, unjust.

Second, too much inequality threatens democratic legitimacy. If life’s chances are sequestered at the top, the rest of the population, rightly, feels that the governance of countries does not serves their needs. Similarly, if the global economic and political order serves the elite in some countries at the expense of the rest of the world, it is major challenge to our existing arrangements.

Third, highly unequal societies are associated with social evils such as ill-health and crime. Some place emphasis on the gini coefficient and argue that inequality damages the health of everybody. In my book, The Health Gap, I emphasise that the ill-health effect of inequality increases with increasing degrees of social disadvantage—the poor suffer the most.
Central to the ill-health effect of inequality is both poverty and relative disadvantage. Absolute poverty means disempowerment in an extreme way: having insufficient money to meet basic needs. Relative disadvantage is related to the social gradient in health. Relative disadvantage, too, is disempowering. Following Amartya Sen I argue that relative inequality deprives people of the freedom to lead a life they have reason to value.
One welcome response to such inequality in health is universal health coverage – the theme of this conference. It is appropriate that it should be held in Thailand, given the great strides that Thailand has made in implementing universal health coverage. It is much needed. I have just come from a meeting in Kolkata where colleagues point to the fact that India’s health care system not only is failing to meet people’s health needs, but out of pocket expenditures are emiserating people. A simple contrast between India and Thailand is instructive. In India, according to WHO figures, of all expenditure on health care private expenditure makes up 73%; of which 87% is out of pocket. That means 63% of all health care expenditure is out of pocket. In Thailand, by contrast, only 20% of health care expenditure is private of which 57% is out of pocket i.e 11% is out of pocket. Out of pocket is 63% in India and 11% in Thailand…and the pockets are shallower in India.
Something else is needed, too. When we began the WHO Commission on Social Determinants of Health we asked rhetorically: why treat people and send them back to the conditions that made them sick? It is the first line of my book, The Health Gap. We need action on the conditions in which people are born, grow, live, work, and age; and on inequities in power, money and resources that give rise to inequities in these conditions of daily life. We need action, in other words, on the social determinants of health. And when people get sick, they need access to health care free at the point of use.
It is an absolute pleasure to be the 2015 Prince Mahidol Award laureate for Public Health. A pleasure for me, personally, of course. But that is of little interest. The pleasure is that this prestigious award recognises the importance of social determinants of health. It validates the hardy band of brothers and sisters who have toiled in this field.
As many of you will know Prince Mahidol was selected by his father the King for a career in the Navy. The Prince thought he could serve his people better by studying medicine, than by pursuing a career in the military. At Harvard Prince Mahidol diverted from medicine to public health and only later finished his medical degree. It is appropriate that there are awards in both Medicine and Public Health. In the Prince Mahidol museum in Siriraj Hospital here in Bangkok is a quote attributed to Prince Mahidol:
“The primary function of men of health science including physicians is not to assume the office of salvagers of wrecks but rather of pilots preventing them”.
There should be no conflict between wishing to prevent the wrecks and dealing with the problems when they occur. I argue strongly with ministers of education, environment, occupation, social security and finance that what they do in their day job influences health. So powerful is the influence of societal action on health, that health equity is a good measure of how we are doing as a society.

Conversely, I seek to get the doctors involved. Somewhat surprisingly I find myself President of the World Medical Association. In that role I am engaging actively with medical societies in all regions of the world to explore what they and other health practitioners can do to address the social determinants of health. I am hugely encouraged.

I say to them that Universal health coverage is vital but it will not abolish inequalities in health. In The Health Gap, I write about Baltimore and London. In both cities we see twenty year gaps in male life expectancy. Twenty years! But there is a crucial difference. In the UK we have universal health coverage, free at the point of use. Further, all round the world, we see difference in health not just between rich and poor, but there is a social gradient: the more years of education, for example, the better the health.

I emphasise disempowerment. If we want to see disempowerment in action, look at the recent paper by Anne Case and Angus Deaton showing a rise in mortality in the US among non-Hispanic whites aged 45-54. And the conditions that carry people off? Poisonings due to drugs and alcohol, suicide, alcoholic liver diseases, and external causes of death. Disempowerment from the social determinants of health rather than lack of health insurance.

Looking more positively, empowerment of women through education has clearly made a major contribution to the reduction in infant and child mortality globally. But the revolution in child survival shows the importance of treatment.

I referred to my recent book, The Health Gap. I wanted to call the book The Organisation of Misery. As one or two of you may know, I have been quoting Pablo Neruda and inviting colleagues to:
Rise up with me…Against the organisation of misery

The publisher said I could not give a book such a title. No one would read it. I proffered The Organisation of Hope. Better, said the publisher, but a bit obtuse.

I compromised. I called the first chapter, The Organisation of Misery, and documented the dramatic inequalities in health within and between countries. I then bring together the evidence on what we can do through the life course to reduce avoidable inequalities in health – health inequities – starting with equity in early child development, education, working conditions and better conditions for older people. I call the last chapter The Organisation of Hope because I document examples from round the world that show we can make a difference.

When in Thailand for the National Health Assembly in December 2009 our Thai colleagues taught me about the triangle that moves the mountain. The three sides of the triangle are government, knowledge including academia, and the people. Get the three sides of the triangle aligned and we can move mountains.

Mahidol Experience (Michael and Alexi go to Bangkok)

As Princesses go… I cannot finish that sentence because, in truth, my experience of Royal Princesses is somewhat limited. I’ll simply have to imagine whether the Thai Royal Princess, Maha Chakri Sirindhorn, really is more modest and straightforward than others. Now that I think about it, I am not at all sure how many others there are. But this Thai Royal Family has a history, at least since Rama I in 1782.

Nor can I pretend that a black tie banquet at a Royal Palace, sitting next to her majesty, and preceded by an award ceremony where she presented me with Prince Mahidol Award for Public Health, was just another one of those things. Nor can I think it routine to sit with the Princess at coffee the next morning, and then walk with her around an exhibition to honour Prince Mahidol, her grandfather. Nor was it quite ordinary taking high tea with the Prime Minister, nor yet was dinner in my honour at the British Embassy in Bangkok and a reception at the US Embassy, and a dinner hosted by the Minister of Public Health, and lunches, and a private tour of the Royal Palace including the stupendous temple of the Emerald Buddha.

Nor, regrettably, can I take for granted the policeman on a motorbike with flashing red light that eased the passage of our royal limousine through Bangkok’s traffic – although I did ask if I could have one of those to take home with me. Nor is it the new normal to be met at the airport in the early hours of Sunday morning by a gracious royal emissary.

In fact the whole six days spent in Bangkok were simply quite extraordinary. To say that my wife and I were given the royal treatment hardly does justice to the whole experience. The gracious dinner at the Thai Medical Association with the whole council, and organised by former WMA President, Wonchat Subhatchaturas, set the tone for everything that was to follow.

At one of my many “impromptu” speeches – by the end of the week, I was expecting the unexpected calls to say a few words at lunches, dinners and press interviews – I reflected that this week of celebration was something really special: celebration of scholarship in the service of humanity. The Royal Princess, the prime minister and senior ministers, the brass bands, the medical students, doctors, nurses, deans and professors were all celebrating these awards. And the awards were for contributions to Medicine and Public Health. As I said in another of my unscripted remarks, one does not pursue research and then policy action to gain an award. The award is a celebration that comes after the fact. In my case, the fact that the award was for social determinants of health and health equity validates and gives succour to ‘we few, we happy few, we band of brothers’ (Henry V) who have toiled in this field.

What do you talk to a Princess about? Why, social determinants of health of course. What else is there? I led up to it.

In my three minutes address at the Royal Banquet, I commented on the inspiration provided by Prince Mahidol. He was told by his father that he would have a senior position in the Navy. He decided he could do more good for the people of Thailand by studying medicine than by working in the military. He took himself off to Harvard and while studying pre-medicine, ‘discovered’ public health and returned to Thailand with a diploma from MIT and Harvard. Subsequently he went back to Harvard to finish medicine.

At the banquet I was sitting between the princess and a gentleman in splendid formal jacket of Thai silk. It turned out he was the very model of modern major-general, a former head of the Thai military. I asked if what I had said about Prince Mahidol had offended. Not at all, he said, he agreed. I then filled his head with the importance of cross-government action on social determinants and health equity, and said that I would seek to convince the Princess that her government should set up a cross-government mechanism to take action forward. He said he agreed with that too and encouraged me to turn attention to Her Majesty. I did. She listened, adding observations along the way.

As we went into post-dinner coffee in yet another splendid room of the Palace, I told the Major-general that I had got half way there but I needed his help to get the rest of the way. At high tea with the PM, the next day, I continued the theme. Let’s see.

I laid out some of my thoughts about it in my ten minute ‘award-winner’s’ speech to the Prince Mahidol Award Conference – see separate entry.

Friday, 20 November 2015

Improving Society in Rural Taiwan


Taiwan has had dramatic improvements in health. In my view that betokens dramatic improvements in society, along with increased prosperity. A good society will find the route out of poverty as well as caring for those who are disadvantaged in other ways. One way to see this was to visit rural Ilan county, on the coast east of Taiwan.

Shu-Ti Chiou has many strings to her bow. She had been health commissioner for Ilan before moving to Taipei. Last year she was prevailed upon to run for mayor in Ilan. She didn’t win, but received campaign expenses proportional to the votes she achieved. She used the money to start a small foundation to promote better health in Ilan.

On a Saturday morning we were taken to Yutian elementary school, to be met by the charismatic head teacher. He was clad in cycling gear, because Shu-Ti’s foundation had a collection of school principles set an inspiring example by doing a prolonged cycling trip, ending up at the Eden Foundation Yilan school – see below.

Two highlights of the school. First, it might be in a poor rural area, but the head teacher was committed to using technology appropriately. Each child was issued with a tablet computer to use at school and home. It was an integral part of the classroom as well as forming a close link between school and home.

Second, after a tour of the lovely school building we had a tea break – no ordinary tea break. Two youngsters performed the Taiwan version of the tea ceremony.  I asked if it was modeled on the Japanese tea ceremony and was told firmly: no, the Japanese got it from the Chinese. It really is a wonderful interlude to a busy day. No dunking of a British Rail tea bag into a mug of boiling water and going back to your desk. The student laid out five cups for the four ‘guests’ and herself, then slowly, methodically, and with practiced movements went through the ritual: warming the receptacle – perhaps best described as a porcelain squat jug; putting tea leaves into it, pouring water on, then discarding immediately – apparently this removes dust from the tea, and perhaps some unpleasant taste; then pouring a new lot of water on the leaves; then filling the small cups – which of course are in the same style of porcelain as the jug. All this is accomplished in absolute silence which adds to the meditative quality of it. Fifteen minutes of this and not only have you had a refreshing tea but you feel calmer, more meditative.

Then onto the Yilan Branch of the Taiwan Fund for Families and Children. Children from disturbed families are brought into the place. If because of their disrupted backgrounds, they are doing badly in school, they will actually attend school on the premises. We were treated to a drumming display by a group of these children who were clearly committed to what they were doing. It is a lovely place. One special area, no shoes, colourful but calming, is where young people can go if they are feeling angry or upset; or where they go with a counsellor.

I asked, I would  wouldn’t I, if they had any measures of success or otherwise of their various activities. Probably not, but it certainly gives children a place to be, to have fun and/or meaningful activities, and to feel a little bit of love from the warm committed social workers in the place.

Last stop was the Eden Foundation Yilan School. It is for educationally subnormal children and young adults. As with our previous two stops, the overwhelming feeling was that of staff who cared. The head teachers arrived on their bicycles and put on a concert for the residents, who appeared most appreciative.

I don’t know how typical these three special places are of what goes on throughout the country, but if this is how the poor, the disturbed and the mentally subnormal are treated, then the country has a great deal going for it.

Doing Better in Taiwan


Politics? Yes, of course, politics. It is always there. But, we argue consistently that concern with health should trump concern with diplomatic political sensitivities. I said it at the World Medical Association General Medical Assembly in Moscow: whatever tensions there may be between Russia and other countries, we work together in the common cause of better health. And it is what I felt when we at the IHE were approached by the Health Promotion Department of the Taiwan government to write a report on how they could address persistent health inequities through action on the social determinants of health. Does that mean we take a view about the continued aggravation about China and Taiwan? Not at all. We would be happy to work with China as we are with Taiwan. (For the Eastern Mediterranean Region of WHO, I have been to Egypt, Morocco, Iran and Tunisia; and joined a meeting in Kuwait by Skype. For WHO Euro I have been to Israel. Health is a shared concern.)

When on a Friday morning, I found myself sharing a joke with President Ma of Taiwan – see photo – my concern was not with international diplomacy but to secure his agreement to whole of government approaches to social determinants of health and health equity. He and I signed a mock-up of the cover of our report for Taiwan.

If we take the ‘do something, do more, do better’ mantra to Taiwan, we would have to say, they are in the latter group. Taiwan has done remarkably well. Life expectancy for men is 77 and for women, 83. This would put them firmly in the European average. A huge improvement remarkably quickly. But health inequalities persist – seen in the social gradient in life expectancy and disability-free life expectancy.

The Director-General of the Health Promotion Administration of the Ministry of Health and Welfare, Shu-Ti Chou, is a charismatic figure – see third photo. Committed, perceptive, well-informed, and clearly loved and admired by her colleagues. I apologised for the depths of my ignorance of Chinese names, but I told her that her name reminded me of the two names in Bertold Brecht’s play, The Good Person of Szechuan. Shen Te was good, caring and generous. But people took advantage of her good nature. She invented an alter ego, Shui Ta, who displayed the more self-centred side of human nature to protect herself. Shu-Ti said that perhaps she embodied a bit of both, caring and concerned, empathetic and embodying better virtues but at the same time having the drive necessary to make progress.

As well as the publicly stated commitment from the President, there is a potentially viable mechanism in Taiwan for whole of government action on SDH: the Committee on Sustainable Development. This committee is chaired by the Prime Minister and has the sustainable development focus of environment, economy and social development. By getting health equity into the last of these three and linking it firmly to the other two, there is reall prospect of making progress.

We plan to work with Taiwan over the coming year as they seek to make progress.

Thursday, 12 November 2015

Harmony and Action in the Caribbean

A population made up of indigenous people, escaped African slaves, French, Spanish and English colonialists, Creoles (mix of Europeans and Africans), Javanese, East Indians, and then sprinklings of Jews, Chinese, Brazilians and a few others – what language do you imagine they might speak?

Why Dutch, of course. This is Suriname, now independent of the Netherlands. It wasn’t always a Dutch colony. In the 17th century the English got New Amsterdam from the Dutch and the Dutch got Suriname from the English. Who got the best of that deal? New Amsterdam, of course, became New York.

Check the map. Suriname is up there on the Caribbean coast of South America between French Guiana and (British) Guiana. It’s capital as every school child knows, well some do, is Paramaribo.

Suriname is special not only because it is the only Dutch-speaking country in South America but it has a population of just over 500,000 and vast swathes of pristine tropical forest. Like much of South America it has a chequered past. But it is now a democracy. I was there, at the invitation of PAHO (Pan American Health Organization), because the government of Suriname has taken on board the importance of social determinants of health and action through, Health in All Policies (HIAP).

Francoise Barten, who I met first at the People’s Health Assembly in Cuenca, Ecuador in 2005, was there to greet me on behalf of PAHO.

The government really are engaged. After a meeting with the Minister of Health I was hosted by the Speaker in the House of Assembly, the Parliament, and gave a lecture to the House on social determinants of health. The next day, at a big national meeting, especially big for a tiny country, the Vice-President, Minister of Foreign Affairs, Minister of Health and Speaker of the House were all there. I have been invited to give a keynote address before, with ministers on the platform. They usually give their speech and leave. A noble exception was the Swedish Minister of Health. This time the ministers all stayed at least for the morning session.

I was also hosted by the Suriname Medical Association and the Faculty of Medicine and gave a talk on The Health Gap.

Above: With First Lady of Suriname, Liliane Ferrier, and Guillermo Troya, PAHO Rep in Suriname

I met the first lady who is leading a country-wide initiative on early child development. We had a good meeting. The First Lady said that she was also the champion across government for HIAP. I told her that I think Suriname is showing the way on whole of government action on SDH. Impressive.

With the First Lady at our meeting was psychologist, Liliane Ferrier who had said to me publicly at the big meeting: I have been waiting for you in Suriname for 25 years!

A little insight into the country. The doctors gave me two books by a Surinamese novelist Cynthia
McCleod. McCleod? In Suriname? A little research revealed that her unmarried name was Ferrier and she was the daughter of a President of the country. Liliane is a Ferrier. Any relation? Yes. First cousin. The former President was her uncle. Liliane’s background included Jewish, Chinese, and a lot else besides, including time spent in the Netherlands.

There is great willingness and interest on the part of government to be active on social determinants of health. An important step is good documentation of the extent of inequalities in health and in the determinants of health.

We may well do some work with them in evaluation of their initiatives on early child development.