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
President
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.

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.



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.