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.

Wednesday, 21 October 2015

Dinner at World Medical Association General Medical Assembly - Moscow - October 2015

Odd topic for a blog perhaps

My heart is full. On inauguration as WMA President, my speech invited National Medical Associations and individual doctors to rise to the challenge of health equity. I talked inequality of social and economic conditions damaging health and said that, at our best, doctors flourished in the cause of social justice. That evening, as I wandered around at the informal dinner chatting to people, the representative from Trinidad and Tobago said to me: you look like you are ready to dance.

“Not dance,” I said, “I’m floating; floating on a sea of well-being”. The question had been whether doctors would think that a message of social determinants was relevant to them. Yet, so many of the representatives here in Moscow have expressed their enthusiasm. The Danish Medical Association says that it is about to release a policy report that will deal with social determinants of health. They said that they had a Danish Marmot Review – Finn Diderichsen’s report – but now the doctors want concrete policy development. The Bolivians wanted to know how I could help. Colombia, Mexico, Costa Rica, Uruguay, Brazil, Argentina, Chile, Nigeria, South Africa, Trinidad and Tobago – all expressing enthusiasm. CMAAO, the Asian Network, wants us to work together. Alabania, goes on.

The doctor from IPPNW had tears in his eyes because both in my inaugural address and at the informal dinner I had mentioned Bernard Lown. The first time was to quote his “never whisper in the presence of wrong”. The second was to say that working in the cause of health unites us, whatever the politics of our countries, or whether our leaders are locked in conflict. I cited the example of IPPNW and working for peace. At the height of the Cold War, two great cardiologists, Bernard Lown from the USA and Dr Chazov from USSR co-founded International Physicians for Prevention of Nuclear War. Building on their shining example, we should have a global movement of Doctors for Health Equity.

After the informal dinner a dozen doctors from Confemel, the Latin American network of Medical Associations, kidnapped me ‘just for five minutes’. At the end of a lively 55 minutes we celebrated our commitment with a little Tequila. I said that we were going to conduct a review of social determinants and health equity in the Americas and wanted to involve the Medical Associations. I in no way counted myself as knowledgeable about Latin America but in the last few years I had visited Brazil, Argentina, Uruguay, Chile, Peru, Colombia, Ecuador, Cuba, Costa Rica and Mexico, as well as the US and Canada. And next week I was going to Suriname. We agreed to explore how to work together and to meet in Buenos Aires in April, if not before.

My heart is full, and my diary overflowing.

I noted for our hosts from the Russian Medical Society, the importance of the great Russian authors for all of us. I said that in a recent profile in the BMJ, I had divided my life into three: before, during, and after reading Tolstoy’s War and Peace. I had a second reason for drawing attention to Tolstoy and that was Isaiah Berlin’s famous essay: The Hedgehog and the Fox. Berlin begins the essay by quoting the Greek poet Archilocus: the fox knows many things but the hedgehog knows one big thing. Berlin thought Dostoevsky was a hedgehog and Tolstoy a fox. Given my obsession with social determinants of health, was I a hedgehog? But in my book, The Health Gap, drawing on our various reports, I emphasise that improvement in health equity requires action through the life course from early child development through to older age. Action can also take place at the level of individuals, communities, governments local and national, and the planet. To keep up with the evidence on that array of possibilities, and changing when the evidence base changes, means being rather fox-like. A hedgehog with fox-like qualities is to follow in the tradition of Berlin’s estimation of Tolstoy’s view of history. Forgive this oversimplification, but Tolstoy, in his musings about theorise of history explores the question of how much influence the individual has, even Napoleon, as against the grand historical sweep. The question of free-will against determinism has resonance in public health. Are individuals the architects of their own poverty and ill-health? Or is it determined by stronger social conditions? It is a terrain worth re-visiting.

The hospitality of the Russian Medical Society and the experience of being in city whose dramatic history is embodied in its astonishingly varied architecture was a fitting backdrop for some big debates appropriate to the WMA.

Tuesday, 20 October 2015

Inaugural Address as WMA President

Inaugural Address as WMA President
Michael Marmot
16 September 2015

Honoured Guests, Colleagues,

In May 2011 Mary hanged herself. She was found in the yard of her grandparents’ house on a First Nations Reserve in the province of British Columbia in Canada. She was fourteen. She was a First Nations, aboriginal, Canadian.

Her story has particulars. All suicides do. She had been physically and emotionally abused at home and in her community, and possibly sexually abused. Her mother was mentally unstable and heard voices telling her to ‘snap’ her child’s head. Officials attributed the suicide to a dysfunctional child welfare system, and to the fact that no one took her complaints of abuse seriously or acted on them.

There is another way to look at Mary’s sadly foreshortened life, and that is to realise that though her personal tragedy was unique, there are many young aboriginal Canadians who experience similar tragedies. In fact, the aboriginal youth suicide rate in British Columbia is five times the average for all young Canadians. One cannot understand fully why Mary saw no way out without also asking why so many other young aboriginal people in British Columbia reached the same desperate point.

The starting point is poverty, bone-grinding poverty, low educational levels and high unemployment. But there were about 200 bands of aborigines in British Columbia, more or less all in poverty. Yet 90% of the adolescent suicides occurred in 12% of the bands. Why some and not others? The difference was empowerment of communities. Empowered communities participated in land claims; self-government; had control over educational, police and fire, and health services; and establishment of ‘cultural’ facilities. The results were clear: the greater the cultural continuity and community control over their destiny, the lower was the youth suicide rate. Poverty is bad but poverty is not destiny. Empowerment of communities can save lives. I draw similar lessons from studying the health of New Zealand Maoris, Indigenous Australians, Native Americans or indeed that of excluded groups elsewhere in the world.

In January 2010, Haiti’s earthquake wreaked havoc and 200,000 people died. Less than two months later a quake 500 times stronger hit Chile and the death toll was in the hundreds. Haiti was underprepared in every way imaginable. Chile was well prepared, with strict building codes, well-organised emergency responses and a long history of dealing with earthquakes. True, the epicentre of the Haitian earthquake was closer to population centres than that of the Chilean quake, but that was only part of the explanation for the different scale of devastation. What turns a natural phenomenon into a disaster is the nature of society. The number of people who died had more to do with Haiti’s lack of societal readiness and response than with the strength of the quake.

In 2011 the London borough of Tottenham broke out in urban riots. The precipitant was the killing of a black man by police. But, unacceptable as that is, it was not the underlying cause. Inequality was the culprit. I had been citing an area of Tottenham as having the worst male life expectancy in London – 18 years fewer than in the best-off area. All in one of the world’s premier global cities. London now has more high-end properties, a price tag more than $5million, than Manhattan, Hong Kong, Singapore or Sydney. It is not surprising that the riots broke out in the area with the worst health. Ill-health does not cause riots. Nor do riots cause ill-health – at least not directly. Relative deprivation causes both urban unrest and illhealth. Ninety per cent of young people arrested in the riots were not in employment, education or training.

Similarly, in Baltimore in the US. When a black man was killed in police custody riots broke out. Not uniformly across the city, but in the area with condemned houses, low levels of education and income and a twenty year disadvantage in life expectancy compared to the area with leafy opulence.

Inequality strains the binds of a cohesive society. In Baltimore, those binds snapped. The immediate effect is civil unrest. The longer term effects is health inequity.

These examples illustrate that the way we organise our affairs, at the community level or, indeed at the whole societal level, are matters of life and death. As doctors we cannot stand idly by while our patients suffer from the way our societies are organised. Inequality of social and economic conditions is at the heart of it.

There are three aspects of Mary’s tragedy worth emphasising. The first is the vital issue of violence to girls and to women. It can be fatal, both because it drives women to suicide and because they may be killed by their partners. Second, I emphasised empowerment of communities. But empowerment of individuals is also of vital importance. A key route to female empowerment, globally, is education. Evidence shows clearly: the greater the education of women the less the likelihood of being subject to domestic violence. Third is the importance of mental illness. Mental illness and substance use disorders constitute the number one cause of years spent with disability, globally. We cannot be concerned with health, globally and in our countries, and not be concerned with mental illness and substance use.

More generally we need to recognise the importance of the mind to health equity. The mind is the major gateway through which social determinants exert their effect on health. Recognizing the importance of the mind takes us back to early child development and what I have called: equity from the start.

In Aldous Huxley’s dystopia, Brave New World, there were five castes. The Alphas and Betas were allowed to develop normally. The Gammas, Deltas, and Epsilons were treated with chemicals to arrest their development intellectually and physically, progressively more affected from Gamma to Epsilon. The result: a neatly stratified society with intellectual function, and physical development, correlated with caste.

That was satire, wasn’t it? We would never, surely, tolerate a state of affairs that stratified people, then made it harder for the lower orders, but helped the higher orders, to reach their full potential. Were we to find a chemical in the water, or in food, that was damaging children’s growth and their brains worldwide, and thus their intellectual development and control of emotions, we would clamour for immediate action. Remove the chemical and allow all our children to flourish, not only the Alphas and Betas. Stop the injustice now.

Yet, unwittingly perhaps, we do tolerate such an unjust state of affairs with seemingly little clamour for change. The pollutant is called social disadvantage and it has profound effects on developing brains and limits children’s intellectual and social development. Note, the pollutant is not only poverty, but also social disadvantage. There is a clear social gradient in intellectual, social, and emotional development—the higher the social position of families the more do children flourish and the better they score on all development measures. This stratification in early child development, from Alpha to Epsilon, arises from inequality in social circumstances.

This social gradient in children’s possibility to fulfil their potential, in its turn, has a profound effect on children’s subsequent life chances. We see a social gradient in school performance and adolescent health; a gradient in the likelihood of being a 20 year old not in employment, education, or training; a gradient in stressful working conditions that damage mental and physical health; a gradient in the quality of communities where people live and work; in social conditions that affect older people; and, central to my concern, a social gradient in adult health. A causal thread runs through these stages of the life course from early childhood, through adulthood to older age and to inequalities in health. The best time to start addressing inequalities in health is with equity from the start. But intervention at any stage of the life course can make a difference. Relieving adult poverty, paying a living wage, reduction in fuel poverty, improving working conditions, improving neighbourhoods, and taking steps to reduce social isolation in older people can save lives.

The health gradient to which these life course influences give rise is dramatic. There is a cottage industry, taking subway rides in various cities and showing how life expectancy drops a year for each stop. I have referred to twenty year gaps in Baltimore and London; but the health differences between rich and poor, dramatic as they are, are only part of the problem. Commonly, people say to me: I am neither rich nor poor; what does any of this have to do with me? The evidence shows that there is a social gradient in health that runs from top to bottom of society. People in the middle have worse health than those above them in the social hierarchy, but better than those below. We calculated for England that if everyone enjoyed the same life expectancy as the top 10%, based on education, there would be 202,000 fewer deaths each year; over 500 a day.

One problem, then, is poverty. Another is inequality. Both damage health and lead to an unjust distribution of health.

I have spent my research life showing that the key determinants of health lie outside the health care system in the conditions in which people are born, grow, live, work and age; and inequities in power, money and resources that give rise to these inequities in conditions of daily life. Since the establishment of the WHO Commission on Social Determinants of Health in 2005, I have been using research knowledge to argue for policies on social determinants of health.

Yet here I am, humbled by assuming office as President of the World Medical Association. Is there not a contradiction? The World Medical Association, WMA, upholds the highest ethical standards of the practice of medicine. It speaks out fearlessly when the right of doctors to pursue their noble calling is threatened. As President, I want the WMA to use the same moral clarity to be active against the causes of ill-health and what I call the causes of the causes – the social determinants of health.

The opening sentence of my recent book, The Health Gap: The Challenge of an Unequal World, was: why treat people and send them back to the conditions that made them sick? No one is as concerned about health and disease as we in the medical and other health professions. It has been and will be my mission to encourage our concerns with the conditions that make people sick.

I am hugely encouraged already. My friends in the Canadian Medical Association conducted Town Hall meetings across Canada to engage the public in discussion on how the conditions of their lives related to their health. The Canadian Medical Association then took the initiative to suggest a meeting at BMA House in London. Twenty countries and 200 people asked to come, including our now-Chair of Council, Ardis Hoven, and then-president, Xavier Deau, and participated with enthusiasm. I apologise in advance: I already have more invitations from medical colleagues, enthusiastic for the health equity agenda, than I could possibly meet. We need a global social movement.

I have been arguing that we have the knowledge of what to do to act on social determinants and health equity; we have the means. We need to ensure that we have the will.
Do we really have the means? Consider. What do the following have in common?

48 million people of Tanzania
7 million people of Paraguay
2 million people of Latvia
top 25 US hedge fund managers

In 2013 each of these four groups had a total income of between $21 and 28 billion. Imagine with me something totally fanciful: that the 25 hedge fund managers gave up their income for one year. It would double the income of Tanzania. The hedge fund managers wouldn’t feel it, because they will earn an average of $1billion each the next year. I am not suggesting for a moment that we simply pass the cash to individual Tanzanians. But think of the clean water that could be piped, the schools that could be built, the nurses trained and employed.

There is a great deal of money sloshing about. Great inequality between countries stops the money being spent in ways that would benefit the poor and the needy.

Suppose, though, that there was reluctance to see ourselves as part of a global community. We would still have to address staggering levels of inequality of income and wealth within countries. Here is an even more fanciful thought. Suppose that the hedge fund managers of New York paid a third of their $24 billion income in tax – unlikely I know – that money could fund 80,000 New York schoolteachers. 80,000.

What has this to do with doctors? At the meeting of National Medical Associations that we held in London we heard inspiring examples of how doctors are already working with communities to deal with the social causes of ill-health. In India I was taken by medical colleagues to a tribal area in Gujarat where the doctors are not only treating people who, hitherto, had no access to health care, but are working with others in community development and education to improve the conditions of daily life for marginalised people. In Brazil, the social gradient in stunting of young children is becoming progressively flatter. In Bangladesh and Peru inequalities in child mortality are decreasing. I am excited by the interest generated in social determinants of health globally in every region of the world: South Africa, Zambia, Morocco, Colombia, Cuba, Costa Rica, Panama, Surinam, Taiwan, Sweden, Norway, Finland, Iceland and … I could go on.

Colleagues, we can make a difference to the causes of the causes of health equity, as part of the practice of medicine. There is another we way we can make a difference, too. I do not go 7 for long without quoting the great German pathologist, Rudolf Virchow, who said that “physicians are the natural attorneys of the poor”. We can, we do, we should speak up about inequity in social conditions that damage the health of the populations that we serve.

It means too, that we should recognise and be vocal about any societal trends that are likely to affect health equity: climate change, trade, financial crises.

I hold a Bernard Lown visiting professorship at Harvard. Bernard Lown, great cardiologist and co-founder of International Physicians for the Prevention of Nuclear War, said: never whisper in the presence of wrong. Already WMA speaks up in a loud voice about the highest ethical standards of our profession. We should not whisper at the gross inequities in the world that give rise to health inequities.

In fact, so close is the link between social conditions and health that, I argue, health equity is a good measure of social progress; much better than income growth. Senator Robert Kennedy in a famous speech criticised Gross National Product as a measure of social progress. He said:

the gross national product does not allow for the health of our children, the quality of their education or the joy of their play. It does not include the beauty of our poetry or the strength of our marriages, the intelligence of our public debate or the integrity of our public officials. It measures neither our wit nor our courage, neither our wisdom nor our learning, neither our compassion nor our devotion to our country, it measures everything in short, except that which makes life worthwhile.

Health and health equity are not only worthwhile in themselves but they reflect much else that makes life worthwhile: the freedom to lead lives we have reason to value.
As doctors, at our best, we flourish in the cause of social justice. There is a great deal of injustice in the world. Can we really be optimistic? Let me quote from Nobel Prize winning poet Seamus Heaney:

History says, don't hope
On this side of the grave.
But then, once in a lifetime
The longed-for tidal wave
Of justice can rise up,
And hope and history rhyme.

So hope for a great sea-change
On the far side of revenge.
Believe that further shore
Is reachable from here.
Believe in miracle
And cures and healing wells.

I have had much reason to praise our medical students at the IFMSA, and our junior doctors. In the spirit of Heaney I say to our younger colleagues: believe in miracle and cures and healing wells not just for our patients but for society, too.

If this sounds idealistic I remember the words of Halfdan Mahler, former Director-General of WHO, who said when we published the report of the Commission on Social Determinants of Health: remember, idealists are the realists in human progress.

I have another poet who has been my companion. When we launched the Commission on Social Determinants of Health in Santiago Chile I quoted Pablo Neruda. I did again at each report we have published and I do so again now. I invite you to:

Rise up with me…
Against the organisation of misery.

Tuesday, 4 August 2015

A Game Changing New Book from Michael Marmot

We are delighted to announce the publication of a ground-breaking new book by Michael Marmot – The Health Gap.

There are dramatic differences in health between countries and within countries. But this is not a simple matter of rich and poor. A poor man in Glasgow is rich compared to the average Indian, but the Glaswegian's life expectancy is 8 years shorter. The Indian is dying of infectious disease linked to his poverty; the Glaswegian of violent death, suicide, heart disease linked to a rich country's version of disadvantage. In all countries, people at relative social disadvantage suffer health disadvantage, dramatically so.

These health inequalities defy usual explanations. Conventional approaches to improving health have emphasised access to technical solutions – improved medical care, sanitation, and control of disease vectors; or behaviours – smoking, drinking – obesity, linked to diabetes, heart disease and cancer. These approaches only go so far. Creating the conditions for people to lead flourishing lives, and thus empowering individuals and communities, is key to reduction of health inequalities.

Michael Marmot addresses these health inequalities and demonstrates ways to make them smaller. The new evidence he offers is compelling. It has the potential to change radically the way we think about health, and indeed society.

Read More…

Order today and get 35% Discount

35% discount available when you pre-order at and quote THE GAP

And read about his first book with Bloomsbury 'The Status Syndrome'.

Wednesday, 29 July 2015

Social Determinants of Health: Structural adjustment and the Zambian Medical Association

One in every 13 Zambian children does not survive to their fifth birthday; in Iceland it is one in 500.

Of a population of 14.5 million Zambians, 2 million have no access to sanitation facilities. Practicing medicine under these circumstances is a challenge – not least because of shortage of human resources for health.

Given this background I was particularly delighted when Dr Mujajati Aaron, President of the Zambia Medical Association, came forward and said he wanted to be part of my call (as President-elect of the World Medical Association, WMA) to National Medical Associations to rise to the challenge of social determinants of health and health equity. Dr Mujajati Aaron invited me to speak at the annual meeting of the Zambia Medical Association – the theme: the role of the Government and Zambia Medical Association in addressing social determinants of health and increasing health equity in Zambia.


Aaron began by asking why this theme? It sounds like social science not medical science. But then he cited figures such as those above and said we cannot solve these problems without action on SDH.

Dr Mzukisi, Chair of the South African Medical Association, said it was a pleasure to come to Zambia not pursued by the South African authorities. He was a great ally when he claimed that the WMA had recognised the importance of shifting from health care to health.

I felt as I do when hearing a much loved piece of music when Jairos Miti discussed early child development. He said we must look at conditions in which parents live as determinants of how parents care for children. Such examination will lead to understanding of children’s health and development.

I was very much taken with the presentation of Gabriel Banda, a former assistant to Kenneth Kaunda, first president of independent Zambia. Again sweet music intellectually, as he talked the language of social determinants of health. He said that basic needs bear closely on people’s health. Basic needs include: water, sanitation, food, shelter, energy, education and learning, livelihood and incomes (of individuals, households, and nations), communication, freedom from violence, safe natural environment and health care. And health can affect basic needs, although he focussed on social causation.

Zambia’s history, he said, is an illustration of what we are seeing in Greece now: of how austerity can damage a country and its population’s health. In his account, Zambia got into financial difficulties that led to a familiar deadly dance with the IMF. In the 1980s if a country was in financial trouble and appealed to the IMF for help with its debts, there was a standard response: we’ll help with debts and you pursue structural adjustment programmes (SAP).

SAP sought to commercialise and marketise provision of goods and services, reduce public spending through spending cuts, removal of subsidies, and increase in tax income, privatisation of public enterprises and liberalisation of finances. Spending cuts involved retirement of workers in the public service and reduction of the retirement age. Institutional memories and capacities declined in health and other fields.

Mr Banda said SAP wanted to make everything business and business everything. By his account, the austerity that SAP brought completely undermined the country’s advances, since independence, in meeting basic needs. The population did not like it. There were riots and people died. In 1987 President Kaunda said: that’s it. No more austerity; we will not continue to implement SAP. But that meant Zambia could not pay its debts. Sounding like Greece? Sanctions brought Zambia to heel and the country was forced to go back to the IMF and World Bank, and continue with liberalisation and diminution of services. Arguably, this hampered the country’s ability to deal with the new HIV/AIDS epidemic.

Given the IMF’s history, as exemplified in Zambia, the fact that the IMF is saying that in Greece, the EC and European Bank are imposing terms that are too tough, tells us either that IMF has learnt something from their grisly record, or that the EC and European Bank have learnt nothing at all from the history of the devastating effects of austerity.

I came away from my meeting with the Zambian Medical Association very encouraged. (But then that is my default state.) They have limited financial resources, the Medical Association has no paid staff, but they would really like to be part of a network of National Medical Associations that are dealing with social determinants of health. They see it as an absolute necessity.

Oh, and Dr Mujajati Aaron said: if you haven’t seen Victoria Falls, you haven’t been to Zambia.

I have and I have. Here’s the evidence: