Monday, 21 November 2011

The Institute of Health Equity

Today, we launch the UCL Institute of Health Equity. It is a statement of looking forward, of optimism about making a difference. When we began the WHO Commission on Social Determinants of Health (CSDH), as chair I declared, with the naiveté unique to an academic: we want to foster a social movement for health equity through action on the social determinants of health. Naïve dream it may have been, but much has happened to suggest that that such a movement is active, influential  and growing. The creation of the Institute of Health Equity is both an expression of that social movement and will play its part in continuing to foster it.

We look forward. But it is also worth reflecting briefly on how we got here. In the preface to Fair Society Healthy Lives, the English Review of health inequalities, I said that we stood on the shoulders of giants in the field of health inequalities. Three of the tallest died in 2009, the year before we published Fair Society Healthy Lives: Jerry Morris, Peter Townsend, and Donald Acheson. Jerry Morris was a pioneer epidemiologist concerned, among other things, with society and health. Peter Townsend had a deep abiding concern with poverty and inequality. Both were members of the Black Committee on Health Inequalities that, in a way, defined the field as a matter for public policy. Picking up the mantle, nearly twenty years later, Donald Acheson again brought the evidence to the attention of policy makers.

I want to acknowledge two other giants who had great influence on my thinking. Len Syme is very much alive and active at UC Berkeley. He showed me that my untutored meanderings in society and health could be made the subject of rigorous scientific enquiry. If anything Len Syme was more entranced by my demonstration of the social gradient in mortality in the Whitehall Study than was I.

Geoffrey Rose, who died two decades ago, by careful thought and analysis reasoned his way to a view of social causes of ill-health, not so different from Syme’s. I learnt much from Geoffrey Rose, including that the determinants of individual differences in health may be different from the determinants of difference between social groups and populations, and it was from him that I borrowed the phrase “the causes of the causes” which became a mantra of the CSDH and subsequent work.

In the decade that followed the Acheson report, health in England improved rapidly for all socioeconomic groups, including for the worst off. Although I was pleased to be a member of the Acheson scientific advisory group, I am not suggesting cause and effect. That said, the improvement in the worst off was welcome, whatever the reason for it. There is a “but”: health improved marginally more rapidly for the better off, so the health inequality gap did not narrow.

I was then asked to conduct a review of health inequalities in England. The question was how the findings of the global WHO CSDH could be applied to one European country. This review was reported as Fair Society Healthy Lives. The Review was commissioned by a Labour Government. Thereby hung a question: would the Coalition Government in Britain take on the recommendations of a review commissioned by the previous government? The Review occupied centre stage in one part of the Coalition Government’s Public Health White Paper.

We continue to bring the evidence to the attention of policy makers: the new Institute will house the European Review of Social Determinants and the Health Divide which will report to the WHO European Regional Committee in September 2012.  And the Institute has wider ambitions to advocate for health equity at local, national and international level, to build capacity to tackle health inequalities and recommend and support implementation of the most effective actions to reduce the tragic and preventable waste of life and good health, which we see across the world.

The Institute will be funded by the Department of Health, UCL and the BMA.  UCL will house the IHE and it has been my home for 26 years where I built the research operation that gave rise to much of my insights on health inequalities. The BMA is interesting. Although I have spent my academic career emphasising the evidence that the key determinants of health lie outside the health care system, I was invited to spend a year as President of the BMA. They supported the health equity agenda enthusiastically. Through the BMA I have engaged with the Medical Royal Colleges, with the World Medical Association and with National Medical Associations, who are keen to ask how medical professionals can engage with the health equity agenda.

The Institute of Health Equity builds on a lifetime’s work of many people. It gives me the privilege of overseeing an independent organisation whose job it will be to continue to advocate for a SD approach to reduce health inequity within and between countries by developing the evidence base, through partnerships on research, evaluation, monitoring and review; the development of policy and interventions to tackle health inequalities; and building capacity by organising and contributing to workshops and training events to spread the knowledge and experience needed to widen expertise.

As I said in another context, quoting Don Quixote: the dogs are barking, Sancho; it is a sign we’re moving.

Monday, 7 November 2011

A Tale of Two Countries

Same country, actually. Ireland. I had a full day in Dublin: a lecture to CARDI (Centre for Ageing Research and Development Ireland), a meeting at the Department of Health, and a lovely occasion at Trinity College Dublin. This full day gave me a glimpse of the two Irelands.

The first is the suddenly poor country that had previously grown rich by people lending each other other people’s money. People were feeling rich, their houses kept going up in value, price actually. They were rich … until the bubble burst. The signs of new riches are everywhere to see in Dublin: the tarting up of the riverside, the new bridges, the buildings in the financial sector, the splendid Terminal 2 at Dublin Airport.

But then came the crisis. The figures below show huge drops in expenditure and decline in GDP and GNP in 2009. They have a long way to come back. And unemployment is at 14.3%.
What the figures show, people feel. The usual informants, car drivers, say that they have never known it so bad. Going hungry and emigration were supposed to be part of Ireland’s sorry history not their bold new present. It is hard to believe that health inequalities will not be a casualty of all this.

On the other hand – there always is another hand – I had a very positive meeting at the Department of Health with the CMO, a minister of health, Ms Roisin Shortall, and others. The question I had been posed was should Ireland do a Marmot Review? The concern was that it was time consuming and expensive in terms of money and intellectual resource. My suggestion was that they take our English Review and adapt it to the Irish context. I’m hopeful.

The second Ireland was captured by Trinity College Dublin. Its enduring beauty is part of the point. The occasion was the award of 6 doctorates honoris causa to, among others, Lord Darzi, Parveen Kumar and me. Trinity has seen so many ups and downs in its 400+ years that, although the current economic mess has to be tolerated, it will not drag this great institution down. The award of honorary doctorates was part of the 300 year anniversary celebrations of the medical school. The occasion was so special because it was to celebrate scholarship. Despite all the push for academic life to contribute to the GDP, for students to see a degree as an economic investment, here was the University spending an afternoon and evening celebrating scholarship. Relevance was not ruled out, but contribution to knowledge and academic pursuits was the whole point. Wonderful.

Trinity’s public orator, a Professor of Latin, wrote the plaudits for the honorary graduands in Latin and recited them with rhetorical flourish. She stole the show. She had, though, strong competition from Mary Robinson, former President of Ireland, who is now the Chancellor of Trinity College Dublin, who put everyone at their ease with her genuine warmth and grace.

From the quarterly Economic Survey ESRI
                                2009                       2010                       2011(up to summer)
Real annual Growth %)
Private Consumer Expenditure

Public Net Current Expenditure


Gross Domestic Product (GDP)

Gross National Product (GNP)

(Annual Growth %)
Harmonised Index of Consumer Prices (HICP)

Consumer Price Index (CPI)

Wage Growth


Unemployment Rate (as % of Labour Force)


Thursday, 3 November 2011

Two Australias

The two pictures below show the “real” Australia: an iconic view of Sydney – 89% of Australians live in urban areas; and the urban settlement of Gumbalanya in West Arnhem Land Northern Territory. Both are Australia. The gap between these two is reflected in differences in health.
Since the beginning of the Commission on Social Determinants of Health, I have been citing the health statistics of Australian Aborigines to make the case for the different faces of poverty and disadvantage. No one in Australia is in any doubt that, on the whole, indigenous Australians live in poverty. Indeed, the figures I have quoted show a life expectancy gap of 17 years between indigenous and non-indigenous Australians. But, and it is a big but, infant mortality of indigenous Australians is “only” 12.5/1000 live births i.e really low on a global scale, albeit 2.5 times that of non-indigenous Australians. Australian Aborigines are carried off in shockingly large numbers by adult mortality: heart disease, lung disease, gastrointestinal disorders, cancer, nutritional and metabolic disorders, and violent deaths. These are “causes” that we do not usually associate with destitution.
 In a recent editorial in the Medical Journal of Australia, I argued that the real causes of the tragic health disadvantage of Australian aborigines can be found in the social determinants of health.
One particularly chilling statistic for Northern Territory comes from incarcerations. The imprisonment rate for the non-indigenous population is 160/100,000 (the figure I have in my head for the UK is 170/100,000); for the indigenous population it is 2100 – about 13 times as high. The prison population is more than 80% indigenous.
The Australian Human Rights Commission in 2008 produced figures of a 17 year gap in life expectancy. The Australian Institute of Health and Welfare recently, 2011, changed that to 11.5 years. Not, they said, because things had improved but because they changed the way they did the calculations. I suppose it matters because the earlier figures, which I quoted on an Australian Broadcasting Commission (ABC) interview, show indigenous Australians to be worse off compared to non-indigenous than similar comparisons in New Zealand, Canada, and the USA.
Over 1999-2003, in Queensland, South Australia, Western Australia and the Northern Territory, 75% of Aboriginal and Torres Strait Islander males and 65% of females died before the age of 65 years compared to 26% of males and 16% of females in the non-Indigenous population. Whatever the life expectancy figures there is a long way to go.

Two faces of Australia. Iconic view of Sydney (with my brother and niece) and the urban settlement of Gumbalanya in West Arnhem Land Northern Territory.