Remarks in opening
expert plenary session at NCD conference in Montevideo
18 October 2017
Michael Marmot
UCL Institute of
Health Equity
NCDs are a global health problem. One purpose of our meeting
here in Montevideo is to plan for an NCD summit to be held in at the UN in New
York in September 2018. If you attend that summit and, while there, go to
Central Park for a little exercise in green space – good for mental as well as
physical health – you may find your life
at risk. Mown down by hordes of high-income joggers.
Much as I applaud people taking responsibility for their
health, these high-income New Yorkers are atypical. Globally, the burden of
NCDs is in middle-income and, increasingly, low-income countries. Within
countries, the so-called diseases of affluence are no longer; the lower people
are in the social hierarchy, the higher the risk of NCDs. We cannot deal with
NCDS, without dealing with the social determinants of health inequities.
There is a rumour going around that poor people are poor
because they make poor choices; and that poor people are unhealthy because they
make unhealthy choices. This rumour is a myth. It has the causal connection
backwards. More accurately, it is not mythical that the rumour exists – I read
it in the press nearly daily – but the evidence points the other way. It is not
poor choices that lead to poverty, but poverty that leads to poor choices. An
Indian villager is more likely to invest in longer term strategies if the
harvest has been good. If it has been poor, he will focus on how to get
calories for his family tomorrow, not on strategies for future prosperity. A
single mother may respond to the admonition to read bed time stories to her
children – it’s good for their long-term future – that she would if she could
be sure that they would have a bed, let alone a book.
So it is with healthy choices. Change circumstances and
people of low income are more likely to adopt the choices that are good for
health. Having time to think about exercise is a luxury that people at the
economic margins may not have, quite apart from lack of amenities; healthy food
may be beyond a household budget. The stress of marginal employment would be
happily forgone if better jobs were available.
Globally, to take effective action on NCDs, we need to
address inequities in NCDs, and this entails action on the social determinants
of health. What can we do?
In the wake of the WHO Commission on Social Determinants of
Health, I was invited by the British Government to conduct a review to answer a
question: how can we apply the findings of your global Commission to one
country, England. In the Marmot Review, Fair
Society Healthy Lives, we identified six domains of recommendations
necessary for reducing avoidable health inequalities, promoting health equity:
·
Give every child the best start in life
·
Education and life-long learning
·
Employment and working conditions
·
Minimum income for healthy living – every one
should have at least the minimum income that would enable them to live a
healthy life
·
Healthy and sustainable places and environments
in which to live and work
·
Taking a social determinants approach to
prevention. Not just looking at smoking and unhealthy diet, for example, but
looking at the causes of the social distribution in these behaviours – the
causes of the causes.
As I have but a few minutes I encourage you to read the
Marmot Review, or my book, The Health
Gap. I will, though, touch on how these six are relevant to prevention of
NCDS.
Early child
development sets a basis for everything that follows in the life course.
Good early child development, leads on to better educational outcomes, better
jobs on graduation, more income, better living conditions, and longer lives.
People in these favoured conditions are more empowered to make the healthy
choices that will reduce the burden of NCDs.
Education is a
step on this life-course journey. There has been emphasis on health literacy,
very welcome, but we should not forget literacy, more generally. Better
educational outcomes give people the life skills not just to negotiate the
health system but to negotiate life.
Employment and
working conditions are vital not just because work earns money that enables
other things to happen. But conditions at work may influence stress pathways
that change NCD risk, in addition to influence on healthy behaviours.
Minimum income for
healthy living. Universal basic income is on the agenda. It is a health
issue. Do I need to make the case for why people need enough money to live
healthy lives? The Minister of Finance may have more influence on health equity
than the Minister of Health.
Healthy environments.
Housing, of course. Working conditions, too. But we now have estimates for the
millions of deaths globally caused by air pollution, respiratory and
cardiovascular deaths principal among them. Increasingly, environmental
pollution is an equity issue.
Social Determinants
and prevention. Alcohol is a good example. We know, in general, that the
higher the mean alcohol consumption of a country, the greater the frequency of
alcohol-associated problems. One strategy, then, must be to aim for lower mean
consumption in the population. It is often said that we should find ways to
collaborate with the private sector. But we are on a collision course with
industry. The brewers don’t want to reduce mean consumption.
When we turn to inequalities and alcohol, we need a further
strategy. In the UK, and other countries, the higher the socioeconomic position
of people the higher their mean
alcohol consumption. Harm goes the other way. The lower the socioeconomic
position, the higher the risk of alcohol-related hospital admissions and
alcohol-associated deaths. We need, then, to address the social causes that put
people at progressively higher risk the lower they are in the social hierarchy;
as well as pursuing the first strategy of reducing population mean consumption.
Increasingly health inequity means inequity in the burden of
NCDs. Therefore, to address NCDs, we must address health inequity, and that
means concerted action on the social determinants of health. Cross government
action is a priority.
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