What you said: Did it include me?

At the finish of my lecture in Auckland, a Maori woman started by saying: “you are the first white man who ... (I got a bit alarmed at where this was going and did not quite hear the finish, but it was along the lines of) ... spoke to me in a way I could believe in; what you said: did it include me?” She then, in traditional Maori fashion, introduced herself in terms of her background: who her grandparents and parents were. But then she said: I think what you said includes me, but I want to hear from you that it is so.

I was overcome. I struggled with my emotions before an audience of 250 people. I could see people in the audience on the edge of their seats in that anxious combination of riveted fascination, embarrassment and empathy one has when someone publicly looks to be at risk of, shock!, displaying emotions. The chair of the NZMA, Paul Ockelford, told me afterwards that he could see the tears in my eyes – he had tears in his eyes when he told me this – as I was visibly moved. Finally, in a small voice I said: if what I said did not include you then I am doing something terribly wrong. Of course, it includes you. I then quoted the song the Thai children sang (quoted in my BMA speech):

                We are all waves of the same sea

We are all stars of the same sky

It’s time to learn to live as one.

Much of the concern with health inequalities in New Zealand is with Maori/non-Maori differences. Martin Tobias concluded that about half of that difference is socioeconomic in origin. There is a good deal of resentment among Maori academics at both halves: the socioeconomic disadvantage and the long history of discrimination. While the health position of New Zealand Maori compared to non-Maori (pakeha) is a good deal better than that of indigenous Australians compared to non-indigenous, Maori life expectancy trails pakeha by about 9 years.

I was keen to see what is happening at community level and asked to visit a Marae – a Maori community centre. I was taken to see the Kokiri Marae Health and Social Services Centre in Lower Hutt, a down at heel area outside the main city of Wellington. The story we were told was one of Maoris being encouraged off the land into the cities to find work and finding not so much work but marginality and social exclusion – a regretfully familiar tale of gangs of young males getting into trouble, alcohol, physical abuse of women and children.

Kokiri Marae was started by and is run by women. They get a variety of government grants to run services. The one man that we met, and it was he that did the traditional Maori greeting, told us the story of how the Marae was founded by his grandmother.

The story of Grandma and the gangs is the stuff of movies. In short, Grandma was in the Lower Hutt in the same poverty as all the other Maoris but wanted to provide a community centre for the young men who were getting into all sorts of trouble in gangs. Every day with whatever ingredients she could find, Grandma made a tureen of soup, and every day for two months she threw it out. She invited the gang members to come and eat, but it had to be on her terms: shoes off, respect, no violence. No respect, no soup. For two months the standoff between Grandma and the gangs continued. They wouldn’t meet her terms and she threw the soup out at the end of the day. Finally, they took their shoes off and came and ate.

“Hollywood ending?”, I asked. “The gang members all became lawyers and members of parliament?” Not quite. Still a lot of mayhem and family violence, but Grandma’s vision flourished.

Among the programmes of the Kokiri Marae is one called “Whanau Ora”. The CSDH and the English Review highlighted empowerment, dignity, participation in society, (long live the Oxford comma!) and the Amartya Sen concept of freedom to lead a life one has reason to value. I was therefore entranced to read the following description of enhancing whanau capabilities:

·         To become self managing

·         To be living healthy lifestyles

·         To be participating fully in society

·         To be confidently participating in Te Ao Maori

·         To be economically secure and successfully involved in wealth creation

·         To be cohesive, resilient and nurturing.

Terrific. This is putting into practice the kind of principles espoused by the CSDH and Fair society Healthy Lives. Does it work? I am convinced that this is wonderful, I told them, but if I want to be able to communicate this to others round the world, I need to have something more, showing that it is effective. We then had a highly nuanced discussion about both the need for evidence of what works, but of the difficulties of doing the right kind of evaluation and their miserable experience in the past at the hands of researchers.

They painted a realistic picture of continuing processes of exclusion, of family violence and young men getting into trouble. But they have hope and commitment and it gives me more grounds for optimism. Maori life expectancy may be lagging behind, but it IS improving. It has risen to the level of whites 20 years ago. Improvement but a long way to go!

Bubbling Up Down Under

A medical colleague in New Zealand said: fancy the doctors taking a lead on social determinants of health! You have opened another front.

The New Zealand Medical Association has produced an excellent statement of the importance of health equity for New Zealand, building on the findings of Fair Society Healthy Lives. (see here) One of the pleasures of the social movement we have been trying to create is that while on the one hand we rely on analyses of data and synthesis of evidence, on the other, much of the action comes through personal relationships.

The immediate past chair of the NZMA, Peter Foley, had come to the BMA meeting a year ago where I was installed as President. He heard me do my best to bring the BMA with me on the social determinants agenda, and said: we should be doing this in New Zealand. He convinced me to visit and organised several events around it in Auckland and Wellington, organised by the present chair, Paul Ockelford, and Don Simmers. In Wellington, the capital, the Minister of Health opened the symposium. I was told that it was not just his speech writer who had read our English report but the minister had read it himself and referred to it liberally in setting out what they were doing.

A parliamentary breakfast, meetings with parliamentarians from across the political spectrum, and public servants, plus the board of the NZMA helped.  Len Cook, who was head of national statistics in New Zealand and the UK suggested that the UK is good on analysis not so good on implementation; in New Zealand, it is the converse: not so good on analysis but good at getting things done. He related this to scale. There is more intellectual fire power in the UK but it is more difficult to implement things.

The Board of the NZMA then met to consider further action – the feedback was all positive. If the NZMA do lead the charge in New Zealand it will be an important example for other countries to follow.

American Medical Association

Even as recently as two years ago, the idea that I would attend a meeting of the American Medical Association was vanishingly remote. But once on the slippery slope... As President of the BMA, I was the official representative at the AMA annual House of Delegates meeting in Chicago. Having met some of the senior AMA people at World Medical Association (WMA) meetings, I could almost “pass” as one of them. But not quite. I had two distinct but contrasting impressions.

The first relates, of course, to the social determinants of health. The incoming AMA President, Peter Carmel and I had met at the WMA meetings in Vancouver and Sydney. He is a paediatric neurosurgeon and I immediately thought there was a grace, an urbanity and humanity about him. After my talk in Sydney he said: I have heard you speak three times now. The first time I thought it was common sense; the second, I realised you had evidence; the third it was clear you are a bomb thrower. I would like you to come to Chicago and I want to expose you to 500 right wingers. Given that the meeting is mostly political, with delegates debating motions – it is accepted that the earth is not flat – there was no such opportunity. Pity. But he did introduce me to several AMA people by telling them how important it was to take note of the social determinants of health.

He even referred to it in his inaugural address, which was impressive. He talked not politics but of the role of the physician that involves empathy and integrity and desire to help. He said his heroes had always been doctors, including his own father. I was struck that religion features highly. He was sworn in, hand on bible, and ending with “so help me God”. The whole proceedings were opened by a Rabbi – Peter Carmel’s Jewish background was an important feature of the proceedings and his three children, their spouses and 6 of 7 of his grandchildren were there – and closed by a bishop. I was asked how it differed from the BMA. I told them that the BMA President has to do without God’s help. The counterfactual might be interesting.

The second abiding impression was that the AMA endorsed Obamacare – the affordable care act. One has to remember the slightly surreal nature of the debate in the US. Romney, when governor of Massachusetts, passed an act that arguably is the basis for Obamacare. As Governor, the act was introduced with great fanfare and it is highly popular in the state. But it is anathema to the Republican right. Today, Romney has somehow to distance himself from something of which, yesterday, he was justifiably proud if he wants the republican presidential nomination, which he is seeking.

Remarkably, perhaps, the AMA has approved Obamacare but there was still a three hour debate on the subject in Chicago. Particularly contentious was the requirement for individuals to have health insurance. People spoke “eloquently” of the fact that America was founded on freedom and forcing individuals to have health insurance was an erosion of that freedom. So is mandatory car insurance and taxation, but I suppose this is a step too far. It would appear that these defenders of liberty would rather have avoidable sickness and people refused care because of inability to pay than have further erosions of freedom.

In his blog Paul Krugman has an interesting take on this notion of freedom. Below is a direct quote from Paul Krugman’s blog:

17/06/2011

Matt Yglesias is having fun with a study from the Mercatus Center purporting to rank states by their levels of freedom. I was disappointed to discover that New Jersey is only the second most tyrannical regime, behind New York.

One of Matt’s readers does the correlations, and finds that:

The Mercatus Institute’s freedom score was significantly linked to (by state)- lower educational attainment (measured by percent of Bachelor degrees or higher), lower population density, lower per capita GDP, increased infant mortality, increased accident mortality, increased incidence of suicide, increased firearm mortality, decreased industrial R&D, and increased income inequality.

This suggests that New Hampshire, which Mercatus considers the freest state (with South Dakota just behind) has its state motto slightly off. It should be “Live free and die.”

So much for freedom, or at least this bizarre version of it – the freedom to be denied medical care when you get sick.

Cold homes: our 21st century challenge

Living in a cold home can make you sick. It’s perhaps not surprising that older people are particularly vulnerable, with cold houses putting them more at risk of heart and lung disease as well as worsening conditions like arthritis and rheumatism.

But when Friends of the Earth asked my research team at University College London to review the evidence of how cold homes affect people’s health, it was shocking to see how much children and young people also suffer.

 Cold, poorly heated homes affect babies’ weight gain and increase the frequency and severity of asthmatic symptoms in children. Teenagers who live in cold houses are five times more likely to risk developing multiple mental health problems than adolescents who have always lived in warm homes.

 The indirect consequences are subtle and worrying. Growing up in a cold home is likely to have a negative effect on children’s educational achievement, emotional well-being and resilience. Over time this can put them at a disadvantage, worsening their life chances and increasing health inequalities.

 The evidence also shows that fuel poverty – when you can’t afford to heat your home properly – is surprisingly widespread. The poorest Britons are hit the hardest, but fuel poverty also affects people from a range of income groups and backgrounds. Treating people made ill by living in a cold home is estimated to cost the NHS hundreds of millions annually a year, not to mention the added expense of social care and the loss to economy of young people not realising their full potential.

 Despite this there is a clear contradiction between the Government’s recognition of the link between health and cold housing, its statements of support for the reduction of fuel poverty and CO₂ emissions and its lack of identifiable commitment to support this agenda through regulation, target setting, guidelines, or funding. The recent cuts to the Warm Front grants scheme with its clear record of health improvement, ahead of any significant detail on the level and arrangement of the future Energy Company Obligation, are of particular concern.

 The impact of the funding cuts to local authorities on investment in fuel poverty and energy efficiency programmes is likely to be highly detrimental. It is estimated that between £3 and £8bn is needed annually to eradicate fuel poverty. Current and expected Government support and financial commitments to dealing with cold homes is simply inadequate.

 There’s a danger that cold homes are dismissed as part of the tough nature of things. We’ve grown used to draughty, poorly insulated old houses, with inefficient boilers and single-glazed windows that make them extortionate or impossible to heat properly. Tenants often put up with bitterly cold rented accommodation – homes rented from a landlord or letting agency are most likely to be the worst insulated.

 But it doesn’t have to be this way. In far colder countries like Finland and Sweden homes are built to protect people against low temperatures and ill health, with decent insulation in walls, lofts and floors.

 It’s unacceptable that in our developed society so many homes are so cold they’re officially dangerous to health, while 4.5million households in the UK suffer from fuel poverty. The health problems caused by cold homes and the stresses of living in fuel poverty are avoidable with the right policies – if there’s the will to do something about it.

 The extent of the problem demands a suitably sized solution – a nationwide refit of the worst, coldest homes. The announcement by Chris Huhne earlier this week that the Government will - due to popular demand – be introducing a minimum energy efficiency standard for private rented homes is a strong and welcome start but it is a long way from a plan to end fuel poverty.

 In this country we have a proud history of ambitious projects to improve public health at home. Pioneering housing reform in the 19^th century introduced drains and lavatories, clean running water, street cleaning and refuse collection. In the process it got rid of cholera that killed thousands each year and made towns cleaner, fresher places to live. The major slum clearances during the 20^th century saw people move to decent, sanitary living conditions.

 A big challenge facing us this century is improving cold British homes.

 It seems to me there’s a double win here, and it shouldn’t be a trade-off. Insulating homes to stop them wasting energy would improve people’s health and wellbeing and protect the environment at the same time. As so often, public health and environmental advances are linked.

 With an Energy Bill being debated in Parliament now is the time to act. None of the previous great strides forward in public health came about by themselves – they took courage, imagination and political will.

 Let’s hope the Government is brave and bold enough to step up to the mark and banish cold homes and fuel poverty to history, where they belong.



Please click here to read the Fuel Poverty and Cold Homes Report.

Visiting Durham

Interesting trip to Durham in the North East. I had been invited by the Vice-Chancellor of Durham University to give a university lecture. It seemed a bit bold, but I made a condition. I pointed out that we were actively trying to involve communities in uptake and implementation of the Inequalities Review, including in the North East. How about using the occasion to engage stakeholders locally who may play a role in taking the agenda forward. He did.

My lecture, billed as A Fairer Society for a Healthier Future was well attended – they announced that the University wouldn’t allow standing room only, although there were a few standers in a packed rom. Following the lecture, there were some excellent questions and comments including:

·         The Marmot Review emphasizes social justice, good; but it does a totally inadequate job at dealing with ethnic specific health problems, and the whole question of racism and discrimination. I referred to the research (by James Nazroo) that shows that much of ethnic differences in health are socio-economic. That said, I agreed with the questioner that we had not given much emphasis to questions of racism and discrimination. Certainly, we had heard from Gypsies and Travellers that they did not recognise themselves in the Report.

·         A representative from a faith community asked by what right did people expect to be able to exploit their natural gifts in the market place. He wanted to open up the discussion in a more fundamental way. I agreed that such discussion needs to be had. When Mervyn King, governor of the Bank of England,  expresses surprise that the public have not become more angry that they have to suffer because of bankers’ excesses, it is time to take notice.

·         During my lecture I had asked if anyone thought other than that much of global health inequalities was in principle preventable. The questioner asked: Every one may know, but does any one care? Indeed!

·         Creating jobs was, of course, important, but creating healthy meaningful work was part of development of social capital. Agreed. I reported what we had heard in Malmo last week: that in the poorest part of the city, with large immigrant populations, unemployment was at 60% for men and 65% for women. As part of Sweden’s million homes programme, there was a proposal to teach people building skills, to make them more employable with all the benefits entailed, and have them involved in building local housing.

·         Part of dealing with the causes of the causes is dealing with the political drivers of the causes of the causes. Agreed. By all means, use the evidence brought together in the  CSDH and the English Review as the basis for a more political analysis and action plan.

 After the lecture and Q and A, there was a policy seminar involving about twenty people from local politics and local government, the health sector, and the university, deftly chaired by Stephen Eames from Co Durham and Darlington NHS Trust.

What struck me was that despite an abundance of reasons for gloom – deprivation and inequalities in the North East, savage public spending cuts, non-stop reorganisation –the seminar participants were not gloomy. The tone was constructive, forward-looking, even optimistic that they could make a real difference.

Three priorities for future work were identified:

·        Early childhood, including mental health

·        Older people

·        Taking the English Review’s six recommendations and shaping public health strategy accordingly.

It was also pointed out that they in Durham and the North East could have an important advocacy role in influencing national policy.

My reactions to the discussion:

·         I was delighted with rhetorical question asked by one: Do we need to be well-informed to be fair. Be a good question for an entrance exam to University. As someone who has spent a great deal of time compiling evidence, my answer, of course, is yes. But I suppose if  you thought that consequentialism was the work of the devil, and fair process was everything, perhaps not. But how would you recognize fair process without good information?

·         A key message that has come through to me is the importance of doing things WITH people not TO them.

·         The public slanging match – Private good, public bad, or vice versa – was not a helpful way forward however useful such simplistic slogans were for politicians. (It was put to me afterwards that I was needlessly disrespectful of politicians as a class. I was contrite and apologized for being simplistic myself)

·         We need an examination of what has worked and, in the future, what does work. Evidence!

·         If, in Durham, they are serious about taking the Marmot Review agenda forward it would be excellent if they set up a mechanism to plan, execute, and monitor. We would be delighted to be kept in touch with their progress.

Second European Review meeting in Malmo, Sweden

We held the Second meeting of the European Review of Social Determinants and the Health Divide in Malmo.

When we began the global Commission, the CSDH, we asked ourselves what success would look like. It never occurred to me to answer: a Commission being set up in Malmo. But that is what happened, and is an undoubted benchmark of success.  A city employee, Anna Balfours, read Closing the Gap in a Generation. She said it spoke to her. They invited Denny Vagero, a commissioner in the CSDH, to give them a seminar. Anna said: as an Englishman you like to hear a British correspondent reporting from abroad. Denny was their foreign correspondent from the world of global health and they took the decision to set up a Malmo Commission to translate th findings of the CSDH into a form suitable to address social determinants and health inequalities in their city.  

The European Review meeting was hosted by leaders of the city of Malmo, who were hospitable, generous and constructive. Their Commission for a Socially Sustainable Malmo, chaired by Sven-Olof Isaacson, was launched with a press conference on Wednesday afternoon, followed by a lecture from me, chaired by the deputy mayor, who is a member of the Malmo Commission. We then had a round table with the Commission on Friday afternoon as a way of cementing their partnership with the European Review. We had a good meeting. It warmed the cockles. On the second morning I felt the Review suddenly took off, caught fire, came alive. It was, and is, exciting. The first meeting had been in Madrid in October. There had been such delay in getting started that we began without contracts having been issued and with difficulty getting everyone together. The first meeting felt a bit anti-climactic. Our task groups, 8 topic groups and five cross-cutting, were to do the work of assembling the evidence about proposals to reduce inequalities in health and the social determinants across Europe. But without contracts they could hardly be expected to function properly, which meant our whole timetable was in danger of slipping.

In the event, the Task Groups have done a terrific job of producing interim reports with outlines of their future work. They were at somewhat different stages, some with draft chapters, others less sure of the scope. But on the whole it was very reassuring. We will have real substance, new evidence and proposals on which to draw and to deliberate. The Senior Advisors got engaged at a private session. They discussed:

·         The report: audience, how political it should be, what is the narrative

·         The conceptual model – they didn’t like the CSDH form of it. The general idea of social determinants as the “causes of the causes” is accepted, but getting it down on paper in a useable form is a challenge

·         We re-emphasised that the Review has to deal with inequalities within and between countries

·         Europe has special features because of the European Union and the European Court of Human Rights.

·         Partners: countries, regions, cities and sectors, including the private sector

·         Should the output be approaches or specific interventions?

·         The subjective reaction of people is important as is the more objective indicators. This implies enlarging the focus to include well-being.

The meeting moved the Review forward intellectually, practically and we have found a wonderful city partner to help shape our endeavours as we both, at very different scales, work to reduce health inequalities across Europe.

New health inequalities data

I was shocked, really shocked, when I saw the data we commissioned the London Health Observatory to collect to give us a baseline for measuring health inequalities in the future. In my review of health inequalities Fair Society, Healthy Lives, published a year ago, we called for a social determinants of health approach to reducing health inequalities. We emphasised the life course. If every child has a good start in life, then his or her chances of succeeding through primary and secondary school, achieving good and fair employment, and living a healthy life right to the end is vastly increased.

The London Health Observatory pulled together the figures for all 150 so-called 'upper tier' local authorities - the ones which will be tasked with overseeing public health under the Coalition Government's proposals. The statistics reflect five key indicators as laid out in Fair Society, Healthy Lives, as being important to monitor over time as a marker of health inequalities: life expectancy at birth, disability free life expectancy; children reaching a good level of development at age five; young people not in employment, education or training (NEET), and the percentage of people in households receiving means tested benefits. Additionally, we included an index showing the slope of the gradient in social inequalities within each local authority area for: life expectancy at birth, disability free life expectancy at birth, and the percentage of people in households receiving means tested benefits. The higher the value of the index, the greater the inequality.

My shock arose because of the proportion of children not achieving a good level of development at age five: 44%. And, of course, there are marked social and geographic variations in that measure. We are failing our children and it will have a devastating effect on health inequalities. There is no question that inequalities in society are, in large measure, responsible for inequalities in early child development.

We have a moral obligation to ensure all children have a good start in life. And a big part of that is parenting. If parents can't parent properly because they are poor, depressed, pressed in by circumstances, then we need to be there to support those parents. A simple intervention like reading to children every day is something that, if parents can't do it, others could step in and help. It can and would make a huge difference. There are data from Canada that suggest half the deficit in readiness for school associated with low income can be reversed by reading to children daily.

Turning to life expectancy at birth, we continue to see the unacceptable gap across the country. Variation across England between local authorities is 11 years for men and 10 years for women. Inequality in male life expectancy between the poorest and most affluent areas within each local authority exceeds nine years for around half of the local authorities in England; the comparable figure for inequality in female life expectancy is six years. Westminster has the widest within area inequality gap, just under 17 years for men, and 11 years for women.

The gap (strictly, the ends of the slope) in disability free life expectancy between the poorest and most affluent areas within each local authority exceeds 10 years for around half of the local authorities in England; the comparable figure for inequality for females is nine years. The widest level of inequality in disability free life expectancy is 20 years for men and 17 years for women living in The Wirral.

The number of young people (aged 16-19) not in employment, education or training (NEET) in the three months to January 2010 is an average of 7%, rising to 14% for those living in Redcar and Cleveland. And the average number of people in households on means tested benefits is 16%, with the figure rising to 41% in Tower Hamlets, London. The widest inequality gap is 61% for young people living in Blackburn and Darwen.

These data represent the baseline measurements for tackling health inequalities, using a social determinants approach. We want local authorities to use these measures to monitor changes. Health inequalities not only cost people's lives and health, they cost society tens of billions of pounds in lost productivity, healthcare and welfare payments. It's been put to me implementing the sort of recommendations in Fair Society, Healthy Lives  in straitened economic circumstances is going to be difficult, but, for example, reading to children is not an expensive intervention.