Inaugural Address as WMA President
Michael Marmot
Moscow
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.
