Prince Mahidol and Social Determinants of Health - Speech

Prince Mahidol and Social Determinants of Health

Michael Marmot

UCL Institute of Health Equity

A recent report from Oxfam showed that just 62 billionaires have the same wealth as the poorest half of the global population. With a bit of a squeeze all 62 could fit into one London double-decker bus. Not so the other 3.6 billion people. Within most countries, too, inequalities of income and wealth have been growing. Should we care?

We should for three reasons. First, as Sir Tony Atkinson highlights in his recent book, Inequality, surveys find that the population in the US and Europe identify inequality as the number one problem in the world. People feel it that is just plain wrong, unfair, unjust.

Second, too much inequality threatens democratic legitimacy. If life’s chances are sequestered at the top, the rest of the population, rightly, feels that the governance of countries does not serves their needs. Similarly, if the global economic and political order serves the elite in some countries at the expense of the rest of the world, it is major challenge to our existing arrangements.

Third, highly unequal societies are associated with social evils such as ill-health and crime. Some place emphasis on the gini coefficient and argue that inequality damages the health of everybody. In my book, The Health Gap, I emphasise that the ill-health effect of inequality increases with increasing degrees of social disadvantage—the poor suffer the most.

Central to the ill-health effect of inequality is both poverty and relative disadvantage. Absolute poverty means disempowerment in an extreme way: having insufficient money to meet basic needs. Relative disadvantage is related to the social gradient in health. Relative disadvantage, too, is disempowering. Following Amartya Sen I argue that relative inequality deprives people of the freedom to lead a life they have reason to value.

One welcome response to such inequality in health is universal health coverage – the theme of this conference. It is appropriate that it should be held in Thailand, given the great strides that Thailand has made in implementing universal health coverage. It is much needed. I have just come from a meeting in Kolkata where colleagues point to the fact that India’s health care system not only is failing to meet people’s health needs, but out of pocket expenditures are emiserating people. A simple contrast between India and Thailand is instructive. In India, according to WHO figures, of all expenditure on health care private expenditure makes up 73%; of which 87% is out of pocket. That means 63% of all health care expenditure is out of pocket. In Thailand, by contrast, only 20% of health care expenditure is private of which 57% is out of pocket i.e 11% is out of pocket. Out of pocket is 63% in India and 11% in Thailand…and the pockets are shallower in India.

Something else is needed, too. When we began the WHO Commission on Social Determinants of Health we asked rhetorically: why treat people and send them back to the conditions that made them sick? It is the first line of my book, The Health Gap. We need action on the conditions in which people are born, grow, live, work, and age; and on inequities in power, money and resources that give rise to inequities in these conditions of daily life. We need action, in other words, on the social determinants of health. And when people get sick, they need access to health care free at the point of use.

It is an absolute pleasure to be the 2015 Prince Mahidol Award laureate for Public Health. A pleasure for me, personally, of course. But that is of little interest. The pleasure is that this prestigious award recognises the importance of social determinants of health. It validates the hardy band of brothers and sisters who have toiled in this field.

As many of you will know Prince Mahidol was selected by his father the King for a career in the Navy. The Prince thought he could serve his people better by studying medicine, than by pursuing a career in the military. At Harvard Prince Mahidol diverted from medicine to public health and only later finished his medical degree. It is appropriate that there are awards in both Medicine and Public Health. In the Prince Mahidol museum in Siriraj Hospital here in Bangkok is a quote attributed to Prince Mahidol:

“The primary function of men of health science including physicians is not to assume the office of salvagers of wrecks but rather of pilots preventing them”.

There should be no conflict between wishing to prevent the wrecks and dealing with the problems when they occur. I argue strongly with ministers of education, environment, occupation, social security and finance that what they do in their day job influences health. So powerful is the influence of societal action on health, that health equity is a good measure of how we are doing as a society.

Conversely, I seek to get the doctors involved. Somewhat surprisingly I find myself President of the World Medical Association. In that role I am engaging actively with medical societies in all regions of the world to explore what they and other health practitioners can do to address the social determinants of health. I am hugely encouraged.

I say to them that Universal health coverage is vital but it will not abolish inequalities in health. In The Health Gap, I write about Baltimore and London. In both cities we see twenty year gaps in male life expectancy. Twenty years! But there is a crucial difference. In the UK we have universal health coverage, free at the point of use. Further, all round the world, we see difference in health not just between rich and poor, but there is a social gradient: the more years of education, for example, the better the health.

I emphasise disempowerment. If we want to see disempowerment in action, look at the recent paper by Anne Case and Angus Deaton showing a rise in mortality in the US among non-Hispanic whites aged 45-54. And the conditions that carry people off? Poisonings due to drugs and alcohol, suicide, alcoholic liver diseases, and external causes of death. Disempowerment from the social determinants of health rather than lack of health insurance.

Looking more positively, empowerment of women through education has clearly made a major contribution to the reduction in infant and child mortality globally. But the revolution in child survival shows the importance of treatment.

I referred to my recent book, The Health Gap. I wanted to call the book The Organisation of Misery. As one or two of you may know, I have been quoting Pablo Neruda and inviting colleagues to:

Rise up with me…Against the organisation of misery

The publisher said I could not give a book such a title. No one would read it. I proffered The Organisation of Hope. Better, said the publisher, but a bit obtuse.

I compromised. I called the first chapter, The Organisation of Misery, and documented the dramatic inequalities in health within and between countries. I then bring together the evidence on what we can do through the life course to reduce avoidable inequalities in health – health inequities – starting with equity in early child development, education, working conditions and better conditions for older people. I call the last chapter The Organisation of Hope because I document examples from round the world that show we can make a difference.

When in Thailand for the National Health Assembly in December 2009 our Thai colleagues taught me about the triangle that moves the mountain. The three sides of the triangle are government, knowledge including academia, and the people. Get the three sides of the triangle aligned and we can move mountains.