Health Equity in England

The Marmot Review 10 Years On

As a part of the Institute of Health Equity's collaborative work with The Health Foundation, which will see the publication of The Marmot Review 10 Years On, in Feb 2020, Professor Sir Michael Marmot wrote a blog piece about the importance of the work, in the context of declining life expectancy and increase in inequalities in health.

'There can be no more important task for those concerned with the health of the population than to reduce health inequalities'

Read the blog in full at The Health Foundation website.

Universities in a post-fact political world

One of my colleagues in Trondheim admitted that as he gets older the tears seem to come more readily. They did on Friday 18 November. Perhaps I should explain.

NTNU, Norwegian University of Science and Technology, in Trondheim awarded me a doctorate honoris causa, their 91^st. The ceremony was a wonderful mixture of Nordic pomp, clockwork precision and Norwegian informality. Apart from two honorary doctors, twice a year approximately 150 students get their doctorates. Impressive.

Like all graduations it was a moving occasion. Certainly, I was moved. My short acceptance speech was along the following lines:

I love graduations. You, dear doctoral graduates, have worked so hard and now you are to be rewarded. You will go out into the world and use your knowledge and skills to make the world a better place.

I find this this graduation occasion special for three reasons. The first, not so important, is that it makes us happy. I work at UCL. The auto-icon of Jeremy Bentham sits in box outside the office of the University President and Provost. Bentham emphasised that social progress should aim at the greatest good for the greatest number. By each of us graduates being happy we add to the world’s utility. But I am not really a Benthamite.

A second more important reason why today is special is because it is a wonderful celebration of what we do in Universities like this one. It stands in stark contrast with what is going on in the world of politics at the moment. With Brexit, far right parties in Norway, Sweden, Denmark and across Europe, the US election, some politicians have declared war on truth, logic, consistency, reason and social justice; not to mention the assault on statistics. What we stand for in universities is all those things: truth, logic, consistency, reason and social justice. We have a vital role to play in standing up for these civilised and civilising values.

The third reason for my valuing this occasion so highly is because I take the award to me as an award to the field in which I work: social justice and health. What I do relies on evidence-based policies and social justice. I am chairing a new Commission on Equity and Health Inequalities in the Americas. At a recent meeting in Washington DC I walked in the Mall and found myself in the area devoted to Martin Luther King Jr. Dr King said:

Injustice anywhere is a threat to justice everywhere. We are caught in an inescapable network of mutuality, tied in a single garment of destiny. Whatever affects one directly affects all indirectly.

The world’s problems are our problems, your problems, my dear new doctors.

My colleagues here in Trondheim asked me if I am optimistic, given all the bad things happening in the world, as I have just laid out. Yes, I am optimistic because I do believe that evidence-based policies and social justice will win out. Martin Luther King said it better.

I believe that unarmed truth and unconditional love will have the final word in reality. This why right, temporarily defeated, is stronger than evil triumphant.

Another Norwegian professor, as if accounting for his colleague’s tendency to shed a tear, said: you spoke from your heart to our hearts. I shed a tear.

Read more about the event.

Doing Better in Taiwan

01/11/2015

Politics? Yes, of course, politics. It is always there. But, we argue consistently that concern with health should trump concern with diplomatic political sensitivities. I said it at the World Medical Association General Medical Assembly in Moscow: whatever tensions there may be between Russia and other countries, we work together in the common cause of better health. And it is what I felt when we at the IHE were approached by the Health Promotion Department of the Taiwan government to write a report on how they could address persistent health inequities through action on the social determinants of health. Does that mean we take a view about the continued aggravation about China and Taiwan? Not at all. We would be happy to work with China as we are with Taiwan. (For the Eastern Mediterranean Region of WHO, I have been to Egypt, Morocco, Iran and Tunisia; and joined a meeting in Kuwait by Skype. For WHO Euro I have been to Israel. Health is a shared concern.)

When on a Friday morning, I found myself sharing a joke with President Ma of Taiwan – see photo – my concern was not with international diplomacy but to secure his agreement to whole of government approaches to social determinants of health and health equity. He and I signed a mock-up of the cover of our report for Taiwan.

 

If we take the ‘do something, do more, do better’ mantra to Taiwan, we would have to say, they are in the latter group. Taiwan has done remarkably well. Life expectancy for men is 77 and for women, 83. This would put them firmly in the European average. A huge improvement remarkably quickly. But health inequalities persist – seen in the social gradient in life expectancy and disability-free life expectancy.

The Director-General of the Health Promotion Administration of the Ministry of Health and Welfare, Shu-Ti Chou, is a charismatic figure – see third photo. Committed, perceptive, well-informed, and clearly loved and admired by her colleagues. I apologised for the depths of my ignorance of Chinese names, but I told her that her name reminded me of the two names in Bertold Brecht’s play, The Good Person of Szechuan. Shen Te was good, caring and generous. But people took advantage of her good nature. She invented an alter ego, Shui Ta, who displayed the more self-centred side of human nature to protect herself. Shu-Ti said that perhaps she embodied a bit of both, caring and concerned, empathetic and embodying better virtues but at the same time having the drive necessary to make progress.

 

As well as the publicly stated commitment from the President, there is a potentially viable mechanism in Taiwan for whole of government action on SDH: the Committee on Sustainable Development. This committee is chaired by the Prime Minister and has the sustainable development focus of environment, economy and social development. By getting health equity into the last of these three and linking it firmly to the other two, there is reall prospect of making progress.


We plan to work with Taiwan over the coming year as they seek to make progress.

Taking Tea with Bernie

“I’ll just nip upstairs. There’s something I want to get for you.” And he does.

The 93 year old Dr Bernard Lown nips upstairs and comes back with a signed copy of his memoir, The Lost Art of Healing; and another slim volume Never Whisper in the Presence of Wrong. The latter is a selection from speeches he gave on nuclear war and global survival. Never whisper in the presence of wrong. It resonates. And he lived by it. Still does.

I am at Harvard briefly as a Bernard Lown visiting professor. It will entail another couple of visits to Harvard – no penance. The best part is the privilege of taking tea with Dr Bernard Lown at his home in Chestnut Hill, a leafy suburb of Boston. (I suspect that there is an inverse correlation between age of Harvard medical professors and the distance west of the Longwood Medical Area of Boston that they live. The newer the recruit, the further out they have to live. Harvard professors, high status, no doubt have long life expectancy, keeping the desirable properties occupied. That said, at 93, Dr Lown must be among the more senior. He is relatively close in.)

I know him as the co-founder, with brother cardiologist Evgeni Chazov of the Soviet Union, of International Physicians for the Prevention of Nuclear War (IPPNW) in 1980. They were awarded the Nobel Peace Prize in 1985. Leaning against a wall, I nearly dislodged a photo of Lown meeting with Mikhail Gorbachev in the Kremlin.

Bernard Lown - Image Source Boston Globe 2008

But there’s so much more. All over the world, patients with cardiac arrhythmias can be treated with cardioversion, a DC electrical shock to the heart, timed to miss a vulnerable interval in the cardiac cycle. Lown developed that. Patients with heart attacks used to be confined to absolute bed rest for weeks. Now they are mobilised quickly to prevent venous thromboembolism and pneumonia. Lown and Dr Samuel Levine, his mentor in cardiology at the Peter Bent Brigham Hospital of Harvard, were responsible for that. Patients treated with digitalis and diuretics could develop fatal cardiac complications. Lown showed that low potassium – which could be caused by diuretics – made digitalis potentially toxic. He did as much as anyone to draw attention to the issue of sudden cardiac death.

He was an early and firm believer in the importance of the mind in both the onset and recovery from cardiovascular disease. Had he done nothing else, his reputation would be secure as having made a fundamental and lasting contribution to the management of patients with cardiovascular disease. But he always saw clearly his wider responsibility to society.

Why is a cardiologist based at Harvard School of Public Health? He graduated from Johns Hopkins in 1945. American paranoia about communism, which led to the excesses of McCarthyism, meant that belonging to many student organisations with a social responsibility put you beyond the pale politically. Simply, his political beliefs made him difficult to employ in the fevered atmosphere of the time. Seems bizarre now. A Harvard professor, he has twenty honorary degrees, numerous medals and awards, a Nobel Peace Prize, and all the recognition as a clinician and scientist that one could imagine. Yet his undoubted ability was not enough. When the famous Brigham hospital was closed to him, he looked around Harvard, but the politics seemed to get in the way. Finally, he found Dr Fred Stare, head of Nutrition, at Harvard School of Public Health who offered him a job, and space for a research lab. Lown told Dr Stare that there were some political issues he should know about. Stare’s response: you’re an American; that’s all I need to know.

The frustration was that the two and a half hours I spent with Dr Lown, and his wife since 1946, Louise, meant that we had only just got started. He said he would give me the tour on my next visit.

Much to discuss.

"In Sweden we don't do VIP..."

But they do a lot else. Perhaps no trappings, but I have no complaints. What they showed me was gift enough. Goteborg is the third of the three Swedish cities/regions – the others are Malmo and Linkoping – that are doing reviews of social determinants of health. Or, as they put it, Swedish Marmot Reviews. It felt like we were having a conversation.

Apparently at the airport, there is a sign promoting the city:

Goteborg, growth.

One of the local hosts proposed a new sign, sadly not adopted:
 

Goteborg: reading to children.

 

Another said that they had recently been to Birmingham on a fact-finding mission, having heard me say, a few years ago, how Birmingham (England) narrowed the gap in early child development between Birmingham and the English average. They were told in Birmingham that the special programmes on Early Child Development were no longer being supported. Disappointing.

The leitmotif of this Goteborg activity is inclusion: 1100 people, mainly employees of the City of Goteborg, came to this conference on socially sustainable Goteborg. I have been to meetings of various kinds in London, but never 1100 people engaging with how to make London a more sustainable place. Per capita, to match Goteborg, such a London meeting would have to have been 11,000.  The day after my visit, 400 of these 1100 were to sit down to work together to plan a more socially sustainable Goteborg, with health equity and sustainable development at its heart.

One of the gifts they gave me was to take me on a quick trip of the city, accompanied by three expert employees of the city. Slightly uncomfortably, I was fitted with a microphone and accompanied by a cameraman. They wanted to capture my reactions (not including post prandial afternoon drowsiness, I hope.) Goteborg “boasts” a nine year gap in life expectancy between small areas. What might that look like on the ground? What I didn’t “see”, but they told me, is that 22% of the population is foreign born, with another 13% or so children of migrants. Sweden had a programme to build a million new homes in the 1960s. In Goteborg, some of these were built in outlying communities that are rather cut off from the city. They are heavily populated by immigrants. These are ‘slums’ done by the Swedes. Apparently well-built, rather neat, five or so storey-blocks of flats, landscaped, no graffiti, no broken glass, but soulless and isolated, cut off from the Central City.

 

Perhaps linked to this isolation, one of the questions I was asked at the conference was what might they be doing about the fact that the 1100 people attending, overwhelmingly, were white. My response was that I wouldn’t start from here. If immigrant communities were cut off from the main stream, geographically, it was perhaps no surprise that they were underrepresented socially.

 

Even egalitarian Sweden has inequality issues with which they must grapple. But they are, grappling. Particularly, they liked our European slogan, which we adopted from Swedes: “Do something, do more, do better.” I think it highly likely they are going to do better. I was invited to come back in three years and see.