Michael Marmot: Prioritising and developing further action on reducing the social gradient in health

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  • Posted:Wednesday 29 November 2017

Delivering the key note address at The King's Fund Annual Conference on 29 November 2017, Professor Sir Michael Marmot, Professor of Epidemiology and Public Health, University College, London, and President, World Medical Association, looks at the role all public sector agencies, and private and voluntary and community sectors, play in the social determinants of health agenda.


What good does it do to treat people and send them back to the conditions that made them sick?  We need to address the conditions that make people sick.  I hope you’ve all seen this; life expectancy by local authority classified according to deprivation.  The top graph is life expectancy, each dot is a neighbourhood.  So to the right as you look at it, you’ve got the most affluent local authorities.  It’s what I’ve been calling for several decades, the social gradient. 

I want to start somewhere else: the United States, because if we’re not careful, this might be where we’re headed, a cautionary tale.  All-cause mortality aged 45-54 from 1990 to 2012 France, German, the UK, Canada, Australia, Sweden, it’s coming down and US non-Hispanic whites mortality is going up.  Things are supposed to get better all the time aren’t they?  And the causes: number 1 poisonings due to drugs and alcohol.  Number 2: suicide.  Number 3: chronic liver disease which is mainly alcohol.  Now here’s a salutary figure, drug, alcohol and suicide mortality rate quartiles, look at the industrial Midwest, the higher the mortality from drugs, alcohol and suicide, the more likely were people to vote for Donald Trump and those same areas by economic distress.  The economic distress that led people to take their own lives and die of alcohol and the like was the same kind of economic distress that led to them voting for Trump.  So when I say the US might be our future, we need to be careful. 

We published this in the summer looking at life expectancy England 2006 to 2015.  From 2010 on, flat for women, nearly flat for men.  Has that slowed down in life expectancy occurred because we’ve reached peak life expectancy?  Well 2006 to 2010 for various European countries, it’s slowed down in all these European countries, 2011 to 2015 but this is males, we’re second bottom and females, we’re bottom in that slow down.  So it’s not that we’ve reached the peak because it’s still rising in other countries.  Is austerity causing this?  The cut in spending, in social care, the adult component social care has been greater than 6% from 2009/10 at a time when the elderly population 65 and above increased by 1/6th.  The spending on healthcare per person is set to go down, that will impact on the quality of life of older people but I don’t know whether it led to shortening of life, but it’s urgent to try and find out.  

During the 1980s there was no north/south difference and mortality was rising, particularly in young men.  I think you can see industrial policy writ large in these figures; suicide was going up, alcohol related deaths.  That’s why I say the US is a cautionary tale and then in the mid 90s, things got better and in the south it was the growth of the service sector, loss of manufacturing jobs, continued to rise in the north and then finally started coming down but the north/south gap continues.  

Can strategies to reduce health and equalities work?  Margaret Whitehead and her colleagues in Liverpool, looked at the poorest 20% of local authorities and compared them with the average.  For males and females in months, in the years before New Labour’s strategy life expectancy gap between the poorest 20% and the average was increasing. During the strategy it decreased.  When we got a new government and a different set of policies it started increasing again.  So it’s consistent with saying, I know this will be a shock, government policy can make a difference.  

I did my English review Fair Society Healthy Lives, we had six domains of recommendations, give every child the best start in life, education and lifelong learning, employment and working conditions.  Everybody in a rich society should have at least the minimum income necessary for a healthy life, what a radical idea.  Healthy and sustainable places to live and work, and taking a social determinates approach to prevention.  

So what are we doing about child poverty?  Well, between May 2015 and April 2019 - these are IFS figures - the long run in impact of tax and benefits formed, by income decile, look at working age families with children.  In the poorest decile, the changes to the tax and benefit system will lead to a 10% drop in income, then 12% for the second poorest and then the more money you have the better off you do as a result of changes to the tax and benefits system. 

So our government policy set in the 2015 Budget and not changed, explicit government policy is to increase inequality and make things worse. I don’t care who the government is, I would like them to look at the health equity impact of all their policies and anything that makes life worse for families with children, will other things equal have an adverse impact on health and equalities.  

So I come back to where I started, what good does it do to treat people and send them back to the conditions that made them sick?