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5 October 2015

The politics of health: a clear-eyed account of inequality and the NHS

The Health Gap: the Challenge of an Unequal World by Michael Marmot reviewed.

By Henry Marsh

“If everyone in England over the age of 30 had the same low mortality as people with university education, there would be 202,000 fewer deaths before the age of 75 each year . . . 2.6 million extra years of life saved each year.” Thus writes Michael Marmot in The Health Gap. Marmot is the doyen of public health and social medicine experts but he is also a distinguished academic-turned-activist and this important book is a call to arms. In a time of austerity, welfare cuts and increasing inequality, it should be read by everybody concerned not just with health care but with politics and society as a whole, because, as Marmot reminds us, “Health is politics.” He shows that you do not need to appeal to any particular political ideology or economic theory to argue the case for greater welfare and social support to improve the health of society. There is overwhelming evidence that our health is determined by the way in which society is organised and not by our individual merit or by the quality of the health-care system.

There has been much argument over the years about how “health” should be defined. One might scoff a little at the breadth of the World Health Organisation’s definition: “complete physical, mental and social well-being and not merely the absence of disease or infirmity”. But it is difficult to disagree with the underlying idea that good health is more than just the absence of disease.

Marmot starts by suggesting that we, ­unlike the philosophers, can agree on what constitutes a good society if we accept a broad definition of health. A good society is one in which health is good and avoidable health inequalities are minimised, because, surely, avoidable health inequalities are iniquitous and good health is good. He then reviews the ways in which our health is shaped by “social determinants”. In all societies, there is what he calls a “social gradient” in health. The higher you are in your society in status and income, the longer you will live and the healthier your longer life will be. It has been observed, he points out, that for every Tube station on the Jubilee Line travelling east from Westminster, as much as a year’s life expectancy is lost.

We need to seek out the “cause of the causes”. Working-class people smoke more, have higher obesity rates, take less exercise and die younger as a result – but why? Those of a right-wing disposition might suggest that it is simply because they are feckless and have not exercised their free will to work hard and live healthy lives. But this, you realise as you read Marmot’s book, is the propaganda of the victors.

He discusses five areas in which epidemiological evidence clearly shows where health inequalities arise that are avoidable, and hence iniquitous. These are all areas in which programmes of welfare or social support have been shown to make a significant difference to health: early child development, education, working conditions, conditions for older people and the development of resilient communities.

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Although academics might quibble that much of the evidence of benefit is circumstantial – “Correlation is not causation,” Marmot concedes – the differences within single countries and between countries both in life expectancy and in disability-free life expectancy are so great that it is very difficult to deny that health is indeed “socially determined”.

Marmot gives countless examples of initiatives, such as the Paths (Promoting Alternative Thinking Strategies) programme for improving early child development in Birmingham and the Oportunidades scheme in Mexico, which have improved the health of the families enrolled. He was responsible in 2005 for the World Health Organisation’s commission on the social determinants of health and in 2010 published Fair Society, Healthy Lives, generally known as the “Marmot review”, at the request of ­Gordon Brown, proposing multiple interventions to promote health in the UK. Three-quarters of local authorities in the UK recently told the King’s Fund that “Marmot principles” are now their top priority.

A recurring theme of the book is that the US, despite having “the best health-care system in the world” – as many Americans like to boast – has appallingly bad statistics for health and life expectancy compared to much of the developed world and especially parts of Scandinavia.

This is further proof that health has little to do with health care and everything to do with the politics of social support and welfare. The politics of this was clearly shown by the American right’s fanatical resistance to “Obamacare”. The ideology behind this opposition is that we are free to choose how we live and therefore that what happens to us is morally deserved and also (the old Cartesian dualism) that mind and matter are separate entities.

Social medicine and neuroscience, however, have clearly shown that both propositions are false. Much of our decision-making is determined by forces within ourselves that are beyond our control, which were shaped in turn by forces that are beyond our  control (but not beyond society’s control) and of which we are often unaware. States of mind can have profound physical consequences on our bodies. (It has been known for years, for instance, that bereaved spouses have a higher mortality rate from almost all causes in the first year after bereavement, and that the unemployed have a high suicide rate.)

Marmot has little truck with the so-called Washington consensus that has guided ­organisations such as the IMF. “The idea that unbridled free markets in everything . . . is the way for countries to grow, develop and ensure better health and greater health equity is contradicted by the evidence.” As he rightly argues, “Health should not be a means to the end of a stronger economy” – it should be the other way around.

By his own admission, Marmot is relentlessly hopeful, describing himself as both an “unreasonable” and an “evidence-based” optimist, but the book is so persuasive that the reader will forgive him this slight contradiction. He writes in a cheerful, conversational style that perhaps reflects his Antipodean upbringing, as does his lack of conservative British fatalism. He is well aware of the difficulties that humanity faces but, as he writes, without the optimism that is needed to drive action, there cannot be any hope for a better future.

Near the end of this splendid and necessary book, the author notes how the great 19th-century German pathologist Rudolf Carl Virchow argued that physicians are the natural attorneys of the poor. Few other doctors have demonstrated this as brilliantly as Michael Marmot.

The Health Gap: The Challenge of an Unequal World by Michael Marmot is published by Bloomsbury (400pp, £20). Henry Marsh’s “Do No Harm: Stories of Life, Death and Brain Surgery” is published by Weidenfeld & Nicolson

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This article appears in the 30 Sep 2015 issue of the New Statesman, The Tory tide