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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.

“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.

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

This article first appeared in the 01 October 2015 issue of the New Statesman, The Tory tide

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A group of men united only by sport was once my idea of hell. What changed?

It struck me, during the course of our team’s annual pre-season dinner, how much I like my team-mates. 

To the cricket team’s annual pre-season dinner. Although I’ve been playing for them for ten years or so, I’ve never been to one of these. This is because when I say “I’ve been playing for them for etc…” you’re probably not getting the right picture. What I mean is: I have played ten matches for them, and last year not at all, with a highest score of 22, and an average of 10.17. If you think that’s unimpressive, it’s a lot better than when I was a schoolboy, and I am just 26th placed out of 50 people who have played ten or more matches for them. Last year I was 25th, I see. Well, I’m going to have to do something about that.

The idea is that if I go to the dinner this time, it will inspire me to get in shape and play a game or two this season. I almost invariably enjoy it when I do, especially the time I was in a record-breaking tenth-wicket partnership of 72 while batting with a broken hand. (Well, finger. But a finger’s a part of the hand, isn’t it? Even the little finger.) I suppose there are times when I don’t enjoy it so much, such as when it’s raining hard enough for the cows in neighbouring fields to sit under a tree, but not hard enough to send us back to the pavilion or, better still, the pub, and the opposition are clouting us all over the ground despite the weather, and if we’d batted first – we never bat first, in my (limited) experience – the other lot would have polished us off about an hour ago, and we could now all be cosily inside the pavilion or, as I said earlier, even better, the pub. Then again, the team is called the Rain Men, so what did I expect?

So signing up for games involves considering a number of factors: some kind of mystic calculation about what the weather will be like, an assessment of how far away the ground is (we’re a nomadic team, so we don’t have one of our own), and how fit I think I’m going to be on the day. That’s the troublesome part. There is, of course, the melancholy of coming back, aching and knackered, at what is usually well after nine in the evening on a Sunday, lugging a cricket bag, like someone who has not been able to let go of his childhood and is out after his bedtime.

The fitness, as I said, is problematic. I got slightly out of puff going for a pee between the second and third paragraphs of this column, so I think there is going to be a lot of tedious spadework in store for me. My dumb-bells are in East Finchley, which I don’t go to, although as my cricket stuff is there too I suppose I’m going to have to bite that bullet sooner or later. If I eschew the dumb-bells then there will always be the floor, gravity, and push-ups. There will always be stairs, somewhere, I can run up and down, while I have the use of my legs. While there is an earth I can walk upon, I can walk upon it. The upper body strength, so I can pick up a cricket bat without falling over, is the thing to aim for, but right now the main goal is to be able to get out of bed and go to the loo without getting winded.

Anyway, the dinner. I decided that I’d walk to the restaurant. This was largely because the restaurant is about 200 yards from where I am holed up at the moment. There is, literally, only one restaurant closer to me. I walked a bit more than 200 yards because I had to swing by Sainsbury’s to pick up a couple of bottles of wine (the McGuigan’s Reserve Cab Sauv at £6.50 a bot, special offer, being the sedative of choice these days), as the restaurant is unlicensed. We met at the pub first, of course.

It struck me, during the course of the evening, how much I like my team-mates. I am by no means the oldest, so many of them are rich in wisdom and experience. (Amazingly, the team won more games last season than it has in its history, but that might have been because I hadn’t played for them.) Two of the people I am particularly fond of couldn’t make it, but at least I got to have A Long Rant About Life In General with Marcus Berkmann, author of two extremely amusing books about the team (Rain Men and Zimmer Men), as well as the greatest book about Star Trek ever written (Set Phasers to Stun).

Imagine: a long table sat at by a group of about 15 men, united only by a sport. It would once have been my idea of hell. So why is it not now? Is it because I actually like these guys? They’re not the typical idea of a cricket club gang, I have to say that. And we do, admittedly, talk about cricket a fair amount. But still. (I even liked I—, who gave up smoking and then had a rush of blood to the head last year and sent a round-robin email to the team saying how much he hated A—, one of our most lovable players. I— couldn’t make it to the dinner, largely on the grounds of not having been invited.) Or am I that lonely? 

Nicholas Lezard is a literary critic for the Guardian and also writes for the Independent. He writes the Down and Out in London column for the New Statesman.

This article first appeared in the 12 April 2018 issue of the New Statesman, Syria’s world war