Social Justice and Health Equity – A talk with Sir Michael Marmot

– We’re thrilled to have this turnout here at the end of a semester,
at the end of a long year for many people in 2018. It’s been a fantastic year here at the School of
Public Health as we’ve been celebrating our 75th
anniversary of the school. Vetting many of our
15,000 alumni that we have who are out around the
community, the state, the world, working to improve
the health of the population for everybody including our
most vulnerable populations and especially our most
vulnerable populations. Before we introduce our speaker today I just want to say a few thank-yous in regard to this 75th anniversary year. First of all to Priya Mehta and her team, Eve Cohen, Mori Hermann, who’ve been at just working flat-out to make all of these events
happen all year long. As well as Linda Andrew Berg
and the communications team has put together a fantastic
75th anniversary edition of our schools magazine. It will be out very
shortly within the week. We will be distributing that
and it should be very exciting for you all to to read about
what the school has been up to more recently as well as talking about our sort of longer history in the school. I also want to give a special shout-out to our dean emeritus Stefano Bertozzi, who did so much to set
up all of the events for this year and and so much
over the last several years. If you’ve missed some of
our 75th anniversary events, for example the the Van
Jones talk last month, that is now available online. We are also recording the event today so if people in the future
couldn’t make it here you can let them know that
we will make this available. Also I just want to give
a special sneak preview of announcement that will be going out to the school community very shortly in terms of our upcoming
events at the commencement. Our commencement speaker
will be Bernard Tyson, leader of Kaiser
Permanente and nonprofits. It’s doing so much in the
community to advance health, not just within the four walls, but out in the community as well. So we’ll have a formal announcement
of that coming up soon. But today we are very pleased to host one of our most distinguished
alumni of this school, Sir Michael Marmot. I had the pleasure to
work with and Sir Michael on the MacArthur Network
on socioeconomic status and help for a number of
years and as you can imagine he was very inspiring part of that network in pushing forward the work
that we were able to do and was certainly a great
education inspiration to me and I’m not going to give
the full introduction to Sir Michael today. I am going to turn over the podium to one of our most esteemed professors, Professor Emeritus Len Syme, who has had a long-standing relationship and mentorship with Sir Michael. So Len will talk more about his many years of working with Sir Michael, but as many of you know
Len is often considered the father of social epidemiology. He is a giant in the field. He’s a giant in our school and so I’m thrilled to introduce Len to come on up and introduce Sir Michael and we’ll have the talk and
we’ll have time for Q&A. So Len please. (audience applauding) – Thank you all. Well it is really a pleasure
to welcome you all here on this special occasion,
especially the 75th anniversary. This is really a remarkable
time in the school. Michael came to Berkeley
to get an MPhD in 1972. It’s interesting now he came here. I was giving a talk in 1971 in New Zealand and at the end of the talk
a guy came up to me and said you really do that stuff at Berkeley? I said yeah. He said you know we’ve got
a medical student at Sydney. He’s the best student in the school, but he’s driving us crazy. (audience laughing) Questions, complaining,
questioning everything. We don’t give fellowships
to students to study abroad because they don’t come back, but if we made an exception in his case, would you take him? (audience laughing) I said yes and that was
the beginning of the story. So as you perhaps know, Michael is Professor of Epidemiology at the University College London. He’s Director of the
Institute of Health Equity in the department of Epi
at the University College. He’s written two very important books, The Health Gap and the Status Syndrome. The list of organizations that which he belongs is
almost too long to go into, but I do need to mention a few. He shares the Commission
on equity and health inequalities in the Americas. He’s been awarded honorary
degrees from 18 universities, including the University
Medical School in Sydney that urged him to travel abroad. He’s been awarded honorary degrees and in 2000 he was knighted by Her Majesty for his work in health inequalities. He’s president of the
British Lung Association. Honorary fellow of the American
College of Epidemiology. Fellow of the American
Academy of Medical Sciences. An honorary fellow of the British Academy. An honorary fellow of the
Faculty of Public Health for the Royal College of Physicians, but to me the most significant
of all of those things is past President of the
British Medical Association and President of the
World Medical Association, bridging the gap between clinical medicine and public health. It’s a remarkable phenomenon, but the thing that I learned this morning was to me the most interesting. Google scholar lists number
of most cited scholars in the world. I can’t remember who’s number one, but number three is Freud, Sigmund Freud. Number 55 is Einstein and
Michael was number 59. So the alumnus we’re talking about is probably the most famous public
health person in the world and it’s a real honor to
have you join us today. (audience applauding) – And it’s an absolute
pleasure to be back in Berkeley and it’s looking so splendid, thank you. Social justice and health equity
is the theme of what I do. I was asked by a younger
member of my extended family, is anyone listening to you? (audience laughing) I thought that youngster is
going to have a bright future. He knows how to ask the right question and in a way Will didn’t
quite ask it that way, but he said what have you been doing since you left Berkeley? Would you come back and tell us? So I’m going to indulge
myself a little bit to try and answer my
young relatives question, is anybody listening to you? So I published a book, The Health Gap. Thank you. And I said this is indulgent, translated into Japanese,
into Korean, and into Italian. La Salute Disugale. Only the Italians would have
me on the cover like that. (audience laughing) Don’t know where they got that from. And not only La Salute
Disugale, unequal health. The Trento in northern Italy, The Trento festival of
economics the year before last had as their theme La Salute Disugale. A festival of economics. And I was invited. I’d quite forgotten that La
Salute Disugale was the theme and I arrived in Trento and
there were all these big posters saying La Salute Disugale. I thought this really odd and then there was a
cardboard cutout of me. (audience laughing) So I had to have a photo taken next to it. (audience laughing) And I sent it to my kids
and one of my sons came back and says I think the cutout
looks better than the original and forgive me for this next one Len. Cross word of La
Repubblica Italia magazine, 146 down, British physician
founder of social epidemiology. Now I don’t know… I don’t know where, I haven’t
got a category on my CV to put that one, but it seems to me it does provide a partial answer to my young relatives question. I mean, Italian crossword puzzles. I’d very much doubt that anyone other than Luca De Fiore
solved the puzzle that day. It seems to me a bit unfair. And I went through my
diary for a few months at the people who asked me
to come and talk to them about social determinants of health. Internal medicine, cardiology,
respiratory disease, mental illness, obstetrics,
cancer, surgery, pediatrics, urban renewal, violence, inclusion health, health psychology, primary care, pharmacy, psychosomatic, violence
and crime, vegetables. (audience laughing) They want to come talk about vegetables. A group of classical scholars in the University of Edinburgh in Scotland asked me to talk about
honor in the ancient world. I said I once saw a film
about Alexander the Great, what can I… They said your message about
leading a life of dignity, we think is highly relevant
and so would I come and do the first of a
set of public lectures? Oh, and public health. So people are, I think they’re listening, at least they’re asking me to come and put it into various domains. Some of you will have heard
about the Whitehall studies of British civil servants, which is how I started doing this because we observed a social gradient. And the gradient that we
observed in Whitehall, we see in the country as a whole. This is life expectancy. Each dot is a neighborhood in England classified by degree of
deprivation and affluence. So to the right as you look at it, you’ve got the most affluent neighborhoods and the top graph is life expectancy and you can see that people near the top have shorter life expectancy
than those at the top. People in the middle, shorter life expectancy
than those near the top. The gradient runs all the
way from top to bottom. The bottom graph is disability
free life expectancy. The gradient is steeper. I hasten to add that I use life
expectancy as an indicator. People often ask well, you
know there’s more to life than just how many years you live. Of course, but it’s an indicator
of how well we’re doing and let me say it now and
I’ll probably say it again, I think it’s a very good indicator of how well we’re doing as a society. And that’s rather important because we’ve been
monitoring since I produced and I’ll tell you about
it in a few moments, since I produced my English review, the so called Marmot review, we’ve been monitoring
health, health inequalities, and social determinants
of health every year, year and a half. Last year we published these figures. Life expectancy at Birth,
that goes back to 1980, but in fact I could go back to the end of the first world war. From between about 1921 and
2011 life expectancy increased about one year every four years. Well that’s six hours every 24 hours. If you’ve been working for six hours today you got that for nothing. Your life expectancy at
the end of that six hours is long as it was at the beginning. That’s terrific, that went on for 90 years and in 2011 it ground to a halt. For men and for women. The government was a bit
sensitive about this. We had a new government elected in 2010. Couldn’t be our fault, surely. Well I spent a day at the
BBC and one thing and another and our Secretary of State for health, our Health Minister
tweeted respect Mahmoud. He didn’t have any punctuation. I didn’t know if there
was a question mark. respect Mahmoud? Or respect Mahmoud. Respect Mahmoud, but since he
was on the BBC this morning life expectancy for men has
increased by 61 minutes. I scratch my head and I tweeted
back what are you saying, question mark. That the Office for National
Statistics got it sums wrong? If ONS got it right, let’s discuss. A colleague of mine tweeted ooh, Jeremy Hunt picked a fight with Mahmoud. (audience laughing) My money’s on Mahmoud. If I do a popular tweet and
I gets retweeted 25 times or some, this was tweeted a 115,000 times. So I wrote to the health
secretary and I said this is a health crisis. You need to take this as seriously as you would a winter bed crisis. And he did. He ignored them both, which
wasn’t what I had in mind. One question that I got
asked was by the press was maybe we’ve just reached… I’m looking like the Italian. (audience laughing) Maybe we’ve just reached
peak life expectancy. It’s got a slowdown sometime. Good question. So we looked across Europe. The pale green is 2006 to 2010 and the dark green, the next five years. And this is women and
indeed it did slow down in most European countries,
which is consistent with the effect of the
global financial crisis and policies of austerity put in place in the wake of the
global financial crisis. But we’re on the bottom. So we’ve not reached peak life expectancy because other European countries
with longer life expectancy than ours, we’re still going up. And you can see why the
government was sensitive because I was making the case that the health of the population tells us something fundamentally
important about how well the needs of the members of
that society are being met. And something’s going wrong. I hasten to add, you won’t believe it, but I am not party political
at least in public. So when I talk about
the Labour government, I’m not trying to make
a party political point. I’m just looking at the evidence. Can strategies to reduce
health inequalities work? The New Labour government
did have a strategy to reduce inequalities. Any evidence that it worked? Well colleagues from Liverpool looked at the gap in life expectancy between the poorest 20%
of local authorities. The bottom quintile and everybody else. In the period before Labour’s strategy, the gap between the poorest
20% and everybody else was increasing, inequalities
were getting bigger. Labour was elected in 1997. Some of us were involved in advising them and their strategy kicked in around 2003. Wow! The gap between the poorest 20% and everybody else got smaller. They were booted out of office. Conservative led coalition
government changed everything and the gap increased again. Inequalities are getting bigger. I did a statistic course
once and as a result I know the correlation
does not equal causation. That’s a joke by the way. So it’s not proof, but
it’s what you’d like to see if the policies were going
to make a difference. It’s consistent with the idea that having a national strategy to reduce health inequalities works and ditching that strategy is bad. And I said this is not
where we want to go. I was sitting in Hong
Kong a couple of weeks ago and the BBC World Service
called me and they said US life expectancy has just
declined for third year. The news had just come
out when I talked to them. Well I’d been showing this slide that life expectancy
declined two years in row, it’s now three years in a row and the big increase in
unintentional injuries. 63,600 deaths, it includes drug overdose, the figures that were
published whenever it was, a week and a half ago, 70,000
deaths due to drug overdose. If you add to that 30,000
deaths due to firearms that’s a 100,000 deaths. It shouldn’t occur. There’s a lot about the
US I don’t understand. I once visited and two
New York baseball teams were playing each other and
they called it the World Series. I really don’t… (audience laughing) So it’s a lot. Someone can explain that to me afterwards, but guns kill 30,000 people. why would you want to do that? quite apart from drugs. So I said in the UK, is
this way we want to go? Is this way we want to end? My wife said to me recently there are three very important democracies that have impacted on our lives and two of them are in absolute crisis. The third is Australia and they
get rid of Prime Minister’s every year or so, but that looks healthy compared with what’s going on in the UK and the US at the moment. And one of the messages is that the mind is an important gateway
by which social determines affect ill-health. Hence all those drug related deaths. It’s psychosocial but there
are social determinants. The gradient in health,
this is life expectancy by year of birth for men. As it by year of birth
life expectancy at age 50. By deciles of income. There’s the gradient in the US. The poorest 10%. People who were born in
1920 will be 50 in 1970. People who were born in
1950 will be 50 in 2000. And you can see the poorest 10%, life expectancy went up a little bit. The next 10% it went up
a bit more and a bit more and more and more and more. So the inequalities got
dramatically bigger. Life expectancy was
improving for everyone, but the inequalities got much bigger. Now some of you have not had lunch and you’re probably feeling
a bit delicate, fragile. Are you strong enough for me
to show you the next slide? I think perhaps should
get informed consent before I show you the next slide. This is women. Exactly. (gasps) Life expectancy is falling
for the bottom 10%. It’s falling for the next 10%. It’s falling for the third decile. The bottom 30% life expectancy at age 50 for women is getting worse. It’s not just that the
inequalities are increasing, but it’s getting worse. This is a national tragedy. Well it’s to deal with
these issues that I chaired, The WHO Commission on social
determinants of health. We called our report Closing
the gap in a generation. We put on the cover social
injustice is killing on a grand scale. Slightly unusual for a WHO report. And we said that key is empowerment. Material, psychosocial and political. In the wake of the WHO report I was invited by the British government to answer the question how
could we apply the findings and recommendations of
your global commission to one country, England. And the so called Marmot review, Fair Society, Healthy Lives, we did a European review
of social determinants and the health divide and we’re in the process of
completing the commission of the Pan American Health Organization on equity and health and
equalities in the Americas. We’ve called our report
just society’s health equity and dignified lives. The executive summary is available. We’re still writing the report, but we’ve got the summary. I’m now going to do the
unpardonable and repeat something that I did here three years ago and they’re two possibilities. One, three of you remember. And the other possibility
is that nobody remembers, but I do it for a reason. When I published my book in 2015, I had drawn attention to
the health gap in Baltimore and I said that if you
live in Roland Park, life expectancy for men 83, and you want to see what
it’s like to live in an area with life expectancy 20 years shorter, you could get on a plane
and fly to Ethiopia. Alternatively you could
go a few miles across town to Upton Druid. The reason I’m showing it now
is before I came here in 2015 to talk about it, Baltimore erupted. And you’ll remember, that the precipitant of that civil unrest was the killing of a
black man by the police or should I say one more
killing of a black man by the police. Now when I say Baltimore erupted, it wasn’t Baltimore it was Upton Druid. And I won’t go through all of it, but a typical young man
growing up in Upton Druid, half of single-parent families
median household income, $17,000, 90% did not go into college. Each year a third of
young people aged 10 to 17 were arrested for juvenile disorder. A third each year. A criminal record by 17. In theory the slate is wiped clean at 18. You’re not supposed to ask. So if young man is asked
have you ever been in trouble with the police he could lie. That’s not a very good
qualification for getting it, well actually, could get
you to the White House, but for normal people it’s
not a very good qualification. I told you I’m not party political. I just slipped up or he
could tell the truth, in which case it’s not a
very good qualification for getting a job. And a hundred non-fatal shootings
for every 10,000 residents and nearly 40 homicides. In Roland Park median
income not $17,000, but 90. 75% complete college. Juvenile arrests one in
50, not one in three, and no non-fatal shootings
and four homicides not 40. Crime maps on geographically to health. They’re the same areas, which
makes one think of the overlap in the causes of crime and
the causes of being arrested and getting into the
criminal justice system. I visited the Northern Territory
of Australia this year. This is the thriving metropolis Areyonga. 230 population and there is
no economic base whatsoever. The only way people could
get any money is crime. What else is there to do? Parenthetically I went to
the health clinic in Areyonga and they’re very proud you know, prevention of diabetes, we
tell people to eat healthily, fruit and veg. Fruit and vegetables? They’ve no money. There is a store. The price of an apple would be
higher than in Alice Springs and in Alice Springs it’s
higher than in Sydney and there’s no economic base at all and they’re telling people
to eat fruit and vegetables. In the Northern Territory, in the desert. And in Alice Springs, there’s the Supreme Court
of the Northern Territory. It looms like this terrible
presence over Alice Springs. Usually it’s the hospital
that’s the largest building, but this is the law court
that is the largest building. And the incarceration rate
for Indigenous Australians, 240 per 100,000. For non-indigenous in
northern territories, 186. A 13 fold difference. 84% of the prison population is indigenous compared with 27% of
the general population. And 72% of the young men in prison have a diagnosed mental
illness and 92 % of the women. What a terrible place to put
somebody with mental illness. In prison. Can you imagine a worse place
to put a damaged young person than in prison? Incarceration rates Japan,
48 per hundred thousand. The UK is a 148 per hundred thousand and the United States is
700 per hundred thousand. You have this pawnshop
for locking people up and it may not be altogether good. If you look at life expectancy
in the bottom income quartile by state-level incarceration rate, the bottom five incarceration rates and the top five incarceration rates and life expectancy is better
for the bottom income quartile in states that have lower
rates of incarceration. It may well be that the mass incarceration is a social determinant of health in addition to all the other things. And in Denmark they claim
that violent offending, 10% of males and 26% of
females have mental illness. In the UK we think 80%
of criminal activity is attributable to people
who had conduct problems in childhood and adolescence. So whether it’s 10% or
it’s 80%, it’s a lot. Therefore prevent mental
illness in children. That’s good for their health and it’s likely to be a way
of keeping him out of prison. In my English review, we had six domains of recommendations. Give every child the best start in life. Education and lifelong learning. Employment and working conditions. Fourth one, really
radical in a rich country. Everybody should have
enough money to live on. I was in Australia recently and I’ll tell you a bit
more about that in a moment and the chief executive of one
of the Health Organization’s said tell me some more
about minimum income for healthy living. I said well I lecture to medical
students at my University. Len doesn’t believe I’m
there long enough to lecture to medical students, but I lecture to first-year medical students. I get them in their pre-cynical phase. (audience laughing) And I talked to them about
minimum income for healthy living and I say part of the calculation for an older person is having enough money to buy presents for their grandchildren. And this chief executive from
this health care organization started to weep. And he said, choking up,
recently my mother told me that my granddad used to go without meals to buy us birthday presents. That’s part of leading a dignified life. Having enough money to buy your children, your grandchildren, a present. And in a rich society we
ought to be able to organize our affairs so everybody could do that. Healthy and sustainable
places to live and work and taking a social determine
approach to prevention. So I’m not going to go through them all. Much as I’d love to, if you’d
like to stay till four o’clock then I’ll keep going, but in case you’ve got
something else to do, I won’t do it all. I told you I’m not party
political so blue and red had no significant, but look
if you would at the blue dots. Ignore the red dots for the moment. What we’re plotting here
is the percent of children who have a good level of
development, age five. For every local authority in England, by level of deprivation. So you see this straight-line relation. The less deprived, the more affluent, the higher the proportion
of children aged five with a good level of development. One strategy for bringing everybody up and thereby reducing inequalities
in early child development is to reduce deprivation. Bring the local authorities
down here up towards the middle. But there’s scatter around the line. For a given level of deprivation
some local authorities are doing better than others. Now you’re allowed to
look at the red dots. The red dots are children
eligible for free school meals. It’s a means-tested benefit
so these are the poor kids. When I first saw these data, I hated it. I got it absolutely wrong. I predicted exactly the opposite. And I did what any scientists would do when you get data that
conflict with your hypothesis. I tried to get rid of the data. I mean a good idea is hard to come by. You can always get more data and I said we must have coded it wrongly. We analyzed it wrong, do it again. And it’s still there. And one difference between
science and politics is in science when you’re
wrong if you don’t admit it, you just get swept off the stage because you’ve become irrelevant. So I was wrong. The poor kids are doing
worse in the affluent areas. The more deprived the area,
the better do the poor kids do. Hey, that’s the opposite
of what I predict. It’s really interesting. So I went to a poor area. So let’s look at England first. 60% of children age five have
a good level of development. The poor kids eligible
for free school meals, just under 45%. The gap is just under 16%. Hackney in East London, a poor area. Rapidly gentrifying, but
a lot of poor kids there. Look at the poor kids. They do as well as the English average. The gap between the poor
kids and the average is 4%. The director of education in Hackney said we tell ourselves every
day poverty is not destiny. We can make a difference. And the evidence supports that. Bath and Northeast Somerset, I don’t expect you to know the
social geography of England, the beautiful Georgian bath setting, gorgeous green countryside. I was catching a train to South Wales and it stopped at Bath
Spa and I called out, what do you do for poor kids in Bath? And I’m not hearing voices, but I imagined them
calling back poor kids? We didn’t know we had any. A-ha. Hey, this is better than rocket science. Focusing on the problem,
you can make a difference. The poor kids in Hackney, they do dramatically better
than the poor kids in Bath. There’s a London effect
and we see it in education. Being poor in London
doesn’t have the same impact on your educational performance as being poor in the rest of the country. And part of that is this spend per pupil is higher in London. The government said that’s
unfair, we better equalize it, and reduce the London spending. No, don’t reduce the London spending, increase it everywhere else. What better is there to do with money than spend it on education? We can solve this. This is not really very difficult. And what about reducing child poverty? Well child poverty less
than 60% median income. In Denmark 9%, Iceland 10%, Norway 10%, Finland just under 1%, Korea. United Kingdom just under 20%. United States 29%. Just below Mexico. I think the real pornography
in the United States is not what that orange
nightmare did with a porn star, it’s the fact that no one’s
talking about child poverty. (audience applauding) This is terrible. No wonder they laughed
at the United Nations when he said this is the
best our nation’s ever been. 29% of kids growing up in poverty and that’s going to have a dramatic impact for the rest of their lives. The other part of early childhood is not lack of the good things, but presence of the bad things. Adverse child experiences. Incarceration, drug abuse, and they all follow the social gradient. These are English data, but it would look similar in California where these studies were first done. And the effect of having four or more adverse child experiences. If you could get rid of four or more adverse child experiences, you’d reduce early sex by a third. Unintended teen pregnancy by 38%. Smoking by a six,
binge-drinking, cannabis. Look at violence perpetration. Half the perpetrators of domestic violence had four or more adverse
child experiences. And even more chilling half the
victims of domestic violence had four or more adverse
childhood experiences. Do something about the social inequalities and adverse child experiences and you change the trajectories for the rest of that child’s life. And this has got nothing
to do with anything. Wealth inequality in OECD countries. This is the share of total
wealth enjoyed by the top 1%. The average for OECD
countries is just under 20%. There’s Japan 10%, Italy
and there coming out as a clear winner is the United States. 2010, 2014, or the latest and their wealth inequality
is going up dramatically. So there’s no money to do
anything about child poverty because these guys are pretty
good at not paying taxes and in fact if they weren’t good already, they’ve been helped by the
legislature to pay less taxes. So how could you deal with child poverty when it’s very important that the top 1% run away with all the money? Ensure a healthy Standard of Living. These UK data. Our politicians say that people are poor because they’re feckless. What was the US thing,
welfare queens and the like? Because they’re feckless… Of people who below the
minimum income threshold, a majority, more than half, were in families were at
least one adult was working. People are poor not
because they’re feckless, but because they’re lowly paid. If you paid them more
they wouldn’t be poor. Gosh that’s complicated. And tax havens. Tax havens increase inequality
50% of wealth in tax havens belonged to the top .01% of
people in advanced economies. That wealth is equivalent
to 5% of global GDP. That’s tax avoidance on a massive scale. Added to that is avoidance
of tax by multinationals. 600 billion euros a year shifted
to the world’s tax havens. 350 billion euros into
European tax havens. I went to a meeting in Luxembourg and I kept looking
around at everybody else thinking who are you defrauding? They’re probably looking
at me the same way. Which country you cheating out of taxes? The Starbucks was asked to come and give evidence of British Parliament and the members of parliament said why don’t you pay taxes in Britain? And Starbucks said we don’t make a profit. So kind of them. Their charity they’re providing
coffee to British people out of the goodness of their hearts. How come you don’t make profit? Well we buy our coffee
beans from the Netherlands. What? I go to the Netherlands quite often. I’ve never seen a coffee plant
anywhere in the Netherlands. They don’t grow coffee
beans in the Netherlands. They grow accountants. They get their coffee beans
from Costa Rica and from Brazil where everybody else
gets coffee beans from, but they make it look like they buy them from the Netherlands
and it’s very expensive to buy coffee beans from the Netherlands because they don’t produce them there. So that way they don’t
pay taxes in Britain. It deprives the EU of a
fifth of corporate taxes. 60 billion euros a year. For the UK it’s 12.7 billion euros. Now this is very parochial. The biggest single lie that the Brits perpetrated was we send
350 million pounds a week to the European Union. It was a lie, they were told
by the statistics authority that it was a lie. They were told not to do it. They put it on the side
of the big red bus, how Trump, Boris Johnson,
just perpetrated that lie and on and on and on. So just out of interest,
350 million pounds a week, 18.2 billion is the
same order of magnitude as the tax avoidance by
multinationals in Britain. We could pay for our
National Health Service if we stopped tax avoidance. I’ve got good news. So I’ve been giving you all this bad news. Cities are getting interested. The city of Coventry in
England declared itself a Marmot city. (audience laughing) You probably don’t know this, but the symbol of a logo
of Coventry is Lady Godiva because she lived in Coventry. You remember the story? She took a kit off and rode
naked through the street. Oh Jesus. If it’s Marmot City, have
I got to take my kit off and get on a bicycle and go naked through. But it’s more exciting than that and they’re improving
early child development, they’re getting jobs for young people. They’re doing all sorts
of wonderful things. I was invited to Trieste. I was told it was an Italian Marmot city. I don’t know if the people
of Trieste knew that, but it was really exciting what
the civilized humane people can do who are absolutely
committed to improving things in their city. It’s just terrific. And we’ve got this health
equity network in the Americas following on from our pas WHO commission. Lots of good things happening. As Len mentioned I spent a year as President of the World
Medical Association. And I pursued the hypothesis that I could get doctors
interested in health. I know. I’d like to set challenges. and not only that, that
I could get them interest in the social determinants of health. I reminded them that the
first line of my book was why treat people and send them back to the conditions that made them sick? We need to deal with the
conditions that make people sick. And my two messages in a
world of post fact politics was evidence-based policy presented in a spirit of social justice. I reminded them that
we said on the report, the cover of the report of the Commission on social determinants of health, social injustice is
killing on a grand scale. I mentioned that we did this
Commission in the Americas. were doing it and we had
a meeting in Washington DC and I went for a walk in the mall. It was during Trump’s inauguration, but there weren’t many
people there so it was okay. (audience laughing) Whoops. And I found myself in the section devoted to Martin Luther King. And Dr. King said I
believe that unarmed truth and unconditional love, and I thought unarmed truth. Evidence-based policy is a slightly more prosaic way of saying that
and unconditional love? Well every spirit of social justice, King said it better, but then he’s one of the
great orator of all time, but I believe that unarmed
truth and unconditional love will have the final word in reality. This is why right temporarily
defeated is stronger than evil triumphant. We’re living in dark times in
the UK and the United States, but with Dr. King we have to believe that we will triumph over evil. It’s winning only temporarily. Let me tell you some more good
news in the face of bad news. One of the advantages of being President of the World Medical Association, I’m clutching at straws here, was that I now have colleagues
in lots of countries. And I was invited by the ABC, the Australian Broadcasting Commission to do a series of radio
lectures in Australia. And the Australian Medical
Association wrote to me and said can we help
you while you’re here? I said yeah, I would
like to see examples of doctors in action on the
social determinants of health. They’re very concerned about the health of Indigenous Australians. The gap between health
of Australian aboriginals and Torres Strait Islanders
for men is 10.6 years, for women 9.4 years. When I got off the plane
a journalist said to me we’ve spent billions of dollars trying to close the health gap and nothing’s worked. What should we be doing? I said I just arrived. I’m jet-lagged. Give me 24 hours, I’ll tell you tomorrow. Well I was taken on this
last visit to The Shed. The Shed is a shed and it’s set up to prevent Aboriginal male
suicide in Western Sydney. These Aboriginal men involved in it, he was one of the clients. And the stories I was
told were just awful. Children removed from families. The men’s cycle into despair. They’re isolated, lost their families, they get depressed and the suicide rate is five times higher than the average. And this center is trying to deal with it and you can see the effect
on me of being told these, one horrendous story after another. But there’s good news. And I was taken to an
Aboriginal community center at the Tharawal Aboriginal Corporation. Southwest of Sydney and shown
around by two Aboriginal women who were administrators at the center. The Belly Cast program Aboriginal women don’t go to antenatal care. So they encourage them to
come in to take plastic casts of their pregnant torsos and decorate them with Aboriginal art. Lovely, absolutely lovely. And the women love it. So they come in at educational gatherings, pregnancy and postnatal care at clinic or at home care for women. So the women get involved
and they get engaged and now they hooked into
this center and the children. When I was there the first time, I’d been twice now. When I was there the first
time the little children were just being put down
for their afternoon nap and I said to the young
woman looking after them how do you know if these
children are developing normally? And she took a stack
of forms off the shelf, one for each child with 30 indicators of cognitive development,
linguistic development, social, emotional, behavioral development. And she’s got these
indicators, one for each child. I said where did you get these from? From the local University. Up to the minute. The older children were
involved in programs and then I went to the
drug and alcohol part. And I said to the woman
running this center, you must have the most difficult
job in this whole place and she said no, I have
the most rewarding job in this whole place. And she took me over to
the wall and showed me an Aboriginal painting and
she said the man who did this, when he came to us he had
all the problems of drugs and alcohol and domestic violence and we helped him put
his life back together and he did this painting
as a gift to say thank you. I have the most rewarding job she said. And then the older people, Grannies Against Removal. The default position
of the childcare system is that Aboriginal
parents are incompetent, take the children away from the families, and here Grannies Against Removal. And a psychologist in this
center gave me the answer to the journalists question. We’ve spent billions but nothing seems to have closed the health gap
and this psychologist said if you spend 200 years
systematically depriving a people of their dignity,
disempowering them, taking away the ability of the people to control their own lives,
it’s hardly surprising that simply spending money won’t solve it. You do need to spend money, but people need to be empowered. I said I was invited by the
ABC to do these lectures and they trailed my
lectures by having me on current affairs program and the moderator asked me to
say something about income. So I said what are the
following groups have in common? The 48 million people who make up the population of Tanzania. The seven million people who make up the population of Paraguay. The two million people who make
up the population of Latvia and the 25 top earning hedge
fund managers in New York and the answer is the previous
year each of those groups had a combined income of
around 25 billion dollars. Imagine, I said, that
the hedge fund managers gave up their money for one year. They wouldn’t miss it. They’re gonna make a billion
dollars each the next year and you transferred
that money to Tanzania. You could double the per-capita income. And I’m not suggesting just
giving it to individual Tanzanians although that would
not be a bad thing to do, but imagine the clean water
you could pack to villages, the clean cookstoves,
the nurses, the teachers, and suppose the hedge fund managers said we couldn’t care less about Tanzanians. Here’s an even more
fanciful thought experiment. Imagine they paid one-third
of their income in tax. I know. You and I pay a third of
our, they don’t pay tax, but imagine they paid a
third of their income tax you could employ 90,000
New York school teachers. And somebody else on the program said you’re in Fantasy land mate. You’re incomplete Fantasy land. Never going to happen. Fantasy land. And the next day was when I went to the Tharawal community health center and one of the doctors
held up a sign of greeting. (audience laughing) I say to you colleagues, let me welcome you into my Fantasy land and let’s dream of a fairer world. (audience applauding) – [Woman] I’m worried that
the UN population projections for the poorest countries
are really wildly off and I’m wondering if you
have any thoughts on that? – Well… Let me answer a slightly
different question. We know things are going serious because the Life Assurance
industry in Britain, they believed our figures. They adjusted their calculations. Wow, we’re not going to have
to pay up for quite as long, this is great, good for business. People are dying sooner, this is terrific. So they already took our figures seriously and adjusted accordingly. Now we need to look in
sub-saharan Africa particularly, it varies enormously. A country like Zambia life
expectancy has been dropping. It’s actually getting worse. There are about 12 countries
in sub-saharan Africa where life expectancy
has not been improving. On the other side the good news is if you look at infant mortality
in the African region, the gap between the
African region and the rest has narrowed dramatically. So between region inequalities
is narrowed dramatically. It means that they will
get older as populations, but it’ll take take awhile. Well fertility has gone
down in many countries. In South Asia particularly,
as women get more educated and availability of family
planning, that combination, fertility goes down. – [Woman] First of all love your talk. Thank you so much for coming
so far to meet with us and I’m wondering if you
have calculated the impact on social determinants
and inequality of Brexit. You can answer the question
here because you’re not at home. – Well it’s difficult to do. It’s difficult to do precisely. I mean the government’s
own calculations is that we’ll knock between 4% and
8% of gross domestic product over the medium-term. Well that’s going to
make everything harder and if you make the
population generally poorer, that’ll make things harder. The second is… and I’m still hoping that
it’s not going to happen, but were we actually to leave and scrap various European directives that protect workers rights for example, that’s gonna make things
worse for workers. So we’re in this ridiculous situation that the leader of the Labour Party, who’s supposed to represent
the interests of workers, is Pro Brexit, which is
going to make poorer people worse off and going to
make workers worse off. In our national health service they’re worried about migrants and you’re more likely to
meet a foreign-born person as a doctor or a nurse than
you are as another patient. We’ve got vacancies in the NHS already because nurses have
stopped coming from Europe and the doctors have stopped coming. I could go on. The European Medicines
Agency is leaving Britain. Euratom, we’ve got problems, you know, how we’re getting an atomic materials and our supplies of insulin
if we leave without a deal, diabetics are going to run
out of insulin and on and on. Brexit will be a disaster. Quite apart from what it’s saying about the country we’ve become. We were a sensible moderate
common sense place. A lot of tolerance, tolerance for people of
different ethnicities and national origins and
the whole Brexit thing has made that worse. Do I sound like I have a view? By golly, I have a view. – [Man] Evidence based mental health, anxiety and depression, Australia built computerized
cognitive behavior therapy. London NHS built computerized
cognitive behavior therapy. The names of those are
our moodgym, E-couch, and Beating the Blues. These are basically unknown
in a little research University Institute you’ve heard of called University of California. You can Google the five medical schools. There’s a big telehealth department.. What does it take to get an
institution to point eyeballs towards something that’s free? So Australia put it up for free. You know I’m talking about? – I’m not familiar. I’ve know about cognitive
behavior therapy, I’m not familiar with these projects. – [Man], Australian
National and so the last two
dean’s of public health ignored me for years so I sued them. What do I do to get at least academics to look at evidence-based
practice rather than, the alternative is our providers who don’t believe in thermometers. They don’t believe in measuring
anxiety and depression. So they think they can read minds and so that the suicide
and the drug rate is… – I mean mental illness is clearly key to the whole social
determinants of health agenda and part of my argument is that people who are concerned with mental illness have to be concerned with
social determinants of health and people concerned
with social determinants have to be concerned with mental illness. My own particular thing has
not been about the treatment so I don’t have any
particular informed view on your question because
that’s not where I focus. But mental illness certainly
features very strongly. Did you? Oh, you’re holding the mic. – [Woman] I’m here because
I’m a member of the vulnerable population as you are
pointing out in the beginning, but I feel empowered now with
the knowledge to know why. If only I can get my voice heard here, but I feel like what’s missing
from like your approach and your analysis to really
dealing with the root causes of the inequities, gender
inequity in our economic system and in particular
healthcare system is that it was designed by masculine cognition, so of course we’re as females
we’re gonna lose the race. And I’m here to represent. I’m in a homeless shelter. I was put in a homeless shelter for women who’ve experienced DV
and human trafficking and when I tried to raise this issue, I literally was just told
I have five days to get out of the shelter because I
tried to say that the policies that they have are discriminating
against feminine cognition with my roommates in the shelter and they actually understand that. So I mean and I’m physically
and mentally disabled and there’s just a lack
of care and compassion. I’m just wondering if there’s anybody here who could help me get my voice heard. I mean there’s a one of
my roommates is a female, she was literally a day away from dying because she couldn’t be heard
in the healthcare system. So it’s like… (person clapping) I feel like is it anybody here, ’cause I the thing is I have
the knowledge to know why, but I don’t know how to get my voice heard and I’m just wondering if
here if you could help. – Well I’m full of sympathy, but I don’t have an answer
to the local problem. – [Man] Thank you his lordship
for entertaining my question. I’m all about titles. So in some of the slides
that you provided, especially with the World
Health Organization reports, could you project or maybe
have some sort of idea of formerly colonized countries
much like the Philippines and the United States, also the territory of Guam, which has a significantly
lower life expectancy rate. What would you suggest or
what will you hypothesize in the links of life expectancy
as well as social mobility in those formerly colonized countries. – Well in our PAHO Commission
report for the first time and I never thought this would happen, I’m going to be author of the report that talks about the impact
on health of colonialism. And when it was first voiced by some indigenous members of our commission and I said you’re talking
about history right? They said no, no we’re
talking about the present and particularly thinking
about First Nation Canadians they said to me, I said I understand, I understand everything. I’ve got a model that
applies to everything. They said you don’t, I’m
sorry you don’t understand. Unless you understand the
relation of indigenous people to the land then your model is inadequate. It’s not wrong, it’s
just not complete enough. And the relation of
indigenous people to the land has been interfered with by colonialism and it’s still ongoing. We don’t have magic wands, but at least we are making it overt. We are talking about the
impact of colonialism particularly on the lives
of indigenous people throughout the Americas. So we will I hope add some
voice to these issues. One last question then we should stop because we’re losing our audience. – [Woman] I have a historical question that doesn’t go quite as
far back as colonialism, but I’m wondering about the
concept of social determinants. Our social gradient in particular and I was just… I’m a professor of Epi
down at San Jose State and one of the things that
I was teaching recently was the Bradford Hill criteria and I was just wondering whether social gradient was a
deliberate kind of nod to the biological gradient
and kind of how you and other social epidemiologists were able to kind of muster the evidence and the support for observing
the social determinants and really getting that bought into. – Well recently I asked
myself two questions. One was where did I get the
phrase social determinants of health from because I lay
no claim to have originated it. I must have got it from somewhere. Somebody told me they’d
seen it somewhere else, but I’m still trying to track that down. And the second question I
asked was where did I get the concept of the gradient from? I know where I got the concept from. I got it from the data
in the Whitehall study. I called it a dose-response relation between where you are in the hiarch and Geoffrey rose who was
my professor in London’s said nah, took it out dose-response. Said we’re not talking about pharmacology. And he took it out so I
called it a social gradient and as I looked, I have a sneaking suspicion
I got it from him. (laughs) I think he takes the
responsibility if not the blame. So I think that’s where I got
the term the gradient from, from Len Syme, but the
idea came from the data. From the Whitehall study of seeing this what I called it the time dose response, but there you are it’s graded. And I was trying to make the difference between absolute poverty and inequality and to compound matters
in my English review, I introduced and this I
take responsibility for, the ugly term proportionate universalism and I was trying to get at the idea that on the one hand if
you concentrate on poverty, which is the default position
of Anglo-Saxon policy, US-British whatever, you
focus on the worst of. You miss the gradient and
then you’ve got a Scandinavian and Nordic approach,
which is Universalist. But what about focusing on the worst of? So either classic British compromise I called it proportionate universalism. The idea that what we want
as Universalist policies. I said a health system for the
poor is a poor health system. An education system for the
poor is a poor education system. So we want to bring everybody
in but we need effort proportionate to need. And the National Health Service does that. If I think the aim would be at age 95 to die bungee jumping and the rope snapped and as you plummeted to your death you wouldn’t say damn,
I paid all those taxes for the health service and I
didn’t get my money’s worth. You’d say what a great way to go, you know at 95 bungee
jumping and the rope snapped, that would be great. So if you didn’t need it they
don’t spend money on you, but if you’ve got diabetes
and congestive cardiac failure and foot ulcers and the like, you need a lot of money spent on you and that’s how it should be. So it’s a universal system with
effort proportionate to need and given my focus on
socio-economic inequalities, let’s have Universalist programs without that proportionate to need and the gradients
crucial to that thinking. (audience applauding) – I’d love ending on a question
about the history of thought because we are all standing
on the shoulders of giants and we owe so much to so
many here who came before us and I am looking forward to seeing so many future Michael Marmots
running around the world continuing to battle these
issues in which as Michael said are still so prevalent. So much with us, there is
so much that we have to do, so I hope that you all are
inspired as I am by this wonderful talk, so one last
round of applause and thank you. (audience applauding) (upbeat music)

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