Michael Marmot: Putting health inequality on the mapBMJ 2010; 340 doi: https://doi.org/10.1136/bmj.b5558 (Published 07 January 2010) Cite this as: BMJ 2010;340:b5558
There is something of Charles Dickens about Michael Marmot. The author and the professor of epidemiology and public health at University College London share a preoccupation with the nuances of society, both dedicating their lives to describing in detail the traits that determine a person’s life, and ultimately their death, and serving them up for public consumption.
Marmot, who takes up the post of BMA president at the end of June, says he feels a resonance with the author. He read two of Dickens’ novels last year, and the opening of Great Expectations, where Pip stands in a cemetery surveying the gravestones of both his parents and the “five little stone lozenges” that belonged to his brothers brought home to him his life’s work—the social causes of premature death.
Literature has been a lifelong passion for Marmot. In his first year as a house officer in Sydney, where he gained his medical degree, he did one year of an English literature degree in his spare time, turning up to lectures in blood stained shoes with his bleeper in his pocket. It was a break from clinical medicine, he says, and a diversion that reflects the path his career took.
Born in north London, Marmot grew up in Sydney “because it wasn’t China.” His father, who had been in Shanghai during the 1920s, returned there in 1948 after the war intending to set up in business. On arriving there, however, he decided that China held too few prospects and moved on to Sydney, where his family joined him.
Marmot was attracted to medicine because it offered further study of the science he enjoyed at school with the added dimension of having the potential to do some good. Although he loved contact with patients, during his second year in a house job he started to question the “social side of things,” and this led him out of the clinic and into academia.
“I used to walk around the hospital wards and I’d say, ‘We saw this chap three months ago, and he came in in acute cardiac failure, we treated him’ or ‘chronic respiratory failure; we treated him, sent him home. Here he is back again.’ And I used to think that medicine, and particularly surgery, is just failed prevention—that if we could treat these people properly, and, particularly, if we could do something about prevention, we could empty the hospital wards,” he said in an interview at Berkeley University in 2002.
While Marmot was doing his house job, his consultant returned from a meeting with the word epidemiology on his lips and the contact details of two professors in the United States. Once he had worked out what epidemiology meant, Marmot wasted no time in writing to them with his view that health was a manifestation of the way society is organised and to get to the bottom of health you have to examine society—a path he has been pursuing ever since.
In 1976 Marmot sealed his name in epidemiology when he took over as lead in the Whitehall studies, the groundbreaking research that first linked social status with health outcomes when it was found that people at the bottom of the civil service hierarchy had higher rates of heart attacks and other major causes of death than those at the top.
Despite his achievements, there is a genuine humility about Marmot and also an enchanting excitable innocence. He looks behind his chair when I ask what his initial reaction was to the BMA’s request for him to become its next president, as though searching for someone more worthy of the post. His response was, “My name is Michael Marmot. Have you got the right number?”
He was appointed chair of the World Health Organization’s commission on the social determinants of health in March 2005. A theme of the commission’s report, “Why treat people . . . without changing what makes them sick?” asks the question which had perplexed him on the wards of Sydney’s Royal Alfred Hospital a generation earlier.
He describes the experience of chairing the WHO commission as “life changing at every level.” And the response to the report, published in August 2008, has left him “over the moon.”
“I am used to the cut and thrust of academic life and thrive on it. It is exciting and wonderful and a privilege to have an academic career. When I started as chair of the commission I thought that other members too would be from an academic background. There were a few, including one Nobel laureate. But the others weren’t. It was a bit shocking for me to find out that the way I knew things as an academic was perhaps a bit limited and that there were other ways of knowing things—for example, by being out in the world doing things. Working with them was amazing and I learnt so much,” he says.
His biggest fear was that the report would have a similar fate to many other such publications and wind up being moved “from the desk, to the floor, to the bookshelf and that is the end of that. But that hasn’t happened,” he said.
On the contrary, the report has spurred action in several countries. It has inspired governments in Brazil, Chile, Argentina, Costa Rica, and Sri Lanka to examine the factors that drive health inequalities among their citizens. Spain, which takes over the European Union presidency in January, has also vowed to make health inequalities a priority of its tenure. Eleven countries from central and eastern Europe have also spent a week discussing how they can take forward the findings of the report.
“There have also been calls from several countries which led to a resolution at the World Health Assembly in 2009 to call on the WHO to take action and report back on what has happened around the world to address health inequalities,” he says.
“If you ask me if the health of one single person has improved as a result of the commission then honestly I don’t know and perhaps it is too early to tell. But there certainly has been a lot of action and the report has not died.”
In the UK the Marmot effect has taken a firm hold. In February Marmot will publish his post-2010 strategic review for tackling health inequalities in England, commissioned in November 2008 in the light of the WHO work by the then secretary of state for health, Alan Johnson.
Although it has been a long time ambition of the Labour government to narrow the health gap between the most disadvantaged and the most well off, the truth is that this has not improved since the late 1990s. On some measures—such as infant mortality—it has even widened from 13% in 1997-9 to 17% in 2004-6.
“If you take life expectancy as a measure then you see that over the last 8-10 years, when the government had a programme for action on health inequalities, life expectancy for the worst off has improved. In fact, it has improved so much that it is now better than the average life expectancy was eight years ago. But what also happened was that the average life expectancy also went up so that the gap between the worst off and the best off has not narrowed,” he says. “Things have got better, but what I would like to see is things getting better for everybody and the gap to narrow.”
The key drivers of health and health inequalities lie outside the healthcare system. What is important are those variables beloved by Dickens—where people are born, where they grow up, their work, and how they live and age.
For those in the health sector reducing health inequalities takes work on three fronts—making universal access to good quality health care a reality, collaboration with other sectors, such as transport and social services, and understanding and measuring outcomes.
Addressing health inequalities is apolitical, says Marmot. He is a passionate advocate of the NHS and expects whatever party is in power after the general election to take forward his review with purpose and commitment.
“The NHS is a very powerful expression of a social commitment. When Nye Bevan launched the NHS he said he had done the most civilised thing he could—to put the health of people before other concerns. Let’s keep doing that,” said Marmot. “Let’s keep the health of people uppermost and let’s keep the wonderful principle on which the NHS is based intact.”
His words echo those of the BMA’s Look After Our NHS campaign and may be part of the reason for the association choosing Marmot as its next president. Whatever the BMA’s motivation, Marmot is not interested in being just a figurehead and has no doubt that his acceptance of the role will help carry forward his own agenda.
“If choosing me and my being there allows me and the BMA to make the health equality issue more visible then that is more than a figurehead—it is galvanising some activities around the agenda and it is saying that the BMA is positioning itself and wants to take more of a public stand on health inequalities; so I am delighted.”
He says that medical associations in Sri Lanka and Canada have already reacted positively to his appointment and are discussing how they can get their own medical associations to adopt the health inequalities agenda. “After all, it is the business of doctors not only to wait until people get sick but also to be advocates for what they can do to prevent them getting ill.”
It is no surprise that Marmot has been thinking about what he will say in his speech when he is inaugurated as president at the BMA’s annual representatives’ meeting at the end of June. It is this speech that often sets the tone of the forthcoming tenure. No prizes for what the contents are likely to be.
Cite this as: BMJ 2010;340:b5558
Competing interests: None declared.