- Fiona Godlee, editor, BMJ
I wrote about the paper by David Stuckler and colleagues when it went online two weeks ago (BMJ 2010;340:c3311, doi:10.1136/bmj.c3311). Now it’s in print, and it couldn’t be more relevant to the debate in the UK and elsewhere about how much to cut from social welfare budgets and what the cuts will do to health. Much damage, is the answer from these authors. They conclude that spending on social welfare may be more important for health than spending on health care. Over the past 30 years when social spending in Europe was high mortality fell, but when it was low, mortality rose substantially.
They quote Michael Marmot: “Austerity need not lead to retrenchment in the welfare state. Indeed the opposite may be necessary.” The opposite—by which I assume he means investment in welfare—seems unlikely in the UK at the moment, but other governments may be in a position to show greater wisdom for the long term.
Michael Marmot gets his own slot in this week’s journal, in an edited version of the speech he gave last week at his inauguration as president of the BMA. You can read the full speech on bmj.com (BMJ 2010;341:c3617, doi:10.1136/bmj.c3617). Highlighting the 44 year difference in life expectancy between women in Zimbabwe and Japan, he puts before us again the uncomfortable fact that this is not due to biology but to social injustice. Rather than focusing solely on known causes of health inequality such as smoking and obesity, we must also deal with “the causes of the causes,” by which he means our unfair economic and social arrangements. Paraphrasing former WHO director general Halfden Mahler, Marmot says, “If we really want to fight the alligators of health inequalities, we have to drain the swamp.”
Is there a role for doctors here? Marmot says there is, but I wonder how easy it is for each of us to see where and how to make our contribution. Within the UK, GPs are being asked by the National Audit Office to target the neediest groups with health inequalities initiatives—prescribing for high blood pressure and cholesterol, and smoking cessation services (doi:10.1136/bmj.c3558). Meanwhile at a meeting in London last week, delegates discussed how to get the millennium development goals (MDGs) back on track, particularly the goals to reduce child mortality by two thirds and maternal mortality by three quarters by 2015 (doi:10.1136/bmj.c3521). They heard the depressing news that little has changed since these goals were set 10 years ago. Worldwide 29 000 children under five die each day, mostly from preventable diseases, and only one in four women in sub-Saharan Africa has access to contraception. But they also heard that there are three “straightforward actions” that are cost effective and could make a big difference: promoting free access to health care for the poor, strengthening the healthcare workforce in developing countries, and involving affected communities in decision making.
Tackling local and global health inequalities is perhaps the great challenge of our generation. Marmot invites us to dream of a fairer world but also calls on us to take the necessary practical steps to achieve it.
Cite this as: BMJ 2010;341:c3658