What has social injustice to do with medicine?

Will Michael Marmot’s crucial review of health inequalities in England meet the same fate as its predecessor by Douglas Black? Certainly, as our editorial by David Hunter and colleagues points out (doi:10.1136/bmj.c684), there are striking parallels in the timing. Published in 1980, the Black report had been commissioned by a Labour government, but it reported to a less than enthusiastic Conservative one. Hunter et al think the Marmot report will fare better. We must hope so, but can we as doctors do more than just hope?

What prompts me to ask is Jane Moore’s letter (doi:10.1136/bmj.c482). In what she rightly calls “the “contrived and fictionalised image” in Fildes’ 19th century painting The Doctor she sees a deception that persists today. “It is a fine example of Victorian spin produced to enhance the image of the medical profession and that of the establishment as a whole, by suggesting they had the power to confront the difficulties encountered by society.”

Are we—doctors and politicians—as powerless to act as she suggests? The challenge posed by the Marmot report is that we cannot afford inaction. As Marmot’s earlier report for WHO starkly stated, “social injustice is killing people on a grand scale.” Inspired by another great creator of Victorian fiction, Charles Dickens, Michael Marmot decided early on in his medical training that medicine and surgery were just failed prevention. As Zosia Kmietowicz captures in her interview with him, Marmot remembers thinking, “If we could do something about prevention, we could empty the hospital wards” (doi:10.1136/bmj.b5558).

Over time, greater understanding of the complexities of how things work at the national and global level has added sophistication to his message while removing nothing of its power. A central question behind the WHO report was “why treat people…without changing what makes them sick?” It’s a question that many countries find hard to answer. While healthcare costs continue to grow, so too does the health gap between rich and poor. Some countries are bucking the trend. Sweden, Mexico, and Cuba get special mention from Clyde Hertzman and colleagues (doi:10.1136/bmj.c468), who call for governments around the world to tackle inequality by investing in early child development, and to make their provisions “universal and generous.”

Marmot is clear that action has to take place across all sectors, and he is encouraged by the response to his WHO report. Countries that haven’t previously prioritised health inequalities are now doing so, as is the European Union under Spain’s presidency. It’s no surprise, but gratifying nonetheless, to hear Marmot’s impassioned support for the NHS. His advice to health professionals is to work on three fronts—providing universal access to good quality care, collaborating with other sectors such as transport and social services, and understanding and measuring outcomes.

Still feeling powerless? You may find inspiration in Iona Heath’s review of Amartya Sen’s new book The Idea of Justice (doi:10.1136/bmj.c659). Heath applauds Sen’s challenge to all those sitting complacently on “the winning side” of social injustice. She also finds support for primary care’s insistent focus on the person rather than their illness. Which leads me to Kieran Sweeney. In a moving obituary (doi:10.1136/bmj.c733) he is honoured for honouring patients above their diseases.