Social justice is good for your health
Fairness in policies helps people live longer, noted analyst argues
Sir Michael Marmot is an award-winning epidemiologist, the former head of the British Medical Association, the chairman of the World Health Organization’s Commission on Social Determinants of Health and a senior adviser to the British government and the mayor of London.
If we want to lower the cost of long-term seniors’ care and reduce the burden on public pension plans and old-age security programs, there’s one easy solution.
“Hand out free cigarettes to the poor,” he says with a wolfish grin. Yes, he’s kidding. But Marmot, in Edmonton this week to speak at a conference organized by the Institute of Health Economics, makes such outrageous statements to make a serious point. Too often, he says, discussions of public health policy focus on saving money.
“We don’t do things because they’re cheap. We do them because they’re right,” Marmot told his audience Thursday. “Social injustice is killing on a grand scale. Inequalities in power, money and resources are the key drivers of inequities in health.”
Marmot’s landmark research on wealth and health is almost as provocative as his “advice” on smoking.
After years of analyzing data from around the world, Marmot has drawn a fascinating conclusion: The wealthier and more socially powerful people are, the longer, on average, they will live.
That might not seem a revolutionary idea. It’s axiomatic that people who don’t have access to nourishing food, clean water or basic health care will die earlier, on average, than people in more affluent countries.
It distresses, but probably doesn’t surprise us, to learn that average live expectancy for a woman in Zimbabwe is 42, while in Japan, it’s 86.
And most of us in Canada understand that our fellow citizens with lower socio-economic status are statistically more likely to smoke, abuse drugs and alcohol, eat junk food, and engage in other life-shortening behaviours.
But Marmot’s analysis is more subtle and subversive. In his landmark Whitehall study, he tracked over decades the physical health and life expectancy of white-collar Londonbased British civil servants.
He found a direct correlation between civil service rank and health and longevity. It wasn’t just that the richest and most powerful civil servants outlived those at the lowest pay grade; up and down the hierarchy, the more status you had, the healthier you were likely to be.
It’s something Marmot calls the social gradient of health. And the more unequal a society, in terms of money and social power, he argues, the greater the health disparities.
Isn’t it possible, I asked him, that people tend to succeed in life because they’re physically healthy and psychologically resilient?
Is the problem that poverty and low social status make people sick? Or that physical and emotional ailments and disabilities make people poor?
“That’s what all economists think. But that’s not what the evidence shows. It’s social circumstances that determine health, not health that determines social circumstances ... and it’s not just about money. It has more to do with social position than money.”
When people feel that they have a stake in the future, he says, they’re more likely to make smart decisions about their own health and safety, whether that relates to whether they smoke, the way they drive or the care they put into raising their children.
By way of example, he says the best way to lower infant mortality is to improve the education of young women in a population, giving mothers both practical knowledge and social power.
“We need to create conditions for people to take control of their lives.”
While politicians and policymakers focus on public health intervention strategies for the poorest of the poor, Marmot argues the nature of the social gradient means that improving social equality, and improving public health, are also in the interests of those in the middle of the slope.
“Focusing solely on the most disadvantaged will not be sufficient,” he says. “A health system for the poor is a poor health system.”
Marmot knows his core thesis — that economic and social justice improve public health — may seem radical. Still, having been knighted in 2000, he doesn’t mind being compared to Don Quixote, the mad knight who jousted with windmills.
Now, he’s looking to recruit a lot of pragmatic Sancho Panzas, to make the practical policy changes that lead where he wants to go.
“Every minister is a health minister and every sector is a health sector,” he says.
“If we put fairness at the heart of all policies, health would improve.”