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Michael Marmot BMA Presidency Acceptance Speech08th July 2010 07:47
In his acceptance speech as BMA president, Michael Marmot told the BMA annual representative meeting on Brighton on 29 June 2010 that doctors should be active in tackling health inequalities and social injustice.
It is midsummer. It is appropriate to have a midsummer night’s dream. In my midsummer night’s dream, what visions did appear!
Me thought I was translated: president of the BMA.
To quote Puck: Lord, what fools these mortals be!
President of the BMA? Surely not. Not me.
I confess to a rich fantasy life but, had I but thought about it, presidency of the BMA would have seemed marginally less probable than playing the viola with the English Chamber Orchestra or winning the senior tournament at Wimbledon.
That I should be surprised to be approached to be president of the BMA is not false modesty—remember: don’t be modest, you’re not that great—no, my surprise was entirely reasonable. My research has been focused on inequalities in health. Latterly the focus has been on what can be done to address the issue. Both in research and policy I have emphasised the circumstances in which people are born, grow, live, work, and age. These all loom larger as causes of health inequalities than defects in our healthcare system. Heart disease is not caused by statin deficiency; stroke is not caused by deficiency of hypotensive agents. I have emphasised not just the causes of health inequalities—behaviours, biological risk factors—but the causes of the causes. The causes of the causes reside in the social and economic arrangements of society: the social determinants of health.
My first reaction, then, was that I was an odd choice for BMA president. My inner monologue quickly changed that to: an imaginative choice. No one is more concerned about health inequalities than the medical profession, whether the causes lie within or without the medical care system. Either way we have to deal with the consequences of inequalities in health. I would argue, and will argue now, that a concern with social injustice as a cause of health inequalities engages the best instincts of the medical profession. For all these reasons, I am really pleased to be taking on the presidency of the BMA.
(Not just pleased, but reassured, when it was explained that the president does not get engaged with the trade union side of the house.)
Agreeing to become president of the BMA presents me with a major challenge: learning to speak without a PowerPoint presentation. I’m an academic. We like our data to support us. The last time I performed in public without slides was in the school play. I played MacDuff in Shakespeare’s Macbeth. Macbeth was of course brought down by the dread virus of ambition.
Shakespeare had ambivalence about ambition. Julius Caesar was assassinated because Brutus and the rest were worried about his ambition.
I want to say a word about ambition.
When I was a student in the 1960s it was uncool to admit to ambition. That, of course, was ridiculous, as everyone in this room, each with ambition, can testify. But the key question is ambitious for what?
My predecessor, Averil Mansfield, said to me: you may be the first BMA president with an agenda—perhaps a politer word for ambition. I do have an agenda, an ambition, an obsession, even, and that is to contribute to reduction of health inequalities. My year as president will have real meaning if I can help encourage other doctors to be active in the challenge to reduce avoidable inequalities in health, not just here within Britain, but globally between countries.
At such a moment as this, perhaps I may be allowed a personal reflection on the link between research and action. I have spent much of my working life on curiosity driven research. A central hypothesis was that the gateway between society and health was through the mind.
I retain that ambition. But something changed along the way.
If, after publishing a paper, someone asked: so what? the answer was: to publish another paper.
At the end of every paper, there was a distinctive bird call: more research is needed, more research is needed. But I now have a new bird call: more action is needed, more action is needed. The two calls harmonise well. To caricature only slightly, I went from wanting to work towards good research to wanting to work towards a good society AND have good research done.
I can sum up the change: I was invited by the British government to conduct a review of health inequalities, and what could be done to address them. I published my review in February this year and entitled it: Fair Society: Healthy Lives. It was a statement that in my judgment, and that of the people who worked with me on the review, if we took seriously the move to a fairer society, health would improve, and health inequalities would diminish.
So close is the link between social and economic arrangements and health that we can see health as social accountant. Health and the fair distribution of health—health inequalities—tell us how we are doing as a society. The simple answer is: we’re doing well but can do better.
Let me illustrate. In my review of health inequalities, Fair Society Healthy Lives, we emphasised not just the poor health of the poor, but that health follows a social gradient; for example, the more years of education the longer the life expectancy and the better the health. Those with university education have the best health. We calculated that if everyone over 30 had the mortality rate as low as those with university education we could prevent 202 000 premature deaths, EACH YEAR. Does anyone in this room think other than that should be largely avoidable?
In the US, a similar calculation suggested that if African-Americans had the same mortality rates as whites there would have been 800 000 fewer deaths over a decade. When I spoke of this to the American Public Health Association one commentator asked movingly, how many times do we need to learn the same lesson? 800 000 times is too many.
Let me go further: life expectancy for women in Zimbabwe is 42, in Afghanistan 44. By contrast, in Japan it is 86. There is no good biological reason why there should be a 44 year difference in life expectancy across the world. This 44 year difference arises because of our social and economic arrangements.
To address these inequalities in health within and between countries, the World Health Organization set up the Commission on Social Determinants of Health. The director-general of WHO, JW Lee, invited me to chair the CSDH.
Our report was published in 2008 as "Closing the gap in a generation." Closing the gap? Are we bonkers? A 44 year gap in life expectancy between countries, an 18 year gap within countries, and we want to close the gap in a generation?
It was a statement that we have in our heads the knowledge, we have in our hands the means, to close the gap in a generation. The question is: what do we have in our hearts? Do we have the political will?
An illustration: we said in the CSDH report that one billion people live in slums. We estimated that it would cost $100 billion to upgrade the world’s slums. I thought: no on one will take us seriously. Who would find $100 billion for anything?
When I last looked we had found $9 trillion to bail out the banks. For one ninetieth of the money we found to bail out the banks every urban dweller could have clean running water. Do we have the knowledge? We have the knowledge. Do we have the means? We have the means. Do we have the will?
When I formulated this view, I was not aware that I knew the motto on the BMA crest—with head, and heart, and hand. Clearly, it was destiny. BMA and I were made for each other.
To come to the heart of the matter. With both the CSDH and the English review of health inequalities, we said that the reason for taking action to reduce social inequalities in health between and within countries was one of social justice. We said that "social injustice was killing on a grand scale"; a toxic combination of poor policies and programmes, unfair economics, and bad politics was responsible for most of the problems of health inequity in the world. The reason for action was an ethical one not an economic one.
In the English review, in my introductory note from the chair, I pointed out that the CSDH report had been criticised as ideology with evidence. The same could be said of the English review. We do have an ideology: health inequalities that are avoidable by reasonable means are quite wrong. Putting them right is a matter of social justice. But the evidence matters.
The evidence suggests that action has to be on the conditions in which people are born, grow, live, work, and age.
Commonly, when we think about action to reduce health inequalities, we debate whether we should focus on smoking, or obesity, or immunisation. Let us remember Halfdan Mahler, the legendary director-general of WHO. In a speech to the World Health Assembly in the mid-1980s Mahler said: "Imagine you are up to your neck in a swamp, fighting alligators; just remember we came to drain the swamp in the first instance."
Colleagues, if we really want to fight the alligators of health inequalities, we have to drain the swamp. We have to deal with the consequences of an unfair set of economic and social arrangements, and with the causes and the causes of the causes of health inequalities.
We published the commission’s report. What happened? I travelled the world, getting jet lag and interference with my gastrointestinal function; did something more happen?
Parenthetically, I have developed a wonderful cure for jet lag. I lie in bed rehearsing one of my speeches and I’m asleep in seconds. I recommend it. Faster than reading Henry James in bed.
On the gastrointestinal front, I did ask at one hotel: Is the water safe to drink? I was told: all the drinking water in this hotel has been passed personally by the manager. I was impressed by the manager’s prodigious talents if not greatly reassured.
Since indulging in this work on social justice and health, I have, however, developed three other medical conditions that perhaps, as a medical audience, you can help me with.
First, a state of near continuous excitement. There must be some pills for this condition. We said we wanted to create a social movement. I scarcely understood what that was. But I would say that the signs are promising.
A Peruvian colleague wrote to me with a quote from Don Quixote. "Ladran, Sancho, segnal que cabalgamos." The dogs are barking, Sancho, it a sign that we are moving.
Among the signs of movement are:
- A WHO resolution.
- A discussion at ECOSOC, and an endorsement of the CSDH from Ban Ki-Moon
- Spain made social determinants of health a priority for their presidency of the EU.
A number of countries have taken it on: Chile, Brazil, Costa Rica, Sri Lanka, Norway, Denmark. I am excited.
Now we have the UK with my inequalities review. With the help of the BMA and the royal colleges I want to keep this on the national agenda.
Is this ambitious? Good heavens yes! Ambitious to create a better society, and a better world.
The second condition I have developed is selective hearing loss. It is somewhat related to my state of evidence based optimism. I cannot hear cynicism. With both the CSDH and the English review the process was inclusive. It involved hundreds of people. The English review of health inequalities is being implemented locally and regionally. Thirty local areas and regions are developing plans to implement the Marmot review. As one US colleague put it: when he argued for social determinants of health, his director told him he had become Marmotised.
The third medical condition is that something has happened to my eyes: they water at embarrassing moments.
Pascaol Macoumbi, former PM of Mozambique and a member of the Commission on Social Determinants of Health, said at the end of our meeting in Vancouver: I haven’t felt so energised since my country got independence. I had this watery condition of my eyes.
When I saw how the Self Employed Women’s Association works to improve life for the poorest most marginal women in India—the right to work, micro-credit schemes, child care, health care, insurance, upgrading slums—again this watery condition of the eyes developed.
In Thailand, they talk of the triangle that moves the mountain: knowledge, politics, and people. That softened me up but I was dry eyed until Thai children sang:
"We are all stars of the same sky.
We are all waves of the same sea.
It is time to learn to live as one."
Then, I lost it.
Let me come back to my theme of ambition for what? The dominant view of the last 30 years has been that we are all greedy and motivated by self interest. Further, by pursuing our self interest society benefits. Wow! The intellectual fount for such view is Adam Smith: "It is not from the benevolence of the butcher, the brewer, or the baker that we expect our dinner, but from their regard to their own interest." In other words, by pursuing our own self interest society flourishes. That idea seems to have driven out all others.
Adam Smith did say that. That’s the part we remember. It is a travesty of Adam Smith to think that is all he said. We’ve forgotten his important other insights: "No society can surely be flourishing and happy, of which the far greater part of the members are poor and miserable."
"To feel much for others and little for ourselves; to restrain our selfishness and exercise our benevolent affections, constitute the perfection of human nature."
In the name of self interest we have allowed inequality to flourish.
Tony Judt: "Under conditions of endemic inequality, all other desirable goals become hard to achieve.
"Inequality is not just a technical problem. It illustrates and exacerbates the loss of social cohesion and the tendency to confine our advantages to ourselves and our families...
"If we remain grotesquely unequal, we shall lose all sense of fraternity...The inculcation of a sense of common purpose and mutual dependence has long been regarded as the linchpin of any community."
At the invitation of the French Ministry of Health I went to Paris to do a day on the Commission on Social Determinants of Health and the English review. For that or other reasons, France is taking up the health inequalities agenda. I asked a French colleague why President Sarkozy, a right of centre president, would embrace this? I was told that all French children grow up with the motto of the French Revolution: Liberté, Egalité, Fraternité. In France they may not do too much about the first and the third, but égalité is central.
In the UK, and the US, the degree of inequality that we have created is harming the next generation. Which among the rich countries has the least social mobility? The US, followed by the UK.
Ambition: If the medical profession were out only for its own interests, we would not have become doctors. Of course, we are exercised by pay and conditions, but at the core our ambitions are not selfish and we are concerned with social justice.
Let us use those twin concerns—for the wellbeing of others and for social justice—to make a difference to health inequalities.
I referred to Don Quixote a few moments ago. At times Don Quixote seemed an appropriate caricature of what I have been doing: a supposed knight running around trying to be chivalrous and everyone laughing at him. When I said this to the Spanish minister of health he said: "We need the idealism of a Don Quixote, the dreamer, and the pragmatism of a Sancho Panza."
So, dream with me of a fairer world, but let us take the pragmatic steps necessary to achieve it. In the words of Pablo Neruda, which I used both at the launch of the global commission and the English review: "Rise up with me against the organisation of misery."
Cite this as: BMJ 2010;341:c3617