When, in 2008, we launched the report of the WHO Commission on Social Determinants of Health, we said we wanted to create a social movement. Not entirely clear what constitutes a social movement, I suppose our network of Marmot Places is one indicator that the movement is happening. In this network, we now have over 60 places across England, Scotland, and Wales, committed to taking a system-wide approach to improving health and reducing health inequity.

Another indicator was provided this past week by Michael Lu, Dean of UC Berkeley School of Public Health. “Social Determinants of Health, the concept, is everywhere in the US”, he said. “It was your WHO Solid Facts publication and your 1999 OUP book, Social Determinants of Health, (co-edited with Richard Wilkinson), followed by the WHO Commission on Social Determinants of Health that put the concept on the agenda. But now, not only is it central to public health schools and action, but it has been embraced by medicine.”

He went on to say: “You did your public health training and PhD at Berkeley. We want to find a way to celebrate and take credit.” It’s true. I must have imbibed the ideas studying under Len Syme, 1971-75. It is, after all, classic Durkheim, Len’s hero. But the term, social determinants of health, was not in use then – hard to find it in the literature – and I didn’t use it until much later, probably our Solid Facts publication.

Precisely because, after my medical training in Sydney, I had spent nearly five years in Berkeley – MPH, PhD and a year teaching – that I was happy to visit now (see the interview that Berkeley School of Public Health did). The occasion was billed as:

Social Forces/Clinical Cases: Breaking Boundaries with The Lancet’s Global Social Medicine Cases and Sir Michael Marmot

 

Marmot Place?

More on the cases in a moment. Marmot Places hit a chord with UC Berkeley faculty and students. We at IHE are not just studying the problems of inequalities but putting these concepts of social determinants of health into action. How about Oakland as a Marmot community, I mused. Not Berkeley. Too atypical. With its famous university, its social movements of various sorts, its holdovers from its hippy past. A small city by San Francisco Bay with a foreign policy. No.

But Oakland, perhaps. Huge inequalities, with deep poverty, and wealthy parts, an important port, manufacturing. A professor at Berkeley, Jason Corburn, said that it should be Richmond. He has been working in Richmond, a city of 120,000 north of Berkeley. It had a boom time as a shipbuilding centre, particularly during World War II. It has had decline and rebound since.

A group working in the West Side of Chicago said they wanted to be the first American Marmot place. I quite like the idea of a bit of competition, especially if it led to two!

 

Social Forces/Clinical Cases

Seth Holmes, a UC Berkeley Professor, had the idea of a clinical case series that would illustrate social determinants of health. We discussed it at some length. He assembled an enthusiastic network of colleagues. One thing led to another and the series is being published in the Lancet. The event in Berkeley, and a similar one three days later at the University of Chicago, were to launch the series. My lecture was to provide context.

One of the cases presented at the Berkeley event centred on an asylum seeker with pain from a stone in the ureter – an extremely painful condition. Because of his status in the system, he didn’t get the care he needed. What he needed and didn’t experience was intercompetency, which the authors define as the trained ability to work effectively in a multidisciplinary team, including those from outside the health care system.

Each of the cases, in Chicago as well as in Berkeley, illustrated the operation of social determinants of health in affecting both the patients’ medical problems and the care they received.

It was exciting to see committed people in Berkeley and Chicago understanding the problems of social determinants of health and trying to make a difference. But what about the national politics? I had the feeling that people were talked out. NIH grants had been cancelled, institutions were struggling. Diversity, equality and inclusion had become dirty words. Autocracy was an all-too-present reality, looming over people’s lives.

 

Chicago

I had made a few short visits to Chicago previously, usually in The Loop, the smart downtown area, where the MacArthur Foundation and the American Medical Association enjoy well-appointed offices. The contrast with the poverty of the South Side is stark. As so often in the US, poverty has a racial bias. The South Side is also famous as the place where future President Obama was a community organiser. He also taught at the University of Chicago for several years.

One can feel the geographic contrast. University of Chicago is an elite private university, founded around 1890 with a donation from John D Rockefeller, and some wealthy Chicagoans. The urban campus stretches south for five blocks from around 55th Street. The housing is elegant and well-ordered, the university buildings impressive. I was staying two blocks north on 53rd. It was striking that a locality that felt so down at heel could be two blocks away from a world famous university. Not an elegant coffee shop or patisserie in sight. No fresh fruit to be had for love or money.

Not sure what I expected of the University of Chicago. Chicago Economics is famous. It seems as though the Nobel Committee in Economic Science has a list of the U. of Chicago Economics faculty and run down the list handing out the Economics Nobel. It doesn’t just seem that way. Counting the first, Paul Samuelson in 1970, there have been 33 Nobel winners by 2023, associated with the Economics Department. They include a high priest of neoliberalism, Milton Friedman, and the guru of the economics of daily life, Gary Becker. It is difficult to get one’s head around 33 Nobel winners, all men, associated with one university department (they weren’t all there when they won the big prize) in 54 years. What were the Nobel Committee thinking, not giving the Prize to a Chicago man every year.

The faculty that I was able to meet were terrific – anything but devotees of neoliberalism. Chosen, I suppose, but real interest in social determinants of health and health equity. A special pleasure was meeting Ayesha Jaco and Eve Shapiro, directors of West Side United, working to address the dramatic health inequalities in their area. It is they that expressed interest in the West Side of Chicago becoming a Marmot Place. Devoutly to be wished.

I was able to squeeze in a visit to the Robie House – the 1910 masterpiece of architect Frank Lloyd Wright – and the University’s Smart Museum of Art. The extra delights of Berkeley were early morning walks in the hills.