Health arises from empowerment
Evidence leads to a radical conclusion - even when care is provided, empowerment matters
WHO's Commission on Social Determinants of Health is due to report in 2008. Its Chairman, Sir Michael Marmot, here tells RealHealthNews his apolitical, but radical philosophy based on evidence, his hopes, and broad conclusions.
>RHN: You’ve made clear that the WHO Commission on Social Determinants of Health is founded on evidence. But is evidence enough to have a political impact?
MM: I start from two assumptions. One, I wouldn’t have spent my life gathering evidence if I didn’t think evidence mattered. And that’s why there’s a Global Forum for Health Research, because research implies that you think evidence matters. And two, ideas and commitment can be powerful.
I went to talk to some leading people in the private sector, and the CEO of a big organisation said, what actually is the Commission? When you talk about ‘we’, whom are you talking about?
I said we have no resources. If we go into a country and they ask ‘what’s in this for us’, the answer is that there’s nothing in it for them - in the sense that we don’t control aid money or financial flows.
But what I can say is that what’s in it for you is the opportunity to improve the health of your population and reduce inequalities in health within your population.
Now, you may say ‘come off it’. In this nasty world, who’s going to respond to an appeal to their better selves?
Well the answer is lots of us will respond to the appeal to our better selves. When I spoke here at IUPHE in Vancouver there were maybe two thousand people in that room, and I guarantee every single one of those responded to the appeal for better selves.
Take Wilbert Keon, the Canadian senator and founder and director of the Ottawa Heart Institute . He now chairs a senate committee where he’s looked at the health differences within Canada. Most of the world would look at Canada and say that the inequities in health in Canada are comparatively mild. But he considered them deeply upsetting. This was a powerful individual who was influenced by the evidence – and then pressed the Canadian Senate to make a statement about it.
So that’s a long answer to your question on political impact. The power of the evidence and the power of the collective organisation of people who are concerned with these issues will change things.
>RHN: But that’s still a minority movement, isn’t it? As the past UN Ambassador on AIDS to Africa, Stephen Lewis, says, globally we are in a neo-liberal consensus, not a social democratic one; and with globalisation that looks rather like continuing. The power of labour movements vanished because it’s possible now to shift jobs anywhere in the world. So there’s no effective organised left wing any longer.
So I’m puzzled how the communities that are deeply affected by their social conditions and poverty in Africa or India or China, or Latin America, or wherever it may be can become a political force. It’s very exciting to imagine that they might be. But so much of the time we have only a group of liberal intellectuals - liberal in the British sense of social democratic - gathering the evidence making the arguments on their behalf. But does the big powerful world have to listen to this?
MM: Well, we’ve taken a view on the Commission for Social Determinants of Health, based on our experience over the last couple of years, that you have to do what one of our commissioners, Fran Bowen, calls a ‘nutcracker’. You have to get in at the top and you have to get in at the grass roots.
In fact the academics are almost the intellectual bit players in this. There has to be political commitment from the top, from the head of government, not just minister of health. And there have to be active grass roots movements - and they’re not the liberal intellectuals. These are people in the front line. These are people who are actually dealing with suffering women and children, disaffected families, the NGOs, the civil society organisations, the front line health workers, the teachers, the community development workers.
I’m not trying to paint a picture of blind optimism in the face of all the evidence to the contrary. But what I am saying is that we can see with some of the countries that we’ve forged a partnership, with Brazil, Chile, Sri Lanka, not to mention Canada, the UK, and Sweden - there’s real evidence of buy-in at the top and real action.
>RHN: In those countries?
MM: In those countries, with real action at the grass roots level. It’s not simple. Our Brazilian colleague, who heads the Brazilian commission on social determinants of health, says how difficult it is to do cross-sectoral work. There are no rosy pictures here that suggest it’s easy, but they’re really trying. Now, that gives me a lot of optimism.
>RHN: So these countries can be leaders, examples of how to get solutions?
MM: Exactly, and it’s very important for the Commission when we report next year that we can say for example, ‘look what’s happening in Brazil’. My Brazilian colleague told me that he was going to a meeting of a dozen Latin American countries on this precise social determinants of health agenda.
Brazil and Chile have been leaders. They’re trying to galvanise action in other countries. There is a ministerial meeting in Buenos Aires in August and I’ve been invited to talk about this agenda. So there are glimmers, chinks of light that suggest it’s worth pushing and pushing.
>RHN: It is true that we all feel a sense of the need for fairness and justice. That’s pretty universal whatever your politics.
MM: Well, the evolutionary psychologists tell me that that’s hard wired.
>RHN: So if you can connect the evidence on poverty with this issue of justice, so that the right can’t argue that the poor are poor because ‘it’s their own fault’ you might be able to create a majority movement, is that the feeling?
MM: That’s exactly the idea. But personally I’ve never been actively engaged in politics, so I’d not like this to be seen as a party political issue. I’m a simple person. There are differences in health among countries, inequalities in health among countries. We think that those could be changed by concerted action globally, nationally, community, families and individuals.
If concerted action will change it, the fact that we’re not doing it is wrong. It’s unfair and unjust.
Now, look within countries. There are big inequalities in health - and I speak from the evidence. There is also evidence that we could reduce those, though not abolish them.
I would say that the evidence would suggest lots of argument, but that we understand enough about the causes [of health inequity] to do something about it. So if they are potentially remediable, and we think we understand something about how to do it, the fact that we’re not doing it is unfair and it’s wrong.
Now, I would like to appeal to every human being along those grounds, regardless of which political party she or he belongs to.
Now, if a politician says, oh yes you think that - but I’ve got to balance all sorts of pressures. Businesses like to grow and there’s the environment and there’s this and that. Well, sure, I’m not the politician, but I think health is of key importance to every single individual. And if a politician is implicitly saying that other things are more important than health then come out and say it, whether he or she is on the left or the right or central or whatever they are. Come out and say ‘I think these other priorities that I have are more important than the health of the population’.
So I’m not political, but let the argument speak for itself and let’s get everybody motivated to push this line.
>RHN: Let me ask about the evidence you’re gathering, because here at IUHPE you did present some very striking evidence, and with a good deal of flair and political sensitivity if I may so, although you say you’re not a politician. But are you collecting brand new evidence, or are you pulling together existing evidence, in such a way as to make a more effective argument?
MM: Largely we’re pulling evidence together. If you’d asked me three years ago, ‘what do you mean by evidence?’, I would have said oh, the sort of things that get published in The Lancet or Nature, that’s what evidence is. Things that get peer reviewed by scientific colleagues and pass a randomised control trial. It could be some sort of experiment or an observational study of high scientific standard.
But I’ve had to change that view.
>RHN: What sort of evidence do you mean? Real stories? Personal action?
MM: Case studies. Examples. I’ve had this argument with the ‘real evidence’ people who say ‘it may be very moving but that doesn’t count as evidence’. Well, OK, then we may as well sit on our hands, because let’s ask what sort of evidence is there from Africa? And the answer is not much.
>RHN: But there is a mountain of stories.
MM: Well, the reason we have commissioners and knowledge networks is to deliberate, and pass judgement, so not to accept uncritically all these stories. So we can say, in our judgement what do we think we could recommend? So I’ve had to take a more broadminded approach to what we consider to be evidence.
>RHN: Personally, you’re in an extraordinary position now; you appear to have a great deal of freedom to find out what is and what is not the case. You’re not politically trapped as the leaders of some organisations are - even at the WHO, which is a governmental organisation, although they do their best. What do you feel about this? What brought you here? How does the responsibility weigh on your shoulders as an individual?
MM: Not for the first time in my life I find myself at the head of something wondering slightly how I got there. It doesn’t feel to me like I aimed for it. I once sat a rather posh dinner and a person sitting opposite me leant over and said conspiratorially, do you know the thing about life? I said, no, what? He said one thing leads to another. So that’s in a way what it feels like.
>RHN: OK, but you’re being very modest. This grew out of a certain perspective that you have in medicine and health.
MM: Well, it was an intersection of a set of beliefs and values, and the data and the evidence. As a young doctor I was aware from the patients that I used to see that their social background, their culture, the circumstances in which they lived, was clearly having an impact on their health. It was just obvious.
But in the way we practice medicine we screen all that out, and you just say ‘take this mixture’ and ‘have this treatment’, ‘come into hospital’, ‘go home’ or whatever.
So the reason that I went into epidemiology and public health was that I was interested in research [into this question]. In the end I was an intellectual. I wanted to do research that studied how people’s social environment affected their health.
But I didn’t have initially a formulated view about inequalities in health. I couldn’t have articulated my statements about injustice and so on when I started doing research.
Then I started with the Whitehall study [which showed a tripling or mortality among lower grades of civil servant – see READ ON]. In fact, initially I started looking at migrants and seeing how when Japanese migrated across the Pacific the rates of heart disease went up. And stroke went the other way. This was the Ni-Hon-San study. It was clear that environment was playing a role and I did my PhD studying aspects of culture that might have been protective.
When I came back to Britain I started working on the Whitehall study and I looked at people’s employment, and that showed this social gradient, which I’d never thought about until I saw the data. That’s what I mean about making an intersection between values and ideas and the data. It was that data, that social gradient, that had me exercised for the last thirty years.
We’re still doing research trying to uncover the reasons, but at some point you say well, could we make a difference? Could we actually apply any of this? So I’d like to pretend I’d spent my life with a passion to improve the world it’s not quite like that. I had real passion as a scientist and investigator to understand things but I always had in mind the idea that we wanted to understand things in order to do something about it. But I didn’t start as a man with a mission.
>RHN: What do you hope for from the Commission’s report? Because so many reports, take the Brundtland report for example, end up on the shelf. They have an impact perhaps in intellectual circles, but do they actually change anything? That’s the thing that one fears so much with all of these great studies.
MM: Well, of course, and that’s what I worry about all the time. The difficulty in formulating the answer to your question is knowing what success would look like. The Brundtland report is actually an interesting example. There is in Britain a sustainable development commission. It wouldn’t be too difficult to trace the intellectual lineage of that back to the Brundtland commission. It actually had a big impact, sustainable development and everybody’s talking about it, the Rio Conference, Kyoto.
>RHN: It didn’t change the world instantly, but it began a movement.
MM: It began a movement. It’s too much, to change the world. Invading Iraq might have changed the world instantly for the worse, but otherwise things don’t change the world instantly. That’s too much to hope for. But I would say the intellectual lineage and the impact of the Brundtland report on sustainable development has been enormous.
>RHN: So you’d like to see something like that out of the Commission on Social Determinants of Health?
MM: Gosh, if that happened I would be over the Moon!
>RHN: Well, let’s hope it does. Meanwhile are you able to give us an indication of any of your likely conclusions?
MM: The Commission hasn’t concluded yet, but we produced a book for the European office of WHO called The Solid Facts, which was translated into 24 languages across Europe and into Japanese. There we summarised the evidence on social determinants of health under ten headings. And of course, some of that we’re considering in the Commission on a global scale.
In The Solid Facts we said that the social gradient in health indicates that social and environmental conditions are important. We said that early child development and education is crucial. We said that stress causes disease. We talked about the importance of healthy work, about social supports, social exclusion. And we talked about addiction to alcohol, tobacco and drugs, being influenced by the social environment.
We said healthy food is a political issue, and that transport is a health issue. And there’s one other thing. We didn’t say anything about housing - but certainly we see neighbourhoods as important. And we’ve published a book giving the evidence: Social Determinants of Health [2 nd edition 2005, see READ ON].
The purpose of The Solid Facts was to summarise the scientific evidence, but to package it in a way that would be useful for policy makers - and in a way that’s what the Commission is doing.
But I’m now taking a further step and saying it’s not enough just to summarise the evidence in a way that policy makers can use. I’m saying let’s try and get some countries to take it up now. Let’s try to get WHO to take it on board. Let’s see if the World Bank could be interested in this. Let’s try and get active. Let’s get civil society engaged, whereas The Solid Facts was just a way of summarising.
Nevertheless it hit a responsive chord. It was WHO European Office’s far and away bestseller. In the first nine months after we published the second edition it was downloaded from the web 220 000 times. Not just hits, but downloaded.
>RHN: May I make one challenge on the evidence? In social studies it’s quite often the case that you get more or less the result you expected. And it’s most striking when you discover something that you didn’t expect, that is quite surprising. Would you identify anything that surprised you in your collection of material?
MM: Well, the social gradient in health in the Whitehall study. That was just a complete shock. When I started looking at it, I like everybody else thought that high status people had more heart disease and poor people got sick from other things. And it just wasn’t correct…. And why would people second from the top have more illness than those at the top?
…We asked could the higher rate of heart disease in people of lower status be attributable to less diagnosis and treatment? But [as a result of the British National Health Service] the answer was no, it can’t be. We looked at our civil servants and what we found was that the lower you were in the employment hierarchy the more investigation you got for heart disease. And the more likely you were to get treatment for heart disease.
In fact, that increased rate of investigation and treatment was more or less in proportion to the increased rate of heart disease. So it looked like people were being investigated and treated for heart disease pretty well independently of whether they were at the top of the civil service or the bottom.
You’d say the people second from top are not in depravation, [but they suffered more heart disease]. In my book I ask the question, why should living in a three bedroom house with a bathroom be worse for your health than living in a five bedroom house with two bathrooms? Nobody thinks that the number of bedrooms or bathrooms are somehow physically related to health.
>RHN: Do we actually have a measured answer to that, or simply a hypothesis?
MM: Well, we’ve got evidence. The degree of control people have over their working lives has strong relation to risk of heart disease. It’s related to the metabolic syndrome, insulin resistance. And we’ve got evidence on the activation of stress pathways of the hypothalamic pituitary adrenal axis.
>RHN: And there is so much lack of control over lives, particularly in developing countries!
MM: My own study showed the people’s lack of control in the work environment led to increased risk of heart disease, mental illness, musculoskeletal disorders, sickness and absence.
And then I started to think about it more, and think about control over lives, and then there were people talking about empowerment. And so I latched onto that, and realised that that’s consistent with what had been coming out of my own research programme.
>RHN: Of course everyone can’t be completely equal.
MM: No, absolutely not.
>RHN: So how do you restructure society so that there’s a greater deal of empowerment and control for everyone, all the way through the system?
MM: Well, some of it’s illusory and some of it isn’t. For example, there was an international study of the automobile industry. The productivity of Japanese car firms is about double the American and European. And Japanese-managed firms in Britain are more productive than British managed firms. So it’s not the Japanese workers - it’s the way they organise it. There were three striking features of the Japanese car plants: one was the amount of training people had before they did the job, the second was that job rotation was greater, and the third was the employee’s ability to make suggestions and have input.
>RHN: One thinks of the Japanese companies of being very hierarchical.
MM: Well they are, but the question is, what are the consequences of those hierarchies? And the consequences are less severe in terms of how much control you have over the job. For example, my hypothesis - from going to Japan and visiting firms, from watching people in [Japanese] academic departments, is that the low status worker has more involvement in the job, more commitment to the job, and feels more a part of the job than the low status worker in Britain or America. And so that’s part of what I mean by control. It doesn’t mean that you’re the managing director, but you feel that you’re not doing things that are totally stupid, or despite your best interests or your judgment.
>RHN: That everyone matters?
MM: Well, that everyone matters. It’s partly politeness to foreigners I suppose, but walking through a factory in Japan, somebody got up from assembling microprocessors or whatever they were doing, sprinted across the floor and picked up something that one of our party had dropped and handed it to them. And then goes sprinting back to the desk and goes on with the assembling. It seems to me that’s a different sort of assembly plant than the ones we’re used to.
Now, you may say that’s not a high degree of control, but it’s what it conveyed to me. And I say this is a hypothesis. It’s not evidence of the Nature scientific journal type evidence, just observing people with more engagement, more involvement and feeling like they belong. More and longer-term observers of Japan’s industrial relations would suggest that that’s the way industrial relations are carried on in Japan.
>RHN: I must say one more thing. There are immense cultural differences between countries, which are historically grounded, possibly even genetically grounded in some cases. When as a Briton one visits North America, particularly the USA, it’s another world. And the behaviour and attitude in all these countries is very difficult to think of changing. I don’t see how you could make England a Japan, for example. Or Japan a Latin Mexico. Isn’t there a limit to what you can learn from each other?
MM: That’s right, but our evidence suggests that people who report themselves to have less control at work have greater risk of heart disease. We don’t have to travel to the Japanese islands to see how they do it.
>RHN: We could do it.
MM: We could say how could we reorganise? Now, what I’m suggesting is the Japanese experience would be consistent with saying that’s actually quite good for the health of workers to have more control. And just possibly for the productivity for the firm as well. So if that were true, it’s in everybody’s interests to do things differently.
>RHN: Even the neo-liberals should jump up and say yes.
MM: Well, they are. I got the interest of management in the British Civil Service when I showed them the sickness absence rates. It’s a gradient. There are six-fold higher absences rates at the bottom of the hierarchy than the top. And I said if people aren’t coming to work maybe when they are at work they’re not very productive either. And surely it must be in your interests to get those absence rates down.
So I approached it from a different angle. The Trades Unions would say we’ve got strong management who are trying to take a big stick and blame the workers for the absence. But I approached it again in an apolitical way, saying everybody surely is concerned with the absence rate. Whether people were off work sick because they hated their work, or they’re off work sick because they’re sick, either way surely you must be interested.
The Unions should be interested because the jobs are so awful that people don’t want to come and do them, and/or they’re getting sick, and management should be interested, because people aren’t doing their jobs. Whether because they hate them or because they’re sick it almost doesn’t matter, surely it must be in everybody’s interests to get the absence rates down.
And so it doesn’t take a big stick to beat people with to ask, how could we improve working conditions so people are more motivated to be at work?