Wednesday, 10 February 2016

Prince Mahidol and Social Determinants of Health - Speech

Prince Mahidol and Social Determinants of Health

Michael Marmot
UCL Institute of Health Equity

A recent report from Oxfam showed that just 62 billionaires have the same wealth as the poorest half of the global population. With a bit of a squeeze all 62 could fit into one London double-decker bus. Not so the other 3.6 billion people. Within most countries, too, inequalities of income and wealth have been growing. Should we care?

We should for three reasons. First, as Sir Tony Atkinson highlights in his recent book, Inequality, surveys find that the population in the US and Europe identify inequality as the number one problem in the world. People feel it that is just plain wrong, unfair, unjust.

Second, too much inequality threatens democratic legitimacy. If life’s chances are sequestered at the top, the rest of the population, rightly, feels that the governance of countries does not serves their needs. Similarly, if the global economic and political order serves the elite in some countries at the expense of the rest of the world, it is major challenge to our existing arrangements.

Third, highly unequal societies are associated with social evils such as ill-health and crime. Some place emphasis on the gini coefficient and argue that inequality damages the health of everybody. In my book, The Health Gap, I emphasise that the ill-health effect of inequality increases with increasing degrees of social disadvantage—the poor suffer the most.
Central to the ill-health effect of inequality is both poverty and relative disadvantage. Absolute poverty means disempowerment in an extreme way: having insufficient money to meet basic needs. Relative disadvantage is related to the social gradient in health. Relative disadvantage, too, is disempowering. Following Amartya Sen I argue that relative inequality deprives people of the freedom to lead a life they have reason to value.
One welcome response to such inequality in health is universal health coverage – the theme of this conference. It is appropriate that it should be held in Thailand, given the great strides that Thailand has made in implementing universal health coverage. It is much needed. I have just come from a meeting in Kolkata where colleagues point to the fact that India’s health care system not only is failing to meet people’s health needs, but out of pocket expenditures are emiserating people. A simple contrast between India and Thailand is instructive. In India, according to WHO figures, of all expenditure on health care private expenditure makes up 73%; of which 87% is out of pocket. That means 63% of all health care expenditure is out of pocket. In Thailand, by contrast, only 20% of health care expenditure is private of which 57% is out of pocket i.e 11% is out of pocket. Out of pocket is 63% in India and 11% in Thailand…and the pockets are shallower in India.
Something else is needed, too. When we began the WHO Commission on Social Determinants of Health we asked rhetorically: why treat people and send them back to the conditions that made them sick? It is the first line of my book, The Health Gap. We need action on the conditions in which people are born, grow, live, work, and age; and on inequities in power, money and resources that give rise to inequities in these conditions of daily life. We need action, in other words, on the social determinants of health. And when people get sick, they need access to health care free at the point of use.
It is an absolute pleasure to be the 2015 Prince Mahidol Award laureate for Public Health. A pleasure for me, personally, of course. But that is of little interest. The pleasure is that this prestigious award recognises the importance of social determinants of health. It validates the hardy band of brothers and sisters who have toiled in this field.
As many of you will know Prince Mahidol was selected by his father the King for a career in the Navy. The Prince thought he could serve his people better by studying medicine, than by pursuing a career in the military. At Harvard Prince Mahidol diverted from medicine to public health and only later finished his medical degree. It is appropriate that there are awards in both Medicine and Public Health. In the Prince Mahidol museum in Siriraj Hospital here in Bangkok is a quote attributed to Prince Mahidol:
“The primary function of men of health science including physicians is not to assume the office of salvagers of wrecks but rather of pilots preventing them”.
There should be no conflict between wishing to prevent the wrecks and dealing with the problems when they occur. I argue strongly with ministers of education, environment, occupation, social security and finance that what they do in their day job influences health. So powerful is the influence of societal action on health, that health equity is a good measure of how we are doing as a society.

Conversely, I seek to get the doctors involved. Somewhat surprisingly I find myself President of the World Medical Association. In that role I am engaging actively with medical societies in all regions of the world to explore what they and other health practitioners can do to address the social determinants of health. I am hugely encouraged.

I say to them that Universal health coverage is vital but it will not abolish inequalities in health. In The Health Gap, I write about Baltimore and London. In both cities we see twenty year gaps in male life expectancy. Twenty years! But there is a crucial difference. In the UK we have universal health coverage, free at the point of use. Further, all round the world, we see difference in health not just between rich and poor, but there is a social gradient: the more years of education, for example, the better the health.

I emphasise disempowerment. If we want to see disempowerment in action, look at the recent paper by Anne Case and Angus Deaton showing a rise in mortality in the US among non-Hispanic whites aged 45-54. And the conditions that carry people off? Poisonings due to drugs and alcohol, suicide, alcoholic liver diseases, and external causes of death. Disempowerment from the social determinants of health rather than lack of health insurance.

Looking more positively, empowerment of women through education has clearly made a major contribution to the reduction in infant and child mortality globally. But the revolution in child survival shows the importance of treatment.

I referred to my recent book, The Health Gap. I wanted to call the book The Organisation of Misery. As one or two of you may know, I have been quoting Pablo Neruda and inviting colleagues to:
Rise up with me…Against the organisation of misery

The publisher said I could not give a book such a title. No one would read it. I proffered The Organisation of Hope. Better, said the publisher, but a bit obtuse.

I compromised. I called the first chapter, The Organisation of Misery, and documented the dramatic inequalities in health within and between countries. I then bring together the evidence on what we can do through the life course to reduce avoidable inequalities in health – health inequities – starting with equity in early child development, education, working conditions and better conditions for older people. I call the last chapter The Organisation of Hope because I document examples from round the world that show we can make a difference.

When in Thailand for the National Health Assembly in December 2009 our Thai colleagues taught me about the triangle that moves the mountain. The three sides of the triangle are government, knowledge including academia, and the people. Get the three sides of the triangle aligned and we can move mountains.

Mahidol Experience (Michael and Alexi go to Bangkok)

As Princesses go… I cannot finish that sentence because, in truth, my experience of Royal Princesses is somewhat limited. I’ll simply have to imagine whether the Thai Royal Princess, Maha Chakri Sirindhorn, really is more modest and straightforward than others. Now that I think about it, I am not at all sure how many others there are. But this Thai Royal Family has a history, at least since Rama I in 1782.

Nor can I pretend that a black tie banquet at a Royal Palace, sitting next to her majesty, and preceded by an award ceremony where she presented me with Prince Mahidol Award for Public Health, was just another one of those things. Nor can I think it routine to sit with the Princess at coffee the next morning, and then walk with her around an exhibition to honour Prince Mahidol, her grandfather. Nor was it quite ordinary taking high tea with the Prime Minister, nor yet was dinner in my honour at the British Embassy in Bangkok and a reception at the US Embassy, and a dinner hosted by the Minister of Public Health, and lunches, and a private tour of the Royal Palace including the stupendous temple of the Emerald Buddha.

Nor, regrettably, can I take for granted the policeman on a motorbike with flashing red light that eased the passage of our royal limousine through Bangkok’s traffic – although I did ask if I could have one of those to take home with me. Nor is it the new normal to be met at the airport in the early hours of Sunday morning by a gracious royal emissary.

In fact the whole six days spent in Bangkok were simply quite extraordinary. To say that my wife and I were given the royal treatment hardly does justice to the whole experience. The gracious dinner at the Thai Medical Association with the whole council, and organised by former WMA President, Wonchat Subhatchaturas, set the tone for everything that was to follow.

At one of my many “impromptu” speeches – by the end of the week, I was expecting the unexpected calls to say a few words at lunches, dinners and press interviews – I reflected that this week of celebration was something really special: celebration of scholarship in the service of humanity. The Royal Princess, the prime minister and senior ministers, the brass bands, the medical students, doctors, nurses, deans and professors were all celebrating these awards. And the awards were for contributions to Medicine and Public Health. As I said in another of my unscripted remarks, one does not pursue research and then policy action to gain an award. The award is a celebration that comes after the fact. In my case, the fact that the award was for social determinants of health and health equity validates and gives succour to ‘we few, we happy few, we band of brothers’ (Henry V) who have toiled in this field.

What do you talk to a Princess about? Why, social determinants of health of course. What else is there? I led up to it.

In my three minutes address at the Royal Banquet, I commented on the inspiration provided by Prince Mahidol. He was told by his father that he would have a senior position in the Navy. He decided he could do more good for the people of Thailand by studying medicine than by working in the military. He took himself off to Harvard and while studying pre-medicine, ‘discovered’ public health and returned to Thailand with a diploma from MIT and Harvard. Subsequently he went back to Harvard to finish medicine.

At the banquet I was sitting between the princess and a gentleman in splendid formal jacket of Thai silk. It turned out he was the very model of modern major-general, a former head of the Thai military. I asked if what I had said about Prince Mahidol had offended. Not at all, he said, he agreed. I then filled his head with the importance of cross-government action on social determinants and health equity, and said that I would seek to convince the Princess that her government should set up a cross-government mechanism to take action forward. He said he agreed with that too and encouraged me to turn attention to Her Majesty. I did. She listened, adding observations along the way.

As we went into post-dinner coffee in yet another splendid room of the Palace, I told the Major-general that I had got half way there but I needed his help to get the rest of the way. At high tea with the PM, the next day, I continued the theme. Let’s see.

I laid out some of my thoughts about it in my ten minute ‘award-winner’s’ speech to the Prince Mahidol Award Conference – see separate entry.

Friday, 20 November 2015

Improving Society in Rural Taiwan


Taiwan has had dramatic improvements in health. In my view that betokens dramatic improvements in society, along with increased prosperity. A good society will find the route out of poverty as well as caring for those who are disadvantaged in other ways. One way to see this was to visit rural Ilan county, on the coast east of Taiwan.

Shu-Ti Chiou has many strings to her bow. She had been health commissioner for Ilan before moving to Taipei. Last year she was prevailed upon to run for mayor in Ilan. She didn’t win, but received campaign expenses proportional to the votes she achieved. She used the money to start a small foundation to promote better health in Ilan.

On a Saturday morning we were taken to Yutian elementary school, to be met by the charismatic head teacher. He was clad in cycling gear, because Shu-Ti’s foundation had a collection of school principles set an inspiring example by doing a prolonged cycling trip, ending up at the Eden Foundation Yilan school – see below.

Two highlights of the school. First, it might be in a poor rural area, but the head teacher was committed to using technology appropriately. Each child was issued with a tablet computer to use at school and home. It was an integral part of the classroom as well as forming a close link between school and home.

Second, after a tour of the lovely school building we had a tea break – no ordinary tea break. Two youngsters performed the Taiwan version of the tea ceremony.  I asked if it was modeled on the Japanese tea ceremony and was told firmly: no, the Japanese got it from the Chinese. It really is a wonderful interlude to a busy day. No dunking of a British Rail tea bag into a mug of boiling water and going back to your desk. The student laid out five cups for the four ‘guests’ and herself, then slowly, methodically, and with practiced movements went through the ritual: warming the receptacle – perhaps best described as a porcelain squat jug; putting tea leaves into it, pouring water on, then discarding immediately – apparently this removes dust from the tea, and perhaps some unpleasant taste; then pouring a new lot of water on the leaves; then filling the small cups – which of course are in the same style of porcelain as the jug. All this is accomplished in absolute silence which adds to the meditative quality of it. Fifteen minutes of this and not only have you had a refreshing tea but you feel calmer, more meditative.

Then onto the Yilan Branch of the Taiwan Fund for Families and Children. Children from disturbed families are brought into the place. If because of their disrupted backgrounds, they are doing badly in school, they will actually attend school on the premises. We were treated to a drumming display by a group of these children who were clearly committed to what they were doing. It is a lovely place. One special area, no shoes, colourful but calming, is where young people can go if they are feeling angry or upset; or where they go with a counsellor.

I asked, I would  wouldn’t I, if they had any measures of success or otherwise of their various activities. Probably not, but it certainly gives children a place to be, to have fun and/or meaningful activities, and to feel a little bit of love from the warm committed social workers in the place.

Last stop was the Eden Foundation Yilan School. It is for educationally subnormal children and young adults. As with our previous two stops, the overwhelming feeling was that of staff who cared. The head teachers arrived on their bicycles and put on a concert for the residents, who appeared most appreciative.

I don’t know how typical these three special places are of what goes on throughout the country, but if this is how the poor, the disturbed and the mentally subnormal are treated, then the country has a great deal going for it.

Doing Better in Taiwan


Politics? Yes, of course, politics. It is always there. But, we argue consistently that concern with health should trump concern with diplomatic political sensitivities. I said it at the World Medical Association General Medical Assembly in Moscow: whatever tensions there may be between Russia and other countries, we work together in the common cause of better health. And it is what I felt when we at the IHE were approached by the Health Promotion Department of the Taiwan government to write a report on how they could address persistent health inequities through action on the social determinants of health. Does that mean we take a view about the continued aggravation about China and Taiwan? Not at all. We would be happy to work with China as we are with Taiwan. (For the Eastern Mediterranean Region of WHO, I have been to Egypt, Morocco, Iran and Tunisia; and joined a meeting in Kuwait by Skype. For WHO Euro I have been to Israel. Health is a shared concern.)

When on a Friday morning, I found myself sharing a joke with President Ma of Taiwan – see photo – my concern was not with international diplomacy but to secure his agreement to whole of government approaches to social determinants of health and health equity. He and I signed a mock-up of the cover of our report for Taiwan.

If we take the ‘do something, do more, do better’ mantra to Taiwan, we would have to say, they are in the latter group. Taiwan has done remarkably well. Life expectancy for men is 77 and for women, 83. This would put them firmly in the European average. A huge improvement remarkably quickly. But health inequalities persist – seen in the social gradient in life expectancy and disability-free life expectancy.

The Director-General of the Health Promotion Administration of the Ministry of Health and Welfare, Shu-Ti Chou, is a charismatic figure – see third photo. Committed, perceptive, well-informed, and clearly loved and admired by her colleagues. I apologised for the depths of my ignorance of Chinese names, but I told her that her name reminded me of the two names in Bertold Brecht’s play, The Good Person of Szechuan. Shen Te was good, caring and generous. But people took advantage of her good nature. She invented an alter ego, Shui Ta, who displayed the more self-centred side of human nature to protect herself. Shu-Ti said that perhaps she embodied a bit of both, caring and concerned, empathetic and embodying better virtues but at the same time having the drive necessary to make progress.

As well as the publicly stated commitment from the President, there is a potentially viable mechanism in Taiwan for whole of government action on SDH: the Committee on Sustainable Development. This committee is chaired by the Prime Minister and has the sustainable development focus of environment, economy and social development. By getting health equity into the last of these three and linking it firmly to the other two, there is reall prospect of making progress.

We plan to work with Taiwan over the coming year as they seek to make progress.

Thursday, 12 November 2015

Harmony and Action in the Caribbean

A population made up of indigenous people, escaped African slaves, French, Spanish and English colonialists, Creoles (mix of Europeans and Africans), Javanese, East Indians, and then sprinklings of Jews, Chinese, Brazilians and a few others – what language do you imagine they might speak?

Why Dutch, of course. This is Suriname, now independent of the Netherlands. It wasn’t always a Dutch colony. In the 17th century the English got New Amsterdam from the Dutch and the Dutch got Suriname from the English. Who got the best of that deal? New Amsterdam, of course, became New York.

Check the map. Suriname is up there on the Caribbean coast of South America between French Guiana and (British) Guiana. It’s capital as every school child knows, well some do, is Paramaribo.

Suriname is special not only because it is the only Dutch-speaking country in South America but it has a population of just over 500,000 and vast swathes of pristine tropical forest. Like much of South America it has a chequered past. But it is now a democracy. I was there, at the invitation of PAHO (Pan American Health Organization), because the government of Suriname has taken on board the importance of social determinants of health and action through, Health in All Policies (HIAP).

Francoise Barten, who I met first at the People’s Health Assembly in Cuenca, Ecuador in 2005, was there to greet me on behalf of PAHO.

The government really are engaged. After a meeting with the Minister of Health I was hosted by the Speaker in the House of Assembly, the Parliament, and gave a lecture to the House on social determinants of health. The next day, at a big national meeting, especially big for a tiny country, the Vice-President, Minister of Foreign Affairs, Minister of Health and Speaker of the House were all there. I have been invited to give a keynote address before, with ministers on the platform. They usually give their speech and leave. A noble exception was the Swedish Minister of Health. This time the ministers all stayed at least for the morning session.

I was also hosted by the Suriname Medical Association and the Faculty of Medicine and gave a talk on The Health Gap.

Above: With First Lady of Suriname, Liliane Ferrier, and Guillermo Troya, PAHO Rep in Suriname

I met the first lady who is leading a country-wide initiative on early child development. We had a good meeting. The First Lady said that she was also the champion across government for HIAP. I told her that I think Suriname is showing the way on whole of government action on SDH. Impressive.

With the First Lady at our meeting was psychologist, Liliane Ferrier who had said to me publicly at the big meeting: I have been waiting for you in Suriname for 25 years!

A little insight into the country. The doctors gave me two books by a Surinamese novelist Cynthia
McCleod. McCleod? In Suriname? A little research revealed that her unmarried name was Ferrier and she was the daughter of a President of the country. Liliane is a Ferrier. Any relation? Yes. First cousin. The former President was her uncle. Liliane’s background included Jewish, Chinese, and a lot else besides, including time spent in the Netherlands.

There is great willingness and interest on the part of government to be active on social determinants of health. An important step is good documentation of the extent of inequalities in health and in the determinants of health.

We may well do some work with them in evaluation of their initiatives on early child development.

Wednesday, 21 October 2015

Dinner at World Medical Association General Medical Assembly - Moscow - October 2015

Odd topic for a blog perhaps

My heart is full. On inauguration as WMA President, my speech invited National Medical Associations and individual doctors to rise to the challenge of health equity. I talked inequality of social and economic conditions damaging health and said that, at our best, doctors flourished in the cause of social justice. That evening, as I wandered around at the informal dinner chatting to people, the representative from Trinidad and Tobago said to me: you look like you are ready to dance.

“Not dance,” I said, “I’m floating; floating on a sea of well-being”. The question had been whether doctors would think that a message of social determinants was relevant to them. Yet, so many of the representatives here in Moscow have expressed their enthusiasm. The Danish Medical Association says that it is about to release a policy report that will deal with social determinants of health. They said that they had a Danish Marmot Review – Finn Diderichsen’s report – but now the doctors want concrete policy development. The Bolivians wanted to know how I could help. Colombia, Mexico, Costa Rica, Uruguay, Brazil, Argentina, Chile, Nigeria, South Africa, Trinidad and Tobago – all expressing enthusiasm. CMAAO, the Asian Network, wants us to work together. Alabania, goes on.

The doctor from IPPNW had tears in his eyes because both in my inaugural address and at the informal dinner I had mentioned Bernard Lown. The first time was to quote his “never whisper in the presence of wrong”. The second was to say that working in the cause of health unites us, whatever the politics of our countries, or whether our leaders are locked in conflict. I cited the example of IPPNW and working for peace. At the height of the Cold War, two great cardiologists, Bernard Lown from the USA and Dr Chazov from USSR co-founded International Physicians for Prevention of Nuclear War. Building on their shining example, we should have a global movement of Doctors for Health Equity.

After the informal dinner a dozen doctors from Confemel, the Latin American network of Medical Associations, kidnapped me ‘just for five minutes’. At the end of a lively 55 minutes we celebrated our commitment with a little Tequila. I said that we were going to conduct a review of social determinants and health equity in the Americas and wanted to involve the Medical Associations. I in no way counted myself as knowledgeable about Latin America but in the last few years I had visited Brazil, Argentina, Uruguay, Chile, Peru, Colombia, Ecuador, Cuba, Costa Rica and Mexico, as well as the US and Canada. And next week I was going to Suriname. We agreed to explore how to work together and to meet in Buenos Aires in April, if not before.

My heart is full, and my diary overflowing.

I noted for our hosts from the Russian Medical Society, the importance of the great Russian authors for all of us. I said that in a recent profile in the BMJ, I had divided my life into three: before, during, and after reading Tolstoy’s War and Peace. I had a second reason for drawing attention to Tolstoy and that was Isaiah Berlin’s famous essay: The Hedgehog and the Fox. Berlin begins the essay by quoting the Greek poet Archilocus: the fox knows many things but the hedgehog knows one big thing. Berlin thought Dostoevsky was a hedgehog and Tolstoy a fox. Given my obsession with social determinants of health, was I a hedgehog? But in my book, The Health Gap, drawing on our various reports, I emphasise that improvement in health equity requires action through the life course from early child development through to older age. Action can also take place at the level of individuals, communities, governments local and national, and the planet. To keep up with the evidence on that array of possibilities, and changing when the evidence base changes, means being rather fox-like. A hedgehog with fox-like qualities is to follow in the tradition of Berlin’s estimation of Tolstoy’s view of history. Forgive this oversimplification, but Tolstoy, in his musings about theorise of history explores the question of how much influence the individual has, even Napoleon, as against the grand historical sweep. The question of free-will against determinism has resonance in public health. Are individuals the architects of their own poverty and ill-health? Or is it determined by stronger social conditions? It is a terrain worth re-visiting.

The hospitality of the Russian Medical Society and the experience of being in city whose dramatic history is embodied in its astonishingly varied architecture was a fitting backdrop for some big debates appropriate to the WMA.

Tuesday, 20 October 2015

Inaugural Address as WMA President

Inaugural Address as WMA President
Michael Marmot
16 September 2015

Honoured Guests, Colleagues,

In May 2011 Mary hanged herself. She was found in the yard of her grandparents’ house on a First Nations Reserve in the province of British Columbia in Canada. She was fourteen. She was a First Nations, aboriginal, Canadian.

Her story has particulars. All suicides do. She had been physically and emotionally abused at home and in her community, and possibly sexually abused. Her mother was mentally unstable and heard voices telling her to ‘snap’ her child’s head. Officials attributed the suicide to a dysfunctional child welfare system, and to the fact that no one took her complaints of abuse seriously or acted on them.

There is another way to look at Mary’s sadly foreshortened life, and that is to realise that though her personal tragedy was unique, there are many young aboriginal Canadians who experience similar tragedies. In fact, the aboriginal youth suicide rate in British Columbia is five times the average for all young Canadians. One cannot understand fully why Mary saw no way out without also asking why so many other young aboriginal people in British Columbia reached the same desperate point.

The starting point is poverty, bone-grinding poverty, low educational levels and high unemployment. But there were about 200 bands of aborigines in British Columbia, more or less all in poverty. Yet 90% of the adolescent suicides occurred in 12% of the bands. Why some and not others? The difference was empowerment of communities. Empowered communities participated in land claims; self-government; had control over educational, police and fire, and health services; and establishment of ‘cultural’ facilities. The results were clear: the greater the cultural continuity and community control over their destiny, the lower was the youth suicide rate. Poverty is bad but poverty is not destiny. Empowerment of communities can save lives. I draw similar lessons from studying the health of New Zealand Maoris, Indigenous Australians, Native Americans or indeed that of excluded groups elsewhere in the world.

In January 2010, Haiti’s earthquake wreaked havoc and 200,000 people died. Less than two months later a quake 500 times stronger hit Chile and the death toll was in the hundreds. Haiti was underprepared in every way imaginable. Chile was well prepared, with strict building codes, well-organised emergency responses and a long history of dealing with earthquakes. True, the epicentre of the Haitian earthquake was closer to population centres than that of the Chilean quake, but that was only part of the explanation for the different scale of devastation. What turns a natural phenomenon into a disaster is the nature of society. The number of people who died had more to do with Haiti’s lack of societal readiness and response than with the strength of the quake.

In 2011 the London borough of Tottenham broke out in urban riots. The precipitant was the killing of a black man by police. But, unacceptable as that is, it was not the underlying cause. Inequality was the culprit. I had been citing an area of Tottenham as having the worst male life expectancy in London – 18 years fewer than in the best-off area. All in one of the world’s premier global cities. London now has more high-end properties, a price tag more than $5million, than Manhattan, Hong Kong, Singapore or Sydney. It is not surprising that the riots broke out in the area with the worst health. Ill-health does not cause riots. Nor do riots cause ill-health – at least not directly. Relative deprivation causes both urban unrest and illhealth. Ninety per cent of young people arrested in the riots were not in employment, education or training.

Similarly, in Baltimore in the US. When a black man was killed in police custody riots broke out. Not uniformly across the city, but in the area with condemned houses, low levels of education and income and a twenty year disadvantage in life expectancy compared to the area with leafy opulence.

Inequality strains the binds of a cohesive society. In Baltimore, those binds snapped. The immediate effect is civil unrest. The longer term effects is health inequity.

These examples illustrate that the way we organise our affairs, at the community level or, indeed at the whole societal level, are matters of life and death. As doctors we cannot stand idly by while our patients suffer from the way our societies are organised. Inequality of social and economic conditions is at the heart of it.

There are three aspects of Mary’s tragedy worth emphasising. The first is the vital issue of violence to girls and to women. It can be fatal, both because it drives women to suicide and because they may be killed by their partners. Second, I emphasised empowerment of communities. But empowerment of individuals is also of vital importance. A key route to female empowerment, globally, is education. Evidence shows clearly: the greater the education of women the less the likelihood of being subject to domestic violence. Third is the importance of mental illness. Mental illness and substance use disorders constitute the number one cause of years spent with disability, globally. We cannot be concerned with health, globally and in our countries, and not be concerned with mental illness and substance use.

More generally we need to recognise the importance of the mind to health equity. The mind is the major gateway through which social determinants exert their effect on health. Recognizing the importance of the mind takes us back to early child development and what I have called: equity from the start.

In Aldous Huxley’s dystopia, Brave New World, there were five castes. The Alphas and Betas were allowed to develop normally. The Gammas, Deltas, and Epsilons were treated with chemicals to arrest their development intellectually and physically, progressively more affected from Gamma to Epsilon. The result: a neatly stratified society with intellectual function, and physical development, correlated with caste.

That was satire, wasn’t it? We would never, surely, tolerate a state of affairs that stratified people, then made it harder for the lower orders, but helped the higher orders, to reach their full potential. Were we to find a chemical in the water, or in food, that was damaging children’s growth and their brains worldwide, and thus their intellectual development and control of emotions, we would clamour for immediate action. Remove the chemical and allow all our children to flourish, not only the Alphas and Betas. Stop the injustice now.

Yet, unwittingly perhaps, we do tolerate such an unjust state of affairs with seemingly little clamour for change. The pollutant is called social disadvantage and it has profound effects on developing brains and limits children’s intellectual and social development. Note, the pollutant is not only poverty, but also social disadvantage. There is a clear social gradient in intellectual, social, and emotional development—the higher the social position of families the more do children flourish and the better they score on all development measures. This stratification in early child development, from Alpha to Epsilon, arises from inequality in social circumstances.

This social gradient in children’s possibility to fulfil their potential, in its turn, has a profound effect on children’s subsequent life chances. We see a social gradient in school performance and adolescent health; a gradient in the likelihood of being a 20 year old not in employment, education, or training; a gradient in stressful working conditions that damage mental and physical health; a gradient in the quality of communities where people live and work; in social conditions that affect older people; and, central to my concern, a social gradient in adult health. A causal thread runs through these stages of the life course from early childhood, through adulthood to older age and to inequalities in health. The best time to start addressing inequalities in health is with equity from the start. But intervention at any stage of the life course can make a difference. Relieving adult poverty, paying a living wage, reduction in fuel poverty, improving working conditions, improving neighbourhoods, and taking steps to reduce social isolation in older people can save lives.

The health gradient to which these life course influences give rise is dramatic. There is a cottage industry, taking subway rides in various cities and showing how life expectancy drops a year for each stop. I have referred to twenty year gaps in Baltimore and London; but the health differences between rich and poor, dramatic as they are, are only part of the problem. Commonly, people say to me: I am neither rich nor poor; what does any of this have to do with me? The evidence shows that there is a social gradient in health that runs from top to bottom of society. People in the middle have worse health than those above them in the social hierarchy, but better than those below. We calculated for England that if everyone enjoyed the same life expectancy as the top 10%, based on education, there would be 202,000 fewer deaths each year; over 500 a day.

One problem, then, is poverty. Another is inequality. Both damage health and lead to an unjust distribution of health.

I have spent my research life showing that the key determinants of health lie outside the health care system in the conditions in which people are born, grow, live, work and age; and inequities in power, money and resources that give rise to these inequities in conditions of daily life. Since the establishment of the WHO Commission on Social Determinants of Health in 2005, I have been using research knowledge to argue for policies on social determinants of health.

Yet here I am, humbled by assuming office as President of the World Medical Association. Is there not a contradiction? The World Medical Association, WMA, upholds the highest ethical standards of the practice of medicine. It speaks out fearlessly when the right of doctors to pursue their noble calling is threatened. As President, I want the WMA to use the same moral clarity to be active against the causes of ill-health and what I call the causes of the causes – the social determinants of health.

The opening sentence of my recent book, The Health Gap: The Challenge of an Unequal World, was: why treat people and send them back to the conditions that made them sick? No one is as concerned about health and disease as we in the medical and other health professions. It has been and will be my mission to encourage our concerns with the conditions that make people sick.

I am hugely encouraged already. My friends in the Canadian Medical Association conducted Town Hall meetings across Canada to engage the public in discussion on how the conditions of their lives related to their health. The Canadian Medical Association then took the initiative to suggest a meeting at BMA House in London. Twenty countries and 200 people asked to come, including our now-Chair of Council, Ardis Hoven, and then-president, Xavier Deau, and participated with enthusiasm. I apologise in advance: I already have more invitations from medical colleagues, enthusiastic for the health equity agenda, than I could possibly meet. We need a global social movement.

I have been arguing that we have the knowledge of what to do to act on social determinants and health equity; we have the means. We need to ensure that we have the will.
Do we really have the means? Consider. What do the following have in common?

48 million people of Tanzania
7 million people of Paraguay
2 million people of Latvia
top 25 US hedge fund managers

In 2013 each of these four groups had a total income of between $21 and 28 billion. Imagine with me something totally fanciful: that the 25 hedge fund managers gave up their income for one year. It would double the income of Tanzania. The hedge fund managers wouldn’t feel it, because they will earn an average of $1billion each the next year. I am not suggesting for a moment that we simply pass the cash to individual Tanzanians. But think of the clean water that could be piped, the schools that could be built, the nurses trained and employed.

There is a great deal of money sloshing about. Great inequality between countries stops the money being spent in ways that would benefit the poor and the needy.

Suppose, though, that there was reluctance to see ourselves as part of a global community. We would still have to address staggering levels of inequality of income and wealth within countries. Here is an even more fanciful thought. Suppose that the hedge fund managers of New York paid a third of their $24 billion income in tax – unlikely I know – that money could fund 80,000 New York schoolteachers. 80,000.

What has this to do with doctors? At the meeting of National Medical Associations that we held in London we heard inspiring examples of how doctors are already working with communities to deal with the social causes of ill-health. In India I was taken by medical colleagues to a tribal area in Gujarat where the doctors are not only treating people who, hitherto, had no access to health care, but are working with others in community development and education to improve the conditions of daily life for marginalised people. In Brazil, the social gradient in stunting of young children is becoming progressively flatter. In Bangladesh and Peru inequalities in child mortality are decreasing. I am excited by the interest generated in social determinants of health globally in every region of the world: South Africa, Zambia, Morocco, Colombia, Cuba, Costa Rica, Panama, Surinam, Taiwan, Sweden, Norway, Finland, Iceland and … I could go on.

Colleagues, we can make a difference to the causes of the causes of health equity, as part of the practice of medicine. There is another we way we can make a difference, too. I do not go 7 for long without quoting the great German pathologist, Rudolf Virchow, who said that “physicians are the natural attorneys of the poor”. We can, we do, we should speak up about inequity in social conditions that damage the health of the populations that we serve.

It means too, that we should recognise and be vocal about any societal trends that are likely to affect health equity: climate change, trade, financial crises.

I hold a Bernard Lown visiting professorship at Harvard. Bernard Lown, great cardiologist and co-founder of International Physicians for the Prevention of Nuclear War, said: never whisper in the presence of wrong. Already WMA speaks up in a loud voice about the highest ethical standards of our profession. We should not whisper at the gross inequities in the world that give rise to health inequities.

In fact, so close is the link between social conditions and health that, I argue, health equity is a good measure of social progress; much better than income growth. Senator Robert Kennedy in a famous speech criticised Gross National Product as a measure of social progress. He said:

the gross national product does not allow for the health of our children, the quality of their education or the joy of their play. It does not include the beauty of our poetry or the strength of our marriages, the intelligence of our public debate or the integrity of our public officials. It measures neither our wit nor our courage, neither our wisdom nor our learning, neither our compassion nor our devotion to our country, it measures everything in short, except that which makes life worthwhile.

Health and health equity are not only worthwhile in themselves but they reflect much else that makes life worthwhile: the freedom to lead lives we have reason to value.
As doctors, at our best, we flourish in the cause of social justice. There is a great deal of injustice in the world. Can we really be optimistic? Let me quote from Nobel Prize winning poet Seamus Heaney:

History says, don't hope
On this side of the grave.
But then, once in a lifetime
The longed-for tidal wave
Of justice can rise up,
And hope and history rhyme.

So hope for a great sea-change
On the far side of revenge.
Believe that further shore
Is reachable from here.
Believe in miracle
And cures and healing wells.

I have had much reason to praise our medical students at the IFMSA, and our junior doctors. In the spirit of Heaney I say to our younger colleagues: believe in miracle and cures and healing wells not just for our patients but for society, too.

If this sounds idealistic I remember the words of Halfdan Mahler, former Director-General of WHO, who said when we published the report of the Commission on Social Determinants of Health: remember, idealists are the realists in human progress.

I have another poet who has been my companion. When we launched the Commission on Social Determinants of Health in Santiago Chile I quoted Pablo Neruda. I did again at each report we have published and I do so again now. I invite you to:

Rise up with me…
Against the organisation of misery.