Wednesday, 12 November 2014

The Social Movement is Alive

Without missing a beat, or even slowing down, the man said: “42nd street that way, (right arm pointing), 41st that way, (left arm).” I smiled intermittently for the rest of the day. I liked to think that this was a typical New York interaction, brisk, business-like but good-natured and well intentioned. My Samaritan, in a flash, and before I needed to say anything, diagnosed that I had emerged blinking and disoriented from the 42nd subway station into one of the ornate corridors of Grand Central Station, looking for inspiration. Equally quickly, no fuss, he solved it. Gratefully, I headed south.

Solving the NY subway, and eschewing taxis, was a means not an end. The ends were engaging first with the New York City Commission of Health and Mental Hygiene (quaint name), then with the New York Academy of Medicine – each headed by an impressive woman.

The Mayor of New York, Bill de Blasio, has social justice and equity at the heart of his concerns. This seems a good moment for New York to get active on social determinants of health. The Health Commissioner, Mary Bassett, had invited to me have lunch with her and fifteen or so of her senior staff, and then give a talk on ‘implementing the Marmot Review’ to those and another hundred staff. There is enthusiasm there. The one doctor in New York who contracted Ebola after his work with MSF in West Africa has diverted the Commissioner and staff in a major way, given the public fear of the issue. Their handling of the issue seems to have gone well. I did wonder, though, if some part of the tens of millions of dollars that New York spent on Ebola had been spent in West Africa…

City level of government may well be the most appropriate level for action on social determinants of health in the US, given the policy immobility of Washington. I was in New York the day after the mid-term elections revealed that with a Democratic President, and Republicans in control of the Senate and the House, who knew what would happen next at Federal level. There is real interest in the NY Health Commission in working across the organs of City government on social determinants of health. I showed them the work we have been doing on monitoring Social Determinants of Health and health inequalities. If London can do it, why not New York?
To the New York Academy of Medicine (to receive a public health award) and to, I hope, engage them as partners in potential activities with New York.

I reminded the audience at New York Academy of Medicine that when we launched the CSDH we said we wanted to foster a social movement. The number of people who said that the CSDH report, Closing the Gap, was influencing their work, suggested that the social movement is alive and well. The Acting Commissioner of Health for the State of New York – as distinct from the City – Howard Zucker, says he keeps a copy of the report on his desk.

Unrelated to social movements, a spare hour spent in the Frick Collection in New York is a revelation. It has a small, but astonishing collection: a Rembrandt self-portrait – one of the merciless self-examinations of his later years; three Vermeers; a Titian; Holbeins; two Turners; a couple of Constables; and a whole slew of Gainsboroughs. The next day, by contrast, between day meetings and the evening occasion at NYAM, I managed an hour at the Neue Galerie, with its fine collection of Gustav Klimt and Egon Schiele. Schiele, particularly captures what an edgy time that was to be in Vienna, early 1900s, soon before the whole empire came crashing down. Schiele and his wife both died, within three days of each other, in the pandemic influenza in 1918.

Tuesday, 11 November 2014

"In Sweden we don't do VIP..."

But they do a lot else. Perhaps no trappings, but I have no complaints. What they showed me was gift enough. Goteborg is the third of the three Swedish cities/regions – the others are Malmo and Linkoping – that are doing reviews of social determinants of health. Or, as they put it, Swedish Marmot Reviews. It felt like we were having a conversation.

Apparently at the airport, there is a sign promoting the city:

Goteborg, growth.

One of the local hosts proposed a new sign, sadly not adopted:

Goteborg: reading to children.

Another said that they had recently been to Birmingham on a fact-finding mission, having heard me say, a few years ago, how Birmingham (England) narrowed the gap in early child development between Birmingham and the English average. They were told in Birmingham that the special programmes on Early Child Development were no longer being supported. Disappointing.

The leitmotif of this Goteborg activity is inclusion: 1100 people, mainly employees of the City of Goteborg, came to this conference on socially sustainable Goteborg. I have been to meetings of various kinds in London, but never 1100 people engaging with how to make London a more sustainable place. Per capita, to match Goteborg, such a London meeting would have to have been 11,000.  The day after my visit, 400 of these 1100 were to sit down to work together to plan a more socially sustainable Goteborg, with health equity and sustainable development at its heart.

One of the gifts they gave me was to take me on a quick trip of the city, accompanied by three expert employees of the city. Slightly uncomfortably, I was fitted with a microphone and accompanied by a cameraman. They wanted to capture my reactions (not including post prandial afternoon drowsiness, I hope.) Goteborg “boasts” a nine year gap in life expectancy between small areas. What might that look like on the ground? What I didn’t “see”, but they told me, is that 22% of the population is foreign born, with another 13% or so children of migrants. Sweden had a programme to build a million new homes in the 1960s. In Goteborg, some of these were built in outlying communities that are rather cut off from the city. They are heavily populated by immigrants. These are ‘slums’ done by the Swedes. Apparently well-built, rather neat, five or so storey-blocks of flats, landscaped, no graffiti, no broken glass, but soulless and isolated, cut off from the Central City.

Perhaps linked to this isolation, one of the questions I was asked at the conference was what might they be doing about the fact that the 1100 people attending, overwhelmingly, were white. My response was that I wouldn’t start from here. If immigrant communities were cut off from the main stream, geographically, it was perhaps no surprise that they were underrepresented socially.

Even egalitarian Sweden has inequality issues with which they must grapple. But they are, grappling. Particularly, they liked our European slogan, which we adopted from Swedes: “Do something, do more, do better.” I think it highly likely they are going to do better. I was invited to come back in three years and see.

Tuesday, 21 October 2014

Singing the same song...

... But now others are singing with you, said a WHO official.

I had just addressed a Ministerial meeting of the WHO Eastern Mediterranean Regional Committee, here in Tunis. The Regional Director of EMRO, Ala Alwan, has taken the initiative to put social determinants of health (SDH) on the agenda for EMRO. In introducing the session this morning he reminded Ministers of the five priorities for the Region: health systems strengthening towards universal coverage; non-communicable diseases; communicable diseases, particularly health security; maternal and child health; emergency preparedness and response. He said that each of these require SDH.

I had a few minutes to give it my best.

When we published Closing the Gap, the CSDH Report, in 2008, I came to the EMRO Regional Committee to present the report. The response was tepid. This time the response was summed up by the WHO official I quoted above. She said that she heard me speak before at WHO Geneva, you may be singing the same song, she said, but now others are singing with you.

We had a good response from the Ministers present. My response underlined the points they made and allowed me to emphasise a few things:

  • Haven't we known about SDH since the 1970's? asked a minister. Yes, it was in Alma Ata 1978, but was ignored. WE had the Washington consensus, IMF structural adjustment, but not SDH. Our knowledge on SDH was not acted on.
  • We need evidence and politics. You do the politics, Ministers; we'll do the evidence. We need to work together.
  • How will we deal with high risk groups? Proportionate Universalism (sorry interpreters) - universalist policies with effort proportionate to need.
  • Need commitment of the centre of government, PM or President, but also need local action.
  • Related: need to take the evidence and adapt it to national and local conditions.
  • Thank you for not forgetting Mental Health.
  • Taking action on SDH is especially challenging in countries torn by conflict. Urgent task to work out how to go forward.
Ala Alwan told the Regional Committee he wanted their approval to work on SDH over the coming year which he proposes to do with us, IHE. I think he got it. He seems pleased.

Friday, 23 May 2014

Peto and Me

Is it possible that Richard Peto and I are really the same person or, at least, indistinguishable? I think that the social and economic circumstances that shape people’s lives shape their health. Richard thinks it is smoking and medical care. I think that the social disruption and disempowerment that characterised the Soviet Union and its breakup led to disastrous levels of health. He thinks it’s alcohol. I think he is a great scientist with a passion to improve the public health. And he? He thinks I am worth educating where I have it wrong, and I have my own passion for improving public health. When the opportunity arises he comes to my lectures, and rarely fails to engage with me. I have never had a conversation with him, or heard him lecture, without learning something and/or being provoked, stimulated and challenged. We both stick close to the evidence but when it comes to how we see the world, we are clearly distinguishable.

At least that’s what I thought. I was checking in for a flight from Bergen in Norway, returning to the UK, when there was Richard Peto right behind me, checking in for the same flight. Probability of that? Out of the blue? Obviously 100% because it happened. But it tickled my fancy that even though Bergen has four million passengers a year, it must be a tad unlikely that Richard Peto and I, without prior planning, or being in Bergen for the same reason, should turn up for the very same flight. We had met in Poznan in Poland but then there was a good reason: we were invited to the same EC meeting. But Bergen?

I had my boarding pass on my smart phone. Richard had a paper pass. As we were going through security, the official called us back: “you have the same seat number”, she said.

“It’s OK”, said I, “we’re friends, we can share a seat.” Richard seemed doubtful as to at least some parts of that proposition. The official then looked at my electronic boarding pass and Richard’s paper one and she said:

“not only do you have the same seat you have the same name, Michael Marmot”.

It was then that I got the giggles. In some countries I probably would have been arrested for giggling going through security. Not Norway. The very idea that people could not distinguish Richard and me, the one from the other, was such a hoot. Not a view shared by colleagues in public health, I think. I was still chuckling when Richard returned with a “Peto” boarding pass for the seat next to mine. Were the gods of probability having fun with us? Same small Norwegian city, same day, same flight, same boarding pass, and now seats next to each other? What did the BA computer know about the identities of Richard and me that had hitherto escaped us?

On the flight, Richard and I pored over data and arguments about public health. At the end of a couple of hours of this, I commented: Richard, we are in some danger of having a meeting of the minds. 
We agreed:

  •          That universal health coverage is far too limited to be the one health goal in the sustainable development goals that will replace the MDGs post-2015
  •          That a health goal should consider health, not just health care. I, of course, would want it to have an equity dimension. Not a priority for Richard.
  •          That alcohol played a major role in fluctuations in mortality among younger men in Russia, ages 15-55 – less so at older ages. The question of why young men should be killing themselves with drink – the causes of the causes – remains highly relevant. Would it explain the widening social gap in life expectancy?
  •          The decline in smoking related deaths in Britain is truly impressive. But so, too, is the remarkable decline in deaths not related to smoking. We differed as to where to look for explanations. Typically, I wanted to look upstream, he further downstream.
  •          That people die of absolute risk not relative risk. Absolute risk is more important for public health decisions.

We also traded accounts of what we had been reading. Richard had been much moved by Vassily Grossman’s heart breaking memoir of retaining his faith despite imprisonment in the former Soviet Union. As my wife read it last summer, and was similarly moved, I got daily bulletins. I am reading Stefan Zweig’s The World of Yesterday, his autobiographical memoir of growing up in the rich cultural and intellectual environment of Vienna in the last days of the Austro-Hungarian Empire, then his dislocation and exile. The book was completed just before his suicide in Brazil in 1942.

Thanks to Richard, I now have a photo on my iPad from the Hubble telescope of what galaxies looked like in the early universe soon after the big bang, 13.8 billion years ago, showing remarkable similarities to computer simulations of these same galaxies. I hadn’t known I needed that but it was an unexpected treat.

Back in London, I explained to a younger colleague that I had intended to read his paper on the ‘plane, but told him of my discussions with Richard as alibi. My colleague’s comment: how wonderful that two people of integrity with respect for the evidence and each other should spend hours discussing the implications for public health. Good point.

Political? Moi?

(Report from Norkopping, Sweden 7 May 2014)

It was put to me in Norkopping that the word among Swedish colleagues was that I had become more political. One of the Swedes said she remembered a talk I gave in Zagreb in 2008 – such joy! she listened – and that I had raised a disapproving eyebrow when a member of the audience said that she was a former Minister of Health in Norway, and congratulated me on my fine political talk. Was I uncomfortable because she said my talk was political?

I suppose I harboured the fiction that I was simply reporting the facts. To be sure, I was doing my best to present them in persuasive fashion. But I studiously avoided making party political statements. One Swedish public health person in Norkopping said that does not make your talks apolitical. I countered that if government policy is making child poverty worse, surely it is our responsibility to point that out, and draw the conclusion that, other things being equal, it will increase inequalities in early child development, and have an adverse impact on health inequalities. I argued in Norkopping that that is reporting the facts. My interlocutor called that political.

In the US, when addressing the American Public Health Association, I showed them the figure that after taxes and transfers, child poverty in the US was higher than in Latvia. I then said: Republicans, Democrats, I couldn’t care less, this is your children’s lives that are being damaged. I challenged my audience: you live in a democracy, this must be the level of child poverty that you want, otherwise you would elect a government that would do something different. Was that political?

I would like to think that whatever the complexion of the government we would be active in showing the relevant facts. Under the Labour Government in Britain, I led a review that reported that after ten years of action health inequalities had not narrowed. It was not comfortable reading for the government, but it was important to report it. We need to do have the same responsibility to report what is happening whatever the complexion of the government.

A Tale of Two Enthusiasms

Norkopping, Sweden 7 May 2014.

Two medical students wrote to me to say that they heard some WHO people say: Social Determinants? It is everything and nothing. My thought: Ah! That familiar world-weary cynicism, makes me feel all is normal with the world. Why be enthusiastic when you could use your cynicism to justify business as usual, or worse.

 By contrast, I have just been to Sweden – the second of several planned trips to Nordic countries this year. It was put to me by a Swedish colleague that we, the Marmot Review team, have become a brand in Sweden, not to mention enthusiasm for social determinants in other Nordic countries. Of course, one could argue that, of any group of countries, the Nordic countries are least in need. They are already doing it, and have relatively narrow health inequalities. Still, our conclusion at the end of the European Review was: do something, do more, do better. The Swedes want to do better.

We have had the Commission for a socially sustainable Malmo. There is a similar Commission taking place in VastGotaland, centred on Gothenberg. And I was in Norkopping, now, to speak at a meeting where the draft recommendations of the Ostergotland Commission were being aired. The conclusions continue the tradition of Closing the Gap with recommendations taking in the life course, and dealing with the causes of the causes. One special feature of the Ostergotland Commission is that it was not just set up by a political decision, but politicians are part of it. The aim is that having been part of the process, the local and regional politicians will be enthusiastic about implementation. Margareta Kristenson, Professor of Social Medicine at Linkoping University said that they considered two possibilities: not having the politicians involved would allow them to be more radical; having politicians as members might mean that they compromised on their conclusions. In the end, they decided that the advantage of having the people whose job would be implementation as part of the process was worth it. Looking at their draft recommendations, I would say that there is not too much evidence of compromise.

When we began the Commission on Social Determinants of Health, we said we wanted to foster a social movement. It is not being taken forward by cynics who say that ‘social determinants is everything and nothing’. As I waited for the Stockholm train at the Railway station at Kolmarden – no I hadn’t heard of it either, but its near Norkopping if that helps – I thought: could I have imagined in my wildest dreams that the social movement for health equity would be thriving in Kolmarden in Sweden.

Monday, 9 December 2013

Finns teach Finns rather well. Can they teach us?

All Finnish primary school children seem to look particularly fresh-faced, healthy, and actively engaged, a bit like their teachers, actually. The head teacher tells me (don’t the head teachers look young), the pupils at Ressu comprehensive school in Helsinki are not from particularly privileged backgrounds. The catchment area has three groups: academics, artists, and working class. The head teacher is polite, well informed, generous with her time, and very indulgent, given that I am not the first to make a pilgrimage to pray at the shrine of Finnish education. Ever since the PISA (Programme of International Student Assessment) showed Finland’s 15 year olds scoring particularly well compared to other European countries on standard tests, people have been wondering how they do it.

The UK made its reputation as being a brainy country – a great many discoveries, wonderful creative arts, brilliant universities. Despite that, we don’t do very well on PISA tests. The US is no slouch when it comes to innovations and skills, either. Why do the Finns do so brilliantly and the British and Americans so badly on internationally standardised tests? It’s quite a neat natural experiment because the UK and Finland do things so differently.

PISA scores in Finland (blue) and the UK (red), 2012[1].


The current approach in the UK to improving education for our children, is for the relevant minister to take central control: abolishing meddlesome local authority control of schools, setting the national curriculum, setting out a programme of school visits by inspectors to make sure they are up to scratch (the schools not the inspectors – might be interesting if it were the other way round), setting the criteria for what children should be able to achieve at various stages of their school career, examine at each of these stages, publish league tables of school performance to name and shame schools; abolish minimum qualifications for teachers in order to stimulate creativity. Oh, and freeze pay of teachers and criticize them as obstructing progress. Throw into the mix repeated discussions of whether abolishing grammar schools in favour of comprehensives didn’t rather lead to mediocrity. One last thing: make everything that goes wrong the fault of the last set of politicians to be in charge, whoever they were.

Finland has followed pretty much the obverse. There is a national curriculum but teachers have a great deal of autonomy in deciding what they teach; schools are under the control of local authorities; there are no tests to see if children have reached the relevant competency at various ages; there is one national test at the end of nine years of basic education in comprehensive schools but the results are not published, not fed back to pupils, and are used by the schools for statistical purposes so they can see how they are doing compared to other schools; all teachers have a master’s degree – unthinkable to have less; teaching is highly prized and teaching jobs are much sought; teacher training is research-based so teachers are encouraged to develop an enquiring approach to sort out solutions for children who are having difficulties.

The Finnish system is based not on managerial control of teachers but on teachers taking responsibility and students taking responsibility. The lack of emphasis on national exams represents not only a judgement that they are not necessary for high levels of performance, witness the high PISA scores, but they represent too narrow an approach to education. Finland is interested in educating future citizens who know how to work with people from diverse backgrounds, are educated in music and culture, have learnt traditional Finnish skills such as working with wood and textiles, and know how to cook.

I put two counter-hypotheses to my hosts – the head teacher and an official from the teachers’ union – one is that school reduces the effect of social disadvantage on educational performance. The other was that the school amplifies the effects of social advantage and disadvantage because the kids from more stimulating backgrounds are better placed to take advantage of what schools have to offer. No question in the teachers’ minds: Finnish comprehensive schools reduce the effect of social disadvantage on educational performance. Children who are having trouble get special attention, up to 30% of pupils. Equality is the most important word in Finnish education.

I suggested that if educational performance follows a bell-shaped curve, their special attention to the children in trouble may have reduced the prevalence of dumb-bells, but it may have reduced elite performance, fewer Nobels. (I am grateful to Helena Cronin for this terminology). They were not having any of that. The teachers work not only at helping the slower kids, but at challenging and extending the more able.

Might it not be the case that Finland’s good performance educationally may have less to do with schools and more to do with a relatively homogeneous population with low levels of child poverty? Typical academic’s question, wanting to isolate relevant variables. They chided me gently. You cannot separate the performance of the schools from the society and culture in which they are embedded. Schools are influenced by culture and society, and their mission is to contribute to society and culture in a positive way.

[1] Creating using the PISA ‘compare your country’ tool at