Monday 24 November 2014

We opened our minds. More important we opened our hearts.


 
Who do you imagine might say something like that? A social worker? A new age traveller? A cleric of one or other faith?
 
How about a Deputy Chief Fire Officer at West Midlands Fire Service. He was launching their report “Improving Lives to Save Lives – the role of West Midlands Fire Service in contributing to Marmot objectives”.
 
He said that they opened their minds to the Marmot Review, Fair Society Healthy Lives, and they opened their hearts to what they could do to help the poor and the needy in the communities they serve and of which they form an important part.
 
Their principles are Prevention, Protection, and Response. They have given an undertaking to respond within five minutes to a call for a fire. They spend between 6 and 10% of their time responding to fires. With training, shifts, and preparation that comes to about half their time. They have been innovative, creative, and committed in using the other half of their time to enhance the communities they serve. They quote us in pointing out that both health and fires follow the social gradient. Prevention of one is likely to help in preventing the other.

One important principle is Making Every Contact Count (MECC). A fire fighter goes into a home to check fire risks and talk about making the home safer. He sees hoarding, which contributes to risk, deprivation, isolation of an elderly person. He doesn’t then say, bad luck. He either works on the problem himself or works with colleagues to figure out who they should be working with. If the fire fighter has reason to suspect domestic violence, for example, he contacts the relevant experts.

They have ‘Marmot Ambassadors’ who are the front line staff whose role is acting on the six domains of recommendations in our Review. They call them the Marmot Six (sounds like a miscarriage of justice – one better than the Birmingham five).

Certainly, they inspired me.
 
We heard moving case studies. A fire in a house led to discovery of an octogenarian, ‘David’, who was burning rubbish in his living room to stay warm – his gas had been cut off. It took a fire officer three weeks of coaxing for David to let her in the door. Turns out he didn’t “do” anything. He didn’t watch TV because his electricity had been cut off 26 years ago. The Fire Officer brought him clothes, Xmas dinner, located his sister, and finally got him on needed medication and into sheltered accommodation. He was in a good deal better state than when they found him.

Each case study was more moving than the last. The fire officers give of their time and effort beyond the call of duty. They are worried that when someone discovers the inspiring work they are doing in preventing fires and improving health and well-being their funding will be cut. It would be a catastrophe if it were.

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.