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.
