New thrust needed to tackle health inequalities globally says UCL scientist

UCL public health scientist, Professor Sir Michael Marmot, writes in a paper published in the Lancet journal on 18th March 2005 that a major new thrust is needed internationally to tackle health inequalities. Professor Marmot, Director of UCL’s International

Centre for Health & Society, will chair the Commission on Social Determinants of Health launched by the World Health Organisation on Friday 18th March bringing together scientists and policy-makers to help reverse the negative impact of social policy on ill-health.

Writing in the Lancet paper, Professor Marmot said: “To reduce inequalities in health across the world there is need for a third major thrust that is complementary to development of health systems and relief of poverty: to take action on the social determinants of health. Such action will include relief of poverty but it will have the broader aim of improving the circumstances in which people live and work.”

The Lancet paper is the first produced by Professor Michael Marmot in his role as Chair of the Commission. It sets out why the health impact of social policy must be taken seriously by governments worldwide and underlines the need for understanding about how social policy affects health (the social determinants of health) globally. There still isn’t any solid understanding of why a richer country isn’t always a healthier one and what social policies might impact on health, argues Marmot.

The Commission will set out guidelines for governments and policy-makers on what changes can be made to reverse high mortality rates and ill-health in countries across the world. Professor Marmot believes that better working conditions have a huge impact on mortality rates, as does education. It isn’t always health policy that impacts on the health of a nation.

Key facts set out in Professor Marmot’s paper include:

• Life expectancy at birth ranges from 34 in Sierra Leone to 81.9 in Japan.
• Differences in adult mortality among countries are large and growing – The probability of a man dying between 15 and 60 is 8.3% in Sweden, 82.1% in Zimbabwe and 46.4 % in Russia.
• Of the 45 million deaths among adults aged 15 years and over in 2002, 32 million were due to non-communicable disease and a further 4.5 million to violent causes.
• There is little correlation between gross national product (GNP) per person and life expectancy.

Greece for example, with GNP at purchasing power parities of just more than $17,000, has life expectancy of 78.1 years; the USA, with GNP of more than $34,000, has life expectancy of 76.9 years. Costa Rica and Cuba stand out as countries with GNPs less than $10,000 and yet life expectancies of 77.9 and 76.5 years.

The paper also illustrates how some governments are rising to the challenge:

• In Sweden, the new strategy for public health is “to create social conditions that will ensure good health for the entire population.” Of 11 policy domains, five relate to social determinants: participation in society, economic and social security, conditions in childhood and adolescence, healthier working life, and environment and products. These are in addition to health promoting medical care and the usual health behaviours.
• ‘Familias en Accion’ in Colombia transfers cash to poor families. To qualify, families must ensure their children receive preventive health care, enrol in school, and attend classes. The results are encouraging: favourable growth of children and fewer episodes of diarrhoea. The Oportunidades programme in Mexico had somewhat similar aims with similarly encouraging results.

Professor Marmot concluded: “International policies have not been pursued as if they had people’s basic needs in mind. (….) Recognising the health effects of poverty is one thing. Taking action to relieve its effects entails a richer understanding of the health effects of social and economic policies.

“The Commission will have one basic dogma: policies that harm human health need to be identified and, where possible, changed.”