IARC 50th Anniversary Conference
Reducing inequalities in global health risk
Prof Sir Michael Marmot - UCL Institute of Health Equity, London, UK
There are huge inequalities in health between countries and inequalities in health within countries. Those systematic inequalities in health between social groups, which could be countries or socioeconomic groups within countries, those systematic inequalities between social groups that are judged to be avoidable by reasonable means and are not avoided are unfair, hence inequitable, hence inequity. So we are the Institute of Health Equity because we think that our challenge is to get the best evidence to reduce avoidable health inequalities globally.
What is the global picture regarding equality in cancer?
Let me talk just generally about health first, that we have something like a forty year gap in life expectancy between the worst off country and the best off, so it’s enormous and, of course, in low income countries a huge burden of communicable disease. But increasingly, even in the low income countries, there’s the double burden of non-communicable and communicable and in middle income countries non-communicable diseases predominate and cancer is a key part of those non-communicable diseases that it goes along with cardiovascular disease, cancer. So as communicable diseases decline we get increasing importance of cancer and other non-communicable diseases. Similarly within countries we see what I call the social gradient in disease. In other words, the higher the status the lower the mortality, the longer the life expectancy and that in general is true for most causes of death. So when we think about cancer specifically, lung cancer follows the social gradient – the lower the status the more likely of people to succumb to lung cancer. Stomach cancer follows the social gradient; there are some significant exceptions – breast cancer and malignant melanoma, leukaemia are significant exceptions – but overall the burden of cancer the lower the status the higher the incidence and mortality.
What is going wrong internationally and within communities?
We could answer this at what one might call a very proximate level or at a more distal level. At the proximate level you could say, ‘It’s obvious what’s going wrong to cause lung cancer is smoking,’ and my question is what causes smoking? So it’s not enough to say people are smoking. And what we see, certainly in all the rich countries but we even see it in India now, the higher the socioeconomic position the lower the prevalence of smoking. So we should be asking not only is smoking contributing to cancer, and of course it is, but what is contributing to the social gradient in smoking - the inequalities, the fact that the lower you are the more likely you are to smoke? Similarly obesity, we know that overweight and obesity contribute to cancer. What we see increasingly in rich countries the lower the status, fewer years of education, lower income, the higher the prevalence of overweight and obesity. So what I call the causes of the causes is asking about the causes of the social distribution of these known risk factors.
What can you do about the situation regarding wealth and health inequality?
I’ve said, slightly rhetorically, in Britain if we want to do something about the obesity problem we have to do something about the inequality problem, that we’re not going to solve it simply by trying to tell people to eat sensibly, it isn’t going to work. And that relates to distribution of wealth, it relates to what we do socially. For example, people say commonly in the US, in the UK particularly but in other European countries, it’s cheaper to eat unhealthily – sugar and fat are quite cheap. So unless we can deal both with the lack of income and the nature of the food supply this is going to be a very difficult problem to solve. We know, for example, though, that it’s not just exposure to risk factors. Take alcohol, alcohol is a cause of cancer. In general people of high status are more likely to drink more. It goes against most people’s prejudices, they assume low status people are boozing all the time, it’s not the case; the higher the status, the higher the main consumption. But alcohol associated harm goes the other way – the lower the status the greater the alcohol associated harm so there is something else that may be pattern of drinking, it may be nutrition that goes with the drinking but there is something else making people more susceptible to the ill effects of alcohol the lower their status.
What do you think can be done practically? Is the problem too difficult to be tackled?
Oh, if I thought that I wouldn’t get out of bed in the morning. I chaired the WHO Commission on Social Determinants of Health, I’ve just published a book called The Health Gap: The Challenge of an Unequal World and that’s a statement that the unequal world is a challenge but we know a great deal about what to do. I’ve been asked, ‘Look, I’m trying to get young people to give up smoking and not do drugs and drink sensibly and I can’t get them to listen to me, what should I do?’ And my response, unhelpfully, is, ‘I wouldn’t start from here.’ Let’s start with good, early child development, good education, good economic opportunities, employment and economic opportunities, and then you will find that people have the resources to interpret the information and make the healthy decisions. And that’s why we’re seeing this social gradient in smoking, a social gradient in obesity, a social gradient in alcohol associated harm. There’s a great deal we can do. Nobody thinks it’s a good thing that with the economic recovery in the US of every dollar of economic growth 92 cents went to the top 1%. Well, actually it’s not true that nobody, the top 1% probably think it’s quite a good thing but nobody outside the top 1% thinks that that’s a good thing. How does society benefit if 92% of every dollar of economic growth goes to this tiny proportion. So inequality is on the agenda. We may not be doing anything about it immediately but we will.
How should this impact the daily life of a medical practitioner?
I’m currently President of the World Medical Association and I’m asked if not daily at least weekly by national medical associations or by doctors, ‘What do you want us to do? We’re totally convinced by your arguments about the social determinants of health but what should we do?’ And I say, ‘Five things: education and training; seeing the patient in the broader perspective - if you’re going to treat someone who is homeless and throw them back onto the street, apart from being morally wrong it’s not very sensible. Thirdly, the healthcare system as employer means the conditions of work for the cleaners and the messengers and the like, the lab technicians as well as the nurses and the doctors. Fourthly, working in partnership with other services, social services and the like, and fifth, advocacy, that the doctors can be the advocates for the changes we need to make to our world to get better health and narrower health inequalities.
What is your take-home message?
We need to use the evidence on health and health inequalities to be advocates for fairer policies. My criterion of fairer policies exactly is those policies that improve health and wellbeing for everybody. In other words, we in the health professions are toiling in the field of social justice, we are trying to create fairer societies to improve health for everybody.