In February 2010, the UK Government published Fair Society, Healthy Lives: Strategic Review of Health Inequalities in England Post- 2010, better known as “The Marmot Review” after its lead author Professor Sir Michael Marmot. The very first words of the report are a variation on a quotation from Pablo Neruda:
“Rise up with me against the organisation of misery” Marmot et al, 2010, p 2
Pablo Neruda was a Chilean writer, a left-wing politician, and a confidant of president Salvador Allende; he died within days of August Pinochet’s coup. An official British document that begins with a quotation from a revolutionary communist would seem to promise unusually radical content.
The Marmot Review (2010) received extensive coverage and acclaim from London’s Guardian newspaper and was covered, albeit more briefly, in the Times and the Daily Telegraph, but few of the initial commentators seemed to believe that any of its main recommendations would actually be implemented. These included improving prenatal and early years provision, better drug addiction treatment, and raising social security payments. Rather than anticipating real progress in tackling health inequalities in the wake of the financial crash, one journalist suggested that:
“This grim situation makes those few Marmot recommendations that need not involve great public expense, such as better workplace procedures to deal with stress at work, all the more important, and everyone should now get behind these.” (Guardian, 2010, March 15, p 30)
If all that can be done to reduce Britain’s grievous and persistent inequalities in health is to try to abate stress in the workplace, what does that say about the commitment of the British (government, academics, public health professionals, and public alike) to truly creating a fairer and healthier society?
The Marmot Review (2010) followed an earlier report also led by Sir Michael. Published just over a year earlier, again with a large cast of distinguished colleagues, he authored the acclaimed WHO Commission on Social Determinants of Health treatise:Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health (CSDH, 2008). Many reviews of this report have now been published, in both high-impact (Davey Smith and Krieger, 2010) and less well-known journals (Pearce and Dorling, 2009). Most of the responses to this earlier global report were positive, welcoming its well-argued call for a shift in focus for WHO, from disease control to improving the social determinants of health.
“The conclusions of the WHO report are a salient reminder to the governments of member states that reducing health inequalities should be a political priority. (Davey Smith and Krieger, 2010, p 530).
Like most other commentators, we welcomed the publication of the UK Marmot Review, but think it is now apposite to suggest that, in comparison to the earlier WHO report, and in contrast to its early precursor in Britain, the Black Report (Black et al, 1980, 1992), it has not succeeded in putting health inequalities back onto the political agenda, even as we write this review (in the days approaching a UK general election).
We suggest that a major (but significant) problem with the UK Marmot Review is that it fails to deal with the need to reduce inequality by failing to focus on the top end of the social hierarchy, as well as the bottom. Although the Review calls for the establishment of a ‘minimum income for healthy living’, there is no suggestion that a maximum income or a constraint on the ratio of top-to-bottom incomes in institutions would also help reduce inequalities, and so improve the health and well-being of the population as a whole.
In a time of severe financial restraint it is far easier to reduce spending by curtailing top incomes than it is to raise incomes at the bottom. However, taxation is only discussed in the Marmot Review with respect to improving low incomes. This is odd because the Review demonstrates in great detail that inequalities in health exhibit a social gradient; these are not simply problems of the poor, so why direct all policy solutions towards the bottom? It makes sense to target services to those who need them most, but even more sense to reduce the social inequalities that actually produce social disparities in health in the first place. We suspect that more radical policy measures were not proposed because the political climate in Britain across the mainstream party spectrum, whilst accepting the rhetoric of ‘fairness’, is actually diffident in its support for the policies needed to create more equality.
If the Marmot Review had suggested curtailing the excesses of the rich it might have been more difficult for those who ideologically oppose it to criticise it on the grounds that its recommendations would support and sustain those who are stereotyped as the feckless poor. Those who actually favour inequality and elitism would have to defend the harmful impact of the extremely affluent on society, rather than turn their attention to the supposed failings of the people who cost society least: the poor.
The vast majority of people benefit when incomes are curtailed at the top. If we curtail top incomes, it is easy to model the benefits – there is far more to go round. The taxation of excessive wealth (perhaps through a land-value tax), regulatory restraint of the bonus culture, and other measures aimed at reducing economic inequalities would help the vast majority of us (in the UK and other rich market democracies) enjoy an improved quality of life, even if such policies did not improve things much for the tiny minority of the super-rich (Wilkinson and Pickett, 2010).
Evidence of hostility towards the poor abounds on the Internet. When poor people joined what little public debate took place on the Marmot Review they were immediately abused. One of the Daily Mail’s online readers, responding to a criticism of his extreme views, said:
“Why are the poor replying to my thread?
GET A JOB and stop scrounging.
Who is paying for your Internet?
I’d sterilise the lot of you!”
– Anthony, Esher, Surrey, 11/2/2010 12:56
Another wrote:
“I would put you up against a wall and put a bullet in your pathetic brain.
I doubt this will be published but oh boy do I feel better now.
– Alan, Gloucester UK, 13/2/2010 15:57”
Obviously the Daily Mail did publish these views; otherwise we would not be able to report them here. The paper published many similarly extreme comments in its online edition. Typical reactions included:
“Perhaps Prof. Sir Michael might revise his recommendations from hard working taxpayers being bled even more to pay for feckless wastrels, to relocating ‘poor’ people to remote mountainous regions and subsistence occupations?
– Penny, London, 14/2/2010 19:34”
These angry reactions towards the poor in Britain, and to academics who research their suffering and support their rights, have become much more common than they were thirty years ago (Dorling 2010, p 28). They reflect a general trend in many affluent countries, but especially in those that have become increasingly unequal. Poor people are increasingly seen as an ‘out’ group. The laziness and innate incapability of the poor, sponging off the rest of us, cost society dear; at the extreme, in the USA, Americans are told more and more often that it is the poor who make you poor (Tropman, 1998).
Britain is not yet as bad as the United States when it comes to public expressions of hatred for those with less money, but it is not that much better, and is certainly a society with less social solidarity than almost anywhere else in Europe. In such an environment of hate, with huge public sector cuts in the offing, with an unregulated media allowing the online promulgation of views that border on fascism and hate crimes, whichever political party forms the next government, it is worth asking whether, in hindsight, the Marmot Review could have painted a more positive picture for societal change.
We believe it could have. We believe there is still time to change attitudes rather than plead for a little more charity for those with less. Much of the strong evidence lies within the hundreds of tables and appendices of the Marmot report. The full Review includes abundant evidence on the importance of the social determinants of health. What is missing is the political courage to deal with the root causes of those social determinants. Why people smoke, rather than trying to get them to stop… why people eat too much, commit violence, trust each other less, invest more money in their children’s education, rather than trying to understand the social inequalities that stand in their way.
We have to look back more than 30 years to see when academics last showed true political commitment to health inequalities. Thirty years ago Inequalities in Health: Report of a Research Working Group chaired by Sir Douglas Black was published (Black et al, 1980, 1992). Among many other recommendations, that Report suggested the following six main aims and measures:
Although the Marmot Review opens with a revolutionary quotation, the six main recommendations of the Marmot Review are unlikely to scare the horses, indeed they are remarkably similar (if in places a little less ambitious) to those of the Black Report. The main recommendations of the Marmot Review, for comparison with the above, are:
Is the Marmot Review really saying – by repeating so much of it – that it is about time we looked back again at the Black Report and realise how little progress we have made? The UK has led the world in research and policies designed to reduce health inequalities. Not only did it commission a series of important reviews, when the UK held the Presidency of the European Union (EU) in the second half of 2005, but one of the issues it chose to highlight during its Presidency was inequalities in health. As part of this effort, it commissioned two reports, one on the extent of health inequalities in EU countries (Mackenbach, 2005), the other summarising policy initiatives adopted to tackle them (Judge et al, 2006). What was clear from these reports was that Britain was ahead of other countries in implementing health policies to reduce health inequalities, but also that health inequalities in the UK have shown no tendency to decline. The growth in inequalities in health between geographically defined communities in Britain is currently accelerating (Thomas, Dorling, and Davey Smith, 2010).
No reviews or policies ‘boldly go’ where all public health researchers know they need to go. And yet our evidence base for the social determinants of health proceeds apace; we learn more and more about the futility of trying to change individual behaviour, and more and more about the importance of influences in the womb and early years of childhood. Indeed, the Marmot Review could have gone much further, if it had only placed greater reliance on Sir Michael Marmot’s own research and that of his colleagues studying life-course effects on health in the British birth cohorts. In contrast to 1980 when the Black Report was published, we now, thanks especially to his work, know much more about the importance of psychosocial influences on population health. We also know much more about the biology of chronic stress (Sapolsky, 2005), about how rank and status harm health (Marmot, 2004). We know that children get the best start in life by being brought up in more equitable societies, rather than in rich ones (Pickett and Wilkinson, 2007). Why did the Marmot Review not make hard hitting recommendations to reduce the harm created by great differences in rank and status? Crucial parts of the contemporary tale are missing in this latest review of health inequalities.
Instead, there is a focus on maximising the ‘capabilities’ of children and young adults. This is the language of economics, not social epidemiology or progressive public health. It is a language that has seeped into our everyday vocabulary and thinking, and it permeates the Marmot Review.
The Marmot Review is indeed welcome, but it tells only part of the story, and provides far less than its authors and most readers already know about what needs to be done.
Were Pablo Neruda around today he might feel that what the Marmot Review recommends is not to actually “rise up with me against the organisation of misery”. There are ways of rising up against the organisation of misery, but they all require far more than attempting the slight abatement of suffering.
At the start of the Marmot Review, when Neruda’s words are quoted, five lines of text have been left out from the relevant stanza (Davey Smith, 2010). Here is the full text including the missing lines:
But stand up,
you, stand up,
but stand up with me
and let us go off together
to fight face to face
against the devil’s webs,
against the system that distributes hunger,
against organized misery
(Neruda, 1972, p 99)2