KIM OATES. The health gap.

Aug 8, 2017

The problem is ………. that we have been pursuing economic policy that benefits the one per cent. Trickle-down economics is defunct and does not work”.

“Politics quickly departs from evidence into the realm of ideology ….. But evidence must be a key part of the conversation.”

“One senior Conservative politician in Britain put it to me that my agenda is closer to Social Democrat than to Conservative thinking …… I make my case on the evidence, not on prior political beliefs.”

These quotes are from Michael Marmot’s book, The Health Gap.  Some may find them controversial, or at least provocative. 

Michael Marmot, a medical graduate of Sydney University, is the president of the World Medical Association, the director of the University College London’s Institute of Health Equity, and a leading researcher on health inequality issues for more than four decades. In 2016 he delivered the 57th Boyer Lectures for the ABC and is the author of several books on health inequities around the world. Fiona Stanley has called him “the world’s most important social commenter and epidemiologist describing the social determinants of health”.

He didn’t plan to become an epidemiologist. In his book “The Health Gap” he recalls that, as a student, he often wondered about the futility of some treatments when so little attention in medicine is paid to the underlying causes of ill-health and to its prevention.

When working as a junior doctor in respiratory medicine, he had a Russian patient with tuberculosis. He was interested in his patient as a person, so when he presented the case to the consultant, instead of the traditional history he said: “MR X, a Russian, is like a character out of Dostoevsky………..He has been a gambler, down on his luck, an alcoholic, unlucky in love, and now, as in in a Russian novel, he has developed TB.”

A few days later, the consultant chest physician drew him aside and said: “I have just the career for you. It’s called epidemiology.” (Anything to get me out of his hair, Marmot comments.) He was dispatched to University of California Berkeley. It was there he had his Damascus moment when Leonard Syme, his supervisor said “Just because you have a medical degree, it doesn’t mean you can understand health. If you want to understand why health is distributed the way it is, you have to understand society.”

This is what Marmot (now Sir Michael Marmot and the holder of a bookcase full of prestigious awards and honorary doctorates) has been doing ever since.

A turning point for Marmot was a study of health in the British Civil Service. The Whitehall study was set up to look at over 18,000 men aged 20-64 (yes, just men, the ten year study was initiated in 1967) in the Civil Service. This showed that men in the lowest grades, such as messengers and doormen had a mortality, including death from heart attack, three times higher than men in the senior administrative grades.

At the time this went against the conventional wisdom. Everyone “knew” that people in top jobs had a high risk of heart attack because of the stress they were under. Some still believe this today, demonstrating that myths die hard. Even Sir William Osler, regarded as one of the greatest clinicians and medical teachers, had described heart disease as being more common in men who worked in high-status occupations, leading to speculation that it was the stress of the job that was killing people.

But the Whitehall study found the opposite. Men in the highest grades had a lower risk of dying from heart attack and most other causes of death, compared with everyone below them. It was not just a gap in health between the bottom and the top. It was a social gradient with progressively higher mortality correlating with progressively lower grades of employment. Marmot called this the “status syndrome”, the title of another of his books.

Although people at the top have more psychological demands, they also have more control, more ability to influence their lives than those who can only struggle to grind out a living. Evidence for a progressive health gradient from poor to rich has now been shown all over the world, including Australia. The lower you are in society, the worse your health.

Marmot writes that he left clinical medicine because he did not think that the causes of ill health and of social inequalities in health had much to do with what doctors do and are trained to do. Health inequalities are strongly related to the conditions in which people are born, educated, grow up and work. These are the social determinants of health, now understood to be key factors in health outcomes.

The answer, Marmot believes, is to improve society. “The Health Gap” provides compelling evidence for this view, based on evidence about what can be done to improve people’s lives, be they poor or relatively comfortably off.

He describes studies from around the world to emphasise his message, in chapters with provocative titles such as “The Organisation of Misery”, “Fair Society, Healthy Lives”, “Education and Empowerment” and “Building Resilient Communities.” In every case, he rests his arguments on data, not on ideology.

This is not a dry book. Marmot uses a wide range of illustrations and writes in a conversational style. Indeed, if you heard the Boyer lectures, you can hear his voice as you read. And if you haven’t heard these Boyer lectures, they are easily downloaded from the ABC website and well worth listening to.

An example of an innovative approach to health was with the Merseyside Fire and Rescue Service. These fire fighters realised that they spent 6 per cent of their time fighting fires, the rest of their time was in preparation. Part of their job involved going into homes in poorer communities to talk about fitting fire alarms. But the occupants told them they had more pressing problems; a leaking roof, poor sanitation, budgeting problems. So they helped them get assistance from the council and other agencies. As well as encouraging people not to smoke in bed, they decided it would be more useful to provide help in giving up smoking.  They negotiated with sporting clubs to agree to get local children and young people into them. They brought children into the fire station and got them growing vegetables. The list of innovations from macho fire fighters goes on. This concept has spread to other fire stations. They use their spare capacity to improve the lives of the communities they serve. Marmot believes that this type of community mobilisation is part of the answer to improving health equity.

Marmot’s arguments are compelling. They are based on evidence, not ideology. They are relevant to health reform in Australia. Reading the “Health Gap” could broaden your horizons.

“The Health Gap” (Bloomsbury, London, 2015)

Kim Oates is an Emeritus Professor of Paediatrics and Child Health at Sydney University and a Clinical Consultant to the Clinical Excellence Commission

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