In presenting his report on health inequalities in England, Sir Michael Marmot responded to the question “what’s the one thing you would recommend based on the review of health inequalities you have just completed?” with “work as hard at you can and as we can to create a fair society. Creating a fair society would improve health and reduce health inequalities”.
The context of the review was the commission on social determinants of health which was set up by the WHO that published its report “Closing the Gap in a Generation” in August 2008. The title was a statement that we do have the knowledge to do it; it was a statement that we have the means to do it; the question was, do we have the will to do it?
“Fair society, healthy lives” has been widely quoted as showing that health inequalities have not narrowed, if anything they have got wider over the last decade. That is true, but if we look at what’s happened to the worst off in the decade from 1997 to 2007, life expectancy improved by 2.9 years in only 10 years. That’s about 7 hours every 24 hours. The issue is improvements were even better for the average and well off, so the gap between rich and poor didn’t narrow. Sir Michael argues that we need to focus on addressing the gradient or variation across social class and deprivation. The gradient suggests that we have to have universal solutions that run across the whole of society rather than the traditional targeted approach.
If everyone in society had the mortality rate of those with a University education, in other words we brought everyone up to the standard of the best off, we would prevent 202,000 people dying aged 30+, dying prematurely, which is 40% of the deaths and that translates, looking at the premature deaths avoided to 2.5 million life years. It would also bring 2.8 million extra years of life free from limiting illness of disability. Putting £ signs on those deaths or life years would be telephone numbers. The economic case us unarguable, we cannot afford to do nothing.
Sir Michael and his team took a life course approach and identified 6 policy areas that could make an enormous difference to improving health and reducing health inequalities. Every child the best start in life, education, a life long education, fair employment and good work for all, a healthy standard of living for all. Create and develop healthy and sustainable places and communities, strengthen the role and impact of ill-health prevention and 2 policy mechanisms, quality and health equity in all policies and effective evidence based delivery systems.
The report is packed full of interesting things, for instance, child development we know is influenced by children being read to every day at age 3. Reading to children every day positively affects cognitive development, it’s really a pretty simple intervention. Data from Canada shows that children read to daily reverses half of the disadvantages associated with low income in readiness to learn when children start school. A really simple intervention and if it wasn’t done by parents it could be done by others. There are lots of other examples and even a plug for the NHS Kidney Care funded Green Nephrology project that Andy Connor and others are driving forward.
But is it just another report? Several have drawn analogies with Douglas Black’s report at the beginning of the 1980s. The Black report was commissioned by a Labour Government and presented to a Conservative one. It was actually published in rather poor photocopy form over the August Bank Holiday weekend. It did have an enormous impact on our understanding and the research community and perhaps should be credited with helping to shape the thinking and trial design for Marmot and other research groups around the globe. In contrast “Fair Society, Healthy Lives” has broad cross party support from all the 3 main political parties. After the election there are likely to be differences in how the programme of work will be approached but this report clearly articulates what’s needed and how progress can be measured.