Public health and health inequalities: a half century of personal involvement

‘Social Injustice is killing people on a grand scale’.

As chair of the World Health Organisation Commission on Social Determinants of Health (CSDH), I put this declaration on the cover of our report.¹ It showed where we stood. Naïve to a fault, I did not intend for our report to be political. Which politician is going to state opposition to social justice? Our report settled the issue. We said that inequity in power, money and resources leads to inequities in the conditions of daily life that, in turn, give rise to avoidable health inequalities—inequities. Just in case the point was not clear, we said that a toxic combination of poor social programmes and policies, unfair economic arrangements and bad politics give rise to the unequal distribution of health damaging experiences.

Inequities in power, money and resources are actually the aim of some political systems—they are a feature not a bug. Action to achieve greater health equity cannot avoid politics. And, if indeed such actions are a key part of public health, public health has to confront politics. Research is less overtly political but that, too, can be questioned. After all, research in public health usually has a question, at least implied: how could the results of this research be used to change things for the better? By its nature that is political.

I started research on social determinants of health in 1972, the year the Faculty of Public Health was established. The CSDH 2005–2008, was, in some measure, an inflexion point for me. It marked the turn from researching the causes of health inequalities—social determinants of health—to formulating recommendations for policy and practice and advocating for change. The change of language from health inequalities to health equity is symbolic of that shift in two ways. We use the term ‘inequities’ to refer to health inequalities that are judged to be avoidable; not avoiding them implies injustice—hence inequity. The second shift is to focus on greater health equity, a positive achievement, rather than avoidable health inequalities, avoidance of an undoubted negative. The activity my colleagues and I established at UCL we call: Institute of Health Equity.

Health inequalities has had an uncertain time of it during these 50 years. For much of that time it was a marginal issue within medicine and medical research. In the UK, there were flurries of policy interest, including the 1980 Black report and the then government’s clumsy approach to suppressing it²; subsequent government denial there is a problem; renewed interest with Acheson, 1998, and then my own Marmot reports, 2010, 2020 and beyond; neglect again.

What I find now quite remarkable is that health inequalities have recognition in a way that it never had. Medical Royal Colleges, the NHS, Integrated Care Systems, local government in cities and regions, national governments in Wales, Scotland and even, almost, government in Westminster. Globally, too, it is on the map. There are initiatives in several of the WHO’s six Regions and a clear role in WHO. In the USA, the language of social determinants of health is heard widely.

When we launched the report of the CSDH I said that we had the ambition to foster a social movement. I am not sure whether we can call the growing recognition of social determinants of health and health equity a social movement. If we can, then I have been part of it these 50 years. What follows is a personal account of research and action on inequalities in health and health equity during the half century of the Faculty’s existence. Gathering and presenting the evidence have been central throughout. What has changed is a developing passion for social justice and impatience for change.

Whitehall: researching an unpopular subject

Whitehall, in 1976, was an unpromising place to study health inequalities. The civil service, then as now, excludes the richest members of society—no bankers, hedge fund managers or tech billionaires; and it excludes the poorest—everyone had a job, no gig economy. At first blush it seemed a rather homogeneous population, not an obvious place to study social and cultural influences on health. Indeed, the Whitehall Study of British civil servants had been set up, by Donald Reid and Geoffrey Rose, as a longitudinal study of smoking and other risk factors for mortality from cardiorespiratory diseases.³ Grade of employment was presented to me for analysis as the only variable that would appeal to my interest in ‘things social’. I had started in epidemiology, in 1972, studying social causes of ill-health in men of Japanese ancestry in California—see below.

My exploration of health inequalities in Whitehall proceeded more from curiosity than from a passion for social justice. The results changed everything for me for the next nearly 50 years. The remarkable finding was the social gradient: the lower the employment grade, the higher the mortality rate from cardiovascular and respiratory diseases and from most other causes of death.⁴ The finding that it was not high status people who were most at risk of heart disease contradicted the prevailing wisdom, but we had evidence that the social class distribution of heart disease had changed, not just in civil servants, but in the country as a whole.⁵

The implications of the social gradient are quite profound. If health inequalities were confined to poor health for the poor, the solution is to focus on the poor. Certainly, that would help. But if people in the middle of the hierarchy have poorer health than those at the top, it implies that we need policies that are more universal. The usual suspects—smoking, plasma cholesterol level, blood pressure, body mass index—accounted for about one-third of the social gradient in mortality from cardiovascular disease. It was this relative lack of success in explaining the gradient that led me to launch the Whitehall II study, with a particular focus on psychosocial influences.⁶

In the 1970s, inequalities in health were a pervasive problem but a niche research interest. My friend and colleague, John Fox, was producing the decennial supplement on occupational mortality in England and Wales that included mortality by social class. He and Abe Adelstein, director of Medical Statistics at the Office of Population Censuses and Surveys, asked the question of how much of occupational differences could be attributed to more general social differences among occupational groups.⁷ Richard Wilkinson, based on his own analyses, wrote an open letter to the Labour Secretary of State for Health, urging him to look into persisting and growing social inequalities in health. Presumably as a response, Sir Douglas Black was invited to form a committee to examine health inequalities and make recommendations.⁸ Wilkinson pursued the relation of income inequality to health and other social outcomes, which resulted in his influential book with Kate Pickett, The Spirit Level.⁹

Abolish inequalities by Newspeak—easier than social action

As is well known, by the time Black reported in 1980, the government had changed, Margaret Thatcher was Prime Minister, and for the next 18 years, inequalities in health went off the policy agenda.

For 18 years I, and the few others in Britain concerned with health inequalities,¹⁰ were doing ‘pure research’. In 1997, the government changed and yesterday’s pure research became today’s applied research. The newly formed Acheson committee on health inequalities, on which I served, wanted to know what evidence there was.¹¹

There had been a dash of Orwellian newspeak. Around 1990, during the Thatcher Premiership, I was invited to produce a paper for the Chief Medical Officer’s Health of the Nation Committee on how to reduce the population burden of cardiovascular disease. I presented worthy population approaches to smoking, diet, physical activity and control of high blood pressure. Given the unfavourable policy environment, it was not obvious that I should say anything about inequalities. In the end, I thought, no half measures. I featured inequalities for three reasons. First, if only half the population benefitted from interventions, it made it harder to achieve a population goal of reduction of cardiovascular disease. Second, if reduction of social inequalities in cardiovascular disease were an explicit goal, strategies might be different. Third, it was morally wrong to have such inequalities.¹²

It was as if I had invited the drafters of the government’s health of the nation strategy to cut along the dotted line. Diet, smoking, physical activity, blood pressure control were all there. Inequalities were nowhere to be seen. In Appendix N (I think, but it is too painful to go back to check) it said that there are ‘variations’ in disease but these were complex and little understood. No action needed.

Jumping ahead to 2022, the current government is again indulging in newspeak, inequalities have become disparities. It cannot have been a random decision to change the language like that, adopting the US term.

From Whitehall to the World

‘Solid Facts’, a publication we prepared for WHO Euro, was our first use of the term, ‘social determinants of health’,¹³ followed up by an OUP book with that title.^14,15 I claim no priority in coining the phrase. I just cannot find where we got it from.

One of the enduring debates through decades of research on social determinants of health is with economists whose starting assumption is that the causal arrow runs from health to wealth, not from wealth to health. In that tradition, the WHO Commission on Macroeconomics and Health proposed that investment was needed to control major killing diseases to get economic growth. Controlling major killing diseases is a worthy aim. That said, better health should be the end, not the means. Surely, better population health is a more worthy goal than economic growth. We should not see health merely as an instrument to some higher purpose, such as a more vibrant economy.

In 2003, I made that case at WHO to the then new Director-General, JW Lee. He agreed to set up the CSDH that I would chair. Closing the Gap in a Generation, our report, was published in 2008. Arguably, it was that report that led to much more widespread recognition of the concept of social determinants of health and use of the term. WHO and the World Bank, together, had placed great emphasis on universal health coverage. Important, of course, but the CSDH argued that to attain greater health equity, social determinants of health were vital. It is a tension that continues. Ministers of Health tend to focus on delivery of health services. Social determinants of health are for the whole of government.

The aim of the CSDH was to put social determinants of health and health equity on the global health agenda. It was not possible to formulate specific recommendations for all countries. We made a virtue of necessity and urged countries and regions within countries to develop their own specific recommendations based on those we set out. Brazil took up the challenge first.¹⁶ Britain was next.

From the World back to Whitehall

Fair Society Health Lives, the Marmot Review¹⁷ came into being because Gordon Brown, as Prime Minister, announced that he had asked me how we could apply the conclusions and recommendations from the global commission to England. Based on our strategic review of the evidence, we set out six domains of recommendations:

• Give every child the best start in life

• Education and life-long learning

• Employment and working conditions

• Minimum income for healthy living

• Healthy and sustainable communities in which to live and work

• Taking a social determinants approach to prevention

We were commissioned by a Labour government, reported in February 2010, and it was utterly predictable that the government would change soon after to a Conservative-led government. People predicted darkly: Marmot will go the way of Black i.e. buried by the government. On paper, at least, the Conservative-led coalition government did not do that. In a public health white paper they said that reduction of health inequalities was a priority and that required investment in the wider determinants of health.

In the event, that is not how things turned out. In February 2020, we published Health Equity in England: the Marmot Review 10 Years On.¹⁸ My summary was: we have lost a decade. And it shows.¹⁹ The rate of improvement in life expectancy slowed markedly, health inequalities increased, and life expectancy went down among people living in the most deprived 10% of areas. Attributing cause and effect is challenging. That said, it was plausible that government policies were responsible. The government’s stated ambition was to roll back the state, implement austerity. The cuts were regressive, both in fiscal policy through the tax and benefit system—the lower the household income, the bigger the drop in income; and in funding of local government—the more deprived the area, the steeper the reduction in local authority spending per person.

The Covid pandemic, predictably, exposed and amplified health inequalities. We called our Covid reports, Build Back Fairer.²⁰ Given the poor health performance in the decade before the pandemic, arguably linked to rolling back of the state, we should not want to re-establish the status quo. Hence, Build Back Fairer.

Racial ethnic differences—coming full circle

A striking finding from ONS, which we highlighted in our Build Back Fairer report, was the high Covid mortality in England and Wales among people classified as Black African, Black Caribbean, Bangladeshi, Pakistani and, to a lesser extent, Indian. Much of the excess could be attributed statistically to where people live and to other socioeconomic characteristics. But not all. In our Commission of PAHO on Equity and Health Inequalities in the Americas, we highlighted structural racism both as a cause of socioeconomic disadvantage and overlapping contributor to health disadvantage—intersectionality.²¹ Applying the same thinking in Britain we have added to the Marmot 6 recommendations: Tackle discrimination, racism and their consequence.

I call it coming full circle because my initial forays into epidemiological research were into the health of migrants and ethnic differences.

When Japanese migrate across the Pacific, to Hawaii and California, rates of stroke go down and rates of heart disease rise. Heart disease rates were higher in California than in Hawaii.^22–24 A genetic explanation—migrants are genetically different from those who don’t budge—is unlikely as it would have to account for distance travelled, which correlated with the increased risk. More plausible is that diet is different.²⁵ A Westernized diet, though, was not the complete explanation. In my own studies of men of Japanese ancestry in the San Francisco Bay Area, we showed acculturation to be linked to risk of coronary heart disease. In particular, men who were raised in a more Japanese cultural environment, and lived within a more Japanese community, had apparent protection from heart disease compared with men who were more westernized in their upbringing and social relations.²⁶

In Britain, analysing mortality by country of birth, we showed that, in addition to the healthy migrant effect, migrants in general have patterns of disease intermediate between those seen in the country of origin and those of the host country.^27,28

Standing on the shoulders of giants

When we launched Fair Society Healthy Lives: the Marmot Review, in 2010,¹⁷ I reflected that in 2009, three giants of health inequalities had died. Jerry Morris, Peter Townsend and Donald Acheson. Morris and Townsend were key members of the Black Committee.⁸ Jerry Morris’s wide-ranging intellect was inspirational. Peter Townsend was the great documenter of poverty in the UK, emphasizing the importance of relative poverty. Donald Acheson, former UK Chief Medical Officer, had chaired the Acheson Committee on health inequalities of which I was a member, set up by the Labour Government. He said that if we broaden our focus beyond poverty to embrace the social gradient in health, we will have to consider psychosocial determinants. Precisely. And we did.

From Geoffrey Rose, we got the simple and evocative phrase: the causes of the causes.²⁹

Although this is a commentary on the UK Faculty of Public Health, I have to mention Len Syme, my PhD supervisor at the University of California Berkeley and long-term friend, who first introduced me to this distinction between why one individual gets sick and not another, and why groups have differing rates of disease. Geoffrey Rose wrote eloquently on this distinction.

The climate crisis is the context for all action to reduce inequities

Our eighth recommendation, added to the Marmot 6 plus racism, is to pursue environmental sustainability and health equity together. The space I give it here is inversely proportional to its importance, which is fundamental. At the request of the UK’s Committee on Climate Change, we produced a report showing how these two agendas must be pursued together.³⁰

Taking action

There are two reasons for working with cities and regions on action to achieve health equity: negative and positive. The negative reason is that we want national governments to act to create fairer societies. If they won’t or can’t, we need to work at a different level. The positive reason is that locally is where people are born, grow, live, work and age. There is more understanding of the reality of people’s lives and the actions necessary to change the social determinants of health.

Coventry was the first Marmot City. They took our 2010 Marmot Review, Fair Society Healthy Lives, and used our six domains of recommendations as a basis for planning across the city. We then worked with Greater Manchester, a city region.³¹ The Institute of Health Equity is now working with cities and regions all round England and in Wales.

The principle underlying all our work on social determinants of health is that health and health equity reflect the nature of society. A crucial role of public health, then, is in working to create fairer and more just societies.

When we launched the CSDH, in Santiago Chile, I quoted the Chilean poet Pablo Neruda and invited our putative social movement to ‘Rise up with me against the organisation of misery.’³²

Michael Marmot, Prof.