Sir Michael Marmot Interview: Conversations with History; Institute of International Studies, UC Berkeley

Redefining Public Health: Epidemiology and Social Stratification: Conversation with Sir Michael Marmot, Professor of Epidemiology and Public Health, University College, London; 3/18/02 by Harry Kreisler
Photo by Jane Scherr

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Changing Society

When you were in that hospital as a young medical doctor, and you saw this person, you said, "Hey, he's been here before. Why am I seeing so many of the same people?" That led you in this life's journey to focus on the relationships that the data revealed. But now you're moving to another step, which is, "Well, once we know that, if we truly know this and it can be proved scientifically, then we can go about changing things." What insights have you garnered about how this scientific information can contribute to a process of changing society, its view of public health, and actually making a difference?

The line that I pursued -- and this is not necessarily the right way, other people can do it different ways -- is not to use the evidence as a soapbox. I didn't think by standing on volumes of data I could then shout louder, and that would work. The line that I've pursed is that we need lots of people to make changes. We need people who are good at standing on soapboxes and formulating ways to change politically, but we also need the evidence. Given that during the time that I've been working in Britain, for nearly the first eighteen years (I went back to England in 1976), we had an intensely conservative government, from 1979 to 1997. And so to bang on about how health and equalities were immoral and unjust would not have reached much favor. But to say, this is what the evidence shows, that if we want to do something about improving health for the whole population, we need to focus on the people whose health is not improving to the same extent as those who are, and ask how can we do something about it, and show the evidence. I've always tried to stick close to the evidence, to say that we need to help the people whose business it is to formulate policy, we need to help them, but we need to help them in the light of our judgment of what the evidence shows.

It's not simply saying, "Here are some facts." Of course, it's trying to achieve a synthesis of the evidence and present it in a way that will help the policymakers. But it's important, in my view, to try and present it to governments of the right as well as the left, so that when we had a change of government in Britain from a Conservative to a Labour government, they were more ready to acknowledge that inequalities in health existed, they were more ready to apply the label "inequalities in health," and they were more ready to try to do something about it. We could then feed our evidence into that process.

In fact, they set up something called the Independent Inquiry into Inequalities in Health, under the chairmanship of a former Chief Medical Officer, Sir Donald Acheson. I served on that inquiry, and the evidence that people like me and others have been accruing over the years was submitted to it and we said, "Here are thirty-nine areas for policy development that we think, based on evidence, we can recommend to you as a government." And now, in fact, I'm involved in another government committee that's trying to take those recommendations and formulate specific policies based on them.

So how did I get involved in the policy? By sticking close to the evidence and saying, "This is what I think it shows, and this is what I think it means."

In this odyssey, has your definition of public health changed in your own mind?

Yes, very much. When I was a medical student, I thought public health was to do with drains. We had lectures from somebody who had been very important in public health in New Guinea, and drew diagrams of how you dig a deep pit latrine. I'm sure it's very important to know how to dig a deep pit latrine in New Guinea, but that's how public health was taught to us. When I went a bit further, I thought public health was about preventing these individual patients from coming back, and then I started to think more about society.

So even when I was in Berkeley, we were doing studies of Japanese migrants, the fact that when Japanese change from one environment to another, their health rates changed; but I still didn't quite think about societal organization. I thought this was to do with their culture and their behavior. It was only when I looked at this gradient, by grade of employee. As a fairly ignorant person, I thought, "What on earth does this mean?" And it was this simple finding of the gradient that got me to thinking about what does it mean, and set me off on this odyssey about the social determinants of health. And that, of course -- you have your own form of the midlife crises -- [led me to] saying, "Well, maybe the purpose of doing this research is not to publish one more paper, important as that is, maybe the purpose of the research is to try and change things." And so you would implement it.

In something that you wrote or said, you pointed out that where this all leads you is to a view of a larger picture, so that, for example, the idea of sustainable development actually comes to have a public health meaning. For example, you were talking about relating transport systems to the general health of the public. Help us understand that.

This was partly an attempt by me to bring different bits of my life together. I spent six years on Her Majesty's Royal Commission on Environmental Pollution. I didn't know anything about environmental pollution, and I guess that's the nature of royal commissions, that you get people who know about something, and then you ask them to deliberate on something else. Everybody around the table was expert in something, but not necessarily what we were deliberating on. But spending six years on this, I tried to think what it had to do with the things that I was interested in.

If you think of sustainable development, people criticize it a bit the way they criticize "stress." You know, "What is it?" You can't define it, you can't measure it, and so on. Sir Michael MarmotThe original Brundtland definition was something like, the next generation shouldn't be compromised by what the present generation should do. But if sustainable development implies three legs of a three-legged stool, economic, social, and environment -- physical, biological environment -- then suddenly, that spoke to me. I thought, "Ah-ha! That's the link between what I do in my day job thinking about inequalities in health, and what I do on this very time-consuming royal commission." Sustainable development is a way of thinking about the economic, the social, and the environmental. Now, I'd like to include, although the sustainable development folks tend to think of the environmental and physical and biological environment, I'd like to muddy the waters and say the environment is also social and economic, it's not just physical.

So if you look both at the environmental problems and the solutions, they clearly have a social/economic dimension. Take the example, should we tax fuel? In the United States, you don't quite understand what taxing fuel means, you should come to Britain and see what taxing fuel means, how much we pay for a litre of gasoline. Should we tax fuel? Well, there's a case to be made, and I think the evidence would probably support it, that if you really tax fuel, you'd have to have a severe tax, really, to change consumption, because the elasticity demand related to the price of fuel is rather shallow, it's not very elastic, and if people need to use their cars, they need to use their cars. But if you really taxed it to the extent that you would change behavior, it's highly likely that richer people would change their behavior less than poorer people. So there would be a real equity dimension to this. By taxing fuel to a really high extent, such that it would change behavior, you might actually make it much harder for poorer people to get about. So if you said that moving about is a right in our society, that would be a right that would be unequally distributed, because richer people would be able to drive their big cars and they would get the riffraff off the road, so that they wouldn't have the roads clogged up with all these old bangers. And the poor people, unless you had good public transport, would have their mobility restricted.

So doing something for good environmental reasons has a clear equity dimension to it, a clear fairness dimension to it. I don't think we should think about the one without the other.

Take the issue of fuel poverty. We know in Britain that if you define fuel poverty as spending something like 10 percent of your income on home heating, then the estimates vary, but it may be several hundred thousand, if not more, households are suffering from fuel poverty. Well, as a royal commission, we've been recommending a carbon tax. What would be the impact of a carbon tax? Poor people would find it even more difficult to heat their homes because the price would go up, and rich people could heat their homes to their heart's content because they would be less sensitive to that price rise. So that thinking about a carbon tax -- and this is a point I made in our own discussions on the royal commission -- we need to think about the equity dimension, so we don't make life harder for people. And, particularly, if we didn't think it would change consumption very much, why would you want to belt poorer people around the head and punish them for being poor even further?

So without addressing their general living standards through the tax and benefit system, I would be most uncomfortable with a flat tax, which is, in the sense, what a consumption tax is. So there are a couple of examples.

Now, broadening it, of how sustainable development and inequalities in health come together, broadening it, we want to look at what constitutes living environments. We were asked by the World Health Organization a few years ago to try and summarize our work on the social determinants of health in a way that might be amenable to policymakers. And as I look at what we came up with -- we called it The Solid Facts -- what we came up with and what people who were talking about sustainable development come up with, thinking about sustainable communities in which people live and work, is a high degree of overlap, that people need to be able to get about, they need to have air that they can breathe, water that's free of chemical pollution, and so on, as well as a habitable social environment.

So I think these two agendas come together, whatever rude words people say about the imprecision of the sustainable development concept.

Dr. Marmot, on that note, our time has run out. Thank you very much for sharing with us this journey, both of your thinking and of your life's work, it's been quite fascinating.

Thank you.

And thank you very much for joining us for this Conversation with History.

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