On an unseasonably warm day in May 2012, Sir Michael Marmot came to Canada for a short visit with the Public Health Agency of Canada and the University of Ottawa, supported by the CIHR Institute of Population and Public Health. His presentation at the University of Ottawa, from which we present video excerpts here, is simultaneously a succinct and a passionate defence of the social determinants of health agenda and its ethical foundations.
Sir Michael is introduced by the Hon. Monique Bégin, a former Canadian Minister of Health and Welfare and a member of the Commission on Social Determinants of Health. She comments that: "Canada ... is so wealthy, despite the scary global economic times, that it manages to mask the reality of poverty, social exclusion, discrimination, employment erosion, mental health, and youth suicides. While one of the world's biggest spenders on health care, we have one of the worst records when it comes to providing an effective social safety net."
The first part of Sir Michael's presentation offers a bit of anecdotal history about the internal processes of the commission. He then makes two main points. First, he is hopeful that the Commission's report may be one of a few international commission reports, like that of the Brundtland Commission on sustainable development (1987) that have a real impact. At least, he says, officials like Commonwealth ministers are talking the language of social determinants of health. Second, he distinguishes the economic case for acting on social determinants of health from the moral case, based on social justice. In words that echo the long-ago wisdom of Anatole France, he concludes that: "The freedom to wallow in poverty," or to be unemployed, "is not a freedom that is much prized."
In the next part of his presentation, Sir Michael emphasizes the importance of the Commission's focus on inequalities of power, money and resources. He goes on to describe history of the British strategic review on health equity, which he also chaired, and its organization around a lifecourse framework; his efforts to advance interest in social determinants of health as president of the British Medical Association; and how initial cynicism was transformed into enthusiastic takeup of his message about the importance of social determinants of women's health among British obstetricians and gynecologists.
Finally, Sir Michael argues that social protection policy matters for health. "The greater the social spending, the lower the all-cause mortality, for 18 EU countries." And he explains a remarkable initiative by the Merseyside Fire & Rescue Service (that's Liverpool, for readers too young to remember where the Beatles came from) to address social determinants of health by helping people apply for grants to improve their housing, quit smoking and increase their levels of physical activity using the gymnasia at fire stations. He ends with the observation that "We are involved in an intensely ethical concern. We are trying to get a more just society."
What can we in Canada learn from this presentation? That could be a long disquisition, but the short version is: blending evidence and passion matters, and we have too few leaders in population health and health social science who are capable of doing so.
Acknowledgements: Many thanks to CIHR's Institute of Population and Public Health for offering these video files.