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Sir Michael Marmot on social determinants of health: Blending evidence and passion

Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
User is currently offline
on Wednesday, 20 February 2013
in CHNET-Works!

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.

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Posted by Ted Schrecker
Ted Schrecker
Ted Schrecker is a clinical scientist at the Élisabeth Bruyère Research Institut
User is currently offline
on Tuesday, 06 November 2012
in CHNET-Works!

"The fog comes," Carl Sandburg famously wrote, "on little cat feet." With roughly the same amount of fanfare, in September a consortium led by Sir Michael Marmot published a summary of its findings on how to reduce health inequities in the 53 countries of the World Health Organization's European region. The region includes some of the wealthiest countries in the world, and some of those with the smallest disparities in health, but is hardly homogeneous. Mortality among children under 5 ranges from just over 2 per 1000 live births in Iceland to more than five times that figure in Bulgaria and Romania. Child poverty on a standardized cross-national measure is higher than 30 percent in Romania, three times as high as in the Nordic countries and a few others. And urban air pollution (concentration of particulate matter) is more than five times as high in the capitals of Turkey and Bulgaria as in those of Estonia and Iceland.

The consortium's argument will be familiar to readers of earlier reports in this vein, including the original Commission on Social Determinants of Health, but several points are worth mentioning because of their direct and immediate transferability to the Canadian context.

  • who euro-review-pic-1Air pollution remains a health hazard in many European cities.
    Photo: eifelyeti110’s photostream; reproduced under a Creative Commons 2.0 licence
    The consortium writes that "[h]uman rights are central in our approach to action on the social determinants of health". The fact that this was not true of the 2008 report has been identified as a significant omission by the distinguished human rights scholar Audrey Chapman, among others.
  • Social protection – including "a minimum standard of healthy living for all" that includes a nutritious and sustainable diet – is clearly and correctly identified as essential for reducing health inequity. Further, the consortium refers approvingly to the United Nations Social Protection Floor Initiative, a relatively low profile effort that is explicitly linked to a human rights approach. Could this be the start of an overdue convergence of concerns about health equity and social policy that often have been addressed by separate organizations and groups of professionals working in isolation from one another?
  • The effects of unemployment and exposure to hazardous work environments are foregrounded, at a time when youth unemployment is higher than 50 percent in two WHO Euro countries and a source of concern throughout the region.
  • Also foregrounded is the issue of health inequities among older Euro region residents – a concern with much broader applicability as populations age and social exclusion threatens to increase, especially in countries with high levels of economic inequality, a troubling trend that was evident even before the economic crisis.
  • Most importantly, both the economic crisis and many policy responses are identified as threats to health equity. In the consortium's words: "Recognition of the health and social consequences of economic austerity packages must be a priority in further shaping of economic and fiscal policy in European countries," with health and social affairs ministries and – at the transnational level – the World Health Organization, UNICEF, and the International Labour Organization given a voice.

who euro-review-pic-2Social exclusion threatens the European elderly, especially those with limited resources.
Photo: Zilverbat.’s photostream, reproduced under a Creative Commons 2.0 licence
Think, for a moment, about what institutionalizing this last recommendation would mean in a Canadian jurisdiction like Ontario.

My previous posting featured an important new report on redesigning social assistance in Ontario. Its arrival, too, could be described with reference to little cat feet. Ontario would do well to adopt both the consortium's insights about the inseparability of social protection and health and its view that "current economic difficulties are a reason for action on social determinants of health not inaction." But where will the necessary leadership come from? However well intentioned the proponents of taxes on 'junk food,' availability restrictions and warning labels on French fries may be, it may not come from them.

Related resource of interest

Video of Sir Michael Marmot's keynote speech at the Canadian Medical Association annual meeting in August 2012, which focused on health equity, is now available online.

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