Social Science & Medicine 71 (2010) 1254e1258

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Social Science & Medicine

journal homepage: www.elsevier.com/locate/socscimed

A social movement, based on evidence, to reduce inequalities in health

Michael Marmot, Jessica Allen, Peter Goldblatt*
Department of Epidemiology and Public Health, University College London, 1-19 Torrington Place, London WC1E 6BT, United Kingdom

a r t i c l e i n f o
Article history: Available online 18 August 2010

At the beginning of the Commission on Social Determinants of Health (2008), the Commissioners said, naively perhaps, that they wanted to create a social movement to advance the cause of health equity through action on the social determinants of health. The hundreds of people, globally, who were involved one way or another with the Commission, and the many more who have risen to its challenge, are part of that movement. Similarly with the Review of Health Inequalities in England, Fair Society, Healthy Lives (Marmot Review, 2010) e called here the Review. The scores of academics and practitioners who helped with the Review, and the many more who are actively working to implement its ndings, could be considered to be part of that movement. Michael Pollan (2010) quotes sociologist Troy Duster on social movements: No movement is as coherent and integrated as it seems from afar, and no movement is as incoherent and fractured as it seems from up close. Six of the eight commentaries here are part of that same social movement even if they illustrate the healthy differences of opinion amongst those who share an understanding of the role of social determinants. The other two represent a very different conceptualisation of health and society, for entirely predictable reasons, discussed below. The differences of opinion among these distinguished commentators represent many of the contrasting views that we heard in developing both the Global and English reports. Setting them against each could be seen as ample justication for us reaching the position we did, without the need for further comment from us, the middle men in this debate. For example:  Chandra and Vogl (2010), and Canning and Bowser (2010) say we put far too much emphasis on income as a determinant of health; Pickett and Dorling (2010) say: far too little e reducing income at the top would benet us all.

 Whitehead and Popay (2010) say that our reports are groundbreaking and have propelled the issue up the political agenda. Nathanson and Hopper (2010) say that the report is bureaucratic and the message is lost in mind-numbing statistics e a road to the Finland Station it is not.  Mackenbach (2010) says that the British experience shows that there may be little we can do to address health inequalities. Whitehead and Popay say that the British experience shows that there is much we can do if only we do things differently.  Nathanson and Hopper say that the Black Report got on the political agenda, with the obvious implication that the Marmot Review wont. Mackenbach and Howden-Chapman (2010) show that they are mistaken.  Lynch et al. (2010) emphasise the need for high quality research evidence on which to base action. No one disagrees with that e the disagreement between commentators is on whether there is enough evidence to take action now. Such disagreements are to be expected when people are asked to write commentaries. That said, they raise important issues that are fundamental to the health inequalities agenda and we will comment on them.

Do we know enough to take action on social inequalities in health? Six of the commentaries are in little doubt that we do; although all, like us, want a stronger evidence base. Lynch et al. thoughtfully lay out the priorities for research in early childhood, and HowdenChapman calls for rigorous evaluation of actions. We agree. A criticism of the Labour Government from the House of Commons Committee on Health Inequalities (Health Select Committee, 2009) was that the government paid insufcient attention to evaluation of initiatives. One view of both the CSDH Report and the English Review is that each of the recommendations represents a research agenda as well as a call to action.

* Corresponding author. E-mail address: p.goldblatt@ucl.ac.uk (P. Goldblatt). 0277-9536/$ e see front matter 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.socscimed.2010.07.011

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What of the other two commentaries, by Canning and Bowser (2010), and by Chandra and Vogl (2010)? Their starting position, like many economists involved in the social determinants debate, is that peoples health determines what happens to them. The Reviews starting position was that what happens to people has a cumulative effect throughout their life course, progressively affecting their health. As one of us has previously remarked (Marmot, 2009 p. 909): This is not just a polite, or even testy, academic debate. The policy implication of these two positions is quite different. If the main causal direction is from health to wealth, the appropriate intervention is to control illness in order to improve an individuals social and economic fortunes or, indeed, eradicate illness to improve the economy of a whole country. If, as I conclude, the main causes of health inequalities reside in the circumstances in which people are born, grow, live, work and agedthe social determinants of healthdthen action to reduce health inequalities must be in those circumstances and the fundamental drivers of those circumstances: economics, social policies and governance. Of course, not all economists share the approach to the evidence in these two commentaries. Amartya Sen was a member of the Commission on Social Determinants of Health, and Sir Tony Atkinson was a Commissioner of the Marmot Review. Each signed up to the conclusions in the respective reports. Jim Smith, whose work showing how health affects income is quoted, also showed elegantly the powerful inuence of education on health; such that income drops out of the model (Smith, 2007).

The role of selection Chandra and Vogl (2010) appear to believe that it is only through the logic of economic reasoning that causation can be understood. If we in public health were as rigorous about evidence as they, we would be more cautious. In the case in hand, social inequalities in health, everything is determined by selection. They concatenate two forms of selection, widely discussed in the epidemiological literature: ehealth leads to social conditions ethe health of any group (e.g. low grade civil servants) is determined by its composition, not by the social conditions experienced by the group. It is a fundamental tenet of science, with which we fully agree, that in making inferences about causation, associations should always be rigorously tested for the possibility of reverse causation e health leads to socioeconomic position e and confounding e an extraneous factor affects both health and the social condition with which it correlates. But it is mystifying to us why one should start from the position that health determines peoples social circumstances rather than the other way round? The issue and the debate have been around for a long time, both in science and the arts. Take a page from Dickenss, Hard Times, on housing for example (Dickens, 1853): In the hardest working part of Coketown, . where Nature was as strongly bricked out as killing airs and gases were bricked in . where the chimneys, for want of air to make a draft, were built in an immense variety of stunted and crooked shapes. (p. 65e66) or a description of working conditions in a northern mill town: all the melancholy-mad elephants, polished and oiled up for the days monotony, were at their heavy exercise again. . Every man was in the forest of looms where Stephen worked to the crashing, smashing, tearing piece of mechanism at which he laboured. (p. 91).

Should we really assume, that these dark satanic mills and airless places, rather than causing terrible illness and shortened lives, selectively employed sick people and those whose backgrounds accounted for all their subsequent illness? That subsequent improvement in living and working conditions, thus abating Victorian squalor, and associated improvements in health were correlation not causation? That while medical care improved health, housing also got better, and an intellectually slack public health profession mistook the improvement in housing and working conditions for causes of improved health? If proponents of this set of assumptions dropped their guard for a moment and accepted the evidence that air pollution, crowded living conditions, ghastly working conditions were causes of illhealth in Victorian times why, a priori, do they start from the position that living and working conditions are not a cause of illhealth in the 21st century? Why do they reject the evidence on selection from the 1970s and 1980s; that workers are selected into employment for good health and not illness (Fox & Collier, 1976; Goldsmith, 1975); that such effects are of limited duration (Fox, Goldblatt, & Adelstein, 1982) and are overtaken by cumulative exposure to work conditions; and that rather than being sustained by selective mobility between jobs, social gradients in the workforce are dampened by selective movement out of the labour force (Goldblatt, 1988, 1989)? Why do they appear to assume that Fig. 1 in the Review (Marmot Review, 2010), reproduced here, linking neighbourhood deprivation to disability-free life expectancy could all be due to a remarkable ability of people to choose places to live depending on their level of health e ill-health leads to neighbourhood income, in other words? At a regional level, it is equally difcult to see how selection explains why the social gradient is widest in the North East and narrowest in the South West, as both regions have a history of out-migration of those needing to nd employment (Marmot Review, 2010). Fair society or fairer allocation of NHS resources? This disagreement between commentators is not just about evidence. It is also about ideology. We think that the health gradient in Fig. 1 is a powerful demonstration of the graded relation between social and economic conditions and health. We are chastised, by Canning and Bowser, for wanting a fairer society to put it right. Instead, they offer the following: The health gradient should be seen as a ashing alarm that our health systems are failing to deliver cost effective health care and a call to allocate health sector resources more effectively. (Canning and Bowser, 2010) Why should it? Where is the evidence for their counter assertion? They are not being more rigorous about causation than we are, as they claim. They simply have a different starting position. This is ideology dressed up, condescendingly, as methodological rigour. We would go further. Given the vast research resources that have gone into evaluating medical interventions, the lack of clear evidence that the main cause of the social gradient in health is differential access to health care, may mean that, indeed, it is not lack of health care that is the cause of the problem. Too little or too much emphasis on income? No topic created as much dissent among the commentators as the Reviews stance on income. One of the more creative voices in public health has been that of Richard Wilkinson. Latterly, Wilkinson and Pickett (2009) have extended Wilkinsons consistent observation that level of inequality is related to overall health of society, and shown that the relative level of income inequality is related to a great many other social problems. One mechanism by

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Fig. 1. Life expectancy and disability-free life expectancy (DFLE) at birth, persons of neighbourhood income level, England, 1999e2003.

which such a relation could operate is that greater level of income inequality is related to higher poverty levels. If reduction of income inequalities led to reduction in poverty health of the worst off would improve. Second, income inequalities may be causal of ill-health in addition to an effect on poverty, either because income inequalities are directly causal, or because income inequalities are a marker of more general inequalities in society that themselves are causal of ill-health. A key mechanism may be relative inequality. The Labour Government, in theory, embraced relative inequality by dening child poverty relative to 60% of median income and declaring an intention to abolish it. In addition, Hills et al. (2010) point out that greater inequality may reduce social mobility: the larger the gap between rungs of the ladder the harder it is to climb the ladder. Lack of social mobility and reduction of chances of improving ones life will, in the language of our reports, be disempowering with devastating effects. We should emphasise that we were concerned with the whole social gradient in health, not only the dramatic health effects of being at the bottom of the distribution. There is still intense debate about how much of the health differentials, among people above the poverty threshold, are due to relative inequalities and how much to absolute differences in living and working conditions. We were inuenced by the Amartya Sen argument that relative differences in income are related to absolute differences in capabilities (Marmot, 2004). Our recommendations, largely, are aimed at the whole social gradient. In the Review (Marmot Review, 2010) we pointed to the lack of progress in reduction of income inequalities e gradients in both gross and post tax income have been largely constant since they widened 20 years ago (Jones, Annan, & Shah, 2009). We also described how the poorest pay proportionately more of their income in taxes than the richest e tax appears to be regressive, not progressive. In particular, for the bottom quintile of income, all

original income is clawed back through the tax system while nal income is dependent on benets (Barnard, 2009). For these reasons, we called for a more progressive system of both tax and benets to address these inequalities. Among the evidence underpinning this call was that from our task group on early child development and education which concluded that if the aim is to reduce inequalities in ECD and education there has to be reduction in inequalities in society. Signicant though income is to health, we do not think that the social gradient in health is primarily the result of income differentials. One of the key messages in the Review report is action on health inequalities requires action across all the social determinants (Marmot Review, 2010, p.16). That is why there are six domains of recommendations in the Review. Income does not of course exist in isolation from these domains. We were greatly impressed by Jerry Morriss work (2000) on a minimum income for healthy living e having enough money for healthy food, transport, social interaction. It is hard to see how even ideologically driven commentators could think that having insufcient money to live on is irrelevant to health inequalities. We also recommended that it is important that there be economic incentives to work, not by setting unemployment benets unconscionably low, but by reducing the cliff edges that make working appear less remunerative than not doing so. Is that too much emphasis on income? We are unrepentant. Capability Nathanson and Hopper (2010) argue that the mantra of giving people control over their lives rings rather oddly, not only because it is an individual not a structural- level variable, but also because taking control is by no means a guarantee of good health: think race car driving or .planting a bomb in Times Square. Similarly Pickett and Dorling (2010) chide the Review for

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its focus on maximising the capabilities of children and young adults e the language of economics. We think this is to miss the point e that social change at grass roots level and health improvement will not happen if people do not have control, capability (Sen, 1999) and capacity in their everyday lives. This will contribute to addressing the stresses associated with disadvantage and enable them to change difcult behaviours, to make improvements to their and their communities lives. But it is wrong to dismiss capabilities and control as simply individual level variables. They are strongly related to the conditions in which people are born, grow, live, work, and age and, in part, their effect on the skills people have acquired and levels of community functioning. It is not surprising to us that Chandra and Vogl (2010) say Economists have demonstrated that early life conditions jointly determine health, educational attainment and labor market outcomes in adulthood. These are all linked through the development of skills, capability and resilience. In contrast to their view that it makes crossesectional relationships extremely difcult to interpret, we conclude that these attributes lead to the reinforcement of advantage or disadvantage right across the life course. Countervailing forces Whitehead and Popay (2010) state that advice about how to tackle countervailing forces driving inequalities is missing completely from the Review and the CSDH. They say that we are too cautious when it comes to criticising the role of big business and the existing power bases, the global economic system, erosion of universalism in social welfare systems, fragmentation and privatisation of health services and labour market policies that have led to growth in insecure and precarious employment. Reviewing the tax and benets system and ensuring a minimum income for health living is one way of dealing with such countervailing forces. We have gone as far as we believe the extensive evidence base (Siegrist et al., 2009) will take us in proposing action on good work for all and sustaining employment for the most disadvantaged. Pickett and Dorling (2010) add to the voices of Whitehead and Popay in wanting us to go further. We are entirely sympathetic to their arguments for dealing with the high incomes of the top earners, and using the tax revenues for the benet of all. There has been debate as to whether income inequalities, as well as being linked to overall population health, are linked to health inequalities. We were impressed, nevertheless, that absolute inequalities in health do seem to be narrower in countries, such as Sweden and Japan, that have narrower income inequalities. We called for a more progressive taxation system, but did not say much else on bankers bonuses, or other top incomes. That said, we are with Pickett and Dorling. The argument that top salaries provide incentives to improve the overall economy, and therefore provide trickle down benets, looks remarkably weak as the world faces up to the aftermath of the worst economic downturn since the great Depression. The harm didnt trickle down either. It gushed down. The losers, as always, were predominantly those closer to the bottom of the social hierarchy not those higher up. In passing, we are not sure why Pickett and Dorling argued that we needed to put more emphasis on the life course. We prefaced our recommendations with the statement central to the Review is a life course perspective (Marmot Review, 2010, p. 20) and then start our recommendations with early childhood, move through education, work and employment, on to living standards. As we have indicated previously, our guiding conceptual framework included the accumulation of advantages and disadvantages throughout the life course.

Although not picked up by the commentators it is worth re-emphasising the importance of sustainability. We believe that by aligning the health inequality and climate change agendas, significant strategic progress can be made on a signicant global agenda. Our recommendations on sustainable local communities are an attempt to put a human scale to the impact of many global phenomena. Not political enough e to the Finland Station it is not The CSDH (2008) concluded that social injustice is killing on a grand scale and pointed to inequities in power, money and resources as major causes of avoidable health inequalities. Both the CSDH and the Review set out to put practical recommendations into an ethical framework. Whitehead and Popay (2010), pleased with this clear statement, claim that the call for social justice is one of the strongest statements to appear in a WHO Report. They do, however, want to go further. Vicente Navarro (2009) also praised the CSDH report but said, in effect, we know who the killers are e there should have been a more overtly political analysis of the perpetrators of social injustice. The CSDH report had a whole section on structural determinants: globalisation, fair nancing, market responsibility, gender equity. Such structural drivers inuence inequalities in the conditions of daily life which, in turn, lead to health avoidable health inequalities. Globalisation featured less strongly in the English Review, although we did refer to structural drivers. In gathering the evidence, and deliberating on it, in the global CSDH, it was clear that changes were needed to the world economic order. But it was beyond the competence of the CSDH or the Review to design such a new system, quite apart from the political question of how to get such a system adopted. We agree both with Navarro (REF TO NAVARRO NEEDED HERE) and with Whitehead and Popay that understanding the political drivers and how to get political change is vital e the more attention given to this agenda the better. Should the CSDH and Review have done more on this more overtly political arena? Quite apart from questions about our competence, there is also the question of whether it would have been the right thing to do. Navarro acknowledged that the CSDH probably went as far as it reasonably could have, given the nature of the CSDH. At the World Health Assembly, debating a resolution on the CSDH, representatives of 39 countries spoke in favour of the resolution that passed unanimously. Had the report been totally anodyne such acceptance would hardly count for much but given the praise for its radicalism, it is possible that Navarro is correct: we could not have gone further even had we known how to. With the Review, we had the example of the Black Report (1980) before us. We wanted to make a strong ethical statement e hence the title, Fair Society, Health Lives e to give the context to our more practical recommendations, and we did not want a new government simply to ditch it, as the Black Report was unceremoniously ditched. Yes, of course, the Black Report had a huge impact on research and thinking, but no impact on policy in Britain for 18 years. In contrast to Pickett and Dorlings view that the Reviews recommendations were similar to (if in places a little less ambitious) than the Black Report, we believe that we built upon what was in the Black Report. By using the evidence that has emerged from research and practice in the last 40 years, we were able to strengthen the framework for action. Which brings us to Nathanson and Hoppers (2010) statement To the Finland Station it is not. Are we, in their judgement, really living in revolutionary times? And is it their judgement that we should be calling for overthrow of the established order, as Lenin

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did at the Finland Station? Or, if we are reading too much into their metaphor, what did they mean? Clearly we irritated them e hence their comments on the nature of our recommendations for early child development. They nd our evidence mind-numbing. However, the aim was to build the recommendations on the evidence. This included the data that show that advantage and disadvantage accumulate across the life course, the scale of wider societal inuences, the successes and failures of policy and last, but not least, what does and does not work. These elements were quite rightly in the Governments terms of reference for the Review. However, for those that nd statistics and evidence a bit overwhelming, we did include an executive summary. If what they meant was that there should be a clearer call to action we can reassure them a little. The call to action has been heard in several quarters. There has been a huge amount of interest, at local and regional level in Britain. Although Whitehead and Popay suggested that our plans for implementation were weak, many national and local organisations are already using the evidence to shape and design interventions, galvanise and mobilise action and implement the recommendations of the Review. Our intention was not to be overly prescriptive, or advocate too many structural, organisational changes which might in fact detract from the most important issues. We believe that this has encouraged local organisations to develop locally relevant plans and actions. What the new central government will make of it, we do not yet know. Are Nathanson and Hopper right that a crisper statement with less evidence, and fewer practical recommendations (such as those for health visitors), and a more revolutionary call for radical societal change, would have more chance of being taken up? That was not our judgement but, as economists might say, we dont have a counter-factual.

the evidence together. We do need a social movement to act on it and to continue to develop the evidence. Appendix. Supplementary material Supplementary material for this article may be found, in the online version, at doi:10.1016/j.socscimed.2010.07.011. References
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Is it possible to reduce health inequalities? Mackenbach (2010), in a thoughtful and well-informed comment, says that the British experiment is of wide international interest. Britain has taken health inequalities seriously. Given the lack of progress in reduction of health inequalities, it leads him to ask: if the British couldnt do it, perhaps the whole enterprise is hopeless. He may be right. But Whitehead and Popay have a different view. They agree that the British government was concerned with health inequalities but did not do what was needed. They identify four reasons why the action taken did not lead to reduction in health inequalities:     Focus on the worst off rather than the gradient Too much emphasis on individual life style Not giving initiatives enough time to work Countervailing forces such as failure to narrow social and income inequalities, and labour market insecurity

Were we not more in sympathy with Whitehead and Popay, than with the its not possible view, we would not have embarked on the Review. As was highlighted in the Review report (Marmot Review, 2010), life expectancy for the bottom quarter of the population, in terms of deprivation, increased by 2.9 years in men and 1.9 years in women (apologies if these statistics are mind-numbing) in only 10 years. Rapid improvement for the worst off is possible. The question is whether we can make the gradient less steep. Many of the commentators feel that the likelihood of achieving that would be increased both by a clearer clarion call and more overt political analysis. We welcome these voices. We have brought