Health. Perspective: Acting On The Evidence To Reduce Inequalities In. Michael Marmot. Cite this article as: http://content.healthaffairs.org/content/18/3/42.
At the Intersection of Health, Health Care and Policy Cite this article as: Michael Marmot Perspective: Acting On The Evidence To Reduce Inequalities In Health Health Affairs, 18, no.3 (1999):42-44 doi: 10.1377/hlthaff.18.3.42
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Perspective Acting On The Evidence To Reduce Inequalities In Health A member of the Scientific Advisory Group explains the Acheson Report, commissioned by the Labour government to examine the health of the British public. by Michael Marmot
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up p os e go v er nm en ts took inequalities in health seriously; what might they do? This is not a fanciful question. In the summer of 1997 the New Labour government in Britain invited Sir Donald Acheson to set up an Independent Inquiry into Inequalities in Health. Its terms of reference included the charge “to identify priority areas for future policy development.” A Scientific Advisory Group, of which I was a member, prepared and signed the report along with Acheson.1 We reviewed the evidence and made thirty-nine recommendations, which have implications across government, not only for the Department of Health. Our starting position was that social inequalities in health continue to be a major problem and have been increasing in Britain and elsewhere and that reduction in the magnitude of these inequalities is fundamentally a matter of social justice. Having identified “five giants of Want, Disease, Ignorance, Squalor and Idleness,” Sir William Beveridge in 1942 set out a national program to deal with these.2 The setting up of the National Health Service (NHS) in Britain has not abolished inequalities in health. As Sir Douglas Black and colleagues concluded in 1980, the causes of these inequalities are more basic than lack of access to high-quality medical care.3 Acheson reached a similar conclusion, but we made a series of recommendations as to how, given
that inequalities exist, the NHS can better deal with them.
Discussing Health Inequalities n Differences among groups. Three points
are central to discussion of inequalities. First, we are talking about systematic differences between groups, not simply differences among individuals. There are two distinct questions: why some disadvantaged people have better health than others, and why one social group has worse health on average than another. The distinction is important. Preventive medicine tends to focus on individual behavior; modern epidemiology has commonly sought to identify individual risk factors that predict individual risk. These are all very important, but they do not address why some socioeconomic groups have higher rates of disease than others. In the first Whitehall study of British civil servants, for example, the established risk factors predicted mortality in individuals, but smoking and other risk factors could not explain why men in lower employment grades had higher mortality than men in higher grades.4 The differences were substantial. Life expectancy at age forty-five was 4.4 years shorter for men in the bottom two grades than in the top two grades. To put this in perspective, eliminating coronary heart disease from this population would add four years to life
Michael Marmot is the founder and director of the International Centre for Health and Society, University College London, United Kingdom. H E A L T H
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expectancy. Taking action, therefore, to re- that the inquiry and its findings are relevant duce social inequalities in health could have a to the United States and other industrialized profound effect on illness and death rates and countries, as well. In the United States health on quality of life. similarly follows a social gradient, and, an isn Social gradient. Second is the question of sue also dealt with in the Acheson inquiry, the social gradient in health and disease. there are large geographic variations by Much of the concern with inequalities in county in the United States. Life expectancy health has been with the effect of material for men, for example, varies from 77.5 years for deprivation: poverty. Indeed, many of the sub- a county in Utah to 62.2 years in the District missions to the Acheson inquiry dealt specifi- of Colu mbia (the second-worst in the cally with poverty. There is, nation).6 however, a separate but reThe Acheson Recom“As a scientific lated issue. The data we remendations advisory group, we viewed made clear that health We were clear from the outset were not charged follows a social gradient: Not that we needed many kinds of only do deprived people have with telling the evidence to frame a recommenworse health than nondefinance minister dation, or else we would have prived people have, but, as the where to set little to offer. The more “upWhitehall and numerous other stream” a potential interventaxation and studies make clear, health status tion, the less susceptible it was benefit levels.” is closely related to socioecoto evaluation using the estabnomic status throughout the solished methodology of randomized controlled cial range. The problem cannot be reduced to trials. Thus, one of our recommendations, poor health for “them”—the deprived—and nicotine replacement therapy for smoking good health for “us”—the nondeprived. cessation, has been evaluated by such a trial, n Health selection. Third, the intimate but breaking the link between material deprirelation between socioeconomic status and vation and smoking in single mothers needs health is not primarily the result of health seother kinds of evidence to support it. lection. There are various versions of the seWhat will happen to our thirty-nine reclection argument—economists label it endoommendations? Will the government take geneity—but essentially they say that health, or individual characteristics that determine any notice and, more importantly, take any health, determines achieved socioeconomic action? Will such action have the desired efposition, rather than social circumstances de- fect? We shall have to wait and see, but the termining health. In other words, the fit rise initial signs are promising. In 1988 the government issued a Green Paper (for consultation) to the top, and the unfit sink. Black considered health selection and dis- on health strategy, Our Healthier Nation, in carded it as the principal explanation for which they put forward their two aims: to inequalities in health. The research that has improve overall health and to reduce inequalifollowed Black, particularly from the longitu- ties in health. In that paper they stated that dinal studies, makes clear that although the results of the Acheson inquiry would inhealth selection does play a part, it is not the form the White Paper that is slated for publimain explanation of the social gradient in cation in 1999. We recommended several other actions, health. 5 We cannot frame social policy on the which may already have been part of the govbasis of this flawed scientific understanding. ernment’s thinking that led to the inquiry. Although the Acheson inquiry reviewed The spirit of our recommendations is already British data and made recommendations to apparent in several new developments in the the British government, I venture to suggest
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British health and social welfare regimes. (1) In three budgets there have been substantial changes to the tax and benefit system that have favored the less well off and children. (2) “Welfare to work” has used tax revenues to get persons ages eighteen to twenty-five off welfare and into training programs and work. (3) Sure Start is a well-funded new national program to provide preschool education for children up to age three, targeted at the poorest 10 percent of localities. (4) Health Action Zones earmark government funding for selected local areas of deprivation; there are funds for health authorities, local authorities, and others to work across sectors to improve health of the most deprived. (5) The Common Agricultural Policy should be revised. (6) The government’s White Paper on tobacco makes recommendations on, for example, the availability of nicotine replacement therapy on NHS prescription. (7) The Department of Health has set up a Health Impact Assessment Unit, which includes health inequality impact assessment. Nutrition, integrated transport, care for the elderly, healthy schools, air pollution, and healthy work environments are all areas in our recommendations that are under discussion across government.
NOTES 1. 2. 3. 4. 5.
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Independent Inquiry into Inequalities in Health (London: Her Majesty’s Stationery Office, 1998). W. Beveridge, Social Insurance and Allied Services (London: HMSO, 1998). D. Black et al., Inequalities in Health: Report of a Research Working Group (London: Department of Health and Social Security, 1980). M.G. Marmot, M.J. Shipley, and G. Rose, “Inequalities in Death—Specific Explanations of a General Pattern,” Lancet (1984): 1003–1006. C. Power, O. Manor, and J. Fox, Health and Class: The Early Years (London: Chapman and Hall, 1991); and M.E.J. Wadsworth, “Serious Illness in Childhood and Its Association with Later-Life Achievement,” in Class and Health, ed. R.G. Wilkinson (London: Tavistock Publications Ltd., 1986), 50–74. U.S. Patterns of Mortality by County and Race, 1965–1994 (Cambridge, Mass.: Harvard Center for Population and Development Studies, 1998).
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e h av e b een c r iti c iz ed for not being specific enough and estimating the cost of our recommendations—in short, for not being political enough. We took the view that as a scientific group we were charged, as stated in our terms of reference, with “identifying priority areas for future policy development,” not with telling the finance minister at what level to set the rate of taxation and benefits. That the government cared about this issue sufficiently to set up an Independent Inquiry is an important first step. It will be vital to monitor what happens next.
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