Scitech | WHO commissioner comments

Grave inter- and intra-country inequities in health outcomes

Last Thursday afternoon, Sir Michael Marmot, Chair of the World Health Organization’s Commission on the Social Determinants of Health, spoke to an audience of over 600 people at the Léa-Roback Research Centre on Social Inequalities of Health in Montreal. Marmot delved into the Commission’s findings and pointed to the steps some countries are taking in reaction to the research.

As the Commission’s report describes, social determinants of health refer to the “conditions in which people are born, grow, live, work, and age,” that affect a person’s health outcome. The report goes on to state that, “where systematic differences in health are judged to be avoidable, by reasonable action globally and within society, they are, quite simply, unjust. It is this that we label health inequity.”

In his talk, Marmot detailed the social gradients – such as inequalities in income and education – that lead to differential health outcomes. Though the Commission completed its work with the publication of the final report on August 28, 2008, Marmot hopes individual governments will continue to act upon the research. He cited the example of the United Kingdom, which has announced an internal review of health inequities, with the purpose of identifying positive country and region-specific policies and practices to correct these inequities.

The McGill Daily sat down with Sir Michael Marmot after his speech to talk about the Commission’s findings, University politics, and the intricacies of health outcome determinants.

McGill Daily: What surprised you most about the Commission’s findings?

Sir Michael Marmot: One was the 28-year gap in life expectancy in Glasgow [a life expectancy of 54 years for people in the district of Calton and 82 years for people living in the district of Lenzie, two neighbourhoods separated by a few kilometres ] and the fact that the poorest people of Glasgow have worse health than the average in India. And, the reverse of that are the countries of relatively low income that have remarkably good health. You can compare countries like Sri Lanka and Russia. Sri Lanka has lower income than Russia and much better health, and that really is a surprise…. These contrasts between remarkably poor health in rich countries and remarkably good health in relatively poor countries, and that clear overlap was a very striking finding. That’s why it leads me to conclude that this [health inequity] is a problem for all of us whether we’re in high income, middle income, or low income countries.

MD: What role do you think universities can play in improving health outcomes for marginalized populations?

MM: The twin roles which are the traditional roles of research, education, and training are obviously key. But also, some university students are keen to get involved in applying their knowledge, not just in gaining the knowledge, not just in doing the research, but saying: “how can we apply it?” So, I think universities have all three roles: the training, the research and understanding, and for those who are interested, the help in application. The other thing…is the wider role of the university. It is an employer, so it has an impact on its local community, and of course it has admission policies, all of which are relevant…. I can’t give you examples of universities that have specifically used those broader functions in low- and middle-income countries. But that said, there are many universities that make linkages with groups in low- and middle-income countries and establish partnerships, which I think is to the benefit of everybody.

MD: There have been examples where research on the social determinants of health in one region or country have been projected onto another region of the world. Do you think this is a tendency, and whether or not you do, what can be done to avoid this?

MM: I think that we have to exercise judgment. Most of the research that goes on in the world goes on in high-income countries. The causes of heart disease are likely to be the same wherever you find them in a narrow biological sense, so that you don’t need to reproduce all of the research on standard biological predictors of heart disease…in every country, to say we know something about causes. Where you get into trouble, is when you’re looking at social, political, cultural, community type aspects, as they do differ. So whereas cholesterol is going to be a risk factor for heart disease whether you’re in Africa, Asia, or North America, the nature of community organization will differ in those different contexts…. It doesn’t mean that everything that is done in high-income countries in terms of research is automatically not applicable in low-income countries, I mean that would be silly. Just as silly as assuming that it is automatically applicable.

MD: Paul Farmer is an advocate of something he calls the “preferential option for the poor,” a concept which advocates giving the poor more than their “fair” share of resources in order to correct health inequities. What do you think about this concept?

MM: I think you’ve got to look carefully at what you mean by fair, when you say “more than their fair share.” If you reach the judgment that the potential benefit of spending is going to be greater where the problems are manifestly greater, then I would say it is fair; it is not more than fair, to invest in those areas where the problems are greater. Where that’s not the case, one’s got then to have a moral position and say, “okay, it might be that it’s harder.” What if the return to investment was more by investing in the suburbs of Montreal than it would be investing in the suburbs of Dakar? If the return to investment were greater in Montreal than in Dakar, should we invest in Montreal rather than Dakar? Well, then we’ve got to exercise ethical judgments and say, “it’s not only return to investment that we’re considering, it’s actually what lays claim on our spending, and it may well be the disproportionate ill health in Dakar compared with Montreal would be the thing that should lay claim to our attention.”

MD: Some people have used the concept of social determinants of health to say that AIDS is a disease of poverty. What do you think about that statement?

MM: Well, it is not quite true. You can call it what you like, but it isn’t quite true. The evidence is that in various African countries, it is not actually the poorest that get AIDS and there are a number of potential reasons why that’s the case – one’s got to be a bit careful. Yes, in general AIDS may well be a disease of poverty. It hasn’t always been that way, and nor is it that way in specific contexts. It may well be that the very poorest aren’t travelling about and aren’t engaged in the wider world, so they’re not at risk. You actually have to be slightly higher-income to be travelling and buying sex, or whatever it is that you’re doing which then puts you at risk. So I think one’s just got to be careful and make sure that the empirical data support the position.

MD: Is the idea of the social determinants of health necessarily synonymous with the social gradients in health?

MM: No, it’s not. The social gradient has been a particular obsession of mine, and it’s clear to me that to address the social gradient in health, you have to address the social determinants of health. But, in large parts of the world there are big gender inequities in health that need to be addressed through addressing the social determinants – that’s not the social gradient. That’s saying that in large parts of the world, women and girls don’t get equal access to education, or food, or health care. So these are social determinants, but it’s not the social gradient.

MD: You said in your lecture that often inequity is a decision made by governments. Does this mean that the population the government represents is disengaged and disinterested in health equity?

MM: Well, that’s not exactly what I said. What I think I did say was that the Minister of Finance can have a big impact on the proportion of people who fall below the poverty line, by the operation of the tax and benefits system. The problem of course, is that if you have an election every three or four or five years, a lot of decisions get taken in that period, and although the population votes, it doesn’t mean it’s voting for each of those decisions that are being made. They’re voting for how the government appears at the time, and so on. And so, when the government changes, it doesn’t necessarily mean that the people were all left wing before and now they’re all right wing, or right wing and now left wing. It means that the last government looked sick or tired, or incompetent. It doesn’t necessarily mean that the population has changed its general view of how things ought to be. So, I think it would be a mistake to read too much into a specific policy decision and say that necessarily reflects the will of the people.

– compiled by Nikki Bozinoff


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