Michael Marmot
"We need to continue research, but we need to put the findings of research into action," said Marmot, who chairs the World Health Organization (WHO) Commission on Social Determinants of Health. The task of the commission is to identify and support interventions that will do the most to improve social conditions that determine health.
"People's social and economic circumstances affect health throughout life, so health policy must be linked to the social and economic determinants of health," he said. "What good does it do to treat people's illnesses, then send them back to the conditions that made them sick?"
In his most famous research, the Whitehall studies of British civil servants, Marmot discovered a surprising social gradient of decreasing health and life expectancy from the top to the bottom of a professional hierarchy, said Lisa Berkman, chair of the HSPH Department of Society, Human Development, and Health, in her introduction.
In other words, it was not the hard-charging executives most at risk of heart attacks; it was the people at the bottom of the hierarchy, which ran contrary to the thinking of the time. A second Whitehall study conducted on a different population of civil servants identified the mechanisms, such as participation in social networks and how much control they had at work.
Now, Marmot wants to address the gradients that have been identified within countries and between countries.
"We have a new mantra, borrowed from Geoffrey Rose: The causes of the causes," Marmot said. "It's not enough to think about the causes in the way that good public health professionals normally do." Rose was an eminent epidemiologist and a professor at the London School of Hygiene and Tropical Medicine.
The usual preventive public health tips include addressing the immediate causes of disease: don't smoke, drink in moderation if at all, don't get fat, and exercise regularly. Such advice, by itself, is not very helpful, asserted Marmot. Equally unhelpful for improving health outcomes would be advising people to change the social circumstances that may put them at risk of dangerous biological responses and risky behaviors: don't be poor, don't have poor parents, don't work in a stressful, low-paid manual job, practice not losing your job, and don't become unemployed.
A model for the Commission is structuring its work around the 10 policy implications developed from the evidence of social determinants on health by Marmot and a colleague in a booklet titled "The Solid Facts," published by the WHO Regional Office for Europe. The 10 action areas are stress, early life, social exclusion, work, unemployment, social support, addiction, food, the social gradient, and transport. These will need to be adapted and enhanced to apply to lower-income countries.
To prompt change, the Commission has several streams of activity. They are gathering evidence that goes beyond rigorous academic studies and includes the experiences of people. They want to identify and promulgate ongoing interventions that are working. And they want to reinforce and encourage leadership on policies with positive health effects, even if they were not enacted with health outcomes in mind, Marmot said.
"We did not want to get to the end of the process in 2008 and write a report that said, here you are, go ahead and implement it," Marmot said. "We wanted to point to countries who had been implementing it before and show how it works."
Marmot will have many examples to reference in his report. In March, a presidential decree in Brazil set up a commission on social determinants of health. A regional group in East Asia formed to learn how countries there developed from being poor nations to being countries with good health. A Nordic group is evaluating what can be exported from their oft-cited experiences that have relevance to other countries.
The Commission can also learn from Chile, which emphasizes inclusivity, universalism, and efficiency, Marmot said. HSPH professor Nancy Krieger asked about a new analysis in a recent book that showed universal programs tend to benefit the best-off people at the expense of the poor. Marmot agreed that the book made a convincing case that targeted, deliberate attempts to reach the poor be included in universal programs.
—CCM
Copyright, 2007, President and Fellows of Harvard College
