Achieving health equity in the Americas

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{***Noah***}

Coming up on Harvard Chan: This Week in Health…

What will it take to achieve health equity?

{***Michael Marmot Soundbite***}
(Costa Rica has a national income of $14,000 per person; life expectancy in Costa Rica is 79. In the poor part of Baltimore it was 63, but the household income is $17,000. And that is why we have to address the social determinants of health. It’s not only income.)

In this week’s episode: One of the world’s leading researchers on health inequalities outlines vast disparities across the Americas—and explains how addressing the social determinants of health can help narrow those gaps.

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{***Noah***}

Hello and welcome to Harvard Chan: This Week in Health…It’s Thursday, May 3, 2018. I’m Noah Leavitt. Amie Montemurro is off this week.

In recent years countries across the Americas have made major improvements in health.

But while life expectancy has increased and infant and maternal mortality rates have fallen, significant inequalities remain.

What can be done to narrow those gaps?

That’s the focus of a new commission launched by the Pan American Health Organization—or PAHO.

The PAHO Commission on Equity and Health Inequalities will eventually issue recommendations in three key areas: social and biological factors, such as healthy aging and race and ethnicity; socioeconomic and political context, such as economic and environmental policies; and pathways to health, such as social safety nets or policies to address obesity.

Members of the commission recently gathered at Morehouse School of Medicine to discuss strategies for achieving health equity.

As part of the gathering Michael Marmot, the chair of the commission, delivered a keynote address: “How Do You Achieve Change?”

The Morehouse School of Medicine was nice enough to share his speech and we wanted to share it with all of you.

Marmot is Professor of Epidemiology and Public Health at University College London and one of the world’s foremost researchers on health inequalities.

Marmot was also the Bernard Lown Visiting Professor of Social and Behavioral Sciences here at the Harvard Chan School.

During his half-hour long talk, Marmot outlined health inequalities across the Americans—from Baltimore to Haiti—and explained how addressing the social determinants of health is critical to narrowing health gaps.

He began his talk by explaining why Morehouse School of Medicine was an ideal venue for discussing this issue.

{***Michael Marmot Speech***}

MICHAEL MARMOT: To have a school of medicine that has as its mission health equity, I don’t know of another school of medicine in the world that has that. I know schools of medicine that the mission is about molecular biology, understanding more the genetic basis of disease, but not health equity. So it’s wonderful to be here and talk about equity and health in the Americas, except I am only a bit.

I’m not going to tell you about the conclusions of our commission, not because they are secret, because we’re not there yet. We’re working on it. But I will give you, I hope, an idea of what we’re doing.

My book, The Health Gap, the opening line was, “Why treat people and send them back to the conditions that made them sick?” And that’s what motivates them, motivates us. And it’s because we want to address what’s happening in the Americas that this commission has been set up.

I was talking about my book, The Health Gap. And I wrote about the US city of Baltimore. And just before I was giving a seminar in the US, Baltimore erupted. The precipitant for the civil unrest in Baltimore was the killing of a black man by the police, or should I say one more killing of a black man by the police. And that was the precipitant of the civil unrest.

But the underlying cause was inequality, because when I say Baltimore erupted, it wasn’t Baltimore. But it was the poor part of Baltimore, Upton/Druid particularly. And I’m going to talk about two people who grew up in Baltimore. And the life expectancy in Upton/Druid, where the riots happened, for men is 63. And in Roland Park, leafy Roland Park, it’s 83.

I was at a meeting in Johns Hopkins. And I was kidnapped by a couple of young doctors who said, you cannot sit here in this lecture hall and not see Baltimore. Come on. Off we go.

So we started in Upton/Druid. There are streets– some of you will know it. There are streets in that part of town where every second house has a diagonal red cross on the door. That’s saying that that house is not fit for human habitation. If there is an emergency, the fire and rescue and police service will not go into that house. Can you imagine what it’s like to live in a street where every second house is declared unfit for human habitation?

Half are single-parent families. Median household income in 2010 was $17,000. And I, please, would ask you to remember that $17,000 figure for a few minutes, because I want to come back to it.

The kids do poorly in school. 90% did not go on to college. Each year a third age 10 to 17 arrested for juvenile disorder. One third each year. The chance of getting to 17 without an arrest is very slim.

In theory, the slate is wiped clean at 18, and you’ll go for a job. And they ask, have you ever been in trouble with the police? You could lie, or you could tell the truth, which in this case is not a very good qualification for a job.

2005 to 2009, there were a hundred non-fatal shootings for every 10,000 residents and nearly 40 homicides. I’ve written recently that in the poor part of Glasgow in Scotland, there is a lot of violence. If you talk to people what it’s like to grow up in that poor part of Glasgow, and the answer is you’re surrounded by threats and violence all the time. But the murder rate is very low, because we don’t have guns.

It’s very hard to kill somebody with a knife. But if you’ve got an assault weapon, you might assault people. But I realize that’s un-American to say that. I’m a foreigner.

And then they took me to beautiful Roland Park where the Johns Hopkins faculty live– lovely, green, leafy Roland Park. Median household income, not 17 but $90,000. 93 percent two-parent families.

The kids do well in school. 76 percent complete college. Juvenile arrests, one in 50.

No non-fatal shootings and four homicides, not 40. Dramatically different. And a 20-year gap in their life expectancy. Life expectancy at 63 in the poor part of Baltimore is worse than the Indian average.

But it’s not just the black residents of the poor part of Baltimore that are at risk. You’ll be familiar with this, I think. This is Anne Case and Angus Deaton’s publication looking at mortality age 45 to 54 from 1990 to 2012 coming down in France, Germany, the UK, Canada, Australia, Sweden. Big differences between France and Sweden and rising in US non-Hispanic whites. That’s US Hispanics looks like the UK, rising in non-Hispanic whites.

And the causes, poisonings due to drugs and alcohol, suicide, chronic liver disease, which is alcohol in origin. Anne Case and Angus Deaton call these deaths of despair. And, not shown here, if you look at the geographic distribution of these deaths of despair, the higher the mortality from drugs, alcohol, and suicide, the greater the likelihood of voting for Donald Trump.

And what’s been happening to life expectancy in the US as a whole, this is life expectancy at 50 by year of birth. So people who were born in 1920 were 50 in 1970. And people who were born in 1950 are 50 in 2000. And you can see for the richest 10%, by income decile, the richer you were, the steeper the increase in life expectancy. The social gradient in life expectancy is getting steeper.

Now it’s Sunday afternoon. And I don’t want to spoil your Sunday afternoon. Are you feeling strong? Are you ready for this next slide?

This is men– oh my god. This is terrible. This is really terrible. Look at this.

The poorest 10%, life expectancy for women is going down. And the next 10% and the middle– sorry, the next 10%. The middle is just starting to go up. So the inequalities are getting dramatically wider.

In fact, the black-white differences are getting a bit smaller, which is very welcome. But the socioeconomic differences are getting bigger. And these gradients that we see, we see everywhere.

This is from Porto Alegre in Brazil. Socioeconomic level of districts, high, medium-high, medium-low, and low, and cardiovascular deaths a very clear social gradient. Looking at under-five mortality rates by income quintile, the poorest, next, next, next, next. That’s Bolivia, Colombia, Guatemala, Haiti, Honduras. We see these gradients everywhere.

Health inequalities are not confined to poor health for the poor and reasonable health for everybody else. But it follows the social gradient, which means not only do we have to focus on poverty and its impact on health, but we have to look at inequality. That means addressing the nature of society as a whole.

As you heard, the foci of our commission is ethnicity and looking at infant mortality for Afro descendant and non-Afro descendant. And in each of these countries, Afro descendants have higher infant mortality than non-Afro descendants. And by indigenous and non-indigenous groups, the blue is indigenous. And in each of these countries, indigenous have higher infant mortality than non-indigenous. So Afro descendant, indigenous, socioeconomic all making a contribution. They overlap.

This is a version of the Preston curve. It’s looking at– it’s plotting life expectancy against gross national income per person, adjusting for purchasing power. I asked you to remember $17,000. So look here.

Costa Rica has a national income of $14,000 per person at purchasing power parity. Life expectancy in Costa Rica is 79. For men, it was about 76. And the poor part of Baltimore was 63.

And they’re richer– because this is adjusting for purchasing power in the poor part of Baltimore. And it’s poor. No one’s in any doubt about that. But the household income was $17,000 adjusting for purchasing power. The average in Costa Rica is $14,000. But men in Costa Rica have 13 years longer life expectancy than in the poor part of Baltimore.

And that is why we have to address the social determinants of health. It’s not only income. If you’re poor- if you’re in a poor country– Haiti is poor. If the national income of Haiti went up, it is highly likely that health would improve. But when you get up to this Costa Rican, Cuba, Chile level and go all the way out here, there’s simply no relation between national income and life expectancy.

It’s very helpful if you’re in a poor country to get national income up to the Costa Rican level. But further increases in national income are not the route to better health. Addressing social conditions is the route to better health.

And it was because of that that we set up the WHO commission on social determinants of health. And unusually for WHO report, we said on the cover, social injustice is killing on a grand scale. WHO wondered what they’d got into with social injustice is killing on a grand scale. And we said that we needed to put empowerment at the heart of what we’re trying to achieve– material, psychosocial, and political.

In the wake of that, I was invited by the British government to answer the question, how could we apply the findings and recommendations of the global commission to one country, England? And I produced The Marmot Review. And we called it Fair Society, Healthy Lives. It was a statement that if you put fairness at the heart of all policy making, health would improve, and health inequalities would diminish.

I was then invited by the European region of WHO to conduct the European review of social determinants in the health divide. And the European region stretches right to the east. It covers the whole of the former Soviet Union. And there are some countries with very poor health. And now we have the Commission on Equity and Health Inequalities in the Americas with the aim to deepen understanding of the main drivers; focus, as you heard [INAUDIBLE] say, on gender, ethnicity, human rights; and the social, economic, environmental, political, and cultural arrangements that would shape health.

I want to go back, because I say we haven’t reached our conclusions on the American Commission, to my English review to give you just a few examples of the kind of action that we proposed in England and that we may well propose in this commission. So in my English review, we had six domains of recommendation– give every child the best start in life, education and lifelong learning, employment and working conditions. Number four was really radical. In a rich country, everyone should have at least the minimum income necessary for a healthy life. The fifth was healthy places to live and work. And the sixth is what I call the causes of the causes, looking at prevention, the causes of ill health– smoking, drinking, diet– but looking at the causes of the social distribution of smoking, drinking, diet, and the like.

Blue and red is not a political statement. I’d like to ask you for the moment to focus on the blue dots. We’ve been monitoring social determinants in England. And one measure that we look at is the proportion of children age 5 that have a good level of development for every local authority in the country. And the blue dots are the average.

So what you can see is the more affluent, the less deprived a local authority, the greater the proportion of children age 5 that have a good level of development. There’s some scatter around the line, which I’ll come to in a moment. But one strategy for improving early child development, which will then translate into better education and better job, more skills, and better health in adult life– one strategy for improving early child development is to reduce poverty. Bring the deprivation level down, the affluence level up towards the middle, and you’ll improve the proportion of children age 5 with a good level of development.

Now you’re allowed to look at the red dots. The red dots are poor children. One way we measure poverty for children in England is eligibility for free school meals. It’s a means-tested benefit. Only the poor children are eligible for free school meals.

When I saw these data, I thought, we’ve got it wrong. I didn’t predict that the poor children would do better in poor areas. I predicted that the poor children would do better in rich areas.

So when I saw these data, like any scientist, I said, the data must be wrong. It’s not possible that my ideas could be wrong. It must be the data. So change the data.

You know what? That’s what you do. That’s what the politicians do. Stop it.

But unfortunately, as Lord Keynes said, when the facts change, I change my opinions. What do you do, sir? And I had to change my opinions, which is very tough for a scientist to change your ideas. The poor kids are doing better in the rich areas. What’s going on?

So I went up to East London, a poor area of London, Hackney. So look at England first. 60% of children age 5 have a good level of development, children eligible for free school meals– the poor kids– just under 45%, the gap just under 16%.

Now Hackney, a poor area of East London, the poor kids are doing as well as the English average. And the gap is only 4%. I said to the director of education in Hackney, what are you doing? And she said, we tell ourselves every day poverty is not destiny.

And that’s what I heard from Martha and David last night about your programs with poor children in Atlanta. Poverty is not destiny. We want to reduce poverty. But we also want to break the link.

Now Bath and North East Somerset– I don’t expect you to know the social geography of Britain, but Bath is a beautiful Georgian city set in rolling hills. It’s absolutely gorgeous. And I caught a train to Wales, stopped at Bath. And I called out, “What do you do for poor kids in Bath?” Now I’m not hearing voices, but I imagined they called back saying, poor kids? We didn’t know we had any.

Aha. Maybe that’s what’s going on. If you don’t focus on the problem, you can’t do anything about it. In Hackney, they focus on the problem. That’s why they get out of bed in the morning. And it makes a real difference.

I don’t know why people lie about what’s going on. The truth is so much more compelling than falsehoods. And the other side, of course, and I learned about ACEs right here in Atlanta. That was the first time I know that studies were done in California. But I heard about them in Jeff Copeland’s house here in Atlanta.

And in England, these Adverse Child Experiences– incarceration, drug abuse, sexual abuse, all these– follow the social gradient. The lower the social position, the greater the likelihood that children will be exposed to adverse child experiences. And if you could eliminate adverse child experiences, you could potentially reduce early sex by a third, unintended teen pregnancy by 38%, smoking, binge drinking, cannabis use.

Look at this. Half the perpetrators of domestic violence were themselves exposed to four or more adverse child experiences. And half the victims of domestic violence were exposed to four or more adverse child experiences.

Early child learning programs can regress some of the issues that come from chaotic family life. And changes in pre-primary education are very impressive and encouraging. In most of these countries, more children are being enrolled in pre-primary education.

And enrollment in pre-primary education is a potent predictor of success in the school system. Kids who spend a year or more in preschool perform better at age 15 on standard tests. Key contribution of work and employment.

One of the issues that we face in the Americas, this is vulnerable employment. In Peru, more than half of women are employed in vulnerable employment. And what that means is that there are no occupational health standards. There’s no security of tenure. There are questionable working conditions.

And it’s an issue, particularly for women, for men too in Colombia, Jamaica, but it’s particularly gendered. And time spent on unpaid work by gender and indigenous status, so in Colombia– indigenous, non-indigenous– Ecuador– indigenous, non-indigenous– you can see that particularly women from indigenous backgrounds are more likely to be spending time on unpaid work. And Afro descendant women, Afro descendant men, non-Afro descendant women, and non-Afro descendant men, Afro descendant women and men are more likely to be unemployed in country after country.

But poverty– what are health people doing talking about poverty? Can we do anything about poverty? Well, you can, actually.

These OECD countries– there’s the United States. It’s looking at child poverty defined as less than 60% median income. In the US, 29% of children are in poverty. In Mexico, 31.6% in poverty.

David will remember, four years ago I addressed the American Public Health Association meeting, 8,000 people. And I showed something similar to this, that the US has such high child poverty levels. And I said– this was four years ago. You had a different person in the White House.

And I said, you live in a democracy. This must be the level of child poverty that you want. Otherwise, you’d elect a government that did something different. But can you change that? Well, yes you can.

This is reducing child poverty by social transfers– taxes and benefits, welfare. Finland reduces its pretax child poverty by 2/3 by taxes and transfers, Iceland similarly, Norway, Denmark Ireland, Sweden, even poor old UK. Oh, you’d rather not use the tax and benefits system.

I was teaching a global health class. And we had a student from Sweden. And when I talked about child poverty and the effect of government policy, this student from Sweden was really confused. She said, you mean some countries just operate their tax and benefit system to have high levels of child poverty? She couldn’t understand why any country would do that.

It is difficult to understand, isn’t it? Why would any country do that? Why would your country only reduce poverty by 18% by taxes and transfers? Pretty rich place.

And my country has decided to make inequality worse. This is the long run impact of tax and benefit reforms in the United Kingdom between 2015 and 2019. Look at families, working age families with children by deciles of income.

If you’re in the bottom decile, the bottom 10%, the Minister of Finance has decreed changes to the tax and benefits system that will lead to your income dropping by 9.5% by 2019. If you’re in the second bottom decile, your income will drop by more than 12%. And then the higher your income, the less the drop. It’s quite possible for the Minister of Finance to redistribute income. Our minister of finance is doing it, just redistributing it upwards and making families with children worse off.

I had a senior politician in London say to me, I’ve been listening to the evidence you gave to the Scottish Parliament. And I thought, what? You’ve been doing what? You should get out more.

And he said, you’re anti-government. And I said, no, I’m not. I’m pro-health equity.

Any policy that’s likely to have an adverse effect on child poverty will have an adverse effect on health inequalities. And that’s what I’m against. And in the US, a less progressive tax code from the 1960s, this is the top 0.1%. From the 1960s to 2013, the top 0.1% had a reduction in their tax by 2.1 percentage points and the bottom 50% an increase by 4.3 percentage points. You’re doing what we’re doing, making the tax system more regressive.

And the much vaulted recent tax bill, by 2027, the top 0.1% will get a 3% reduction. And the bottom 50% will get a 2% reduction. This is what the evidence shows.

But it’s possible to make a difference really quickly. Look at Peru. Under-five mortality per 1,000 live births by mother’s education. No education, primary, secondary or higher. The gap, 35 to 106, is 71 to 1,000 live births.

Now, 12 years later, there’s still a gradient. But the gap’s 23. This is why I’ve been going around the world describing myself as an evidence-based optimist. The evidence shows we can make a difference.

At a meeting of our commission in Washington, DC, I went for a walk in the mall. And I found myself in the area devoted to Martin Luther King. And you’ll be familiar with this. “I believe that unarmed truth and unconditional love”– and I thought, evidence-based policy. Yeah, unarmed truth presented in the spirit of social justice.

Well, unconditional love sounds rather better than my version of it, but that will do. We’ll have the final word in reality. That is why right temporarily defeated is stronger than evil triumphant.

I was on a current affairs television program to trail my lectures. And I was asked by the chap in the middle who keeps score something about income inequality. So I said, what do the 48 million people who make up the population of Tanzania have in common with the 7 million people who make up the population of Paraguay and the 2 million people who make up the population of Latvia and the top-earning 25 hedge fund managers in New York? And the answer was the previous year, each of those groups had a combined income of around $25 billion.

I said, imagine that the hedge fund managers gave up their money for one year. They wouldn’t miss it. They’re going to make a billion dollars each the next year. And you transferred that $25 billion to Tanzania, you could double the per capita income.

I’m not suggesting giving it to individual Tanzanians, although that would not be a bad thing to do. But imagine the clean water you could pipe to villages, the clean cookstoves you could supply, the nurses, the teachers you could employ. Now I know this sounds unlikely. But just suppose the hedge fund managers said, we could not care less about Tanzania.

Here’s an even more fanciful thought experiment. Imagine they paid one third of their income in tax. You and I pay a third of our income in tax. But imagine that hedge fund manager. I know it’s fanciful. But if they paid a third of their income in tax, you could employ 90,000 New York school teachers.

And someone else on the panel said, you’re in fantasy land, mate. You’re in complete fantasy land. That’s never going to happen.

I was a bit shocked by all this. And I quoted Halfdan Mahler, the legendary former Director General of WHO. I said, the idealists of today are the realists of tomorrow.

And the next day, I went to an aboriginal community health center 50 kilometers south of Sydney. And the doctors greeted me with it– they watched this television program. The doctors greeted me with a sign.

So let me invite you into my fantasy land. And let’s dream of a fairer world. Thank you.

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{***Noah***}

That was Michael Marmot discussing health equity at the Morehouse School of Medicine.

And if you want to learn more about this, we’ll have much more information on our website, hsph.me/thisweekinhealth.

You’ll find video of Michael Marmot’s speech and also more information about the PAHO Commission.

And you heard Marmot discuss Angus Deaton’s research on “Deaths of Despair.”

Marmot and Deaton recently spoke together about that during an event here at the Harvard Chan School, and we’ll have a link to a story about that as well.

Again, you can find all that at hsph.me/thisweekinhealth

That’s all for this week’s episode.

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