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Sir Michael Marmot: the health cost of austerity

Written by on 27 mai 2020

Sir Michael Marmot is the world expert on health inequality. In 2010 he was asked to chair a Review of Health Inequalities in England, known as the ‘Marmot Review‘. In it, the authors proposed the most effective ways to reduce health inequalities in years to come. In February this year, they published The Marmot Review 10 Years On. It revealed the adverse health effects of a decade of austerity politics in the UK. Sir Michael Marmot is an advisor to the World Health Organisation and the director of the UCL Institute of Health Equity.

Let’s start with the basics. What do we mean by these terms, health, inequality or inequity?

We mean differences in health between social groups. By tradition in the UK those social groups are usually defined on the basis of some socio-economic measure. In the past, we used to call it social class. It could be income, education, level of deprivation of the area in which people live. Increasingly, we’ve added inequality in health between other ways of defining social groups, ethnicity for example. In the UK, we talk about black Asian minority ethnic (BAME) groups.

And the difference between inequalities in health and health inequities is that those systematic inequalities in health between social groups that are judged to be avoidable by reasonable means, and are not avoided, are unfair and inequitable.

And according to your research, what are the driving forces behind health inequalities?

Well, the Marmot Review in 2010 looked at the causes of health inequalities in England and what we could do about them. And there was a lot of interest across Europe. It was an English review, but it tapped into similar concerns in other European countries.

So we identified six domains that are both causes and areas for interventions. Early child development. Education and lifelong learning. The third is employment and working conditions. The fourth was having enough money to live on, the minimum necessary for a healthy life . The fifth: healthy and sustainable places to live and work. And the sixth was lifestyle; smoking, drinking, eating and the like.

And you notice I haven’t mentioned healthcare. When people think about health inequalities, usually they think about inequalities in access to healthcare. Inequalities in access to healthcare are important, but they’re not the major cause of inequalities in health. Inequalities in health arise from inequalities in society. Our judgment was the way those inequalities in society operate is through those six domains that I’ve identified.

In your 2020 review, ten years on from Marmot 2010, you studied the health impact of the recession in the UK and the austerity politics that came in its aftermath. What were your findings?

“We looked at what happened between 2010 and 2020, and in terms of health, we saw three things. The first was the rate of increase of life expectancy slowed dramatically and nearly ground to a halt. Second, there was a continued increase in health inequalities. And third, life expectancy for the poorest women outside London actually went down. And the question was why? And it relates very much, I think, to what we’re going to do faced with the economic and social crisis that’s a result of the pandemic.

Well, the government in Britain in 2010 presented reduction of the debt and the deficit as some kind of moral question. They said we have no alternative to reduce the debt and the deficit. And they rolled back the state. Public expenditure in 2010 was about 42 percent of GDP. In France, it’s a bit higher than that. And by twenty, eighteen, nineteen, it had gone from 42 percent to 35 percent. And the second thing was this reduction in public spending was sharply regressive.

The poorer the area, the bigger the reduction in public spending. The poorer the family, the more they lost out as a result of the government’s changes. And we think when we go through each of the domains that I played up in Marmot 2010, public policy in each of those areas was in the direction that was likely to  damage health; increases toinchild poverty, closing off Sure Start children’s centres, reduction in spending on education, the rise of the gig economy, problems for families with children, economic problems, not having enough money to buy food, and problems with housing and the environment. So they all were moving in the wrong direction.

One of the outcomes of austerity you just mentioned was a decrease in life expectancy for some women. Why just women?

It’s a good question and it’s slightly unexpected, given that in general, the health inequalities that we see tend to be bigger in men than women. The House of Commons library did a report two or three years ago and pointed out that something like three quarters of the cuts associated with austerity had fallen on women. Whether it was the bedroom tax, whether it was cuts to child benefits… Now that impacts on families, so men as well, but particularly on women.

So faced with a recession like the one we’re beginning to see today because of the coronavirus pandemic, how do we protect health?

“I know what not to do. Don’t do what we did in 2010. That fetish with austerity caused damage. If our politicians believe that somehow they could get away with it, you know, that money was being wasted or whatever. Well, the evidence in my 2020 report is that that wasn’t true. We must not go back to the status quo. After the global financial crisis in 2007-8, there was a concerted effort to go back to the status quo, to let the finance sector be dominant, not to regulate them in any serious way. Austerity and making the poor poorer. But by and large, no real change.

I think that’s not the way to go forward. The two issues when you poll people that they’re concerned about are the climate crisis and inequality. My view is we’ve got to act on those at the same time. And that means asking ourselves the question of how do we do things differently? And the fundamental driver should no longer be growth of the economy or getting the debt and the deficit down.

It should be how do we create a better society with greater health and wellbeing and a fair distribution of health and wellbeing? And I’d like to think that my 2020 report says a lot of what we can do, it wasn’t just a negative report. It wasn’t just warning what not to do. It was a positive report. It said a great deal about how we could make things better and what we could do in each of those domains that I’ve listed.

What do you think should be the measure for the health of a nation?

Well, I’ve quoted the New Zealand government, their 2019 Treasury document. It puts wellbeing as the overriding objective to create the conditions for people to have choices and capabilities to lead the lives they value. Goodness, no mention of GDP. That prime minister in New Zealand wasn’t just good in a crisis. She was setting the direction for the country to say we want to create the conditions for better wellbeing for our population. How do we do that? That’s what we should be doing right across Europe.

And what role can the EU play, in your opinion, in bringing about a healthy recovery from this period?

“There are moves in the EU to talk about a green economy. A green new deal has to look at sustainability, and I would argue has to look at inequalities. The way we know if we’re moving in the right direction on inequalities is to look at health inequalities. Moving towards sustainability and equity at the same time. There’s much that individual member states can do, and there’s much I would say that the EU can do in setting the direction.

We’re facing huge challenges. But we need to get people looking at the evidence, both of what causes the problems, and what the solutions are, and unite around those to work towards creating fairer, more sustainable societies.”

Sir Michael Marmot is director of the UCL Institute of Health Equity, and advisor to the World Health Organisation. Health Equity in England: The Marmot Review 10 Years On was published in February 2020.


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