Sir Michael Marmot, who was recently in Australia to deliver the ABC’s 2016 Boyer lectures is one of University of Sydney Medical School’s most distinguished alumni. So wrote Emeritus Professor Stephen Leeder, of the University’s School of Public health, when he reviewed Marmot’s book, The Health Gap: the Challenge of an Unequal World, for the Medical School’s Summer edition of Radius earlier this year.
As you will see below, Leeder penned not just a review, but a tribute and a fitting read, as we wait for the ABC to broadcast Marmot’s remaining Boyer Lectures in the coming weeks.
Stephen Leeder writes:
When Michael Marmot was an intern at Sydney’s Royal Prince Alfred Hospital, Peter Harvey, a chest physician, recommended that he pursue a career in epidemiology because he ‘was asking too many awkward questions’ about the influence of social class on the health of the patients he was seeing, so Marmot went to America with that purpose.
Epidemiology with heart
At Berkeley School of Public Health he worked with Leonard Syme, epidemiologist and social scientist, comparing heart disease death rates among Japanese people who had migrated to California. Those who retained their “Japaneseness” had less heart disease than those who assimilated. This could not be explained by differences in dietary habits, smoking, blood pressure or obesity. This was not to say that the conventional risk factors were powerless but rather that societal factors were at work as well.
After a productive stint at Berkeley, Marmot moved back to London, where he’d been born and lived for his first four years. He was attracted to London’s social stratification as an object of study.
He began working with epidemiologist Donald Reid at the London School of Hygiene and Tropical Medicine in 1976, and settled in London, directing the Institute of Health Equity at University College London (UCL).
In the 70’s Marmot showed that London civil servants at Whitehall differed in their health according to where they fit in the hierarchy. Again, conventional risk factors did not explain all the variations. Empowerment and control, more the higher up, modified their influence.
That a medical epidemiologist has not confined himself to the study of death statistics about men and women, broken down by age and sex, is itself remarkable. But Marmot has also led a tireless campaign for the recognition of the importance of social determinants of health and the necessity of social change for the achievement of equitably distributed health and health care.
Policy shaper, gentle disrupter
Medical interventions alone will not solve this problem. With age he has become, in his own words, more involved in policy and politics as powerful conduits for the evidence accumulated from social and epidemiological studies.
He was a keen commuting cyclist until a serious fall left him with a fractured femur in 2013. He is president-elect of the World Medical Association, having served as president of the BMA.
Marmot’s career says much about his political skill for communicating his disturbing moral message without lighting fires in conservative tents.
He has a prodigious research pedigree and yet also possesses the ability to lead the development of health policy – in the UK and through international commissions at the WHO – that expresses in readily understood and challenging terms the facts of social inequality, the horrible gaps especially in health that exist worldwide between the haves and the have-nots, the empowered and the disempowered, of which our Aboriginal health gap is a glaring and depressing example. Equally importantly he offers suggestions, based on evidence, on what can be done.
A book of conviction
Marmot’s latest book, The Health Gap: the Challenge of an Unequal World, reflects what the BMJ describes as ‘his conviction that evidence should form the basis of policy and that people can make a difference’.
In an interview with the BMJ in September this year, Marmot was asked: What personal ambition do you still have? He replied, “Encouraging as many countries as possible to become active on social determinants of health: social justice demands it. As president of the World Medical Association I want the doctors to take action, too. Health equity is a global concern, and evidence shows that we can make a huge difference really quickly. My ambition? I want my evidence-based optimism to catch on.”
The Health Gap has 11 chapters. It is encyclopaedic – always readable, erudite, evidence-informed, warmly personal and frequently entertaining. Marmot begins with an examination of the factors that lead to health inequalities that are unjust – principally because they are amenable to change. These he refers to as health inequities, driving home the ethical dimension.
The second chapter explores the tension between social and personal responsibility for health. Marmot came in for stern criticism for his advocacy for an understanding of health that was seriously socially determined, with the London Telegraph accusing him of leading an unholy alliance of ‘puritans, health fascists and nanny-state control freaks.’
The chapter concludes by quoting Amartya Sen’s words that our task is ‘to create the conditions for people to have the freedom to lead lives they have reason to value’.
In later chapters Marmot considers the power of early childhood experiences to shape our physical and mental lives. He explores the interplay between health and education, and the reciprocal relation between work and health (or illness) and the importance of a sense of control for workers to remain healthy.
Optimism in action
The book concludes with an examination of the impact of the various reports and commissions that Marmot has inspired and worked on, and their global reach. In October 2011, the First World Conference on Social Determinants of Health was held in Rio de Janeiro – a watershed event with wide international subscription and endorsement.
Marmot is an undentable optimist. With regard to overcoming the disempowerment that spins out from the way we organise and sustain our societies and damages health, Marmot has a message for everyone who occupies a powerful position, including doctors. “Do something. Do more. Do it better.”
THE HEALTH GAP: THE CHALLENGE OF AN UNEQUAL WORLD Michael Marmot Bloomsbury pp 387 RRP $35.00
*Stephen Leeder is emeritus Professor of Public Health and Community Medicine, Menzies Centre for Health Policy and School of Public Health, University of Sydney
This is a lightly edited version of a book review that first appeared in Radius Sydney Medical School Magazine, 2016 Summer Edition.