The social gradient for health

The United States spends more on healthcare than any other country but about a sixth of its population lacks health insurance. This should change gradually with the Affordable Care Act, Obamacare, but the figures are still not pretty. However, many Americans believe they have the best healthcare in the world.

Let us, for the moment, assume it is true. Why then would young adults in the US have less chance of surviving to 60 than young adults in Costa Rica, Cuba or Slovenia, let alone Sweden, the UK and most other European countries

It is a provocative start to a ground-breaking book — The Health Gap: The Challenge of an Unequal World.

The author, Sir Michael Marmot, does not rest with that rousing query, the inaugural teaser. His answer — medical care, and even public health, have little to do with life expectancy. The high mortality of young American men comes from homicide, suicide, car crashes, other accidents, drugs, alcohol and some other disorders. However, to Marmot, to blame homicide or other violent deaths on lack of medical care is a bit like blaming broken windows on a lack of suppliers of new window panes.

Such vivid imagery coupled with a style that engages and entertains even as it informs is what makes Marmot’s magnum opus of nearly 400 pages such compelling reading even if you are not a public health expert.

Marmot is not a man you take lightly. He is professor of epidemiology and public health at University College London, current president of the World Medical Association and chaired the Commission on Social Determinants of Health set up by the World Health Organisation in 2005.

The central question in the book goes to the heart of one of the most profound dilemmas of our times: Why treat people and send them back to the conditions that made them sick Why not deal with the conditions that make people sick or what is known in development jargon as “social determinants of health ”

In essence, that means where you are on the socio-economic ladder directly affects your health and life expectancy. Countries that have an overwhelmingly healthy population have got there by not just addressing the healthcare delivery system but many of the factors that impact health and which are outside the health sector.

Marmot’s book rests on the thesis that social injustice is bad for our health and an excessive focus on lifestyle and personal responsibility misses the point. Health can only be a personal responsibility, says Marmot, if social conditions allow all individuals to make healthy choices.

The book packs passion and punch. What makes it so engrossing is the extensive research the author has tapped into, both his and that of others. Page after page sledgehammers the message that the poorer you are, the more likely you are to live a shorter, less healthy and in all likelihood less happy life. This holds good between and within countries.

But this is not a simple matter of rich and poor. In every country, people who suffer from social disadvantage also face health disadvantage. Within countries, the higher the social status of individuals, the better their health.

Inequalities in early child development, for example, lead to inequalities in education. Educational outcome is typically linked to the kind of of job you get or whether you have a job at all, if you have enough money to get by, and the choices you make about smoking, drinking and lifestyle. All of these, Marmot stresses, will have an impact on health and health inequalities.

But it does not have to be this way.

“Taking control of your life and exercising, eating, and drinking sensibly, having time off on happy holidays, was all very well if you were comfortably off financially and socially,” Marmot writes. But “were we going to tell the immigrant with a marginal, lonely existence to stop eating fish and chips and take out membership in a gym ”

If you have access to good doctors, good dentists and the government provides health support in some form, you are likely to be in better health than those who don’t. But what explains poor health in countries where there is good medical care, a secure system and relative wealth The answer is massive inequities.

Marmot’s book underlines what many of us know intuitively but what policymakers are reluctant to acknowledge. Health of a nation is a proxy indicator of its political and economic choices, the incentives and dis-incentives that are on offer. The waistline of the planet is expanding — be it in Egypt or Mexico, 70 per cent of women are overweight. Rational choice, perhaps, but growth in processed foods and decline in opportunities for physical activity are more potent explanations.

Marmot taps into the work of many eminent Indians and those whose work has focused on India to make his case, including Amartya Sen, Jean Dreze, Abhijit Banerjee and Esther Duflo.

He dwells at length on “Education and Empowerment”, key determinants of health. There is an example of a Mexican scheme, where cash subsidies are given so families will take their children to clinics and keep them in school. Clearly, education is a form of empowerment, leading to better jobs, pay, conditions and health. He says India’s economic growth rate of six to eight per cent a year is the envy of the rich world, but it is likely that the benefits of that growth would reach further if education were more widely spread.

The Health Gap is of great relevance to Indians as it comes ar a time when many in policy circles view improvements in health through the prism of technical solutions alone — improved medical care, sanitation and control of disease vectors. These are important but what matters equally is what Marmot calls the social gradient.

If we put a value to healthy India, we need to have difficult and politically contentious conversations — what hampers creation of conditions for people to lead flourishing lives and empowering individuals and communities. A simple growth in gross domestic product alone will not reduce the health gap. To find out how countries have successfully reduced such a gap, read the book.

Patralekha Chatterjee focuses on development issues in India and emerging economies. She can be reached at patralekha.chatterjee@gmail.com