Sir Michael Marmot: “Do something, do more, do better”
This is the strong, convincing and passionate invitation that Sir Michael Marmot loudly throws at the audience that takes part at the fourth edition of the 4words conference, in the session dedicated to sustainability; a plea that is directed to governments as well as to single citizens, to take action in order to diminish social and health inequalities and create the sustainability that future generations will require.
The battle for health fairness and for sustainability, according to the well-known British epidemiologist, can in fact be superimposed and could belong to the same single program. Sir Marmot demonstrates this by comparing the 17 sustainable development objectives set by the UN for the 2030 Agenda and the requests contained in “Just societies: health equity and dignified lives”, the report published in October 2019 by the Commission of the Pan American health organization on equity and health inequalities in the Americas (Paho), of which he is Chairman.
This report analyses the factors that affect people’s health conditions and suggests actions aimed at diminish health inequalities. The original assumption is that health is determined by social factors such as socioeconomic level, the ethnic group they belong to, gender, etc., as well as by three specific structural factors:
- the political, social, cultural, and economic context;
- the climate change, natural environment, the relationship with the land;
- the persistence of colonialism and racism.
All of these factors provide significant repercussions on people’s daily life conditions, as Marmot proves in his report. However, how to intervene practically? “It is required to create the conditions so that people may live a decent life”, stated Marmot, “only then we will have also created the conditions to promote health equity”, and in order to do that, two are the main mechanisms: promote human rights and act on health social determinants and on good governments, all of which are tightly connected.
However, Marmot clears away misleading assumptions, like the one that states that good health most of all derives from income: showing the National income level of Costa Rica that has a GDP of 17.000 dollars per-capita, adjusted for purchasing power, and the United States’ GDP, which is 58.000 dollars per-capita, simply shows that there is no relation between national income and life expectancy. “A country won’t get better health for its citizens by becoming richer”, stated the well-known epidemiologist. The United States has a per-capita GDP 20 per cent higher compared to Canada, for example, but the life expectancy is from 2 to 4 years shorter.
The data related to inequalities and mortality in the United States and Costa Rica confirm that: if it is true that a US citizen with a high socioeconomic level could expert a mortality level in fact shorter than in Costa Rica, it is also true that with a low socioeconomic level the US citizen will have a higher mortality rate than a Costa Rica citizen. In terms of pure income, a poor American is anyway much richer than a poor Costa Rican but, states Marmot, “in terms of health it will be more convenient to be poor in Costa Rica!”. To summarise, health is not just a matter of income. Inequalities in mortality are stronger, the gradient is steeper and when he talks about social gradient Marmot means not just that a poor person will have poor health, but that the lower you are in the social scale, the higher the mortality rate will be and the lower the life expectancy, heavier will be the burden for one’s health. This is a particularly marked phenomenon in the United States.
The inequalities in power, money and resources cause health injustice. “Health inequities are not a footnote to the health matter, they are the real issue”, states the epidemiologist strongly; therefore we shall intervene on their determinants with targeted social actions and political will: Argentina, for instance, has obtained the reduction of income inequalities thanks to an extended social protection system based upon “in kind” (public expenditures that translate into service performances and similar) transfers and “direct” (taxes and subsidies) transfers; Costa Rica has already intervened on environment in 2016 using renewable energy almost for 100 per cent.
If we realize the role that education has played in promoting the development of a decent life, we can understand the importance of the interventions aimed at facilitate the access to the education system since early childhood: attending preschool is critical because it will produce better school outcomes, the chance to gain a title that may ensure a higher income, better life conditions, a greater control of one’s own life and a better health. And all from early childhood. Simple interventions during preschool can make a huge difference, just as economic measures can contribute to stop child mortality: this can be seen in Brazil, where the conditional money transfer plan “Bolsa Familia” subsidises poor women as long as their children join a nutrition and health checks program and older children stay in school. The outcome is a reduction of mortality in five years old children and below (due in particular to diarrhoea and malnutrition) the greater the geographical area covered by the program. A similar outcome is achieved by the extensive social safety networks operating in Uruguay and Chile, where coverage is 90 per cent for people located in the lowest income quintile: “It will be possible to make a great difference very quickly!” emphasised Marmot passionately.
From childhood to working life, a serious problem affecting all of the Americas is the so-called “informal” work, i.e. work that is not regulated by legal or contractual rules, which implies dramatically worse working and health conditions. Luckily, the trend in the “informality” rate, announced Marmot, is positive in almost all of the Latin American countries. Likewise are reassuring, although with huge variations among the countries, the percentages of elderly people that in South America get a social security contributory pension, the only way to help them have a decent life.
In order to hope to intervene on health inequalities, it is necessary to think in terms of “macro-drivers”, suggests Marmot, as they are the factors that affect people’s health. This also applies to the prevention of violence, be it from illegal drug trades (as in the case of people involved in drug cartels clashes) or gender-based violence, as it happens in Bolivia, where two thirds of women are victims of violence from their partner. “This is a tragic proportion”, denounced Marmot, “that follows the social gradient: less education, communities that suffer from huge deprivation, greater risk of domestic violence from partners. Women’s right to live a decent life cannot be proclaimed if all this is happening”.
When we talk about climate, then, we shall always keep in our mind the repercussions on equity: there are zones in both Americas, like Honduras or El Salvador, where a large part of the population does not have access to uncontaminated water sources. And what can we say about air pollution? The mortality rate in Haiti and in Guyana is impressive. “In Delhi, recently”, said Marmot, “the air was so polluted that people were told not to go out in the streets. However, when the street is your home, what should you do? Air pollution hits people in an unequal manner as well”.
The great absentee of this digression on the promotion of health and sustainability would seem to be, paradoxically, the healthcare system itself, but in the end, Marmot specifies: “Healthcare systems are vital, but don’t think that spending more on the healthcare system is the solution”. Then he mentions the data elaborated by the World Health Organization showing that 10 per cent of the health of European population is due to the healthcare systems, while the remaining 90 per cent is due to social and environmental factors. This is the reason why Marmot reiterates that in the framework of a discussion on health inequalities and on sustainability, social factors proved to be central: “The sustainable development programme has made the concept of intergenerational equity clear. If we want the world we leave to our children and nephews to be a sustainable place, we must match the various forms of iniquities”, ended Marmot. “Good governance and human rights, these are the keys to act effectively on inequalities”, and the Nelson Mandela quote with which he ended his report couldn’t have been more appropriate.
“Overcoming poverty is not a gesture of charity. It is an act of justice. It is the protection of fundamental human rights, the right to dignity and a decent life.” – Nelson Mandela, London 2005
Silvana Guida, Il Pensiero Scientifico Editore
Commission of the Pan american health organization on equity and health inequalities in the Americas. Just societies: health equity and dignified lives. Washington, DC: PAHO, 2019.
Richard Wilkinson: Equity as precondition for sustainability
“Many people believe that inequalities matter only when they lead to poverty. I would like you instead to think of them in terms of relations”. This is how Richard Wilkinson, professor emeritus of social epidemiology at the University of Nottingham and author of many essays on the topic of inequalities, began his speech during the session dedicated to sustainability in the 2020 edition of the 4words conference. From this point of view, in fact, the many effects associated with inequalities of income have to do with psychological mechanisms of dominance and subordination, of superiority and inferiority, which influence self-perception and generate anxiety and worries about the judgement of others.
In the first stage of his report, Wilkinson has introduced a series of correlations between a country’s level of income inequality, specified as the relation between the average income of the richest 10 per cent and the poorest 10 per cent of the population, and various health, economic and psycho-social parameters. The first of these studies dealt with taking part to local groups and associations of volunteers : “It represents social cohesion, community’s vitality, how much we have to deal with others at a local level, he explained, and you can see that the participation rate in community life is much higher in the more egalitarian societies”. The second parameter considered was instead the level of mutual trust, investigated in the framework of a research asking questions like “do you reckon that other people can be trustworthy?”. These surveys show that in the less egalitarian countries people trust others significantly less. Other studies showed that in the less egalitarian societies people are less inclined to help those most in need, such as the challenged people or the elderly. “We essentially become more anti-social”, explained the British scholar. “There are studies, from all over the world, that show an increase even the homicide rates, because violence comes out in people that feel they are not being respected or that feel humiliated” . Furthermore, other studies have taken into account the level of happiness and health in people, showing how the quality of existing social relationships between the members of a community can be important. “How many friends do we have? Are we involved in community life? What is the quality of our relationships? These are absolutely critical aspects, for happiness as well as for health”.
Wilkinson then listed a long series of other parameters that he has proven were correlated to the income inequality level of various countries, among which child mortality, children’s well-being, bullying at school, the level of mathematic and literary knowledge, drug abuse, the imprisonment rate, mental health, obesity, social mobility and life expectancy. “It seems to be implausible that such different outcomes have really been influenced by the inequalities, he explained, but actually all these factors have a common element: these are problems characterized by a social gradient. […] We are not talking about anything different from what we have always called class or status”.
Nowadays, plenty of evidence related to the causes of these occurrences is available, and it proves how in the less egalitarian societies social classes or socio-economic status would become more influential. “The greatest material differences lead to greater social distances, highlighted Wilkinson, we have the tendency to judge mostly upon classes and status and to take into consideration external well-being as an indication for the internal one. Consequently, we worry much more about how we are seen by others and our anxiety relating to how others judge us increases”. A type of anxiety, this, that in the less egalitarian societies shows up more strongly regardless the income level. Showing a diagram related to status anxiety between groups having different income, in fact, Wilkinson has highlighted how this would be much lower in the more egalitarian countries compared to the less egalitarian ones. “What inequality does is impairing our confidence about our own value, he added, and this is true for many forms of chronic stress of which we know the biology and mechanisms through which they affect our health”.
Studies that have investigated which element would increase the levels of cortisol, which are associated with the level of stress, showed that the more impactful tasks are those that include a threat of social-evaluation. “Situations where you can be judged in a negative way”, explained Wilkinson. “This is what has surfaced from a meta-analysis of 208 different studies: we are particularly sensitive about this type of insecurities, worrying about how others see and judge us” . Now, thanks to Shery Johnson and her colleagues of the University of California work, we also know the reason for our sensitivity, thanks to what she calls the ‘System of behavioural dominance’” . According to this model, anxiety and depression are associated with feelings of subordination and submission and by the desire to avoid them, while the destructive behaviours and the maniac-narcissistic features are associated to self-perceptions of power or to a greater attention to social dominance. In the less egalitarian societies, thus, people have a greater probability to undertake feelings of low self-esteem and find social contact more stressing. “There are two types of answers in the less egalitarian societies: people that talk greatly about themselves and become narcissistic or even psychopaths, or those that get depressed or avoid social life”.
However, the way we mainly show ourselves to the eyes of others is, according to Wilkinson, through consumption. “There are many studies that show that if you live in a less egalitarian area you have a greater probability to spend money for a sports car, clothes and such. […] What we spend the money on does not produce any real benefit to society: the biggest spending in countries like the United States, Italy or the United Kingdom pertains to this form of status competition, which is a zero-sum game. It is obviously creating damages, because consumerism is one of the greatest obstacles towards achieving of environmental sustainability”.
The professor emeritus of social epidemiology of the University of Nottingham ended his speech talking about the relation between inequalities and climate changes. “I believe that greater equality is a precondition to move towards greater environmental sustainability. We know that in the less egalitarian countries the economic leaders deem the International agreements on climate less important, while in the more egalitarian ones they have a greater probability to act in favour of the environment. We also know that people recycle more in the more egalitarian countries and tend to use bicycles more. I believe that part of this connection with environmental problems concerns the first aspect that I mentioned: social cohesion. If you are less in touch with other people your interactions are mostly mediated by status competition. Finally, you are less aware of public good, of the good of mankind, which is a concept absolutely crucial in order to face the climate crisis”.
Fabio Ambrosino, Think2it
 Lancee B, Van de Werfhorst HG. Income inequality and participation: A comparison of 24 European countries. Social Science Research 2012;41(5):1166-78.
 Daly M, Wilson M, Vasdev S. Income inequality and homicide rates in Canada and the United States. Canadian Journal of Criminology and Criminal Justice 2001;43:219-36.
 Dickerson SS, Kemeny ME. Acute stressors and cortisol responses. Psychological Bulletin 2004;130(3):355-91.
 Johnson SL, Leedom LJ, Muhtadie L. The Dominance Behavioral System and Psychopathology. Psychological Bulletin, 2012;138(4):692-743.
Sustainability and health: do we need greater awareness?
“When I think of the word sustainability, it comes to my mind immediately the Italian National Health System”. This is how Silvio Garattini opened the session dedicated to sustainability, founder of the Pharmacological Research Institute Mario Negri in Milan. “Nowadays we give universal healthcare for granted, but its survival is really up to us”. According to Garattini our society has the tendency to give the right to health for granted, but forgets that rights go hand in hand with duties. One of them is to maintain our health, because if we don’t we do not just damage ourselves, but the whole community. Not all good lifestyles depend on us, though, because many depend on the society we live in the so-called social determinants. “I believe that what we need to take home from this session and from the word sustainability is the commitment to spread these concepts. Social determinants have a huge impact on the differences between north and south of Italy: from obesity to the mortality rate. This concept must enter primary schools, medicine schools, ministries, the Parliament. If we act together we will be able to do great things”.
“The topic the two speakers addressed today has been first of all a topic focused on social conscience and awareness”. Sabina Nuti, rector of the Sant’Anna High School of Pisa, is of the same belief, and she summarized the speeches of Sir Michael Marmot and Richard Wilkinson, two pillars of social epidemiology. The two speakers, with different but integrated perspectives, have in fact shown how the inequalities issues and their determinants are also crucial in the healthcare sector. Differences in terms of health and life expectancy have all too often at their origin socio-economic issues: education level, level of democracy in a social context. “We must raise our head on this topic, ends the professor, and ask our politicians to work in a medium-long period prospect, connecting the topic of sustainability to the change in our world system: climate changes, justice, fight against poverty”.