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dr. georges benjamin: one of the opportunitiesof my job is i get to meet some fascinating people. i really get an opportunity to introduceour keynote speaker, professor sir michael marmot. let me tell you a little bit aboutmike. as many of you know, he is really the guy that has pulled together this conceptamong others in the world. he really focused this issue on the social determinates of health.he's really gotten our attention on this issue, globally.he just recently finished chairing a commission for the world heath organization on the socialdeterminates of health, which we believe really will set up a conceptual framework on howwe should approach this issue. in the year 2000 he was knighted by her majesty the queenfor services to epidemiology and understanding
the whole issue of health inequities. it hasreceived international acclaim. he's vice president of academia europea, aformer associate member of the institute of medicine, and a chair on the commission onsocial determinants of health set up by the world health organization. he won the balzanprize in epidemiology in 2004. gave the harveian oration in 2006 and won the william b. grahamprize for health service in research for 2008. those are awards which are important but letme tell you a little personal story. i'm sitting up in my office trying to figureout who would be best to talk to us at this time of transition around public health. anemail came across my desk of an exchange that i saw with some of our members and michael,basically with him giving his regrets that
he was not able to make it for one of theirsessions that they were trying to pull together; kind of bemusing the fact that, well if itwas just a day or two early he could probably make it.a light bulb went off and i got my blackberry out and sent him a quick email. he was ableto make it. he flew here from london last night. he'll be with us today. he's hoppingon a plane tonight and hopping back through london to be in stockholm. he wanted to behere. with that i just want to bring to the podium my friend, sir michael marmot.now, one other thing, i was in london fairly recently and we missed another opportunityto give an award to dr. marmot. i'd like to bring professor alan maryon-davis back upfrom the royal society of public health for
just one moment for a special presentation.alan maryon-davis: thank you. the royal society of pubic health, just to continue where ileft off, has approximately 7,000 members worldwide and confers over 100,000qualifications per year. now that may be small in american term but it's pretty big in uk terms. the society works closelywith the uk department of health, the european union, and the world health organization. it's a new and strong, powerfulvoice for public health in the uk and globally. the accolade of honorary fellowship of the royal society for publichealth is a rare distinction.
only a handful are awarded each year to peoplewho've truly distinguished themselves and are at the very top of their game.without doubt, professor sir michael marmot is absolutely at the top of his game. i firstmichael back in the '70s, the 1970's, when michael was working on the whitehallstudies with professor jeffrey rose and looking at the effects of social gradient on health outcomes. i was workingat the health education council and michael advised us on reaching disadvantaged people. even in those early days, that journeycontinues right up to today with the publication on the commission on -- the
report of the commission on social determinantsof health. this report is hugely important and reenergizes the whole debate about social justice that began with thosevictorian social reformers. i have very great pleasure, indeed, in conferring the honorary fellowship of the royal society forpublic health on professor sir michael marmot. michael marmot: my goodness what a lot ofpeople. it has been a long journey, and i don't mean coming from london to san diego. i mean coming from the 1970's and doingresearch on the social gradient in health and trying to take it to the point.
having been a researcher all of my life, whenpeople ask me at the end of publishing a paper the question "so what?" i would say, "another paper." that's what you do.maybe i'm just getting older but i think the "so what?" question is the one that i want to address today. it was, indeed, themotivation for agreeing to chair the who commission on social determinants of health. we published out report on the 28thof august. if i can have my slides up. that's a wonderfullogo but i'm going to be a little inhibited if i have to speak to that for 20
minutes. we published the report on the 28thof august. we called it "closing the gap in a generation." it was a statement that it was the judgment of the commissionthat we have the knowledge to make an enormous difference. do i think that the health gap will close in a generation? noi don't because i don't think that we will apply the knowledge that we have.in a way the challenge that i want to put before you today, and what the commissiontried to put before the global community when it published its report, is that we dohave the knowledge. we do know what to do to close the health gap in a
generation. it was put to us at the beginningof the commission's work, that no government would take us seriously unless we could show that it was good for the economyto improve health and reduce health inequities. i resisted that argument stubbornly. in theevents of the last weeks i would say, "bear that out." the position we took was that improving health, and promoting healthequity, was a matter of social justice. we should do it because it is the right thing to do. if we don't do it having, in our hands, the meansto make a difference we will, rightly, be judged harshly for
that failure. we put, at the heart of whatwe were considering with the commission, empowerment of individuals, of communities, and indeed of whole countries.we see empowerment as having the dimensions ofmaterial well being; if you can't afford to feed your children, you can't be empowered;psycho, social, having control over your life, and political -- having voice.the commission was seeking to create the conditions for people to lead flourishing lives. oneof the criticisms that, predictably, we got in recommending actionon the social determinants of health: aren't you taking away from individuals,
their own responsibility? my argument is,absolutely not. what we are trying to do it to create the conditions where people can take control over their own lives. theycannot control their own lives. they cannot make decisions that improve their health without material, psychosocial, andpolitical empowerment. that's what we're seeking to achieve.please bring my slides back. there's this conditioned reflex, when you clap they thinkit's all over. why now? i could expand on that at some length but i won't. i wouldsay there is a tide running in our favor at the moment but we have to seize that
tide. if we don't it will run into the sand.we have the opportunity to make a difference. i'd like to think that the election that you're having here quite soon,at long last. and americans think cricket is boring. this is the moment.the commission was concerned with health inequalities within and between countries and we took theposition that health inequalities that are judged, to be avoidable,are unfair and hence labeled as inequities. i'll say a word about the social gradient. when we published out report, youwouldn't know if from the us press because it was ignored completely. if you read
the british press it was widely covered, butyou would think our report was all about glasgow. men in the worst off area of the scottishcity, glasgow, have a life expectancy of 54. in the best they have a life expectancy of 82, a 28-year difference inlife expectancy. now i know that in the us, rightly you are concerned about differential access to health care. we, inbritain, have a national health service. it's not perfect. it's close to universal access. there are differences but everybodyin glasgow has access to primary health care, free at the point of use. there is
a 28-year difference in life expectancy. lifeexpectancy for men in glasgow is eight years shorter than the average in india. in india, 80 percent of the population liveson $2.00 a day or less. no one in glasgow lives on $2.00 a day or less.you turn on the tap in glasgow, sorry the faucet, and the water that comes out is safeto drink. there's sanitation. people have enough calories and they have shelteryet there is that 28-year gap. in washington, dc; 63 life expectancy for a black man. in montgomery county, maryland close-byit's 80, a 17-year difference. i show the glasgow figures a long with the
washington, dc figures because you might immediatelyjump to the conclusion that the washington, dc versus montgomery county, maryland is because of lack of access to healthcare. it has to be the right thing to do to construct a health care system that has universal access, regardless of abilityto pay. do not for one moment believe that if youachieve that you will abolish health inequities. very little of that 17 year gap between washington, dc and montgomery county,maryland could be attributed to lack of health care. i make no comment about
the cuban figures versus the us other thanto say it's one of the triumphs of us foreign policy, which is not setting the bar very high.i said i wanted to touch on the gradient. in showing you the figures for the poorestversus the richest part of glasgow it's possible to think that the problem is thepoorest of the poor. we have to address the problem of the poorest of the poor. in the whitehall study british civil servants-- no one lives on $2.00 a day or less, the global definition of poverty. yet there's a social gradient; the lower you arein the hierarchy the higher the mortality.
it continues to the oldest age. if you say british civil servants may be wonderfulpeople but we're not going to make health policy on the basis of the british civil service then his life expectancy atage 25, by education, in the us it is a social gradient. the implications of that are quite profound.if you focus on the poorest of the poor we can all sign-up. politians of all partiescan sign-up to the aim of eradicating poverty but the social gradient means thatwe have to take action across the whole of society. we're all involved. if people
second from the top have worse health thanthose at the top, people third from the top has worse health than the second from the top. we're all involved and that impliessocial action across the whole of society. so important is the education that it hasa profound effect on health. it's been estimated that medical advances averted 180,000 adult deaths in the us between 1996and 2002. that's enormous, absolutely enormous. when you think of any other figure for deaths; whether it's iraq or 9/11,whatever it is, 180,000 adult deaths averted is enormous; a great triumph of
the medical system.addressing educational inequalities would have saved 1.4 million lives. i know thatit is of deep concern: the issue of racial/ ethnic differences in the us. we put,in the report of the commission on the social determinants of health, this figure that in the us 886.202 deaths wouldhave been averted between '91 and 2000 if the mortality rates between whites and african-americans were equalized. one memberof this association commenting on this figure said, in a most moving email, "do we really need more lessons on the socialdeterminates of health before we begin to
act? 800,000 is far too many painful lessons for me."it is a global commission and people tend to think that when you're thinking about poverty,inequalities, and inequities in health globally, the issue has so much todo with communicable disease. we know, of course, that in every region of the world other than the very poorest the major burdenof disease is non-communicable disease, injuries, and violence. in the poorest regions it's approximately an equal burdenfrom communicable disease and non-communicable disease. they have the double
burden.when we look at something like obesity that we think as being a problem for the rich countries,indeed it is. but look at mexico. look at brazil. obesity increasinglyis becoming a problem for all middle income countries as well as high- income countries. we said very little in the reportof the commission on social determinants of health about climate change but i think it's absolutely vital to bring the agendastogether. when the commission conducted a workshop innew orleans it was very clear to us that one shouldn't speak of natural
disasters, one should talk of natural phenomena.it's social organization that turns natural phenomena into natural disasters. it is always the disadvantagedwho suffer most. we saw it in new orleans and we see it globally. deaths from climate change are affecting people in poorcountries much more than in the rich. our conclusion, from three years of work,was that it really is achievable. we really can make a difference to health equity but we do have to change our focus. imagineyou're wrestling with an alligator in a swamp. the alligator is health in equity
and we're fighting with each other as to whetherwe should take action on smoking, on obesity, on safe sex, or universal health insurance. halfdan mahler, the powerful,inspirational, former director general of who in a speech to the world health assembly in 1986 said, "when you're up toyour neck in mud fighting alligators remember you came to drain the swamp in the first place."that's the challenge and that's what the commission set out to do. the areas for action identifiedby the commission were firstly, the conditions in which people areborn, grow, live, work, and age. secondly,
the structural drivers of those conditions on a global, national, and locallevel. thirdly, the importance of monitoring training and research. i began by saying i spent my whole life in research.i'm not going to forget that past but what i now realize is how important it is for the research and the action to go on at thesame time. gurtur* says it better than i, "it's not enoughto know, you must also use the knowledge. it's not enough to wish you must also act. thinking in order to act. actingin order to think. that's the sum of all wisdom."
we have to marshal the knowledge that we have and try and put it into actionbut we have to continually be critical of what we're doing, to evaluate it and to say, "how can we make a difference?"i want, in this short time, to give you a couple of examples of the evidence we gathered.i was talking with some colleagues this morning and they said, "how do you getthe message across?" i said, "for me, it's with the evidence. let the evidence talk." in europe we've been talking abouthealth in our policies. the commission said we should screen all policies for their
impact, not just on health, but on healthequity. fair financing. let me just show you and example.this slide from our nordic knowledge network from the commission looks at the proportionof people who are relatively poor. poverty was defined as less than 60% medianincome. for those at the back who may not be able to see this, if you look at the figures for the us and the uk, pre-tax, povertylevels in the us are lower than in the uk. the effect of tax and benefits, income redistribution, is to reduce povertylevels in the us by 24 percent and to reduce them in the uk by 50 percent. the
minister of finance is involved in ethicaldecision-making. the actions of the minister of finance havea fundamental impact on health inequity. yes, economics is important not so much the economics of the actions that we in thehealth sector take but the fact that the minister of finance can make a decision. what would we like the poverty levels to be?high or low? it's within the decision making power of the government. look, for example, finland, norway, and sweden. theaffect of redistribution there is to reduce poverty levels by over 70 percent. this
is not given by god or darwin, depending onwho your favorite is; this is given by the minister of finance. we have global responsibilities. look at the figures forsub- saharan africa, for example. this is government revenue from direct taxation, from sales tax, and from the tariffs on trade.if we negotiate in favor of free trade and we say to a government you have to removeyour tariff barriers we are, in a stroke, removing between 30 and 40 percentof government revenue. free trade may be a good thing, although i wished we practiced it in europe, the subsidy to europeanagriculture in one week is equal to the subsidy
to an african culture in one year and we call that free trade. but if webelieve in free trade instead of the monumental hypocrisy that we now practice, we would have to come up with alternate arrangementsbefore stripping a government of 40 percent of it's revenue. then saying that you've got to invest in education, heathcare, and social protection. continuing the fair financing theme, the blueline there shows the proportion of gross national income from the rich countries that goes to overseas developmentassistance. the rich countries committed themselves
to giving 9.7 percent of gross national income in overseas developmentassistance. it's now around 0.3. as our incomes have grown the proportion that we give hasn't grown in the same way. that'soverseas development assistance, aid. we need to put that in a context and here the context is debt service. you can see thesmall bars going out to the right are development assistance and the bars to the left are service on debts.in the mid '90s about $50 billion a year went from the rich countries to the developingcountries. now $600 billion a year
comes out of the developing countries intothe coffers of the rich countries. fair financing means coming to grips with what we're doing. healthy places. we put in ourreport, an estimate that it would cost $100 billion to upgrade the world's slums. currently one billion people in the worldlive in slums. when we put that, as the chief writer/editor of the report, i thought, "could we really say that? it lookssuch a silly sum of money. $100 billion?" my government put รข£500 billion -- when theydid that it was worth about $900 billion. now it's worth about $750 billion. --
put $900 billion into saving the banks. for1/9 of that every urban dweller could have clean running water and sanitation. please don't tell me that we haven't got themoney. we have the money, we choose to use it in particular ways.our commissioner from india working in gujarat as part of the self- employed women's association,i'll say a word about that before i end, said to the women, the poorestwomen in india who are part of the self- employed women's association, "what do you want?" they said, "the first thing, wedo not want to move into concrete blocks. we'd like better housing but we want to
stay where we are but we would like runningwater. we would like a bathroom. we would like somewhere to cool. for $500 per household they achieved that. the women, themselves,had to contribute $50 to that. that's enormous if you're living on $1-2 a day $50 is enormous.the women themselves were sufficiently committed that they had to contribute. following theinvestment in these slums there was an improvement in health, decline in waterborne diseases, the children started going to school. the women were able to take paid work no longer having to stand inlong lines to collect water.
universal healthcare. i said that this isnot the panacea but it is very important. every year 100 million people are forced into poverty because of catastrophic, outof pocket, health care expenditure. a large number of other people are not quite forced into poverty but severely disadvantaged.but it's not just the health care system. let me take you back to a paper we published a couple of years ago. in the usyou spend $6,000 per head on medical care. we in the uk spend $2,560, adjusting for purchasing power. the question is whatdo you get for that?
the answer is, not much. this is health differencesbetween england and the us and men and women age 55-64. it was white men and women -- to try and get the cross-nationalcomparison more appropriate. you can see the social gradient there classified here by income. you can see the social gradientfor heart disease and diabetes and for four other major conditions. at each level of income the americans were sickerthan the english. 92 percent of this sample had access to health insurance, had health insurance. it was not a health careissue. is it reasonable? is it rational? is
it logical to be optimistic? i would say, yes. that's an evidence-biased optimism.look at what's happened to under five mortality rates in country after country. look, forexample, at egypt. in 1970, under five mortality rates were in excess of 230per thousand live births. by 2005 it was down to about 30-35. in fact, the rates in egypt in 2005 were below the rates in portugalor greece 30 years earlier. we can make dramatic changes very quickly. in fact, the main issue for most of these countriesis now the persisting inequities within the country so that the gains are
more fairly shared. i'm also optimistic becausethings are happening. in brazil they set up a commission on socialdeterminants of health as a daughter of the who commission. they produced their report also, in august. this is presidentlula looking pretty pleased, i would say, holding a copy of the brazilian report with the health minister, the governor ofthe state, and the president of the commission. you probably can't see that but that is me. i'm not the one with the turban.i'm the other one with the prime minister of india, dr. manmohan singh.you probably can't see that but he is holding
a copy of our report and he said, "what doyou want me to do?" i wouldn't have the courage to tell somebody who's the primeminister of a country of nearly 1.1 billion people what he should be doing but i did say that if you look at our report therecommendations are rather general. they had to be. we're dealing with sub-saharan africa, rural and urban india, glasgow, washingtondc and everything else. they had to be fairly general. "it would be wonderful," i said to him, "if you could takethe report and develop solutions, practical policies, that are appropriate for
india. it would be good for india and it wouldbe good for the world." but what if governments don't act? it is importantto get sign- up from the top of government. many governments in the american region -- particularly latin america,canada, but strikingly not the united states of america -- have signed up. so then what? do you throw up your hands? i wasin california earlier this year and people were throwing up their hands saying the government won't act. there's nothingwe can do. so, i showed them the example that one ortwo of you have seen before. coming back to
the self- employed women's association of india -- when the commission made a sitevisit to india we were given some insight into the lives of the vegetable sellers. these women sit all day with a littlerag in front of them and a few vegetables and they sit in the market and sell these vegetables.the women, of course, were being ripped off by loan sharks who were lending them moneyat rates exceeding 20 percent interest a month. sewa, the self- employed women'sassociation, started a bank; the sewa bank micro-credit scheme. i went to a meeting
of the governors of this bank. i've neverbeen invited to bank of america governors or barclay's bank but the sewa bank. at the end of it, these women in their coloredsaris sit there and they sing the gujarati version of "we shall overcome" with a clenched fist. i'm not sure if they do thatin bank of america. they were being ripped off by the vegetablewholesalers. sewa became the middle woman, buying from the growers at reasonable prices and selling to the retailers at reasonableprices. they were being harassed by the police. sewa fought, to the supreme
court of india, for the right of these womento pursue their trade. the children are sitting there in the sun and the monsoon rains. sewa started childcare. they get sick.sewa started health services. i've already talked to you about the housing. now they have a new problem; pensions.when mirai chatterjee, who you saw in the photo with manmohan singh, who was a memberof the commission -- she said that when she was asked to join the commission she askedthe members, these women, "should i join?" the members said to her, "go and tell them what our lives are like. tell themwhat we live everyday of our lives. it's not
difficult. go and tell them about us." i would hope that this distinguishedorganization, the american public health association, will be part of building a social movement for action on the social determinantsof health and health equity. martin luther king said, "we're confrontedwith the severe urgency of now. in this unfolding conundrum of life and history there is such a thing as being too late. wemay cry out desperately for time to pause in her passage but time is deaf to every plea and rushes on. over the bleachedbones and jumbled residues of numerous civilizations
are written the pathetic words, "too late." i quote dr. king becauseit was pointed out to me that we published the report on the 28th of august, which was the 40th anniversary of his "i havea dream" speech. david satcher, who was one of our commissioners,quoted benjamin elijah mays at martin luther king's funeral saying, "the tragedy is not to have your dreams unfulfilled.the tragedy is not to dream in the first place." i would like you to dream with me and to dream of a world where socialjustice is taken seriously.
