There have been times when I wished that Michael Marmot would attend to what I – as a sociologist – regard as root or fundamental causes of health inequalities, that he would talk and write about capitalism and class division and conflict. We have talked about this. He is of course an epidemiologist not a sociologist, so maybe there is a division of labour there. He has also long been committed to collecting and interpreting data and in communicating his analyses to those in a position to ‘make a difference’. He is in this sense an ‘insider’, not easy to ignore or dismiss and with a chance of being heard. I am an ‘outsider’ with no chance of being taken seriously by what it is perfectly reasonable to call ‘the political face of the ruling class’ (in my terminology, the power elite of the state that remains responsive to that tiny hard core – less than 1% of the population – of capital monopolists within the UK’s capitalist executive). My formula remains: capital buys power to make policy. But Michael has been intervening more in national debates recently, and using the data he has accumulated and refined to challenge the iniquitous neoliberal status quo.
His new publication is Build Back Fairer: The COVID-19 Marmot Review. The Tory slogan of ‘Build Back Better’ is contextualised from the outset. A return to the status quo ante would be ‘a tragic mistake’ is the unambiguous message. I cannot do justice to this text in a short blog, but I will summarise its principal themes and conclusions.
The main theme is the importance of equity (that is, inequalities that can be effectively addressed and reduced).
Marmot begins by outlining the main features of health in the population of England prior to the arrival of the pandemic in 2020. He lists nine:
- Since 2010 improvements in life expectancy in England have stalled, something that has not happened since at least 1900. ‘If health has stopped improving it is a sign that society has stopped improving.’ When a society flourishes health tends to flourish too.
- The health of a population is not just a function of its funding of healthcare. Health is closely linked to the conditions in which people are born, grow, live, work and age ‘and inequities in power, money and resources’ (the social determinants of health).
- The slowdown in life expectancy increase is just not down to severe winters. More than 80% of the slowdown between 2011 and 2019 resulted from influences other than winter-associated mortality.
- Life expectancy follows the social gradient: the more deprived the area, the shorter the life expectancy. This gradient has become steeper: inequalities in life expectancy have increased. Among women in the most deprived 10% of areas, life expectancy fell between 2010-12 and 2016-18.
- There are marked differences in life expectancy, particularly among people living in more deprived areas. Differences both within and between regions have tended to increase. For both men and women, the largest decreases in life expectancy were seen in the most deprived 10% of neighbourhoods in North-East England and the largest increases in the least deprived 10% of neighbourhoods in London.
- There is no evidence of a decrease in mortality for people under 50. In fact, mortality rates have increased for people aged 45-49. It is likely that social and economic conditions have undermined health at these ages.
- The gradient in healthy life expectancy is steeper than that of life expectancy. This means that people in more deprived areas spend more of their shorter lives in ill health than those in less deprived areas.
- The amount of time people spent in poor health increased across England between 2010 and 2020. Inequalities in poor health harm individuals, families and communities and are costly for public expenditure. They are also not inevitable and can be reduced with the right policies.
- Large funding cuts have affected the social determinants across the whole of England, but deprived areas and areas outside London and the South East experienced larger cuts than wealthier areas and their capacity to improve social determinants of health has been particularly undermined.
COVID has exposed and amplified the inequalities observed in Marmot’s 10 Years On Report ‘and the economic harm caused by containment measures – lockdowns, tier systems, social isolation measures – will further damage health and widen health inequalities. Moreover inequalities in COVID mortality rates follow a similar gradient to that seen for all causes of death and the causes of inequalities in COVID are similar to the causes of inequalities in health more generally. The contribution of health behaviours is often explicable in terms of the social determinants of health (the cause of causes).
Alarmingly high rates of COVID-related mortality have been reported in BAME communities. Much of this is down to living in deprived areas, which is often the product of longstanding inequalities and structural racism. But there is also evidence that many people from BAME communities have not been well protected at work, and less well protected that their white colleagues.
There are four apparent reasons why the toll in England from COVID is particularly high:
- The governance and political culture before and during the pandemic have damaged social cohesion and inclusiveness, undermined trust, de-emphasised the importance of the common good, and ‘failed to take the political decisions that would have recognised health and wellbeing of the population as priority.’
- Widening inequities in power, money and resources between individuals, communities and regions have generated inequalities in the conditions of life, which in turn generate inequalities in health generally, and COVID specifically. ‘They augur badly for health inequalities as we emerge from the pandemic.’
- Government policies of austerityreduced public expenditure, 2010-2020. Among the effects were regressive cuts in spending by local government, including adult social care, failure of health care spending to rise in accord with demographic and historical patterns, and cuts to public health funding. These were in addition to cuts in welfare to families with children, cuts in education spending per school student, and the closure of Children’s Centres. ‘England entered the pandemic with its public services in a depleted state and its tax and benefit system regeared to the disadvantage of lower income groups.’
- Health had stopped improving, and there was a high prevalence of the health conditions that increase case fatality ratios of COVID.
Fourteen lessons are outlined, with reference to the principle of ‘building back fairer’:
- Good health for the whole population is pivotal and should be the highest priority for government.
- Good governance, which increases trust, social cohesion and effective interventions re-COVID, is critical.
- Commitment to the common good is essential and the government has a clear enabling role and is a crucial source for accurate information and advice.
- There should be no trade-off between the economy and health: managing the pandemic well allows the economy to flourish in the longer term, which is supportive of health.
- Long-term strategic policies are required to reduce health inequalities, with equity as the focus.
- Multi-sector action is needed from national, regional and local governments, in collaboration with civil society.
- Inequalities in social and economic conditions damage health, and the unequal conditions prevailing when COVID arrived contributed to the high and unequal death toll from COVID in England.
- Containment measures will damage health: they are essential, but failure to properly control the pandemic means that containment measures have lasted longer and damaged economic and social domains, which will in turn worsen health inequalities.
- Austerity harmed health: policies that prioritised repaying the debt over the needs of the population have harmed health and ‘laid the ground for a more prolonged pandemic with high mortality and great inequality.’ The lesson is: do not re-impose austerity when the economy is struggling.
- Societal change: the enormous changes that have occurred in patterns of working and living during the pandemic must lead to considerations of societal functioning post-pandemic. ‘Consideration must be given to changing patterns of work, such as a four-day week, provision of universal basic income and universal basic services.
- Investment: the pandemic needs to be controlled and economic and social infrastructure need to be supported. Government can and must spend if they are to ‘build back fairer’ (the spending announced by the government in November 2020 will not be sufficient to mitigate the unequal impacts of containment).
- Key workers: during the pandemic there has been a high correlation between low pay and having to continue to work in frontline occupations. These people need to be recognised and valued.
- Green economy: the temporary reductions in air pollution and in the rate of greenhouse gas emissions must be sustained and will have benefits for health equity as well as jobs and the economy.
Marmot points out that there is considerable continuity between his COVID report and his earlier reviews. He reinforces the key messages from the ’10 Years On’ publication:
- Give every child the best start in life
- Enable all children, young people and adults to maximise their capabilities and have control over their lives
- Create fair employment and good work for all
- Ensure a healthy standard of living for all
- Create and develop healthy and sustainable places and communities
- Strengthen the role and impact of ill health prevention
Finally, in this brief and condensed summary blog, three ‘policy approaches to building back fairer’ are registered:
- Inequalities strategy: a national strategy needs to be developed for action on the social determinants of health, and this needs now to be extended to become a national strategy on health inequalities, led by the PM, ‘to reduce widening social, economic, environmental and health inequalities’. This should have high priority.
- Proportionate universalism: to deal with inequalities in health, especially the social gradient, universal solutions are required ‘but with effort proportionate to need’.
- Regional inequalities: COVID is adding to pre-existing regional inequalities, and if levelling up is to be achieved these regional inequalities must have high priority.
The summary points I have reproduced here are backed up by data. I think they represent a stronger ‘insider’ intervention than hitherto, though Michael would doubtless point out the degree of continuity over time. My own sociological and ‘outsider’ contributions to the debate on health inequalities have focused on the social structural mechanisms or factors that have: (a) led to a progressive widening of health inequalities during post-1970s financialised of rentier capitalism, and (b) stymied campaigns to introduce a set of policies to reverse this widening. I must just make this point, and mention my ‘class/command dynamic’, in passing, even as I celebrate Michael’s latest contribution the debate.