In my mind there are two quotes that really encapsulate what the Marmot Review is. The first is the epigraph, and for me it was breathtaking to find it here:

Rise up with me against the organisation of misery.
–Pablo Neruda

The second? A clear outline of where exactly the researchers began:

The starting point for this Review is that health inequalities that are preventable by reasonable means are unfair. Putting them right is a matter of social justice. A debate about how to close the health gap has to be a debate about what sort of society people want.

Surely it is time we started there and moved forward. It does note (and I chuckled at this, I’m not sure why):

It is sometimes difficult for many people to accept that serious and persistent health inequalities exist in England.

By ‘many people’ I assume they mean the happy middle and upper classes with reasonable health. But on the other side of the class (and race and nationality and gender and sexuality) lines, it is no real surprise that the WHO (World Health Organisation) Commission on Social Determinants of Health should have ‘surveyed the world scene and concluded that “social injustice is killing on a grand scale.”‘ Is that the kind of world we support?

Most would answer no. I also think most would agree with this:

Economic growth is not the most important measure of our country’s success. The fair distribution of health, well-being and
sustainability are important social goals. Tackling social inequalities in health and tackling climate change must go together.

I like too this call to the health profession to begin to engage with the fact that our socioeceonomic position is more determinative of our health than any prescription or therapy that they can give  — as well as to policymakers and politicians to lower our NHS bills by increasing equality and opportunity in our society:

People with higher socioeconomic position in society have a greater array of life chances and more opportunities to lead a flourishing life. They also have better health. The two are linked: the more favoured people are, socially and economically, the better their health. This link between social conditions and health is not a footnote to the ‘real’ concerns with health – health care and unhealthy behaviours – it should become the main focus.

The two main policy goals they propose are these:

• To create an enabling society that maximises individual and community potential

• To ensure social justice, health and sustainability are at the heart of all policies.

Wouldn’t that be great? These break down into 6 more concrete policy suggestions (and these are made more and more concrete for implementation at the end of the report):

• 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 healthy standard of living for all

• Create and develop healthy and sustainable places and communities

• Strengthen the role and impact of ill health prevention

The evidence they marshal in support of these positions is so impressive, beginning with the weight of these first two graphs as shown below. The first represents over ten years difference between the wealthiest and the poorest in how long they may statistically expect to live. Over ten years. More sobering, perhaps, is the number of years available to us to live  in fullness of life and health, without disability. For the very poorest, they can expect age and ill-health related disabilities in their early fifties — it breaks my heart.

For the heartless, imagine the fucking economic cost of that.

Direct NHS healthcare costs in England associated with treating the consequences of inequality amount to £5.5 billion per year for treating acute illness and mental illness and prescriptions.228 These activities represent approximately one third of the NHS budget. In consequence, it is likely that the full impact of health inequalities on direct healthcare costs is considerably greater than this.

The review also notes:

As further illustration, we have drawn on Figure1 a line at 68 years – the pensionable age to which England is moving. With the levels of disability shown, more than three-quarters of the population do not have disability-free life expectancy as far as the age of 68. If society wishes to have a healthy population, working until 68 years, it is essential to take action to both raise the general level of health and flatten the social gradient.

Ah, to be 68 and working for the bosses while disabled, I can’t wait.

The power of the second graph is the difference in mortality between regions. This also breaks my heart. Surely the point of a nation and a national government is to aim for some level of parity in opportunity and life.

The graphic below is  crazy too, it shows the effect of wealth and environment on intelligence (or at least, the ability to show intelligence through testing). This is about class and education, which of course intersects with health but also with our ability to become the person we want to be, live the lives we are capable of living. The review explains:

As Figure 6 shows, children who have low cognitive scores at 22 months of age but who grow up in families of high socioeconomic position improve their relative scores as they approach the age of 10. The relative position of children with high scores at 22 months, but who grow up in families of low socioeconomic position, worsens as they approach age 10.

Are you ready to change the world yet?

From education you move into work — and poor people’s work is killing them. Worse, though, is that the lack of work is also killing them.

Getting people into work is therefore of critical importance for reducing health inequalities. However, jobs need to be sustainable and offer a minimum level of quality, to include not only a decent living wage, but also opportunities for in-work development, the flexibility to enable people to balance work and family life, and protection from adverse working conditions that can damage health.

Another graphic to blow your mind — the direct link between employment and mortality:

The dramatic increase in unemployment in the United Kingdom during the early 1980s stimulated research on the link between unemployment and health. Figure 8 shows the social gradient in the subsequent mortality of those that experienced unemployment in the early 1980s. For each occupational class, the unemployed have higher mortality than the employed.

It’s community that I’m most interested in, perhaps because I think it is a way to mitigate all of these things while we fight to make the world more fair, and because everything goes to show that the closer and more supportive a community is, the healthier its members are. Building that kind of community where I live and work feels like something I can actually do to make a difference (that and join a union). But thinking geographically, the physical neighbourhood we live in also has a huge impact on our lives, both in terms of quality and length:

In the poorest neighbourhoods of England, life expectancy is 67, similar to the national average in Egypt or Thailand, and lower than the average in Ecuador, China and Belize, all countries that have a lower Gross Domestic Product and do not have a national health service.

Now ain’t that something? Here’s another set of bullet points on environment and health:

• The conditions in which people are born, grow, live, work, and age are responsible for health inequalities.

• Early childhood, in particular, impacts on health and disadvantage throughout life.

• The cumulative effects of hazards and disadvantage through life produce a finely graded social patterning of disease and ill health.

• Negative health outcomes are linked to the stress people experience and the levels of control people have over their lives and this stress and control is socially graded.

• Mental well-being has a profound role in shaping physical health and contributing to life chances, as well as being important to individuals and as a societal measure.

This evokes the complexities shaping these things a little better:

the distribution of health and well-being needs to be understood in relation to a range of factors that interact in complex ways. These factors include: material circumstances, for example whether you live in a decent house with enough money to live healthily; social cohesion, for example whether you live in a safe neighbourhood without fear of crime; psychosocial factors, for example whether you have good support from family and friends; behaviours, for example whether you smoke, eat healthily or take exercise; and biological factors, for example whether you have a history of particular illnesses in your family. In turn, these factors are influenced by social position, itself shaped by education, occupation, income, gender, ethnicity and race. All these influences are affected by the socio-political and cultural and social context in which they sit.

These are many of the things that determine where we live, and the kinds of support we can expect. Once our place of residence is decided, the other health issues kick in. So much of this is really about the physical hazards that exist in poorer neighbourhoods (and there is more work on this than is shown here), but also the mental hazards of poverty, and the lack of power and control that comes with it. The lack therefore, of even the possibility of true wellness.

There is substantial evidence of a social gradient in the quality of neighbourhoods. Poorer people are more likely to live in more deprived neighbourhoods. The more deprived the neighbourhood, the more likely it is to have social and environmental characteristics presenting risks to health. These include poor housing, higher rates of crime, poorer air quality, a lack of green spaces and places for children to play and more risks to safety from traffic. In the 30 years between 1970 and 2000 Britain saw a substantial increase in the geographical concentration and segregation of poverty and wealth. Since 2000 there seems to have been little progress in reducing this. Urban clustering of poverty has increased…wealthy households have become concentrated on the outskirts and areas surrounding major cities. During the same period, major restructuring of the British economy has led to the loss of manufacturing and traditional industries, with high levels of economic inactivity becoming concentrated in particular localities and neighbourhoods.

It is this segregation of poverty and wealth that is also the problem, a writing off of estate and neighbourhoods and what looks like the whole Northeast of the country.

Since reading Appleyard’s Liveable Streets, I’ve also been thinking a lot about how community is destroyed by streets and cars and traffic, and it is the poorest that suffer most — this graph really brings it home:

I do like the fact that they point out that these are not just issues for the poor, however, although they clearly suffer most and resources should be targeted accordingly. They write

…everyone beneath the very best-off experiences some effect of
health inequalities. If the focus were only on those most in need and social action were successful in improving their plight, what about those just above the bottom or at the median, who have worse health than those above them? All must be included in actions to create a fairer society.

This also means health providers and community workers actually working together closely in taking on some of these problems.

Community engagement on a systematic basis is an essential element in partnership working for addressing health inequalities. Without this, reducing health inequalities will not be possible.

This approach requires mapping community assets, identifying barriers to participation and influencing and building community capacity through systematic and sustained community development.

They look at different ways this could happen. One is through focusing on building stronger social support networks to fight the high levels of stress, isolation and depression found in communities facing high level of deprivation, which can lead to ‘increased risk of premature death’. They note the effectiveness both of social networks and participation in improving mental health generally, but also the importance of including communities and individuals in the design of interventions.

They give some recommendations on how to go about things, which in the end lead to local individuals and communities being able to have power over their health, their lives, and the neighbourhoods they live in.

1. First, identifying population needs better quality information from communities. In theory this can lead to health improvements and reduced health inequalities through an increased uptake of more effective services, particularly preventative services, and/or more effective interventions.

2. Second, improving governance and guardianship and promoting and supporting communities to participate in directing and controlling local services and/or interventions. This will help to improve the appropriateness and accessibility of services and interventions, increase uptake and effectiveness and influence health outcomes.

3. A third way to reduce social isolation is to develop social capital by enhancing community empowerment. This helps to develop relationships of trust, reciprocity and exchange within communities, strengthening social capital.

4. Lastly, increasing control and community empowerment may result in communities acting to change their social, material and political environments.

    

Somethings about what not to do (but what gets done all the damn time), because the point is empowering people which in itself creates better health:

To achieve this goal community engagement practices need to move beyond what are often routine, brief consultations, to involving individuals in partnerships to define problems and develop local solutions to address those problems.

Which involves

Building active and sustainable communities based on principles of social justice. This is about changing power structures to remove barriers that prevent people from participating in the issues that affect their lives.

Promoting this approach sets a new task for political, civic and public service leadership in creating the conditions which enable individuals and communities to take control of their own lives, and in developing and sustaining a wider range of capabilities across the life course.

I like this idea of the life course, it is not one of the ways in which community organisers or planners tend to think, but makes perfect sense when looking at how negative impacts — in health and everything else — accumulate over our lifetimes and those of our children. I’ve also run into a few people, women for the most part, really trying to think about this in architecture and planning, how people age through housing and community, how their needs and desires change.

I also like how this review ties health in to climate change. They never say out right that all of this is academic in the face of massive environmental catastrophe, but it was in my mind at least. They do relate community and social health to increased green spaces, more walking, healthier work, more use of public transport  and etc which all contribute to making everything more sustainable.

I had a few quibbles of course. Any review of this kind, looking at the big picture, will have the problem I think of speaking in big categories, lumping categories of people in together as though they are all one thing. Sometimes I was a bit troubled as it threw around generalisations — such as the study of kids receiving free meals at schools and how terrible their outcomes were by whether they were irish, black, gypsy/ traveller/ roma children. That shit bothers me. I was one of those kids. Every now and then the language starts to shut our potential off, to overcome, to think bigger, to improve our lives and others like us. To set poor kids apart as if they can’t have a hand in changing this.

That might just be me on my high horse, some of this came a little close to home. It’s always a fine balance though, between recognising the power of structural injustices and constraints, and respecting the abilities of those who most suffer under them.

Even as it did make some of the distinctions above, and never forgot to mention the complexities of race and class in this picture, it also failed to look at them in any real way. Gender too is absent. It does, however, provide a good foundation for exploring these equity and justice issues further.

There’s also some technical language that highlights the bureaucratisation of the field. I quote you as an example ‘middle-level Super Output Areas (MSOAs)’ which I suppose are required for policy discussions to change public health practices as they are existing realities, yet they make you want to hit the person who coined them.

And for those in the non-profit world (and increasingly other areas) always in search of how to stay funded, there are a couple of nice passages on some things I wish all funders and policy makers could understand. Principally that things take time, projects need to grow organically and be tailored to different people and institutions in different areas, relationships and trust only come after years, not days or weeks.

Reviews often look for new interventions, particular policies that may help turn the corner or make significant impact in improving service quality. However, a stream of new initiatives may not achieve as much as consistent and concerted action across a range of policy areas. A social determinants approach to health inequalities highlights how it is the intersection between different domains that is critical – health and work, health and housing and planning, health and early years education. Success is more likely to come from the cumulative impact from a range of complementary programmes than from any one individual programme and through more effective, coherent delivery systems and accountability mechanisms….. achieving reductions in health inequalities requires coherent, concerted, long-term, cross-cutting policies, backed by sufficient investment.

There are also some practical points on how funding is killing smaller organisations, despite the fact that they are highly committed, flexible and most integrated into the communities they serve, making them most likely to be the most effective.

There is increasing concern that the current commissioning environment disadvantages the third sector generally and may even threaten the survival of smaller voluntary organisations. The range of factors includes:

• The inability of smaller organisations to marshal the resources, including the time, skills and knowledge, to effectively compete for tenders

• Commissioning practices favouring larger organisations and the statutory sector, for example, clustering services to be put out to tender in a single contract can lead to smaller and niche providers being squeezed out

• Short-term contracts with insufficient time for development and consequences for staff recruitment and retention

• The growing requirement for contracts to be delivered on tighter funding, leaving little scope for developmental work and innovation.

Recipe for disaster really, and the unhelpful bureaucratization of exactly the kind of community work that bureaucratization strangles dead and can never on its own get right.

Anyway, this report is mostly wonderful. You can download it here.