Michael Marmot, the British Medical Association, and the Social Determinants of Health

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The social determinants of health are real and profound. They are the aspects of life outside the medical office and hospital, outside of drugs and surgery, that affect our health. Income differences, education differences, and differences in social cohesion, to name a few, have been extensively described in the literature and have even made some headway in the medical curriculum at many schools. Addressing health disparities is a major focus of our Healthy People 2020 effort. Recognizing and addressing the social determinants of health has been, and will continue to be, the primary focus of this blog. A few recent posts addressing this topic include Healthful Behaviors: Why do people adopt them? Or not? October 8, 2011 and "Health in All" policies to eliminate health disparities are a real answer, August 18, 2011, and a little longer ago, Social Determinants, Personal Responsibility, and Health System Outcomes, September 12, 2010.

Some of the most important work in the area of social determinants of health has been done by the British physician and epidemiologist Sir Michael Marmot, whose “Whitehall” studies, begun decades ago, showed that health status was associated with socioeconomic class. He has continued this with his recent work “Fair Society, Health Lives”[1]. Thus, it should not come as a surprise that it was under Dr. Marmot’s recently-completed tenure as President that the British Medical Association (BMA) issued its report “Social Determinants of Health: What Doctors Can Do”, in October 2011. It is more interesting that Dr. Marmot, in his introduction to the report, notes that “ … as I mentioned in my presidency acceptance speech, I was surprised at being approached to be president at all,” because “My work has been focused on inequalities in health where I have emphasised the circumstances in which people are born, grow, live, work, and age rather than anything specifically to do with health care provision. I have emphasised not just the causes of health inequalities—behaviours, biological risk factors—but the causes of the causes. The causes of the causes reside in the social and economic arrangements of society: the social  determinants of health. More than that though more recently my work has looked at what can be done to address these issues across the life-course.”

Many of us in medicine, even on this side of the Atlantic, were thrilled that the BMA had chosen Dr. Marmot as its president precisely for these reasons. The current report shows that this was well-placed enthusiasm, for it marks a the commitment of the BMA to improving the health of the British population even, and perhaps especially, when that requires physicians to work outside of their “usual” venues. That is, when the work requires collaboration with other professionals, particularly educators but also social service agencies, to be effective. And to exercise their roles as community leaders, not simply purveyors of drugs, operations, and individual advice: “We recognise that not every doctor has the opportunity to change the social determinants of health throughout the life course of individual patients and have thus included other ways in which they can make a difference, as doctors working as community leaders.”

“Social Determinants of Health: What Doctors Can Do” presents conceptual models and large-scale goals, as well as principled statements of how physicians must act to create conditions of social justice and reduce the gradient of health disparity that results from different life circumstance. For example, it takes from “Fair Society, Healthy Lives” the following set of policy objectives that physicians and their organizations should work towards:

A - Give every child the best start in life

B - Enable all children, young people and adults to maximise their capabilities and have

control over their lives

C - Create fair employment and good work for all

D - Ensure healthy standard of living for all

E - Create and develop healthy and sustainable places and communities

F - Strengthen the role and impact of ill health prevention

          (These are expanded upon in “Annex A”, beginning on p. 26)

However, the paper goes beyond these generalities and provides specific examples of programs that have been and are in place in different communities across Britain that have made an impact on these areas. The BMA commits that they “will keep examples of effective actions on our website, and encourage the World Medical Association to garner international examples, to aid doctors seeking ways to make a difference.” One example of this two-phased approach of identifying the problems and seeking examples of solution is in “The Health Impacts of Cold Homes and Fuel Poverty report”, whose main findings of direct impacts included:

          - Countries which have more energy efficient housing have lower excess winter deaths (EWDs).

          - EWDs are almost three times higher in the coldest quarter of housing that in the warmest quarter.

          - Around 40% of EWDs are attributable to cardiovascular diseases.

          - Around 33% of EWDs are attributable to respiratory diseases.

          - Mental health is negatively affected by fuel poverty and cold housing for any age group.

          - Cold housing increases the level of minor illnesses such as colds and flu and exacerbates existing conditions such as arthritis and rheumatism.

          - Cold housing negatively affects dexterity and increases the risk of accidents and injuries in the home.

Main findings of indirect impacts:

- Cold housing negatively affects children’s educational attainment, emotional well-being and resilience.

- Fuel poverty negatively affects dietary opportunities and choices.

- Investing in the energy efficiency of housing can help stimulate the labour market and economy, as well as creating opportunities for skilling up the construction workforce.”

They then describe a program in Manchester that is working to addresses this problem.

Another intervention is occurring in an impoverished part of England, where the “Bromley-by-Bow Centre aims to serve the local community by providing a wide range ofservices and activities, which are integrated and co-operative in nature. They host the local GP surgery, a variety of social enterprises, a children’s centre, artists’ studios, a healthy living centre, and provide adult education courses, care and health services for vulnerable adults, outreach programmes and a range of advice services. This approach enables GPs to refer patients to services that help to tackle the social determinants of ill health, including welfare, employment, housing and debt advice services.”

A society can never achieve a significant improvement in health, or decrease health disparities, unless it consciously and forthrightly addresses the social determinants of health. Physicians can be leaders in this effort, or they can sit comfortably in their offices and hospitals tending to the individual health problems of people that could have been prevented before. Dr. Marmot says  

“During my tenure I have been struck, but not surprised, by members’ utter commitment to

improving the health, not just of individual patients, but of society as a whole….As the year progressed I could see more and more how my tenure at the BMA and my work on the social determinants of health were a perfect fit. Time after time I was faced with examples where doctors were working tirelessly to increase fairness and social justice by acting on the social determinants of health to reduce health inequalities.”

That makes me proud of my colleagues in Britain and in the BMA, but these are also characteristics of many doctors in the US. And of many medical students, who are driven by their desire to make a difference. The US is not the UK (we don’t, for one really big example, have a national health service or even a national health insurance program!), but we have real needs and real caring people, including physicians. We just need to keep focused on health and how to improve it and not be dissuaded by tangential issues. We need to maintain the energy and idealism of medical students and ensure that it grows, rather than withers, thoughout their careers.

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[1] Marmot M, Allen J, Goldblatt P et al (2010) Fair Society, healthy lives: strategic review of health inequalites in England post 2010. London.

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Compromised public health ethics across the pond: Britain too!

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Not long ago, I wrote of the “consumer alliance” between the American Academy of Family Physicians (AAFP) and the Coca-Cola company (The AAFP, Coca-Cola, and Ethics: Serving the public interest?, August 20, 2010). In that piece, I also noted the close relationship between the American Dietetic Association (ADA) and Hershey’s. For the record, I did not believe that these were, um, healthful, for the American people. I cited the work of Howard Brody, who looked at the ethics of the conflict of interest specifically in the Coca-Cola/AAFP case (and yes, there is definitely a conflict of interest whether or not that conflict results in prejudicial outcomes).

It turns out that this kind of arrangement is not limited to the United States. Indeed, Dr Alex Scott-Samuel, Director of EQUAL (Equity in Health Research and Development Unit) in the Division of Public Health at theUniversity of Liverpool, brings our attention to an article in the British newspaper the Guardian. It reports that in the United Kingdom, the “…Department of Health is putting the fast food companies McDonald's and KFC and processed food and drink manufacturers such as PepsiCo, Kellogg's, Unilever, Mars and Diageo at the heart of writing government policy on obesity, alcohol and diet-related disease”, an apparently far more malignant development.

The potential advantage of a government-run national health system is that it can insure that health care is provided for everyone, as I have often lauded. The public health role, however, is one that is even more commonly a public one, even in the United States, but in the UK the influence of the Department of Health over public health policy is even greater than in the US because they do not have independent state governments with their own health departments and health policies. We are, of course, familiar with the “fox guarding the henhouse” method of making public policy, which seemed to have reached its apex in the GW Bush administration with the big oil companies writing energy policy. Or maybe not; recently we discovered from a recent NPR investigative report (we need more of those) that the noxious Arizona immigration law was actually written by the private, for-profit prison industry as a way to increase business! (“They even named it. They called it the 'Support Our Law Enforcement and Safe Neighborhoods Act.’")

Is, then, the public’s health just another example of this type of “consumer alliance” (I really love this term!) – the British call them “responsibility deals”, more enigmatic, perhaps, but not more accurate – or is it another matter? Clearly, as demonstrated by the BP oil spill in the Gulf of Mexico, energy policy is critically related to health. And a law that makes it illegal for a person, a US citizen, to stop an offer humanitarian life-saving help to someone they find wandering and half-dead in the Arizona desert, not to mention imprisons and deports those who are not legally here, impacts on their health. Certainly these policies impact the rest of their lives.

Maybe it is because this is happening in the UK that makes it stand out. Maybe because some of us, myself included, have seen the UK and other European countries (and certainly there are many differences between European countries) as more focused on the health of their citizens. I know that there have been any number of problems with and criticisms of British health and social policy, including those of Julian Tudor Hart (“the inverse care law”[1], Medical Student Selection, December 14, 2008) and Sir Michael Marmot (the “Whitehall studies”, Health Outcomes: The interaction of class and health behaviors, May 9, 2010), and continued by current public health experts and scholars. I guess that the presence of the British National Health Service and its universal access have been so overwhelmingly positive in this regard that I have regarded such criticisms as those of people who “don’t know how good they have it”. Let me be clear: I never doubted that the concerns were valid, but rather that they may minimize the good things present in the system; in the same way I know that those in US cities with public hospitals are correct when they point to the underfunding, second class care, and inequities that they suffer, but at least, unlike where I live, they have public hospitals.

This initiative is, clearly, malignant. It is unquestionable “conflict of interest” for those whose interest is in selling more of their products, however unwholesome they may be, to be involved in the writing of public health policy around the use of, and advertisement of, those products. And, moreover, they will certainly ensure the insertion of policies that benefit themselves at the same time as they harm the public’s health. Note that it goes beyond food (and junk food); not only does the “food network to tackle diet and health problems includes processed food manufacturers, fast food companies,”, but “The alcohol responsibility deal network is chaired by the head of the lobby group the Wine and Spirit Trade Association.” Wow. One consumer advocate noted "This is the equivalent of putting the tobacco industry in charge of smoke-free spaces." It’s quite an achievement. Even Philip Morris couldn’t get to chair the cigarette control board!

Obviously, that this is occurring shortly after the Conservative Party has taken control of the British government is not a coincidence. It is part of a very successful strategy to transfer not all most, but virtually all, wealth and power to those who are already most wealthy and powerful. In the US, despite the control of the White House and both houses of Congress by the supposedly more progressive Democratic party, this consolidation is proceeding apace, clearly helped by Supreme Court decisions such as Citizens United that essentially removed all limits on corporate contributions to political campaigns.

Having input from corporations that stand to benefit from legislation or policy is one thing, as long as it is balanced by input from consumer groups – and the welfare of the people is the final criterion for making a decision, not maximizing corporate profit. In this case, the case of the public’s health, the decision should be clear cut.

[1] Tudor Hart, Julian, “Three decades of the inverse care law”, Br Med J, 2000 Jan 1;320(7226):15-8.
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Health Outcomes: The interaction of class and health behaviors

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I have recently discussed (Poverty, Primary Care and the Cost of Medical Care, February 10, 2010) the “Whitehall Studies” conducted by Sir Michael Marmot and colleagues that “demonstrate that there is a more or less linear correlation between health (including longevity) and increasing social class". That piece discussed the report of a panel headed by Marmot, “Fair Society, Healthy Lives”, that shows that these problems have not been resolved. A new paper from the follow-up “Whitehall II” study, conducted by Silvia Stringhini and colleagues from both Britain and France, “Association of socioeconomic position with health behavior and mortality”, (JAMA Mar24/31,2010;303(12):1159-66), examined the role of alcohol, tobacco, diet, and physical activity in accounting for these differences over an extraordinarily long 24-year follow-up period.

Stringhini, et. al., found that in fact adverse health behaviors accounted for about 42% of the increase in mortality in lower socioeconomic groups (which was about 1.6 times as high in lowest than in the highest socioeconomic group). Smoking was the most powerful negative factor, with the others contributing a smaller amount. “There was a marked social gradient in health behaviors at baseline. Participants in the lower socioeconomic positions were more likely to smoke, abstain from alcohol consumption, follow an unhealthy diet, and be physically inactive and less likely to consume heavy amounts of alcohol.” Most of this is consistent with the observations of physicians and epidemiologists in the US, with the surprising exception of alcohol use being lower in lower income groups. This may be a difference between the US and Britain; in Britain, in the 20th century, cirrhosis was a disease largely of the upper class who could afford the highly taxed, and high alcohol content, distilled spirits. Another possibility (and this is my speculation, not data) is that the lower socioeconomic group studied by Whitehall II in England may have a large component of Muslims, who do not drink. In any case, the impact of smoking, poor diet, and physical inactivity accounted for a significant part of the class difference in mortality, although it did not account for even the majority of that difference.

Thus, this study supports two well-established assumptions: 1) that adverse health behaviors are a significant contributor to ill health and higher age-adjusted mortality rate, and 2) that people in lower socioeconomic groups have worse health and higher mortality rates, much, but not all, of which can be associated with their higher rates of adverse health behaviors. Previous work on the results of Whitehall have suggested, and demonstrated evidentiary support for, the hypothesis that stress in daily life (of worrying about how you will pay the rent and feed your family, whether you are going to lose your job, or, particularly in the case of ethnic and racial minorities, not only whether you will be arrested or harassed by the authorities but the indignities of ongoing discrimination), mediated through only partially understood neurochemical pathways, account for much of this effect. However, to the extent that people can divest themselves of risky health behaviors, they can decrease, if not eliminate, their higher risk for adverse health outcomes.

In the same issue of JAMA, James R. Dunn of McMaster University in Canada, has a very insightful editorial commenting on the Stringhini article, “Health behavior vs the stress of low socioeconomic status and health outcomes” (JAMA, Mar24/31, 2010;303(12):1199-1200). He repeats the caution of the Whitehall authors that the population studied in the Whitehall cohort may not be representative of the British population overall (and, by extension, of the US or Canadian population). Indeed, the cohort was originally selected by Marmot and colleagues to reduce the confounding that might come from general studies of people in different classes because of occupational risks. Dunn points to the association of the stress of low socioeconomic status and the prevalence of adverse health behaviors: “…it is possible to consider both factors [stress and behavior] as part of the same pathway between relatively low socioeconomic status and health. Unhealthy behaviors are more common among individuals with low socioeconomic status because of the stress of low socioeconomic status. Accordingly, there is a direct causal pathway between low socioeconomic status and poor health as well as an indirect causal pathway through health behavior, which reinforce one another over the lifecourse.” That is, the stress of being poor makes you more likely to do unhealthful things that we know about (smoking, poor diet, low physical activity) that make you less healthy, and also makes you less healthy through a pathway that we don’t completely understand.

Dunn notes that while changing health behaviors in lower socioeconomic populations would be a good thing, “The problem is that traditional individually oriented health behavior education interventions are not very effective, and individuals with low socioeconomic status have been notoriously difficult to reach with such programs”. He discusses a variety of early childhood developmental characteristics, especially “executive function” and “self regulation” which might increase the probability of not adopting or stopping adverse health behaviors, which are on average less well developed in those growing up in lower socioeconomic groups, presumably also as a result of the stress impacting them as young children.

The relatively good news from the Stringhini study is that the prevalence of many adverse health behaviors did decrease over the time period studied. For smoking, the prevalence decrease from 10.1% to 4.8% in the highest, and from 29.7% to 16.5% in the lowest socioeconomic groups and unhealthy diet from 5.8% to 1.0% and 14.9% to 5.2% respectively diet; on the other hand, sedentary behavior increased from 6.6% to 21.4% in the highest and from 35.4% to 41.6% in the lowest socioeconomic groups. Again, extending this to the whole British population is uncertain, and in the US the prevalence of obesity (a combination of both poor diet and physical inactivity) is growing at a staggering rate in all age groups, and especially in low socioeconomic groups.

The take-home message is that all people should be encouraged and supported to adopt healthful and eschew unhealthful behaviors, particularly related to smoking, diet and exercise, and the degree to which any programs can be demonstrated to be successful for large numbers of individuals or, better yet, groups, they should be promulgated and replicated. However, to have greater success, programs will have to strike closer at the etiologies of these behaviors. A lower level, achievable (and achieved in some jurisdictions) by legislation, exemplified by indoor smoking bans, calorie and fat content labeling of foods, especially fast foods, and banning the use of toys as gifts in fast-food meals (as recently done in Santa Clara County, CA), can have much more significant impact (see “Promoting health through tobacco taxation” by Ali and Koplan from JAMA, and “Cardiovascular effect of bans on smoking in public places: a systematic review and meta-analysis” by Meyer, et. al., in JACC, cited in The Public’s Health: Smoking and Salt, February 6, 2010).

The greatest changes, however, involve even more significant societal changes: the elimination of the wide disparity in income and opportunity, thus socioeconomic status, and of racism. Health-focused, as well as social justice focused, policies should try to achieve this end, but in the US it will be a long time coming. In the meantime, it remains a good idea to choose your parents wisely; being born white and rich still significantly enhances your health status.
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