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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Capability: understanding why people may not adopt healthful behaviors

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In Social Determinants, Personal Responsibility, and Health System Outcomes, I discussed the limitations of the potentially attractive (at least to the empowered) concept of “personal responsibility”. In its more malignant form, personal “accountability” as put forward by John Mackey of Whole Foods, there is the implicit – sometimes explicit – suggestion that people might be denied care if they had not personally taken on the behaviors that might have helped prevent the condition. Of course, which behaviors, for which conditions, and how much remains unspecified. Aerobic exercise 60 minutes daily? Or would 30 minutes 3 times a week qualify? No sweets, or cookies only on Sunday? How many? I am reminded (well, I’m old) of former North Carolina senator Jesse Helms who was against funding the treatment of AIDS as it came from inappropriate and immoral behavior (MSM sex and IV drugs were, I think, what he had in mind). Of course, he strongly supported both tobacco and funding the treatment of heart disease (such as he, a heavy smoker, had).

Of course, I’m sure that, today, smoking is on John Mackey’s “no-no” list, but it is the concept of “your bad habits are worse than my bad habits” that is emblematic of the “different from me is bad” phenomenon that ebbs and flows in world history, and has become increasing common both in this country and around the world. The Tea Party movement is one domestic example; at the “Values Conference” recently held in Washington, Christine O’Donnell, the newly-elected Republican candidate for Senate in Delaware, wowed the crowd with the line "We're not trying to take back our country. We ARE our country." Except, of course, for those who are not part of “we”. Me, for example. And those other ‘others’: those who believe in brotherhood, caring, and diversity.

But surely John Mackey is not embracing racism or prejudice? Classism, maybe; certainly discrimination against those who don’t adopt the health behaviors that he endorses. One might ask: why don’t they? And, if one does, we can get a good answer from a wonderful article that appeared in the recent Annals of Family Medicine, “Capability and clinical success”, by RL Ferrer and AV Carrasco (disclosure: Dr. Ferrer has previously been a guest-author on this blog.) Going beyond the “social determinants of health”, which is a relatively passive model in that it mainly just describes them, Drs. Ferrer and Carrasco discuss the concept of “capability” of health behaviors. They draw upon the work of Nobel Prize-winning economist Amartya Sen, who introduced this concept, and that of Jennifer Prah Ruger of Yale, who has developed its use in health (e.g., “Health capability: conceptualization and operationalization” in the January, 2010 issue of the American Journal of Public Health). The concept of “capability” goes beyond simply evaluating people’s behaviors, and looks at opportunity to perform those behaviors, which is not equally available to all:

“What distinguishes the capability framework from other approaches to evaluation is its emphasis on opportunity as well as achievement. Turning raw capacity (e.g., the ability to walk) into action (walking for 60 minutes a day) to achieve a goal (being physically fit) requires that there be real opportunities to do so. Examining the set of potential opportunities that are viable for a given person (a capability set) helps to define what goals are attainable. For instance, a capability set for physical activity would encompass the various modes and durations of physical activity that are realistically achievable given a person’s constraints of time, money, support from others, physical abilities, and what is locally available.”

Capability is influenced by individual, social, psychological and environmental factors, as well as by income. Money – or lack of it – is a major component, but not the only one, because other features can mitigate or exacerbate financial issues. The concept of “social capital” developed by Robert Putnam (“Bowling Alone”[1]) and others is one formulation of this. In his book Heat Wave[2], Eric Klinenberg describes how the deaths in the 1995 Chicago heat wave, while associated with age, illness, poverty and availability of air-conditioning, were also associated with the availability of social supports. He notes the differential death rates in two adjacent low-income communities. In one, the decimation of the commercial sector and fear of crime had people locked in hot apartments, while in the other neighbors checked on the old, sick, and poor, and merchants on the vibrant shopping street allowed them access to their air-conditioned stores. “A capability perspective,” write Ferrer and Carrasco, “implies that poverty should not be defined primarily by income but by scarce opportunity to pursue valued activities and goals. Strong external supports create opportunities that enable people with limited income to pursue their goals for healthy living. Capability is thus a key mediator of the relationship between socioeconomic position and outcomes.”

What Ferrer and Carrasco add to the discussion is the clinical component, discussing how the clinical relationship can take account of capability, and how the clinician can play a role in enhancing the health of patients through understanding and acting to help ameliorate its impact on those who have little. They suggest an example of a series of questions (their Table 2) that a clinician can ask in order to assess an individual’s capability of adopting different healthful behaviors. They also provide suggestions for how the clinician or practice can access help through social service agencies, public health departments, programs of connectors or promotores, and grass-roots agencies. Clinicians may be able to assist in helping people gain access to wholesome food or places to exercise, and to groups that would support their activities.

Of course, in some cases, maybe often, these programs will not already exist. In that case, it could become the role of the clinician or the practice, or even better the health system (or, to use the terms of the new ACA law (PL 111-148), the 'Accountable Care Organization') to help develop such programs in the interest of promoting the health of its patients. Indeed, we should and must if we are interested in promoting health and not just casting blame.

[1] Putnam, Robert D., 2000, Bowling Alone: The Collapse and Revival of American Community, Simon & Schuster, New York, NY
[2] Klinenberg, Eric., 2002, Heat Wave: A Social Autopsy of a Disaster in Chicago, University of Chicago Press, Chicago.
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Social Determinants, Personal Responsibility, and Health System Outcomes

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Whole Foods, Inc., CEO John Mackey has been both an outspoken critic of the Obama administration's health reform plan and an advocate for “personal accountability” suggesting that people’s health behaviors – including such things as smoking, poor diet, obesity, and lack of exercise -- account for much of their health risk, and thus people should be held responsible for the poor choices that they make, receiving fewer health benefits if they have not taken the steps to maintain their own health. He has recently made this argument in an op-ed piece in the Wall St. Journal, “The Whole Foods alternative to Obamacare” (August 11, 2010). Subtitled “Eight things we can do to improve health care without adding to the deficit”, Mackey runs through a list of proposals that feature inequity, maintaining and increasing the health and wealth of those who already have the most of it; that would create enormous increases in insurance company profit, would not meet the health needs of those who have needs, and would end up costing a fortune. The “controls” are all on services that would benefit people, the “freedom” is all for corporations to continue to have unfettered access to excessive profit.

“All countries with socialized medicine ration health care by forcing their citizens to wait in lines to receive scarce treatments,” he writes. Of course, his definition of “socialized” includes the health systems of every single developed country in the world outside the US, whether they have a National Health Service (e.g., UK), single-payer insurance (e.g., Canada) or a mixed system that includes private insurers that are regulated (e.g., Switzerland, Germany). What is unsaid by Mackey is that the system he proposes (much like the current one in the US) does not eliminate lines for everyone but rations by wealth and insurance status. CEOs like him do not have to wait in lines, but the further down the socioeconomic ladder you are, the longer the line becomes, until, at the end, unlike in those other countries, there are tens of millions of people who can’t get on the line at all. Unsurprisingly, these proposals are likely to resonate with and please the readers of the Wall St. Journal’s editorial pages. The US health system is not only incredibly expensive (not because it covers everyone, which it doesn’t, but because of the huge profits taken out of the system by Mackey’s fellow CEOs) and unfair, but it performs poorly on virtually all dimensions (see the Commonwealth Fund’s 2010 report, “Mirror, Mirror on the Wall”, with results summarized in the attached figure).

More insidiously, however, some of these arguments can appeal to many others, who see sense in expecting people to take “responsibility” for their health and act in healthful ways: “Unfortunately many of our health-care problems are self-inflicted: two-thirds of Americans are now overweight and one-third are obese. Most of the diseases that kill us and account for about 70% of all health-care spending—heart disease, cancer, stroke, diabetes and obesity—are mostly preventable through proper diet, exercise, not smoking, minimal alcohol consumption and other healthy lifestyle choices.” Eat nutritious food, exercise, don’t smoke or take illegal drugs or drink to excess, etc. This is good advice, and all of us should try to take it. I’m sure that it is advice that many of the employees of Whole Foods – the ones who are young and healthy – appreciate, because it validates what they do, and see – the “outcome” is that they are young and healthy. It is possible that there are other Whole Foods employees, not young and healthy but older and/or with chronic disease – who many not find his advice, or the company’s health plan, to be of such great value. His essay may be a call to action for those who, given some combination of youth, genetic luck, good health, and socioeconomic opportunity, are still not doing all they can.

But health behaviors – and the health care system – are not the only determinants of health. Indeed, the Determinants of Health model from Healthy People 2010 (see figure) make clear that there are m any factors that impact health, most of which are ignored by Mackey and his ilk. They are also not all going to be addressed by health system reform, whether that in the current “Obama” plan or even in a more extensive change, advocated by people like me and the Physicians for a National Health Program to be more like the other, much higher performing systems in other countries. That system change is necessary, but not, in itself, sufficient. The environment, both physical and socio-economic, have tremendous impact. In addition, issues not specifically on this model, such as the impact of race (racism, not perhaps overt but in terms of the impact of “perception of race” on those of color). These are the Social Determinants of Health, and have been written about extensively, in a literature that is either unknown to or rejected by Mackey and his friends. Perhaps the clearest exposition of the Social Determinants is by Camara Phyllis Jones, MD, MPH, PhD, of the Centers for Disease Control and Prevention (CDC), who has written extensively on this topic. However, she has also developed a cartoon depicting how the social determinants of health intersect with the health care system as well as how the different levels of the health care system (primary, secondary, tertiary prevention, and treatment) interact with each other. Her slide show, “Social Determinants of Health and Equity, the Impacts of Racism on Health” is available on line and contains these cartoons. They demonstrate, through the use of a cliff analogy, the role of these different factors. Although very useful for teaching children, their clarity is also of great value for teaching health professionals. And they might even be understood by CEOs.

With Dr. Jones’ permission, Neal Palafox, MD, of the University of Hawaii, produced slides based on her model, one of which is reproduced here. It represents health risk as a cliff. If someone falls off, we can provide medical care (the ambulance); however this is variably available for people (access to care). If we can identify diseases and treat them before they require expensive care, this is secondary prevention (the net also represents “safety net” health services). Better yet, we can provide primary prevention – keep people from falling off the cliff (the fence). Some of this is achieved through the individual behavior changes like those advocated by Mackey. The social determinants, however, which he ignores, are represented by the distance that people are from the edge of the cliff; some folks are at greater risk. As Dr. Jones also develops in her slides, many of those same people are those who have less protection by the fence, or the net, or for whom, when they do get sick (fall off the cliff) the ambulance is not there, or even “going in the wrong direction”.

Most of the discussion of these issues are among those of us who are relatively privileged. We may not be wealthy CEOs like John Mackey, but we are educated, literate, and consumers of ideas. Most of us are at least middle-class; even those who may say “no, I don’t have money” are usually in that status temporarily (e.g., from being students), but have the values and self-efficacy that comes from our class, socioeconomic, and educational background. This group certainly includes all the politicians, pundits, academics and successful businesspeople – and medical students. It may be hard to believe, but the vast majority of people are not in that group. Check out income demographics: according to the US census, in 2000 only 12.29% of households – not individuals – had incomes over $100,000 a year, and only 2.37% over $200,000; 2008 estimates indicate household income >$100,000 is the top quintile, and the top 5% is >$180,000.

We absolutely need health reform, real reform, that will begin to move us in the direction of the high-performing health systems in other countries. We also need to encourage healthful behaviors. However, rather than penalizing others whose circumstances – genetic, socioeconomic, social, racial, physical – make that more difficult, we need to develop programs, that require, as Dr. Jones notes, “…collaboration with multiple sectors outside of health, including education, housing, labor, justice, transportation, agriculture and environment.”

And we need to get started.
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