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Social Science & Medicine 71 (2010) 1254e1258

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Social Science & Medicine

journal homepage: www.elsevier .com/locate/socscimed

A social movement, based on evidence, to reduce inequalities in health

Michael Marmot, Jessica Allen, Peter Goldblatt*

Department of Epidemiology and Public Health, University College London, 1-19 Torrington Place, London WC1E 6BT, United Kingdom

a r t i c l e i n f o

Article history:Available online 18 August 2010

* Corresponding author.E-mail address: p.goldblatt@ucl.ac.uk (P. Goldblatt

0277-9536/$ e see front matter � 2010 Elsevier Ltd.doi:10.1016/j.socscimed.2010.07.011

At the beginning of the Commission on Social Determinants ofHealth (2008), the Commissioners said, naively perhaps, that theywanted to create a social movement to advance the cause of healthequity through action on the social determinants of health. Thehundreds of people, globally, who were involved one way oranother with the Commission, and the many more who have risento its challenge, are part of that movement. Similarly with theReview of Health Inequalities in England, Fair Society, Healthy Lives(Marmot Review, 2010) e called here the Review. The scores ofacademics and practitioners who helped with the Review, and themany more who are actively working to implement its findings,could be considered to be part of that movement.

Michael Pollan (2010) quotes sociologist Troy Duster on socialmovements: “No movement is as coherent and integrated as itseems from afar, and no movement is as incoherent and fracturedas it seems from up close”. Six of the eight commentaries here arepart of that same social movement even if they illustrate thehealthy differences of opinion amongst those who share anunderstanding of the role of social determinants. The other tworepresent a very different conceptualisation of health and society,for entirely predictable reasons, discussed below.

The differences of opinion among these distinguishedcommentators represent many of the contrasting views that weheard in developing both the Global and English reports. Settingthem against each could be seen as ample justification for usreaching the position we did, without the need for furthercomment from us, the middle men in this debate. For example:

� Chandra and Vogl (2010), and Canning and Bowser (2010) saywe put far too much emphasis on income as a determinant ofhealth; Pickett and Dorling (2010) say: far too little e reducingincome at the top would benefit us all.

).

All rights reserved.

� Whitehead and Popay (2010) say that our reports aregroundbreaking and have propelled the issue up the politicalagenda. Nathanson and Hopper (2010) say that the report isbureaucratic and the message is lost in mind-numbing statis-tics e a road to the Finland Station it is not.

� Mackenbach (2010) says that the British experience shows thatthere may be little we can do to address health inequalities.Whitehead and Popay say that the British experience showsthat there is much we can do if only we do things differently.

� Nathanson and Hopper say that the Black Report got on thepolitical agenda, with the obvious implication that the MarmotReview won’t. Mackenbach and Howden-Chapman (2010)show that they are mistaken.

� Lynch et al. (2010) emphasise the need for high quality researchevidence onwhich to base action. No one disagrees with thatethe disagreement between commentators is on whether thereis enough evidence to take action now.

Such disagreements are to be expected when people are askedto write commentaries. That said, they raise important issues thatare fundamental to the health inequalities agenda and we willcomment on them.

Do we know enough to take action on social inequalities inhealth?

Six of the commentaries are in little doubt that we do; althoughall, like us, want a stronger evidence base. Lynch et al. thoughtfullylay out the priorities for research in early childhood, and Howden-Chapman calls for rigorous evaluation of actions. We agree. Acriticism of the Labour Government from the House of CommonsCommittee on Health Inequalities (Health Select Committee, 2009)was that the government paid insufficient attention to evaluation ofinitiatives. One view of both the CSDH Report and the EnglishReview is that each of the recommendations represents a researchagenda as well as a call to action.

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What of the other two commentaries, by Canning and Bowser(2010), and by Chandra and Vogl (2010)? Their starting position,like many economists involved in the social determinants debate, isthat peoples’ health determines what happens to them. TheReview’s starting position was that what happens to people hasa cumulative effect throughout their life course, progressivelyaffecting their health.

As one of us has previously remarked (Marmot, 2009 p. 909):This is not just a polite, or even testy, academic debate. The

policy implication of these two positions is quite different. If themain causal direction is from health to wealth, the appropriateintervention is to control illness in order to improve an individual’ssocial and economic fortunes or, indeed, eradicate illness toimprove the economy of a whole country. If, as I conclude, the maincauses of health inequalities reside in the circumstances in whichpeople are born, grow, live, work and agedthe social determinantsof healthdthen action to reduce health inequalities must be inthose circumstances and the fundamental drivers of thosecircumstances: economics, social policies and governance.

Of course, not all economists share the approach to the evidencein these two commentaries. Amartya Sen was a member of theCommission on Social Determinants of Health, and Sir TonyAtkinson was a Commissioner of the Marmot Review. Eachsigned up to the conclusions in the respective reports. Jim Smith,whose work showing how health affects income is quoted, alsoshowed elegantly the powerful influence of education onhealth; such that income drops out of the model (Smith, 2007).

The role of selection

Chandra and Vogl (2010) appear to believe that it is onlythrough the logic of economic reasoning that causation can beunderstood. If we in public health were as rigorous about evidenceas they, we would be more cautious. In the case in hand, socialinequalities in health, everything is determined by “selection”.They concatenate two forms of selection, widely discussed in theepidemiological literature:

ehealth leads to social conditionsethe health of any group (e.g. low grade civil servants) isdetermined by its composition, not by the social conditionsexperienced by the group.

It is a fundamental tenetof science,withwhichwe fullyagree, thatinmaking inferences about causation, associations should always berigorously tested for the possibility of reverse causation e healthleads to socioeconomic positione and confoundinge an extraneousfactor affects both health and the social condition with which itcorrelates. But it is mystifying to us why one should start from theposition that health determines people’s social circumstances ratherthan the other way round?

The issue and the debate have been around for a long time, bothin science and the arts. Take a page from Dickens’s, Hard Times, onhousing for example (Dickens, 1853): “In the hardest working partof Coketown,.where Nature was as strongly bricked out as killingairs and gases were bricked in . where the chimneys, for want ofair to make a draft, were built in an immense variety of stunted andcrooked shapes.” (p. 65e66) or a description of working conditionsin a northern mill town: “all the melancholy-mad elephants, pol-ished and oiled up for the day’s monotony, were at their heavyexercise again. . Every man was in the forest of looms whereStephen worked to the crashing, smashing, tearing piece of mech-anism at which he laboured.” (p. 91).

Should we really assume, that these dark satanic mills andairless places, rather than causing terrible illness and shortenedlives, selectively employed sick people and those whose back-grounds accounted for all their subsequent illness? That subse-quent improvement in living and working conditions, thus abatingVictorian squalor, and associated improvements in health werecorrelation not causation? That while medical care improvedhealth, housing also got better, and an intellectually slack publichealth profession mistook the improvement in housing andworking conditions for causes of improved health?

If proponents of this set of assumptions dropped their guard fora moment and accepted the evidence that air pollution, crowdedliving conditions, ghastly working conditions were causes of ill-health in Victorian times why, a priori, do they start from theposition that living and working conditions are not a cause of ill-health in the 21st century? Why do they reject the evidence onselection from the 1970s and 1980s; that workers are selected intoemployment for good health and not illness (Fox & Collier, 1976;Goldsmith, 1975); that such effects are of limited duration (Fox,Goldblatt, & Adelstein, 1982) and are overtaken by cumulativeexposure to work conditions; and that rather than being sustainedby selective mobility between jobs, social gradients in the work-force are dampened by selective movement out of the labour force(Goldblatt,1988,1989)?Why do they appear to assume that Fig.1 inthe Review (Marmot Review, 2010), reproduced here, linkingneighbourhood deprivation to disability-free life expectancy couldall be due to a remarkable ability of people to choose places to livedepending on their level of health e ill-health leads to neigh-bourhood income, in other words? At a regional level, it is equallydifficult to see how selection explains why the social gradient iswidest in the North East and narrowest in the South West, as bothregions have a history of out-migration of those needing to findemployment (Marmot Review, 2010).

Fair society or fairer allocation of NHS resources?

This disagreement between commentators is not just aboutevidence. It is also about ideology. We think that the healthgradient in Fig. 1 is a powerful demonstration of the graded relationbetween social and economic conditions and health. We are chas-tised, by Canning and Bowser, for wanting a fairer society to put itright. Instead, they offer the following:

“The health gradient should be seen as a flashing alarm that ourhealth systems are failing to deliver cost effective health care anda call to allocate health sector resources more effectively.” (Canningand Bowser, 2010)

Why should it? Where is the evidence for their counter asser-tion? They are not being more rigorous about causation than weare, as they claim. They simply have a different starting position.This is ideology dressed up, condescendingly, as methodologicalrigour. We would go further. Given the vast research resources thathave gone into evaluating medical interventions, the lack of clearevidence that the main cause of the social gradient in health isdifferential access to health care, may mean that, indeed, it is notlack of health care that is the cause of the problem.

Too little or too much emphasis on income?

No topic created as much dissent among the commentators asthe Review’s stance on income. One of the more creative voices inpublic health has been that of Richard Wilkinson. Latterly,Wilkinson and Pickett (2009) have extendedWilkinson’s consistentobservation that level of inequality is related to overall health ofsociety, and shown that the relative level of income inequality isrelated to a great many other social problems. One mechanism by

Fig. 1. Life expectancy and disability-free life expectancy (DFLE) at birth, persons of neighbourhood income level, England, 1999e2003.

M. Marmot et al. / Social Science & Medicine 71 (2010) 1254e12581256

which such a relation could operate is that greater level of incomeinequality is related to higher poverty levels. If reduction of incomeinequalities led to reduction in poverty health of the worst offwould improve.

Second, income inequalities may be causal of ill-health inaddition to an effect on poverty, either because income inequalitiesare directly causal, or because income inequalities are a marker ofmore general inequalities in society that themselves are causal ofill-health. A key mechanism may be relative inequality. The LabourGovernment, in theory, embraced relative inequality by definingchild poverty relative to 60% of median income and declaring anintention to abolish it.

In addition, Hills et al. (2010) point out that greater inequalitymay reduce social mobility: the larger the gap between rungs of theladder the harder it is to climb the ladder. Lack of socialmobility andreduction of chances of improving one’s life will, in the language ofour reports, be disempowering with devastating effects.

We should emphasise that we were concerned with the wholesocial gradient in health, not only the dramatic health effects ofbeing at the bottom of the distribution. There is still intense debateabout how much of the health differentials, among people abovethe poverty threshold, are due to relative inequalities and howmuch to absolute differences in living and working conditions. Wewere influenced by the Amartya Sen argument that relativedifferences in income are related to absolute differences in capa-bilities (Marmot, 2004). Our recommendations, largely, are aimedat the whole social gradient.

In the Review (Marmot Review, 2010) we pointed to the lack ofprogress in reduction of income inequalities e gradients in bothgross and post tax income have been largely constant since theywidened 20 years ago (Jones, Annan, & Shah, 2009). We alsodescribed how the poorest pay proportionately more of theirincome in taxes than the richest e tax appears to be regressive, notprogressive. In particular, for the bottom quintile of income, all

original income is clawed back through the tax system while finalincome is dependent on benefits (Barnard, 2009). For these reasons,we called for a more progressive system of both tax and benefits toaddress these inequalities. Among the evidence underpinning thiscall was that from our task group on early child development andeducation which concluded that if the aim is to reduce inequalitiesin ECD and education there has to be reduction in inequalities insociety.

Significant though income is to health, we do not think that thesocial gradient in health is primarily the result of income differ-entials. One of the key messages in the Review report is “action onhealth inequalities requires action across all the social determi-nants” (Marmot Review, 2010, p.16). That is why there are sixdomains of recommendations in the Review.

Income does not of course exist in isolation from these domains.We were greatly impressed by Jerry Morris’s work (2000) ona minimum income for healthy living e having enough money forhealthy food, transport, social interaction. It is hard to see how evenideologically driven commentators could think that having insuf-ficient money to live on is irrelevant to health inequalities. We alsorecommended that it is important that there be economic incen-tives to work, not by setting unemployment benefits unconscio-nably low, but by reducing the cliff edges thatmakeworking appearless remunerative than not doing so.

Is that too much emphasis on income? We are unrepentant.

Capability

Nathanson and Hopper (2010) argue that the mantra of givingpeople control over their lives “rings rather oddly, not onlybecause it is an individual not a structural- level variable, but alsobecause taking control is by no means a guarantee of goodhealth: think race car driving or .planting a bomb in TimesSquare”. Similarly Pickett and Dorling (2010) chide the Review for

M. Marmot et al. / Social Science & Medicine 71 (2010) 1254e1258 1257

its “focus on maximising the capabilities of children and youngadults e the language of economics”.

We think this is to miss the point e that social change at grassroots level and health improvementwill not happen if people do nothave control, capability (Sen, 1999) and capacity in their everydaylives. This will contribute to addressing the stresses associated withdisadvantage and enable them to change difficult behaviours, tomake improvements to their and their communities’ lives.

But it is wrong to dismiss capabilities and control as simplyindividual level variables. They are strongly related to the condi-tions in which people are born, grow, live, work, and age and, inpart, their effect on the skills people have acquired and levels ofcommunity functioning. It is not surprising to us that Chandra andVogl (2010) say “Economists have demonstrated that early lifeconditions jointly determine health, educational attainment andlabor market outcomes in adulthood”. These are all linked throughthe development of skills, capability and resilience. In contrast totheir view that it makes “crossesectional relationships extremelydifficult to interpret”, we conclude that these attributes lead to thereinforcement of advantage or disadvantage right across the lifecourse.

Countervailing forces

Whitehead and Popay (2010) state that advice about how totackle countervailing forces driving inequalities is missingcompletely from the Review and the CSDH. They say that we are toocautious when it comes to criticising the role of big business andthe existing power bases, the global economic system, erosion ofuniversalism in social welfare systems, fragmentation and privati-sation of health services and labour market policies that have led togrowth in insecure and precarious employment.

Reviewing the tax and benefits system and ensuring a minimumincome for health living is one way of dealing with such counter-vailing forces. We have gone as far as we believe the extensiveevidence base (Siegrist et al., 2009) will take us in proposing actionon good work for all and sustaining employment for the mostdisadvantaged.

Pickett and Dorling (2010) add to the voices of Whitehead andPopay in wanting us to go further. We are entirely sympathetic totheir arguments for dealing with the high incomes of the topearners, and using the tax revenues for the benefit of all. There hasbeen debate as to whether income inequalities, as well as beinglinked to overall population health, are linked to health inequal-ities.Wewere impressed, nevertheless, that absolute inequalities inhealth do seem to be narrower in countries, such as Sweden andJapan, that have narrower income inequalities. We called for amoreprogressive taxation system, but did not say much else on bankers’bonuses, or other top incomes. That said, we are with Pickett andDorling. The argument that top salaries provide incentives toimprove the overall economy, and therefore provide trickle downbenefits, looks remarkably weak as the world faces up to theaftermath of the worst economic downturn since the greatDepression. The harm didn’t trickle down either. It gushed down.The losers, as always, were predominantly those closer tothe bottom of the social hierarchy not those higher up.

In passing, we are not sure why Pickett and Dorling argued thatwe needed to put more emphasis on the life course. We prefacedour recommendations with the statement “central to the Review isa life course perspective” (Marmot Review, 2010, p. 20) and thenstart our recommendations with early childhood, move througheducation, work and employment, on to living standards. As wehave indicated previously, our guiding conceptual frameworkincluded the accumulation of advantages and disadvantagesthroughout the life course.

Although not picked up by the commentators it is worthre-emphasising the importance of sustainability.We believe that byaligning the health inequality and climate change agendas, signif-icant strategic progress can be made on a significant global agenda.Our recommendations on sustainable local communities are anattempt to put a human scale to the impact of many globalphenomena.

Not political enough e to the Finland Station it is not

The CSDH (2008) concluded that social injustice is killing ona grand scale and pointed to inequities in power, money andresources as major causes of avoidable health inequalities. Both theCSDH and the Review set out to put practical recommendationsinto an ethical framework.

Whitehead and Popay (2010), pleased with this clear statement,claim that the call for social justice is one of the strongest state-ments to appear in a WHO Report. They do, however, want to gofurther. Vicente Navarro (2009) also praised the CSDH report butsaid, in effect, we know who the killers aree there should havebeen a more overtly political analysis of the perpetrators of socialinjustice.

The CSDH report had a whole section on structural determi-nants: globalisation, fair financing, market responsibility, genderequity. Such structural drivers influence inequalities in the condi-tions of daily life which, in turn, lead to health avoidable healthinequalities. Globalisation featured less strongly in the EnglishReview, although we did refer to structural drivers.

In gathering the evidence, and deliberating on it, in the globalCSDH, it was clear that changes were needed to the worldeconomic order. But it was beyond the competence of the CSDH orthe Review to design such a new system, quite apart from thepolitical question of how to get such a system adopted. We agreeboth with Navarro (REF TO NAVARRO NEEDED HERE) and withWhitehead and Popay that understanding the political drivers andhow to get political change is vital e the more attention given tothis agenda the better.

Should the CSDH and Review have done more on this moreovertly political arena? Quite apart from questions about ourcompetence, there is also the question of whether it would havebeen the right thing to do. Navarro acknowledged that the CSDHprobably went as far as it reasonably could have, given the nature ofthe CSDH. At the World Health Assembly, debating a resolution onthe CSDH, representatives of 39 countries spoke in favour of theresolution that passed unanimously. Had the report been totallyanodyne such acceptance would hardly count for much but giventhe praise for its radicalism, it is possible that Navarro is correct: wecould not have gone further even had we known how to.

With the Review, we had the example of the Black Report (1980)before us. We wanted to make a strong ethical statement e hencethe title, Fair Society, Health Lives e to give the context to our morepractical recommendations, and we did not want a new govern-ment simply to ditch it, as the Black Report was unceremoniouslyditched. Yes, of course, the Black Report had a huge impact onresearch and thinking, but no impact on policy in Britain for 18years. In contrast to Pickett and Dorling’s view that the Review’srecommendations were similar to (if in places a little less ambi-tious) than the Black Report, we believe that we built upon whatwas in the Black Report. By using the evidence that has emergedfrom research and practice in the last 40 years, we were able tostrengthen the framework for action.

Which brings us to Nathanson and Hopper’s (2010) statement“To the Finland Station it is not”. Are we, in their judgement, reallyliving in revolutionary times? And is it their judgement that weshould be calling for overthrow of the established order, as Lenin

M. Marmot et al. / Social Science & Medicine 71 (2010) 1254e12581258

did at the Finland Station? Or, if we are reading too much into theirmetaphor, what did they mean? Clearly we irritated them e hencetheir comments on the nature of our recommendations for earlychild development. They find our evidence mind-numbing.However, the aim was to build the recommendations on theevidence. This included the data that show that advantage anddisadvantage accumulate across the life course, the scale of widersocietal influences, the successes and failures of policy and last, butnot least, what does and does not work. These elements were quiterightly in the Government’s terms of reference for the Review.However, for those that find statistics and evidence a bit over-whelming, we did include an executive summary.

If what they meant was that there should be a clearer call toaction we can reassure them a little. The call to action has beenheard in several quarters. There has been a huge amount of interest,at local and regional level in Britain. Although Whitehead andPopay suggested that our plans for implementation were weak,many national and local organisations are already using theevidence to shape and design interventions, galvanise and mobiliseaction and implement the recommendations of the Review. Ourintention was not to be overly prescriptive, or advocate too manystructural, organisational changes which might in fact detract fromthe most important issues. We believe that this has encouragedlocal organisations to develop locally relevant plans and actions.

What the new central government will make of it, we do not yetknow. Are Nathanson and Hopper right that a crisper statementwith less evidence, and fewer practical recommendations (such asthose for health visitors), and a more revolutionary call for radicalsocietal change, would have more chance of being taken up? Thatwas not our judgement but, as economists might say, we don’t havea counter-factual.

Is it possible to reduce health inequalities?

Mackenbach (2010), in a thoughtful and well-informedcomment, says that the British experiment is of wide internationalinterest. Britain has taken health inequalities seriously. Given thelack of progress in reduction of health inequalities, it leads him toask: if the British couldn’t do it, perhaps the whole enterprise ishopeless.

He may be right. But Whitehead and Popay have a differentview. They agree that the British government was concerned withhealth inequalities but did not do what was needed. They identifyfour reasons why the action taken did not lead to reduction inhealth inequalities:

� Focus on the worst off rather than the gradient� Too much emphasis on individual life style� Not giving initiatives enough time to work� Countervailing forces such as failure to narrow social andincome inequalities, and labour market insecurity

Were we not more in sympathy with Whitehead and Popay,than with the ‘it’s not possible’ view, we would not haveembarked on the Review. As was highlighted in the Reviewreport (Marmot Review, 2010), life expectancy for the bottomquarter of the population, in terms of deprivation, increased by2.9 years in men and 1.9 years in women (apologies if thesestatistics are mind-numbing) in only 10 years. Rapid improve-ment for the worst off is possible. The question is whether wecan make the gradient less steep.

Many of the commentators feel that the likelihood of achievingthat would be increased both by a clearer clarion call and moreovert political analysis. We welcome these voices. We have brought

the evidence together. We do need a social movement to act on itand to continue to develop the evidence.

Appendix. Supplementary material

Supplementary material for this article may be found, in theonline version, at doi:10.1016/j.socscimed.2010.07.011.

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