Dealing with an epidemic of disempowerment

What does a resident of Calton in Glasgow have in common with the average American?

Neither is very healthy.

All over the world health, as measured by life expectancy, is improving. But, not improving as much in Glasgow, especially not in Calton, a poorer part of the city; nor among middle-aged Americans, especially not among people of low education.

When, in 2015, Angus Deaton won the Nobel Prize for Economic Science it generated the expected press interest. When, a few weeks later, Anne Case and Angus Deaton, both Princeton economists, published a paper on trends in mortality in the US it generated ten times the press interest. What the paper showed was truly shocking. Case and Deaton examined trends in mortality rates in men and women, aged 45 to 54, from 1990 to 2012. Rates were coming down in France, Germany, UK, Canada, Australia and Sweden; as they were in US Hispanics. But in non-Hispanic whites, rates were rising. The fewer the years spent in education the steeper the rise. The social gradient in mortality was getting steeper.

This mortality crisis is not a medical care issue. The causes of the catastrophic loss of life were, in order: poisonings due to drugs and alcohol, suicide, liver disease (mainly alcohol); and then, of course, there are violent deaths. Case and Deaton call this an epidemic of despair. I might have used the word disempowerment.

Back in Glasgow, we have a similar problem. The Glasgow Centre for Population Health recently published a report that compared mortality in Glasgow with that in Liverpool and Manchester. The three cities have similar levels of poverty and inequality, yet Glasgow has higher mortality rates. The biggest relative excess in Glasgow was from drug overdose and poisonings, suicide, alcohol related causes and ‘external’ causes of death – the same group of causes accounting for the high mortality of non-Hispanic white Americans. These causes are psychosocial in origin. The mind is an important gateway through which social conditions affect health and health inequalities.

Health inequalities exist not only between Glasgow and other cities but within Glasgow itself. When we published Closing the Gap in a Generation (the report of the WHO Commission on Social Determinants of Health – which I chaired) I compared Calton, where male life expectancy is 54, with Glasgow’s Lenzie, where life expectancy is 82. That is a 28 year gap in life expectancy in one Scottish city.

Documenting the problem of health inequalities, and monitoring changes, is important but so, too, is working out what to do about them. In my book, The Health Gap, I follow the life of ‘Jimmy’, a typical Calton resident, to help understand how experiences through the life course act to cause health and ill-health in adulthood. Hence, where to intervene to reduce health inequalities.

Jimmy’s start in life was characterised by adverse childhood experiences (ACEs). He came from a single parent family in poverty. His mother had a succession of male partners each of whom abused Jimmy, physically if not sexually. He had behaviour problems by the time he reached school and did poorly educationally. Inevitably he got involved in gangs and violence. He left school to no proper job. His diet looks like a health educator’s nightmare. Any money he gets goes on drink and drugs – as another despairing Glasgow resident said: he is one drink away from the abyss.

If you are of a bent to blame Jimmy for his unhealthy behaviour, I invite you to go to Calton and lecture Jimmy about the virtues of non-smoking and five fruit and veg a day. Useless, as these are neither priorities for Jimmy nor are they within Jimmy’s individual control.

To improve chances of a healthy life for people like Jimmy action is needed through the life course, as set out in the Marmot Review, Fair Society Healthy Lives:

• give every child the best start in life
• education and life-long learning
• employment and working conditions
• having enough money to lead a healthy life
• healthy and sustainable environments
• taking a social determinants approach to prevention: acting on the ‘causes of the causes’.

I tell the story of Jimmy to make clear what happens at the social extreme. But the real drama is that health follows the social gradient. Jimmy at the bottom, with the most adverse social conditions, has the worst health. But as one moves up the social scale, and social conditions improve progressively, health improves. So everyone’s health is affected by where they are on the social gradient and everyone has the potential to benefit from these recommendations. True in Glasgow as it is in the US.

Making such recommendations is far from academic unreality. I am hugely encouraged by the take-up we have had to our recommendations, nationally and globally. Coventry, for example, has become a Marmot City. Local government has taken the lead in putting into practice the Marmot 6 (outlined above). Many other local authorities are taking similar actions.

The funding climate is adverse, to put it mildly. That said, we are giving local government the opportunities and the guidance to put health equity at the centre of their activities. A practical pursuit of social justice.

Sir Michael Marmot (@MichaelMarmot) is Director of the Institute of Health Equity (UCL Department of Epidemiology & Public Health)