In February 2020, Michael Marmot stood in front of a room of people (including myself) and pronounced the 2010s a “lost decade”. Following the austerity cuts of the David Cameron years, life expectancy was falling for the poorest and had slowed to a crawl for all but the wealthiest, he noted in the follow-up report to his landmark 2010 review on health inequalities.
Within weeks of that new report, the UK “limped” into the Covid-19 pandemic, and now – according to Marmot – it is facing its third crisis of health inequalities, brought about, this time, by the rise in the cost of living.
The UK is headed towards a “significant humanitarian crisis with thousands of lives lost and millions of children’s development blighted”, he and his team at University College London (UCL) have warned in their most recent report on fuel poverty.
“That stress associated with poverty will damage children’s brains, it will damage child development,” he tells Spotlight in a call. “The impact on health inequalities will be seen, not just in this generation, but in the children in the next generation, because children’s growth and development will be damaged by their parents’ struggle.”
Marmot, the director of the Institute for Health Equity (IHE) at UCL, is one of the UK’s foremost researchers on health inequality. The 77-year-old speaks in an ordered and systematic way, outlining how, when a household cannot keep warm at a reasonable cost, the causes are poverty, the price of fuel and energy inefficient housing – “all avoidable”. Cuts to benefits and home insulation programmes under austerity and the creation of a “bonkers” energy market are all policy decisions, he notes. Marmot cites a report by the Food Foundation that the poorest 10 per cent of people would need to spend 74 per cent of their income to eat healthily.
But it is “dignity” that has increasingly preoccupied him. “If you can’t afford to feed your children, you can’t lead a life of dignity,” he says. “If you have to beg the landlord for relief because you can’t pay the rent on Friday, that’s a threat to dignity.” This “struggle” to make ends meet has a direct impact on people through stress and its physical and mental health effects. In a study from the late 1970s, Marmot challenged the received wisdom that heart disease was an illness of stressed high-flyers, finding that the lower someone’s social status the higher their mortality was from heart disease. “I’ve been pursuing that ever since – the gradient,” he says.
Marmot began his career as a medical doctor, working in a hospital in Sydney, Australia, where he emigrated as a child with his parents. He observed patients being brought in, patched up – physically and mentally – and then discharged into the very same social conditions that had caused their health issues. “That seemed to me a bit inadequate,” he says. It was this observation that led him to study epidemiology in the US and then return to the UK to pursue that research with an applied edge.
“I came at this as a public health researcher, looking at health, and then looking at the inequalities in health, and then asking, how did they come about? And then asking, ‘Well, if we think we’ve got some understanding of what causes them, what can we do about it?’”
The latter question has proved the most challenging. Marmot gives out a long, loud sigh when asked how to get governments to reduce inequalities. While his work has largely been ignored by Westminster, it has found favour in local government, the devolved nations and other national governments. In September, Luton declared itself a “Marmot Town”, pledging to act in line with Marmot’s and the IHE report’s recommendations.
“One way we get change is working with the people who really want to do things differently. And we find them at local government and city and regional government,” he observes.
Marmot is not concerned with matters of party politics, though he asserts that “we certainly need to change government policy. And if the current government won’t change policy, then we need a different government.” The quality of debate during the recent Conservative leadership contest, with its focus on tax cuts, was “degraded”, he says.
Nor is Marmot impressed with how the government has responded to recent strike action by railway workers, who rejected a pay offer below inflation. “I would like the other side to acknowledge it’s pretty hard. If we’re offering you a raise that’s below inflation, we recognise the hardship that causes,” he says. Marmot served as president of the British Medical Association (BMA), the trade union for doctors (an honorary role, he points out). Beyond the role that unions play in protecting the interests of members, he believes they can also advocate for a healthier population.
IHE’s approach has been developed to incorporate the challenges posed by climate change and systemic racism and discrimination. In 2020, his followup to the Marmot review noted the stark inequalities for some ethnic minority groups when it came to maternity care and mental health. Yet it concluded that the evidence base was not yet strong enough to point to discrimination as a factor. What changed?
“Covid,” he says. The “astonishingly high mortality” among people of colour could not be accounted for by socioeconomic inequality. “We’ve got to look at racism,” he says, highlighting disparities in determinants of health such as education, employment and the experience of policing and the criminal justice system.
Internationally, Marmot points out, there are examples of rich, poor and middle-income countries that have achieved progress on health inequalities. The Norwegian government commissioned his team to do some work on its low, but widening health disparities. Meanwhile Vietnam, Brazil and Sri Lanka have all taken great strides in health equity. There are theories, he says, as to why and how this has happened, but nothing conclusive. Marmot speculates that Brazil’s Bolsa Família scheme of cash transfers to poor households, which are paid to women, could be key to how the country has helped reduce inequalities in the early years of a child’s life. More broadly, he believes that the status of women and investment in education are important factors in health inequality in poorer countries like Sri Lanka.
Marmot’s interest in disparities is reflected in one of his other great interests – literature, a subject he studied while taking his medical degree. The opening of Charles Dickens’s Great Expectations, he says, is a poignant illustration of the desperate poverty of the young protagonist Pip. He also admires George Bernard Shaw. “We’ve got politicians talking about the undeserving poor, as if they just discovered it as a concept, and Shaw nailed it to the wall with his satire [in the play Pygmalion],” he says.
Marmot is still trying to get some of the basic points across to Westminster. “If it would take 74 per cent of household income to eat healthily, stop blaming the individual. You can give them all the advice in the world, but what are they going to do with it?”
This article originally appeared in a Spotlight supplement on healthcare.