University College London (UCL) professor Michael Marmot, who was knighted in 2000, is a global health inequality scholar. He served as president of the World Medical Association. Born in 1945, he devoted his entire life to studying the effects of social conditions on health and disease. ‘Why, at best, treat the patient and then return him to the environment in which he got the disease?’ His 2015 book, The Health Gap, begins with this sentence: He became a doctor because he wanted to help people become healthy, but the doctor’s prescriptions and treatment were only temporary solutions. He turned to public health research because he wanted to cure the conditions that caused it, not the disease.
The response to COVID-19 was both epidemiologic and sociological. This is because, as important as managing the spread of the virus, it was important to understand the socio-economic crisis caused by the infectious disease. As an epidemiologist, Professor Marmot’s research topics are mainly directed toward the latter. Since 2005, he served as the chairman of the World Health Organization (WHO) ‘Social Determinants of Health Committee’ to investigate the health gap between and within countries for the first time. It was a study that raised health inequality to the main agenda of the international community. After that, provincial cities such as Manchester and Coventry in England declared ‘Marmot City’. These cities have formed a kind of local government network to reduce health inequality.
Professor Marmot’s report ‘Build Back Fairer’, which deals with health inequality in the UK during the pandemic, is an extension of the problem that has been occupied for over 40 years. It means rebuilding the post-COVID-19 world more equitably. It borrowed the slogan “Build Back Better” from Joe Biden’s presidential nomination. “Pandemic has exposed and amplified fundamental inequalities in society,” Marmot said. “We need to ask ourselves what kind of society we want to create as we get out of the pandemic.”
I met him on September 30th in a laboratory in Bloomsbury, London. We asked him what lessons British society has learned from the COVID-19 pandemic. Just a week ago, former British Prime Minister Liz Truss announced a tax cut based on the ‘rich tax cut’, and the global financial market was shaking. “There was a lot of evidence that the new government would do nothing to reduce inequality, but their first step was to increase inequality,” Marmott said.
Since the early days of the COVID-19 pandemic, health inequality has been investigated in various ways.
Some might say that I, as a public health scientist, don’t talk enough about controlling the virus and increasing vaccinations. Because I’m mainly talking about inequality. Of course, scientific advice on viruses is needed in a crisis situation. Thanks to that, we were able to develop a vaccine very quickly. However, what our team showed in the ‘Build Back Fairer’ report in December 2020 is another reality of the pandemic. An analysis of the COVID-19 mortality rate showed that the risk was much higher in poor areas, in essential industries with face-to-face work, and in African, Asian, and other ethnic minorities. The issue of inequality was not mentioned in the scientific advice delivered to the UK quarantine authorities.
Why is COVID-19 so harsh on certain races?
Racial inequality in COVID-19 death rates was partly related to housing conditions. They often live in overcrowded residential areas that are vulnerable to the spread of the virus, and the proportion of ethnic minorities is high in the ‘frontline’ occupations called essential workers. This fact raises the following questions: ‘Why are certain racial groups at a socio-economic disadvantage?’ The pandemic has exposed and amplified fundamental inequalities in British society. We need to address the issue of structural racism.
The UK has a high death rate from COVID-19. What do you think is the reason for the great damage despite the existence of a public health crisis response system?
To see how the UK has responded to COVID-19, we need to go back to pre-COVID-19. In February 2020, just before the outbreak of the pandemic, our team published a report on health inequality in the UK, The Marmot Review: 10 Years Later. According to the report, the poorer the regions, the higher the death rate and the shorter the life expectancy. In the past decade, health inequality in the UK has been widening. However, when the first wave of COVID-19 began, Britain had a very high excess mortality rate in Europe as well. What’s the connection between heightened health inequality over the past decade and high mortality rates during the pandemic?
I think there are three factors. These include politics that does not prioritize health, deepening socio-economic inequality, and declining public service spending. The priority of the elected government (Conservative Party) in 2010 was austerity policy. The austerity was done in a retrograde manner. When looking at the amount of expenditure per capita by local government, the decrease was greater as the region became poorer. Public health and education budgets have also been cut. That is where we stood right before COVID-19. Life before the pandemic was not very healthy. To pay attention to all these realities, the report was titled ‘Build Back Fairer’.
Why did you say it should be changed ‘fairer’ instead of ‘better’?
If we say ‘rebuild for the better’ and don’t consider equity, then maybe the economy is growing. Financial industry workers may be getting paid more and more. But are those caring for the elderly being paid enough? British society is experiencing several socio-economic crises after the pandemic, including fuel poverty, food poverty and cost of living crisis. Rebuilding more equitably starts with understanding the reality that the cost of living crisis has different impacts on different levels of poverty, and that the poor suffer far more than the rich.
Health inequality has been said to be a “solvable” problem. Bridging the gap deepened after the pandemic does not seem straightforward.
A political decision is required. This means that we need a government that recognizes the problem of health inequality. However, on September 23, the British government announced a large-scale tax cut. The UK economy turned into a very unreliable economy in one day. The International Monetary Fund (IMF) has also publicly criticized it, saying it would “increase inequality.” I have called for ‘rebuild more fairly’ after the pandemic, but the prospects are bleak. On the other hand, the Norwegian government asked me if I could get my advice based on a ‘build back pairer’. Health inequality was also growing in Norway. Our team is advising the Norwegian government to achieve better health equity.
What motivated you to become interested in social determinants of health?
Because they knew that health inequality could not be reduced through the health system. In 2011, he served as president of the British Medical Association (BMA). Then he held a meeting with doctors from medical associations from 20 countries on the topic of what a doctor can do about the social determinants of health. It was a two-day meeting. On his way home from the first meeting, he saw people sleeping with their sleeping bags on the steps of the church. The first thought that came to my mind was really stupid. ‘It’s only 9:15 at night, so why do you go to bed so early?’ If you have a home, you will have time to talk with your family, read a book, or watch TV, but what else can homeless people do without money and a home? I told the doctors at the meeting the next day. “Is this part of our responsibility?” “Aren’t we curing them and putting them back to sleep on the road?” It was neither rational nor ethical. It’s not just about quitting smoking and getting more exercise, it’s about looking into the social determinants of smoking, an unhealthy diet, and lack of physical activity.
What lessons has UK society learned from the pandemic?
Who was moving society? They were delivery workers, drivers, supermarket workers, cleaning workers, health workers, social workers, not bankers or investors. Imagine that caregivers and nurses stop working. But did British society value them? Looking at the wages, it doesn’t seem that way. 60% of caregivers in the UK take care of the elderly for less than living wage. Will you change the bandage and inject yourself on your leg? That’s just part of the job of a care worker. We must value their work.
© EPN