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The Health Gap by Sir Michael Marmot

You will probably know the name ‘Marmot’ from the Marmot Review (see Review Roundup here) published in 2010 and from a previous blog post of mine entitled ‘Leading scientist affirms importance of Early Years’.

Sir Michael Marmot has been publishing again, and this is an incredibly powerful book with a deceptively simple message, summed up in the first and last sentences:

Why treat people and send them back to the conditions that made them sick?

Do something, Do more, Do it better

It continues the messages from the Status Syndrome and Fair Society, Healthy Lives that investigate the health inequalities that exist across the social gradient. In its most basic form, this says that the poorer you are, (or the lower the social status you have) the more likely you are to suffer from ill health (mental and physical) and the shorter expected life span.

This is reasonably intuitive. If you have access to good doctors, good dentists and the government provides health support in some form, you are likely to be in better health than those who don’t.

However – and this is the knock out blow – even in countries where there is good medical care, a secure system and relative wealth, there are still massive health inequities. Just as one example (and there are many in the book) ‘The US ranks at around 50 on what is called male ‘adult mortality’… fifty out of 194’ (Page 33) or, put another way, there are 49 countries where a young man is MORE likely to survive to his sixteenth birthday than if you were in the US.

But the US has wealth, a health system, knowledge and an ability to control all these things. So why aren’t their young men the most likely to survive to their sixteenth birthday?

Sir Michael’s research has demonstrated that the answer rests in the social conditions that influence health. When society is not cared for and nurtured, then we all feel the effects. But not just ‘society’ as a concept – real life society with all its ‘haves’ and ‘have-nots’, from the lowest 1% in the gradient to the highest 1%.

It is an excellent read – with lots of real-life examples and clear explanations. It starts with a background and grounding in the research, then the next four chapters consider early childhood, education, working life and retirement (in that order). Then, in good Bronfenbrenner style, the communities, wider implications and finally a world view is considered.

My particular area of interest was chapter 4, ‘Equity from the Start’, which analyses the Early Years of children, their place on the social gradient and the role that this has to play in making society fairer, more healthy and reducing the health gap. And especially to see what the Early Years sector could do to close the gap between child development of those at the bottom of the social gradient and those at the top.

The good news is that the research showed that ‘provision of high-quality services for early childhood makes a huge difference’ (page 140) and, in fact, the whole chapter concludes that ‘early child development matters hugely for subsequent health and health equity’ and that ‘The developing mind of the child is key.’ (page 142).

However, the suggestion was again put that the state paying for childcare (‘free’ childcare hours in nursery, for example) enabled parents to work, reducing poverty and thus helping children up the social gradient (better health, better opportunities etc.). We know there are issues with this – in general, it is only free at point of use because the setting has to subsidise in some other way, which usually means those low paid practitioners do not get a pay rise; those that may be in most need are not always accessing it; do parents actually go out to work as a result of having free childcare?

Chapter 4 is then followed by a chapter on ‘Education and Empowerment’. Here, on page 166, there is an example of a Mexican scheme, where cash subsidies are given so families will take their children to clinics and keep them in school. He also suggests in this chapter that education is a form of empowerment, leading to better jobs, better pay, better conditions, better health.

My own conclusion from this information is that maybe the ‘free’ childcare hours should be for more than just coming to nursery or pre-school – maybe this should include an element of bus fares to go to the dentist or free classes where parents can learn about the vital home learning environment?

In addition, rather than this payment being focused on getting parents into paid employment, maybe this should be focused on parents getting a minimum level of education, to empower them to get better jobs in the long term? Surely this would reduce the social gradients more effectively across the board than a mum claiming 30 free hours of childcare to work in a minimum wage job?

Further chapters go on to discuss the ways that work can affect your health and what communities and ‘fair societies’ can do to ameliorate this.

It is indicative of the whole book that the final chapter is entitled ‘The Organisation of Hope’. Throughout the book, there is a sense of optimism – that there are solutions. Not only that, the solutions are achievable, given the right circumstances and a strong will to make them happen.

This book really is worth reading and re-reading. It gives such a clear picture of how society and health are dependent on each other, and, most importantly, what we should be striving for to improve both.

You can get your copy here: The Health Gap: The Challenge of an Unequal World

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