Michael Marmot - The Health Gap: The Challenge of an Unequal World

THE HEALTH GAP

THE HEALTH GAP

The Challenge of an Unequal World

MICHAEL MARMOT

For Alexi, Andre, Daniel and Deborah

CONTENTS

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

The woman looked the very picture of misery. Her gait almost apologetic, she approached the doctor and sat down, huddling into the chair. The dreariness of the outpatients clinic, unloved and uncared for, could not have helped. It certainly did nothing for my mood.

When were you last time completely well? asked the psychiatrist in a thick middle-European accent. Psychiatrists are supposed to have middle-European accents. Even in Australia, this one did.

Oh doctor, said the patient, my husband is drinking again and beating me, my son is back in prison, my teenage daughter is pregnant, and I cry most days, have no energy, difficulty sleeping. I feel life is not worth living.

It was hardly surprising that she was depressed. My mood dipped further. As a medical student in the 1960s I was sitting in Psychiatry Outpatients at Royal Prince Alfred Hospital, a teaching hospital of the University of Sydney.

The psychiatrist told the woman to stop taking the blue pills and try these red pills. He wrote out an appointment for a months time and, still a picture of misery, she was gone. Thats it? No more? To incredulous medical students he explained that there was very little else he could do.

The idea that she was suffering from red-pill deficiency was not compelling. It seemed startlingly obvious that her depression was related to her life circumstances. The psychiatrist might have been correct that there was little that he personally could do. Although, as I will show you, I have come to question that. To me, that should not imply that there was nothing that could be done. We should be paying attention to the causes of her depression. The question of who we should be, and what we could do, explains why I discarded my flirtation with psychiatry and pursued a career researching the social causes of ill-health and, latterly, advocating action. This book is the result of the journey that began in that dreary outpatients clinic all those years ago.

And it was not just a question of mental illness. The conditions of peoples lives could lead to physical illness as well. The inner-city teaching hospital where I trained in Sydney served a large immigrant population, at that time from Greece, Yugoslavia and southern Italy. Members of this population, with very little English to explain their symptoms, would come into the Accident and Emergency Department with a pain in the belly. As young doctors we were told to give them some antacids and send them home. I found this absurd. People would come in with problems in their lives and we would treat them with a bottle of white mixture. We needed the tools, I thought, to deal with the problems in their lives.

A respected senior colleague put it to me that there is continuity in the life of the mind. Perhaps it is not surprising that stressful circumstances should cause mental illness, he said, but it is inherently unlikely that stress in life could cause physical ill-health. He was wrong, of course. I did not have the evidence to contradict him at the time, but I do now. The evidence linking the life of the mind with avoidable ill-health will run right through this book. Death, for example, is rather physical, it is not just in the mind. We know that people with mental ill-health have life expectancy between Whatever is going on in the mind is having a profound effect on peoples risk of physical illness and their risk of death, as well as on mental illness. And what goes on in the mind is profoundly influenced by the conditions in which people are born, grow, live, work and age, and by the inequities in power, money and resources that influence these conditions of daily life. A major part of this book is examining how that works and what we can do about it.

The more I thought about it at the time, the more I thought that medicine was failed prevention. By that I mean most of medicine, not just pain in the belly in marginal groups or depression in women suffering domestic violence. Surgery seems a rather crude approach to cancer. Lung cancer is almost entirely preventable by eliminating smoking. I didnt know it at the time, but about a third of cancers can be prevented by diet. Heart disease surely we would want to prevent that, rather than simply wait for the heart attack and treat. Stroke ought to be preventable by diet and treating high blood pressure. We need surgery for trauma, of course, but could we not take steps to reduce the risk of trauma? That said, having had a bad bicycle accident, I am very grateful for high-quality surgical care, free at the point of use (thank you, National Health Service).

As for prevention, it seemed to me then, and I have evidence now, that taking control of your life and exercising, eating and drinking sensibly, having time off on happy holidays, was all very well if you were comfortably off financially and socially (and going to the private clinics, not the public hospital where I was then working). Were we going to tell the woman in Psychiatry Outpatients that she should stop smoking and, as soon as her husband stopped beating her, she should make sure that he and she had five fruit and vegetables a day (we did know about healthy eating then, even if we didnt have the five a day slogan)? Were we going to tell the immigrant with a marginal, lonely existence to stop eating fish and chips and take out membership in a gym? And for those who assert that health is a matter of personal responsibility, should we tell the depressed woman to pull her socks up and sort herself out?

The thought then occurred that a preponderance of the patients I was seeing were disadvantaged socially. Not in desperate poverty: the husband of the depressed woman was working; the migrants, like probably most migrants, were working hard to get a toehold in society. But they were at the lower end of the social scale. In fact, all the things that happened to the depressed woman domestic violence, son in prison, teenage daughter pregnant are more common in people at that end of the scale. I was seeing social disadvantage in action; not poverty so much as low social status leading to life problems that were leading to ill-health.

She had an illness. The fire was raging. Treating her with pills might help put out the fire. Should we not be in the business of fire prevention as well? Why treat people and send them back to the conditions that made them sick? And that, I told myself, entails dealing with the conditions that make people sick, not simply prescribing pills or, if interested in prevention, telling people to behave better. At that time, and since, I have never met a patient who lost weight because the doctor told her to.

As doctors we are trained to treat the sick. Of course; but if behaviour, and health, are linked to peoples social conditions, I asked myself whose job it should be to improve social conditions. Shouldnt the doctor, or at least this doctor, be involved? I became a doctor because I wanted to help people be healthier. If simply treating them when they got sick was, at best, a temporary remedy, then the doctor should be involved in improving the conditions that made them sick.

I had a cause. I still do.

It was not a cause, though, that many of my seniors in medicine were prepared to endorse. They were too busy putting out fires to expend effort improving the conditions that promoted these fires.

While thinking these thoughts and working as a junior doctor in the respiratory medicine ward, I had a Russian patient with tuberculosis. When I presented the patient to my seniors, I didnt start with his medical history but, I now blush to recall, said that Mr X, a Russian, was like a character out of Dostoevsky. He had stubbed his toe on the highway of life (cringe). He had been a gambler down on his luck, an alcoholic, unlucky in love, and now, as if in a Russian novel, had developed TB.