Public health prof.: Health inequalities solutions lie outside healthcare sector

There are huge health inequalities in the EU and most of them were created by policies pursued outside the healthcare systems, says Michael Marmot.

Sir Michael Marmot is professor of Epidemiology and Public Health at University College London. The European Commission recently published a report by Marmot on health inequalities in the EU. Marmot spoke to EURACTIV's Henriette Jacobsen.

Why do we need to care or worry about health inequalities in the EU?

For two important reasons: One is there are big differences in health between countries and particularly between the newer member states and the EU15, but even within the EU15 there are big differences in health between countries. And second, there are even bigger inequalities within countries. All EU member states have inequalities in health within countries, some bigger than others. The differences are enormous. This means that if we’re concerned with health, we have to be concerned with health inequalities because what we see is the improvement in health, that has been happening in general for most European countries across the EU, has been happening at a different speed depending on people’s socio-economic level.

So in many countries we have seen a faster improvement in health measured for example as life expectancy and people with more education, people with a higher income, people living in more affluent areas than people with less education, lower income or living in less affluent areas.

Where do you mainly see the health inequalities, apart from life expectancy?

We do see inequalities in virtually, not everyone, but virtually every health measure we can find. We see big differences in inequalities in mortality from heart attacks and heart diseases. We see big differences in mental illness, depression which follows the social gradient and anxiety.

What I mean when I say ‘following the social gradient’ is that it’s not only the difference between the poor and everybody else, but we see a social-gradient phenomenon: The more education you have, the better health. The more income you have, the better the health. It’s a step-wise relation. It’s not simply poor health for poor people and good health for everybody else. It’s graded and we see that gradation for most major causes of death, morbidity and also for mental illness.  

Is there a health area, where you see inequalities, that particularly makes you worry?

Firstly, it’s hard to show an effect in the short term because for example for heart disease… it takes a long time for heart diseases to develop so the effect of a crisis which began in 2008 with the latest statistics from 2010 or 2011, it’s a bit too early to see the effects of the crisis. That said, we do see an effect on suicide of the rising unemployment. In general, the greater the rise in unemployment per country, the greater the impact on suicide.

Now that you are mentioning unemployment, what are some of the outside components which effect health inequality?

Well, we were commissioned to do a review in England in London at a small scale of the likely impact of the recession and the policies put in place following the recession on health inequalities. We identified three key determinants: Income, housing and employment. So we said if the recession and the policies put in place as a consequence of the recession had an adverse impact on people’s income, housing and unemployment, then we could expect to see perhaps in the medium term an adverse impact on health inequalities. It’s an issue of great concern.

Now we have done two reviews and I talked about this in Brussels. One review was commissioned by the World Health Organisation’s (WHO) regional office, and those three social determinants come out very strongly in our European review. The second review we did was commissioned by the European Commission and again we emphasized the importance of these social determinants. 

In order to have less health inequalities, are you saying that the solution then cannot be found alone within the health sector?

Yes, you notice I haven’t mentioned healthcare yet. In some countries, rumour has it that in Greece there are real issues about the recession having a negative impact of availability of healthcare. If there are budgetary constraints on healthcare, it may well have a negative impact on access to healthcare in various parts of the EU. I’m not downplaying the importance of that, but emphasising and identifying the social determinants of health inequalities. We need access to healthcare when we get sick. I’m talking about the social determinants of getting sick in the first place and there’s much a government can do, but not just within the health sector.

A government can support housing, there’s much it can do through the social welfare system and the fiscal system to reduce poverty. Of course there’s no question that the policies of austerity raise unemployment. You may pursue policies of austerity for other reasons, but to argue that the unemployment in Spain, Greece, Portugal and Italy is unrelated to policies of austerity flies in the face of the evidence.

A couple of weeks ago, some health experts criticised the Greek government and the troika for being in denial of the current healthcare problems in Greece, with rising infant mortality, more HIV incidents, malaria has returned and so on. Where did they go wrong, creating these health disasters in Greece?

Greece was in trouble. There’s no question about that. There were problems with the way the governments kept the books. There was widespread tax avoidance, so there’s no question that Greece was in trouble and the EU was complicit with Greece not meeting the criteria for membership of the eurozone. But I would say that there’s also no question that the remedy has made the problems far worse that it needed to. The troika has been so strict in demanding that the Greek government cut and squeeze has created huge problems.

While I have already said that it’s hard to see effects on health in the short term, I think there are health ill-effects showing up in Greece.  

If you had been health minister in Greece, while all of this was happening, what would you have done instead?

I think the Greek population is very lucky that I was not the health minister. I think that the health minister has a responsibility to be the advocate across government for policies that will have a positive impact on health and reducing health inequalities. So, yes, as health minister, one needs to do what one can within shrinking budgets to preserve vital health services and access to health services. But the health minister also has a responsibility across the whole of government to push for policies that will have a beneficial effect on health and health inequalities.

In a country such as Spain, the government advised nurses and doctors not to treat illegal migrants. In Greece, humanitarian groups are giving basic health services for free, as it is estimated that around 6 million Greeks have lost their health insurance. How okay is it to say in a crisis like this that ‘we can no longer take care illegal migrants, we need to focus on our own citizens’?

I’m nervous. It depends how you define illegal migrants. I’m nervous that there’s a real invitation because of austerity and difficult times to start getting small-minded, narrow, restricted in focus and intolerant. The next step is racial and ethnic minorities. I’m nervous of going down that route.

We have talked about Greece, but which other EU member states do not have the right policies to combat health inequalities?

We reported on a survey where we tried to assess how well countries were doing in terms of policy responses on social determinants and health inequalities. There were three clusters of countries: Countries with a relatively positive and active response on health inequalities, those with variable response and those that were doing very little.

We looked at what’s been happening since 2006. So those who were doing well in 2006 and still had a positive policy response in 2010 included Denmark, Finland, Norway and the UK. Those who were doing less in 2006, sort of in the middle group, but had intensified their response included Estonia, Latvia, Spain and Iceland. At the other end, countries that had been doing well in 2006, but had decreased the intensity of the policy response, perhaps because of the recession, included Ireland and the Netherlands. Those who hadn’t been doing much in 2006 and were doing even less in 2010 included Cyprus, Greece and Hungary.

So we got quite a spread across EU member states of those who have an intensive action and those not doing much at all.

Those countries that do take action, what exactly are they doing?

We asked them about a variety of responses on health inequalities and that could include a huge range of actions and it did include questions outside the health sector. It wasn’t only actions in the health sector, and it could include having targets for reduction of health inequalities and actions outside the sector on social determinants on health as well as within the sector.

Clearly some actions were focused explicitly on health inequalities and some were pursuing policies that would have a beneficial effect, but they weren’t done specifically for health reasons, but we were focusing on those that had some focus on health inequalities.

Now there are some EU member states that have recovered from the crisis, so maybe it’s time to do some investing. Where would it be the right place to make investment in the health sector at the moment as you see it?

In our WHO European review, we identified four domains. The first was through the life course, the second was looking at the wider society which included fiscal policies, social protection and so on. The third was the macro-economic environment which includes trade that has an impact both within the member states in the EU and outside supranational bodies such as the EU itself. And the fourth was on systems including health systems.

Within the life course, we identified early child development and education. We identified employment and working conditions, including active labour market and employment programmes. We identified spending on social welfare. We said that the more generous the social spending in general, the better the health and the narrow the health inequalities. And of course, supporting older people and improving occupational health standards. So these are not either/or. We should be spending on preschool, improving early child development and making sure we have active labour market programmes so that young people don’t leave school like they are now in Greece, Spain, Portugal and Italy to become unemployed.

What can the Commission do in order to reduce health inequalities in the EU member states?

To the extent that Commission policies impact on social welfare spending… For example, newer member states told us as I was doing the European review that they had to improve social spending, regulations and occupational health standards in order to join the European Union. So the European Union had a good effect in spreading better standards in social protection and occupational health to newer member states. Other states, that are outside the European Union, that would like to join are aware that they got to improve things if they want to be able to join. It's a good effect which the European Union is having on newer member states.

Now, I don't know how much the European Commission can change policies within countries. If you believe eurosceptics in Britain, it has far to much influence in changing policies in countries. So you are reflecting a view from Brussels that it has no influence. Where the truth lies in that spectrum, I'm not sure.

But certainly, trying to get an understanding of how social determinants operate and that there's much a government can do and that foisting policies… If the European Commission as part of the trigger is foisting policies on countries like Greece that are making matters worse in terms of health and health inequalities then there's a lot the European Commission can do.