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Speech by the Rt Hon Alan Johnson MP, Secretary of State for Health, 6 November 2008: International Conference on the Social Determinants of Health

Thank you all for attending this conference, particularly to those of you who’ve come from overseas.
 
It is an important gathering and I believe it is highly symbolic that we are holding it in London. It is a city that, to paraphrase my namesake, Samuel Johnson, offers as much of life as the world can show.

Three hundred languages are spoken in a city that hosts four world heritage sites, the largest collection of modern art and the  busiest airport in the world. There are few places that can compete with London either as a cultural or economic centre. 

But London is also steeped in inequality, a place where extreme wealth and extreme poverty exist side by side. If you walk from Harrods in Knightsbridge in the Royal Borough of Kensington and Chelsea to the Harrow Road, which sits in the same borough, life expectancy will have declined by seven years for men and nine years for women.

London is living proof of the fact that even in the most prosperous and wealthy cities and countries, there are unsettling and I believe unacceptable disparities in health and wellbeing, which are perpetuated by social class, race and gender.

If this were a characteristic of London alone, then there would not be so many representatives from countries across the world gathered here today. The WHO Commission on the Social Determinants of Health, led so ably by Professor Sir Michael Marmot, showed clearly that while differences in life expectancy and infant mortality between countries were significant, the differences within them were often more astonishing. 

In recent years, governments have become accustomed to working together on issues such as climate change, and more recently, the economy. The current financial crisis is being felt in every country in the world, and global co-operation and strong international leadership is essential to address its effects. The major problem is that whilst finance is global, governance is not.

Sir Michael Marmot’s report makes clear that the issue of health inequality also demands a global response.  I believe that at an international level, we have to apply the same vigour and commitment to addressing inequality as our governments are currently applying to stabilising the world economy.

 We no longer have the luxury of seeing health policy as a purely domestic issue. “Think global, act local,” is a popular mantra among environmental campaigners. But it applies as much to health as it does to the environment.

On the most basic level, infectious diseases have never respected international borders, and in an age where it is possible to travel around the world in 24 hours, what once might have remained a locally contained health problem can quickly become a global pandemic. 

But there are also opportunities, because good ideas can be as infectious as deadly disease. The fact that universities and scientists from different countries can collaborate with greater ease is expanding the boundaries of medical science. The credit for some of the most interesting innovations in health policy being applied in this country goes not to our civil servants, or Whitehall mandarins, as we sometimes refer to them, but to policy makers and community groups as far away as Pakistan and Brazil.

The NHS Health trainers scheme, where advisers on health and wellbeing are drawn from local communities and support people at risk of poor health to change their lifestyles, is based on a similar model in Hala, Pakistan, where women are trained to provide health advice to pregnant women and new mothers. 

Our nurse-led family partnerships, where health professionals, working with other public and voluntary services give intensive support to vulnerable first-time parents to build a secure, loving home for their children, is an idea that was first trialled in the USA. And the Street Cred project being piloted in Tower Hamlets, here in London, which enables women to take out small loans to start social enterprises or businesses that benefit other women in the community, is based on the micro-credit scheme, which originates in Bangladesh.

These ideas, drawn from all over the world, are applicable because while the challenges that different countries face may vary, health inequality is auniversal feature in all health systems, as are its causes.

It would be logical to conclude that in countries where clean drinking water, sanitation and free healthcare are universal, life expectancy would be universally better than in parts of the world which lack such infrastructure. But relative poverty and deprivation and the poor health they cause are not found exclusively in poor countries – they are found in the richest and the most prosperous too.

While on average, people in more prosperous countries enjoy longer, healthier lives, these factors still vary from region to region, town to town and street to street. A baby born in Birmingham, in the West Midlands is six times more likely to die before its first birthday than a baby born in Eastleigh, in the south of England, just as a baby born in the slums of Nairobi is 2.5 times more likely to die than a baby in a more affluent part of that city.

Some of you may have arrived here by Eurostar, via St Pancras International station, and you might also have paid a visit to the longest champagne bar in Europe. But in the surrounding area of Somers Town, people can expect to live not many years beyond their 60th birthday, compared to five miles north in Hampstead, where people live well into their late 70s and early 80s.

You will find similar disparities in many of Europe’s most prosperous cities, even in countries such as Sweden, which is widely acknowledged as having one of the most progressive health and welfare systems in the world.

Such discrepancies cannot be explained by genetics, lack of sanitation, civil war, or an unlucky predisposition to infectious disease. They are symptoms of deprivation, of poor education, lack of opportunity and lack of aspiration. These are diseases that the best doctors, the biggest hospitals and the finest medical technology cannot cure. There is no pill for poverty. There is no cure for deprivation. Doctors alone cannot deal with intergenerational unemployment and local schools that have failed successive generations of pupils.

Sir Michael Marmot’s famous study of civil servants working in different occupations in Whitehall demonstrated irrefutably that those with the least seniority, who had the least control over their working environment had the poorest health, and their poor health was directly attributable to their relative lack of seniority. By contrast, those at the top of the pile had the best health and the longest life expectancy. This rule applies to every country in the world regardless of the level of deprivation it experiences. 

As the Prime Minister has said, the temptation in these difficult economic times, is to see addressing the deeply complex social determinants of poor health as a luxury we can’t afford, whereas in fact, it is a problem we can’t afford to neglect.

If we ignore these issues because of the current economic situation, then when the downturn is over, we’ll be left with even more pronounced social problems, as the inequalities that lead to exclusion and prevent people from being fit, active and productive citizens will have deepened further. 

But policy makers will be only too familiar with the consequences of doing nothing. In the UK, it was recognised in the 1970s that the major determinant of poor health was poverty.  Sir Douglas Black in his seminal work on the issue, called not just for more doctors, but for increases in child benefit, improvements in maternity allowances, more pre-school education, and an expansion of childcare and better housing.

For eighteen years, his findings were ignored as too difficult and costly to implement. We still bear the burden of those two lost decades - the mortality rate among men of working age in the early 1970s was almost twice as high in unskilled groups as for those in professional groups. But by the early 90s, this gap had widened to three times higher.

Since my government came to office in 1997, addressing the disparities in wealth and opportunity that can entrench disadvantage and in turn, exacerbate poor health has been a priority.

The Programme for Action on health inequality has led to significant increases in life expectancy among the poorest groups– 2.7 years for men and 1.7 years for women. After eight years of concerted effort, the health and wellbeing of the poorest in our society is now the same as the health of the rest of the population when we began this quest eight years ago.

But the dramatic and welcome improvement in the overall health of the population, irrespective of social class, means that the most disadvantaged groups are still playing catch-up, and the inequality gap is growing.

We need to take action on three fronts.

First, we need to address the wider determinants of inequality. Here in Britain, we are making good progress. Only two weeks ago, the OECD reported that there has been faster growth in income equality in the UK than in any other developed country, and that the poverty rate had fallen well below the international average.

The rapid growth in employment, the introduction of tax credits, the first ever national minimum wage, greater investment in education, housing and children’s services, as well as a dramatic increase in the funding of healthcare – all these things are beginning to make a difference. We are seeing the emergence of a country where prosperity and fairness are increasing in equal measure.

But where there is no social mobility, there is no health mobility. Poverty and unemployment are still too often inherited by children as if they were genetically predetermined conditions.

So in June, the Prime Minister announced that there will be a white paper on social mobility. Earlier this week, we published the evidence base for this paper. It showed that after decades of stagnation, we are once more becoming more socially mobile and it set out our ambitions for the future - to improve early years education, school standards and training to give people a fairer chance of fulfilling their potential.

Second, we need to improve access to health services among the most deprived communities. There is a causal link between limited primary care services and lower life expectancy. Despite increases in GP and practice nurse numbers, there are still twice as many primary care professionals in Cambridgeshire as there are in Manchester and residents of Cambridgeshire will on average live 6 years longer.

This is why we have provided new investment for over one hundred new practices in the most poorly served parts of England.  This is in addition to the 152 GP-led health centres – one in every primary care trust that will open 8am to 8pm, 7 days a week – which will also play a vital role in improving access to wider community health services.

But while low life expectancy in some areas can at least in part be attributable to poor access to health services, it is not always a question of a lack of NHS resources. Michael Marmot puts it very well when he says that health inequalities in this country do not arise because of differences in healthcare, but because of differences in the causes of illness. Preventable lifestyle disease is one of the major culprit in health inequality. 

Smoking is still responsible for 80,000 deaths per year. And while smoking rates are declining steadily, it is among poorer socio-economic groups that smoking is still more prevalent.  Today, over two thirds of all adults and one third of all children are either overweight or obese. If current trends continue, by 2050, this will rise to nine out of ten adults and two thirds of all children. Obesity will be responsible for 58 per cent of all type 2 diabetes cases, 21 per cent of all heart disease and a nine year reduction in life expectancy.

Obesity is disproportionately seen in deprived communities, where substandard local amenities, exclusion and lack of information about health and wellbeing conspire against good health. Some politicians and commentators in this country are inclined to talk airily about “personal responsibility” and the “choices” that people make that either protect or damage their health. And of course, individual choices people make are important.

But people living in the poorest suburbs of London, Manchester or Glasgow do not choose to die 6, 7, 11 or even 28 years earlier than their richer neighbours. The less people are able to be actors in their own destiny, the more chaotic their daily existence, the more unlikely they are to make decisions that may have a positive effect on their own health in the future. 

So thirdly, we need to do more to support people to improve their lifestyles. In February, we launched the Government’s obesity strategy: Healthy Weight, Healthy Lives. The strategy set out how we could support parents and very young children with targeted advice and breast-feeding promotion schemes, how in schools and communities, we would promote healthy food and how, by working with employers, we would make it easier for people to build exercise into their lives. This is an agenda that reaches across the whole of society, government and the media.  A key component of it is our national social marketing campaign, Change 4 Life, a grassroots movement to support families across the country to eat better, live better and be more active. 

I believe that the steps we are taking to tackle the determinants of poor health will reduce inequality and improve the overall health and wellbeing of this country. But our focus on health inequality must be relentless – it must be an integral part of every aspect of health and social policy.

I can today announce that I have asked Professor Sir Michael Marmot, drawing on the excellent evidence of the WHO’s social determinants of health commission, to lead a review, based on the best global evidence on how we can do more to tackle health inequality in this country.

One of the defining moments of this government was in 1999, when we pledged to eradicate child poverty by 2020. It is perhaps the most challenging target any modern government has set. It has also been one of the most important catalysts for improving the life chances for children in this country, and I believe, the overall wellbeing of our society. We need to be equally ambitious in our efforts to tackle health inequality. Just as we are striving to eradicate child poverty, the question I want Michael Marmot to ask in his review, is whether it is possible in this country to eradicate health inequality, and what actions we as a government and society have to take to make this happen.

Aristotle once said that the worst form of inequality is to try to make unequal things equal. But it is the role of any responsible government to challenge inequality – whether that’s in health, wealth or opportunity – wherever it is found.

I came in to politics for two reasons: to eradicate poverty and to eliminate inequality.

We do not level the playing field by making things worse for those who enjoy the best health and the most opportunity, we do this by raising standards in all public services for everyone who uses them. But in addition, we must be committed to tackling the determinants of inequality – we cannot resign responsibility because the problem is too complex, or because it seems too difficult to make any progress in the current economic climate.

Michael Marmot’s work shows stark differences in life expectancy between countries and within them. But his report is also a bound version of optimism because it shows us that such inequalities can be addressed.

George Orwell once said that pessimists have more opportunities to say: “I told you so,” and some of my political colleagues still think optimism’s an eye condition.

But I believe there’s just cause for optimism in this country – we have the right framework in place, and we are already seeing a shift in income equality, with the health of the poorest improving dramatically. But it’s essential that we continue to focus on this issue for decades to come – nationally and internationally in order to ensure that our citizens enjoy the wellbeing that modern society can now provide.

Thank you very much.