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07 September 2015
BAMT Q&A with Prof. Sir Michael Marmot, author of 'The Health Gap'

How does The Health Gap relate specifically to those providing Music Therapy? 

A central insight of The Health Gap is that the mind is the major gateway by which the social environment influences health. One should not focus on the mind to the exclusion of the social conditions that have impact on it. That said, the mind is key to physical as well as mental health and is, of course, the territory of music therapists. 

What motivated you to write The Health Gap?
George Orwell, answering the question ‘why I write’, said: “I sit down to write a book …because there is some lie I want to expose, some fact to which I want to draw attention, and my initial concern is to get a hearing.” Not bad. Inequalities in health within and between countries are of immense concern. The good news is that we know what to do to improve health and, crucially, have it more fairly distributed. I want to get the good news heard. George Orwell also pointed to personal reasons for writing. They apply, too. 

What does the Health Gap mean?
If we look across the world there is a 40 year gap in life expectancy between the healthiest country – women in Japan – and the least healthy, in sub-Saharan Africa. Within countries, there is a twenty year gap in life expectancy between the best off and the worst off, even within one city such as Glasgow, London or Baltimore. The ‘health gap’ is also shorthand for the social gradient, which needs a bit more explanation. People in the middle of the social hierarchy, you and I, have health that is better than those at the bottom, but worse than those at the top. Health tracks the social hierarchy all the way from top to bottom. 

What are health inequalities?
If we describe people by their education, their income, their occupation or the general level of affluence of the area in which they live, we find a systematic pattern: the higher the social position the better the health. Not just life expectancy, as just described, but less illness and greater ability to function well at older ages. Where we judge these inequalities to be avoidable by reasonable means, they are unfair, inequitable. 

What causes The Health Gap?
When people, and policy makers, think of health they tend to think of health care and, perhaps, of life style. A major reason for writing The Health Gap was to show the evidence that inequalities in health are caused by social conditions in which we are born, grow, live, work and age; and inequities in power, money and resources that give rise to the conditions of daily life.   

When did you first become concerned about The Health Gap?
It became clear to me, even as a medical student, that social conditions changed people’s risk of getting sick. I first became aware of the systematic evidence when I was involved in the Whitehall studies of British Civil Servants. Among men and women, who were neither the richest nor the poorest of society, the higher the position in the occupational hierarchy the better the health and the longer the life expectancy. 

Of what part of the book are you most proud?
Pride? Doesn’t quite describe it. My ambition was to make the evidence ‘real’. To turn the hundreds of scientific papers and reams of expert opinions into something that made sense in the lives of you and me. Scientific findings can often be shocking or surprising but, after reflection, seem obviously to be true. My hope is that the reader, though perhaps initially surprised or shocked, recognises the truth of our understanding of the causes of health inequalities and what we can do about them.  

Why are you so motivated to bridge The Health Gap?
I, like my most doctors and nurses, went into medicine because I wanted to cure the sick. But then I asked the question: why treat people and send them back to the conditions that made them sick in the first place. Cure and prevention: it’s the same motivation. I am so strongly motivated to improve social conditions, and make them fairer, because it will improve health for everyone and reduce inequalities. 

Memorable moments in public health?
Meeting politicians and other policy makers is important. But what stands out is the evidence of people and communities triumphing over adversity. Meeting the outcaste women who are members of the Self-Employed Women’s Association in Gujarat, and seeing how seeming impossible barriers are overcome, and their lives transformed, is inspiring and memorable. Such experiences are to be had among the poor and dispossessed in many countries. I think to myself: if they can do it with their huge problems, we can do it with our comparatively minor ones. 

What do you hope to achieve by publishing The Health Gap?
I wanted to bring to a wider audience the understanding that how we organise our social affairs is a major determinant of how healthy we are. This insight should shape the way people think about their health but also how they think about their society. My basic assumption is that knowledge is better than prejudice, light better than darkness when it comes to deciding what sort of society we want. There is a great deal of knowledge out there as to what should go in to these big decisions. The Health Gap, by showing how society affects health inequalities will, I hope, contribute to public understanding. 

You were born in Australia, trained in public health in America, then moved to the UK as a practitioner - where would you call home, and why?
Health is global and so is our scientific understanding of the causes of ill-health. Wherever I go in the world I find kindred souls who are passionate about applying our understanding to improve society and reduce health inequalities. I feel at home with all these people in these diverse cultures. There are many places I could plop down and find much to do and good people to do it with. That said, Britain is a basically caring, tolerant democratic society, which respects the rule of law, and with high standards of education and intellectual activity and wonderfully creative arts. No matter how critical I might be of specific policies, and I am, I enjoy the benefits such a decent well-organised society. 

What next?
Ah! Much to be done: both to continue to improve our knowledge and understanding and to apply what we know. I will continue to push for the cause of health equity. In the immediate future our UCL Institute of Health Equity will continue to synthesise the best information for concrete advice on policy and practice. In October 2015, I take up the Presidency of the World Medical Association and will be giving it my upmost to garner the interest and enthusiasm of the world’s doctors for the cause. We have been advising the European Region of the World Health Organisation and are now working with the Eastern Mediterranean Region, and will soon start on a review of social determinants and health equity in the Americas. It is exciting to see the evidence of people responding to the evidence and inspiration of what we can do to make the world a fairer place.

Published by Bloomsbury - 10 September 2015, Hardback £20

Sir Michael Marmot, Professor of Epidemiology and Public Health at UCL, is Director of the UCL Institute of Health Equity and, a leading expert on health inequalities both in the UK and globally. He takes up presidency of the World Medical Association in October 2015 and is currently Harvard's Lown visiting professor. Sir Michael chaired the WHO Commission on Social Determinants of Health (2005-8), the recommendations of which have been adopted by the World Health Assembly and by many countries. He conducted a review of health inequalities for the British Government in 2010. The 'Marmot Rewiew' and its recommendations are now being implemented in three-quarters of local authorities in England. 

For further information please contact Jude Drake at Bloomsbury. 
T: 020 7631 5543