What kind of society are we aiming for?

An interview with internationally recognised health expert Michael Marmot on health inequalities in the UK and across Europe, the effects of COVID-19 on society, and why being Prime Minister is not one of his personal ambitions.

Interview: Dietmar Schobel


Prof. Marmot, what do we know about health inequalities within and between European countries?

Michael Marmot: Life expectancy varies hugely between the European countries, and also between different sections of the population in the individual countries themselves. As a general rule, we can say that life expectancy increases with income and the level of education – this is true in Norway just as in Bulgaria. Factors such as working conditions and the quality of our neighbourhood have a considerable influence on our state of health as well, however. On the whole, we know that the differences in health between population groups are greater in Eastern and Southern Europe than in Western and Northern Europe.


In the “Marmot Review” – a scientific publication from 2010 chaired by yourself – you described the health inequalities in England and proposed strategies for their reduction. The “Marmot Review 10 Years On” focussed on developments up until early 2020. What were the most important changes during these years?

Michael Marmot: Until 2010 life expectancy in England was continually on the rise, just like in many other countries. On average, life expectancy was increasing by no less than a year every four years. But from 2011 onwards, in England these improvements slowed dramatically, they almost ground to a halt. For part of the decade 2010-2020 life expectancy for women actually fell in the most deprived communities outside London, and in some regions it fell for men as well. The time spent in poor health increased for men and women everywhere in England. In other OECD countries the situation worsened during these years as well, although England – besides the USA and Iceland – was among the countries that were affected particularly severely.


How did this downward trend affect the health inequalities between the different population groups?

Michael Marmot: The health inequalities between the poorest and richest people deteriorated even further in many countries. And it was especially in the poorer groups of society where the rise in life expectancy slowed down or even fell. More than anything else, this development was also a result of the austerity policies that were implemented in many countries following the financial crisis of 2008. Government spending was cut, and specifically expenditure on public health. As far as the goals of reducing health inequalities and establishing health equity are concerned, it can definitely be said that we have lost a whole decade. But that review only describes the changes up until the beginning of the COVID-19 pandemic.


What effects did the coronavirus outbreak in Europe in February 2020 have on the existing health inequalities?

Michael Marmot: At the start, there was a lot of talk about the COVID-19 pandemic affecting us all in the same way, and that society must stick together. But the reality was very different. Once again, it was especially the socially disadvantaged groups of society who were affected particularly severely by the COVID-19 pandemic. These include, for example, poorer people, marginalised ethnic minorities, low-paid essential workers, migrants, incarcerated populations and homeless people. Their rate of infection was above-average compared to the rest of society, and once they had contracted COVID-19 they had a greater risk of dying from the virus. For instance, the risk of a fatal COVID-19 infection was twice as high for people in the most socially disadvantaged regions of England and Wales compared to people from the richest regions. Figures from the Office for National Statistics in the United Kingdom confirmed this back in July 2020. The reasons for these differences are to be found in the social determinants of health, in other words in the conditions in which people are born, grow, work, live, and age – and in people’s access to power, money and resources. For instance, the homes cramped full of people, the unequal access to acceptable public health information, inequitable access to affordable treatment, prevention and vaccination, and other reasons.


The financial crisis from 2008 onwards was followed in early 2020 by the COVID-19 pandemic. Right now we are suffering from inflation and an impending economic crisis as consequences of the war in Ukraine. And we also need to deal with the major challenges posed by climate change and other environmental problems that have been brewing for decades. Are you worried that the topic of health equity could be pushed much further down on the political agenda considering the current situation?

Michael Marmot: I am always worried (laughs). However, I would also like to point out that my first scientific publication on health inequalities is from 1978, which was 44 years ago. And that political interest in the topic has never been as great as it is right now. Working together with the team at the Institute of Health Equity headed by me at University College London, I am endeavouring to ensure that societies are built back fairer after the COVID-19 pandemic. For example, for the Greater Manchester region in the north-west of England, we have prepared a report containing recommendations of how this can best be implemented. The report contains very concrete objectives and measures for the next steps and beyond. And in other regions and cities of the UK, people are also very aware of the importance of health equity.


What are your recommendations for decision makers who take the topic seriously and are striving to achieve greater health equity over the long term?

Michael Marmot: As we need to start with the social determinants for health in order to achieve noticeable change, the goal of health equity ultimately requires a comprehensive programme in the area of social policy. I like to think that it could be embraced by politicians on the left and the right. We have to ask ourselves: What kind of society are we aiming for? In connection with this, the six areas in which work is particularly needed are:

*       Give every child the best start in life

*       Enable all children, young people and adults to maximise their capabilities and have control over their lives

*       Create fair employment and good work for all

*       Ensure a healthy standard of living for all

*       Create and develop healthy and sustainable places and communities

*       Strengthen the role and impact of ill-health prevention.


In your view, what is the most important area and where should we begin?

Michael Marmot: I am unwilling to spotlight any individual measures because it is actually necessary to work across the board and in all areas at the same time. After all, if you have to spend the majority of your income on rent, how can you afford to eat healthily when unhealthy food is usually much cheaper? Time and again, I am asked what I would do if I were Prime Minister. I usually reply: “I would make a mess” (laughs). And so I know when to leave well alone as far as that kind of task is concerned, but instead I would give the Prime Minister and the government some strong advice, namely to put the health and well-being of people before their work. We have to do all that is reasonably possible to reduce the avoidable causes of disease and illness, as these also increase the costs to the economy.

Michael Marmot, Photo: UCL Institute of Health Equity

Sir Michael Gideon Marmot was born in 1945 and is an internationally recognised expert on health inequalities. He is Professor of Epidemiology and Public Health at University College London (UCL) and Director of The UCL Institute of Health Equity.