Tuesday, November 1, 2011

Michael Marmot, the British Medical Association, and the Social Determinants of Health

The social determinants of health are real and profound. They are the aspects of life outside the medical office and hospital, outside of drugs and surgery, that affect our health. Income differences, education differences, and differences in social cohesion, to name a few, have been extensively described in the literature and have even made some headway in the medical curriculum at many schools. Addressing health disparities is a major focus of our Healthy People 2020 effort. Recognizing and addressing the social determinants of health has been, and will continue to be, the primary focus of this blog. A few recent posts addressing this topic include Healthful Behaviors: Why do people adopt them? Or not? October 8, 2011 and "Health in All" policies to eliminate health disparities are a real answer, August 18, 2011, and a little longer ago, Social Determinants, Personal Responsibility, and Health System Outcomes, September 12, 2010.

Some of the most important work in the area of social determinants of health has been done by the British physician and epidemiologist Sir Michael Marmot, whose “Whitehall” studies, begun decades ago, showed that health status was associated with socioeconomic class. He has continued this with his recent work “Fair Society, Health Lives”[1]. Thus, it should not come as a surprise that it was under Dr. Marmot’s recently-completed tenure as President that the British Medical Association (BMA) issued its report “Social Determinants of Health: What Doctors Can Do”, in October 2011. It is more interesting that Dr. Marmot, in his introduction to the report, notes that “ … as I mentioned in my presidency acceptance speech, I was surprised at being approached to be president at all,” because “My work has been focused on inequalities in health where I have emphasised the circumstances in which people are born, grow, live, work, and age rather than anything specifically to do with health care provision. I have emphasised not just the causes of health inequalities—behaviours, biological risk factors—but the causes of the causes. The causes of the causes reside in the social and economic arrangements of society: the social  determinants of health. More than that though more recently my work has looked at what can be done to address these issues across the life-course.”

Many of us in medicine, even on this side of the Atlantic, were thrilled that the BMA had chosen Dr. Marmot as its president precisely for these reasons. The current report shows that this was well-placed enthusiasm, for it marks a the commitment of the BMA to improving the health of the British population even, and perhaps especially, when that requires physicians to work outside of their “usual” venues. That is, when the work requires collaboration with other professionals, particularly educators but also social service agencies, to be effective. And to exercise their roles as community leaders, not simply purveyors of drugs, operations, and individual advice: “We recognise that not every doctor has the opportunity to change the social determinants of health throughout the life course of individual patients and have thus included other ways in which they can make a difference, as doctors working as community leaders.”

Social Determinants of Health: What Doctors Can Do” presents conceptual models and large-scale goals, as well as principled statements of how physicians must act to create conditions of social justice and reduce the gradient of health disparity that results from different life circumstance. For example, it takes from “Fair Society, Healthy Lives” the following set of policy objectives that physicians and their organizations should work towards:
A - Give every child the best start in life
B - Enable all children, young people and adults to maximise their capabilities and have
control over their lives
C - Create fair employment and good work for all
D - Ensure healthy standard of living for all
E - Create and develop healthy and sustainable places and communities
F - Strengthen the role and impact of ill health prevention
          (These are expanded upon in “Annex A”, beginning on p. 26)

However, the paper goes beyond these generalities and provides specific examples of programs that have been and are in place in different communities across Britain that have made an impact on these areas. The BMA commits that they “will keep examples of effective actions on our website, and encourage the World Medical Association to garner international examples, to aid doctors seeking ways to make a difference.” One example of this two-phased approach of identifying the problems and seeking examples of solution is in “The Health Impacts of Cold Homes and Fuel Poverty report”, whose main findings of direct impacts included:
          - Countries which have more energy efficient housing have lower excess winter deaths (EWDs).
          - EWDs are almost three times higher in the coldest quarter of housing that in the warmest quarter.
          - Around 40% of EWDs are attributable to cardiovascular diseases.
          - Around 33% of EWDs are attributable to respiratory diseases.
          - Mental health is negatively affected by fuel poverty and cold housing for any age group.
          - Cold housing increases the level of minor illnesses such as colds and flu and exacerbates existing conditions such as arthritis and rheumatism.
          - Cold housing negatively affects dexterity and increases the risk of accidents and injuries in the home.
Main findings of indirect impacts:
- Cold housing negatively affects children’s educational attainment, emotional well-being and resilience.
- Fuel poverty negatively affects dietary opportunities and choices.
- Investing in the energy efficiency of housing can help stimulate the labour market and economy, as well as creating opportunities for skilling up the construction workforce.”
They then describe a program in Manchester that is working to addresses this problem.

Another intervention is occurring in an impoverished part of England, where the “Bromley-by-Bow Centre aims to serve the local community by providing a wide range ofservices and activities, which are integrated and co-operative in nature. They host the local GP surgery, a variety of social enterprises, a children’s centre, artists’ studios, a healthy living centre, and provide adult education courses, care and health services for vulnerable adults, outreach programmes and a range of advice services. This approach enables GPs to refer patients to services that help to tackle the social determinants of ill health, including welfare, employment, housing and debt advice services.”

A society can never achieve a significant improvement in health, or decrease health disparities, unless it consciously and forthrightly addresses the social determinants of health. Physicians can be leaders in this effort, or they can sit comfortably in their offices and hospitals tending to the individual health problems of people that could have been prevented before. Dr. Marmot says  
“During my tenure I have been struck, but not surprised, by members’ utter commitment to
improving the health, not just of individual patients, but of society as a whole….As the year progressed I could see more and more how my tenure at the BMA and my work on the social determinants of health were a perfect fit. Time after time I was faced with examples where doctors were working tirelessly to increase fairness and social justice by acting on the social determinants of health to reduce health inequalities.”
That makes me proud of my colleagues in Britain and in the BMA, but these are also characteristics of many doctors in the US. And of many medical students, who are driven by their desire to make a difference. The US is not the UK (we don’t, for one really big example, have a national health service or even a national health insurance program!), but we have real needs and real caring people, including physicians. We just need to keep focused on health and how to improve it and not be dissuaded by tangential issues. We need to maintain the energy and idealism of medical students and ensure that it grows, rather than withers, thoughout their careers.

[1] Marmot M, Allen J, Goldblatt P et al (2010) Fair Society, healthy lives: strategic review of health inequalites in England post 2010. London.


Josh Freeman said...

From Alex Scott-Samuel in the UK:

Thanks for the post about Michael Marmot, Josh. There was a very interesting interview with him on our Radio 4 yesterday - it's here, though I think you may not be able to access it in the US:


Recently Michael was one of nearly 500 public health practitioners who signed a letter (attached) to members of our House of Lords asking them to block a government bill which will turn our NHS into a commercial market. This was brave of him and the rumours are that he has since had lots of pressure from the government.

Bob Bowman said...

Let Us Review 11/2/2012

Marmot and others have given important awareness. We are fortunate to have institutions that share this vision. But do we accomplish what we say we should do?

AAFP has a mission, vision, values, and objectives that are consistent with these lofty goals.

AAFP has one main deficit - failure for 30 years to increase family medicine residency graduates.

To accomplish mission, vision, values, and objectives it takes dedicated specific health access primary care workforce. In blogs and other postings, I have indicated that only family practice that stays family practice can suffice, something only family physicians do - by design (so far).

11/2/2011 is a day that will live in infamy in the history of primary care with 27.4% cuts by CMS final rule. An entire decade of damage will result from a short period of time.

It is hard to see a way that our government could do more to damage these important access and social determinant principles. Cuts in primary care are cuts in people, services, jobs, and economics in locations most in need of all of these.

11/2/2011 represents a direct assault upon the mission,vision, values, and objectives of AAFP and the life's work of all dedicated to health access primary care. Sadly it represents Medicare turned against the elderly who are 2 to 3 times more in need of primary are. Sadly it represents an Obama health plan that boasts the importance of primary care to accomplish its goals, but cuts primary care spending and primary care workforce. 11/2/2012 represents the antithesis of economic recovery for most Americans as primary care is the most important health spending impact in 30,000 zip codes where 65% of Americans reside.

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