world medicine association president president michael examines healthcare inequalities. he's interviewed by christine at the global health council. >> host: so, michael marmot, it's a pleasure to have you to speak about your book the health gap. you've written are out of the social determinants for some time and i wanted to start by reading a quick quote from the end of the book but i think it gets us off to a good place. this political damage of health creates health inequities. such disempowerment may take different forms in the low, middle and high income countries but the just distribution was

similar. your book is about health. it's not specifically about health care. and it's about equity. can you tell us a little bit about what this means and why you decided to write this book now? >> guest: they run the two words health and care together. i spend very little time talking about health care in the book because what i say it is when people get sick they need access to high-quality health care. but it's not a lack of healthcare that caused the illness in the first place. a lack of access adds insult to the injury of getting sick in those places. so, i'm very much pushing the idea that although healthcare is

a vital issue and the worlds discovered universal healthcare coverage which is great, and the u.s. is trying to do something about serving the under terms in terms of access to healthcare, i am talking about the way we organize our affairs in society which impact on health and the unfair distribution judged by reasonable means to be avoidable. the reason i read the book now is in a way to do two things. one is i chaired the commission on social terms of health in the wake of that i was asked to chair the review of health qualities in england and i did a review for the region of who and

i wanted to communicate it to a wide wider readership which is why i tried to write in accessible form but i think we need to get a much more public discussion of how our affairs and the way we organize them in society impact on people's health and well-being and the fact that we are discussing it now is exactly what i want to do. >> host: one of the major points that you make is that poverty itself is a contributor to rate person's state of health but it's not the be-all and end-all of the decisions around how someone's health holds. can you speak to?

>> guest: if that? >> guest: if you haven't got any money which isn't a bad working definition having a bit more money makes a difference, no question and that is true whether you are a low income countries where low income person so if you are the poor in the united states, having a bit more money helps if you haven't caught the minimum necessary for a healthy life and that's really disempowering. you can't pay their rent or buy food for your children. so, money really matters if you are below the minimum. above that threshold, whether you are a country or individual within a country other threshold of the minimum necessary for a healthy life, it is a slightly comforted concept that i quote much and say that relative inequalities with respect to

income translate into absolute inequalities with respect to capabilities that he calls capabilities in other words translating it's not what you have to do but what you can do with what you have. and that if adding relatively low income means your kids haven't caught the latest because you haven't got enough money you can't entertain children's friends for birthday parties and all of those things that means you haven't got enough money to have a decent life. it's not just the money committed to a decent life means and that will change with society but that's what i mean by saying the way that it gets operationalized will be different if you are in india and if you are in baltimore.

the concept is the same of having enough to lead a decent life and with a decent life means is to some extent determined by the prevailing culture. so you need much more money to have a decent life in baltimore and many more absolute dollars then you do in india. we know that they have a life expectancy about the indian average despite having many times the income and that's what i mean by it's not just what you have that's it's what you can do with what you have come and there's a related point which is when we think about the health of the poor we think about the health as they call that

inequalities or inequities but let's call it what it is, it's been a inequality and in equity. think about attitudes to poverty if you are of a particular political persuasion you may think they are of their own misfortune so if they are the political persuasion you may think that poverty in the richest societies a stain on that which society and so we should do something about it but either way it's i'm not rich but i'm not poor so if there is any supply to me, my answer is yes,

you and i are right in the middle of all of this because what the evidence shows in the u.s., the uk and in a whole slew of other countries where we have data is a social gradient in health and by that i mean if we classify people by education or income or socioeconomic level of the neighborhood what we find is people at the top of the hierarchy had the best health and a little bit below them have good health and it runs all the way from top to bottom so the poor are at the end of the spectrum. the people we don't normally think of as poor or lower down and have worse health than they might otherwise if we could have faced shallow gradient and in that the average is involved in

the person assisting goodness it's not me, that person is affected by it's so instead of thinking about the poor with think about the rich and what we want is everybody to have good health. i calculated in by ten that for the average person committee had eight fewer years of a healthy life compared with people at the top, and a healthy life means later on said declining grip strength and cognitive function and shorter life that translates into something like 202,000 extra deaths each year compared with the top 2%.

translating that to the u.s. if the figures were the same, multiply that by five and that is a million extra deaths each year attributable to not having the socioeconomic level at the top 10%. that is enormous, which means the gradient suggests we should be focusing not only on the poor but on improving society. >> host: you just laid out a convincing argument for this but there's also an economic argument for this as well. we know that when people are in better health, it costs the system less. i think you get to that in your book as well. >> guest: i do, but i am easy about it because i do think the moral argument is the important one. i don't think health is an

instrument to something else i think that it is a fundamental importance and people value health. they don't value it so that way they can get a higher income. they value it because they value getting up in the morning and feeling that they are not limited by heart disease or malaria or whatever. they value it because they the value being healthy. and given that, i'm very happy if there is an economic argument for doing what i suggest that icq politicians this is naïve, i know that i'd make a virtue of naïveté. i say to the politicians what did you go into the government to do? didn't you go into the government to improve the well-being of your population? nevermind who.

but appeal to people's better instincts you go to the government to improve things for the population into the way that i want to measure those things is health and fair distribution of health because i think it is the outcome of all of the other things that we want to have happen in society. >> host: so you use evidence to advance a moral argument and you have just spoken to how you speak with politicians out of this. how do you work on making the evidence alone more sticky getting politicians to really hear about, and i guess that's why i was asking about the economic argument as well because sometimes i think we find that we can present lots of evidence and at the end of the day the politicians have their own take. but i think you found in a number of countries that it is sticking. can you tell us about the

countries that you are seeking success along these lines? >> guest: the first two were brazil and chile when we were doing the commission of the on social determinants of health that i chaired and i talked to the senior colleagues in brazil and he said this is the best thing that has ever come out of the who and we haven't even reported. we were just getting going he said we should do something like this in brazil and he convinced him that he should set up the brazilian commission. they did something similar in chile. they have a look at the government policy and graham in equity filter. they looked at all different aspects of the policy and assessed the degree they were addressing what i called the social determinants of health. in a country like sweden you

might say of course they jumped to it. they didn't. i talked to senior positions several times, the minister of public health, the senior publications, but they said they looked at the commission report and said we could do this for our city. they set up a commission and there are parts where there are 60% male unemployment so not only did did have the opinion best assumed in central sweden but they did it at the city level and talking to the local politicians who have taken this on board, the equity carries

within equity and evidence and finally having gotten all the cities to do reviews and the government of sweden is filtering up and there's a lot of action at the local level and amount of interest it could filter out. if you think about education, it's important in both places but as i said at the end of the book how you operationalize them

and what it means is different. we made a virtue of mississippi and he said that it was important for countries and over the regions to take this on and figure out what it means in their own national context. i was invited to do a review in britain by the then labour government. this was 2009 and you have done this commission. how can we translate the findings of the recommendations so one country, england, it has a history to do a review in 1978

and by the time he reported margaret thatcher was premised her and she said i wanted no part of this. this doesn't fit my agenda at all. i was commissioned by a labour government who was predictable that we would have a conservative minister in downing street after the 2010 election. people said he would go the way that it didn't go that way. the government issued a paper and said this is the government's response. we have to put the reduction of the health qualities at the center of the strategy and we will not do this through the health-care system. the need to take action on the social determinants of health. >> host: and why did they let your recommendations go forward?

i've asked myself that question not just in relation to the uk that when we began the commission people said some of this we have known about before you are were not the first to burst into this. you have some distinguished. what makes you think it will be any different? i didn't have a very good answer to that question other than we would try hard not simply to watch if it was going to be different with try to influence beyond take would be different because partners like sweden and the like and we got partners who then became advocates for the commission and these ideas.

they talked about the election and about the big society and he was trying to make it clear he wasn't going to be the same as margaret thatcher. we can have a discussion about that. but, so i come along with this and it probably helped a little bit of hype is present in the association of the time so that i would have access to the health secretary. we invited him to come and give debate so i have some direct input for him and that probably helped a bit. but also there's there is a perception in the world and

evidence that any poverty has gone too far and that there are health problems that follow from this inequality that has gone too far that are not simply going to be told with a universal health coverage by the usual approaches. we need something different. i met somebody from i won't say which state but a u.s. state the other day in taiwan. he never heard of the commission of the social determinants of health, but he was talking the language, the social determinants of health. it's not me and it's not not the who commission that he knows he got it from. i know where it came from and that is a different question. he did and he was talking the

language. but it's more saying it is happening and coming back to the uk was happening at the local level they are acknowledging the importance that we have three quarters of local authorities in england that have this implementation plan, and i talk about some of that in the book and that's terrific. >> host: how do you perceive the thoughts about equity and in equity that have changed over the time that you have been working on this issue? you have had a big influence on this but has it been a process where are we going from here on this topic? >> i think that generally across the world initially when people think about health and equity,

they meant in equity in access to health care because that somehow easily is conceptualized people get sick, they don't get access to healthcare. >> you have to walk kilometers to get their. >> and it got extended out of it that was the underlining approach to it. think of the child's survival resolution -- revolution. why should the children of low income countries die when we have the means to stop it and ground. and i think that was the sort of equity that we have in the targeted interventions but now think about the non-

communicable disease in brazil, mortality from cardiovascular disease, in buenos aires if you look at the social distribution, the lower the income of that was the education of the higher the prevalence. if we think we can do something about that but we don't that is an equitable and it's not just about access to health care so i have been working hard to change the conversation on the cover of the commission reportedly said social injustice is killing on a grand scale and i stick by that i then asked myself and my sure

that i know what i mean by social injustice. so i have a chapter in the book where i actually explored theories about social justice and which ones best help me understand both in equities and i think i have a larger sense of freedom to lead a life that you had reason to value and that in equity in that freedom is close to my that's close to my idea of empowerment and having control of your life, and equity and that freedom and it causes health inequities. >> host: can you speak a bit more about something interesting that comes out in the book and the idea that again when you are lower in the hierarchy, you have less control over your setting as you talk about workplace and

how that can lead to the obvious things because you don't have control over the life? >> guest: i used the idea of control as an organizing principle to organize my thoughts as it were but i also use it anyway because there's good evidence there is good evidence that it directly influences how. and i think about empowerment in three ways which you cited at the beginning. material, so coming back to the low income family who can't make ends meet, that is disempowering and it damages health perhaps because of bad nutrition and bought some psychological concept but because people don't get shelter and so all of those things damage health if they

don't get adequate nutrition they won't grow properly and their brains won't develop so it's very material so in that case, disempowerment is in a sense an organizing principle and a way of describing it. the second way is psychosocial lack of control and that is damaged in two ways. i talk about baltimore before. if you go into a low-income community in baltimore and say to these young men you know you really shouldn't smoke. you could get lung cancer when you're 52, i wouldn't see say on television what they are likely to say to you but they would probably be quite articulate in telling you where to go and what to do when you got there and they are right if you have a 30% chance each year of being put in

prison each year come if they have a minority chance of getting through to their 20s without having been put in prison and they may well get shot out and present in your saying don't smoke about one mechanism is you don't care about smoking and diet or doing drugs and we have seen this recent paper in the united states that non-hispanic white men have a rising mortality and it's from drug and alcohol-related poisonings, suicide, awful, chronic liver disease and to a lesser extent, so-called external course. they are all things that

deprived men get in poor communities and deprived white men get. in a way, as somebody living in a low-income situations that, we all have to pay state or pain in some way. in her case it was beer, cigarettes and ice cream. a young man said that he was one drink away from the abyss. so in the one way it can damage health in a way that you have all of these harmful behaviors because you feel i don't have control of my life anyway anyway

survival escape of alcohol and drugs and the other way is that it actually changed the endocrine system and it starts in early childhood. it explains to the stresses pathways throughout life and we know what happens in early childhood changes the way the organism responds to stress later in life and we are learning more about how those pathways work. elizabeth blackburn who won the prize for her work on chromosomes, she's been working with a psychologist in san francisco sharing housedress how did the -- how stress operates. one is you kill yourself with drugs and poisonings and are

killed of one thing or the other but another is damaged disease but the earlier one that i talked about with the material deprivation. >> host: and we are also seeing with the intergenerational link are very strong. so with the apparent health that gets into the biological and material ways passed on to children and this -- >> there's not a politician who would stand up and say that i believe in inequality of opportunity and every politician right, center, left believes in equality of opportunity but it shows that inequality in this generation affects the life chances of the next generation and the one after october 4 generation is set and the one after so it shows very clearly that the greater the income

inequality affecting this generation the less social mobility there is. you have less income inequality and much more mixing and much more social mobility so what's happening to the appearance is impacting on the next-generation and there may also be some interesting genetic mechanisms to get past but i don't go into that in the book. but there are psychological impacts that get passed down from one generation to the next so all politicians are in favor of equality of opportunity but we don't have it. the playing field is very

tilted. >> host: the idea of the social determinants of health as we talked about its health but it's much more and when we think about dealing with politicians and government is inherently multisectoral it's not just the health ministry, it's education, economic growth in all sorts from all sorts of things, transportation, environment. so why don't you just read a quick excerpt and we can ask you something more about that. so, you say i would argue that discussions on preserving the planet must take equity within a generation the generation into account in and between countries and you get a great example of this that i guess i find very interesting. for example, congestion charging if you drive your car into the central city is a good green tax but like all consumption taxes that tends to be regressive and

that it takes a higher portion of a person's income than of a rich person's. i have raised this and environmental struggles that have been told don't don't display of a perfectly good tax by worrying about equity and i attempted to resort to damage a quickie with your perfectly good taxes. we need to bring the environmental and health agendas together we have a big climate change summit coming up in paris and at the end of the month and i think that climate change is very much on everyone's mind is a perfect example of this cross sectoral relationship when we think about health. how can we influence policymakers to work across the silos to put down some of their guard and build alliances rather than protect their own turf cracks >> guest: i was in taiwan the week before last and we did a

report for the government on social determinants of health and i presented it to president of taiwan and he said this is great we need cross government action and i think i know how to do that. we have a sustainable development committee. it's been looking at environment and economy but now it needs to the social determinants and health equity. i was absolutely delighted and we had a good meeting.

we need cross sector action and we need to put health equity in the context of economic development and that's what sustainable development should really be about. too often the health and the health equity part are forgotten. there have been some very welcome along this couple of commissions trying to bring health back into the environmental consideration. but it shouldn't just be health, it should be health equity and the example that you read out. we could have taxes that make it much harder. the end result is high enough to change behavior to get you would have thought rolls-royce and then driving around the empty seats because they couldn't afford to get off the streets and then we could drive our big cars around the streets.

that's not the future of the pond. we want it to be sustainable and fear within the countries and between countries. it should be equity between countries as well as within. the idea when you are looking between the countries of contraction and convergence that we and other rich countries ought to be pumping out fewer greenhouse gases and allow for more to come from the four countries so that is the convergence but within the context of the attraction gets at the equity between the countries. so i think because as they said that climate change might be an inconvenience for people in the rich countries it's life and death in poor countries with droughts and in tolerable conditions and great population

movements because of the equity dimension that is the key. >> host: and we see the other people going on in the poor countries spilled over into the countries as well. look at what we are dealing with >> guest: absolutely. i think about this in a way that i think about conflict that what turns the environment problem into a disaster is the way we cope with it socially. and it's a bit like conflict. who is fleeing, the poor and the disadvantaged, there's a lot of higher educated people that are fleeing. but i wrote elsewhere about the troubles of northern ireland.

it wasn't the lawyers and the middle classes that was the poor who were being caught up in a religious conflict and that's what it looks like whenever we get conflicts and in general that's what it looks like when we get environmental problems, and i quote in the book the difference between haiti's earthquake in chile the death toll was 200,000 chile had an earthquake that was 500 times stronger and was in the hundreds. chile had a strict codes and emergency services and better organized society. he wasn't prepared in any way. so, the environment and the social organization come together.

>> host: i'm going to switch tracks a little bit. you mentioned that you were the president of the world medical association. so, a couple of questions about that. you are obviously a physician that you are also an epidemiologist and i will just say as a fellow epidemiologist, i get questions all the time about what that is. i don't expect them to be doing this kind of work and talking about these kind of issues. can you talk about what it means for you to be an epidemiologist and how you have been able to evolve your career to become an influential voice in health and equity in general? >> guest: i will come back to the medicine thing in a moment.

in my case one thing led to another. it's not that i had a grand plan i thought thought i was practicing medicine in sydney as a training doctor, i forget what good does it do to treat people and send them back to the conditions that made them sick and that was an insight that i had. i was totally ignorant and i haven't read anything so i didn't know the scholarly people were writing books on this topic is just too ignorant i was just too ignorant but that was my own insight what good does it do to send them back to the conditions that made them sick and then i thought well is there a line of work that deals with that and as i laid out in the introduction, one of the consultant physicians in sydney said there is.

it's called epidemiology but it was a particular sort of epidemiology. i don't care for labels much but the social epidemiology which was looking at the conditions that make people sick and that's what he was doing and he was teaching me and other people to examine social conditions and look at the impact on health. i would have been as could be doing research. that was just perfect. curiosity driven research. as i mentioned a little while ago because when i went back to the uk, soon after i got there, margaret thatcher was elected prime minister and she said there are no health inequalities and so that wasn't a topic on

which you could do research but had any practical implications so i did research for 18 years in the conservative government that i was as happy as could be getting support from the u.s. for studying the british civil servants can i quite like the idea of the government supporting my research of the british government brokers. and then the government changed, the labour government came in and said we want to do something about health inequalities. suddenly yesterday's research became today's applied research. i started thinking about the medical officer that chaired the committee. i started thinking what if somebody took this seriously and what if they took it seriously

globally. jeffrey sachs chaired the commission for the who and it said in approved health in order to get a more vibrant economy. and i thought at the time the recommendation to spend billions patrolling hiv, tuberculosis and valerio was great and i'm sure i would rather the world spent on those things and whatever else they spend billions on so that was great. but as i said at the beginning of this conversation, i didn't see it as an instrument of economic growth, i saw bad economic and social conditions. she said it he said it would be quite good to get the backing so

they set up the commission on the social determinants of health and now i found myself in tears her incognito -- care for the week of terror incognito and i didn't know anything about the process globally. we have traffic commissioners who did know a thing didn't know a thing or two about the policy and they have been presidents, government ministers and they were really wise and helpful and brought a lot of the wisdom to bear on the question. i still wouldn't claim that i know how to influence the power to the policy process. what we did as a commission and what i do as an individual is bring the evidence, package it in the best way that i know how, presented in the present it in the clearest way that i know how if you ask how to get from there

to there from the best presentation to getting the policy changed i can tell you when we managed it but i'm not quite sure that i understand why. >> host: it goes into the policy blackbox. >> guest: scientists say to me we studied that and we can tell you. >> host: going back to the role as the president of the world medical association, we talked a bit about health and health care and how they are not synonymous, but you also talked about but are actually treating in a healthcare setting and realizing that i was not the most effective way to be implementing on a larger scale. so beyond the idea that we need publications to embrace the idea we should be presuming to change

how healthcare providers are trained and the framework in which they operate. so, how are you using your role to also influence health and how healthcare is actually being rolled out? >> i think it is a slightly odd position for me to be president of the world medical association as when i was president i spent my life saying the key determinants of health lying outside of the healthcare system and then they put me ahead. i made it very clear now that i have an agenda and it's not being delighted in having having democratic associations around the world. my agenda is the social determinants of health and

health equity. i want to get the doctors involved and they say okay we are convinced but what do you want us to do. we will produce the report for the world medical association, but what we said from the doctors in britain, and i think the report of the world medical association won't be that different, five things, education and training. the second is seeing the patient in a broader perspective of the former canadian association practiced medicine among the homeless. he said how can i treat the consequences of the drug abuse and so on and send them back onto the street i've got to get involved in making sure they've got shelter. that's part of the good medical treatment. third is recognizing the health

system 1.4 million people work in the national health service and it's not just the conditions that the doctors at the cleaners and the water systems and the nurses and the lab assistants and the impact on the local community since he hasn't player and a stakeholder in the fourth is working in partnership you need to be able to work with the other services so you may be treating their ear infection but what about the services that are promoting the early childhood development for example working with older people and social care coming back to the president in taiwan that's what he was saying i will try to get all the sectors working together.

and the fifth positions of the natural attorneys of the poor we should be advocates of there's a great deal they can do without prodding from being a doctor yes by all means treat the sick but get involved in these other issues at the same time. it is symptomatic that -- i didn't hide what i was on about and i'd only been president for just under four weeks but was president elect and for example the had a meeting while heavy meeting while i was president elect that suggested in london

we didn't invite anybody but we just informed the national medical association as the meeting was going on. 20 countries were represented, 200 people came to the meeting and we were discussing how the national medical association including the american medical association could get engaged in the social determinants of health to promote health equity. >> host: we are kind of coming to the end of the conversation that i wanted to ask a question, you were interviewed about and i also will put the plug-in in the book because it is very readable and it is written in a language that i think is very engaging as someone that gets interviewed a lot is there a question that you wish people would ask you that you haven't heard yet? and putting you on the spot you

can say yes or no but is there something you would like to talk about but you haven't had a chance to in this interview were previous? >> guest: you are putting me on the spot. one of the things on my mind is that i said in the book and i said with the who commission we wanted to create a social movement for health equity. i wasn't entirely clear what the movement looked like or how you get there and i'm not sure that it is likely to answer that because i'm not sure what it is but it is something that exercises me. i said how pleased i am when i hear people talking the language of the social determinants of health and i'm pleased when somebody comes up to me, if it happens frequently saying i was part of the knowledge network

that was synthesizing knowledge for the global commission and they are proud and pleased that they were part of that because they feel they are part of the social movement so the question that i ask myself is what would success look like in terms of creating a social movement and how would we know that we are getting there and if you had asked me that question i'm sure i would have given you a good answer but i certainly asked myself the question i don't have a glib answer. i say in the book book i'm an evidence-based optimist because i see lots of good things happening and i focus on the good things that are happening. it's not that i ignore the bad things. we need to address them but focusing on the good things are happening shines that are happening shines a light and gives us something on which we can focus.

it's told us this is possible. i was having a conversation in san francisco recently and i'm sure you've had this conversation many times, people wringing their hands saying it's impossible to get a change in the script block and i said first that this is a very u.s. conversation. i tend not to have that conversation in other parts of the world even though other parts of the world they have had far less political problems if with ethnic violence and people of different religions and the like. but second if we the second if we can't get action there we can get action there. you can't do it at the local level do it at the national level. i mean, there's got to be an entry point and we can see in

the countries of low-income, middle-income and high income inspiring examples where people are making progress. we see the countries of improving, a major challenge, given that the sick countries are becoming less poor getting closer to those in the rich countries but a major issue is the continuing and in some cases increasing health inequity within the countries. so my evidence-based optimism doesn't lead me to ignore the problems in front of us and a question that i have been asked not in interviews so much but i have been asked is going around

the world and talking to people come how do you keep it up and my answer is because i feel we are making progress. if i get an invitation i think what we are talking about is rubbish and we would like to demolish you. >> host: probably not high on the list. >> guest: not a lot of places to go. if i get an invitation saying we are interested in what you are talking about and we really would like to make a difference come earlier this year i got an invitation to columbia saying we are planning for a post-conflict columbia. i may be an optimist but i try not to have illusions slave no illusions that it's going to be. colombia is one of the most unequal. they may be planning for a post-conflict but it's not over

yet. some people hope that they will sign an agreement and that 50 years will be over so i was only too happy to accept an invitation to be part of a conversation of planning for the post-conflict and to talk about health equity and social determinants of health. it may not not happen but it's worth it and the reception i got was heartwarming. >> host: i was going to ask about being an optimist but i think that you have already spoken to that beautifully. if you can give advice to a young person who is really interested in working to influence social justice working for the cause of a quirky tv to

-- of equity and what would you say to them? >> guest: i don't mind giving the government that i find much more nervous about getting young people advice. it's too important. young people might possibly listen and see the responsibility is too deep. when i was going to taiwan a couple of weeks ago somebody wrote can we meet him when he's here and my sister wrote back and said he always says yes to students so i'm sure he will be happy to do that. and the student that introduced me sad by her cute talk at the international confederation of the association meeting in the canadian and you changed my life and changed my career.

when we do talk to medical students and junior doctors we have the passionate social justice and health and there are ways that you can do that. you can become a researcher or an activist from a caring commission and i can't tell an individual young person which is the best but what i can do is try to infuse them in social justice and health and icy to the senior doctors at the world medical association remember why he went into medicine in the first place, he wanted to help people and particularly wanted to help people who were suffering. that puts us all on the same side of health equity.

>> host: i can't think of a better place to end this because that is a very forward-looking idea and so thank you so much for this this has been a great conversation for me to be part of and you have inspired me and i think we will look forward to whatever the next chapter is and what you are working on. thank you very much. >> that was "after words" booktv signature program which offers the latest nonfiction books are interviewed. watch past programs online at booktv.org. >> your book lost decades the making of america's debt crisis and the long recovery, how big is the u.s. debt and who owns