write with the musician and be in the room when these cords are being created i find the most enjoyable. >> host: david ritz, we appreciate your sitting down with book tv. >> guest: my pleasure. >> host: so sir michael marmot, you have written extensively on the social chairman of health for a long time. i wanted to start by reading a quick quote from the end of the book that i think

it's us off to a good place. you argue that this empowerment, psychosocial political damaging and creates health equity. such disempowerment may take different forms, but the general approach to promoting a just distribution of health is similar. your book is really about health, not specifically about healthcare. within health it is about equity. can you tell us a little bit about what this means and why you decided to write this book now. >> guest: when people think about health they run the two words healthcare together as if they are one word. people find it very difficult to say health, not healthcare. as been very little time talking about healthcare

because people get sick they need access to high-quality health care. but it is not lack of healthcare that causes the illness in the 1st place. lack of access adds insult to the injury of getting sick. so, i am very much pushing the idea that although healthcare is a vital issue in the world's discovering universal health coverage, which is great, and the us is trying to do something about trying to serve the underserved and give them access to healthcare, i am talking about the way we organize our affairs in society which impact on health and the unfair distribution of health health inequality now is it away two things i was asked

to chair. i did a review for the european region of who. we have learned a great deal. i don't just mean me. i wanted to communicated to a wider readership colleges try tied to write it in an accessible form. 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, hence the fact that we are discussing it now. >> wonderful.

and i think one of the major points you make is that poverty itself is a contributor to a person state of health, but it is really not the be-all end-all that results in the decision around how someone's health involves and how they seek care. >> if you have not got any money, which is not a bad working definition of poverty than having a bit more money makes a difference, no question. that is true whether you are a low income country or low income person with a high income country. having a bit more money really helps. if you have i got the minimum have a healthy life which is really disempowering. he disempowering. you can't pay the rent or buy food for your children. so money matters if you are below the minimum necessary for a healthy life.

above that threshold, whether you are a country or individual within the country above that threshold the minimum is a slightly complicated concept. i say that relative inequalities with respect to income translate into absolute inequalities with respect to capability. in other words, translating that's her english, it is not what you have but what you can do with what you have. and that if having relatively low income means your kids have not got the latest sneakers although important they all have football replica shirts. they can't hold the heads of public without shame, you

can't entertain children's friends for birthday parties. to some extent determined by the prevailing culture. a decent life in india and a decent life in baltimore complaining much more money have aa decent life in baltimore, many more dollars for rupees. we know that men in the poorest part of baltimore had a life expectancy about

average despite having many times the income which is what i mean by is not just what you have but what you can do with what you have. and there is a related point comeau what we think about the health of the poor we think about health inequalities or inequities. in the us you are more likely to say disparities. call it what it is. the unfair distribution of health. commonly we think about poor health. think about attitudes to poverty. if you are of a particular political persuasion you may think the poor are architects of their own misfortune. they are poor because of their own poor volition, poor choices, so they've got no one to blame but themselves.

if your good differentvery different political persuasion you may think poverty in our society is a stain on average society, and so we should do something about it. either way, you think it is not me. i am not poor. i may not be rich, but i am not poor. my answer is, yes, you and i are in the middle of this because with the evidence shows in the us, uk, and in a whole slew of other countries is there is a social gradient, and by that, i mean, by education or income or socioeconomic level of neighborhood what we find is people at the top of the hierarchy of the best health, people a little bit love them have good health but not quite as good as the people on top, and it runs all the way from top to

bottom. the poor are at the end of the spectrum, but before spectrum, but people we don't normally think of as poor actually have herself and they might otherwise. the social gradient command that idea that the averages involved, the person who says think goodness it is not me, that person is actually affected by it. let's think about the rich. i don't mean sending the social workers around, let's think about the rich. i calculated burden that for the average person they have eight fewer years of healthy life compare with people at the top.

the cognitive function short life, that translates into something like 202,000 extra deaths each year. compared with the top 10 percent. now, translating that into the us the same, multiply that by five, that's a million extra deaths each year attributable to not having the socioeconomic development of the top 10 percent. the gradient suggests we should be focusing on only on the board with improving society. >> there is an economic argument. we know that when people

learn better health because the system less. economic growth is improved and you get to that in your book. >> i do, but i am queasy queasy about it because i do think the moral argument is an important one. i don't think health is an instrument to something else. i think health is of fundamental importance and people value health. they don't value it because of where they can get a higher income because they value being healthy, getting up in the morning and feeling that they are not limited by heart disease were malaria. they value it because they value being healthy. and given that i am very happy that there is an economic argument for doing what i suggest. my argument is a moral one. i say the politicians, this

is naïve i know what to make a virtue of naïveté. what you go in the government to do? trudging through the well-being of your population? appeal to people's better instincts; the government to improve things for the population. the way i want to measure those things is health and the fair distribution of health because it is the outcome of all the other things that we want to have happen in society. >> you really use to advance a moral argument and have spoken to how you speak with politicians about this. how can we work on making the evidence a little more sticky targeting politicians

to really here that call, and i, and i guess that is why i was asking for the economic argument as well because sometimes i find that we can present lots of evidence and at the end of the day politicians have their own take on it. i think you found in a number of countries it is ticking. doing the who commission i talked to a senior colleague in brazil is send this is the depth -- the best thing. and we had not even reported he convinced president lula that he should set up the resulting commission. they did something similar enjoy thought they had look

at government policy. elected all different aspects of government policy and assess the degree to which they were compressing what i call the social determinants of health. a country like sweden you might say of course the jump. i talked to senior politician several times, minister of public health, politicians. they look at the commission report that so we can do this. the number is evident city. sweden, everyone has everything. 60 percent male unemployment

big issues. and now in central sweden, so they did it at the city level. talking to local politicians the equity of the moral argument carries with it equity and evidence. and now it is just getting going, but having got all these cities to do the do reviews and the government of sweden. >> filtering up. >> filtering out. and who knows. the us, there is a lot of action at the local level, a level, a lot of interest of local level. >> good to know. >> it could filter out. >> and i believe in the uk.

>> in the uk, so with the who commission, it was global. if you think about education in india and glasco, it is important in both places, but asplaces, but as i say that the end of the book how you operationalize and what it means to improve education and glasco, the principle is the same, but the challenges are different. so we made a virtue of necessity and said it was really very important for countries in the regions to take this on and figure out what it means in their own national context. but to mention brazil and chile, sweden. i was invited to do a review in britain by the then labor government.

we will come back to that of in a moment. then labor government. this was 2,009. he had done this commission. acme translate the findings and recommendations? it has a history. commissioned by a labor government in 1978. the time he reported margaret thatcher was prime minister. he was commissioned by labor prime minister. she said, i want no part of this. this doesn't fit my agenda at all. i was commissioned by labor government. it was utterly predictable that we would have a conservative prime minister on downing street after the 2010 election. people said moment will go the way. it didn't go that way. the government issued a

public health white paper and said this is the government's response. we have to put rejection of health equalities at the center of our public health strategy, and we will not do this to the healthcare system. we need to take action. >> if i may, why the difference, why did they let your recommendations go forward? >> i have asked myself that question not just in relation to the uk, but when we began the who commission people said, some of this we have known about before. you are not the 1st ever burst into the scene. you know, you've got some distinguished forebears. what makes you think it will be any different. and i did not have a very good answer to that question other than we would try hard not simply to watch aif it

was going to be different but try and influence. and we got partners like brazil and chile and the uk, sweden, got partners who then became advocates before the election about the big society. we can have a discussion about that. but i come along with this and that fit with the big society. it probably helped that i was president of the british medical association, so i had access.

we invited him. but also i think that there is a perception of the world and evidence for this that inequality is gone too far. they are not simply going to be dealt with by universal health coverage, we need something different. i met somebody from why won't say which state but a us state the other day it never heard of me, never heard of the who commission,

but he was talking the language of social determinants of health. i was delighted. it's not me and is not the who commission. >> but it is percolating out >> he didn't, but he was talking that language. answering a question as to why it's happening now. coming back to the uk. acknowledging the importance of it. they had implementation plans. and ii talk about some of that in the book. and that's terrific. >> how do you perceive the thought about equity and equity changing over the

time you have been working on this issue. obviously you have the biggest influence. has it been an iterative process? where we going from here. initially when people think about health inequity the hitmen and equity and access to healthcare is that easily conceptualize how people get sick, don't get access to healthcare. got extended out. think about the resolution

all i should children in low income countries die we have the needs to stop it. that's the equity, but now i think about noncommunicable disease and porto alegre, brazil, mortality from cardiovascular disease follows a social gradient. lower your socioeconomic district the higher your mortality. buenos aires, if you look at the social distribution of diabetes, the lower the income the less the education the higher the problems of diabetes. if we think we can do something about that, that is unfair, and equitable and not just about access to healthcare. so i have been working hard

to change the conversation. onon the cover of the who commission report we said social injustice is killing on a grand scale. and i stick by that, but i then ask myself, am i sure i know what, i mean? i have a chapter in the book where i actually explore theories about social justice and which ones best help me understand health inequities, and i think i have quoted said once. freedom to leave the life you had reason to value and that inequity, and that's very close to my idea of having control of your life for that freedom damage

itself and causes health inequity. >> could you speak a bit more about the idea of empowerment of control? that is something interesting that comes out of the book, and the idea that when you are lower in a hierarchy you have less control over your setting and talk a lot about workplace and how that can lead to poor health not necessarily because of environmental pollutant that because you don't have control over your life. >> i use the idea of control as an organizing principle to organize my thoughts, as it were, but i also use it in a way because there is good evidence that directly influences health, and i think about empowerment three ways: material, so

come back to the low income family who can't make ends meet. that is disempowering. and it damages health perhaps because of that nutrition. >> the development. >> all of those things damage health. they don't get adequate nutrition. and so it is very material. in that case disempowerment is innocence an organizing principle. the 2nd way is psychosocial lack of control of your life which damages health in two ways, i talked abouti talked about baltimore before. if you go into a low-income committee in baltimore and say to these young men, you know, you really shouldn't smoke, you'll get lung

cancer when you're 52 i would not say on television what they are likely to say, but they would probably be quite articulate and crisp and telling you where to go and what to do when you got there. and they are right. if they have got a 30 percent chance each year of being put in prison each year, if they have a minority chance of getting through to their 20s without being put in prison and they may well get shot and you are saying don't smoke, well, that disempowerment, one mechanism is you don't care about smoking and i've been doing drugs command we have seen this recent paper in the united states non-hispanic white men now verizon mortality.

what from? drug and alcohol related poisonings. suicide, alcohol, chronic liver disease and to a lesser extent so-called external causes of death which include homicides, traffic crashes and the like all of the things that department invested it and upon appointment get, and they are psychosocial. why would you kill yourself with drugs? well, this disempowerment, lack of control of your life. and in a way that somebody living in a low income situation said comeau we have all got to escape our pain some way. she said in her case it was. cigarettes and ice cream.

a young man in glasgow said he was one drink away from the abyss. the securing the pain of the soul, he said. one way it can damage health is that you have all these harmful behaviors. the other way, chronic stress the changes the narrow enterprise system. >> which we are learning more more about affecting brain developments, stress pathways. we know that what happens, childhood changes the way the organism response to stress later in life. and they are learning more about how those pathways work.

she has been working with the psychologist in san francisco showing how stress affects. so they are really very interesting biological parties. one is you kill yourself with drugs, one thing or the other, but the other is the stress pathways. the earlier when i talked about, material deprivation. >> and we are seeing intergenerational he very strong. that gets passed on the children. >> there is another politician who would stand up and say i believe in an equality of opportunity. everybody believes in equality of opportunity. what the evidence shows is

that inequality in this generation affects the life chances of the next generation and the one after until the 4th generation. and so for example the evidence shows that the greater the income inequality the less social mobility there is. well, you have a lot of income inequality. rich parents average children, poor parents are poor children. you have much more mixing and social mobility. what is happening to the parents is impacting on the next generation. i don't go into that in the book.

current area of research but the sociopsychological impact they get passed down, so all politicians are in favor of equality of opportunity. the playing field is very jilted. >> right. switching gears a little bit , the idea of social determinants of health, health but much much more. it is inherently multisectoral, not just the health ministry. it is education, economic growth, all sorts of things, transportation, environment. why don't you just read a quick expert -- excerpt and ask you something more about that.

must take equity within the generation to account within and between countries. it takes a higher proportion of a poor person's income that a rich person. i had raised to this and environmental circles and then tolduntil don't spoil a perfectly good tax by worrying about equity. the big climate change summit.

happily informs policymakers torque across silos, to put down some of the guard and build alliances rather than protect their own turf. >> i was in taiwan last week. we did a report for the taiwanese government, social determinants of health. representative to the president taiwan. he said this is great. when he crossed government action. the presence of that. nowadays selected.

now, i was over the moon. when you to put health equity in the context of economic development and the environment. that is what sustainable development should be about, but too often the health and the health equity part get forgotten. they have done commissions trying to bring health back in to the environmental consideration. they should be health equity in the example you. we could have taxes that

make it much harder. the end result is high enough to change behavior cobbles rises driving around. that is not the future we want. we wanted to the sustainable and fair. the idea when you're looking between countries we and there is countries pumping out fewer greenhouse gases and a lot more to come from poorer countries. that is the convergence. within the context it to the equity dimension between.

so very much it is life-and-death and poor countries with drought an intolerable conditions and great population, equity dimension is key. >> and ultimately i think that the people going on in poor countries spills over in the rich countries as well. look at what we are doing with syria. >> i think that ability i think the conflict. what turns environmental problem into a disaster is the way we cope with that

socially. and it is a bit like conflict. but in general i wrote elsewhere about the troubles in northern ireland. it was not the lawyers in the middle classes, it was the poor who were caught up, and that is what it looks like, and in general that is what it looks like when we get environmental problems. i quote the difference between haiti's earthquake in chile's earthquake. the death toll in haiti is 200,000,, chile had a quick that was 500 times stronger than the haiti quake and the

death toll was in the hundreds. chile had strict building codes and good emergency services, it was a better organize society. haiti was unprepared in every way. so the environment and social organization come together. >> i'm going to switch back to little bit. you mentioned your the president of the world medical association. a couple questions about that. you are obviously a physician. i would say the fellow epidemiologist diet questions all the time about what that is. >> it is not to do is scan. >> precisely. and i don't thinki don't think most people expect their physician to be doing this kind of work and talking about these kinds of issues.

could he talk ayou talk a little bit about what it means for you to be in epidemiologist and how you have been able to evolve your career to really become an influential voice in the health and equity in general >> well, i come -- will come back to the medicine thing in a moment. my case one thing led to another. it is not that i had a grand plan. what i was practicing medicine in sydney's attorney doctor, what good does it do treat people and send them back to the conditions that made them sick. i was totally ignorant and had not read anything. i did not know scholarly people back to the

conditions that made them sick? and i thought, is there a lot of work that deals with that? and as i lay on the introduction, one of the consultant physicians in sydney said that there is. it is called epidemiology. it was a particular sort. which was looking at the conditions that make people sick social i was just terrific.

mentioned a little while ago because soon after i got there was elected prime minister and said there are no health inequalities. so it was a topic on which you can do research that had any practical implications. so i did. search for 18 years. british government. and then the government changed. the labor government came in and said we want to do something about health and equality. suddenly yesterday's.

search became today's applied research. and i started thinking about a former chief medical officer, started thinking, what if somebody took this seriously and what if it took it seriously globally it said improve health in order to get a more vibrant economy. and i thought of the time that the recommendation to spend billions controlling hiv and tuberculosis and malaria was great. bombing people or wherever else they spend billions on. done. as i said at the beginning,

i did not see it as a better way. so i talked and said why don't we set up a group to say that and he said,said, it would be quite good to get who back in. who set up the commission. now i found myself into her incognito trying to bring the best evidence to influence policy globally and did not no anything about the policy process. we had some terrific commissioners who did know a thing or two about policy. government ministers and they were wise and helpful and brought a lot of their wisdom to bear. i still would not claim i

know how to influence the policy process. whatwhat we did as a commissioner what ideas individual's bring the evidence, package in the best way i know how, presented in the clearest where i know how but if you asked me the question is how we get from there to their comeau well, i can tell you when we have managed it but i'm not quite sure we understand why. >> it goes into the policy black box. >> and political scientists say comeau we study the black boxing can tell you, let's work together. >> going back to your role we talked a bit about health and health care and how they are not synonymous but we also talked about that you

are actually treating in a healthcare setting and realizing i was not the most effective way to be influencing health a larger scale. beyond the idea that we need politicians to embrace the idea of social determinants of health, we should be pushing presumably to change how healthcare providers for healthcare providers are trained in the framework in which they operate. how are you using your role at the world medical association to influence how healthcare is actually being rolled out. >> it is a slightly odd position. spent my life saying it lies outside the healthcare system. very strange.

i'm a very clear that i have an agenda. imagine that is not being polite and having dinner with national medical associations around the world. my agenda is social determinants of health and health equity. i want to get the doctors involved. they say okay, they are convinced. what do you want us to do? we will produce a report. don't think it would be that different the 2nd is seeing the patient in a broader perspective

practicing medicine among the homeless. how can i treat panama and diabetes and send them back to the street? i have to get involved in making sure that they have got shelter. seeing the patient in a broader perspective. the 3rd is recognizing the health system is employer. 1.4 million people work in the national health service, and it is not just the conditions of the doctors but the cleaners in the water systems and the nurses and also the impact on the local community. we need to work with the other services for what

about the services that are promoting early child development. so working in partnership, coming back to the present, that's what he was saying. try to get all the sectors working together. physicians and the natural attorneys of the poor, we should be advocates. all of those, there is a great deal the doctors can do and national medical associations can do as doctors without departing from being a dr. by all means treat the sick, but get involved in these other issues at the same time. the fact that they asked me to put my name forward is symptomatic that they were

open to that. >> yeah. i did not hide what i was on about. had been president just under four weeks. we had a meeting at the canadian medical association suggested in london, we did not invite anybody but we informed the national medical association that the meeting was going on, 20 countries were represented, 200 people came to the meeting, and we were discussing how national medical associations could get engaged in a social determinants of health to promote health equity. >> that is very encouraging. >> it is. so we are coming to the end of our conversation, not quite, but, but i wanted to ask you a question which is, you are interviewed a lot.

you are a very good interviewing. i will put a plug in for the book because it is readable. written in language that i think is very engaging. as someone who gets interviewed a lot, is there question that you wish people would ask you that you have not heard yet? i am putting you on the spot. is there something that you would like to talk about that you have not have the chance to either in this interview were previous? >> you are putting me on the spot. one of the things on my mind is not i said in the book and i said with the who commission that we wanted to create a social movement for health equity. ..

and how would we know we're getting there? >> host: right. >> guest: ing and if you -- and if you had asked me that question, i'm sure i would have given you a glib answer. [laughter] but i certainly ask myself the question, i don't have a glib answer. i say in the book that i'm an

evidence-based p 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 that are happening shines a light, gives us something on which we can focus. it tells us, hey, or this is possible. i was having conversation san francisco recently, and i'm sure you've had this conversation many, many times, people wringing their hands saying it's impossible to get change. just dysfunctional washington gridlock, you mow the argument. and i said -- you know the argument. and i said, firstly, this is a very u.s. conversation. i tend not to have that conversation -- >> host: really? yeah. >> guest: -- in other parts of the world. even though other parts of the world may have far worse political problems, you know?

but secondly, if we can't get action there, we can get action there. can't do it at the federal level, do it at the local level. 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 countries of low income, middle income and high income inspiring examples where people are making progress. we see countries' health improving. a major challenge given that hitherto poor, sick countries are becoming less poor, less sick countries, and the health's getting closer to those of the richer countries. but a major issue is the continuing and in some cases increasing health inequity within countries. so my evidence-based optimism doesn't lead me to ignore the

problems in front of us. and a question i have been asked -- not in interviews so much, but i have been asked -- is you're going around the world more or less ceaselessly -- [laughter] and talking to people. how do you keep it up? and my answer is, because i feel we're making progress and that, this is a bias example. if i get an invitation saying we think what you're talking about is rubbish and we'd like you to come so we can demolish you -- >> host: probably not high on the list. >> guest: if i get an invitation that says we're really interested in what you're talking about and we really would like to make a difference. so earlier this year i got an invitation to columbia saying we're planning for a

post-conflict colombia. now, i may be an optimist, but i try not to have illusions. >> host: right. >> guest: so i have no illusions that it's going to be simple. colombia is one of the most unequal countries in latin america. they may be planning for postconflict colombia, but it's not over yet. >> host: right. >> guest: everybody, not everybody, but some people hope they will sign an agreement with farc and that 50 years of war will be over, and they can -- >> host: yeah. >> guest: so i was only too happy to accept an invitation to be part of a conversation of planning for postconflict colombia and to talk about health equity and social determinants of health. now, it may not happen, but that's worth it. >> host: yeah. >> guest: and the reception i got was heart warming. >> host: i was going to ask you about being an optimist, but i think you've just spoken to that beautifully.

if you could give advice to a young person who is really interested in working to influence social justice and working for the cause of equity, what kind of advice would you give them? >> guest: i've said more than once that i don't mind giving governments advice, i'm much more nervous about giving young people advice. [laughter] you know, it's far too important. governments can ignore me, but young people might just possibly listen, and so the responsibility's too deep. when i was going to taiwan a couple weeks ago, somebody wrote, a medical student wrote, and my assistant got the e-mail and said could we, the students and junior doctors in taiwan, would like to meet michael when he's here. my assistant always says yes to

students, so i'm sure he'll be happy to do that. and the student who introduced me said i heard you talk at the international federation of medical students' association meeting in copenhagen a couple of years ago. and you changed my life. and changed my career. >> host: yeah. >> guest: i had a bit of trouble beginning my conversation, because the tears were rolling down my cheeks. [laughter] so i can't tell young people what to do. but when i do talk to medical students and junior doctors, i do try and enthuse them with my passion for social justice and health. >> host: yeah. >> guest: and the various ways you could do that. you could become a researcher, you could become an activist, you could become a caring clinician. and i can't tell an individual young person which is the best more them. but what i can do is try and enthuse them more social justice

and health. >> host: yeah. >> guest: and i say to the senior doctors at the world medical association remember why you went into medicine in the be first place. you wanted to help people. and you particularly wanted to help people who were suffering. well, that puts us all on the same side of health equity. >> host: yep. well, i can't think of a better place to end this, because i think that's a very forward-looking idea. and so, sir michael marmot, thank you so much for this. this has been a great conversation for me to be part of, and you have reinspired me, and i think that we will look forward to whatever is the next chapter in what you are working on. >> guest: thank you very much. >> host: so thank you very much. >> guest: it's been a pleasure. >> host: pleasure. >> that was "after words," booktv's signature program in which authors of the latest nonfiction books are interviewed. watch pa