Host hello. Its a pleasure to be here today to talk about your new book the health gap. Youve written extensively around the social determinants of health for a long 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. The different power, material, health and creates health and equity. They take different forms of local monopoly and high income country but the general approach to promoting the just distribution of health is similar. Its similarly about health. Can you tell us a little bit about what this means and why you decided to write this book now . Guest when you run the two words health and care together. I spend little time talking about health care in the book because what i say it is when people get sick they need access to highquality health care but its not a lack of healthcare that caused the illness in the first place. Its the lack of access and insults to the injury of getting sick. So i very much pushing the idea that although healthcare, the world has discovered universal healthcare coverage which is great, and the u. S. Is trying to do something about trying to serve the younger terms in terms of healthcare. Im talking about what the ways we with the ways we use our society to impact on health and the unfair distribution of healthcare to be judged by. It is a way to do things. One day as i chaired the who commission in the wake of that i was asked to chair the review of the Health Properties in a wind. I did a review for the year. The european region. And i dont just mean me, i mean all the people involved. And i wanted to communicate it to the readership which is why i try to tried to write it 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 Peoples Health and wellbeing and the fact that we are discussing it now is exactly what i wanted to do. And i think one of the major points that you make is that poverty is solve is a contributor to a persons state of health but its really not the beall be all and the end all that makes or that results in the decisions about how someones health and faults and how they seek healthcare. Can you speak to that a little bit . Guest if you havent got any money which isnt a bad working definition of poverty than having a bit more money dicks a different and that is true whether you are a low Income Countries or low income person within a high income country. So if you are the who are in the United States or the uk, having a bit more money helps. If you havent caught the minimum necessary, you cant have a healthy life and that is really disempowering. You cant pay their the rent or buy food for your children. So, money really matters if you are below the minimum necessary. Above that threshold whether you are a country or an individual within a country above the threshold, the minimum necessary is a highly complicated concept that i say with respect to income translates into absolute inequalities with respect to capabilities. In other words its not what you have but what you can do with what you have and that is having a relatively low income means that your kids havent got the latest auto in britain they all have football replica shirts and they cant hold their heads up in public without shame because you havent got enough money to do that, you cant entertain childrens friends for birthday parties and all of those things that means you havent got enough money for a decent life. Its not just the money its what a decent life means and that will change with society but thats what i mean that it will be different if you are in india or baltimore. The concept is the same of having enough to lead a decent life and what a decent life means is to some extent determined by the prevailing culture so a decent life in india and in baltimore you need much more money to have a decent life in baltimore and many more absolute dollars. We know despite having many times the income thats what i mean by not just what you can have but what you can do with what you have and theres a related point which is when we think about the health and the poor as i at the pool or as i call it in a quality or inequities but lets call it what it is, its inequality and in equity into the unfair distribution. We think about poor health for the poor. 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 devotion and choices so they have no one to blame but themselves. If you are of a different political persuasion you may think that poverty in the societies a stain on that society and so we should do something about it. But either way, you think its not me. I am not poor, i may not be rich, but im not poor so it doesnt apply 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 a whole slew of other countries where we have data there is a social gradient 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 have good health but not quite as good as the people at the top and it runs all the way from top to bottom, so the poor are then at the end of the spectrum. The people we dont normally think of as poor or lower down and actually have worse health than they might otherwise if we could have a shallow social gradient. And that idea that the average is involved for the first says its not me, im not poor, that person is actually affected. So instead of thinking about the poor, lets think about the rich and the rich and i dont rich and i dont mean sending the social workers around to find out if youre okay with all that funny. Lets find out about the rich. We want everybody to have good health and the people at the top. I calculated in britain that for the average person person they had eight fewer years of healthy life compared with people at the top and a healthy life means declining grip strength, decline in walking and cognitive function in shorter life. That translates into Something Like 202,000 extra deaths each year compared with the top 10 . Now, translating that to the u. S. If the figures were the same, multiply that by five, thats a million extra deaths each year that are attributable to not having 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 and you just laid out a very convincing argument i think for this. Theres also an economic argument for this as well. We know that when people are in Better Health and it costs the system less. Economic growth is improved. You get to that in your book as well. Guest i do, but i am queasy about it because i do think the moral argument is the important one. I dont think that health is an instrument to something else. I think it is a fundamental importance and people value health and value it because that way they can get a higher income but then getting up in the morning and feeling that they are not limited by Heart Disease or malaria or whatever they value and given that, im very happy if theres an economic argument for doing what i suggest that the great but that isnt mine, mine is a moral one and icq politician this is naive, i know that i make a virtue of naivete. I say to politicians what did you go into government to do . Didnt you go into try to improve the wellbeing of your population . I went to line my own pocket and things like that. But to do better instincts to go into the government to prove things for the population. And the way i want to measure those things as health and the unfair distribution of wealth because i think that health is the outcome of all the other things that we want to have happen in society. Guest you use defense to advance a moral argument and you talked about how youve spoken to politicians about this. How do we work on making the evidence of little more sticky getting politicians to hear that call, and i guess that is why i was asking about the economic argument as well because sometimes i think that we find we can present lots of evidence at the end and at the end of the day the politicians have their own take on it but i think you found in a number of countries it is sticking. Can you tell us about the countries that you are seeing success along these lines . Guest first two were brazil and chile when we were doing the who commission on social determinants of health, which i chaired. And i talked to the senior colleagues in brazil and he said this is the best thing that has come out of the who and we havent even reported. We were just getting going. He said we should do Something Like this in brazil and he convinced the then president that he should set up a brazilian commission. They did something similar in chile but they had to look at government policy and in a sense they ran an equity filter over it for the different aspects of the government policy and to assess the degree to which they were addressing what i call the social determinants of health. In a country like sweden you might say of course they jumped to it. They didnt. I talked to senior politicians several times. Theres other senior politicians, but the city said they looked at the who Commission Report and said we can do this for our city. They set up the commission for the immigrant city and you think the speed and everybody has everything. While, they have 60 male unemployment so they have big issues. They did it at the city level and talking to the politicians that took this on board, the moral argument really carries with them equity and evidence. Theres evidence that you can do something and now its just getting going but finally having gotten all the cities to do reviews the government in sweden showed up to filter into the government in sweden and who knows. The u. S. Theres a lot of action at the local level, a lot of interest at the local level. Host thats good to know. Guest it could filter out. Host and in the uk you are seeing the same thing. Guest in the uk with the who commission, it was global. If you think about education, and india and in alaska, it is important in both places. But as i said at the end of the book how you operationalize and what it means to improve education and glasco is different. The principle is the same, education is important that the challenge is different. So we made a virtue of necessity. And we said it was important for the countries and 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 but we will come back to that in a moment if i may come of that then Labour Government and this was in 2009. The question was you have done this commission. How can we translate the findings of the recommendation for one country lacks it has a history commissioned by the Labour Government to do a review of the Health Inequalities of 1978. By the time we reported Margaret Thatcher was the Prime Minister so commissioned by the labour paymaster that Margaret Thatcher and she said i wanted no part of this. This doesnt fit in my agenda at all. Utterly predictable that we would have a conservative Prime Minister in downing street after the 2010 election. People said that it didnt go that way. The government issued a public paper that said this is the governments response to the review. We have to put reduction on the Health Qualities at the center of the strategy, and we will not do this through the whole care system. We need to take action on the social determinants of health. Host and if they make him a wide difference. Why did they let your recommendations go forward . Guest ive asked myself that question not just in relation to the uk but when we began the Commission People said some of this weve known about before. You were not the first to ever burst into this. Youve got some distinguished. What makes you think that there will be any different . And i didnt 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 to try to influence that the outtake would be different. We got partners like brazil and chile and the uk and sweden. We got partners who then became advocates for the commission and for these ideas. In the uk, the Prime Minister talked before the 2010 election about the big society, and he was trying to make it clear that he wasnt going to be the same as Margaret Thatcher. So i come along with this and benefited society and helped that i was president of the British Association at the time so i had access and impact we invited him to come and debate with me at the British Medical Association house of house of the house of commons so i had some direct input with him and that probably helped a bit. But also, i think that there is some perception in the world and theres evidence of this that inequality has gone too far and there are Health Problems that follow that are simply going not simply going to be dealt with by universal Health Coverage or the usual approaches. We need something different. I met somebody from i wont say which state, but a state the other day in taiwan and he has never heard of the who commission, that he was talking the language of the social determinants of health. I was the lighted them absolutely delighted that success because its not me and its not the commission that he knows he got it from. Host but but thats percolating out. Guest i know where it came from, thats a different question. He did and that he was talking about language. So thats hard answering your question as to why its happened now. But its more saying this is happening so its like coming back to the uk. Whats happening at the National Level at College College and the importance of it but we have three quarters of local authorities in england. I talk about this in the book and its terrific. Host how do you perceive the thoughts about equity that have changed over time that you have been working on this issue. In this process where are we going from here. Guest i think that generally across the world and initially when people think about health and equity they met in equities and access to healthcare is. They get sick and dont have access to healthcare. You have to walk 10 kilometers to get their. And it got extended extended out a bit for children children and the women come countries if they dont get immunized and poor children dont get immunized with damages their health and that is sort of unfair. So that was i think the underlining approach to it and think about the Child Survival revolution. That is the equity that we got in these interventions. But now think about the non Communicable Diseases in the port and brazil and cardiovascular disease that follows at the social district and the higher the mortality. If you look at the social distribution of diabetes over the income, the less the education, the higher the prevalence of diabetes. If we think we can do something about that but we dont commit that is inequitable and its not just about access to health care so i have been working hard to change the conversation on the cover of the Commission Report we said said the social injustices killing on a grand scale and i stick by that but i dont ask myself in my sure by what i mean. I have a chapter in the book on social justice and which ones best help me understand equities it ive quoted them already have the freedom to lead a life that you had reason to value and that in equity and the freedom thats close to my idea of an empowerment in having control of your life, if it damages and causes health inequities. Host could you talk more about the empowerment control because i think that is 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, and you talk a lot about the workplace and how that can lead to poor health not necessarily because of an environmental pollutant or some of the more obvious things but also you dont have control over your life. Guest i use it as an organizing principle but i also use it anyway because theres good evidence that it directly influences health and i think about empowerment in three ways which were cited at the beginning, material. So, coming back into the income family, you cant make ends meet. That is disempowering. And it damages health perhaps because of bad nutrition, not some psychological concept but because people dont get shelter and develop. All of those things Damage Health if they dont get adequate nutrition they wont grow properly into their brains wont develop and so its very material. So, in that case, disempowerment is in a sends an organizing principle. Its a way of describing it. The second way is lack of control into the damages help in two ways. If you i talked about a baltimore before. If you were going you go into a lowincome community in baltimore and say to these young men, you know, you really shouldnt smoke. You could get cancer when youre 52 if you smoke, i couldnt say on television that they are likely to say to do but they would probably be quite articulate and crisp in telling you where to go and what to do when you got there. And they are right. If theyve got a 30 chance each year of being put in prison each year come if they have a minority of a chance of getting through to their 20s without having been imprisoned, and they may well get a shot if not imprisoned, and youre saying dont smoke come a long mechanism is you dont care about smoking and dying and doing drugs and weve seen this recent paper in the United States that white Nonhispanic White men have been rising in what is the mortality from comments from drug and out of whole related poisoning, suicide, alcohol from Liver Disease command to a lesser extent sometimes the external cause of death that includes homicide, traffic crashes and the like. They are all the things that deprive a man get in communities and deprived white men get into their psychosocial. It was the lack of control and in a way as somebody living in lowincome situations that we all have to escape our pain in some way. She said in her case it was beer, cigarettes and ice cream. A young man in moscow he was one drink away from the abyss. And thats disempowerment. So in one way it can Damage Health. You feel i dont control my life anyway so i will escape with alcohol and drugs. And anyway, ways to change the enterprise system. And it starts Early Childhood and affects Brain Development and stress pathways throughout. We know what happens in Early Childhood changes the way the organism responds to stress later in life. She has been working with a psychologist in San Francisco showing how stressed so they are really interesting biological pathways by which stress operates, so one is you kill your self with drugs and poisoning. So get killed with one thing or another and the other is the express pathways that damage the disease. But the early one that i talked about were the material deprivations. Host there are also the different links that are strong so with the parents house so that that gets into the biological and three always passed on to children and then guestbook is not the position of stand up and say i believe in the inequality of opportunity. Every publication right center, anybody believes in equality of opportunity. Thats what the evidence shows his dna quality of this generation affects the life chances of the next generation and the one after until the fourth generation. So the evidence shows very clearly that the greater the income inequality of effecting this generation the less social mobility that is. You have a public income inequality. You have a lot of income inequality than rich parents have rich parents and portraits of poor children and you have less quality than youve got much more mixing and much more social mobility. So, whats happening to the parents is impacting the next generation and there may also be some genetic mechanisms that get passed but i dont go into that in the book. Its a very interesting area of research. But certainly certainly this socalled debate the social and psychological impacts that get passed down from one generation to the next so the politicians were in favor of the quality of opportunity that we dont have it. When we think about dealing with politicians and governments on its inherently multisectoral, not just the health industry. It is education and Economic Growth and all sorts of things and in the environment. I wanted to just read a quick excerpt and ask you something more about that. You say i would argue that the discussions on preserving the planet must take equity within the generation into account in between the countries. And you get a great example about this that i think its very interesting. For example, congestion charging. Charging if you drive into the city as a good cream tax. Ive raised this in environmental circles and have been told dont spoil it could tax by worrying about equity. We need to bring the environment all and equity agendas together. We have a big Climate Change coming up in paris at the end of the month and Climate Change is very much on everyones mind. That is a perfect example of the cross sectoral relationship. How can we influence policymakers to work across the silos to put down their guard and to build alliances rather than protect their own curse . Guest well, i was in taiwan last week, the week before last. [laughter] where am i. . And we did a report on social determinants of health and presented it to the president in taiwan and he said this is great. We need cross government action. And i think i know how to do if we have a Sustainable Development committee. We were delighted we have a good meeting and somebody said afterwards the president of the World Medical association meets the president in taiwan. Because here is the president saying we need cross sector action and we need to put Health Equity in the context of Economic Development and the environment. Thats what Sustainable Development should be about. But too often the health and the Health Equity part gets forgotten. Thereve been some very welcomed news in the last couple of commissions trying to bring health back into the considerations but it shouldnt just be health should be Health Equity into the example that you read out a could have taxes that make it much harder. If it was high enough to change the Behavior Committee would have the rollsroyce driving around at the empty seat debate streets because they couldnt kick back and forth across the street and then we could drive our big cars around the streets. Thats not the future we want. We want to be sustainable if we want to be fair in that countries and in between countries. It should be equity between countries as well as within it. The idea when you are looking beyond the contraction and convergence of that we in the rich countries ought to be pumping out fewer Greenhouse Gases and allow more to come with the poor countries so thats the convergence but within the context of the overall contract and gets the dimension between the countries, so i think thats very much because the Climate Change might be an inconvenience for people its like death in poor countries with droughts and intolerable conditions in the population movements because the equity dimension is the key. Host we see the upheaval going on and it spills over to look at what we are dealing with in syria. Guest if it is used in the way that i think about conflict that what turns the environmental problem into the disaster is the way that we cope with it socially and it didnt like conflict. Who is actually fleeing. I wrote elsewhere about the troubles in northern ireland. It wasnt the lawyers and the middle classes. It was the poor that were being caught up in that conflict and thats what it looks like whenever we get conflicts in general thats what it looks like when we get environmental problems and i quote in the book the difference between the earthquake and chilis earthquake. The death toll was 200,000. Chile had a quake that was 500 times stronger than the haiti quake and they have strict building codes and emergency services. It is a better organized society. Haiti wasnt prepared in any way so the environment in the social organization come together. Host i am going to switch tracks a little bit. You mentioned you are the president of were the president of the World Medical association. So a couple of questions about that. You are obviously a physician. But you are also an epidemiologist and i will say as a fellow epidemiologist i get questions all the time about what that is. I dont think most people expect their physician 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 ive come to this and i will come back to that in a moment. In my case, one thing led to another. Its not that i had a grand plan. I thought when i was practicing medicine as a trainee doctor, i began my book with the sentence what good does it do to treat people and send them back to the conditions and that is an insight that i had. I havent read anything so i didnt know that scholarly people were writing books on the topic. I was too ignorant to that was my own insight. But to send them back to the conditions that made them sick and i thought is there any line of work that deals with that. One of the consultant physicians in sydney said there is. Its called epidemiology but it was a particular sort of epidemiology. I dont care for illegals much that the social epidemiology which was looking at the conditions that made people sick and who i did a phd with. He was teaching me and teaching other people to examine social conditions to look at the impact on health. For much of the time i was happy as can be a. As they mentioned a little while ago as i went back to the uk. Elected Prime Minister she said there are no health any qualities. So it wasnt a topic on which you can do research. Studying the british Civil Servants liked the idea of the u. S. Government supporting the research on the british government. They said we want to do something about health any qualities and suddenly yesterdays research became todays flight research. I started thinking what if somebody took this seriously. Jeffrey sachs chaired the commission on the who and it said in approved health in order to get a more vibrant economy. We thought that it was great but we saw better social and economic conditions. So i said why dont we set up a group to see that and he said it would be quite good to get them backing for it so they set up the commission on social determinants of health and now i found myself in terror incognito. I was trying to bring the best evidence, and i didnt know anything about the policy process globally. We have such terrific commissioners who didnt know a thing or two in the government ministers and they brought in with their wisdom to their on the question. Its what we did as a commission and what i do as an individual. Was presented in the clearest way we know how but if you ask me how to we get from there to there to the best presentation of the evidence to getting policy change i can tell you when we managed it but im not quite sure that i understand why. Host it goes into the policy blackbox. Guest the study that blackbox and we can say grace but put it together. Guest host going back to your role as the World Medical association, so weve talked a bit about health and health care and how they are not synonymous. You also talked about how you were factually treating in a healthcare setting and realizing that that was not the most effective way to the actually influencing health on a larger scale. So beyond the idea that we need politicians to embrace the idea of the social determinants of health and we should also be pushing presumably to change the providers and how they are trained into the framework in which they operate so how are you using your role to also influence how healthcare is actually being ruled out . Guest for me to be president of the Healthcare Association as i did when i was president of the British Medical Association i spend my life saying the key determinants of health by outside of the Healthcare System and then they make me seem very strange so i made very clear that i had an agenda. My agenda is not being polite and having dinner with the National Medical associations around the world. They say okay we are okay but what do you want us to do . We will produce a report for the World Medical association. The second is seeing the patient in the proper perspective. He said how can i treat diabetes and the consequences into the drug abuse and send them back to the streets to get involved in making sure theyve got shoulder its not just the conditions that the doctors come its the cleaners and systems and the Lab Assistants and the impact on the local community. So seeing the Health System as an employee or and stakeholder working in partnership and Young Children in the two work with Young Children so you may be treating their middle ear infection but what about the services that are promoting Early Childhood development for example working with older people and social care and supporting. So working in partnership and to come back to the president of taiwan thats what he was saying we will try to get them working together. We should be advocates. So all of those i think theres a great deal of the doctors can do into the medical associations can do as doctors without departing from being a doctor and by all seems treat the sick but get involved in the other issues at the same time. The fact that the asked me to put my name forward as president in the World Medical association is symptomatic. But for example we had a meeting while i was president elect of the Canadian Medical Association said and suggested in one day and we london we didnt invite anybody but we just informed the medical association as the meeting was going on. We were discussing how the National Medical association including could get engaged in the social determinants of health to promote Health Equity. Thats very encouraging. Host we are kind of coming to the end of the conversation, not quite, but i wanted to ask you a question which is you are interviewed a lot and you are a very good interviewee. And i will find a plug for the buck its book is written in a language that is very engaging. And someone who gets interviewed a lot is there a question that the risk you ask people would ask that you havent heard yet . Im putting you on the spot and you can say no but is there something that you would like to talk about that you have and have the chance to either in this interview were previous interviews . 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 that we wanted to create a social movement for Health Equity through action on the social terms of health. I wasnt entirely clear what it looked like or how you get there and im not sure that i would like you to answer to these two ask me that question because 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 am pleased when somebody comes up to me and it happens frequently to say i was part of the Knowledge Network and was synthesizing knowledge for the who Global Commission and they are proud and pleased that they were part of it because they feel part of the social movement. So the question i asked myself is what would success look like in terms of creating a social movement and how do we know we are getting there and if you have asked that question im sure i would have given you a glib answer but i certainly asked myself the question. Im an evidencebased optimist because i see lots of good things happening. Its not that i ignore the bad things. We need to address them. But focusing on the good things happening, sharing some light gives us something which we can focus. It tells us this is possible. I was having a conversation recently and im sure youve had this conversation many times. People wringing their hands saying its impossible to get the change into the dysfunctional. You would know the argument and i said 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 had far less political problems you know, ethnic violence, massacres, people of different religions and the like that second come if we cant get action there, we can get action there. Cant do it at the federal level, do it at the local level. You cant at the local level, go to the National Level. There has to be an exit point and we can see in the countries of lowincome and middleincome high income examples where people are making progress we see them improving in a major challenge for the six countries that are becoming less poor and getting closer to those in the richer countries. But the major issue is continuing in some cases increasing Health Inequity in some cases. So, my evidencebased optimism doesnt lead me to ignore the problems in front of us and a question that i have been asked not in interviews so much that i have been asked is doing around the world and talking to people how do you keep it up and i feel we are making progress and this is an example i tend not to go if i get an invitation thats rubbish and we would like you to come so we can demolish this not a lot of other places to go. I. I get an invitation saying we are interested in what youre talking about and we really would like to make a difference. So, earlier this year i got an invitation to columbia saying we are planning for a postconflict columbia. Now i might be an optimist, but i try not to have delusions. So i had no illusions that have no illusions that its going to be simple. Columbia is one of the most unequal in latin america and they may be planning for the postconflict columbia but its not over yet. Everybody, not everybody but some people hope that they will sign an agreement and that 50 years of the war will be over and so i was was me too happy to accept an invitation to the part of the conversation of planning for the postconflict columbia and to talk about the Health Equities and social determinants of health. It may not happen, but its worth it and the reception i got was heartwarming. Host i was going to ask about being an optimist but you spoke to that beautifully. If you can give advice to a young person, who he 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 ive said more than once that i dont mind giving government advice. I am much more nervous about giving young people a device. Its far too important. The government can ignore me but young people might just listen, so the responsibility is deep. So i cannot tell young people what to do. But if medical students and Junior Doctors i do try to infuse them with my passion for social justice. And the various ways you can do that. A researcher, activist, but what i can do is for social justice. I say to the senior doctors we wanted to help people. That also puts us on the same side. I cannot think of a better place to end this. We thank you so much for this. Is a great conversation and to be a part of an you have inspired me and we look forward for what you were working on. Thank you very much. Good evening. And the head librarian and mint please silence any ce