UCL Minds


Transcript: Episode 34

How can we make healthcare fairer after COVID-19?


people, inequalities, pandemic, deprived, poverty, income, government, michael marmot, ucl, health, february, health inequalities, reduction, deprivation, life expectancy, lockdown, gig economy, greater, called, regressive


Michael Marmot, Vivienne Parry


Vivienne Parry  00:03

Hello and welcome back to Coronavirus: The Whole Story. My name is Vivienne Parry. I'm a writer broadcaster and UCL alumna, bringing you the latest in Coronavirus news from the UCL community. And we start this year just as we started our very first episode in lockdown. Last week we bought you our Coronavirus year and review episode reflecting on what we've learned about Coronavirus, museum experts and their research. But this week's episode is a little different. We're going for the full New Year's resolution, looking at what we need to change to make our communities safer and fairer for the future. Just over a decade ago, the Institute of Health Equity released the landmark study fair society healthy lives also known as the Marmot review, in February 2020. The Health Foundation published a follow up study, the Marmot review 10 years on and in December last year, the COVID-19 Marmot Review, Build Back Fairer authored by Michael Marmot, Jessica Allen, Peter Goldblatt, Eleanor Hurd and Joana Morrison was published. It shows how some groups in areas have been affected more than others, both by the virus itself and by the measures taken to contain the virus. It made a number of recommendations on how to build back better and fairer so who better to talk about the report, the Michael Marmot himself. So Michael Marmot is professor of epidemiology here at UCL and director of the UCL Institute for Health Equity. Michael has been researching health inequality for over 40 years. Throughout his career, he's advised the British government and the who he served as president of the British Medical Association and of the world Medical Association. Currently, he's the chair of the commission of equity and health inequalities in the Americas. And he's the recipient of multiple prestigious awards. Michael, welcome to you. I wanted to start not actually with a COVID-19 review, but the one that was published in February last year, that kind of the 10 year sequel, if you like, of the initial Marmot review, because I wanted to place this in the context of, of where we were at the beginning of last year.


Michael Marmot  02:19

We look back over the decade from 2010. And what had happened to health and health inequalities, and what are the possible reasons. And the picture was grim. Life expectancy, which had been improving in England, as in other rich countries, about one year, every four years, and that improvement has gone on for a century. In 2010 11, it slowed markedly the rate of improvement in life expectancy in men and women just about ground to a halt. Second, there was a continued increase in health inequalities. And we saw that particularly when looking at levels of deprivation, but also when looking at regions. So if you were in the least deprived 10% of areas, it didn't match, no matter where in the country you lived, your health was pretty good, and was improving a bit. If you were in the most deprived 10% it mattered enormously where you live, the disadvantage of living in the northeast, and the Northwest was much bigger for the bottom 10% the worst deprived Desa than it was for the least deprived. And outside London, life expectancy was declining. So these three pictures slow down improvement in health increase in in inequalities, and health for the worst of getting worse. And that picture, particularly of the slowdown, people ask, well, life expectancy has got to slow down sometime. We can't go on forever. Yeah, true. So we looked at other rich countries. And the slow down, the rate of improvement in life expectancy was the slowest in the UK than in any other rich country except Iceland and the United States. So no, we hadn't reached peak life expectancy. We were in a bad place in terms of health and in a worse place than most other rich countries.


Vivienne Parry  04:40

And what were the principal reasons for that? Well,


Michael Marmot  04:43

the obvious thing we had to ask was if the slowdown began in 2010 11, what happened in 2010? There was a new government, a conservative led coalition government. They were a bit sensitive. Surely you wouldn't be alleging there was anything we did that could be responsible for this, could you? Well, we were cautious. We didn't want to jump to conclusions. But it was inescapable that the rolling back of the state austerity, which was done in a most regressive way, had to be playing a role. And the government was quite successful in rolling back the state in 2010 42% of GDP went in public expenditure. And by 2019, that 42% had gone down to 35%. And the reduction in public spending, as I said, had been done in a most regressive way. If we look, for example, at spending by local government, and classify areas by quintiles by 20%, of deprivation, in the least deprived 20%, local government spending went down by 16% per person. And then the more deprived the area, the bigger the reduction. So in the most deprived 20%. Local government spending went down by 32% per person. Now, the more deprived the area, the greater the need, the greater the need, the greater the reduction. This was we called for expenditure effort proportionate to need, this was effort inversely proportionate to need, the greater the need, the greater the reduction in spending. So it was done in the most regressive way. And then, of course, changes to the tax and benefit system introduced in the middle of the decade. If you analyse that by deciles of income, if you take families with children, those in the bottom 10% of income, as a result of the Chancellor's changes to the tax and benefit system would get a 14% reduction in income, the second poorest decile, something like a 12% reduction. And then the richer the family with children, the smaller the reduction, I showed that to a former government minister, and said your government's policy was to make poor people poorer. And he said, Well, maybe it wasn't our explicit policy. Well, they're pretty smart people in the Treasury, they must have told the chancellor, this was the predictable effect of his policies, and he did it. So whether it was explicit or implicit, the fact is, your policies made poor people poorer. And the reduction in public spending was greater in areas of greater need, it would be hard to argue that that was irrelevant to the growth of health inequalities and the slowdown in health improvement that we saw.


Vivienne Parry  08:03

So then we have and you've laid it out beautifully, a situation in which we have a very vulnerable population made even more vulnerable, by austerity or changes in benefits. And then we have COVID. So from your COVID review, tell us what happened next, because the one thing that we can say for certain even those of us who do not have your, you know, expertise in epidemiology, and your academic background, what we can all say and all see is that COVID has shown an extraordinary spotlight on inequalities,


Michael Marmot  08:44

very much from the beginning of the pandemic, I said that pandemics, expose the underlying inequalities in society and amplify them. You have to go back to 1630, in northern Italy, to see an example where a pandemic reduced inequalities because it killed so many people. But that was a temporary interruption of the growth of inequality in Italy, so that the pandemic would expose the underlying inequalities in society and amplify them. And initially, when the Prince of Wales got infected, when the Prime Minister got infected with the actor Tom Hanks was infected. People said, this is the great leveller nonsense. People coming back from skiing holidays might have been getting infected. But once it took hold, we saw a social gradient in mortality from COVID-19. That was almost exactly parallel to the social gradient in mortality from all causes. In other words, the more deprived the area, the higher the mortality from all causes, and the highest mortality from COVID-19. The excess in the bottom two or three deciles. For COVID-19. Over and above the old cause the relative excess, we think is related to employment in frontline occupations and living in overcrowded, possibly multi generational households, which would promote transmission of the virus and exposure. So the first thing we saw was the inequalities that look very similar to the inequalities in health more generally, that we've been watching. The second thing we saw was a big excess in different black, Asian and minority ethnic groups, which we had referred to in my 10 years on report, but was not so dramatic, as we saw with COVID-19. Most of that can be attributed to where people live, which is linked to deprivation, and to other socio economic measures, most of it, some not in black, African, black Caribbean, but in Bangladeshi and Pakistani groups could also be linked to prior ill health, diabetes, obesity, cardiovascular pulmonary disease, but most of it was the excess in black Asian and minority ethnic groups could be attributed to deprivation and geography. The third thing we saw was that the excess mortality from at the time of COVID-19. So in other words, is not just COVID-19. I'm sure you've covered this before. But looking at the deaths that would have been predicted to have occurred in 2020, based on the rates in the previous five years, and then how many more occurred, so the excess mortality, and that turns out to be a better measure for comparing what's happened in different countries. And the excess mortality in the UK was higher than in any other European country was higher in England and in Scotland, and Wales and Northern Ireland, and the UK was higher than in any other European country. And we look with alarm at the neglect of COVID-19 in the united states that the gross mismanagement, the total neglect by the President of the United States, the excess mortality in the UK was higher than in the US. So then I asked myself, what's the link between what we saw and reported in February 2020? And what happened with COVID-19? And I think of the link in four ways. In other words, why did we have such a poor health position over the last decade? And why did we manage the pandemic so catastrophic, Lee badly, and I think of four potential links. The first is the quality of governance and political culture. And by political culture, I include giving money to the private sector for tests, trace, and isolate as part of an ideology against the public sector. Why would you not put testing and tracing in the hands of local public health? Why would you give it to some corporation with no expertise in this at all, other than either ideology, or rather sordid corruption? So the quality of governance and political culture, second, is the inequalities. And we've seen that with COVID-19, that dramatic inequalities in mortality that look very similar to the inequalities of mortality more generally. Third, is the disinvestment in the public sector and public services that local public health had about 800 million pounds removed from its budget from 2012. On Public Health England had its budget reduced by about 40% from 2012. And then got blamed because they weren't doing things properly. I've already talked about the regressive nature of the reduction in spending by local government. So we were in a parlous state. And nevermind how poorly paid workers were in care homes. And they were part of the gig economy. We were in a very powerless state, and the force link between where we were February 2020, and where we are now was the fact we weren't very healthy. And that also puts us at high risk. So I think why We've got is a diagnosis of what went badly wrong from 2010 on was exaggerated the pipe the pandemic. And that's why I called my December report, the one published last month. Build back fairer, it's a time to think not, how do we reestablish the status quo ante? How do we get back to where we were, before the pandemic? Because where we were was not a good place? How do we build back fairer? How do we use this to create a fairer society.


Vivienne Parry  15:36

So we have a situation where we have people in low income and in areas of deprivation, not only more likely to get infected, because of the kind of jobs that they do or where they live, or places you could say, or their underlying health problems. But then you also have something built on top of that was, which was actually the measures to contain the virus, which also impacted on people who were in socio economic circumstances that were difficult, in a much, much more impactful way than on people if you had, you know, better circumstances.


Michael Marmot  16:13

Yeah, I mean, just just simple correlation. If you look by income group, at the proportion of people who were in industries that were closed down shattered industries, the lower the income, the greater the likelihood that you were employed in a shattered industry. So you've got closed down, with the furlough scheme, replacing up to 80% of your income. If you were low income, and you're now getting 80% of your income, that's better than nothing. But it's not great. If you were close to the poverty line, we know that most people below the poverty line, a majority, not most a majority, more than 50% of people in poverty were in work, so that people weren't in poverty, because they had no work. More than half the people below the poverty line were in work. So work was badly paid. And if you're now getting 80% of that, you're even more likely to be in poverty, or the industry got closed down and you didn't get adequate compensation. For whatever reason, you were part of the gig economy, you weren't considered an employee. And then the other side is well, okay, you did go out to work because you were a frontline worker, and you were at high risk of COVID-19. So we could see both things happening, the effect of the societal response was to exaggerate inequalities to make poor people poorer. And then the other side is, if you didn't have your work taken away from you, you're at high risk of getting infection.


Vivienne Parry  17:58

And then if you did have to self


Michael Marmot  18:00

isolate, you find yourself perhaps without income at all. And so it's hardly surprising that people, perhaps one self isolating because they simply couldn't afford to do that. Well, Andy Burnham stood tall, as mayor of Greater Manchester. And his criticism of the government was not so much. We're against lockdown. But we're against lockdown and throwing people into extreme poverty, if you want them to do the right thing, make it economically possible for them to do the right thing. He was very concerned about the inequalities in Manchester, deep, deep poverty in pockets of Greater Manchester. And he was concerned that the response would make that worse, if you don't make it feasible economically for people to self isolate. It's hardly surprising that they're not terribly enthusiastic about doing it.


Vivienne Parry  19:05

So a big part of your report on COVID was making specific recommendations to government. Can you talk us through some of the main ones and how you expect them to be met? Well, we


Michael Marmot  19:17

picked up on what we'd said in February 2020, which in turn picked up on what we'd said in 2010. And let me just say, again, that I think the overarching recommendations a deal to deal with these four causes that I identified that link out poor health situation, pre COVID with our poor management of the pandemic, and that is the quality of governance, the level of inequalities, the disinvestment in public services, and the state of health of the population. So putting equity of health and well being At the heart of all policies to build back has to be key that requires good governance, it requires a change of focus that that change, the focus shouldn't just be how do we get the gross domestic product back to where it was, and growing at a healthy rate again, but how do we get greater equity of health and well being. And then we have specific recommendations, and they were in five domains. The first is early child development. We documented back in February that people know, they've been raised in child poverty, the number of children in poverty, the prime minister said in Parliament that the number of children poverty had gone down. That was a lie. He was called on that line, and he doubled down on it the following week. I thought if you've misled parliament, you suppose to fess up. Anyway, we documented the rise in child poverty, it is true that if you say how does poverty now compare, taking 2010 as a standard, but that's ridiculous. You could say, well, absolute poverty had gone down. But the definition, international organisations use is less than 60%, median income, and child poverty went up, that's got to be a priority. We said that instead of having child poverty at around 20 to 23%, it should be 10 or 11%, what it is in the Nordic countries and South Korea. And then the other part of early childhood is 1000. Sure, start children's centres closed, reinvesting in supporting families in the early childhood phase with the good that children's centres can do. Second, is education. And, of course, that's all over the front pages at the moment. We had already said back in February, that the inequalities in education had to be addressed as a matter of urgency, that the lower you are in the social hierarchy, the more deprived the less good the performance in standard test GCSEs or a levels, and that the level of inequality in educational outcome needed to be addressed and could be addressed. Then, of course, with lockdown and the closure of the schools, there's good evidence we documented this, that poorer children are falling further behind. So that lockdown, as we said more generally will amplify the inequalities. The third is employment and working conditions. One of the things that we drew attention to in 2020 February, the good news was that unemployment had gone down over the decade. Good. That's very welcome. But the gig economy had gone up. More people were on zero hours contracts on insecure employment. And the quality of work is vital. I mean, one of the things the pandemic should have revealed to us is how valuable people are who hitherto we'd neglected care workers. We know that health care workers were now what a vital role they play. I think we've always recognised that we just didn't pay nurses properly. But we've always recognised health care workers, but workers in social care and care homes, delivery drivers to people who collect the rubbish, the supermarket checkout stands as staffed by heroes and heroines, they they keep our society running, and we don't value them. And I don't just mean we don't value them with money. That's true, we don't. But we don't value the crucial role they play in making society function. So employment, and I also speculated about the four day week. And there's evidence from particularly from New Zealand, that you could work fewer hours without loss of productivity. And so trying to rebalance work and leisure. So employment is the third area. The force which I prefer to is having enough money to live On minimum income for healthy living, it should be an aim of society to eliminate child poverty to the extent possible. Now, it's a relative measure, that's impossible to eliminate. But as I said, to get the level of child poverty down to 10, or 11%, as it is in the Nordic countries, and that everyone who works should get a living wage. And people who can't work should have a benefit system that's sufficiently generous, to enable them to lead a healthy life. And the fifth is healthy and sustainable communities, housing is a huge issue, the rise in homelessness, the rise in the numbers of rough sleepers are the very visible end of the housing crisis. But also, we documented the increase in the proportion of people who have to pay a mortgage, more than a third of their income on housing. And of course, the lower your income, the more likely that is to be the case. So housing communities, and one of the lessons we should have learned from lockdown is how wonderful it is to have fewer cars on the street. So development of communities and housing. So we made very tangible recommendations on all of those five, the one that we left out from my 2010 review, was what you might call lifestyle prevention. It's the one that government tends to focus on smoking, diet and the like, terribly important. But we pointed out, take diet, for people in the bottom 10% of household income, were they to follow the government's healthy eating advice, they would spend 74% of their income on food. So the reason they don't eat healthily is not because they haven't been listening to the five a day message or whatever. It's because they're poor, and they simply can't afford it.


Vivienne Parry  27:15

There are so many things. What I would normally do in this programme is I asked each person what one thing that they would do with my magic wand, that would really make a difference. And you know, there are many, many things that's contained in that list of yours, that list of five things. But what one thing do you think would really start to unlock this,


Michael Marmot  27:42

I would put equity of health and well being at the heart of all government policy, that would be the major national commitment of government, of civil society, government, national, local, the voluntary sector, that should be the major national commitment, we want equity of health and well being at the heart of government policy.


Vivienne Parry  28:08

And it is interesting that Joe Biden has done exactly that. He has appointed a woman called Marcella Nunez Smith, who was chair of the COVID-19 equity task force to be specifically charged with health inequalities


Michael Marmot  28:24

and improving them and jacinda ardern Prime Minister of New Zealand before COVID, her Treasury in 2019 had a well being economy at the heart of what the Treasury, the Ministry of Finance, wanting to achieve a well being approach based on a capability to lead a life of dignity. So what do I want, if I'm only allowed one thing, I want that national commitment to equity of health and well being at the heart at the centre of what we're trying to achieve? And then those five domains that I've elaborated are ways to achieve it.


Vivienne Parry  29:08

So Michael Marmot, thank you so much for talking to us. It's always an enormous pleasure. And what you say is so insightful, so thoughtful, and actually rather shaming I have come more and more during this lockdown in this period of COVID. To see society developing into the two halves, you know, those who can afford to work from home have space, and those who find themselves in jobs, but poverty, who are serving those people who who can afford to do better thing is just simply not right. So you've been listening to Coronavirus: The Whole Story. This episode was presented by myself Vivienne Parry, produced by UCL with support from the UCL Health of the Public and UCL Grand Challenges and edited by splendid Cerys Bradley. I was joined today by the peerless Professor Michael Marmot. If you'd like to hear more of these podcasts from UCL Minds, subscribe wherever you download your podcasts, or visit ucl.ac.uk forward slash Coronavirus. This podcast is brought to you by UCL Minds bringing together UCL knowledge, insights and expertise through events, digital content and activities open to everyone. Hope to be with you again soon. Bye for now.