In June 2010 the British Medical Association (BMA), which describes itself as an “independent trade union and professional association for doctors and medical students,” appointed a new president: Professor Sir Michael Marmot, a public health physician who grew up and did his initial studies in Australia.

According to Croakey (the Health Blog attached to Crikey), in his acceptance speech Professor Marmot said that he had been relieved to realise that the BMA president is not responsible for the “trade union side of the house”—i.e. advocating for doctors’ incomes and working conditions. Instead, Marmot sees his job as pushing for action on health inequalities, both in Britain and globally.

“My year as president will have real meaning if I can help encourage other doctors to be active in the challenge to reduce avoidable inequalities in health, not just here within Britain, but globally between countries,” he said.

In Australia, we’re familiar with the idea of health inequality primarily via the drive to “close the gap” between the mortality rates and health outcomes of Indigenous Australians and non-Indigenous Australians. However, in the UK the debate about health inequalities is more wide ranging, largely due to the work of Professor Marmot.  

Throughout the course of his long career, Professor Marmot has been behind some very interesting research into the cultural, social and economic factors that influence health. An early example of this is a 1976 study comparing the rates of chronic heart disease amongst men of Japanese ancestry who lived in three different locations: Japan, Hawaii and California.

The study found that rates of chronic heart disease were lowest in Japan, intermediate in Hawaii and highest in California. Intriguingly, the researchers found that the differences were “not completely explained by differences in dietary intake, serum cholesterol, blood pressure or smoking”. Moreover, Japanese-Americans who lived traditional Japanese lifestyles had levels of chronic heart disease as low as those observed in Japan, while the group that was most Westernised had a three to five times more chronic heart disease.

With these kinds of findings under his belt, it makes sense that Professor Marmot has gone on to declare that the “unnecessary disease and suffering of disadvantaged people, whether in poor countries or rich, is a result of the way we organise our affairs in society.”

For Professor Marmot, the circumstances in which people live and work are of fundamental importance to their health. This idea has come to be known as the ‘social determinants’ of health.

The World Health Organisation (WHO) defines the social determinants of health as “the conditions in which people are born, grow, live, work and age, including the health system.” (Professor Marmot led the World Health Organisation's (WHO) review of the social determinants of health.)

“Our children,” WHO says, “have dramatically different life chances depending on where they were born. In Japan or Sweden they can expect to live more than 80 years; in Brazil, 72 years; India, 63 years; and in one of several African countries, fewer than 50 years. And within countries, the differences in life chances are dramatic and are seen worldwide. The poorest of the poor have high levels of illness and premature mortality. But poor health is not confined to those worst off. In countries at all levels of income, health and illness follow a social gradient: the lower the socioeconomic position, the worse the health.”

Work is widely recognised to be a social determinant of health. If you are working, there is a structure to the day and you are receiving an income, so your socio-economic status is higher as a consequence. There is some level of activity within the day, you are likely to smoke and drink less on average, and you are more likely to engage in regular social interactions.

Rosemary Mackenzie, of the Workers Information Resource Centre in South Australia, sent RTWMatters a sobering slice of information about the number of claimants in South Australia who have suicided each year over the last five years. This led to some discussion in the office about the link between being out of work and suicide rates, and whether the compensation system itself intensifies the mental health strains associated with unemployment and long term work absence.

The WHO report into the social determinants of health notes that traditionally, society has looked to the health sector to deal with concerns about health. However the report calls for all policymakers and programs to do what they can do to positively influence health outcomes. Health departments, they say, can champion a social determinants approach to health, and should support other policymakers in creating policies that promote health equity.

Perhaps compensation in and of itself should be explored as a social determinant of health. And if it was, how might this influence policy and practice?