key: cord-0904508-bts1h5sv
authors: Marmot, Michael
title: Society and the slow burn of inequality
date: 2020-04-30
journal: Lancet
DOI: 10.1016/s0140-6736(20)30940-5
sha: 19d7673c8662931dcfada443d9aaf523edaa16b5
doc_id: 904508
cord_uid: bts1h5sv

nan

On June 14, 2017, Grenfell Tower, a high-rise housing block in the Royal London Borough of Kensington and Chelsea, UK, went up in flames. 72 people died, among the poorest and most marginalised in society. A dramatic conflagration such as this could teach us two kinds of lessons, if we were but open to receiving them. This event exposed underlying problems in society and it showed us that we have to do things differently. In the case of Grenfell, the underlying societal problem was deep-seated and enduring social inequalities and resultant health inequalities. The mean salary in that London borough in 2017 was £123 000, whereas the median of the salaries in the area was £32 700, which points to a huge contrast between high and low earners. In Golborne Ward, adjacent to Grenfell Tower, life expectancy for men was 22 years shorter than that in the richest part of the borough, near the luxury department store, Harrods. The slow burn of injustice, and avoidable health inequalities, is less dramatic than the conflagrationpoor people dying in a fire-but no less profound, and more enduring. As to what can be done differently, the Grenfell Tower Inquiry is examining that question, but it does seem that, to save money, building standards were tolerated that should not have been and, indeed, might not have been in buildings designed for richer inhabitants.

In a similar way, epidemics expose something funda mental about a society and, if we have the capacity to learn, teach us that things can be done differently. The USA has become one of the countries worst hit by coronavirus disease 2019 , both in cases and deaths. Apart from the mendacity, incompetence, narcissism, and disdain for expertise of the man at the top, there may be strong messages about the nature of US society and the response to the pandemic. Anne Case and Angus Deaton's book Deaths of Despair and the Future of Capitalism drew attention to US exceptionalism in the form of an epidemic of deaths from drugs, alcohol, and suicide, linked to the failures of capitalism, US style. Paul Krugman, Nobel Prize-winning economist and New York Times columnist, suggests a link between this annual toll of excess deaths and deaths from the COVID-19 pandemic that should have been avoided. He writes: "when we conduct a post-mortem on this pandemic-a stock phrase that, in this case, isn't a metaphor-we'll probably find that the same hostility to government that routinely undermines efforts to help Americans in need played a crucial role in slowing an effective response to the current crisis."

In the UK, when the Prince of Wales and the Prime Minister became infected, along with tens of thousands of lesser mortals, it sparked comments along the lines of COVID-19 as "the great equaliser". Of course, once lockdown went into place, it exposed the fault lines in society: those who could work from home and those who could not; those who could retreat to holiday homes and those in crowded flats; those with income reserves and those who could not afford to buy food; those in a position to offer home education to their children and those not so fortunate or well equipped. Elsewhere, in India, for example, the lockdown has been devastating to those in the informal economy. Migrant workers find themselves homeless, or far away from their home villages; access to food, medicines, and health care has become problematic for some vulnerable populations. In effect, the lockdown has partly shifted epidemic risk to the underprivileged.

It is too early to say precisely what lessons can be learned, but two already stand out. First, respect for expertise. It might have been a politician's sound bite, having had too much of experts, but it is clear that response to a pandemic needs the best minds and the best science available. So, too, do social and economic policies if they are not to make health inequalities worse. The second message is also clear, and it is this that I want to explore further here: the crucial role of government. Ronald Reagan's famous phrase, "the most terrifying nine words in the English language are: I'm from the government and I'm here to help", is not being much quoted at the moment even by small-state ideologues. In the USA, the stuttering response to the pandemic was predicted, eerily, by Michael Lewis in The Fifth Risk. Lewis documents the way that the Trump administration hollowed out the federal government, leaving senior positions in key departments vacant and appointing cronies or ignorant ideologues to head those same departments. Yet, when needs must, the US Government did agree to a huge spending package to ease the economic pain of the COVID-19 shutdown.

In the UK, the Conservative Government described its own spending plans as "whatever it takes", closed down the The art of medicine Society and the slow burn of inequality Jeff J Mitchell/Getty Images www.thelancet.com Vol 395 May 2, 2020 country, in essence socialised the economy, and all but instituted government-funded universal basic income. The UK Government of 2020, although led by the same political party as the government elected in 2010, has departed dramatically from so-called austerity orthodoxy. In 2010, the UK Government presented austerity to the country almost as a moral endeavour. High government debt and deficits were held to be shockingly irresponsible. "The government has maxed out the nation's credit card" may have been the most economically illiterate statement of the time-one might have hoped that a Prime Minister would know the difference between a household budget and a national budget; when did a household last change rates of indirect taxation, issue government bonds, or have its central bank indulge in quantitative easing-but it wasn't unique.

If faced with a shocking health crisis, the COVID-19 pandemic, the UK Government is prepared to cast such orthodoxy aside, then perhaps austerity, which began in 2010, was not an economic or moral necessity but a political choice, one that failed to take seriously a national crisis of a slower more fundamental and enduring kind: health and health inequalities. The government was prepared to do what it takes to deal with the conflagration of the pandemic but not, a decade ago, with the slow burning injustice of health inequalities.

It is the slow burn and the role of government in doing nothing to put out the fire, even possibly fanning the flames, that was the subject of Health Equity in England: the Marmot Review 10 Years On (Marmot 2020) , produced by my colleagues and me at the UCL Institute of Health Equity and published earlier this year. Marmot 2020 potentially responds to both demands: making clear what are the fault lines in society; and showing how things can be done differently.

The background to our analysis of UK Government policy since 2010 was the slow burning injustice of health inequalities with its effect on the overall health of the population. We highlighted three components. First, the stalling of life expectancy. An increase in life expectancy in England, of about 1 year every 4 years, that had lasted from the end of the 19th century slowed in 2010 and more or less ground to a halt. Years spent in ill-health increased. Second, inequalities in health continued to increase-the social gradient in health became steeper, and regional differences increased. Third, life expectancy for women in the poorest areas of the country outside London declined.

A simple summary of Marmot 2020 is that if health has stopped improving and health inequalities have got worse society has stopped improving and inequalities in society have got worse. So strong is the relation between social determinants and the health of societies that health and health inequalities tell us something fundamental about how well society is meeting the needs of its members. It is highly likely that something dramatic happened in 2010 that led to the health picture that we have seen develop.

There were two distinguishing features of UK Government strategies pursued since 2010: rolling back of the statepublic expenditure went from 42% of gross domestic product (GDP) in 2010 to 35% in 2018-and being sharply regressive-the poorer you were, the more likely you were to be disadvantaged by the changes government made.

Whatever the reason for such clearly regressive policieswhether driven by some economic ideology, or rather grisly political calculations-their effect was to make the poor poorer and to deprive those in need of services. It is highly likely that these policies had an important role in the health picture in England.

The excuse for these policies of austerity in 2010, in the UK as in many other countries, was the 2007-08 global financial crisis. After the conflagration of the COVID-19 pandemic, the world will be facing a bigger, deeper economic and financial crisis. The International Monetary Fund, as of April 14, 2020, predicted that the global economy will decline by 3% in 2020. By contrast, it declined by 0·1% in 2009. On the basis of the evidence set out in Marmot 2020 , it would be little short of a calamity if the UK and other countries reacted either by seeking to re-establish the status quo or, worse, took the crisis as an excuse for re-imposing policies of austerity.

The aim should not be simply to find a way to restore growth of GDP, but to create better societies, characterised by better health and narrower health inequities. The findings of Marmot 2020 show what the building blocks of those better societies should be: reductions of child poverty, and funding of services to improve outcomes for children; proper funding for education; improvement of working conditions; ensuring that everyone has at least the minimum income to lead a healthy life; creating healthy and sustainable environments in which to live and work; and creating the conditions for people to pursue healthy behaviours.

Pursuing these ends will entail recognition of the proper role of the state, the importance of policies other than debt reduction, and responding in an equitable way to the climate crisis. The New Zealand Treasury shows what is possible. Before the COVID-19 pandemic, it put a wellbeing approach-enabling people to have the capabilities they need to lead lives of purpose, balance, and meaning-at the heart of its policies. Such an approach would be a major step to combating the slow-burning injustice of health inequalities. As US politicians say, never waste a good crisis. The public health crisis has become an economic and social crisis. As we emerge from the COVID-19 pandemic, it is important to look forward to the kind of societies that we want.

UCL Institute of Health Equity, UCL Department of Epidemiology and Public Health, London WC1E 7HB, UK m.marmot@ucl.ac.uk @MichaelMarmot

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