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Governments must not return to business as usual after Covid, says Sir Michael Marmot

HPF caught up with leading global advocate for action on the social determinants of health and health inequalities, Sir Michael Marmot recently to get his views on issues including lessons learned from Covid-19, how it has amplified underlying health inequalities and the need for governments to follow NZ’s lead and put a wellbeing approach at the heart of policy.

The Professor of Epidemiology and Public Health at University College London and the Director of The UCL Institute of Health Equity (pictured speaking at the world health promotion conference in Rotorua last year) also touches on the climate crisis and the role of health promoters in helping to tackle these global challenges.


HAUORA: What are some of the lessons we have learned from Covid-19?

SIR MICHAEL: Two keys lessons from the UK, that I think are more widely applicable, came with the onset of the pandemic. First, was respect for science and evidence. In the UK there had been overt disregard for the opinions of experts. For example, the assessments from economists that Brexit would harm the economy – probably making inequality worse – were dismissed as fear-mongering. In the US, the dismissal of science was worse, imperilling the planet, when the US President labelled climate change “a hoax”. Come the pandemic, suddenly our politicians were openly expressing their appreciation for the science in countries across Europe but, catastrophically, not in the US or Brazil.

A second lesson relates to public expenditure. After the financial crisis of 2007/8 many governments adopted austerity as their creed. With the economic shock that followed lockdown, suddenly austerity and concern about government debt was put on hold. “Whatever it takes”, said the British Prime Minister. Countries at high levels of human development spent a great deal, and increased national debt, to reduce the economic burden of the pandemic and societal response to it.

I would like to think there is third lesson: the importance of government in delivering the public good. That lesson has only partly been learned.


HAUORA: When the pandemic first hit, many commented that it had been the “great leveller” or “equaliser” but you have pointed out that it has actually exposed “underlying health inequalities” and amplified them. Can you please elaborate on this?

SIR MICHAEL: There are two aspects to these inequalities, at least: the toll that Covid-19 is taking on the population health; and the effect of the societal response, lockdown, on inequalities. In the UK, our Office of National Statistics (ONS) has been impressive in the regular and timely output of publications on the pandemic. Related to my theme, there are three observations that both reveal and amplify the underlying inequalities in society. First, is the high mortality from Covid-19 in those in front-line occupations: workers in social care, drivers, shop assistants, and chefs. These occupations were already at the lower end of the social hierarchy, and lowly paid.

Second, mortality rates from Covid-19 follow the social gradient: the more deprived the area the greater the mortality rate. This Covid-19 gradient looks very similar to the gradient from all causes. This suggests that the causes of inequalities in health more generally are likely to be the causes of inequalities in Covid-19 mortality.

Third, there is high mortality among Black, Asian and Minority Ethnic Groups. Much of this excess can be accounted for statistically by deprivation. We can no longer ignore structural racism that gives rise to the systematic disadvantage of some ethnic groups, not just in Britain, but more generally.

Lockdown itself has exaggerated inequalities. People in higher status occupations were far more likely than those in lower status to be able to work from home. Higher income people could spend less on entertainments and dining out, thus increasing their income and savings. It was precisely these occupations where workers lost their jobs or were exposed to the virus. We have seen exaggerations of food poverty during the pandemic.


HAUORA: You have said you would like to see a ‘wellbeing economy’ emerge from this crisis and in fact it was just last year at the global health promotion conference in Rotorua, NZ that you commended the ‘wellbeing approach’ taken by NZ. Recently you were quoted as saying: “The New Zealand Treasury shows what is possible. Before the COVID-19 pandemic, it put a wellbeing approach… at the heart of its policies.” Would you like to see governments following a similar direction post-Covid?

SIR MICHAEL: In Britain, my colleagues and I published a report, Health Equity in England: the Marmot Review 10 Years On, on the eve of lockdown, February 2020. I had published the Marmot Review in 2010 on what we could do to address health inequalities, in the light of the Commission on Social Determinants of Health. My 10 Years On Review, Marmot 2020, presented a grim picture: marked slowing of the improvement of life expectancy; increased health inequalities; and falling life expectancy for women in the most deprived areas outside London. Therefore, as we emerge from the pandemic, the status quo ante is hardly something we want to reproduce. Ideally, we need to use this dramatic shock to create a better society, to deliver sustainable health equity. And, to do that, we need to put wellbeing at the heart of what we are seeking to achieve.


HAUORA: The NZ Government, and our PM, have been lauded world-wide for their handling of the Covid crisis. What is your view?

SIR MICHAEL: From the outside, it appeared that Prime Minister Ardern displayed several characteristics that were key to controlling the pandemic: she was decisive in initiating control measures in quick and timely fashion; she was clear in her communication about the threat faced and what was needed from the population to combat the threat; her actions were evidenced-based; she was empathetic. Honesty, clarity, decisiveness, consistency and human warmth were not characteristics that were in abundant display elsewhere.


HAUORA: While Covid-19 has been the overriding issue for the world over the past few months, the call to fight climate change is ramping up again – particularly as experts have linked Covid-19 to planetary health. What is your advice to countries/governments on how to tackle this? Do you feel that indigenous knowledge needs to play a more major role?

SIR MICHAEL: Sustainable health equity has to be the watchword as the global community recovers from the biological, social and economic shocks attendant on the pandemic. The twin challenges of dramatic inequalities and the climate crisis have to be tackled together.


HAUORA: How can health promotion contribute more effectively towards addressing these global challenges?

SIR MICHAEL: I see health promotion as tackling the social determinants of health. Health, and health inequalities are good measures of how we are doing as societies. Therefore, those of us committed to improving health and reducing health inequalities need to be active participants in what constitutes the good society.