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