Last January 29-31, 2016, I was blessed to attend the Prince Mahidol Award Conference (PMAC) – Thailand’s annual global health event – for the third time, and I felt very elated that this year’s award for public health went to Sir Michael Marmot – a global health icon who of course needs no introduction. This news did not come as a surprise though – I remember, it was December 2014, during a meeting of our committee on social determinants of health and transformative health workforce education at WHO in Geneva, a few of us were pondering about the possibility of the Prince Mahidol Award being given to Professor Marmot. Months later, I met Sir Michael in Kolkata under what looked like a banyan tree (making him appear like a true guru!), and to my surprise he exclaimed: “Thank you for suggesting my nomination!” I’m sure it was an idea of many and not one, but my shock was towards my discovery that he already knows! (Of course he would know, as he was asked by the awards committee to submit many documents.)
Actually, on my way to PMAC, I was reading his latest book, “The Health Gap.” I made sure to bring my hardbound copy to Bangkok, and even dropped by Kinokuniya (a bookstore) to buy two more, so that I have back-up copies should my first copy get drenched in the rain (in tropical Manila of course!). On the first day of PMAC, Sir Michael had a book signing session. Because I was busily interacting with colleagues, I ended up being at the end of the queue. Then, it was the end – the staff are pulling him out as he was expected to meet the Prime Minister that afternoon. To catch his attention, I shouted “Congratulations!” and ran to him. We had a bit of chat but he was already being literally pulled by the Thai guards as if a prisoner. I saw his beaming smile turn into an apologetic grin, as he cannot anymore stay upon orders from the palace. Because he was not able to sign my three copies, I will have to wait – and I told him, I’ll bring them all should I drop by London in the unforeseeable future. Meanwhile, I decided to return the favor – and so I wrote this essay!
Going back to the book, “The Health Gap” is indeed an enthralling read. I am notorious for not finishing my books, but this one couldn’t slip away from my hands. Certainly I am biased – my dedication is partly because of my personal admiration for Sir Michael and his contributions to public health. But in this book, one will see a different kind of Sir Michael, which makes it mesmerizing. I am used to reading his journal articles such as the Whitehall II Study, or the 200-plus page report of the WHO Commission on Social Determinants of Health which he chaired from 2005-2008, or the Marmot Review of health inequalities in England, or his Lancet commentaries, or his book “The Status Syndrome” which could be described as the “laymanized” version of all the other things I just mentioned.
Meanwhile, in “The Health Gap,” it is not only Sir Michael the social epidemiologist who is speaking – I was hearing Sir Michael the philosopher too. For instance, his accounts of his personal journey trying to reconcile his public health evidence with philosophical theories were enlightening as well as inspiring to a young physician like me who learned very little philosophy in the confines of the medical school. Quoting philosophers such as John Rawls and Amartya Sen is surely taboo for the world’s most rigid medical journals, but in his book, Sir Michael was free to converse with these great thinkers, albeit imaginatively, through his musings about health equity and social justice.
In one part, he even suggested that health could be the answer to many of the age-old philosophical debates that still persist today – no one wants to be un-healthy, and health can be viewed as the ultimate manifestation of justice in society. I’m not quite sure though if the technocrats from the World Bank and other international agencies – who, by the way, were also present in PMAC, if not dominating the speakers’ list in the conference sessions – are ready to cut their addiction to Gross Domestic Product and other economic measures of “development” and instead heed the proposal of Sir Michael and use health as the real indicator of progress. (By the way, the book also narrates Sir Michael’s experience being trapped in a room full of economists, witnessing their irrational devotion to “rational choice” and “utility” – but I will not spoil it for your ultimate reading experience!)
A global health rockstar’s autograph. Sir Michael Marmot signing a copy of the report of the WHO Commission on Social Determinants of Health as Renzo looks on, Copenhagen, August 2011.
Nonetheless, Sir Michael acknowledges the importance of improving the economy and all things that comprise “the conditions in which people are born, grow, live, work and age” – in short, the social determinants of health. And he is pretty consistent about this in his book, as the bulk of the chapters delved into specific priority determinants that need to be addressed such as early childhood development, education, employment, and community resilience. He and the Commission that he headed had repeatedly emphasized that it is not just the healthcare system that enhances health and closes the health divide – it was ironic though that this year’s PMAC, where his advocacy for social determinants was recognized, focused on the theme “Priority Setting for Universal Health Coverage,” looking into things such as assessments of health technologies using cost-effectiveness tools and decision-making processes for who gets what in terms of health services.
These are all important, but not sufficient, as action on the social determinants of health is what is truly needed to close the health gap. Sadly, in one panel during the conference, a World Bank representative even said that while he acknowledges the importance of social determinants, they are difficult to measure, and therefore difficult to fund. He even admitted that the myriad departments of the World Bank, which I believe is the world body that covers the greatest number of social determinants, find it difficult to even talk to each other. I felt sad upon hearing this, my idealism and longing for a “World Bank” of ideas and solutions to social determinants being temporarily crushed.
But it seems there is hope. Nearing towards the end of the book, I got personally moved when Sir Michael wrote about the World Conference on Social Determinants of Health held in Rio de Janeiro in 2011. He was particularly proud about that conference, which was in a way a gift to him by the Brazilian government and other Member States and a concrete expression of their commitment to addressing the social determinants of health. However, the Rio Political Declaration that came out of the conference lacked the ambition of his Commission’s report, and here Sir Michael talked about the statement that was distributed to the conference delegates at the closing plenary by the International Federation of Medical Students’ Associations (IFMSA), “[pointing] out [that] inequities in power, money, and resources were airbrushed from the Rio Declaration – too strong for ministerial stomachs.”
This portion gave me goosebumps, because, as the head of the 10-member medical student delegation of IFMSA – the only 10 young people in a sea of a thousand ministers, public health experts, and advocates – I was blessed to have been given the opportunity to lead the drafting of what Sir Michael once called the “alternative Rio declaration.” By putting it in his book, he made that simple gesture historic. And he did not just do it once – he also wrote about our statement in his chapter in the second edition of “Social Epidemiology” by Berkman, Kawachi, and Glymour – the official textbook of the discipline. I never imagined that such a statement coming from the youth would make a huge impact on him.
I now look back at 2011, the first time I met Sir Michael in person – it was in Denmark, during the 60th anniversary conference of IFMSA. My task was to moderate the session in which he was our keynote speaker, but the energy in the room, the passion of the medical student audience, and the inspiration of Sir Michael were just so difficult to moderate that the session extended for 3 hours! Certainly, that was bad moderation, but the impact that session made on IFMSA and the world’s medical students is certainly not bad at all! Sir Michael would repeat to me during several encounters that followed that one Minister of Health even approached him during a WHO conference, saying that he learned about him through his daughter who listened to his inspiring lecture on that cold morning in Copenhagen. That IFMSA event turned Sir Michael the epidemiologist and philosopher into a global health rockstar! (And these blogs by medical students who attended that conference are enough proof – here and here!)
And of course, among the world’s medical students, there was me, whose career as a doctor and whose views on health and society were helped shaped by Sir Michael and his scholarship. Our several encounters between IFMSA and PMAC, our various indirect engagements (through the Lancet-University of Oslo Commission and the WHO committee on transformative education), and his writings such as “The Health Gap” were all transformational. Amused by my eclectic concern for all things public health, someone asked me recently, “Why don’t you stick to working on social determinants of health? Why do you still dip your feet into a variety of issues, from universal health coverage to migrant health to climate change?” My response was simple: “Aren’t these the arenas where the social determinants of health operate?”
The social determinants of health approach, further advanced by the works of Sir Michael and many other public health thinkers who went before and who followed him, reminds us all that the challenge of the 21st century is health inequity, the solution to this challenge cannot be siloed into disciplines anymore, and the vision for global health should that be of social justice. But as I implied, this is not a brand new idea – Hippocrates and Virchow have articulated it, Alma Ata put it on paper, and now, scientist-philosophers such as Sir Michael Marmot are telling us through a combination of rigorous evidence and deep philosophy the concrete ways for turning these visions into reality. Maybe soon we will be witnessing a great revival of these ideas and values, now that Sir Michael is the leader of the world’s doctors as the new president of the World Medical Association. Hopefully, this is the time to reorient the global health community to look to health equity and its social determinants and to listen to the gospel of Sir Michael. Just like his Prince Mahidol Award, which I think is long overdue though, change is never too late.
A 2014 Emerging Voice for Global Health, Renzo Guinto, MD is the campaigner for the Healthy Energy Initiative of Health Care Without Harm (HCWH)-Asia, director of #Reimagine Global Health, and co-investigator at the Universal Health Care Study Group at the University of the Philippines Manila. Recently named 2016 Aspen New Voices Fellow by the Aspen Institute, he played a leadership role in institutionalizing the social determinants of health approach in the International Federation of Medical Students’ Associations as the founding coordinator of the IFMSA Global Health Equity Initiative and later Liaison Officer to the WHO back in his student days.