Written by Helen Stedeford (UCL Life & Medical Sciences)

Public health expert Sir Michael Marmot introduced his book The Health Gap by sharing the story of Mary, a First Nations Canadian who hanged herself aged 14. Every case is tragically unique, however the suicide rate among young First Nations members is five times higher than for other young Canadians – why? The suicide rate for Indian cotton farmers is much higher than for Indians in other rural occupations – why? Poverty – at least that’s part of the answer.

Using case studies and population statistics, Marmot illustrated the social gradient in health, which is found in all societies; those at the top of the income ladder have low levels of disease and long lives, and with each step down the ladder the chance of physical and mental illness, and early death, increases. So began a fascinating evening of discussion between Marmot, The Lancet’s Tamara Lucas and audience members.

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Far from ‘closing the gap’ in life expectancy, health inequalities in Europe have deepened further. Drawing upon his forthcoming review of health inequalities in Europe, Michael Marmotargued that social inequalities, with their impact on life expectancy, should be at the top of the public agenda and we should place fairness at the heart of decision-making for health.

Integral to Marmot’s work is the graded relationship between social deprivation and a multitude of health outcomes. He reports that male life expectancy in the Russian Federation is 20 years less than in Iceland, but also highlights “huge differences within countries” and that “the gradient is increasing”.

Alcohol use: a cause or consequence of inequality?
What is driving the social gradient in health? Panel member Christopher Gerry stressed that “Alcohol matters”, and quoting Richard Peto said: “More than half of all deaths of people of working age in Russia are caused by alcohol.” But importantly, Gerry identified alcohol as just the proximate cause: “What makes people drink in the way that they do is the real question.”

Marmot was quick to distinguish between immediate causes and the underlying psychosocial mechanisms that drive unhealthy behaviours. In the case of Russia: “Some people are utterly convinced that alcohol plays a role, the main role” in health inequalities. But he disagreed, while acknowledging its role in violent deaths.

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