The Health Gap: The Challenge of an Unequal World by Michael Marmot
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Bloomsbury Publishing PLC
Jeete Raho' - 'May You Keep Living' - is a blessing given by Punjabi elders. Wishing one another a long life with good health is a common salutation in many cultures. An ultimate goal of economic progress is to enable people to lead longer and healthier lives. Michael Marmot explains in his book, The Health Gap: The Challenge of an Unequal World, the conditions in which people can expect to lead longer and healthier lives. Marmot has spent a lifetime researching these conditions. He presents his evidence compellingly, with a mixture of statistical evidence from many credible sources and human stories from around the world that ground abstractions in reality.
The US spends as much as 17 per cent of its GDP, more than any other country does, on healthcare. Yet, young adults in the US have lesser chance of surviving to sixty than young adults in Costa Rica, Cuba or Slovenia (let alone in Japan and most European countries). 'Lives lost before fifty' is a measure of how many people in a country die before they reach the age of fifty - a measure of overall health conditions in a country. It would surprise many that the US and UK fare worse than Italy and Portugal which are considered economically sick countries!
There is no direct co-relation between economic growth and improvement of citizens' health. Many factors are at work and Marmot explains these lucidly. Spending a larger portion of GDP on healthcare, which is a popular demand in India, is not the solution. If it were, the US, which spends the most, should have the healthiest people, which it does not. 'Healthcare' is being confused with 'medical treatment' of people.
For example, life expectancy of males in the Calton area of Glasgow is fifty four; whereas in Lenzie, a few kilometres away, it is eighty two! Poverty is not an adequate explanation for people in Calton having lower life expectancy than even people in Nepal. Calton's residents are neither deprived of basic necessities of food and shelter, nor of public goods of sanitation and clean water. The cause of their low life expectancies is deeper. Marmot shows, with case studies from many countries - 'developing' and 'developed' - that the root cause of significantly lower life expectancy is the quality of the social relationships within which people are born and grow. Thus, he gets to the heart of the onion of health. The outer layer is the medical treatment people need more frequently when the inner layer of public health is sick. Deeper within the onion is the root cause of poor public health. These are the quality of relationships of the communities in which people live, and the values that guide economic policies. Marmot calls these the 'social determinants' of health.
'Family values' are often touted by people on both sides of the political spectrum as very important for creating good societies and strong nations. 'Caring' for others in the family, and 'fairness' amongst family members are core 'family' values. Yet, when these same values, of caring and fairness, are sought to be extended into economic policy, the two sides become politically divided. Those promoting such values are decried as 'socialists': which seems to have become a bad word in economics. Marmot explains what must be done to improve health; but even he is at pains to say that he is not promoting socialism, but a better capitalism!
India's economy is growing fast. Worryingly, the health of its citizens is not improving as fast as in most other countries. Faster GDP growth is not an end in itself; it is valuable when it produces practical outcomes for citizens.
The most valuable outcome is a long, disability-free life, which every child born in India should be able to look forward to, but sadly does not. India needs to rethink its approach to the improvement of health of its citizens along with economic growth. It must go beyond the war of the economic 'isms' to the practical heart of the matter. Michael Marmot's book is well worth reading.
(The reviewer is a management consultant and former member of Planning Commission of India.)