Social justice and health equity
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Welcome to the LSE Events Podcast by the London School of Economics and Political Science. Get ready to hear from some of the most influential international figures in the social sciences. So welcome, everyone. My name is Larry Kramer. I am the president. I have to look at the notes, right? I am the president and vice chancellor here at the London School of Economics. And it's my privilege and pleasure to welcome you all to this very, very special event this evening. Tonight's LSE, annual LSE Health Lecture.

This year, LSE Health is celebrating its 30th anniversary, which for anybody who's been in a university knows that's an incredible record for any research center. Over the past three decades, LSE Health has established itself as one of the world's major bridges between health research and policymaking, consistently producing research and scholarship that's taken up

by taking up for health policy decision making at the highest national and international levels. The subject of tonight's lecture is very much in keeping them with the best traditions of the center.

So most of you may know this, the term social gradient in health is a term that's used to describe the persistent, pervasive correlation between health and socioeconomic status. It's a phenomenon that naturally is of great interest to an institution like ours, which is focused on the social sciences. You can observe the social gradient in health both within and across localities and at the local, regional, national, and global levels. So then the question is what can be done about it?

There is, on the one hand, clear evidence that discrete policy interventions can make a difference in addressing gaps in health and health coverage. But on the other hand, it's equally clear that efforts to address those gaps can't be confined to the healthcare system. You also need to address the wide array of conditions in which people are born, grow up, live, work, and age.

So eliminating the health gap then is possible only by understanding and taking a comprehensive, holistic approach to the social determinants of health, which, of course, begin with the person's economic circumstances but certainly don't end there. And, of course, now we have a whole new problem to deal with as we think about addressing these gaps and a whole set of new challenges as funding disappears and programs are being eliminated around the world.

So our speaker tonight may know more about these issues than anyone else alive. We're very fortunate to have him here to explore them with us.

Professor Sir Michael Marmot is professor of epidemiology at UCL, where he is also director of the Institute of Health Equity. He's an esteemed public health expert. He's been leading rigorous longitudinal research on the social gradient of health for decades, and he has wide experience translating that research into evidence that it can be and has been used for public policy.

He's worked with the WHO as advisor to the Director General on the social determinants of health. He served as president of the British Medical Association and then the World Medical Association,

He was a member of the Royal Commission on Environmental Pollution. In 2000, he was knighted for services to public health and in 2023 was appointed a Companion of Honor in the King's New Year's Honors. So all that is actually fairly amazing, but I'm going to tell you actually the best way to put it. I have a friend visiting me right now. He's one of the leading intellectuals in the United States. And when I told him I was coming to do this lecture, he said to me, "Oh, he is the man."

Thank you. Social justice is my theme, but the evidence really matters. The opening line of my book, The Health Gap, my book, was why treat people and send them back to the conditions that made them sick, particularly

At the time of the pandemic, we think a great deal about the health care system, as we should. But my concern is with the conditions that make people sick in the first place, the social determinants of health. I chaired the World Health Organization Commission on Social Determinants of Health. It was a global commission. And then in the wake of that,

We made a virtue of necessity. We said, this is for every country in the world, but how can you make recommendations suitable for every country in the world? We said, particular jurisdictions need to take it up and develop it. Gordon Brown was prime minister.

He invited me to conduct a review to answer the question, how could we apply the findings and recommendations of your global commission to one country, England? And that led to the Marmot Review, Fair Society, Healthy Lives. We then did a European review for WHO.

the Eastern Mediterranean Regional Office, the Americas, we did three regional reviews for WHO. We put on the cover of our WHO report, and EMRO picked it up, social injustice is killing people on a grand scale. Slightly unusual for a WHO report to say that, but that's what we said. One country labelled our report

ideology with evidence. I quite like that. So we do have an ideology. Social injustice is wrong. And if it's killing people, we need to do something about it. But the evidence really matters. And I want to talk about three things this evening. Epidemiologists don't always talk about dignity, freedom and hope. But that's what I want to talk about. Dignity.

Nelson Mandela said overcoming poverty is not a gesture of charity, it's an act of justice.

It's the protection of fundamental human rights, the right to dignity and a decent life. And in fact, in our review in the Americas, we talked very much about the right to a dignified life. We said take the actions necessary

to get equity in the opportunity to lead a dignified life. And you will be taking the actions necessary to achieve greater health equity. So overcoming poverty is not a gesture of charity. In my 2010 review, and then we did health equity in England, the Marmot Review, 10 years on, initially we had six domains of recommendations.

based on the evidence. Give every child the best start in life, education and lifelong learning, employment and working conditions. Number four is in the news every day at the moment. People should have enough money to live on. What a radical idea. Number five...

healthy and sustainable places in which to live and work, including housing. We've done quite a lot on housing recently. Number six, taking a social determinants approach to prevention. In the light of COVID, we added tackle discrimination, racism and their outcomes. We did a big report for London on structural racism, ethnicity and health.

And number eight really should have been there all along. Pursue environmental sustainability and health equity together. Let's look at what's been happening in England, very similar in Wales, Scotland and Northern Ireland. Life expectancy was improving about one year every four years.

I've started this in 1999. I could start it in 1919 and for a hundred years life expectancy had been improving about one year every four years for women and for men. In 2010-11 there was a break in the curve. The rate of improvement slowed dramatically.

just about ground to a halt. And then the first three years of the pandemic, life expectancy fell. That was not an inevitable consequence of the pandemic. It did not fall in many countries. We experienced a 14-year period where life expectancy did not improve at all. I don't know of another 14-year period in peacetime where life expectancy failed to improve in the UK.

then just think the implied promise is that things will get better all the time. And that had been true, but it stopped getting better. And if you accept the proposition, which has influenced all my work, that health tells us something fundamental about the nature of society and how well society is meeting human needs,

then if health stopped improving, it meant society stopped improving. People's needs were no longer being met. And if we look at inequalities, for simplicity I've got the least deprived 10% and the most deprived 10%. If you're in the least deprived 10%, if you're rich, it doesn't much matter where in the country you live.

The regional differences were quite small and life expectancy was improving a bit for the least deprived 10%. For the most deprived, it was going up in London and going down in virtually every region outside London. And the regional differences are much bigger. So if you're, the greater the deprivation, the greater the impact of where you live.

So if you're in the northeast or the northwest, the consequences for your health of a given level of deprivation are bigger. And you can see that the inequalities got bigger and life expectancy for the poorest people got worse. That's what happened pre-pandemic. And then the pandemic amplified all of that.

How was that achieved? That's quite an achievement to interrupt a 100-year trajectory and reverse it. Well, the government worked hard at it. Their number one priority was austerity, cutting back public expenditure. They're quite open about that. In 2009-10, public sector expenditure was 42% of GDP.

Over the decade, it went down year on year. By 2019-20, that 42% had become 35%. Then came the pandemic and the Chancellor said, whatever it takes. We've got an economic crisis, whatever it takes.

By the way, can you remember who the Chancellor was? It's pretty difficult because between the Brexit referendum and 2024 we had seven Chancellors, seven Ministers of Finance. We only had five Prime Ministers. We had seven Secretaries of State for Health, ten Housing Ministers. Ah, the chaos!

utter chaos. But he said, it was Rishi Sirak was the Chancellor, you knew that, whatever it takes. And I thought, faced with a financial crisis,

after the global financial crisis, the Chancellor didn't say whatever it takes. He said it was a moral imperative, an economic necessity to cut. The bond vigilantes would come and tear up our markets and goodness knows what. Well, here he said whatever it takes. Oh, you mean that was a political choice?

It wasn't a moral necessity. It wasn't an economic imperative. It was a political choice to cut public sector expenditure. In my 2010 review, we coined the rather awkward term 'proportionate universalism'. I was trying to combine two ideas: a Nordic approach to public policy, universalist policies, and a more Anglo-Saxon approach

targeting means tested benefits. We launched three communities in Scotland and I said an Anglo-Saxon approach that I nearly got lynched. Well, you know what I mean. Anyway, targeting. So I was trying to combine the two of them. So if this is the gradient, let's say less deprivation, longer life expectancy. If you focus only on the most deprived,

you might improve their health. But what about the people who are above the threshold of intervention, but you don't intervene on them? They're still at health disadvantage. So we said universalist policies with effort proportionate to need. What did we get post 2010? We plotted life expectancy for every local authority in England

in 2010-12 and then looked at the subsequent reduction in local government spending power by 2019-20. The shorter the life expectancy in 2010-12, the steeper the reduction in local government spending power. The kindest explanation I can give for this is absent-mindedness.

They didn't know what they were doing. But that looks pretty systematic. In what moral universe could this be the right thing to do? The sicker the community, the more money you take away. And if the people in government said, no, no, no, no, no, we weren't targeting sick communities. We were just targeting poor communities. We were just taking money away from poor areas. That's better. Could this...

be part of the explanation for the slowdown in health improvement, the increase in inequalities, the decline in life expectancy in the poorest areas? Yeah, I think it could. We did a calculation that I'd wanted to do for a long time. People like me are always talking about the poor health of the poor compared with everyone else.

And it is an issue, of course. I said, let's focus on the health of the rich. I don't mean water skiing accidents while on holiday in Barbados. I mean the low mortality of the least deprived tells us what's possible, potentially. So we made the calculation, what if...

everybody had the low mortality of the least deprived 10%. So everything above that is excess. The greater the deprivation, the greater the number of excess deaths. So we calculated over the decade from 2009-2020, there were one million excess deaths linked to deprivation.

Now, there was a social gradient pre-2010, but it got steeper and we calculated that of the one million excess, there were 148,000 excess, excess deaths. Arguably, austerity killed 148,000 people.

It's not just the UK not doing so well. I hasten to add this is pre-Trump II. US total public expenditure, percent of GDP. The US is a bit below the OECD average. Health expenditure, wow, the US is right at the very top. They don't get much for it. They don't spend much on unemployment. And life expectancy...

Well, let's look at some more. Americans die early. I love the US. Every time I look at England or UK, I look at the US and we look okay. So across the income gradient, at every level of income, the Americans have shorter life expectancy than the UK.

this well-known medical journal, the New York Times, February this year. The US is doing amazingly. Increase in total GDP, I say, is doing up to 2023. It ain't doing so well just at the moment. And there's 37 other high-income countries. There's China. But now, look, rank one is the best.

Out of 39 countries, the US ranks 29th in life expectancy. So the GDP is roaring ahead, better than everybody except China.

life expectancy and their rankings declining from 1990 to 2023. Prevalence of depression, one being the least depressed, one is good. So they rank 32 out of 39. Wow. Income inequality, I'm a bit surprised. I thought they'd be lower ranking, that it's only 13. Life satisfaction,

Child death rate 33 out of 39 rich countries OECD 33 the United States I showed you they spend far more on health care than any other country and look at the child death rate the murder rate

I mean Canadians must be just lusting to become the 51st state. I mean look at this, it'd be wonderful to increase our child death rate, to increase our murder rate, to all get depressed. We just, suicide rate, Canadians would love to be Americans. The drug death rate, 39 out of 39 countries, not doing well. And the thing about how badly the US is doing,

Somehow a whole presidential election got fought last year without mentioning it, without mentioning it. Did you hear either of the candidates talk about it? Make Americans sick again? So my second topic is freedom. As I, Berlin famously said, freedom for the wolves as often meant death to the sheep.

So we're not talking about the freedom of the techno-libertarians who are trying to take on over the US at the moment, Elon Musk being their representative. That's one notion of freedom. Destroy the state.

get rid of taxes and regulations and let masters of the universe rule. That's not the notion of freedom that I've been pursuing. I prefer the Amartya Sen approach. We not only value living well and satisfactorily, but also appreciate having control over our lives. The Sen approach is creating the conditions

for people to lead lives they have reason to value. That's the approach to freedom I think we should take. Previous head of LSE talked about this issue of intergenerational equity. The Gallup organization

surveys people and says, "Do you think children today will have a better, worse off or roughly the same life to you?" The global average, 44%, only 44% of people think today's children will have a better life. I would have said than, but Gallup presumably knows English.

In the UK, fewer than one third of people think children will have a better life. In the European Union, it's 30%. Think what I said a few minutes ago. The implied promise was things will get better all the time.

If you ask my parents' generation, "Do you think your children will have a better life than you?" They would have said yes, and they're right. And people in Nigeria think that, in Pakistan. Things can only get better.

We had bathrooms, indoor toilets, you guys thought children would have. They'd go to school, they'd go to university, they'd have a national health service. Things will get better. Now, today's adults are saying, "We messed it up for our children." Only a third think children will have a better life than them. And they may be right. One way of thinking of opportunities for children is to think about social mobility.

In general, rich parents have rich children when they grow up. Poor parents have poor children when they grow up. Middle income parents have middle income children when they grow up. Social mobility, one way of thinking about it is, can you get out of that stratum into which you were born? If we look, ask the question,

At the current rate of social mobility, how many generations would it take for someone at the 10th centile of income to get to the median, to the 50th centile? In Denmark, two generations. In Finland, Norway or Sweden, three generations. In the UK and the US, five generations. In Brazil, nine generations.

I was invited to give a talk to the European office of WHO. Wonderful invitation. We're having this meeting. We'd like you to give an inspirational address on the second day from 9:05 to 9:10. How could I say no?

And so I'm sitting there with 53 representatives of 53 member states and said, where would you rather be from the point of view of social mobility, Denmark or Brazil? Because I can tell you we're heading for Brazil. Why? Well, broadly speaking, there are two classes of influence on social mobility. One is income inequality.

the greater the income inequality, the less social mobility. And second, investment in early childhood. If we look at change in child income poverty rates, where child poverty is defined as living in a household at less than 60% of median income, in the UK, we had the fastest increase of 38 rich countries.

doing really badly. And expenditure on children 0 to 5, the OECD average is around $6,000 per child per year at purchasing power parities. In Norway, they spend about $12,000. Denmark, Sweden, France, Finland, the average is $6,000. We spend about $6,000. I love the US, they spend about $3,000.

So we don't spend, we've got high rates of child poverty and we don't spend to improve conditions for early childhood. Guess what? That relates to lack of social mobility. And the child poverty reduction effect of cash benefits in 33 OECD and EU countries. So this is child poverty before transfers.

And then the blue line is child poverty after transfers. And you can see that you can use, look at Ireland, you can use the tax and benefit system to make a huge difference to child poverty. Finland, high rates of child poverty before transfers, they don't like their kids growing up in poverty. So they use the tax and benefit system to reduce it.

We don't. When I pointed out that child poverty was going up in my 2020 review, and government said, oh no, we've reduced absolute poverty. I don't want to upset you by telling you how they define absolute poverty, but it's another story. The Joseph Ramfri Foundation measures destitution as doing without two or more of six basics. Housing,

heat, light, food, clothing and toiletries. In 2022, one million children were living in a state of destitution. That was a 2.5-fold increase in five years. Children being admitted to hospital with rickets, scurvy, Victorian diseases,

And I said we've done a few reports on housing. We've been particularly interested in cold homes. Fuel poverty has three components: the thermal property of the dwelling, and we have one of the worst in Europe. Over 50% of homes need upgrading to bring them up to a decent energy conservation level.

Second, poverty and real wages have flatlined since 2011 compared to a rise in most OECD countries and the price of fuel 30% higher than the European average.

At the London School of Economics you'll explain to me why the price we pay for fuel is the marginal cost of the last unit. So when the price of gas goes up we pay more for wind power. And you'll explain to me why that's perfectly rational. But I'm a doctor, what would I know? But what I do know is the impact on people. If you look at the percent of the household budget spent on energy,

In France, if you're in the top 10% of income, you spend 6% of your household budget on energy. In the UK, if you're in the top 10%, you spend 6% of your household budget on energy. In France, if you're in the bottom 10%, you spend 10%.

of your household budget on energy. In the UK, if you're in the poorest 10%, you spend 18%. That gap in the amount spent on energy between the poorest and richest 10% is bigger in the UK than in any other European country. The UK is not a good place to be poor. About the only big country I can think of where it's worse is the United States. And then pandemics.

Co-chairing Global Council on Inequality, AIDS and Pandemics, Winnie Pyanyima, the head of UNAIDS. We launched it in Brazil. Joe Stiglitz, economist, is one of the other co-chairs, and Monica Gengos, former first lady of Namibia. Interesting. I said not all countries got an increase in mortality during the pandemic.

If you look at excess mortality during 2020, the first year of the pandemic, and healthy life expectancy improvement for people under 65,

in the decade before the pandemic, so that's improvement. What you see is the bigger the improvement in healthy life expectancy pre-pandemic, the smaller the excess mortality during the first year of the pandemic. In fact, these countries, the excess was negative. There was no excess.

And they were the ones like Denmark, Latvia, Hungary, Finland, Slovakia. They were the ones that had better improvement in healthy life expectancy. The US was doing really badly and we weren't doing very well. And we had a big excess mortality in the first year of the pandemic. In other words, how the country was managing its health pre-pandemic related to how it managed the pandemic. I've already told you

five prime ministers, seven ministers of finance. We were not managing things well at all, quite apart from a decade of austerity. And life expectancy in the US falling, that's 2019, 2020, 2021. Scotland, Northern Ireland, Germany, England and Wales. So the US was doing worse, but we were doing pretty badly in 2021.

Our review for the Global Council on Inequality, AIDS and Pandemics, countries with higher rates of income inequality have higher rates of death of COVID-19, of AIDS deaths and of HIV infection. Look at this in New York City. Life expectancy, the so-called Hispanic paradox, greater for Hispanics than for non-Hispanic whites. There's blacks.

And then the pandemic hit and it hit Hispanic really hard and African Americans really hard. So it increased the inequalities. In Brazil, white people have seen falling rates of HIV. Black people face rising rates in recent years. So our council is dealing with this inequality issue in AIDS and pandemics.

And all of what I've been saying is before what's happening right as we speak. Trump withdrew funding from WHO. The US funds 25% of WHO, but it funds 65% of the International Organization for Migration, more than half of UNHCR, more than half of the World Food Program, the World UN Population Fund, the International Rescue Committee.

If all of this is under threat, it's not just WHO, very important as it is, but all these other organisations that are crucial for the social determinants of health. The World Food Programme, if it loses half its funding, good heavens. The children who won't get school meals, the people in refugee camps who'll starve,

6 million people could die from HIV and AIDS if US funding stops. And PEPFAR is supposed to have been exempted, but in practice the money's not getting through.

And in fact, when exempted, they said they'd take away 60% of the funding, the 60% that supports prevention and health services, and leave the 40% for drugs. But the 40% isn't getting through. I'd forgotten about the hope one. Is there any grounds at all for hope? Well, so we, our council,

met the G20 and the G20 committed to tackling the social determinants of pandemics. Why am I showing you this Italian? You knew that didn't you? Hello. The Italian Institute of Public Health has established an Italian network of Marmots cities and

I say 40 plus, we're going to have 50 Marmot places in England, Wales and Scotland. We've just launched three places in Scotland. So Coventry was the first Marmot city. It took my 2010 report.

six domains of recommendations, the City Council said we're going to make this the basis for going forward in Coventry with cross sector working. Greater Manchester, Cheshire, Merseyside, Lancashire and Cumbria, Luton, Leeds, Gwent and legal in general. Not trivial company, it has 1.3 trillion

under investment. They said, what can business do on health equity? So we produced a report, the Business of Health Equity, the Marmot Review for Industry. And we said three things, good quality work, pay everyone a real living wage,

good conditions of work, good for business. Second, goods and services. If you're the tobacco industry, forget it, we can't work with you. If you're the food industry, which side are you on? Are you on the side, we all need the food industry, we don't grow our own food, but are you on the side of making health worse or improving it?

And the third is the wider impact on communities, the environment. I said I was co-chairing this commission with Joe Stiglitz. He gave me his latest book. The challenge was to read it before he publishes the next one, which I did.

And I said, Joe, we call this social democracy. He said, yeah, but I was writing it for a US audience, so he calls it progressive capitalism. Create a learning society, a rich ecology of institutions, rebalancing power relations, inequalities and social justice, the role of the state.

Not communism, not Thatcher-Reaganism, but somewhere in between, recognising the important role of the state as it is being dismantled in front of his and everybody else's eyes in the US at the moment, and putting economics in its place. It's important, but it's not everything.

When Keir Starmer launched his health mission as leader of the opposition, they produced a technical appendix to his health mission. On page 12, you saw that, didn't you? Page 12 of the technical appendix. The next Labour government will amplify the approach of Marmot, C-Sycrea, Manchester and Coventry, by making England a Marmot country. My goodness, that's grounds for hope.

I often get asked, "Are you optimistic?" And a Brazilian colleague pointed out to me when I said that I was an evidence-based optimist. He said, "You're using the English language incorrectly. You're not an optimist." He said, "You're hopeful." Optimism and pessimism imply certainty. You know things are going to get better. You know they're going to get worse. Hope is fears opposite.

We don't know that they're going to get better, but by golly, we can work to try and make a difference. I was in Northern Ireland recently, though I thought Irish poet, Irish poet, Seamus Heaney. History says don't hope on this side of the grave, but then once in a lifetime, the longed for tidal wave of justice can rise up and hope and history rhyme.

I think we need to make this a moment where hope and history rhyme. Thank you. Hi, I'm interrupting this event to tell you about another awesome LSE podcast that we think you'd enjoy. LSE IQ asks social scientists and other experts to answer one intelligent question. Like, why do people believe in conspiracy theories? Or, can we afford the super-rich?

Come check us out. Just search for LSE IQ wherever you get your podcasts. Now, back to the event. Brilliant. Well, it's great to finish on a note of hope, if not optimism.

So thank you so much, Sir Michael. I'm going to take some questions. Before I do, I just want to make a note of thanks, particularly to Professor Elias Marciales, who leads LSE Health, for organising this event, supported by Sophia and Chloe, and of course to you for accepting the invitation to come here. I should say who I am as well. I'm Andrew Street and I'm head of the

Department of Health Policy. Now, what we'll do is, in the interests of microphonic efficiency, I'm going to take some questions. We'll take one from the balcony, one from this side.

and one from this side. So, and then we'll work in threes and we'll take then some questions from those that are online and I think there's quite a lot of people online. So if you're online and you haven't put your question through, please put your question through and then Chloe will read them out in the allotted slot. Okay? So,

Let's start in the balcony. Put your hands up if you have a question. Also put your hands up down here so we can move the microphones around. So, from the balcony, please. Please do not be shy. This is your one chance to ask Sir Michael your burning question. So would you like to give a microphone to one of the people here? Just at the other end. Yeah, one in, and then you'll come later. We've only got three questions here at the moment. The balcony, you're very shy.

Okay, I'm gonna... and one here, okay. Balcony, I'm gonna come back to you, not if the others want to hear it back. Okay, brilliant. So we'll start in the balcony, then we'll take your question, then yours, then online, and then I'll come back to the next round. Okay, so please just say your name and ask Sir Michael your question, please. Okay, my name is Janet Thomas, and question to Sir Michael.

Why don't we care about children in England? Why don't I care about children? We'll just take three questions. Why don't we care? OK, that's a tough one. Well, my question was, first of all, I'm Rakeem. I hope to be a doctor in the future. And my question was, in my lifetime, do you think anything's going to get better or are we essentially just doomed? Good, Rakeem. In Rakeem's lifetime...

Are things going to get better or are we just doomed? And the question here... Yes, in the global cancer space there's been great success with a thing called City Cancer Challenge where people have gone to cities in lower middle income countries and actually worked with the mayor and the local businesses and improved cancer services.

I was very interested in the idea of the Marmot cities. Do we now have to go to cities when central government has failed to deliver on promise? Is that the place to go? Great. Okay. So, would you like to answer those three questions? Yeah. I think I misheard the first question. I thought you were asking why don't I care about children, but I think you said why don't we care about children now.

We've been acting as if we don't care about anything. We don't care about the health and well-being of the population is the way we've been acting. Now, when you say we, and let me add that I maintain the fiction that I'm not party political. What the evidence shows is that under New Labour, they took half a million children out of poverty. They established Sure Start,

and the Institute for Fiscal Studies published just last year the positive impact on Sure Start on education, on educational performance. So the, and I'm not arguing from a political, party political standpoint, but the fact is when a government decides to do something about it, they can. 500,000 fewer children in poverty

Sure Start actually improving, trying to break the link between poverty and poor outcomes. So we stopped caring. We closed 1,000 Sure Start children's centres. We increased the level of child poverty. After housing costs in 2010, child poverty was 27%.

by 2019 it was 30%. That's a lot. It went down in the first year of the pandemic and it particularly went down when the Chancellor uprated Universal Credit by £20 a week. And then one day he said, "I'm going to take it away." And from one day to the next,

200,000 more children were thrown into poverty. I wonder if he went to bed that night and said, "Gosh, did I have a good day today. 200,000 more children into poverty." So it's not the case that we collectively don't care about children. We've had a government

that acted as if they didn't care about children. Look at those figures on destitution. Children being admitted to hospital with scurvy and rickets. We behave as if we don't care about children. But it is possible to make a difference quite quickly. I don't want to go on too long about it, but it's so important. On my last visit to Liverpool,

I met with a number of voluntary community groups, voluntary community sector, and I said

The view that I took was that we needed the Minister of Finance, the Chancellor, to reduce child poverty. What you could do locally is to try to break the link between child poverty and poor outcomes by supporting families and the like, which is what's happening in these Marmot places. The Citizens Advice Bureau said, no, that's not the case. We're reducing poverty.

because we're helping people get access to all the benefits to which they're entitled. We're helping people get into work. So we're actually reducing poverty. So there are committed people all around the country trying to improve the lot of children. Are things going to get better or worse? I have enough difficulty explaining what happened in the past, let alone predicting the future.

We could say, if you do this, then that might happen, and if you do this, then that might happen. I was even cautious to say what was happening during the decayed 14 years of austerity. So I was thinking about the U.S. figures. I showed you some pretty disastrous figures for the U.S.,

Even with all the terrible things that are happening right now as we speak, I would not be confident in predicting what's going to happen. It looks ghastly. It's likely that things will get worse, but I wouldn't be confident. Who knows? So it's very difficult to predict the future. And that's why I talk about hope rather than optimism. If we all band together to make a difference...

then we can try and make that a better future, not a worse one. Forgive my poor hearing. If I understood your question, thinking at a global level, that we should be thinking perhaps about cities rather than countries, I agree. For example, I was talking with a colleague from Colombia

the week before last. Colombia is 50 million people, a huge complicated country, 7 million people internally displaced by conflict and the like. How do you get Colombia as a whole to get active? But she was saying, well, maybe we could do it at the city level.

and similarly we've been we were talking to mexico more than 100 million people very complicated it the conversation ground to a halt but i think working at a place-based level might be a better way to do it and i mean we've been working at places

in the UK for a negative and a positive reason. The negative reason is because the national government was going in the other direction. The positive reason is we were invited in. These places really wanted to make a difference. We launched in Newcastle

There's absolutely no correlation between Newcastle declaring themselves a Marmot City and winning the League Cup. There's absolutely no correlation. And there were only 300 people celebrating the launch of Newcastle as a Marmot City. But the Civic Centre was full and the level of enthusiasm in the room was palpable.

So Newcastle is not saying we'll wait for wonderful things to happen from central government. They're saying we want to create the community where our young people have the opportunity to flourish and we're going to do it. So yeah, I think the place-based is certainly one way to go.

Lovely, thank you. Chloe, do we have some questions online? Can we take the online ones first, please? I promise I'll come back to you in a second.

Yes, we have a question from Anoushka Akhtar and she says, "Keen to hear Samarmat's views on the present siloed way of working across healthcare and social care, NHS versus local authority separation when it comes to funding and service delivery. Do you think it will get more interlinked moving forward and what could be some enablers for this outcome?" It could get more. Interlinked? More. More connected? That's a tough question. Just repeat the key thing from Anoushka again?

What are your views on the present siloed way of working across healthcare and social care? And how will it become more interlinked? It might be a bit challenging, given that NHS England is no more. Or it might become less challenging. Do you want me to ask one more? Yes, I would like to see...

I got my language wrong. Under the previous Labour government, you know, they were talking about joined up working and I said stitched up government. They said no, no, we didn't mean stitched up, we meant joined up. I mean, it's very clear and it comes back to the question about working at local level that we need cross-sector working.

And in Coventry, if you go on the web and look at what they're doing in Coventry, you can click on any one of my eight principles for Coventry and you can see how they're trying to implement them. They've got, forgive me, a Marmot implementation group which has got city government, other public sector bodies, education,

Fire and Rescue Service, police, health and care, the voluntary community and faith sectors. Not as big a representation of business as I would like, but they're trying to get business involved. And this is vital. So, I mean, behind the question is the obvious one of social care work.

properly funded and organised, it would relieve burden on the NHS. And, you know, one government after another keeps saying, "Yeah, we'll solve social care. We've just got to go on holiday first and then we've got to work out the decline of English football and after that we'll solve social care." We'd quite like them to solve it a bit earlier.

but it keeps getting pushed down the road. But it's not just health and social care, it's child services, education, it's community planning. I mean all of this is vital. Housing. We, the Institute of Health Equity, are full of support for 1.5 million new houses, but

They've got to take health equity into account. Got to make sure, and they've got to take into account where they're plonked. Are they in a good environment that's going to be good for health? So we'd like equity of health and well-being to be crucial to all the decisions government makes right across the patch.

Thank you. I'm going to take three more questions from the floor. With the constraints caused by globalisation on the role of the finances of government, it seems to be very difficult for government in Britain to even maintain the level of social services and welfare that exists at present.

that situation of growing economic competition from Asia and other places is going to become even more difficult in the decades to come. Based upon that harsh reality, would not your ideals run into the sand? My ideal? Run into the sand. And one here. Yeah. Thank you very much, Professor Mahmoud, for a very enlightening. I work in Pakistan on issues of health,

inequalities and I have used your work in Pakistan and it was absolutely very insightful. So my questions are two basically. You have referenced Pakistan in relation to children's survey. Where it shows 80% of the people think that children's future in Pakistan will be better. I just would like to know when this survey was conducted

And of course the second question is about, I mean, England, given the vast cuts which are being proposed to benefits and also the reorganizations of NHS, how it will affect health inequalities in England. And I mean, you also mentioned the importance of taking action. And I mean, what would you suggest in the way of action to address

you know the cuts and I mean their impacts on health. Yes, thank you. Thank you. And there was one in the balcony as well. Thank you also for an amazing lecture.

I think from everything you've been saying, it's hard not to view the bigger picture as just the result of a lot of competing values. My question to you, because the evidence is obviously there, how do we adapt the way that we're communicating to perhaps political circles where certain values aren't embedded in their systems so that it resonates in a powerful way?

Thank you. So a bit about social care cuts there. Do you want to take them in turn? I will. So let me, if I got your question correctly, answer it more generally about government funding. I'm not a politician. And so I can say what I would have done, which is being honest and say, I'm going to raise taxes.

Instead of saying, "No, no, no, no, we're going to get growth. That'll solve everything. Economic growth will solve everything." That'd be garbage, complete and utter garbage. We all knew it was utter garbage. So you box yourself into a space where just about the worst tax to raise was the employer's contribution to national insurance. What about reforming council tax?

There must be a zillion people in this august institution who could tell the government why and how they should have reformed council tax. I remember in one of his books, Tony Atkinson saying,

many people have died of boredom thinking about funding of local government but the fact is he said to have progressive taxation at local level is an important way forward so there are all sorts of things they could have done and would have done and I'm not a politician when

The orange nightmare in the White House said, you know, I'm on Russia's side now. And the Prime Minister stood up and said, we're going to have to spend more on defence.

This was totally unexpected, totally unpredicted. This came out of the blue. So we will raise taxes. Not we'll cut overseas development assistance from a measly 0.5% of GDP down to 0.2% of GDP. We'll raise taxes. Totally, we wouldn't. We're not breaking a promise. We just couldn't have predicted this. So that's what...

That said, the 50 places we're working in have suffered brutal cuts to their funding, brutal cuts, but they're all working away trying to make a difference to people's lives to improve health and health equity. So the funding really matters, but it's not all that there is. There's quite a lot one can do. And as I say, I'm not a politician. You can see why.

We did a...

a commission for the so-called Eastern Mediterranean region of WHO. And Pakistan, I think not for geographic reasons, is part of the Eastern Mediterranean. Seems to me quite a long way from the Eastern Mediterranean. But anyway, Pakistan, Afghanistan are all part of the Eastern Mediterranean region. And what we said-- I'm thinking a lot about--

You've got the richest countries in the world in that region per capita, you know Qatar and the like and you've got among the poorest and we very much use the mantra that we one of our European colleagues had: do something, do more, do better. If you're a country, low-income,

with very little action on the social determinants of health. Do something. Provide clean water for everybody. That will make a huge difference. That's not giving people the opportunity to flourish, but it's a good start. So do something.

Now, my own view, I tend not to subscribe to a hierarchy of needs, get the clean water and then worry about meaningful lives. I think people should have meaningful lives at the same time as they have clean water. It's important to be thinking about the quality of people's lives, of dignity. And so it's absolutely vital.

And we took the view with our Eastern Mediterranean Commission that there's something here for every country in the region.

things can get better. And we know globally how much things did get better. The reduction in child poverty globally, the reduction in under five mortality globally, things did get better. In fact, the poorer countries had a bigger improvement in under five mortality than the middle and high income countries. So this is my evidence-based hopefulness.

It's not quite answering your question, but it's my approach to Pakistan. Your question is, how do we communicate? A while ago, when I said I'm not party political, but I was asked to brief the Shadow Cabinet.

when Labour shadowed Cabinet in opposition. And at the end we had quite a good discussion, a talk and a good discussion. At the end one of the senior politicians, now a minister, said, "We're nice people, we've got nice ideas, but we don't seem to be getting our ideas across. What could you advise us?"

And I said, "Certain things come with age and experience, and knowing what I'm not good at is one of them, and I certainly would not pretend to any expertise of telling politicians how to communicate. But I can tell you what I do. I tell the truth, it rules me out, and I argue from the evidence.

And I present, I try and engage people in a discussion about social justice, which comes back to your first question. Why don't we care about our children? If we could engage people in that discussion of social justice and tell the truth and look at the evidence, I think we'll make a difference. And local politicians in 50 areas have been listening. Thank you.

Another online question, and then we're going to take some more from the floor. We have a number of questions from the live audience about the role and impact of AI on the future of health equity, including this one from Jonathan Jeffries, who says, I was wondering whether the potential impact of AI may come to bear on the quality and type of remunerated work of the future, and if this is something that you have considered. I mean...

Of the many things about which I know little, AI looms large. I'm not a Luddite, so I don't start from the proposition that a new development like this has to be bad.

I do start from the proposition that most new developments increase inequalities in the initial stages and then they percolate through. The mobile phone probably increased inequalities when it got first introduced, but now people in Indian villages can watch the World Cup on their mobile phone. I don't know if that's a good thing or a bad thing, but it's certainly...

It means that it's percolated through. They can make a phone call, they can call an ambulance, they can do stuff. So I think of AI the same way. It has great potential, particularly if these techno libertarians that I talked about, I mean if their model for the US is to destroy the government,

and have these supermen with their AI running everything with no government, no regulations and no taxes. This is a dystopian nightmare. So AI has the potential to create a dystopian nightmare. But it also obviously has enormous potential for benefit, used properly and controlled.

The question is, who's to be master? I'm going to take three more from the floor. We'll start here, then there, then pass it behind. Do you want to... Actually, you start, come here, then pass it. Hello, I'm from the Department of International Development here at LSE. How do we reconcile the ring-fencing of donor money in low- and middle-income countries, like the verticalisation of...

disease programs with the need for social justice. In other words, if countries or even cities can't make their own decisions about their own money that's being given to them, how do they join up the work? How do they work across sectors, which is what has been implied about what's needed in social justice?

There are some parts of the country that seem to have fallen into a spiral of despair. I'm thinking of Blackpool, parts of Lincolnshire and so on. And to the extent that people living there have any hope whatsoever, they seem to have invested it in political parties like Reform that I don't think is terribly sympathetic to the policies that you're proposing. Can you see any prospect whatsoever of breaking that spiral or reversing it?

Hi, my name is Alex from and I do a Masters in Public Health. Can you speak up a bit? Yeah.

Alex, you're the Master of Public Health. So one of the things is that nowadays we're going to be seeing more of a trend towards militarization of Europe, militarization of many of the countries, high-income countries that you did talk about. Do you think in the near future, even, there might be another sort of grand bargain where you say, look, we can't

increase health spending, we have to increase military, or we have to even decrease health spending from where it is in order to increase military. Do you think that will happen? And if it did, how would that affect things? Excellent. Thank you very much. Let's take those three then. I mean, like many people, I have mixed views about overseas development of systems. Ideally, I mean,

One argument is it's like a resource curse. It's Dutch disease. You give too much aid, it has the same impact as a resource curse and we don't want to do that. I mean, presumably, the aim of overseas development assistance should be

to redress some of the problems that, quote, we caused and help countries get to the point where they don't need it. But when you think of the way we've rigged the international system...

I remember in Zambia, a pediatrician telling me that after the IMF came into town to solve their problems, infant mortality would go up. And they called IMF the Infant Mortality Fund.

because that's what they were doing. You know, they had one model in town and no matter how much damage they did, they rode into town with their one model, caused damage and rode out of town again. So we need to be a bit careful about all of this. Now the

the Accra Declaration tried to get some principles of how aid should be coordinated. That countries needed to take ownership, their priorities were important, there needed to be some coordination amongst the donors so you didn't have

20 donors all with their priorities that perhaps were competing. It was important the donors wanted transparency. They wanted to know that their money was being used in a good way. So this declaration was supposed to lead to transparency for the donors. But I think thinking of aid as a step

in a journey is the right way to think about it.

And certainly not to cut it off from one day to the next, not to say we were giving $40 billion a year to global health and we'll stop that now in 75 billion. I think those were the American figures roughly. And we'll stop that overnight. That's no way to do it. We've got to be thinking about a transition. And we don't want...

experts from international organizations or civil servants in other countries telling the recipient countries how they ought to behave. So it's a challenging scape. I reviewed many years ago for The Lancet two books on global governance for health.

I was more confused having read these two books than I was. One of them said, "We need to think of global governance for health as a mosh pit." I made an emergency call to one of my children and said, "What's a mosh pit?" They said, "It's the bit in front of the band where people do free dancing." Well, you can see the mess. So we need to make progress there. It is a total mess.

But we, I think, should be seeing it as transitional, not a permanent arrangement of funding coming from high-income to low-income countries. Martin, I get asked, do I have a theory of change? And I have a very sophisticated theory of change. I bang on a door, and if it doesn't open, I don't bang my head against the door. I find a door that will open.

So this may be not the answer you're looking for, but you're asking what about the communities that are spiralling down? The 50 we're working in have invited us in. They want us there. So I'm not spending my time banging my head against a wall in the ones that don't want us. And maybe that's a council of despair. We should worry about them too.

Talking to you, I'm not expecting sympathy from the amount of travelling I'm going doing to Northumberland and Newcastle and Kings Lynn and Wales and so on. But they all want us there. They're just really excited. And I'd like to think they'll be contagion. It'll spread. A while ago, so health versus military spending. I mean, firstly...

When the OECD or the IMF talk about health expenditure, they don't mean health expenditure. They mean health services expenditure. I think reduction of child poverty is health expenditure. I think improving...

the girls in secondary education is health expenditure. Improving the ratio of girls to boys in education is health expenditure. Housing is health expenditure. It's interesting that with the exception of health

expenditure. The US has very low social expenditure and very high military expenditure and it hasn't served them very well. I showed you where they rank in life expectancy, in depression, in murder, in homicide, in child mortality. It hasn't served them very well. The countries that spend more on social expenditure do much better in health and well-being.

Unfortunately, because of bad actors, we're having to think once again about military expenditure. I was listening to an interview with... She's the head of King's College, Cambridge. I was listening to an interview with her and she said... She reminded that people should read Keynes's...

the economic consequence of the peace which I have to say I have read. There's a book with the end of laissez-faire and the economic consequences of the peace and it's a remarkable essay. He wrote it in 1926 and he said that the settlement, the economic settlement in Europe

what the victors are doing to Germany will lead to another world war. There should be, he said, an iron and steel community. It was calling for the European Union rather than another world war. And it was remarkably prescient. You asked me to predict were things going to get better. I'm no...

so I can't predict. But Keynes predicted that they'd get a good deal worse because of the economic settlement. And we're heading in that direction right now of what's going on, you know, saying, yeah, yeah, Putin can have part of Ukraine. Well, all right, if he... The Baltics. Who cares about the Baltics? And Poland. Well, Poland's not very important. What... What...

A historian friend of mine said that he started watching a clip of Zelensky's visit to the Oval Office and he had two reactions. The first was he quickly switched to English.

a replay of Federer at Wimbledon. It was somehow more to better for his mental health than watching this clip of Trump and Vance ganging up on Zelensky in the Oval Office. And he said it was the worst diplomatic incident he can remember. And then he said, I think it was equivalent to Hitler

tearing strips off the head of Czechoslovakia because he hadn't given him the Sudetenland. That's what it was like, he said. Well, that's where we are right now. So to come back, you know, I'd always be on the side of reduced child poverty, spend on education, spend on adult social care, not on defence. Unfortunately, we have to spend on defence too.

And I would raise taxes in order to do it because we've got to do both. We have time for one last question. It kind of links to what you just said, actually. I know this is a discussion about health and not politics or economics.

proper funding is what will give hope, I think. And I work in special educational needs and we need money and health needs money and everybody needs money. So an LSE graduate, Gary Stevenson, who's an economist and ex-trader,

formerly working class boy, he talks nearly as eloquently and certainly as passionately about wealth inequality as you do about health inequality. And he calls for taxing wealth, not income. So taxing assets and wealth. Do you think this kind of shift in taxation is possible to provide the funding that you need for a better world for you to live in and all of us need? Well, I mean...

I'm not a tax expert and I'm at the London School of Economics, so there are probably hundreds of people here who are more skilled than I am at this question. But just look at wealth. Jeff Bezos' income is probably less than yours and mine. His wealth grows by billions.

all the time and it's tax free. So I don't know about you and I but we probably pay a third of our income in tax, you know, entirely reasonable thing to do. I'd like to see a more progressive income tax system than we have but what about wealth? You know, people who are growing their wealth

I mean that growth in billionaires in the US during the pandemic, the pandemic may have been bad for a lot of people, was pretty good for billionaires, their wealth went up enormously. Well, why shouldn't they contribute to the society with a minuscule tax on their wealth would be quite a reasonable thing to do.

when I said before about Tony Atkinson, the revered Tony Atkinson, saying we should have a more progressive local taxation,

Even the Economist newspaper, as they call themselves, has pointed out how much Buckingham Palace pays in council tax and how much a modest dwelling in Newcastle pays in council. The rate is ridiculous. It's ridiculous. And when the council tax bans were formed in 1990 or whenever it was, nothing changed.

Well, you know, my children live in East London, areas that have been rapidly gentrified, once my kids moved in there. But, you know, it's ridiculous. Their council tax is at the rate it was when these were very deprived areas. We need a proper progressive taxation, and wealth and property should be part of that.

Brilliant. Before we say thank you to Sir Michael, I just want to say that there are refreshments

on the fifth floor in the senior common room and that will still be an opportunity for those who haven't had the chance to ask Sir Michael a question, a chance to corner him and ask your questions there. It's on the fifth floor. As anyone who has LSE knows, the lifts here aren't great. So if anyone needs to get their steps in, I really encourage you to use the stairs and leave the lifts for those of us who are more in need of it than you might be.

But I would like to thank Sir Michael. I mean, it feels that the world is very unfair and it's getting more unfair as the days progress. But I would really like to thank Sir Michael for presenting the facts to us and the evidence with humour,

with hope and also with some suggestions about what might be done to maybe rectify matters for the future. So, Sir Michael, thank you so much for honouring us with your presence today. APPLAUSE

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