Sir-Michael-Marmot-Inaugural-Speech
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1
Inaugural
Address
as
WMA
President
Michael
Marmot
Moscow
16
September
2015
Honoured
Guests,
Colleagues,
In
May
2011
Mary
hanged
herself.
She
was
found
in
the
yard
of
her
grandparents’
house
on
a
First
Nations
Reserve
in
the
province
of
British
Columbia
in
Canada.
She
was
fourteen.
She
was
a
First
Nations,
aboriginal,
Canadian.
Her
story
has
particulars.
All
suicides
do.
She
had
been
physically
and
emotionally
abused
at
home
and
in
her
community,
and
possibly
sexually
abused.
Her
mother
was
mentally
unstable
and
heard
voices
telling
her
to
‘snap’
her
child’s
head.
Officials
attributed
the
suicide
to
a
dysfunctional
child
welfare
system,
and
to
the
fact
that
no
one
took
her
complaints
of
abuse
seriously
or
acted
on
them.
There
is
another
way
to
look
at
Mary’s
sadly
foreshortened
life,
and
that
is
to
realise
that
though
her
personal
tragedy
was
unique,
there
are
many
young
aboriginal
Canadians
who
experience
similar
tragedies.
In
fact,
the
aboriginal
youth
suicide
rate
in
British
Columbia
is
five
times
the
average
for
all
young
Canadians.
One
cannot
understand
fully
why
Mary
saw
no
way
out
without
also
asking
why
so
many
other
young
aboriginal
people
in
British
Columbia
reached
the
same
desperate
point.
The
starting
point
is
poverty,
bone-‐grinding
poverty,
low
educational
levels
and
high
unemployment.
But
there
were
about
200
bands
of
aborigines
in
British
Columbia,
more
or
less
all
in
poverty.
Yet
90%
of
the
adolescent
suicides
occurred
in
12%
of
the
bands.
Why
some
and
not
others?
The
difference
was
empowerment
of
communities.
Empowered
communities
participated
in
land
claims;
self-‐government;
had
control
over
educational,
police
and
fire,
and
health
services;
and
establishment
of
‘cultural’
facilities.
The
results
were
clear:
the
greater
the
cultural
continuity
and
community
control
over
their
destiny,
the
lower
was
the
youth
suicide
rate.
Poverty
is
bad
but
poverty
is
not
destiny.
Empowerment
of
communities
can
save
lives.
I
draw
similar
lessons
from
studying
the
health
of
New
Zealand
2
Maoris,
Indigenous
Australians,
Native
Americans
or
indeed
that
of
excluded
groups
elsewhere
in
the
world.
-‐-‐-‐
In
January
2010,
Haiti’s
earthquake
wreaked
havoc
and
200,000
people
died.
Less
than
two
months
later
a
quake
500
times
stronger
hit
Chile
and
the
death
toll
was
in
the
hundreds.
Haiti
was
underprepared
in
every
way
imaginable.
Chile
was
well
prepared,
with
strict
building
codes,
well-‐organised
emergency
responses
and
a
long
history
of
dealing
with
earthquakes.
True,
the
epicentre
of
the
Haitian
earthquake
was
closer
to
population
centres
than
that
of
the
Chilean
quake,
but
that
was
only
part
of
the
explanation
for
the
different
scale
of
devastation.
What
turns
a
natural
phenomenon
into
a
disaster
is
the
nature
of
society.
The
number
of
people
who
died
had
more
to
do
with
Haiti’s
lack
of
societal
readiness
and
response
than
with
the
strength
of
the
quake.
-‐-‐-‐
In
2011
the
London
borough
of
Tottenham
broke
out
in
urban
riots.
The
precipitant
was
the
killing
of
a
black
man
by
police.
But,
unacceptable
as
that
is,
it
was
not
the
underlying
cause.
Inequality
was
the
culprit.
I
had
been
citing
an
area
of
Tottenham
as
having
the
worst
male
life
expectancy
in
London
–
18
years
fewer
than
in
the
best-‐off
area.
All
in
one
of
the
world’s
premier
global
cities.
London
now
has
more
high-‐end
properties,
a
price
tag
more
than
$5million,
than
Manhattan,
Hong
Kong,
Singapore
or
Sydney.
It
is
not
surprising
that
the
riots
broke
out
in
the
area
with
the
worst
health.
Ill-‐health
does
not
cause
riots.
Nor
do
riots
cause
ill-‐health
–
at
least
not
directly.
Relative
deprivation
causes
both
urban
unrest
and
ill-‐
health.
Ninety
per
cent
of
young
people
arrested
in
the
riots
were
not
in
employment,
education
or
training.
Similarly,
in
Baltimore
in
the
US.
When
a
black
man
was
killed
in
police
custody
riots
broke
out.
Not
uniformly
across
the
city,
but
in
the
area
with
condemned
houses,
low
levels
of
education
and
income
and
a
twenty
year
disadvantage
in
life
expectancy
compared
to
the
area
with
leafy
opulence.
Inequality
strains
the
binds
of
a
cohesive
society.
In
Baltimore,
those
binds
snapped.
The
immediate
effect
is
civil
unrest.
The
longer
term
effects
is
health
inequity.
-‐-‐-‐
3
These
examples
illustrate
that
the
way
we
organise
our
affairs,
at
the
community
level
or,
indeed
at
the
whole
societal
level,
are
matters
of
life
and
death.
As
doctors
we
cannot
stand
idly
by
while
our
patients
suffer
from
the
way
our
societies
are
organised.
Inequality
of
social
and
economic
conditions
is
at
the
heart
of
it.
There
are
three
aspects
of
Mary’s
tragedy
worth
emphasising.
The
first
is
the
vital
issue
of
violence
to
girls
and
to
women.
It
can
be
fatal,
both
because
it
drives
women
to
suicide
and
because
they
may
be
killed
by
their
partners.
Second,
I
emphasised
empowerment
of
communities.
But
empowerment
of
individuals
is
also
of
vital
importance.
A
key
route
to
female
empowerment,
globally,
is
education.
Evidence
shows
clearly:
the
greater
the
education
of
women
the
less
the
likelihood
of
being
subject
to
domestic
violence.
Third
is
the
importance
of
mental
illness.
Mental
illness
and
substance
use
disorders
constitute
the
number
one
cause
of
years
spent
with
disability,
globally.
We
cannot
be
concerned
with
health,
globally
and
in
our
countries,
and
not
be
concerned
with
mental
illness
and
substance
use.
More
generally
we
need
to
recognise
the
importance
of
the
mind
to
health
equity.
The
mind
is
the
major
gateway
through
which
social
determinants
exert
their
effect
on
health.
Recognizing
the
importance
of
the
mind
takes
us
back
to
early
child
development
and
what
I
have
called:
equity
from
the
start.
In
Aldous
Huxley’s
dystopia,
Brave
New
World,
there
were
five
castes.
The
Alphas
and
Betas
were
allowed
to
develop
normally.
The
Gammas,
Deltas,
and
Epsilons
were
treated
with
chemicals
to
arrest
their
development
intellectually
and
physically,
progressively
more
affected
from
Gamma
to
Epsilon.
The
result:
a
neatly
stratified
society
with
intellectual
function,
and
physical
development,
correlated
with
caste.
That
was
satire,
wasn’t
it?
We
would
never,
surely,
tolerate
a
state
of
affairs
that
stratified
people,
then
made
it
harder
for
the
lower
orders,
but
helped
the
higher
orders,
to
reach
their
full
potential.
Were
we
to
find
a
chemical
in
the
water,
or
in
food,
that
was
damaging
children’s
growth
and
their
brains
worldwide,
and
thus
their
intellectual
development
and
control
of
emotions,
we
would
clamour
for
immediate
action.
Remove
the
chemical
and
allow
all
our
children
to
flourish,
not
only
the
Alphas
and
Betas.
Stop
the
injustice
now.
4
Yet,
unwittingly
perhaps,
we
do
tolerate
such
an
unjust
state
of
affairs
with
seemingly
little
clamour
for
change.
The
pollutant
is
called
social
disadvantage
and
it
has
profound
effects
on
developing
brains
and
limits
children’s
intellectual
and
social
development.
Note,
the
pollutant
is
not
only
poverty,
but
also
social
disadvantage.
There
is
a
clear
social
gradient
in
intellectual,
social,
and
emotional
development—the
higher
the
social
position
of
families
the
more
do
children
flourish
and
the
better
they
score
on
all
development
measures.
This
stratification
in
early
child
development,
from
Alpha
to
Epsilon,
arises
from
inequality
in
social
circumstances.
This
social
gradient
in
children’s
possibility
to
fulfil
their
potential,
in
its
turn,
has
a
profound
effect
on
children’s
subsequent
life
chances.
We
see
a
social
gradient
in
school
performance
and
adolescent
health;
a
gradient
in
the
likelihood
of
being
a
20
year
old
not
in
employment,
education,
or
training;
a
gradient
in
stressful
working
conditions
that
damage
mental
and
physical
health;
a
gradient
in
the
quality
of
communities
where
people
live
and
work;
in
social
conditions
that
affect
older
people;
and,
central
to
my
concern,
a
social
gradient
in
adult
health.
A
causal
thread
runs
through
these
stages
of
the
life
course
from
early
childhood,
through
adulthood
to
older
age
and
to
inequalities
in
health.
The
best
time
to
start
addressing
inequalities
in
health
is
with
equity
from
the
start.
But
intervention
at
any
stage
of
the
life
course
can
make
a
difference.
Relieving
adult
poverty,
paying
a
living
wage,
reduction
in
fuel
poverty,
improving
working
conditions,
improving
neighbourhoods,
and
taking
steps
to
reduce
social
isolation
in
older
people
can
save
lives.
The
health
gradient
to
which
these
life
course
influences
give
rise
is
dramatic.
There
is
a
cottage
industry,
taking
subway
rides
in
various
cities
and
showing
how
life
expectancy
drops
a
year
for
each
stop.
I
have
referred
to
twenty
year
gaps
in
Baltimore
and
London;
but
the
health
differences
between
rich
and
poor,
dramatic
as
they
are,
are
only
part
of
the
problem.
Commonly,
people
say
to
me:
I
am
neither
rich
nor
poor;
what
does
any
of
this
have
to
do
with
me?
The
evidence
shows
that
there
is
a
social
gradient
in
health
that
runs
from
top
to
bottom
of
society.
People
in
the
middle
have
worse
health
than
those
above
them
in
the
social
hierarchy,
but
better
than
those
below.
We
calculated
for
England
that
if
everyone
enjoyed
the
same
life
expectancy
as
the
top
10%,
based
on
education,
there
would
be
202,000
fewer
deaths
each
year;
over
500
a
day.
One
problem,
then,
is
poverty.
Another
is
inequality.
Both
damage
health
and
lead
to
an
unjust
distribution
of
health.
5
I
have
spent
my
research
life
showing
that
the
key
determinants
of
health
lie
outside
the
health
care
system
in
the
conditions
in
which
people
are
born,
grow,
live,
work
and
age;
and
inequities
in
power,
money
and
resources
that
give
rise
to
these
inequities
in
conditions
of
daily
life.
Since
the
establishment
of
the
WHO
Commission
on
Social
Determinants
of
Health
in
2005,
I
have
been
using
research
knowledge
to
argue
for
policies
on
social
determinants
of
health.
Yet
here
I
am,
humbled
by
assuming
office
as
President
of
the
World
Medical
Association.
Is
there
not
a
contradiction?
The
World
Medical
Association,
WMA,
upholds
the
highest
ethical
standards
of
the
practice
of
medicine.
It
speaks
out
fearlessly
when
the
right
of
doctors
to
pursue
their
noble
calling
is
threatened.
As
President,
I
want
the
WMA
to
use
the
same
moral
clarity
to
be
active
against
the
causes
of
ill-‐health
and
what
I
call
the
causes
of
the
causes
–
the
social
determinants
of
health.
The
opening
sentence
of
my
recent
book,
The
Health
Gap:
The
Challenge
of
an
Unequal
World,
was:
why
treat
people
and
send
them
back
to
the
conditions
that
made
them
sick?
No
one
is
as
concerned
about
health
and
disease
as
we
in
the
medical
and
other
health
professions.
It
has
been
and
will
be
my
mission
to
encourage
our
concerns
with
the
conditions
that
make
people
sick.
I
am
hugely
encouraged
already.
My
friends
in
the
Canadian
Medical
Association
conducted
Town
Hall
meetings
across
Canada
to
engage
the
public
in
discussion
on
how
the
conditions
of
their
lives
related
to
their
health.
The
Canadian
Medical
Association
then
took
the
initiative
to
suggest
a
meeting
at
BMA
House
in
London.
Twenty
countries
and
200
people
asked
to
come,
including
our
now-‐Chair
of
Council,
Ardis
Hoven,
and
then-‐president,
Xavier
Deau,
and
participated
with
enthusiasm.
I
apologise
in
advance:
I
already
have
more
invitations
from
medical
colleagues,
enthusiastic
for
the
health
equity
agenda,
than
I
could
possibly
meet.
We
need
a
global
social
movement.
I
have
been
arguing
that
we
have
the
knowledge
of
what
to
do
to
act
on
social
determinants
and
health
equity;
we
have
the
means.
We
need
to
ensure
that
we
have
the
will.
Do
we
really
have
the
means?
Consider.
What
do
the
following
have
in
common?
48
million
people
of
Tanzania
6
7
million
people
of
Paraguay
2
million
people
of
Latvia
top
25
US
hedge
fund
managers
In
2013
each
of
these
four
groups
had
a
total
income
of
between
$21
and
28
billion.
Imagine
with
me
something
totally
fanciful:
that
the
25
hedge
fund
managers
gave
up
their
income
for
one
year.
It
would
double
the
income
of
Tanzania.
The
hedge
fund
managers
wouldn’t
feel
it,
because
they
will
earn
an
average
of
$1billion
each
the
next
year.
I
am
not
suggesting
for
a
moment
that
we
simply
pass
the
cash
to
individual
Tanzanians.
But
think
of
the
clean
water
that
could
be
piped,
the
schools
that
could
be
built,
the
nurses
trained
and
employed.
There
is
a
great
deal
of
money
sloshing
about.
Great
inequality
between
countries
stops
the
money
being
spent
in
ways
that
would
benefit
the
poor
and
the
needy.
Suppose,
though,
that
there
was
reluctance
to
see
ourselves
as
part
of
a
global
community.
We
would
still
have
to
address
staggering
levels
of
inequality
of
income
and
wealth
within
countries.
Here
is
an
even
more
fanciful
thought.
Suppose
that
the
hedge
fund
managers
of
New
York
paid
a
third
of
their
$24
billion
income
in
tax
–
unlikely
I
know
–
that
money
could
fund
80,000
New
York
schoolteachers.
80,000.
What
has
this
to
do
with
doctors?
At
the
meeting
of
National
Medical
Associations
that
we
held
in
London
we
heard
inspiring
examples
of
how
doctors
are
already
working
with
communities
to
deal
with
the
social
causes
of
ill-‐health.
In
India
I
was
taken
by
medical
colleagues
to
a
tribal
area
in
Gujarat
where
the
doctors
are
not
only
treating
people
who,
hitherto,
had
no
access
to
health
care,
but
are
working
with
others
in
community
development
and
education
to
improve
the
conditions
of
daily
life
for
marginalised
people.
In
Brazil,
the
social
gradient
in
stunting
of
young
children
is
becoming
progressively
flatter.
In
Bangladesh
and
Peru
inequalities
in
child
mortality
are
decreasing.
I
am
excited
by
the
interest
generated
in
social
determinants
of
health
globally
in
every
region
of
the
world:
South
Africa,
Zambia,
Morocco,
Colombia,
Cuba,
Costa
Rica,
Panama,
Surinam,
Taiwan,
Sweden,
Norway,
Finland,
Iceland
and
…
I
could
go
on.
Colleagues,
we
can
make
a
difference
to
the
causes
of
the
causes
of
health
equity,
as
part
of
the
practice
of
medicine.
There
is
another
we
way
we
can
make
a
difference,
too.
I
do
not
go
7
for
long
without
quoting
the
great
German
pathologist,
Rudolf
Virchow,
who
said
that
“physicians
are
the
natural
attorneys
of
the
poor”.
We
can,
we
do,
we
should
speak
up
about
inequity
in
social
conditions
that
damage
the
health
of
the
populations
that
we
serve.
It
means
too,
that
we
should
recognise
and
be
vocal
about
any
societal
trends
that
are
likely
to
affect
health
equity:
climate
change,
trade,
financial
crises.
I
hold
a
Bernard
Lown
visiting
professorship
at
Harvard.
Bernard
Lown,
great
cardiologist
and
co-‐founder
of
International
Physicians
for
the
Prevention
of
Nuclear
War,
said:
never
whisper
in
the
presence
of
wrong.
Already
WMA
speaks
up
in
a
loud
voice
about
the
highest
ethical
standards
of
our
profession.
We
should
not
whisper
at
the
gross
inequities
in
the
world
that
give
rise
to
health
inequities.
In
fact,
so
close
is
the
link
between
social
conditions
and
health
that,
I
argue,
health
equity
is
a
good
measure
of
social
progress;
much
better
than
income
growth.
Senator
Robert
Kennedy
in
a
famous
speech
criticised
Gross
National
Product
as
a
measure
of
social
progress.
He
said:
the
gross
national
product
does
not
allow
for
the
health
of
our
children,
the
quality
of
their
education
or
the
joy
of
their
play.
It
does
not
include
the
beauty
of
our
poetry
or
the
strength
of
our
marriages,
the
intelligence
of
our
public
debate
or
the
integrity
of
our
public
officials.
It
measures
neither
our
wit
nor
our
courage,
neither
our
wisdom
nor
our
learning,
neither
our
compassion
nor
our
devotion
to
our
country,
it
measures
everything
in
short,
except
that
which
makes
life
worthwhile.
Health
and
health
equity
are
not
only
worthwhile
in
themselves
but
they
reflect
much
else
that
makes
life
worthwhile:
the
freedom
to
lead
lives
we
have
reason
to
value.
As
doctors,
at
our
best,
we
flourish
in
the
cause
of
social
justice.
There
is
a
great
deal
of
injustice
in
the
world.
Can
we
really
be
optimistic?
Let
me
quote
from
Nobel
Prize
winning
poet
Seamus
Heaney:
History
says,
don’t
hope
On
this
side
of
the
grave.
8
But
then,
once
in
a
lifetime
The
longed-‐for
tidal
wave
Of
justice
can
rise
up,
And
hope
and
history
rhyme.
So
hope
for
a
great
sea-‐change
On
the
far
side
of
revenge.
Believe
that
further
shore
Is
reachable
from
here.
Believe
in
miracle
And
cures
and
healing
wells.
I
have
had
much
reason
to
praise
our
medical
students
at
the
IFMSA,
and
our
junior
doctors.
In
the
spirit
of
Heaney
I
say
to
our
younger
colleagues:
believe
in
miracle
and
cures
and
healing
wells
not
just
for
our
patients
but
for
society,
too.
If
this
sounds
idealistic
I
remember
the
words
of
Halfdan
Mahler,
former
Director-‐General
of
WHO,
who
said
when
we
published
the
report
of
the
Commission
on
Social
Determinants
of
Health:
remember,
idealists
are
the
realists
in
human
progress.
I
have
another
poet
who
has
been
my
companion.
When
we
launched
the
Commission
on
Social
Determinants
of
Health
in
Santiago
Chile
I
quoted
Pablo
Neruda.
I
did
again
at
each
report
we
have
published
and
I
do
so
again
now.
I
invite
you
to:
Rise
up
with
me…
Against
the
organisation
of
misery.