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The Marmot Review – Social revolution by Stealth
Social Science & Medicine 71 (2010) 1237e1239
Contents lists available at ScienceDirect
Social Science & Medicine journal homepage: www.elsevier.com/locate/socscimed
The Marmot Review e Social revolution by Stealth Constance Nathanson*, Kim Hopper Columbia University, Mailman School of Public Health, New York, NY 10032, USA
a r t i c l e i n f o Article history: Available online 5 August 2010 Keywords: Fair Society, Healthy Lives (The Marmot Review) Health inequalities
Introduction “Rise up with me against the organisation of misery” is the epigraph chosen by Sir Michael Marmot for his deceptively bureaucratic report to Britain’s Secretary of State for Health on the policy challenge of health inequalities. Those words, from the poet and icon of the left, Pablo Neruda, are a reasonably accurate summary of the report’s underlying message: “the fundamental drivers that give rise to [social inequalities in health are] inequities in power, money and resources”(Marmot, 2010, p.16), and serious engagement with those inequities requires that power and resources be redistributed from those at the top to those lower down on the social ladder (Marmot, 2010, p.151). Epigraph not withstanding, this message is otherwise well disguised in an almost mind-numbing recital of statistics, tables and graphs documenting the social gradient in everything from mortality to use of public parks to children’s bedtime hours, followed by detailed recommendationsdheavily documented and illustrated with case studiesdon what should be done and/or is being done to level the gradient. This is revolution without revolutionaries and politicsdfor many of the report’s recommendations will be politically contentiousdwithout politicians. Readers of Social Science & Medicine (as opposed, perhaps, to readers of the Financial Times) will probably find little to disagree with in recommendations for one year’s paid parental leave following childbirth and a minimum living wage for everyone (among many others). The key question, and the one to which we will devote the bulk of this essay, isdabsent politicians and/or revolutionariesd how are these radical changes to come about?
* Corresponding author. Tel.: þ1 212 305 1593. E-mail address: [email protected] (C. Nathanson). 0277-9536/$ e see front matter Ó 2010 Published by Elsevier Ltd. doi:10.1016/j.socscimed.2010.07.007
First, however, we will briefly overview the contents of the Marmot Review 2010, paying particular attention to the report’s framing of health inequalities and to its construction of causal chains between the “causes of the causes” (inequalities) and their health consequences. Health inequalities as a public problem The Marmot Review has an illustrious pedigree, beginning with Edwin Chadwick’s Report on the Sanitary Condition of the Labouring Population of Great Britain in 1842, running through the Black (1980) and Acheson (1998) Reports, with nods to the nineteenthcentury French hygiènistes and the 1974 Lalonde report, A New Perspective on the Health of Canadians. Although sharing with Marmot the conviction that health care systems are not the solution to problems of population health, Lalonde had nothing to say about social inequalities. And while the nineteenth-century French were convinced of the link between poverty and disease, they were unprepared to advocate for the revolutionary measures they believed (perhaps correctly) would be necessary to make a change. Only the British have taken the injuries of class seriously as a public problem worthy of official attention at the highest levels of government. However, although Chadwick represented the problem as one of engineeringdfixing the “places and structuresdpipes, streets, houses”(Hamlin 1994, p. 144) of the urban poor, and Black (1980) emphasized conditions of “material deprivation,” only Marmot has identified the condition to be addresseddthe disease, if you willdas inequality itself: the unfair, unjust, and (to Marmot and his colleagues) unacceptable inequalities in health between those at the top of the social scale and everyone else. From this perspective, “a preferential option for the poor” is clearly insufficient as a corrective to health inequalities (Paul Farmer and a host of allies notwithstanding [see e.g., Farmer, 2003]). It’s the
1238
C. Nathanson, K. Hopper / Social Science & Medicine 71 (2010) 1237e1239
entire range of imbalancedthe gradient itselfdthat must be tackled. If sheer weight of data is sufficient to raise a problem from the status of background noise (“for ye have the poor always with you”) to “something that public action should ‘do something about’” (Gusfield, 1981: p.10), then the Marmot report has done its work admirably. Marmot’s central thesis is that “the relationship between social circumstances and health is a graded one: the higher a person’s social position, the better his or her health” (Marmot, 2010, p.37). As we have said, this point is documented in ferocious detail and in elegant graphs throughout the text and in upwards of 65 tables and figures demonstrating not just the gradient in health outcomes (e.g., life expectancy, infant and adult mortality, morbidity, disability), but also gradients in a very wide range of “intervening variables” (e.g., early cognitive development, schooling, uncertain employment and unemployment, “metabolic syndrome,” air pollution, green spaces, and so on). Nevertheless, the mechanisms by which this chain of causation produces desirable and/or undesirable health outcomes remain somewhat unclear: “.serious health inequalities .cannot be attributed simply to genetic makeup, ‘bad’ unhealthy behaviour [pace Lalonde], or differences in access to medical care..Social and economic differences in health status reflect, and are caused by, social and economic inequalities in society” (2010, p.16). Yes, but if we exclude unhealthy behaviors and access to medical care, then how do “social and economic inequalities” produce their effects? Transmission, we infer, occurs through the cumulative impact of negatively signed “intervening variables”dpoor cognitive development, exposure to air pollution, etc.don “the conditions of daily lifedthe conditions in which people are born, live, work and age.”(2010, p.37). There is, in addition, a fourth, somewhat less explicit, link in the chain, running between the “intervening variables” and health outcomes and variously phrased as stress, selfesteem, self-confidence, social capital, social networks, social support or, more generally, the ability to “take control” of one’s life. Indeed, the report states early on that its “central ambition.is to create the conditions for people to take control over their own lives” (2010, p.18). Given the report’s overall emphasis on social structural determinants of health, this latter mantra (recurring throughout the report) rings rather oddly, not only because it is an individual- not a structural-level variable, but also because “taking control” is by no means a guarantee of good health: think race car driving or mountain climbing, or planting a bomb in Times Square. The report’s Nerudian gloss is further blunted and depoliticized by the priority given to infants and toddlers as the vanguard of social change. Innocent children, uncorrupted by the world, putty in the hands of experts who know better than their parents, have always and forever been a preferred target of moral reformers. This is due in part, of course, to their relative political marketability, but also to Marmot and colleagues’ evident conviction of the strain that disadvantagedthe mundane humiliations and worries of chronic povertydplaces on parenting (not to speak of spousal relationships, face-to-face time and interest, and general home atmosphere). Perhaps adults are beyond the pale of reform (as the report sometimes appears to suggest) but they are also likely to be more resistant to the intrusions of health visitors, health trainers, health championsdthe panoply of street-level workers envisioned by the Marmot report as leading the health charge at the local level. There is something very cozy, and peculiarly Britishdharking back to the lady health visitors of the late nineteenth-centurydabout the notion of “intensive home-visiting programmes”(2010, p.97) as the means of bringing light to the heathen. The report suggests that these visits are welcomed by young mothersdas they undoubtedly often aredbut the aura of noblesse oblige still clings.
The road to Nirvana How to get there from heredhow to accomplish the revolutiondis the subject matter of Chapters 3 (essentially a critique of current British government strategies to address health inequalities) and 5 (“Making it happen”). Roads to be avoided include small bore programs with short time scales and, coming in for the greatest anathema, programs that focus on “lifestyle” change: “Health inequalities are likely to persist between socioeconomic groups, even if lifestyle factors (such as smoking) are equalized.” (2010, p.86). Indeed, such “interventions to improve health may increase inequalities”(2010, p.86) because the rich, not the poor, have the resources, know-how, time and inclination to take them up and put them to use, as our colleagues Link and Phelan have unfailingly reminded us (Link, 2008; Link & Phelen, 1995; Phelen, Link, Diez-Roux, Kawachi, & Levin, 2004). How then to make it happen? This brings us, in the first instance, to questions of ownership and responsibility (cf. Gusfield, 1981: p.9e16). Who has the authority to define and describe the problem of health inequalities and where falls the responsibility for solving the problemdthe obligation to actually do something about it? These questions are at least partially answered in the present case by the structure of the Marmot Review itself. Authority to define the problem and to make recommendations for its solution was vested in an illustrious group of 11 experts (six of whom are titled, four of whom are physicians) chaired by Professor Sir Michael Marmot, and responsibility for solving the problem lies with the officials who commissioned the report, the Secretary of State for Health and his colleagues in the British government. How these latter officials should go about their work is, of course, a principal topic of the review’s recommendations. Among the clearest messages of the Marmot report is that responsibility for addressing health inequalities should not be limited to the National Health Service or to any other single government department, nationally or locally: “responsibility for the social determinants of health lies across government”(p.152). This imperative is reinforced by the recommendation that “all national and local policies and strategies should be routinely scrutinised through a health equity impact statement”(p.152). Recognizing, however, that everyone’s responsibility rapidly becomes the responsibility of none, Marmot proposes what amounts to a health inequalities tsar: lead political responsibility would be vested “at Cabinet level with the Secretary of State for Health,” supported by “a joint multi-skilled cross-cutting team with a single director” (p.152, emphasis ours). Immediately preceding this proposal, and arguably in contradiction to it, the authors make some of their strongest statements about the need for a redistribution of power and resources to local communities: “Without citizen participation and community engagement fostered by public service organisations, it will be difficult to improve penetration of interventions and to impact on health inequalities” (p.151). Reconciling centralized policy coordination with grassroots participation is politically and ideologically tricky, perhaps particularly so for parliamentary systems that combine concentration of political power in the executive branch with a relatively weak voluntary sector (weak relative, say, to the United States). As has become evident over the past 20 years in France, it is one thing to advocate for citizen participation in health policy and, in the absence of a tradition of participation and of preexisting organizational templates, quite another to convert that rhetoric into reality (Callon et al. 2001, Pierru 2007). In light of the strong statements about devolving power to citizens and communities with which Chapter 5 (the “making it happen” chapter) opens, succeeding comments about what the report labels “the third
C. Nathanson, K. Hopper / Social Science & Medicine 71 (2010) 1237e1239
sector” (jargon which we take to refer to voluntary organizations) are particularly striking. The “third sector” is clearly perceived as the weakest link in the spectrum of local bodies that are to be tasked with addressing health inequalities: poorly funded, heavily dependent on government grants and contracts, and more often than not ignored by local governments and others engaged in policy planning (p.160). If power and resources are to be redistributed to citizens and communities, where then will those resources go? Do Local Governments and Local Councils have any history of mobilizing local citizenry to assert power and demand change in the social, health, and welfare policies that affect them? Chapter 5 makes frequent reference to “Local Strategic Partnerships” (LSPs), “multiagency partnerships bringing together the different parts of the public, private, community and voluntary sectors locally”(p.158) but then goes on to say that “LSPs do not have legal powers or resources of their own”(p.161). Their power is currently limited to exhortation, and it is unclear whether they have a strong track record of “community engagement.” Given what appears to be the underfunding of existing bodies, it seems quite possible that a redistribution of resources to the local level would lead not to increased “partnership working” (another British term of art) but to increased competition. One of us (Nathanson 2007) has argued that public health action comes about through “some combination of three ingredients: perceived peril to the nation or to the accepted social order, state interest and capacity, and advocacy group pressure” (p.248e249). In the present case, none of the stars are favorably aligned. Insofar as Britain is in peril, the peril is perceived as a threat to its financial health not to the health of its people, and the solution prescribed (at least by the Financial Times) could not be further from the recommendations of the Marmot Review. “The next government will have to cut public sector pay, freeze benefits, slash jobs, abolish a range of welfare entitlements and take the ax to programs such as school building and road maintenance” (cited in Friedman, 2010, p. 8). The report itself was commissioned by the outgoing Labour government. Whatever the capacity of the new Conservative - LiberalDemocrat coalition government, its interest in health inequalities is bound, at the very least, be less than that of its predecessor. Finally, there is nothing in Marmot to suggest that advocacy group pressure played an important role in originating this report or in shaping its contents. The implications of the Marmot Review are revolutionary
1239
but the work itself is that of a small and highly elite body of scientific and policy experts. A road to the Finland Station it is not. Given the report’s uncompromising ambition to flatten the social gradient by swinging up its left, downward-leaning, taildand its seeming blindness to the obstacles along this revolutionary road, are we left with more than another addition to an already impressive stack of similarly pitched and equally scholarly reports? Perhaps. As in the present case, the Black Report (1980) was commissioned by a Labour government. It was very-ill received by the Conservative government in power by the time the report was presented. Nonetheless, the recommendations of the Black report (and the subsequent Acheson report), particularly the commitment to end child poverty, guided many policy actions of the late Labour government. Sooner or later, when the political stars are again aligned and the opportunity for action presents itself, activists lying in wait may take the Marmot Review off the shelf, dust it up, and use itdlike Chairman Mao’s Little Red Bookdas a guide to action.
References Callon, M., Lascoumes, P., & Barthe, Y. (2001). Agir dans un monde incertain. Essai sur la démocratie technique. Paris: Le Seuil. Chadwick, Edwin. 1842 (1965). Report on an Inquiry into the Sanitary Condition of the Labouring Population of Great Britain. Edinburgh: Edinburgh University Press. Farmer, P. (2003). Pathologies of power: Health, human rights, and the new war on the poor. Berkeley: University of California Press. Friedman, T. (May 8, 2010). Root canal politics. New York Times: News in Review. p. 8. Gusfield, J. R. (1981). The culture of public problems. Drinking driving and the symbolic order. Chicago: The University of Chicago Press. Independent Inquiry into Inequalities in Health Report. Chairman: Sir Donald Acheson. London: Her Majesty’s Stationery Office, 1998. (“The Acheson Report”). Inequalities in Health: The Black Report and The Health Divide (2nd edition). Penguin Books, 1992. (“The Black Report,” first published in 1980). Link, B. G. (2008). Epidemiological sociology and the social shaping of population health. Journal of Health and Social Behavior, 49(December), 367e384. Link, B. G., & Phelen, Jo C. (1995). Social conditions as fundamental causes of disease. Journal of Health and Social Behavior, 35(Extra Issue), 80e94. Marmot, M. (2010). Fair society, healthy lives: Strategic review of health inequalities in England post-2010. London: The Marmot Review. Nathanson, C. A. (2007). Disease prevention as social change: The state, society, and public health in the United States, France, Great Britain, and Canada. New York: Russell Sage Foundation. Phelen, Jo C., Link, Bruce G., Diez-Roux, A., Kawachi, Ichiro, & Levin, Bruce (2004). Journal of Health and Social Behavior, 45(September), 265e285. Pierru, F. (2007). Hippocrate Malade de ses Réformes. Broissieux. France: Éditions du Croquant.
Contents lists available at ScienceDirect
Social Science & Medicine journal homepage: www.elsevier.com/locate/socscimed
The Marmot Review e Social revolution by Stealth Constance Nathanson*, Kim Hopper Columbia University, Mailman School of Public Health, New York, NY 10032, USA
a r t i c l e i n f o Article history: Available online 5 August 2010 Keywords: Fair Society, Healthy Lives (The Marmot Review) Health inequalities
Introduction “Rise up with me against the organisation of misery” is the epigraph chosen by Sir Michael Marmot for his deceptively bureaucratic report to Britain’s Secretary of State for Health on the policy challenge of health inequalities. Those words, from the poet and icon of the left, Pablo Neruda, are a reasonably accurate summary of the report’s underlying message: “the fundamental drivers that give rise to [social inequalities in health are] inequities in power, money and resources”(Marmot, 2010, p.16), and serious engagement with those inequities requires that power and resources be redistributed from those at the top to those lower down on the social ladder (Marmot, 2010, p.151). Epigraph not withstanding, this message is otherwise well disguised in an almost mind-numbing recital of statistics, tables and graphs documenting the social gradient in everything from mortality to use of public parks to children’s bedtime hours, followed by detailed recommendationsdheavily documented and illustrated with case studiesdon what should be done and/or is being done to level the gradient. This is revolution without revolutionaries and politicsdfor many of the report’s recommendations will be politically contentiousdwithout politicians. Readers of Social Science & Medicine (as opposed, perhaps, to readers of the Financial Times) will probably find little to disagree with in recommendations for one year’s paid parental leave following childbirth and a minimum living wage for everyone (among many others). The key question, and the one to which we will devote the bulk of this essay, isdabsent politicians and/or revolutionariesd how are these radical changes to come about?
* Corresponding author. Tel.: þ1 212 305 1593. E-mail address: [email protected] (C. Nathanson). 0277-9536/$ e see front matter Ó 2010 Published by Elsevier Ltd. doi:10.1016/j.socscimed.2010.07.007
First, however, we will briefly overview the contents of the Marmot Review 2010, paying particular attention to the report’s framing of health inequalities and to its construction of causal chains between the “causes of the causes” (inequalities) and their health consequences. Health inequalities as a public problem The Marmot Review has an illustrious pedigree, beginning with Edwin Chadwick’s Report on the Sanitary Condition of the Labouring Population of Great Britain in 1842, running through the Black (1980) and Acheson (1998) Reports, with nods to the nineteenthcentury French hygiènistes and the 1974 Lalonde report, A New Perspective on the Health of Canadians. Although sharing with Marmot the conviction that health care systems are not the solution to problems of population health, Lalonde had nothing to say about social inequalities. And while the nineteenth-century French were convinced of the link between poverty and disease, they were unprepared to advocate for the revolutionary measures they believed (perhaps correctly) would be necessary to make a change. Only the British have taken the injuries of class seriously as a public problem worthy of official attention at the highest levels of government. However, although Chadwick represented the problem as one of engineeringdfixing the “places and structuresdpipes, streets, houses”(Hamlin 1994, p. 144) of the urban poor, and Black (1980) emphasized conditions of “material deprivation,” only Marmot has identified the condition to be addresseddthe disease, if you willdas inequality itself: the unfair, unjust, and (to Marmot and his colleagues) unacceptable inequalities in health between those at the top of the social scale and everyone else. From this perspective, “a preferential option for the poor” is clearly insufficient as a corrective to health inequalities (Paul Farmer and a host of allies notwithstanding [see e.g., Farmer, 2003]). It’s the
1238
C. Nathanson, K. Hopper / Social Science & Medicine 71 (2010) 1237e1239
entire range of imbalancedthe gradient itselfdthat must be tackled. If sheer weight of data is sufficient to raise a problem from the status of background noise (“for ye have the poor always with you”) to “something that public action should ‘do something about’” (Gusfield, 1981: p.10), then the Marmot report has done its work admirably. Marmot’s central thesis is that “the relationship between social circumstances and health is a graded one: the higher a person’s social position, the better his or her health” (Marmot, 2010, p.37). As we have said, this point is documented in ferocious detail and in elegant graphs throughout the text and in upwards of 65 tables and figures demonstrating not just the gradient in health outcomes (e.g., life expectancy, infant and adult mortality, morbidity, disability), but also gradients in a very wide range of “intervening variables” (e.g., early cognitive development, schooling, uncertain employment and unemployment, “metabolic syndrome,” air pollution, green spaces, and so on). Nevertheless, the mechanisms by which this chain of causation produces desirable and/or undesirable health outcomes remain somewhat unclear: “.serious health inequalities .cannot be attributed simply to genetic makeup, ‘bad’ unhealthy behaviour [pace Lalonde], or differences in access to medical care..Social and economic differences in health status reflect, and are caused by, social and economic inequalities in society” (2010, p.16). Yes, but if we exclude unhealthy behaviors and access to medical care, then how do “social and economic inequalities” produce their effects? Transmission, we infer, occurs through the cumulative impact of negatively signed “intervening variables”dpoor cognitive development, exposure to air pollution, etc.don “the conditions of daily lifedthe conditions in which people are born, live, work and age.”(2010, p.37). There is, in addition, a fourth, somewhat less explicit, link in the chain, running between the “intervening variables” and health outcomes and variously phrased as stress, selfesteem, self-confidence, social capital, social networks, social support or, more generally, the ability to “take control” of one’s life. Indeed, the report states early on that its “central ambition.is to create the conditions for people to take control over their own lives” (2010, p.18). Given the report’s overall emphasis on social structural determinants of health, this latter mantra (recurring throughout the report) rings rather oddly, not only because it is an individual- not a structural-level variable, but also because “taking control” is by no means a guarantee of good health: think race car driving or mountain climbing, or planting a bomb in Times Square. The report’s Nerudian gloss is further blunted and depoliticized by the priority given to infants and toddlers as the vanguard of social change. Innocent children, uncorrupted by the world, putty in the hands of experts who know better than their parents, have always and forever been a preferred target of moral reformers. This is due in part, of course, to their relative political marketability, but also to Marmot and colleagues’ evident conviction of the strain that disadvantagedthe mundane humiliations and worries of chronic povertydplaces on parenting (not to speak of spousal relationships, face-to-face time and interest, and general home atmosphere). Perhaps adults are beyond the pale of reform (as the report sometimes appears to suggest) but they are also likely to be more resistant to the intrusions of health visitors, health trainers, health championsdthe panoply of street-level workers envisioned by the Marmot report as leading the health charge at the local level. There is something very cozy, and peculiarly Britishdharking back to the lady health visitors of the late nineteenth-centurydabout the notion of “intensive home-visiting programmes”(2010, p.97) as the means of bringing light to the heathen. The report suggests that these visits are welcomed by young mothersdas they undoubtedly often aredbut the aura of noblesse oblige still clings.
The road to Nirvana How to get there from heredhow to accomplish the revolutiondis the subject matter of Chapters 3 (essentially a critique of current British government strategies to address health inequalities) and 5 (“Making it happen”). Roads to be avoided include small bore programs with short time scales and, coming in for the greatest anathema, programs that focus on “lifestyle” change: “Health inequalities are likely to persist between socioeconomic groups, even if lifestyle factors (such as smoking) are equalized.” (2010, p.86). Indeed, such “interventions to improve health may increase inequalities”(2010, p.86) because the rich, not the poor, have the resources, know-how, time and inclination to take them up and put them to use, as our colleagues Link and Phelan have unfailingly reminded us (Link, 2008; Link & Phelen, 1995; Phelen, Link, Diez-Roux, Kawachi, & Levin, 2004). How then to make it happen? This brings us, in the first instance, to questions of ownership and responsibility (cf. Gusfield, 1981: p.9e16). Who has the authority to define and describe the problem of health inequalities and where falls the responsibility for solving the problemdthe obligation to actually do something about it? These questions are at least partially answered in the present case by the structure of the Marmot Review itself. Authority to define the problem and to make recommendations for its solution was vested in an illustrious group of 11 experts (six of whom are titled, four of whom are physicians) chaired by Professor Sir Michael Marmot, and responsibility for solving the problem lies with the officials who commissioned the report, the Secretary of State for Health and his colleagues in the British government. How these latter officials should go about their work is, of course, a principal topic of the review’s recommendations. Among the clearest messages of the Marmot report is that responsibility for addressing health inequalities should not be limited to the National Health Service or to any other single government department, nationally or locally: “responsibility for the social determinants of health lies across government”(p.152). This imperative is reinforced by the recommendation that “all national and local policies and strategies should be routinely scrutinised through a health equity impact statement”(p.152). Recognizing, however, that everyone’s responsibility rapidly becomes the responsibility of none, Marmot proposes what amounts to a health inequalities tsar: lead political responsibility would be vested “at Cabinet level with the Secretary of State for Health,” supported by “a joint multi-skilled cross-cutting team with a single director” (p.152, emphasis ours). Immediately preceding this proposal, and arguably in contradiction to it, the authors make some of their strongest statements about the need for a redistribution of power and resources to local communities: “Without citizen participation and community engagement fostered by public service organisations, it will be difficult to improve penetration of interventions and to impact on health inequalities” (p.151). Reconciling centralized policy coordination with grassroots participation is politically and ideologically tricky, perhaps particularly so for parliamentary systems that combine concentration of political power in the executive branch with a relatively weak voluntary sector (weak relative, say, to the United States). As has become evident over the past 20 years in France, it is one thing to advocate for citizen participation in health policy and, in the absence of a tradition of participation and of preexisting organizational templates, quite another to convert that rhetoric into reality (Callon et al. 2001, Pierru 2007). In light of the strong statements about devolving power to citizens and communities with which Chapter 5 (the “making it happen” chapter) opens, succeeding comments about what the report labels “the third
C. Nathanson, K. Hopper / Social Science & Medicine 71 (2010) 1237e1239
sector” (jargon which we take to refer to voluntary organizations) are particularly striking. The “third sector” is clearly perceived as the weakest link in the spectrum of local bodies that are to be tasked with addressing health inequalities: poorly funded, heavily dependent on government grants and contracts, and more often than not ignored by local governments and others engaged in policy planning (p.160). If power and resources are to be redistributed to citizens and communities, where then will those resources go? Do Local Governments and Local Councils have any history of mobilizing local citizenry to assert power and demand change in the social, health, and welfare policies that affect them? Chapter 5 makes frequent reference to “Local Strategic Partnerships” (LSPs), “multiagency partnerships bringing together the different parts of the public, private, community and voluntary sectors locally”(p.158) but then goes on to say that “LSPs do not have legal powers or resources of their own”(p.161). Their power is currently limited to exhortation, and it is unclear whether they have a strong track record of “community engagement.” Given what appears to be the underfunding of existing bodies, it seems quite possible that a redistribution of resources to the local level would lead not to increased “partnership working” (another British term of art) but to increased competition. One of us (Nathanson 2007) has argued that public health action comes about through “some combination of three ingredients: perceived peril to the nation or to the accepted social order, state interest and capacity, and advocacy group pressure” (p.248e249). In the present case, none of the stars are favorably aligned. Insofar as Britain is in peril, the peril is perceived as a threat to its financial health not to the health of its people, and the solution prescribed (at least by the Financial Times) could not be further from the recommendations of the Marmot Review. “The next government will have to cut public sector pay, freeze benefits, slash jobs, abolish a range of welfare entitlements and take the ax to programs such as school building and road maintenance” (cited in Friedman, 2010, p. 8). The report itself was commissioned by the outgoing Labour government. Whatever the capacity of the new Conservative - LiberalDemocrat coalition government, its interest in health inequalities is bound, at the very least, be less than that of its predecessor. Finally, there is nothing in Marmot to suggest that advocacy group pressure played an important role in originating this report or in shaping its contents. The implications of the Marmot Review are revolutionary
1239
but the work itself is that of a small and highly elite body of scientific and policy experts. A road to the Finland Station it is not. Given the report’s uncompromising ambition to flatten the social gradient by swinging up its left, downward-leaning, taildand its seeming blindness to the obstacles along this revolutionary road, are we left with more than another addition to an already impressive stack of similarly pitched and equally scholarly reports? Perhaps. As in the present case, the Black Report (1980) was commissioned by a Labour government. It was very-ill received by the Conservative government in power by the time the report was presented. Nonetheless, the recommendations of the Black report (and the subsequent Acheson report), particularly the commitment to end child poverty, guided many policy actions of the late Labour government. Sooner or later, when the political stars are again aligned and the opportunity for action presents itself, activists lying in wait may take the Marmot Review off the shelf, dust it up, and use itdlike Chairman Mao’s Little Red Bookdas a guide to action.
References Callon, M., Lascoumes, P., & Barthe, Y. (2001). Agir dans un monde incertain. Essai sur la démocratie technique. Paris: Le Seuil. Chadwick, Edwin. 1842 (1965). Report on an Inquiry into the Sanitary Condition of the Labouring Population of Great Britain. Edinburgh: Edinburgh University Press. Farmer, P. (2003). Pathologies of power: Health, human rights, and the new war on the poor. Berkeley: University of California Press. Friedman, T. (May 8, 2010). Root canal politics. New York Times: News in Review. p. 8. Gusfield, J. R. (1981). The culture of public problems. Drinking driving and the symbolic order. Chicago: The University of Chicago Press. Independent Inquiry into Inequalities in Health Report. Chairman: Sir Donald Acheson. London: Her Majesty’s Stationery Office, 1998. (“The Acheson Report”). Inequalities in Health: The Black Report and The Health Divide (2nd edition). Penguin Books, 1992. (“The Black Report,” first published in 1980). Link, B. G. (2008). Epidemiological sociology and the social shaping of population health. Journal of Health and Social Behavior, 49(December), 367e384. Link, B. G., & Phelen, Jo C. (1995). Social conditions as fundamental causes of disease. Journal of Health and Social Behavior, 35(Extra Issue), 80e94. Marmot, M. (2010). Fair society, healthy lives: Strategic review of health inequalities in England post-2010. London: The Marmot Review. Nathanson, C. A. (2007). Disease prevention as social change: The state, society, and public health in the United States, France, Great Britain, and Canada. New York: Russell Sage Foundation. Phelen, Jo C., Link, Bruce G., Diez-Roux, A., Kawachi, Ichiro, & Levin, Bruce (2004). Journal of Health and Social Behavior, 45(September), 265e285. Pierru, F. (2007). Hippocrate Malade de ses Réformes. Broissieux. France: Éditions du Croquant.