On the 25th February, hundreds of people gathered in Westminster, just a stone’s throw away from Parliament, to hear the latest findings from Professor Sir Michael Marmot’s new report, Health Equity in England, The Marmot Review 10 years on.
The room was charged with anger and frustration as we heard how little had improved since Fair Society, Healthy Lives, Marmot’s report of 10 years ago. If anything, the situation was worse, with more people living in poor health, and life expectancy falling for some groups, most notably for men and women living in the most deprived communities.
But there was also a sense of restless energy and a collective hope that we might, at last, see change. After all, we had a Government that was committed to ‘levelling up’ - and here it was being presented with evidence that could no longer be ignored.
At the same time - less than a month before we went into lockdown - new cases of COVID-19 were emerging all over the globe. We knew it was coming - but little did we realise how far it would come to expose the frailty of our public health system and the terrible consequences of our long-standing failure to invest in prevention or to address inequalities in health.
More than four months on, we are still a long way from understanding the true nature of this virus and its effects. What we do know is that mortality in our poorest areas has been twice that of the wealthiest and the impact on minority ethnic communities has been devastating. The virus has not only highlighted inequalities: it has exacerbated them and used them as vectors for transmission with unbelievable speed and unimaginable human and economic consequences.
The truth is, we should not have been surprised. Marmot’s data is backed up by dozens of studies and hundreds of human stories. They all tell us the same thing - that public health outcomes are determined by factors outside our individual control; by inequalities in our social, environmental and economic circumstances, as well as our age, gender, ethnicity, and sexuality.
'The social conditions in society render you more likely to get illness and to die earlier the lower you are in the social hierarchy. If it's a pandemic, you succumb to the pandemic, and if it's a non-communicable disease you succumb to that too.'Sir Michael Marmot
The evidence has not been contested. But even though we have long known that up to 75 per cent of our health is determined by upstream determinants that could be addressed, the UK continues to spend little more than 4 per cent of health research funding on public health and prevention, with a tiny fraction of this on developing and testing real world solutions. And even though there has been promising action, in places like Coventry, Greater Manchester and Bradford - research commissioned by Nesta shows that R&D spending continues to be regionally imbalanced, with nearly half of all public and charitable R&D investment concentrated in the ‘golden triangle’ of London, Oxford and Cambridge, the three most unequal cities in the UK.
The pandemic has catapulted population health and health inequalities to the top of the national policy agenda, yet they remain poor cousins to the more headline-friendly fields of biomedicine and technology; seemingly less exciting than the race for a new vaccine or the allure of a ‘world beating track and trace system’. And this is only too apparent when you look at who is giving advice to the Government’s SAGE Committee; with just six of the 55 experts appearing to have any kind of specialist background in social determinants research or health inequalities, and just one with experience in an operational public health role.
Furthermore, there is still no formal mechanism for engaging the public in decisions about our steps out of lockdown, how people want to be supported or what it would mean to them to ‘build back better.’ This is now an urgent priority, particularly for those considered most vulnerable to the virus who may be facing an indefinite period of self isolation.
Since the first Marmot report ten years ago, Nesta has been working with innovators, frontline workers and citizen activists to create new ways to improve health through a people-powered approach.
Last year, we began advocating for the creation of an innovation and research centre that would work across government and civic society, encouraging partnerships, transdisciplinary and community participation approaches and generating and testing new ideas to improve health and address inequalities. As an independent public health body, it would convene experts from multiple fields alongside representatives from communities across the UK, and it would provide clear, impartial, evidence-based leadership and advice.
Just before the pandemic, we started to consider the kinds of topics and questions that a body of this kind would work on and how it could work in partnership with local people and places to prioritise what matters most to them. We worried that the urgent need to protect the public from COVID-19 would divert attention away from the need to address structural inequalities and improve health for all. Would this mean that a new body of the kind we had been calling for would no longer be needed?
Far from it. In fact, imagine the difference it might it have made if such a body had already been in existence and had been able to rapidly convene diverse groups of experts and citizens, build understanding, and offer independent advice about the likely impacts of a whole range of infection control interventions on people’s health, well being and health equity? And imagine if it was here now - how it might offer funding, support and expertise to local authorities and their academic and community partners, to help them design and rigorously test new solutions to build back healthier and stronger than before.
COVID-19 has exposed just how far inequalities impact health and why our long-standing bias towards biomedical research and treatment services has left far too many people at risk of developing health conditions that could have been prevented. We cannot let this happen again. This week the Government re-confirmed its commitment to significantly increasing public R&D spending to £22 billion by 2025 as part of a new R&D roadmap. It also asked important questions about whether the UK has the right balance of funding across different types of research and institutions to ‘ensure it translates its research and innovation into tangible benefits for citizens’. If it is committed to ‘levelling up’ and addressing the unequal consequences of the pandemic and their structural causes, we strongly urge it to prioritise public health research and to establish a new independent body to take this work forward.
Amongst all the tragedy of the last few months, we have also seen a new spirit of cooperation - from local communities taking ownership and action, to services working together across traditional siloes, to people standing together to fight racism and demand equity. There is a need for change - and optimism that it can happen. But it won’t happen by accident - it will need serious investment and a far more equitable and collaborative approach to research, innovation and decision-making.