Gabriel Scally: A grotesque parody of fairness

It’s a long way to go from Bristol to Boston for a conference, but I’m adding to my carbon footprint and attending the 141st American Public Health association meeting. It’s an enormous meeting. Despite some tough times in the US local public health departments, 13 000 people are making this meeting, yet again, the biggest public health gathering in the world.

The APHA has a track record of attracting high profile speakers to its opening session. The highlight of the 2012 opening was a tour de force by the Democrat House of Representatives leader, Nancy Pelosi. That was always going be tough act to follow. The audience at the 2013 opening session was captivated not by a high profile American politician, a movie star or novelist, but by an English public health academic. Those of us who have heard Sir Michael Marmot speak at conferences over the past years have come to know what to expect. His contribution in respect of the social determinants of health is truly outstanding and is of global significance. His impeccably measured, intellectual, and analytical presentations have convinced world leaders and policy makers to take health equity seriously. We all expected more of the same.

But this time what we got wasn’t the Michael Marmot we expected. There was an outpouring of passion, anger, and steely commitment that gripped and shook his enormous audience. With his very first words he invited members of his audience to look along the row and count ten women. He contrasted the one in every ten women who die from a maternal related condition in Afghanistan, with the one in 46 500 women who die of the same cause in some of the most prosperous European countries. Marmot deemed it an entirely unnecessary and preventable toll of lives. He went on to state that a toxic combination of poorer social policies and programmes, unfair economic arrangements, and bad governance is responsible for most of the health inequities that we see.

In the most compelling section of his address he turned his fire squarely and accurately on the British government. Explaining that he had put the concept of “fairness” at the centre of his prescription to improve health and reduce health inequalities, he expressed slight regret about the terminology. The precise words of his next remarks were:  “The government in Britain that we have now, the Conservative led coalition government, uses the word ‘fairness’ as if it has no meaning at all. They cut the top rate of tax—and they call it fair. They cut benefits to the poor—and they call it fair. They cut services to the disadvantaged—and they call it fair. I call it a grotesque parody of fairness!

Not surprisingly, his passionate defence of the poor and castigation of the British government were the main topic of conversation for the rest of the day. Seeking to explain what we had experienced I though back to Thomas Paine, the 18th century Englishman and American revolutionary, who wrote, “These are the times that try men’s souls.” After Michael Marmot’s speech in Boston we know there is at least one more man whose soul has been sorely tried and who isn’t afraid to speak out plainly and fearlessly in defence of civilisation and humanity.

Gabriel Scally is professor of public health and planning at the University of the West of England and director of the WHO Collaborating Centre for Healthy Urban Environments.

Competing interests: The author has completed the ICMJE uniform disclosure form at and declares: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • David Hunter

    It’s not the first time Sir Michael has graced the APHA with his presence. He did so at San Diego in 2008 on the occasion of his report from the global Commission on the Social Determinants of Health. I recall seeing him then speaking to 1200 delegates most of whom were transfixed by Marmot’s image displayed on large plasma screens throughout the convention hall. His messages then about toxic policies contributing to widening health inequalitieis. still rings true and a great deal has happened since then. Maybe he should be saying these things a bit louder at home, too. Why should the Americans have the benefit of his wisdom and advocacy?

  • nrg_solutions

    @David Hunter – Have you not read this

    I believe his voice is loud and clear – it’s just that very many people in Government and the NHS are simply not responding. If Govt spent as much energy transforming the Health Service into a pro-active, preventative force instead of selling it off piece by piece to their cronies, we might actually have a chance of reducing the appalling health inequalities in this country.

    We could start by aligning the aims of of the now defunct DoH Warm Homes Healthy People policy with Energy Company Obligation Fuel Poverty policies and dealing with the worst health inequality of all – living in a cold home.

  • Gareth Williams

    Good to hear that Sir Michael Marmot is making these comments to the APHA, and it is a message that we need to hear back home, as David Hunter suggests. However, I think there is a large piece of ground between ‘impeccably measured, intellectual, and analytical presentations’ and ‘an outpouring of passion, anger, and steely commitment’. It is called community organizing and engagement and it can help translate analysis into action and turn our passionate outpourings into something more than hot air.

  • YouKnowBestOfAll

    The case that health inequalities should be addressed not only on moral/compassionate grounds, as these represent also inefficient and unsustainable allocation of limited public resources, has been put in August 2006 at 11th World Congress on Public Health in the presentation “Equity – A Premise for Efficiency in Public Health”, available here:

    So far, neither the UN Commission on Social Determinants of Health, nor the Marmot Review, nor the recent Review of SDH in EU could reveal/explain the generative mechanisms for health inequalities. This has been done with the Panayotov Matrix back in 2006, and in details in August 2008 The matrix explains the generative mechanisms and provides universal explanations and predictions, thus facilitates making the right choices (policies and/or interventions) to reduce health inequalities at any local context.