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Hello. I'm Jane Hutcheon. Welcome to the program,
where my guest is epidemiologist and public health expert
Sir Michael Marmot. Sir Michael is a professor and the president
of the World Medical Association. He was in Australia delivering
the ABC's 2016 Boyer Lecture Series. His family came to Australia
after the Second World War when he was four. He was the first member of his family
to go to university, becoming a doctor
before moving to the US and UK to research
international public health.

Sir Michael Marmot,
welcome to One Plus One. Thank you. Do you call yourself a Brit
or an Aussie? I'm confused.

I have to confess that I always,
for a long time, supported the English cricket team
'cause they were the underdog. They always got
absolutely humiliated by Australia. So, it was easy to support England
'cause they were the underdog, and then I kind of got the habit,
so now I support England. Oh, well, we'll forgive you, just this once!
Thank you. You were born in London in 1945. What kind of surroundings
did your family live in? Was it a well-off place? They'd been upwardly mobile, so it was sort of the lower end
of middle-class, whatever that means. They'd gone from
the East End of London, which was the very poor area
where migrants pitch up, and they'd moved north. So, it's the classic migration. The Indians have followed the Jews
around London, doing exactly the same thing. So, it was a very comfortable,
but not affluent, environment. And what kind of business
did your father work in? In the schmatta business,
in the rag trade.

So, he was making ladies' dresses,
not very successfully. And what was the reason your family moved to Australia
when you were four? I believe you were the youngest of... I'm the youngest of three boys. Three boys? England, post-World War II,
was in a state of privation. I mean, England pre-World War II
had been pretty deprived, gone through the Depression
and things were pretty nasty. After the war, there was
the continuation of rationing, things weren't working very well. My dad had been in Shanghai
in the 1920s and he said, "I'm going to take my family
back to Shanghai." So, we're moving to China. So, he said to my mum,
"I'm going to Shanghai. "I'll go first and get settled and
then you follow with the children." And my mother got a phone call
and she said, "Where are you?" He said, "I'm in Sydney." She said,
"I thought you were going to China. "Where's Sydney?" He said, "It's in Australia.
It's great here." "Oh, what happened to China?" Well, there was this chap
called Mao Tse-tung. It wasn't a very good time to set up
as a petty bourgeois in China, so he went to Sydney. And he said, "Sell the house.
Bring the children. "We're moving to Australia." And my dutiful mother
sold the house, packed the three children and we sailed off on the SS Tranto
for six weeks and arrived in Sydney
in August 1949. So, how did things go
as a new family in Australia? You lived in Sydney? We lived in Sydney. We were initially in Clovelly and then we moved to
the Eastern Suburbs, to Dover Heights,
and my dad made a good go of it. Again,
he stayed in the ladies' dresses, stayed in the rag trade. Um, and once again, I had a very secure,
comfortable childhood. So, as a boy, did you know that you wanted to work in medicine? I was really interested in science.

I was interested in the intellectual
challenge of science and... But I wasn't comfortable that
I was going to be any good at it. It didn't seem to me
there was much point being a second-rate scientist. You know, you're either going to be
Einstein or it's not worth doing, was somehow the way
I thought about it. And medicine seemed to have
this extra something about helping people,
actually doing good for people, applying science in the interest
of benefiting people. So, that did attract me and, of course,
being a good Jewish boy, you've either got to do medicine
or law or something like that, so I did medicine. So, did much change when
you arrived at Sydney University? Was it pretty much
as you expected it to be? Well, I worked very hard at medicine for two or three years, and then...I discovered that there was a whole university
out there. Discovered! There was a whole university
out there. And all that anatomy
and biochemistry, which was good and I did well at it, but there were people interested
in politics and literature and social things. I think I knew that medicine,
fascinating as it was, was a bit limited. And while I was fascinated
in the basic science of medicine and I was looking forward
to clinical medicine, but how did that relate
to society and politics and all those other things
that friends were doing? Because you did go to work
at a hospital where you saw how
people's social environment affected their illness. What did you mean by that? At that time, the late 1960s, Newtown was a lot of Greek,
Italian migrants. Particularly couldn't... Or Yugoslav as well. Couldn't speak English very well.

And they would come into
the accident and emergency with a pain in the belly,
and we were told, as young doctors, "Give them a bottle of white mixture
and they'll go home." What was the white mixture? Oh, it was antacids
of some form or another. "Give them a bottle of antacids
and send them home." And, then, I was not well read. I mean, I'd studied medicine, but I hadn't looked more broadly
at what was going on, but it seemed to me they were
coming in with problems in living and it was absurd to give them
a bottle of white mixture to cure their problems in living. I mean, if they're having difficulty
integrating into the society and that was causing them problems and they were coming in
with a pain in the belly, then simply a bottle
of white mixture wasn't going to help their problems. We had to somehow deal
with the issues that, really, they were facing. Did you fight it at the time? I was told... I mean, there was... In my final year of medicine,
one surgeon said to me, "Let me give you some advice. "You've got to learn a lot of stuff
to get through your final exams. "Stop asking questions. "Just learn it." Well, that wasn't very comfortable
and I remember one of my senior junior doctors
saying, complaining that she had to
do a ward round with me and it was going to be torture,
'cause I keep asking, "Why are we doing this?
Why are we doing that?" So, I guess I never stopped
asking questions. And they're of two forms,
one was scientific, I mean, "What's was the rationale
for doing what we're doing?" But the other was more related
to what I've been talking about, "How did this person come to be here "and what are we doing about
the conditions that got them here?" As opposed to just patching them up
and sending them out again? And sending them home. So, not too long after that, you went to the United States,
you went to Berkeley University. And you switched your field of study,
you weren't a clinician anymore, was that influenced directly by your
experience working in the hospital? It was indeed. I was working for a chest physician. Well, actually
I wasn't working for him directly, named Peter Harvey,
he was a consultant and he went off
to a meeting in New Zealand. And he knew the way I thought and he came back and he said, "I've got just the thing for you." I said, "What's that?"
He said, "Epidemiology." I said, "What's that?" And he said, "I've been to this
meeting in Wellington, "in New Zealand "and these terrific guys all work
together, doctors and statisticians "and anthropologists and they study
how the pattern of disease varies "depending on the kind of conditions
in which people are living. "And I think that would be
the right thing for you." And there were two
terrific people there, one called John Cassel,
at Chapel Hill in North Carolina and Len Syme in Berkeley. And in the '60s,
we'd all heard of Berkeley, 'cause of the free speech movement
and everything, I'd never heard of Chapel Hill,
so I went to Berkeley and Len Syme said,
"Yes, send him to us." I think the first thing
you worked on was... ..or one of the first things you
worked on was coronary heart disease and stroke in Japanese men
who were living in the United States. And then you moved to
the United Kingdom after that. I wonder, was that first study
that you worked on, did that set you up for this
40-year career in epidemiology? The Japanese study was looking
at how men of Japanese ancestry as they migrated across the Pacific
their rate of heart disease went up and their rate of stroke went down. Which meant environment,
in the broader sense of the word, includes the way you live, was clearly having
an impact on their rate of disease and what I showed in my PhD was the more traditional
the Japanese were in California, the lower the rate of heart disease, the more acculturated, the more
assimilated they were in California, the higher the rate of heart
disease, so, yes, it did set me up to see the social environment as
a big impact on the rate of disease. So, was the implication from that if Japanese people
were more Americanised and lived a more Americanised life,
their health was a tad worse? It was and the obvious explanation was, well, it must be the diet. Right.
But it was wrong. Oh, OK. (LAUGHS) It's the most obvious explanation,
but it wasn't the right one. What was the right one? Because, of course, the Japanese
in California were eating more fat in their diet
than the Japanese in Japan. But among the Japanese
who were more traditional, compared with those
who were more westernised, there was very little
difference in the diet. So, it was the culture? It was the culture. And our hypothesis
was that Japanese culture had stress reducing devices. In other words,
being part of a cohesive society, having strong social networks, actually protected you
from the slings and arrows of outrageous society and that was protecting them
from heart disease. So that was very much the idea that
I had in mind when I went to the UK. You've been in the UK
for about 40 years. God, yeah, I have. But in those early days
it was interesting, because you arrived there
just a few years before the Thatcher era. And during the Thatcher era, there wasn't a lot of research into
issues like health and equality. I wonder, did you feel, in a sense, in those early years
that you were just treading water, biding your time? Well, I wasn't treading water,
but in public health, when you do research, ideally, you'd like somebody to do something
with the answer. But I was doing pure research. Because during the Thatcher years, nobody was going to do anything
with the answer, nor could I
make a big deal of the fact that I was doing research
on social inequalities in health. I always told the truth,
but I didn't say, "Social inequalities in health
are a stain on our society "and we've got to...
You know, it's moral issue!" I didn't say any of that, I said, "I'm studying civil servants "and the lower they are
in the hierarchy, "the higher the risk of disease. "Wow, this is really interesting." By studying the causes
of the social gradient, perhaps we can understand more
about the causes of diabetes and of heart disease. And all of that was true. I just didn't put it in the context
of social inequalities and health. So I got lots of research money, but nobody was interested
in the practical implications of the research,
because inequalities and health were moved off the agenda
by Margaret Thatcher. Well, let's talk
a little bit about that concept of inequalities in health,
because, I think, from that early study that you did,
the Whitehall study of more than 10,000 civil servants, right up to what you're studying
at the moment, it's, in a sense, the same message, that you can have somebody who
appears to be quite well-off, but it depends on
so many more things whether they have good health
or not. And, certainly,
in the civil servants, you've found that
the lower down the job, the poorer the health? And civil servants turned out to be a remarkably interesting
population to study. You might've thought
at first blush - a bit unpromising. If you want to study
inequalities in health, why would you go
to the civil service? By definition,
there's no-one unemployed. There's no-one really poor
and there's no-one really rich. There are no hedge fund managers
or rich bankers, so we've got this
remarkable hierarchy. Exquisitely well classified. The civil service,
the public service, really knows where people
are in the hierarchy, and we found that health follows that exquisitely
well-stratified gradient. The lower they were,
the worse their health, so this was clearly not simply
about poverty and wealth. It was something else related
to your position in the hierarchy. So, if that also follows for society, what is it about people who are
on the lower end of the scale that makes them less good in health? So, I've spent my life
since then both studying, trying to answer your question, and having come up with what I think is a set of answers, trying to apply it. And I think it starts
right at the beginning of life, preconception. Right at the very beginning. So, what happens in pregnancy
and the outcome at birth. Early childhood development's
absolutely vital. Not just physical growth, but social and
emotional development. Cognitive and linguistic
development, behaviour. All of those are key. And that prepares
children for school. Children who do better
on these measures, it's highly predictive of how well
they'll do in school. And that in turn
is highly predictive of the kind of job you'll have,
how much income you'll have, where you'll live, and all of those cumulatively
make an impact on health. Trying to explain this complex mix, I talk about having control
over your life, which in turn influences
the kinds of decisions you make. If you've got control of your life, when somebody comes along and says, "You know, don't smoke
and don't eat nasty food," and, "Do exercise,"
and all of those things, you're much more empowered
to handle that, to know what to do with it, to decide whether
to do something about it, to make those healthy choices,
to think in terms of the future. So, that's one set of pathways. The second set of pathways relates to my work
with the Japanese. Stress-reducing devices. Having control over your life
means that life is less stressful. So, are you saying, in a sense,
it's a psychological issue? Because you can find people
from the lower end of the scale, as we've been discussing, who are perfectly happy
with what they're doing, and you can find people
at the top end of the scale who are perfectly unhappy
with their lives. I think the mind... ..as Woody Allen says, "The body's second
most interesting organ," but it's a very interesting organ. And I think the mind is the gateway between the social environment
and physical and mental health. So, it is a psychological issue. The mind is what's
receiving the messages, but its psychological impact
by the nature of society and, indeed, by where you are
in the social hierarchy so that the social environment
is key, but the way it influences health
is through psychological processes and the mind, at least in part. So, even something
that's really biological, like the hazards of smoking, is in turn psychological
because it's a behaviour and social, because it's influenced
by the social environment. So, I think all the way from social, psychological, biological,
health and disease.

Let's talk a little bit
about obesity. We're frequently told that the reason why a lot of
the Western world is getting larger, apart from the increase in sugary
soft drinks and fatty foods, is perhaps a lack of willpower. Is that a wrong take?
Is that unfair? I think it's not wrong.
It's just insufficient. It's incomplete.
Let's look at children. Are you going to blame children
for their lack of willpower? What we find in Britain, and Australian colleagues tell me
it's similar in Australia, is that the rise in childhood
obesity which has worried us all has now levelled off in children
from more advantaged backgrounds. So, for example, in Britain we've looked
at obesity by deciles - 10% of the income, each 10%. The bottom 10%, next 10%, so on. And what we find is
this remarkable gradient - the more deprived,
the higher the level of obesity. Remarkable gradient in children. And then we've looked at it
over time, and the rise has stopped. Obesity has stopped going up
in the top decile, in the second and the third
from the top, but it's continuing
to increase down the bottom. Are you going to say, "Ah, those kids down the bottom
have got no willpower. "It's their fault." What?
These are 10-year-old children. Are you going to start blaming
10-year-old children for not exercising willpower? So, what's happening at the top
of the scale there? I think it's what they're being fed. Now, if you ask parents, "Why are you feeding
your children Big Macs? "Why are you feeding them
oven-ready chips?" Or whatever it is. "It's cheap." "Get a lot of calories." "We have a lot of difficulty
making ends meet." "Our budgets are not
stretching to food." In Britain, we know that
the density of fast food outlets increases as you go down
the social gradient. The more deprived the area, the greater the density
of fast food outlets. You know, "What's the difference
between a musician and a pizza?" I have a son who's a musician. I was asked, and the answer is,
"A pizza can feed a family of four." And really cheaply. And of course, the...

The economic incentive
is to have a bigger pizza. For only this bit more, you can have a ginormous pizza
which is much more. And a coffee. You know, do you want
the ordinary-sized coffee or the simply ginormous coffee?
Exactly. Well, the cost per calorie
of the ginormous coffee is half the cost per calorie
of the ordinary-sized coffee. So, there are these
economic incentives, and if you're really poor, you respond to those
economic incentives. How else are you going
to feed your family? I'd like to talk a bit more
about the big picture. You're back in Australia. You have said that
if Indigenous Australia was separated from
the rest of the country... On the Human Development Index, I think Australia,
as a whole, is around two? Two. If we were two separate countries, the Indigenous country
would be below 100. Yeah. Yet, every year,
the same policies come out. There is a Closing the Gap policy,
but I suppose the implication is that there is still
a major gap to close. Why is it that it seems
like an unreachable goal? I don't think
it's an unreachable goal. Why has it been
an unreachable goal until now? I can't pretend that I've got
a detailed answer to that question, that I know well enough,
in detail, what has happened and what hasn't happened. What I can say, looking at
First Nations people in Canada and Maoris in New Zealand... In Maoris in New Zealand, the gap in life expectancy has gone
from something like 17 years to seven years. They're really galloping along. I mean, it's still huge -
seven years is a lot - but the sense I get
from New Zealand and Canada is where it's working is
because communities are empowered. So, just as I said,
I think empowerment, control over your life is key to understanding
the social gradients in health. I don't think
it's conceptually different. And, indeed, I made a set
of recommendations in England when I was commissioned
by the government to do a review of
health and equalities in England, and I talked about six domains -
early child development, education, employment and living conditions, minimum income for healthy living -
having enough money - environment - housing,
community and the like - and then taking a social determinist
approach to prevention. I think all six of those apply
to Australian Indigenous people, only more so. So, I don't think
it's categorically different. I think it's the same kind
of explanations, only more so. And my first response,
when people say, "But we've thrown
billions of dollars at the problem "and it hasn't solved it," was to talk about
First Nation communities in Canada, where the communities
had control over land grants, so participating in discussion
over land tenure. They controlled the fire and police
and education and health. There was cultural continuity. There was empowerment
of communities. And it seems to me
that's absolutely key, and the impression I get
is of widespread disempowerment of the Indigenous population. In this country?
In this country. You have a gallery of people
on your wall in your office back in London,
people who inspire you. I wonder, who takes pride of place
on that wall? Well, in order,
Len Syme is the first photo 'cause he was the one
I did my PhD with, and he really got me going,
I guess, in this area. And I've got two professors
of epidemiology at the London School of Hygiene
& Tropical Medicine, Donald Reid and Geoffrey Rose, who taught me
about intellectual rigour - that it's all very well
to want to do good things, but you've got to have the evidence,
and the science really matters. And know the numbers, have the data. They really taught me
intellectual rigour. And then there's a key person, a man with the unlikely name
of Fraser Mustard. He was a basic scientist
who discovered society and created communities
of scholars in Canada - the Canadian Institute
for Advanced Research - communities of scholars. And he, again, discovered me
and the Whitehall Study. And a British civil servant said,
"You've got to come to Canada "because your work is having
a huge policy impact in Canada."

I said, "It's not in Britain. "We've got Margaret Thatcher
as prime minister "and she couldn't care less." "Well, it is in Canada," he said. And so he, more than anybody, got me thinking about
the policy implications. So, I was taught to do
rigorous science by Reid and Rose. I was taught to think about society
by Leonard Syme. And I was taught by Fraser that it's OK to think about
the policy implications, to use the best science
to try and change society. So, I love that,
in your gallery of inspiring people, there's not a single person there
I've heard of, but they're all people
within your own sphere that have inspired you
and taken you to the next level. Would that be fair?
Yeah, absolutely. So, it's not heroes
from out of the wider world. Bill Gates, Einstein.
No. I mean, you know,
like everybody else... They're probably a bit obvious. ..I'm impressed by those people. No, these are people
who influenced me, so... That sounds egocentric,
but it's not. It's...it's autobiographical. They're people who changed my life
and got me doing what I'm doing. So, Michael Marmot, it's been
such a pleasure speaking with you. I've learned so much. Thank you for joining me
on One Plus One. Well, thank you very much.
A pleasure for me.

One Plus One is available on iview. You can browse the archive
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