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Michael Marmot: The Health Gap

Physicians for a National Health Program, McCanne Quote of the day
December 31, 2015

The Health Gap: The Challenge of an Unequal World
by Michael Marmot

From Chapter 1 - The Organisation of Misery

I have used two terms, health inequalities and health inequities. From now on, I am going to use the term health inequities to refer to those systemic inequalities in health between social groups that are judged to be avoidable by reasonable means. Such an approach does not cut off debate. There is ample disagreement as to what are "reasonable means." But it focuses the argument. Why is this fundamental? Because if people are suffering from ill-health in ways that could be remedied but are not, that is quite simply unjust.

From Chapter 9 - Fair Societies

Proportionate universalism

It was the evidence provided by our Nordic colleagues that led us, at the UCL Institute of Health Equity, to come up with the ugly neologism "proportionate universalism." Let me explain.

When the British government was planning its Sure Start policy for early child development, I went to a meeting at Her Majesty's Treasury to discuss the proposed programmme. It turned out that the initial plans for Sure Start were to target it at the most deprived communities. I showed the group the social gradient in literacy of young people according to parents' education and pointed out that at the top, parents with the highest levels of education, our young people's literacy levels were on a par with Sweden and Japan. But the gradient was steeper in Britain than in Japan and Sweden; the result was that the lower you go in the social hierarchy the worse our young people score compared with Sweden and Japan. The implication was that Sure Start should be for everyone, not only for the worst off.

The senior Treasury official, the wonderful Norman Glass (deceased sadly), said: "Don't come to me with that Scandinavian nonsense about universal interventions. We're Anglo-Saxons. We target and focus on the worst off."

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