good evening and thank you so much for being here tonight i know you came to listen to me of course this is a wonderful venue it is impressive i would say that everyone including michael marmot who is certainly traveling the world all the time every person i was saying must be impressed by the beauty of the place and also by the wealth in terms of richness of the agenda of this festival certainly those working in the health sector must be incredibly impressed by the fact that it was possible to put together an agenda that entails that different perspectives are considered when addressing health and economy and you see in the health sector we do not have a festival of this sort perhaps it is so that nobody of us would be able to cover and grasp all the aspects that pertain to health so as i said a wonderful festival a precious opportunity a valuable opportunity and it was a discovery for me as well because i met jose pelaterza and this proves that there are also nice publishers which is a new thing for me i'm here with sir michael mahmoud i'm sure that you all know what sir michael has been doing over the years um and i also checked wikipedia you see and actually the article in wikipedia is well done and i'm sure that everybody has read the same source i don't know what to add but anyway i would say that sir michael is a sort of ambassador of the health determinants social determinants and we have of course both aspects of her health and disease and this is indeed this is one of the aspects that are key and that have to be addressed when addressing epidemiology because of course determinants are not easy at all they are complex things this might sound something which is not close to the daily life of the physicians of clinicians but it is not so should i teach a young student of medicine something about epidemiology i would resort to an example which often michael mahmoud quotes which explains that nothing is more frustrating for a physician than managing to cure a person and give this person back to the same environment that caused the disease so this is basically the idea the concept the evidence actually that should serve as a bridge between clinical practice and assistance and those studying health policies michael muhammad often times by those who perhaps dislike his work is judged as a person who underlines excessively the political aspects of the job of being a doctor of being a physician and he answers that it is not like that and yet as a matter of fact there is something which is profoundly political in the engagement aspect of citizens in demanding for a for more equity and fairness in the health sector and in health conditions so you see we live in a world where injustice sometimes is not considered with the seriousness it deserves some days ago i purchased a number of books about decision making about daily decision making actually and it happened to me that i found a book by an american it's an american actually writes an author who is very well known and she published a book that i disliked she writes in the beginning of the book and i don't want to mention names that the goal of our actions in order to live better must be that of becoming tight to injustice which is exactly the opposite of what michael marmot says i'm about to conclude my introduction i will only add that we have here a person of outstanding modernity suffices to know that i feel so lucky that i had the fortune of reading the health gap and this lucky event happened for me because i found a tweet by michael marmot where he wrote finally i i finished writing my book and luckily publisher later is not here and doesn't hear me say that today this mirrors what happens in the publishing sector but happily after uh short after that we could have the book uh michael marmot is very clear is crystal clear very strict as well and i mean rigorous in his work and i was impressed by an interview that he made with a young canadian physician published in a very beautiful journal where he summarized into four points what i think the health of the future should be michael marmot said that the four pillars of the four legs of the table of health should be popular storytelling is i'm talking about narrative medicine i'm talking of course about the health sector and medicine well i must say that michael marmot provides a wonderful combination of the stories of people and evidence in health so you see we have a singer in italy who is called the pepino di capri and back in 1965 happened to sing before the beatles so i'm like pepino di capri here and i give the floor to the beatles to michael marmot thank you for that introduction i heard a lot of nice words but i heard one thing that was really shocking he said people who don't like michael marmot's work i'm shocked didn't realize it was true but there we are as you quoted the first lines of my book the health gap was what good does it do to treat people and send them back to the conditions that made them sick when people talk about health commonly what they mean is health care health care is very important when we get sick we need access to high quality health care but it's not lack of health care that leads to ill health in the first place no more than is headache caused by aspirin deficiency if you've got a headache it's quite good to take an aspirin but that wasn't the cause of the headache so we need to distinguish between the causes of ill health and health inequalities and the treatment that we need now when i arrived here yesterday i saw the signs and i thought that looks a bit familiar and la salvade des igualas i've seen that before somewhat yeah my book we had a discussion as to which of us would remem mention i will be signing copies of my book later at the bookshop i was in miami recently a couple of weeks ago and just before i got there you may have read that a teenager a black teenager was shot by a white policeman for the crime of leaving a party in a motor car and he was murdered by a white policeman in my book i write about the u.s city of baltimore maryland and i was talking about the health gap in the u.s and the month before baltimore had erupted in civil unrest the precipitant of the civil unrest was the killing of a black man in police custody or should i say one more killing of a black man by the police that was the precipitant but the underlying cause was inequality because when i say baltimore erupted i'm being slightly inaccurate it was not the whole of baltimore it was the deprived inner city part upton druid and i'd been writing about baltimore in the worst off part of baltimore where the riots happened life expectancy for men was 63. and in roman park leafy rowland park 83 i was at a meeting at johns hopkins university which is in baltimore and a couple of young doctors kidnapped me and said you cannot sit here in this university and not see baltimore so they took me we started in roland park beautiful leafy green roland park where the johns hopkins professors live and if you live in roland park life expectancy 83 for men and you want to see what is it like to live somewhere where the life expectancy is 63 you could get on a plane and fly to ethiopia alternatively you could travel a few kilometers across town to where it's 63 in roland park and when they took me to roland park there are some streets where every second house has a diagonal red cross on the door that dwelling has been condemned as unfit for human habitation if there's an emergency the emergency services won't go in there the fire and police can you imagine what it's like in the richest country in the world by luxembourg the richard with its ill-gotten gains but we'll leave that out can you imagine what it's like to live in the richest country of the world where on a street where every second house is condemned as unfit for human habitation and so i talk about leshon growing up in upton druid half the families the single parent families median household income was 17 000 i'd like you to remember that figure of 17 000 the kids do poorly in school they do badly in reading tests a high rate of truancy they drop out 90 percent did not go on to college look at this each year a third of young people aged 10 to 17 are arrested for juvenile disorder a third each year the chance of getting to 18 without having been arrested is really very small in theory the slate is wiped clean at 18. you go for a job and they ask have you ever been in trouble with the police you could lie which is not a very good qualification actually it could get you to the white house couldn't it lying but but for normal people lying is not a good qualification for a job it's terrible thinking what this man is doing to the world that we inhabit but i divert so being arrested is catastrophic for your future life and over that five-year period there were a hundred non-fatal shootings for every 10 000 residents and nearly 40 homicides when i was in miami recently and i was giving the commencement address to the graduating class and i said in glasgow we have a lot of violence people get beaten up we have crime but we have almost no killings because we have no guns i thought i might get lynched talking about how bad guns are and in roland park 93 percent two parent families median household income ninety thousand dollars not seventeen thousand dollars the kids do well in school they don't drop out seventy five percent complete college as distinct from ninety percent not going on to college juvenile arrests not one in three but one in 50 each year no non-fatal shootings and four homicides one-tenth the homicide rate it's easy to see why health might be bad in upton druid but two caveats one a median household income of seventeen thousand dollars on a global scale is fantastically rich costa rica where male life expectancy is about 76 13 years longer has a median income per person adjusting for purchasing power of 13 000 so the poor people of baltimore are really rich on a global scale but they're very poor health and the second is that inequalities in health are not confined to poor health for the poor these are still us figures by years of education for white women black women white men and black men the more years of education the longer the life expectancy it is a gradient and commonly i get asked why should i care i'm not poor so why should i care i don't really care about the poor so it's a very bad problem but it's not my problem and my response is the gradient is your problem because everybody below the top has worse health than those at the very top and in the u.s it's affecting everybody and case and angus dayton published this paper in 2015. anger statement said that when he won the nobel prize for economics in 2015 there was quite a lot of interest from the press and when they published this paper there was 10 times the interest in the press it's looking at mortality of 45 to 54 year olds and what you can see is it's declining from 1990 to 2012 it's declining in france germany uk canada australia sweden all of those countries big differences between france and sweden but all of those countries it's declining as it is in u.s hispanics but in u.s non-hispanic whites it's going up the fewer the years of education the steeper the rise so the gradient is getting steeper but even for people with more years of education it was not declining and what are the causes there's a lot of debate in the us about health care but this is not a health care issue number one poisonings due to drugs and alcohol number two suicide number three alcoholic liver disease and then of course there's violent deaths poisonings was number one with drugs and alcohol as long as black people in the u.s were using crack cocaine that was seen as a criminal issue when white people are misusing opioids that's seen as a medical issue fundamental racism which we can't ignore but that's not all there is the gradient these are data from england figure one in my book which will be available afterwards the top graph is life expectancy and each dot represents a small area a neighborhood and they're classified by level of deprivation so as you look at it to the right are the most affluent neighborhoods and to the left are the most deprived and what you can see is people near the top have shorter life expectancy than those at the top those in the middle shorter life expectancy than those near the top all the way from top to bottom the bottom graph is disability free life expectancy and the gradient is steeper and the two lines there the dotted line are figures for 1999 to 2003 and the solid line is 10 years later and what you can see is health has improved for everybody but the gradient hasn't changed and i would argue that we should have two societal goals to improve health for everybody and to reduce inequality and in most of our european countries we're doing pretty well on the first of improving health for everybody but not doing very well on the second of reducing inequality and the magnitude of those inequalities varies enormously the red dots are people with primary education and the blue triangles those with tertiary education looking at life expectancy for eu member states and you can see that sweden and italy have among the longest life expectancy this is for men and a relatively shallow gradient a relatively small gap between those with primary education and those with tertiary education when we look at bulgaria romania croatia slovenia much lower average and a huge gap another way of saying this is we do know how to get good health in bulgaria romania and those other countries because people with university education get it the disadvantage of being in one of those central eastern european countries is much bigger if you have only primary education the reason i show this is because it shows that the gradient the health gap can vary because if it was always the same everywhere well you'd say what can we do about it but this way there's a the evidence shows there's a great deal we can do i don't want us to forget mental illness important part of the story data from england people of lower social class have higher levels of mental illness than those of higher true for men and for women and there are higher rates of mental illness in women as part of the who commission on social determinants of health which i chaired we reviewed the evidence on depression and the expert group that we had said that the relation of low socioeconomic position to depression globally not just uk globally was very convincing low education very convincing unemployment and underemployment very convincing and then these others strong evidence go on so putting this together the question is can we do something about it i decided i didn't only want to study the problem although i've spent my life studying the problem i wanted to see if we could use the best evidence to address the problem and i chaired the who commission on social determinants of health we published our report in 2008 and we called it closing the gap in a generation and we put on the cover of our report social injustice is killing on a grand scale slightly unusual for a who publication social injustice is killing on a grand scale and we said at the heart of what we wanted to do was to achieve empowerment of individuals of communities and indeed of whole countries material psychosocial and political we wanted to create the conditions for people to have control over their lives note the concept of freedom is very important but it shouldn't be hijacked by the right freedom is fundamental but we have to create the conditions for people to be empowered that young man growing up in upton druid in baltimore cannot be empowered he doesn't have freedom he has the tragic imprint on him of his life circumstances he doesn't have freedom create the conditions for him to have control over his life then he can do what he wants so our conceptual framework we have the distribution of health and well-being we look at material circumstances social cohesion psychosocial factors behavior biological factors and the health care system these are distributed unequally by education occupation income gender ethnicity and race and then we need to look at the socio-economic and political context and this is what we call the social determinants of health and health inequities and i would argue that the mind i almost said the gateway is an important gateway by which social circumstances affect ill health the impact on mental illness and well-being but also psychosocial pathways to physical illness that might be through behaviors smoking diet and the like and also stress pathways i've been interested in the inequalities in health in glasgow and there is a glasgow effect in scotland of very poor health these data compare glasgow with liverpool and manchester similar levels of poverty you've heard of those places because they have good football teams but they also have a lot of poverty and inequality similar levels of poverty and inequality but higher mortality in glasgow look at the causes drug related poisonings alcohol suicide and external courses the same as i just showed you for the us these are psychosocially determined and harry burns the former chief medical officer of scotland who gave me those data says the major element of premature death in scotland is psychosocially determined low control low self-efficacy and self-esteem so in my english review which was convened to ask how can we translate the findings of the who commission to one country england and i was commissioned by a labor government in britain it's hard to remember when we had a labor government in britain but it was embraced by the conservative-led coalition government and i had six domains of recommendations and i'll touch on them briefly so the first give every child the best start in life we've been monitoring the quality of early child development what this graph shows i hope is the proportion of children age five that have a good level of development for each local authority in england again classified by level of deprivation as you look at it the most affluent to the right and what you see is a very clear relation the more affluent the area the higher the proportion of children age five that have a good level of development it's a gradient and i say this is almost like a political litmus test people on the left say it's poverty people on the right say it's poor parenting and i say they're both correct the social circumstances in which you're trying to raise your children impact your ability to be a good parent i was looking at data from the us there are estimated to be one and a half million households in the united states living on two dollars a day or less cashless households suppose some do-gooding person like me goes and they're all single mothers goes to one of these households and says to this single mother you must read bedtime stories to your children her response might be i would if i had a bed let alone a book and this scatter around the line for a given level of deprivation some local areas are doing better than others and that suggests two strategies reduce deprivation bring the level of early child development of those in the poorer neighborhoods up towards the middle and the other is for a given level of deprivation work out what is breaking the link between deprivation and poor early child development so looking at parenting activities we asked in the millennium cohort study we asked parents is it important to talk to a child age three about 20 percent of parents deny that it's important to talk to a child age three and that follows the social gradient we asked is it important to cuddle a child age three is there an experience in this world more rewarding than cuddling a child more rewarding both to the cuddler and the cuddly about 20 of parents deny that it's important to cuddle a child age three and that follows the social gradient so we looked at talking cuddling playing singing all those parenting things and they were all less common as you go down the income quintiles so if you look at socio-emotional difficulties of children age 3 and age 5 there's a gradient and about half of that gradient could be explained statistically by parenting activities and that's what i mean by the economic and social circumstances in which parents find themselves have impact on their ability to do these good things so breaking the link but we can reduce poverty this is looking at child poverty rates where poverty is defined as less than 60 percent median income so it's a relative measure for each country before and after taxes and transfers compare latvia and sweden in latvia before taxes and transfers child poverty was 35 in sweden it was 32 percent after taxes and transfers child poverty in latvia was still 25 in sweden it was 12 in sweden they don't like child poverty so they use the fiscal system to reduce it i was writing a piece about the health gap about my book for an american publication scientific american and i thought if i put sweden in there you know what americans think about sweden you know it's some marxist leninist hellhole so i compared the us with australia i thought australia sounds a bit like texas or maybe california and before and the poverty measure i had was not 60 percent it was less than 50 percent median income before taxes and transfers the property level in the us was about 23 that's 50 percent median income and in australia was 29 23 in the us 29 after taxes and transfers poverty levels in the us were still 23 percent and in australia had gone from 29 to 11 and the editor of scientific americans said i think you should take that out of the article i said why he said i think you're talking about redistribution and that won't wash with an american audience i said i think that's why we should leave it in he said well i don't get it let me try he said this is by email let me try and see if i understand this what you're saying is that in australia they tax income people middle and higher income people and use that money to reduce poverty i said yeah he said some countries actually do that i said now you're starting to understand why you have that high mortality in middle age in the u.s it starts with early childhood and you can break the link between early child poverty deprivation and poor early child development hackney is a relatively poor part of east london and i got on my bicycle and peddled out to hackney before i fell off my bicycle and fractured my femur but that's another story and they said to me in hackney we tell ourselves every day that poverty is not destiny we can break that link and i said show me we'll look at the data in britain we use eligibility for free school meals fsm free school meals as a poverty measure it's a means-tested benefit and if you look at the english data the average 60 percent of pupils in england have a good level of development age five those poorer children eligible for free school meals it's just under 45 so the gap is just under 16 now look at hackney the poor kids are doing as well as the english average they really did break the link the gap is only four percent look at bath a northeast somerset beautiful georgian bath lovely place to visit the gap's enormous my guess is if you go to bath and you say what do you do for poor children in bath they say poor children we didn't know we had any if you go to hackney and say what do you do for poor children they've got lots of them that's why they get out of bed in the morning to deal with the problems of disadvantage and you focus on the problem you can make a difference the other issue in early childhood is not just the lack of good development but it's the presence of adverse things adverse child experiences verbal abuse physical abuse sexual abuse parental separation domestic violence mental illness in the parents alcohol abuse and the parents drug use and being in prison are all adverse child experiences potentially if you could prevent adverse child experiences and need i say they follow the gradient the lower the social position the more frequent our adverse child experiences you could potentially reduce early sex by a third unintended teen pregnant pregnancy by 38 percent look at violence perpetration domestic violence you could potentially reduce the perpetration of domestic violence by half by abolishing adverse child experiences and even more chillingly look at victimization of domestic violence half the victims of domestic violence were themselves subject to adverse child experiences and in fact domestic violence one in three women globally has experienced domestic violence something like 60 percent of women who are murdered globally are murdered by their partner six percent of men are murdered by their domestic partner domestic violence is a global issue but preventing adverse child experiences improving early childhood would do a great deal education and lifelong learning i'm going to try and go a bit faster what we see these are pisa scores program of international student assessment not the leaning tower of um done by the oecd looking at maths results at age 15 by economic and social classification quartiles finland always does the best in europe it has a social gradient the higher the economic and social classification the higher the scores at age 15 on maths the uk our top quartile doesn't do quite as well as the top quartile in finland and our bottom quartile does much worse the gradient's steeper look at the us i don't have it in for the u.s really i don't but look how steep the social gradient is so i talked about problems in early childhood in the us now we've got a social gradient in school performance we know that for probably the bottom eighty percent of income earners income has really not improved much in the last three decades in the us so taking a life course approach it's not quite so mysterious why what and case and angus didn't call an epidemic of despair might account for that rise in mortality i've been talking at various points today about the high youth unemployment young people unemployment in italy which is a calamity and social policies make a difference this is from david stuckler who i went to here this morning but he looked like a young woman with an anyway he wasn't here but from david stucklin and what this shows is for countries a three percent rise in unemployment is associated with a three percent rise in the suicide rate of that country were there no expenditure on social protection eastern european countries spend about thirty seven dollars ahead on social protection and a three percent rise in unemployment is associated with about a 2.5 percent rise in suicide western european countries we spend on average about a hundred and fifty dollars ahead and a three percent rise in unemployment is associated with the less than one percent rise in suicide so unemployment is bad for mental health the idea as some of our politicians tell us that unemployment is a lifestyle choice is totally contradicted by the evidence so little to people like unemployment that they kill themselves that was on working conditions but i want you to get out of here this evening uh ensure a healthy standard of living for all thomas piketty who somehow no one's ever heard of and his colleagues produce these data looking at income shares in the united states in 1928 the top one percent of income earners had 23 percent of total household income and you know what happened next the great crash of 1929 and it all came tumbling down including the share enjoyed by the top one percent and right through the 1950s and 1960s when the u.s economy just kept growing and growing and growing and growing and growing and the top 1 had 10 or less of total household income then the reagan thatcher era neoliberalism whatever you want to call it suddenly it took off again and by 2007 the top one percent had 23 of total household income and you remember what happened next we had a global financial crisis now i work in a university i know that correlation is not causation and that it's an unproved hypothesis that the unconscionable greed of the top one percent brought the world's economy to its knees but you have to admit it's a credible hypothesis and that level of inequality will of course be damaging health healthy and sustainable places and communities and strengthen the role and impact of prevention i want to take a few minutes to finish because there's a contradiction i said at the beginning what good does it do to treat people and send them back to the conditions that made them sick health inequalities primarily is not a medical care issue and then for some strange reason i spent a year as president of the world medical association so all these doctors i was dealing with so i pursued the hypothesis that i could get doctors interested in health i know that seems a bit unlikely but i thought it was worth trying and my two messages in a world of post-fact politics was evidence-based policy presented in a spirit of social justice remember we said on the cover of the commission on social determinants of health social injustice is killing on a grand scale i'm currently sharing a commission on equity and health inequalities in the americas that was set up by the pan-american health organization and we were having a meeting in washington dc and i found myself walking in the mall for non-americans the mall is that area of washington that was sparsely populated during donald trump's inaugural i was in the martin luther king area and martin luther king said i believe that unarmed truth and unconditional love and i thought unarmed truth that's like evidence-based policy unconditional love spirit of social justice dr king said it better than i did but i think we were saying the same thing that unarmed truth and unconditional love will have the final word in reality this is why right temporarily defeated is stronger than evil triumphant we are in a very dark place politically but i believe with martin luther king that right temporarily defeated is stronger than evil triumphant so the mission for my presidency of wma and for my life was health equity through action on the social determinants of health and i laid out five areas the doctors and medical associations could get engaged i want to talk a little bit about working in partnership i was invited by the abc the australian broadcasting commission it's the australian version of the bbc the national broadcaster to give a series of radio lectures and the australian medical association wrote to me and said we hear you're coming can we help you in any way and i said i'd like to see doctors in action on the social determinants of health they said would you like to visit an aboriginal community center i said love to because the tragedy the shame in australia is that indigenous australians aboriginals and torres strait islanders have for men life expectancy 10.6 years shorter than the australian average and for women 9.4 years shorter and they said to me we've spent billions of dollars trying to address this issue and nothing works what should we do this was the day i arrived in australia i said i've been here four hours give me another 24 hours and i'll give you the answer well after i went to the thorough aboriginal corporation i started to have an answer this is run by the indigenous community is a center 50 kilometers south of sydney they have doctors there the popular belly cast program aboriginal women pregnant women don't attend antenatal classes so they get the women to take plaster casts of their pregnant torsos and then they decorate them with aboriginal art it's gorgeous absolutely gorgeous and the women love it so once they're in doing this then they come post-natally and to classes and child care and the like so they get them in i mean look at this it's gorgeous they have legal services a department of housing center link various services disability support when i was there the little children the two-year-olds were just bedding down for their afternoon nap gorgeous little children and i said to the woman who was looking after them how do you know if these children are developing normally and she took a pile of sheets off the shelf one for each child with 30 indicators of child development i said where did you get these from i got them from the university so up to the minute looking at quality of early child development and the older children the deadly homework club i mean terrific stuff and they've got these well-evaluated programs when i went to the there's a campus there i went to the part of the campus that deals with drug and alcohol problems big aboriginal woman and i said to her you must have the most difficult job in this whole center and she said no i have the most rewarding job in this whole center and she took me over and showed me an aboriginal painting on the wall and said the man who did that when he came to us he had all the problems of drugs and alcohol and domestic violence and we helped him put his life back together and this was his gift to us i have the most rewarding job in this center good tucker all round they have subsidized fruit and vegetables for the community and the older people i don't know if you can see that grannies against removal there was a phase a shameful phase in australia where children were being removed aboriginal children were being removed from their families to bring them up white with catastrophic results and i talked to a psychologist at the center and she said it's still going on because now children are being removed because of violence and drugs and the like in the family so grannies against removal i mentioned i did these lectures and as part of giving the lectures the abc had their current affairs program panel on inequality and the convener said to me he read my lectures could you tell us what you said in your lectures about income so i said what do the 48 million people who make up the population of tanzania the 7 million people who make up the population of paraguay the 2 million people who make up the population of latvia and the top earning 25 hedge fund managers in new york have in common and the answer is the previous year each of those groups had a combined income of around 25 billion dollars and then i said here's a thought experiment suppose the hedge fund managers gave up their income for one year wouldn't hurt them they're going to earn a billion dollars each the next year and we transferred that money to tanzania we double the per capita income and suppose you didn't want to just give the cash to individual tanzanians think of the clean water you could pipe to the villages the schools you could build the nurses you could employ and if that's too fanciful a thought experiment here's another even more fanciful thought experiment suppose the hedge fund managers paid one-third of their income in tax i know that's totally fanciful you and i pay but they don't pay tax but suppose they paid one third of their income in tax you could employ 90 000 new york school teachers another member of the panel said to me you're in fantasyland mate you're in complete fantasy land that's never going to happen global capitalism has solved the problems and you're in fantasyland when i went to the tarawell aboriginal community center the next day one of the doctors greeted me with this sign welcome to fantasyland i asked the abc if i could change the text of my first leg of the the ending of my first lecture i said yes so i said in this lecture i have laid out systematic health inequalities within between countries and in the lectures that follow i will talk about what we can do but that will include inequities in power money and resources but i've been told i'm in fantasyland imagine i said when martin luther king rose in washington to make his most famous speech and he said i have a dream that on the red hills of georgia the sons of former slaves and the sons of former slave owners will sit down together at the table of brotherhood instead he said i've been told i'm in fantasyland there would have been no civil rights act so come join me in my fantasy land and let's dream of a fairer world thank you hmm can i come back please now such a pleasure such an honor listening to michael marmot and it always happened on the eve of a weekend and i would like to go back distributing daily papers as i used to do 40 50 years ago well which daily could i be distributing delivering these days it's difficult because i don't have i mean there's very little that i could choose from these days anyway i think we have like 10 or 15 minutes more time for a couple of questions from the audience if you have if you have any now feel free feel free to ask questions i'm sure there's a microphone going around much for your internet for your discussion especially your experience in england um it's uh it's very interesting regarding the the uh inequality and uh but one one aspect that i have seen going on in this festival is the relation between inequality and the lack of education the correlation is extremely strong uh in england especially i think england is a unique state in europe where the education is in a very critical position where a very good education is left in the hands of private sector now then even the labor even the tony blair started with his campaign by saying educational education education but in the end i i have seen that there was not a real act not a very radical change the situation hasn't changed after i think seven years of his government and even with today with the corby we don't see a very important stress in the in this sector when to break the vicious circle between education and mental mental health health in general it's it's very important and not not only the the have but today um this the the the social the achievement of a different social uh state so it looks like that there was a import a political need to keep the status quo because if we don't change the if you don't we don't break the the the circle of the education left it only to the very good elite of the of the british society there is not a the vicious circle is not cannot be broken yes thank you for that the situation in britain is that approximately seven percent of children are educated in the private sector and of entrance to oxford and cambridge approximately 50 percent are educated in the private sector you don't have to be a very good statistician to know seven percent in the general population 50 in oxbridge this is a glaring inequality and it's a reasonable assumption that there are a lot of children who are not educated privately who have the potential to do just as well but they're not living up to their potential because of the education they're getting now what we see if you look at deciles of deprivation of areas the the metric we use in england is the percent of children who at their national exams age 15 get five gcses they're called at c or above c b a or a star these are national exams what we see in the most deprived decile it's about thirty percent of children only thirty percent get as many as five c's in the top decile it's about seventy percent and it's a gradient you mentioned tony blair what his government did was to increase the funding for education reduce class size and we did see educational standards rise every year there's a big discussion about is it a real rise or is it an artifact because the marking got easier but standards rose but the gradient didn't change the inequalities didn't change and i think they didn't change because one of the big predictors of educational performance is readiness for school is early child development and those inequalities in early child development were very stubborn we didn't do nearly enough to change that so these two issues the relatively small percent of youngsters who are educated privately but they have a disproportionate impact not only do they go to oxford and cambridge they're in the british olympic team there are more olympic athletes than the seven percent i've gotten the figure i think it's about 20 or 25 percent of olympic athletes were educated privately so success academically sportingly theater our actors overwhelmingly went to private school so that's tiny seven percents having a disproportionate impact so i think we need both to deal with the seven percent and with the gradient and we haven't done it um good evening um i'd like to well ah thank you good evening um i think what you said this evening is really great because it brings back um the necessity of having a purpose in economic activity so you brought back also the the principles of the social values um but what i personally think and um i'd like to have your advice what i'd like to know what you think about it is that there's a great problem because um when we go back from our world of fantasy and we come back uh in the world we live in work that is an element that you showed as fundamental for the um for the creation of conditions uh uh to permit to every individual to choose how his own life when you go to talk about work we see that today work is not oriented by purposes of social equality or even quality of the life of every individual but to short-term profitability finance you were talking about hedge fund before finance the way of working in finance has grow has taken already the the way to work in every area of our life so i think we should also resolve this problem so how can we put together work for a short-term in terms of pure monetary profit and on the other side um the creation of social values that put together also the community through work and i'll thank you i'm sure i'll embarrass that young man because i did a radio interview this afternoon at rai and i was wandering back through the streets and suddenly four young men came up to me he was one and he they said are you michael marmot and i said yes they said could we buy you a cup of coffee we're high school students and we've driven here from florence because we wanted to come to this festival and this young man said and i've read a couple of chapters of your book so it's a privilege when i saw some of my colleagues they said why are you smiling so i told them about this experience work is absolutely fundamental i could have shown you figures that i have but too many things to talk about that in britain now half more than half the people below the minimum income threshold in poverty are in households where at least one adult is working people are in poverty not because they're lazy and they don't want to work they're in poverty because they're lowly paid so the first thing we want work to do is to get people out of poverty to give them enough money to be able to lead a dignified life and by the way i meant to say when let me divert for a moment when i said after i'd been to the thorough community center i came back to the people who said to me we've spent billions trying to reduce the health gap between indigenous and non-indigenous australians and it hasn't worked why not and i then said because for 200 years you've systematically deprived of people of their dignity and their self-esteem and the possibility to lead meaningful lives and then you ask why doesn't simply spending money solve the problem you do have to spend money on good services on good schools on good communities but you've got to find a way to address this lack of dignity and that relates to your question about work work is important to earn money but it's also a way of having dignity having a role in society knowing it's meaningful and the gig economy doesn't do that and to the extent that we're moving to short-term part-time work in the gig economy as a fundamental threat to self-esteem to dignity and potentially to health and health equity now can i please ask you to ask very short questions please very short question presentation and a great summary now i'd like to link to a comment made by luca when he said i like to go out and sell a newspaper that i was selling 50 years ago but i would not know which one to just to say we grew up our generation in an idea it was simplified there were the good and the bad no the bad were responsible for all what's wrong in the society and the good whereas simple now we are in a situation where this is not so black and white and even if we look at what should be the good in the society you don't always see you know that understanding of social problems the com component of generosity to help to make the transfer social transfer to equalize conditions now we see what the situation is in uk we see italy we see that object there are differences now how we would address now in your opinion to convince not the bad because these are the better as in martin luther king story but the good were less big less committed to be good yeah and i don't i i that's by the way my fellow englishman elio rubily um i think we're doing a terrible draw job of engaging the general public more widely in these issues i think we've not done a good job and it's great that a publisher is interested a festival of economics is interested but this is hardly the general public this is interested wonderful people and it's great if i can convince you but we need to do a broader set of issues i'm an optimist so when i see everything's terrible i can see a glimmer of light and say it's going to get better look at what's going on in britain at the moment you know which is terrible post-brexit that terrible politics is ghastly i think there's signs that we're moving back towards understanding a set of values what you know what's happened during this current election campaign a deeply deeply deeply unpopular leader of the labour party who had zero chance of being elected prime minister says we're going to spend more on the national health service we're going to spend more on education we're going to spend more on free child care we're going to employ more police and we're going to break the freeze in public sector pay and people said hey that's pretty good we don't like that guy with a beard he's ghastly we don't want him to be our prime minister but we quite like the offer that's being made and i think this pendulum from total selfishness i mean how can god i'm obsessed by this orange nightmare in the white house i mean this is the apotheosis of selfishness this is selfishness in pure culture he's two guys um what are their names hr and the other one you know the national security they wrote a piece and they said forget the world community this is about a race to see who comes out on top they're explaining why in his ignorance he blamed germany for their trade policies he didn't apparently understand that germany is part of the european union and germany doesn't have trade policies the european union has trade policies that but he's too ignorant to understand that but but it was privileging selfishness i think selfishness has gone so far that we're now starting to see the pendulum swinging back uh amateur sen who i could see his photo outside i had dinner with him in miami he said he supported bernie sanders he supported bernie he said his wife supported hillary but amateur supported bernie i think we're seeing the pendulum swinging back and it relates to the question that young man asked me that the limits of selfishness and self-interest are becoming all too apparent now remember what i said evidence-based policy presented in a spirit of social justice so we need the evidence of what we can do i have this wonderful image of a people's march on parliament with a banner saying what do we need evidence-based policies when do we want it after peer review i can't quite see the parliament giving in to that set of demands but that is what we want we want evidence-based policies after peer review but presented in a spirit of social justice and we will get out of this terrible place we're in i would like to thank whole from the bottom of my heart michael marmot when we started thinking about the topic for this year's festival and tito bowery thought about health we did not have a title we thought of the topic we did not have a title and since i'm a publisher i know how important titles are and then we found your book and i was so lucky to to meet luca fiore and your title actually the book your book's title was perfect for this festival and your presence here today testifies to your evidence-based quality because your line of reasoning is based on evidence on figures on numbers but it has such a strong message among the numbers thank you so much for bringing it to this festival thank you thank you very much thank you enjoy the rest of the evening you