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Addressing Health Inequalities: How can the Marmot Reviews help us?

"We repeat: the problem is not poor ‘choices’; the problem is poverty.... The rhetoric of the “undeserving poor” as justification for harmful social policies should have no place in Building Back Fairer." So ends the Marmot Review, Covid-19 edition. The ultimate message of the three damning reports into the state of health inequality in England is that ill health, including during a pandemic, is caused more by the social determinants of health than by poor healthcare systems. People become sick because of structural issues, health inequalities, and due to social factors that determine their health.

Recommended Strategies to Address Health Inequalities

The first Marmot Review (1), published in February 2010, outlined the conceptual framework underlying how to reduce health inequalities and finally proposed six policy objectives to improve these domains:

  1. Give every child the best start in life

  2. Enable all children, young people and adults to maximise their capabilities and have control over their lives

  3. Create fair employment and good work for all

  4. Ensure a healthy standard of living for all

  5. Create and develop healthy and sustainable places and communities

  6. Strengthen the role and impact of ill-health prevention

Impact of Austerity on Health

The second Marmot Review (2) was published a decade later in February 2020. In this report the evidence was compiled to describe what occurred in the domains set out in the original review and the effects of a decade of austerity were analysed. With children's centres closed, child poverty rising, insecure labour and zero hours contracts, a crisis in affordable housing and rising homelessness, and poverty leading to reliance on food banks, to 'left behind communities' with no jobs and no hope, the conclusions reached were unsurprising. This report showed that for almost all the domains discussed a decade previously, outcomes had worsened. Some of these difficulties were the direct result of government policies, whilst some resulted from failure to counter adverse trends such as increased economic inequalities or market failures.

Health Inequalities in a Pandemic

Most recent is the Covid-19 Marmot Review (3), published in December 2020. It describes how Covid-19 has exposed and amplified pre-existing inequalities, and that the containment measures have magnified socioeconomic divides further. The report also emphasises the impact of poverty on people’s decisions: “"The evidence suggests that poverty leads to poor choices; not poor choices to poverty. For example, we have cited data from the Food Foundation that households in England in the bottom 10 percent of household income would need to spend 74 percent of household income on food were they to follow official healthy eating advice. We repeat: the problem is not poor ‘choices’; the problem is poverty... During the pandemic this has become even more clear. Frontline workers were at high risk because they were doing essential work. People did not feed their children well not because they were spending money on the wrong things, or because they hadn’t taken cooking classes, but because they lost their jobs. The rhetoric of the “undeserving poor” as justification for harmful social policies should have no place in Building Back Fairer."

COVID-19, Education and Inequalities

To take a specific example, the impact of Covid-19 on inequalities in the lives of children and young people is a key component of understanding the long-term impacts of the pandemic. The attainment gap between disadvantaged children and their better-off peers starts in early years settings, where those providers in the most deprived areas have the least robustness and are most likely to close. During the pandemic, in early years settings, inequalities have worsened, with the loss of schooling further exacerbating inequalities for school-age children (see graph below).

Educational inequalities have been seen throughout the pandemic impacting on the most disadvantaged and marginalised. Research by the IFS found that 58% of primary school students in the poorest families do not have access to their own dedicated study space. Poor governance has not helped. The digital access scheme rolled out in May and July 2020 was insufficient, and by October 2020 the Department for Education (DfE) announced an 80% reduction in numbers of laptops for disadvantaged students, just two days after the Government used Covid-19 emergency powers to impose the legal duty on schools to provide remote education. There are also particular inequalities in carers' capacities to homeschool, which are most apparent in children with Special Educational Needs and Disability, where the loss of specialist teaching and support has had an outsized impact. Further, children excluded from mainstream education are more likely to have fallen through the cracks with the challenge of Covid-19. The disruptions to exams have also widened existing gaps. A Financial Times analysis of Ofqual data showed that pupils at Independent schools and secondary selective schools benefited most from the teacher assessed moderated A-level results in summer 2020 (see graph below).

Figures from The COVID-19 Marmot Review (3) show disparities in dailing learning time and in A-level results for school-age children during the COVID-19 pandemic.

Access to resources and the home learning environment are just two areas where poorer kids suffer more, lack of funding has also played a key role. Educational funding was already suffering inequalities, with the most deprived schools suffering the largest funding cuts per student since 2009-10. The 2.2% funding increase announced in November 2020 is not sufficient for the challenges faced now, and to redress the pre-existing inequalities in education.

Hope for the future?

But there is still hope, echoed by Professor Dorling in his talk "Can the pandemic and recession reduce our complacency about poverty and health?" (4) where he described the different kinetics of the impact of austerity and of the pandemic. Even though we cannot change the insidious harm already done by austerity, the effects of the pandemic are abrupt and indisputable enough to bring inequalities into sharp contrast. Health inequalities can be reduced but only with coordinated and sustained efforts.

A survey of public health professionals found that the biggest advances in public health in this century have been the smoking ban, the sugar tax, and the Marmot Review. See for yourself.

More about the author: Nikhil Singh

Nikhil Singh, 4th year medical student, at the University of Cambridge, with an interest in inequalities in health and wealth.


1: Marmot, M. Fair Society, Healthy Lives : the Marmot Review : Strategic Review of Health Inequalities in England Post-2010. (2010) ISBN 9780956487001

2: Health Equity in England: the Marmot Review 10 Years On, BMJ 2020;368:m693

3: Michael Marmot, Jessica Allen, Peter Goldblatt, Eleanor Herd, Joana Morrison (2020). Build Back Fairer: The COVID-19 Marmot Review. The Pandemic, Socioeconomic and Health Inequalities in England. London: Institute of Health Equity.

4: Blog: https://www.studentsforglobalhealthcambridge.com/post/can-the-pandemic-recession-reduce-our-complacency-about-poverty-and-health ; YouTube: https://youtu.be/6FhsO_GfyWQ

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