Medical Care, Social Determinants of Health, and Health Equity

• Date: 01 June 2018
• DOI: http://doi.org/10.1002/wmh3.261
• Published date: 01 June 2018

Medical Care, Social Determinants of Health, and Health

Equity

Michael Marmot

Sir Michael Marmot writes on public health, social determinants of health, and health equity.

KEY WORDS: medical care, social determinants of health, health equity

I was invited to address a meeting of the American Gynecological and

Obstetrical Society 4 years ago. I said to my audience that if they told me that

American obstetricians delivered the best obstetric care in the world, I had no

reason to disbelieve them. There was a problem, however. At that time, the

lifetime risk of a maternal death in the United States was 1 in 1,800.

To get a sense of where the U.S. f‌igure f‌its globally, I asked them to think of

22 women of childbearing age. If we were in Afghanistan, one of those women

would die of a maternal-related death. By contrast, in the best-off country on this

metric, Italy, you would have to count 18,000 women to get one death, on

average. The United States is a good deal safer than Afghanistan, but on this

particular measure it ranks behind 62 other countries (Marmot, 2015). Parentheti-

cally, the numbers have changed, but the point has not. In 2015, the World Bank

has Sierra Leone with the highest lifetime risk of a maternal death, with one

woman dying in 17; and Greece with the lowest, at one woman in 23,700. The U.S.

ranks behind 45 other countries (World Bank, 2015).

I suggested further that if I invited the members of the audience to write

down the characteristics of the women who died of a maternal-related cause, they

would all write down versions of: the poor and socially excluded, women who

were subject to discrimination or were otherwise outside the system. They would

be illustrating extremes of inequalities in health.

They would be illustrating something else, too. Social determinants of health

and access to health care are separable, but not separate issues in practice. By this

I mean: when health professionals contemplate inequalities in health, the default

position is to consider inequalities in health care. Indeed, when international

agencies speak of “investing in health,” they actually mean: investing in health

care. Yet, when I speak of health I usually refer to social determinants of health. It

World Medical & Health Policy, Vol. 10, No. 2, 2018

195

doi: 10.1002/wmh3.261

#2018 Policy Studies Organization