Sir Michael Marmot on COVID-19, inequality, and the future of society

Professor Sir Michael Marmot joins Jessamy and Gavin to discuss how inequality and injustice have directly contributed to poorer COVID-19 outcomes, and what has to change in society post-pandemic.

Read all of our content at https://www.thelancet.com/?dgcid=buzzsprout_tlv_podcast_generic_lancet

Check out all the podcasts from The Lancet Group:
https://www.thelancet.com/multimedia/podcasts?dgcid=buzzsprout_tlv_podcast_generic_lancet

Continue this conversation on social!
Follow us today at...
https://thelancet.bsky.social/
https://instagram.com/thelancetgroup
https://facebook.com/thelancetmedicaljournal
https://linkedIn.com/company/the-lancet
https://youtube.com/thelancettv

Transcript

This transcript was automatically generated using speech recognition technology and may differ from the original audio. In citing or otherwise referring to the contents of this podcast, please ensure that you are quoting the recorded audio rather than this transcript.

Jessamy: Hello and welcome to The Lancet Voice. If you're listening to this on thelancet. com, you can subscribe to The Lancet Voice wherever you usually get your podcasts and you'll be notified whenever there's a new episode. It's March 5th, 2021 and I'm Jessamy Bagonal. And 

Gavin: I'm Gavin Cleaver. Professor Sir Michael Marmot is a giant of public health and health equity.

He's the author of the Marmot Report, which is one of the most influential works of public health in the recent history of the UK. And he's currently the director of the UCL Institute of Health Equity. Yasmeen and I spoke to him to discuss the last 12 months and talk about what a recovery from COVID 19 looks like.

Jessamy: Michael, you've spent a long period or much of your life researching inequalities. To what extent do you think the inequalities that are present in the UK has contributed to the UK COVID 19 situation? 

Michael: Yeah, I've asked myself that question, and I've got an incomplete answer to the question. Let me put it in context.

I produced a report In February last year, the Marmot Review 10 years on, and we showed three features of health in the UK, in England, that were very troubling. The first was a slowdown in improvement. In life expectancy, and that slowdown was more marked than in any other rich country except Iceland and the United States.

The second was an increase in health inequalities. So there's a social gradient in health, the more deprived the area. The shorter the life expectancy and that social gradient had got steeper, the inequalities got bigger. And third, for the poorest people outside London, life expectancy was going down. So inequalities were a big feature of the poor health that we saw before the pandemic crashed upon us.

And then came the pandemic. And what we saw was a social gradient in mortality from COVID 19 that looked almost identical to the social gradient in all cause mortality. I say almost identical the excess mortality for COVID 19 in the bottom three deciles was slightly higher than for all causes, which we think relates to working in frontline occupations, occupational exposure to the virus and living in overcrowded, perhaps multigenerational households.

Why did we have such poor health? Coming into the pandemic and why did we have the biggest excess mortality during the pandemic in Europe and I suggested four potential links. The first was the quality of governance and political culture. The second was the magnitude of inequalities, social and economic inequalities in society.

The third was the disinvestment. In public services, which was done in a regressive way pre pandemic. And the fourth was that we weren't very healthy, which puts us at higher risk. So all of those I think are important. And then to come back to your original question, what about inequalities? Given that we see the similar social gradient for COVID 19, as we see for all cause mortality, it's obviously important.

And if I can give you an analogy, a few years ago I was giving a lecture in Krakow in Poland, and a distinguished British scientist was in the audience. And he said to me afterwards, I don't know why you're talking about all this social and economic stuff. We know the causes of heart disease. It's smoking and poor diet and overweight.

Why are you talking about social and economic causes? We know the causes. You could say we know the cause of COVID 19 is exposure to the virus and maybe some predisposition to severity given infection. Why are you talking about all this social and economic stuff? Who gets exposed to the virus and why?

And then who's at risk of more severe illness given exposure. It's social and economic and linked to inequalities. So it's fundamental. 

Jessamy: And you touched there a little bit on disinvestment and kind of this regressive way that it was done, after the kind of Great Recession. To what extent do you think that austerity compounded the problems that we've seen in the UK and perhaps hampered the NHS's ability to respond to COVID 19?

Michael: Firstly, we know that NHS funding had, over the long term, increased at just under 4 percent a year, in real terms. And during the Parliament that began in 2010, it increased at maybe 1 percent a year, or just under. Dramatic difference. Now you could say it's still an increase, but if NHS inflation should be something like 2 percent above normal inflation, the population's got bigger, the population's got older, there are new initiatives that cost money, then 1 percent inflation is below what you need to more or less keep steady pace, so the NHS was underfunded.

That number of hospital beds went down. The number of nurses employed went down. When we then look at local authority spending, let me take total local authority spending per person by the level of deprivation of the area. If we look at the least deprived 20 percent of areas, local authority spending went down by around 16%.

And then the more deprived, the greater the reduction in local authority spending, so that in the most deprived 20 percent of areas, it went down not by 16, but by 32%. The greater the deprivation, the greater the need. The greater the need, the greater the reduction in spending. Now let's take one that's on all our minds, adult social care.

The reduction in spending on adult social care was around 3 percent in the least deprived quintile and around 16 percent in the most deprived quintile. We know that even in the second or third wave, there's still a high mortality in care homes. We don't pay care workers properly. We've reduced the funding for adult social care.

It's hard to argue that these significant and regressive cuts in public spending were irrelevant. You'd have to believe that everything local government did and the health service did doesn't matter. So you could cut with impunity. It's not a very radical case to say that if you cut, and cut in a regressive way, it'll have consequences.

And we're seeing those consequences during the pandemic. 

Gavin: What have we been seeing so far in terms of the kind of effects on black and minority ethnic communities from the pandemic, from COVID 19? And what kind of more research do we need to do in this area? 

Michael: In my Marmot review 10 years on, the report that we published in February, Last year, just 12 months ago, we looked at health in black, Asian and minority ethnic groups.

There is not as much data as we would like, unfortunately. But to the extent that we could look at it, we showed some worse health compared to the white majority population. But it wasn't so dramatic. Then came COVID 19. the pandemic and the excess mortality in black British from Africa, black British from the Caribbean, Pakistani, Bangladeshi, particularly women and men was really striking.

Now, much of it, not all of it. Much of it can be linked to deprivation because in the ONS figures when allowances were made for geography where people live, which is linked to deprivation and other socioeconomic characteristics, much, but not all of the excess could be explained. Not all. And then there's the issue of doctors and other health workers.

Why should there be excess mortality, particularly in doctors, from COVID 19? They're not, by and large, in the most deprived deciles of the population. They're doctors. They're reasonably well paid. And we don't understand that very well. It's been suggested, speculated that perhaps doctors of minority ethnic background might be less protected by PPE, more exposed to exposure on the front line.

That's a suggestion, I don't know if it's true. That really needs to be sorted out. And the whole issue, the overlap between structural racism and economic and social disadvantage needs further attention. I've been arguing for some time that most of the racial ethnic differences were socioeconomic.

They are in large measure socioeconomic, but that leads to two questions. One is, why? Why should people from particular ethnic backgrounds be more socially and economically deprived? But the second question is, what else is going on? Because it's not only socioeconomic. And that's where the issue of structural racism comes into play.

Gavin: So we wanted to ask as well about inequality in life expectancy. Now, in the U. S., Angus Dayton and Case famously wrote about the deaths of despair, and how this kind of inequality in life expectancy has been brewing for decades. What are your thoughts on this, especially in light of the pandemic? 

Michael: Anne Case was the first author, so forgive my gentle rebuke, but so what Anne and Angus did was look at the rise in mortality in middle aged, non Hispanic, white men and women.

And it was quite striking. We're used to health getting better all the time, mortality going down. And it wasn't, it was going up. It was going down in all the comparison countries that they looked at. But in this subgroup, it was going up. And the rise in mortality was related to years of education.

It was a gradient. The fewer the years of education, the steeper the rise in mortality. And the diseases that made up that rise were what they call deaths of despair, poisonings due to largely opioids, drugs, suicide, and alcohol related deaths. Wow. So this is very important. In their book, Deaths of Despair, they didn't look so much at the gradient.

They focused on people without a four year college degree. But as I say, in their data, it was a graded phenomenon. It wasn't one group versus the rest. It was graded. But they focused on people without a four year college degree. And they went through. all the relevant aspects of people's lives and showed that their lives had got worse.

If they were looking at education, looking at employment, looking at neighborhoods and community relationships, they got worse. The structure of social life had got worse. In fact, when they started doing that work, Angus Deaton wrote to me. When they, he said, we've got a paper coming out in the National Academy of Science and it will be grist to your meal, because I've been a bit critical of both Anne Case and Angus Deaton.

Why do you pay so little attention to social determinants of health? And then Angus wrote to me and said this will be, quote, grist to your meal. And indeed it was. It was all the kinds of things that I've been writing about, that since we did the WHO Commission on Social Determinants of Health and the English Review.

So it's entirely consistent with what we've been writing about. And then I looked at this pattern of deaths of despair and thought, where have we seen that? We've seen that in Glasgow, colleagues in Glasgow some years ago, looked at the excess mortality in Glasgow compared with Liverpool and Manchester, and the biggest relative excess in Glasgow were poisonings, suicide, alcohol related causes, and violent deaths, external causes of death, deaths of despair, and There it was in Glasgow in the data.

So what Case and Deaton described in the US is entirely consistent with what firstly in terms of inequalities more generally we see in the UK. And then in terms of deaths of despair, what we saw in Glasgow. Now, one huge difference. Thank goodness is we don't have the opioid poisonings. So what I had described in February last year was a slowdown in improvement rather than actual decline, except in the bottom 10, the most deprived decile outside London.

And there we did see declines in life expectancy. 

Gavin: So unemployment is almost certainly really quite high in the UK at the moment, but a lot of it's being covered up by furlough schemes for example, and globally, we can see jobs and work changing, although we're not seeing the consequences so far, I think.

What have we learned from other periods of high unemployment in terms of how it impacts health in the country? 

Michael: After the 2008 global financial crisis, David Stoeckler and Martin McKee and others looked across Europe and what they saw firstly was no impact on all cause mortality. And that's quite interesting.

It turns out in the Great Depression in the early 30s, there was no impact in overall mortality. Now, they still had prohibition in the U. S. in the early part. But there was no impact that could be seen on all cause mortality. But there was a big impact on suicide. But there were, for example, fewer car crashes.

I guess people were poor, couldn't take their car out, driving less. But there was a big increase in suicide. And that increase in suicide correlated with the rise in unemployment. That's the first thing. More unemployment at a national level. Higher suicide. But the second finding was really interesting.

The more generous the country was in unemployment benefits and active labor market programs to try and get people back into work, the weaker the link between the rise in unemployment and the rise in suicide. So in other words, there are predictable adverse impacts, particularly on mental health, from the rise in unemployment, but it can be mitigated.

My government policy can make a difference. Which is quite encouraging. 

Jessamy: I mean in the UK now things seem fairly grim from a sort of healthcare system point of view, but what would you like to see moving forward in terms of a plan for the NHS and social care in a sort of wider form? 

Michael: I'd like to look at it more broadly than just the NHS and social care.

They're vital. I did my February report last year, it was ten years after the initial Marmot review. The report I did in February was 10 months after the 10 years on, you might ask why didn't I do one 10 weeks after the December report and then go crazy this way, but the reason I did it was because of the pandemic and for two reasons.

One is that I made a whole set of recommendations back in February that kind of got forgotten because of the pandemic. But the second was, and I called it Build Back Fairer, that the pandemic not only exposed the underlying inequalities in society, but amplified them and lockdown and the societal response contributed to them.

We're all presumably speaking from our homes. We can work from home. The more deprived the area, the lower the income of individuals, the greater the impossibility of working from home. The more people had to go out to work or were in shuttered industries. So the pandemic and the societal response, and because we handled the pandemic so badly, we had the biggest negative hit to our economy in Europe.

So the two are linked. In other words, as we think about. Building back. It's not just social care and the health service. It's having a fundamental look at the nature of society. And that's why I called my report Build Back Fairer. And there are two ways I would like us to approach it. The first, at a more general level, is put equity of health and being at the heart of all government policy.

In other words, the aim should not be to restore economic growth. Because we'll all feel better if the GDP becomes positive again in GDP growth. The aim should be to create greater equity of health and well being. And if restoring economic growth is a means to that end, fine. Economic growth should not be the end.

And that means that we do not want to go back to the status quo. As I've described where we were a year ago in February 2020 was far from desirable. Health had stopped improving, inequalities were getting bigger and health for the poorest people was getting worse. That's not desirable. We need to really be thinking.

For babies born now, as we emerge from the pandemic and older people now and people of working age, in other words, right through the life course, what is a better society looks based on the evidence that we've compiled? We and others have compiled about the determinants of health at every stage in the life course.

So yes, adult social care is thinking about the end of life and I said in my Build Back Fair report, why don't we have a proper profession for workers in adult social care with decent pay and conditions, not as so many are be part of the gig economy. But that's a more general issue. One thing we realized from the pandemic was who keeps our society running.

It's the care workers, it's the health workers, it's the delivery drivers, it's the bus drivers, it's the people working in the food sector. They keep our society going, the dustmen, the postmen, and we pay them miserably. Many are in the gig economy. Lacking in respect. We need a thorough rethinking about the nature of work.

There had been some debate about universal basic income. I think we need to think about universal basic services, as well as universal basic income. To take one specific example. It's highly likely that if children in poorer families had access to a computer and broadband, the educational divide that increased during lockdown might have been mitigated, might have been less severe.

Access to broadband should be thought of as a utility. We don't think of access to clean water as something you can only have if you're a richer person. We think of access to clean water as something everybody should have access to. And we don't say, Oh you're poor. You've got to make do. We try and make sure everybody has it.

Why not think about broadband that way? We think about primary school and secondary school that way. Every child should have access regardless of ability to pay. We think about our cherished NHS that way. Everyone should have access regardless of ability to pay. Do we really think that the way people should remain fed is to have resort to food banks?

Do we think that's the way forward? A million people were going to food banks in a year before the pandemic. We know food insecurity. Increased dramatically during the pandemic. So in other words, we need to have a pretty radical rethink. It's good that we've got footballers thinking about this. It'd be quite good if we had politicians thinking about it too.

Of what kind of society we want, based on principles of equity, of health and well being. 

Jessamy: Given we had the financial crisis of 2008 and then things went, back to business as normal in terms of political economy and how we view many things, social welfare, protecting the environment, caring for each other, what, how hopeful are you that we might see these changes?

Michael: Did I say? I think I'm out of sight so that's one answer I'm hopeful, so having sighed I can now be more positive I'm hopeful that things are changing, you, we're doing this podcast, this wasn't top of the Lancet's agenda two decades ago, it was closer to the Lancet's agenda one decade ago.

And now it's much closer to the top of the agenda or the British Medical Journal. I've been pushing the Royal College of Physicians for some time. They set up a health inequalities group and then they got the other medical Royal Colleges to sign up. When I published my report in February last year, This Health Inequalities Alliance wrote an open letter to the Prime Minister urging him to act on my recommendations.

They've continued to recruit members to the alliance. They now have 140 organizations signed up. Medical Royal Colleges, Royal College of Nursing, lots of the medical charities and so on. Things are changing. We published our report in December and I was asked the question, is anyone listening to you?

Which is a version of the question you asked me. And people meant politicians. And I said We published our report with a seminar, a launch seminar at nine o'clock on a Tuesday morning before Christmas, and 1, 900 people tuned into that webinar. Yeah, people are listening, and if enough people listen, the politicians will start to listen.

For what it's worth, In the last couple of weeks, I've been approached by senior conservative politicians. Admittedly, they're at the rather awkward end. They're not, dyed in the wool Brexiters. But I've been approached by senior conservative politicians and senior labor politicians. I don't think that there's a linear process from a set of conversations to getting changes in policy, but my side, notwithstanding I think there are more people talking these issues now.

And the more people are doing it the more likelihood of change. We've been working with Coventry as a Marmot City. We're working with Greater Manchester. We're going to start work with Cheshire and Merseyside. We've been working with Gateshead. We've got local governments signed up. And it's only so long, I would say.

that national governments can ignore it. And when I talk about the failure of governance in the decade after 2010, and the failure of governance during the pandemic. In a way, it's a failure to put equity of health and being at the heart of government policy. To say fiscal rectitude, austerity, is government policy.

That's our mission. Fiscal rectitude. And who cares what happens. It was actually worse than that. It was actually, we're doing damage, but That's not our priority. One shouldn't do those forms of damage. We can see the impact on health and health equity. So how hopeful am I? If I was really hopeful, I would've given you a very short answer.

But I've given you an evidence-based answer to say I think we're making progress. 

Jessamy: And I think there is some historical sort of guidelines almost. When you look back at the sort of seventies and eighties and that quite radical shift in. economic thinking about almost trying to increase inequalities to try and increase, the financialization sort of markets are everything that the way that happened, there was such a sort of a drive a political, lobbying, and it was a very well planned and organized sort of movement.

Do you think that there's A similar one that can happen to put health and being at the center. 

Michael: Yeah, thank you for saying that. Absolutely right. I'm sure it can. You're absolutely right. What happened in the late 70s and the 80s was not an accident. It was planned. And we know who planned it. We know Hayek, Schumpeter Milton Friedman.

We know the 

Jessamy: economist 

Michael: who planned it. Hayek was Margaret Thatcher's Bible. She said everybody should read Hayek. So this was neoliberalism. As it came to be called and it was planned for a long time, they had summit meetings in Alpine places and they planned the whole deal when the International Monetary Fund.

So give you more evidence for my hopefulness size, notwithstanding when the IMF the year before last, published a report. The IMF, the International Monetary Fund, the high priests of neoliberalism, published a report saying neoliberalism oversold? When Martin Wolf in the Financial Times, no socialist, talked about the rent seeking economy that had gone too far.

I think, wow, the IMF, the FT, the chief economics commentator in the FT, talking about the rent seeking economy gone too far. Lord Peter Hennessy, historian, was in touch with me recently. He said, It's time for beverage. World War II, 1944, the most unpromising title for a report ever, whatever it was called, an inquiry into social insurance or something.

But it laid the basis for the welfare state. If you take those indicators of the IMF and the Financial Times, It's quite possible to argue that neoliberalism is coming to the end of its natural life. Let me give you a statistic that I've just put into an essay I've done for The Lancet, so your readers can read it as well as your listeners listen to it.

A group in the U. S. looked at, I think it's 640 U. S. billionaires, at what happened to their wealth. between March 2020 and December 2020. In other words, during the pandemic and these 640 billionaires increased their wealth by 1 trillion in nine months. It means that they could write checks for every single one of the 330 million Americans for 3, 000.

And these billionaires would have the same wealth as they had before the pandemic happened. Is that sustainable? Is that really, is that a model that can continue? And, arguably, Brexit, Trump, populism, all these ghastly things, are a result of that unsustainable model. So, one wants things to change, not because the old system crashed, but one would like things to change because people have a positive thi thirst for change for the better.

But you could argue that old model has run its course. And there is time for a new beverage.

Jessamy: So I think you could ask why we decided to talk about inequalities and COVID 19 now. There's been so much said about it over the last year. Michael Marmot released his report in December about the implications that inequalities had in COVID 19 in the UK. And I think we felt that it was important to provide this slightly alternative view to what our listeners may have heard from another person who's played an important role in the pandemic, Jeremy Hunt, and his view on the last 10, 20 years in the UK, in terms of health spending and austerity and the effect that had on inequality.

Gavin: Yeah. He was quite forthcoming. He It gives, it gives a particular perspective on inequality in the UK, and I think it's super important that we give that kind of rounded overall view. That's why we chose to speak to Michael Marmot, and I think it was a really interesting insight into talking about the direct effect of inequality on health outcomes in the UK.

That's something that we've seen around the world as well. In fact, if we have one golden rule for COVID 19, it's that the worse the inequality that a person or population is suffering, the worse the outcomes for COVID 19 that they seem to have. 

Jessamy: Yeah, and I think Michael is a perfect person to provide that viewpoint.

He's been you know, culminating this argument about the social determinants for health for over 30 years. And what we've seen is that's transcended any national borders and that the overall baseline of the health of your population and therefore what inequalities are at play in terms of poverty, education, housing, all of those other aspects.

have had such a huge impact on the pandemic. 

Gavin: Yeah, his work does absolutely transcend borders, doesn't it? When I interviewed Sherelle Barber for the Black History Month podcast a couple of weeks ago, she spoke in such glowing terms of Michael Marmot and it was so great to hear that, that kind of public health message that he's spent his career putting forward has gotten out to such a wide audience.

Jessamy: I think one of the things that I really drew from the conversation is this consideration of how do we move forward from now to change in a philosophical way the way we view healthcare. as part of society and then what the function of it is, not that it should be a result of a prosperous economy, but that it is in fact the driving force and the foundation of an economy.

How we make that change is obviously extremely difficult, but there are, as Michael pointed out, there are signs of hope, I think. 

Gavin: Yes, it's just the real crux of the matter, isn't it, is moving health to that kind of foundational aspect of society of actually thinking in the broad philosophical sense, as you were mentioning there, what are we all here for?

Why do we have government? Why do we pool our resources in this way? Is it so that a few people can make an awful lot of money? There'd be a free. economically as they want to, or is it actually for the betterment of all? Is it for the provision of greater health? Is it for the provision of better results?

Is it for the furtherment of as many people in society as is possible, rather than the protection of individual freedoms? And I think that is the kind of base that we're driving at here. 

Jessamy: Yes, and you and I were talking about it before, before we recorded this, just on the kind of historically what's happened after all of these huge events, whether it's the Industrial Revolution, whether it's the Great Depression in the 30s, and the sort of World Wars, that there has been a desperate need to have a change in the way we run our economies because Things required that to revitalize and to move on.

And what we saw from the Great Recession in 2008 9 was that there wasn't a change. We just got back to business as usual. And Michael there points to, the Beverage Report, which is actually called Social Insurance and Allied Services, which is such an uninspiring name. But there have been calls that we need something like that again, and I think not only do we need that sort of real direction in how we should be looking at welfare and social funding for the future, but we need a complete change in the way that we're viewing the intersection between health and our economies.

Gavin: I think this appetite for change is being expressed politically. You can see that around the world in kind of political outcomes of political outsiders that are doing so well that maybe wouldn't have got a look in 10, 20 years ago before the Great Recession. That appetite isn't finding any particular, basis that has proven workable in terms of change so far, actually, really these people that have, captured a lot of attention and were preaching change have really just been more of the same, if anything, as we saw from the Trump commission that the Lancet published recently, it's actually an accelerated version of the same under the guise of something new and fresh.

So I think it's fair to say that the appetite for change is there, that they were. The kind of discussion we were having with Michael, the kind of reset of the way that we do things, as you said the appetite definitely exists, but it's not really found a basis yet, it's not really found its public expression in any kind of coherent way so far.

Jessamy: I think that vision, yeah is lacking still. I think what is clear is COVID 19 has reframed so many things and allowed, the way that all of these different aspects, these different threads of our society, whether it's work, whether it's health, whether it's our sort of the way we run our politics, our education.

to be absolutely clear that they're so interlinked, the environment, climate change. I think that view of the world, people are beginning to understand. And the next thing is if we now understand how interrelated all of those things are, and that actually we can't go on thinking that we can have these different aspects in silos, and we can take funding away from here, and take funding away from there, and that other things are not going to be affected.

What is the new political system that we should be running to overcome that? And I think that it is about thinking completely in a different way, technology, the way we work, all of these, the way we socialize, everything is changing so much that. the way we've looked at economics in the past can't be translated to now.

I think there needs to be a different format that takes into account these huge changes that we've had, but also the huge changes that are coming. 

Gavin: And I think part of that is acknowledging the deep complexity of all these problems. There are such a huge amount of, as you touched on there, interrelated issues that affect health.

and outcomes and politics at a really base level. And I think we've still really struggled to articulate the deep complexity of issues like race, of issues like climate and the way that those are all interrelated and affect each other, affect society, and they affect the way we do things, and they have to be Acknowledged and dealt with in a way that we haven't really figured out yet because we're still looking for these kind of politically simple answers.

Jessamy: Yeah, and I think that the uncomfortableness, which so many people feel that have led them to champion different causes, climate change, me too, race, all hugely important. But for me, they stem from the fact that we cannot compute the fact that we've made so much progress. Based on social injustices and that those two things run counter to each other.

And we now need some way of being able to understand that we can continue to progress. We can continue to have, to make money, that markets are important, that innovation, technology, everything is very crucial. But it doesn't have to mean that there are huge portions of society that are left behind and that we build that on social injustices.

Gavin: I think it is interesting to, to talk about in the way that Michael highlighted the way the conversation has moved on in the last 10 years, in the last 20 years, as he said. 20 years ago, this would have been something quite tangential to the Lancet's output. But actually now thinking about inequality and the climate is actually something that is completely central and vital to the Lancet.

And that's not diluted our message at all. We're still completely focused on better science, better health outcomes, but actually it's an acknowledgement of the way the conversation in the last 20 years has moved on to incorporate things like. inequality and climate and how society's progress has been built on inequality and injustice into the center of this health conversation.

Jessamy: And how really it cannot go on for very much longer, I think, without major problems in our society, the cracks are already there and if those aren't faced and developed and directed with something new that is a vision forward. different to the past, then I think there's a real risk that we go down some quite dark routes.

Gavin: I was trying to end this on a more upbeat note. The conversation is moving on, but I agree with you, there are still risks inherent in not moving that conversation onto a broader societal level fast enough. 

Jessamy: Thanks for listening to this Lancet Voice. You can subscribe to the Lancet Voice wherever you usually get your podcasts, and we'd like to see you again next time.