 Falch am brydol nhw ar edrych i gyfleoedd y sgol yw archweddau ar fy unirbyn fettau, gallwn dwi'n rhaid i'n fawr mewn i'r fawr. Felly y llif er rhaid i, yn fawr, y byd o fawr a'r rhaid i'n bwysig o'r gwerth o'r ddechrau ond i'n ddifen o'r their i siaradau ar yr oedol yn ddechrau i chi. Dyna dweud bod yn ddifen o'n meddwl yn dweud beth oes yn ddechrau'r gwaith. Mae'r gaelach y gallu, mae'n bwysig yn cael ei sgol yng Nghaerhau i'w ddweud, ond rwy'n cael ei ddweud, mae'n cael ei wneud bod yn cyd-ais i'r un oed yn gallu am ystod yn y dda. Felly, yn rhan oedd ystod, rwy'n gweithio'n cael ei ddweud. Rwy'n cael ei ddweud ar y maen nhw, neu rwy'n cael eu ddechrau, rwy'n cael eu ddweud, rwy'n cael eu Glasgo. A dyna'r chi'n gweld ei gallu yn gwasgol fath y gallai ymdweith i'r safudfa. Gwasgol o hyd yn ymwiydydd i yw'r gwasgol yn gennym. Mae hwn yn ymdweithio ar y pethau'r gwybod'i pryd yn tynnu'r gwsieil yw'r fath. Yw gwrando ofi gwybod ymdweith, felly, y gallwn ysgolwch, yn ymwneud y prydwyr o'i gweithio, mae'n ddysgu'r ffridwm hwnnw i'ch gael ffraith, mae'n ddim yn ddigon i'ch gweithio. Felly, ytod ydych chi'n wneud, ac mae'n ddigon i gael ffraith yma, am y cyfnod gyfrifol o'i gweithio i ddigon i'ch gweithio i gael ffraith? Mae, os ydym o'r ddych chi, a mae'n gweithio i'ch gweithio i'ch gweithio bod y pwyllwch i'ch gweithio i'ch gweithio, I thought I'd give you some of the key messages and then you can leave or go to sleep or do whatever you want. So what am I going to talk about and what are the messages? Economic and social policies drive health inequities and urban health inequities. So I say that as a statement of fact and I hope I'll demonstrate that, but there really is a dearth of evidence that both quantifies and really it makes explicit the relationships between public policy and I'm not talking just about health policy, I'm talking about public policy on health inequities and some of the work of colleagues that we've heard about is really all about trying to demonstrate that impact. The danger of being small is that you can't see the screen. We've spoken about governance both implicitly and explicitly yesterday and today and I would argue that the architecture of governance is still inadequate to address the complexities of urban health inequities and that in an overall sense if we are going to think about and do something about health inequity then we're talking about the political economy of health. And we're all talking about how bad our cities are. Well, I'll claim this one for myself from Glasgow. I'm from the working class area of Glasgow that's mentioned there. So men with a life expectancy of 54 years compared to a more affluent part of Glasgow with a life expectancy of 82. When we launched these data, and I'll speak about where these came from, when we launched these data the media went ballistic. The notion that in Scotland and in Glasgow this flourishing city that we have these sorts of differences and for the footballers, well, the soccer, the real footballer soccer, fans in the room. If you follow Glasgow Celtic you may remember Tommy Burns. Tommy Burns was one of the best footballers in the world. He died at the age of 51. Four of his five siblings died under the age of 55 all from that part of Glasgow. What's happening? But there's a gradient and this goes to some of the discussion we had earlier. Is it about targeting? Is it about universalism? If we only think about those marked differences between the top and the bottom, we miss the fact that there's quite a significant burden, health burden or death burden somewhere along the social gradient. And these data, I think, demonstrate that. If I press the red button, is that the pointer? Or am I going to? The idea of thinking about both the differences but also the gradient. We might say there are differences in health, differences in death, differences in health. We started to have a conversation last night about what do we mean by health inequities. If you're talking about inequities, to me you're starting to talk about a value system. The notion of it's not just about difference and it's not just about inequality, it's about the fact that there is unfairness in those differences. And I had the privilege to work with the WHO's Commission on Social Determines of Health in the report that we released in 2008 on the back cover said, social injustice is killing people on a grand scale. And one of the most, one of the comments that we got about the commission's report was it was ideology but with an evidence base, which we took as a great compliment. So, yes, we laid bare that it was about social justice, it was about human rights, but that there was an evidence base that actually you could do something about that. And for the many economists in the room, if you want an efficiency argument as to why you would do something about health inequities, it costs an awful lot of money to have them in the system and I won't read through the figures. And then the argument, well, is it not about national wealth? Is that the important thing if we want to do something about health and we want to do something about health inequities? Is it about economic growth? If it was only about economic growth, then Costa Rica, Sri Lanka, Kerala would have nowhere near the life expectancy that they currently have. These are all data but it makes the point that two countries with this very, very different national wealth in terms of GDP per capita has very similar life expectancy at birth. So there's something else that matters. And of course I'm talking then about the social determinants of health as being some of the key drivers of those health and health inequities. And what do I mean by that? Well, it's this combination of structural determinants, so power, money and resources, so matters of trade, matters of labour arrangements around the world, that affect our everyday living conditions and we've spoken an awful lot about everyday living conditions so whether it's the physical built environment, et cetera. And that combination of those more upstream structural factors with the daily living conditions contribute towards empowerment, having enough material resource, having psychosocial control over our lives and having political voice and together contributing to health inequities. And if we might just demonstrate that differently, it's the combination of all of the things on the left hand side. If it's about having the freedom to lead a life that we have reason to value, empowerment, material, psychosocial and political voice and control, is that what we mean by human development? And I'm afraid to put the next slide up just based on the conversation I was having at lunchtime. But this notion of how do we value what's a successful society? Is it about the dollar sign? Why do we now read every day, we think it's important that we read about the Dow Jones or we've got the psyche of the dollar being the most important outcome. But arguably, and we spoke about yesterday's subjective well-being, maybe it's about the distribution of health, it could be a marker, so a distribution of physical and distribution of mental well-being. I'm not going to go into the daily living conditions, but suffice to say that they matter. I think we spoke about them an awful lot yesterday and many of the urban people in the room know all of this more than me. But it's socially graded just to remind us that the experience of the built and urban form is very socially graded and that's in England. So again, that steep social gradient, if we only focused on the bottom, we miss the fact that the next rung in the social ladder has a worse experience compared to the next rung in the social ladder that has a worse experience. So everybody's part of this. And of course I've got to speak about food, it's one of the areas that I do a lot of work in. Being from Glasgow, we have one of the highest levels of heart disease in the world, and one of the reasons is this picture on the left-hand side, which is the deep fried Mars bar. And it's not an urban myth, and it actually tastes really quite nice. For those of you who don't know the deep fried Mars bar, it's a chocolate bar with caramel on the inside, you wrap it in batter and you drop it into oil, and you buy it when you go into the fast food outlet as you buy your deep fried pizza. But the reason I put it up really is to talk about issues of availability, of affordability and of acceptability. The deep fried Mars bar along with the deep fried pizza is readily available, it's not an urban myth, it's in every fast food outlet in Glasgow. It's also very affordable. So compare, if we're talking about buying the healthy foods when you go in and you've got this on offer and it tastes kind of nice, of course you're going to buy it. And then it's socially acceptable, it's now on the menu in the more affluent restaurants in the city of Glasgow. So we've changed, we've normalised this food to be something that we want to consume. And I don't think that's per chance. I spend a lot of my time fighting with the food processing industry who battle to get these sorts of foods into the shops. And we've got some of the levers, if we were to use some of the government and planning levers through planning and the food service sector. But I do want to talk more about power, money and resources because I think this is really what shapes those daily living conditions within cities. Why do I think trade has anything to do with urban health inequities? Trade is a very important mechanism for economic development and certainly for many low and middle income countries where much of the urban growth is currently happening. Being part of the global trading system is vital for economic development, but it's the nature of the trade that's important for health equity. But trade brings revenue for countries where the taxation system is not the primary source of public spending revenue. Trade is an important part of that. So the notion then of countries entering into trade agreements where they have to reduce their tariffs very significantly which therefore means they reduce their public revenue spending capacity has implications then for dealing with some of these social and urban policies that we would like countries and cities to spend money on. It's quite far upstream in our thinking but I would say from a political economy of health perspective it's an area we need to think about. What about working conditions? I'm not advocating that everybody should have or should be wanting to buy the big match. You can see there's a theme of food in my talks. But of course the big match is the index. It standardises the price of food. So what this graph is showing is that the salaries in cities in parts of the world are much less compared to other parts of the world and that's of course not a big surprise. But the point of the slide is if we are thinking about urban health inequities and having enough material resource to lead a life we have reason to value then thinking about the precariousness of global labour arrangements and the everyday working conditions is also part of the arsenal to address urban health inequities. But who's got the power in all of this and this is coming to the issue of governance and we've spoken, we've had discussions about the top down the bottom up approaches to addressing health inequities. This is an image from Fran Baum in Australia. It's not one or the other. It's a combination of course. And I want to use this example of the cigarette plane packaging. We know that cigarette uptake, smoking uptake happens in cities. It happens at an earlier age in cities and then that social contagion into rural locations. Australia is currently fighting from a public health perspective to regulate the branding on the package, on the tobacco package. The idea of having no logos on the cigarette packaging. Now of course that's sent the tobacco industry into a frenzy around the world. No logos, a question of are we in breach of intellectual property through the trips agreement, so we're going back to trade. So it came from a health concern but took us into the trade and investment world where for us in the public health community we've struggled to deal with all of that. In terms of being equipped to have that sort of discussion it will pass. At the moment including Hong Kong and a number of other countries around the world Australia is going through the World Trade Organisation's judicial system being questioned as to a team a word. But as I say it's likely, very likely that it will pass. That will be a major, major win for public health and will have huge implications for urban health. What about the who's got the power in terms of local planning if you know I lived in Ireland for a long time and if you know the city of Dublin and there's a part of Dublin called Temple Bar. Ireland went through the Celtic Tiger rapid economic growth. What happened I'll let you read it, I don't want to read it all out was the Irish government decided to just have all sorts of incentives around property development and it happened in a way and we're reaping the not the rewards of it now. Ireland is in terrible trouble partly because of it, not exclusively. But what we saw happening in the centre of Dublin in this area called Temple Bar was increase in crime rates and increase in drinking on the streets. If you ever visit Dublin and visit Temple Bar area it is just truly disgusting what happens in the evenings around. Ireland already had a problem with alcohol but it's now got an even greater problem. Partly because the control of the local planning was taking out of the hands of the local planners. But there are of course good examples of real participatory governance where you have community involvement saying this is what we the community need in order to achieve our desires in terms of health and social needs. The before and the after pictures of Favella in Brazil I took these slides from a colleague which was based on community so it was community driven based on the needs and desires of the community funded by local government with input from private investment a very we were talking about democratic control yesterday and it matters it matters for health outcomes this is indigenous control urban youths in Canada down the left hand side is the suicide rates and really the point of the slide is how it drops off with increasing community control so the idea of self-determination community controlled and organized services we saw this incredible drop off in youth urban suicide rates in Canada so what do we need we've set up this global action for health equity network that's a plug that we're online please have a look what I'm speaking about is all of these different sectors that affect urban health and the idea it's very easy to say political will on the right hand side is Gordon Brown who was the prime minister at the time when we launched the commission's report in 2008 the prime minister stood up and opened the conference it wasn't the minister for health it was the prime minister who said at the centre of my government I think that health equity is something that we should be concerned with and we are going to think about this in a whole of government approach how it plays out of course it's very different on the left hand side is not just a picture of a whole motley crew but at the centre is the mayor of New Orleans we were invited by the former surgeon general of the US to come to New Orleans and expose after Hurricane Katrina and expose the social fault lines he said this was not about this natural disaster the aftermath of that it wasn't about the natural disaster it was about the underlying social inequities and the mayor of the mayor of New Orleans again stood up and said what we are trying to do is get the health care system together with the urban planning system together with the natural disaster system people to talk together to do it in an integrated way it's happened particularly well but colleagues from the US will tell us otherwise central to all of this of moving forward is an explicit policy framework that puts health equity at the centre it's not about saying we'll target this group or we'll target that group it's right at the centre what we want to do is address health inequities and then let's work out how we do that I spend a lot of my work is around complex systems and how they produce health inequities and the idea of let's embrace the complexity please the call for ways of thinking about evidence and modelling and so forth absolutely but this systematic consideration so whether it's the health the health impact approach of systematically assessing what other sectors are doing but also thinking about the systems and processes the idea of how do systems reinforce issues of racism or issues of gender inequities some of these systemic social inequities that produce themselves in terms of produce the health inequities and there's some very nice examples of how you might do that I'll just give this example from south Australia I won't speak it through but if anybody's interested that again came at the premier's level so the head of the government of south Australia not the department of health the head of government said we want to do something about health we want to do something about health inequities we think it's part we think it's a central issue for us new ministers get around the table and work out how we do it and to finish the idea of the data if we don't have the data we don't have a problem and we don't have any action and we're going to hear about some of that from colleagues now but I would say there's a caveat to that we know an awful lot and we know about many of the things that can be done so not having the data is not an excuse to not do something so it's the two things and I really just want to pick up on this bit at the bottom asking the question differently one of my concerns if we talk about within health inequities why do the poor people behave the way they do the feckless poor and it puts it back on to the poor a question might another way of asking that question is why on earth are people poor in the first place what is it about those structural inequities that are contributing to that and to finish what's really exciting for me in this room is the diversity of disciplines I've truly I've learnt a huge amount yesterday and today but it's also incredibly difficult to do really working across disciplines the notion of having interdisciplinary groups is just I've yet to see that done really well so how do we get all of these people together and this is a fantastic way to do it so to finish and for my New Zealand colleagues in the room this idea of having the freedom to lead a life we have reason to value I think this writer from New Zealand sums up what I understood we were speaking about thank you