Michael Marmot has discovered an important societal aspect: those of higher station enjoy a greater standard of health; lifestyle has little to do with it.
Have you ever wondered why the queen is still alive? And Prince Philip? Why her mother only died when she was 101? Elizabeth Murdoch, 103? Gough Whitlam, 98? Malcolm Fraser, 85? Why Bob Hawke is still with us at 88? And David Attenborough at 92? What do you think? Good genes, moderate alcohol intake, disciplined exercise regime, never smoked, the best healthcare money can buy? According to Michael Marmot, the answer to that question is: none of the above.
Of course, genetics, lifestyle, and good doctors help. But the most important determinant of how long people live the (healthy!) lives they enjoy is their power and social standing. With that answer, Michael Marmot does more than most to help us solve a few major problems. This is why he is part of the tiny series (of two) I started a few weeks ago. In part one, I looked at the solutions Hugh McKay has to offer. This time, the focus is on Sir Michael.
Sir Michael, at 73 a mere pup, is an interesting man. He has the most boring sounding job on the planet, Professor of Epidemiology and Public Health at University College London, but when you see him give a talk, it is like listening to Che Guevara in a suit. He is proof that science, the disimpassioned calculation of facts and figures, can lead you to radical conclusions about humankind and where it needs to go. Let me introduce you.
Marmot was born in London but moved to Sydney when he was four where he eventually did a degree in medicine at the University of Sydney. After a Masters at Berkeley in California, he got himself a fascinating job: setting up what has become known as the Whitehall Studies. This investigation looked at 18,000 civil servants in the British bureaucracy and, after ten years, concluded that the lower people were placed in the hierarchy, the higher their mortality rate. Marmot called it “the status syndrome” and pointed towards power and self-determination as a cause. The lower your rank, the less influence you’ve got over your job and your life. And that kills people. While people who are at the top of the pyramid (the queen, a PM) live longer because they are more in control of their lives.
It was a groundbreaking discovery for a number of reasons. First of all, because it concerns all of us. All of us are somewhere on that gradient. Most of us are in the middle, which means that although we live longer than people below us, the people above us die later than we do. So, you are better off than the copy boy, but worse than your boss. And that is food for thought, because it means that what is making us sick is inequality, more than lack of exercise or drinking beer. It also means that health is far less an individual issue than we think. Of course, if you eat shit food, don’t move, and you smoke, you put yourself at risk. They are the causes of something like obesity and types of cancer and, in the end, death. But what, Michael Marmot asks, are the causes of the causes? And that is where some interesting facts and figures come in.
If we allow people meaningful work that they can influence themselves, Marmot says, we can close the health gap in a generation.
The difference between the bottom and the top of the graph is 17 years, on average. For some populations, like Indigenous and generally poor people in the world, it is more. In fact, pinpointing where it goes wrong has proved surprisingly easy. Turns out there are social determinants of health: education is the first and most important one; the better you are educated, the longer you tend to live. Men and women in their forties with less than 12 years of education have a 70% higher mortality risk than the highest educated, for instance. But a close second is what Marmot calls community participation and control, the level in which you (are able to) influence and access your direct environment. Do you vote? Do you feel that you can call the police for help? Do the ambulance and fire service come to your door? Do you have a member of government who will look out for you? Marmot gives the example of certain areas in the U.S. where the war on drugs has turned into a game of cat and mouse between the police and (mostly) young black men. Police are being rewarded for arresting them and, as Marmot says, all black men need to do to get arrested is breathe. All they need to do to get shot and killed is breathe too, and that has meant that people don’t feel safe in their own homes, let alone on their own streets. This has influenced their feeling of control and empowerment. As a consequence, people in those areas die much sooner than their counterparts in the leafy neighborhoods a few miles away.
It is this “epidemic of despair” that is worrying Marmot. But he goes much further than that. Because, he says, even if you don’t care about the poor, or think they are architects of their own misfortune, you should care about the health gap of the hierarchy. Because somewhere in that gradient is you. Don’t forget that there is eight years between a person in the middle and the people at the top. Also, we are not just talking about death, but also about cancer, Alzheimer’s, lack of strength, difficulty walking, having to live with disabilities. All these things are worse the lower you get on the scale. Even more scary is that IQ is on there, too. IQ, it turns out, is not God-given or even that genetic. If you grew up in a family with a low socio-economic status, your IQ declines throughout your childhood, especially compared to your richer classmate. If you are the child of rich and powerful parents and have a low IQ, just hang in there. Because your IQ will grow the older you get. Socio-economic status overrides the influence of genes; the social outweighs the biological. Again, health is far less an individual issue than we think it is. It is also less only about money than it is about power and social mobility. If you live in a country where your parents’ class and status strongly determines yours, you are stuck with the health issues they are experiencing. Unless you can get access to good and long-term education. Education is good for your health and the health of your children and grandchildren. The single biggest contributor to the reduction of infant mortality, globally, is the education of women. It works better than any medical intervention.
A close second is what Marmot calls community participation and control, the level in which you (are able to) influence and access your direct environment.
All of this sounds very deterministic. But Sir Michael Marmot is an optimist. Because, he says, we know, through all the research that has been done over many decades, what causes health inequalities. And with that knowledge comes the possibility – no, the need – to fix it. If we know that inequalities kill, we also know that we need a greater equality of money, power, and resources to cure the disease. So: 1. Give every child the best start in life; 2. Allow people meaningful work that they can influence themselves; 3. Get closer to social justice by allowing people access to and power within resilient communities. If we work on those three things, Marmot says, we can close the health gap in a generation. As an illustration, he gives an example of unjust inequity: the top 25 hedge fund managers in America have the same annual income as the whole of the population of Tanzania. Each of them “earn” a billion dollars a year, if anybody can ever, morally speaking, “earn” that amount of money. If all of them gave up those “earnings” for a year, that would double the income of every inhabitant of Tanzania. The hedge fund managers wouldn’t feel it, but the change for the people of Tanzania would mean that in that year almost 20,000 less children would die there. Alternatively, if the hedge fund managers didn’t want to send their money to Africa, they could pay a third of their income in taxes, like the rest of us. That would give a salary to 80,000 New York school teachers.
The point is, Marmot says, we have the means to do something. But do we have the will? When we do, we can achieve great things. New Zealand, for instance, has reduced the gap in life expectancy between Maori and non-Maori people from 17 to 7 years, partly by reducing the extremes in income and power inequality. Australia, on the other hand, is sliding from one of the most equal societies in the world to one where the differences are getting bigger and bigger. Since the 1970s, real earnings by the top 10% have risen by 59%. For people at the bottom of the scale, this is only 15%. And, of course, this has consequences: when you make more money, you can invest the surplus. That then turns into capital, which will make you even richer. The bottom of the hierarchy is just scraping by with what will always be just income, not capital. This will make the inequalities, over time, bigger and bigger, and therefore increase the gap in health expectancy even more.
An extra problem is that we know that great inequalities are inconsistent with a functioning democracy. With a functioning society and community, even. Look at what is happening in the U.S. at the moment. A lack of fairness undermines everything. As Marmot says: the opposite of poverty is not wealth, but justice, and social injustice is killing on a grand scale and putting the future of the planet at risk. Nevertheless, this is not a matter of destiny. If you empower people, you start the process of change. You will even flatten the hierarchy, so all of us have an opportunity to live well into healthy old age. Like the queen, or David Attenborough. Wouldn’t that be something?
For this article I have used the following sources:
Michael Marmot The Health Gap. The Challenge of an Unequal World (London, Bloomsbury, 2015)
Boyer Lectures 2016: Michael Marmot on the social determinants of ill health
The Boyer Lectures (part 1)
The Boyer Lectures (part 2)
Close the Health Gap | Michael Marmot