The Health Gap

[book review]

Someone (possibly Stalin) once said “When one man dies, it’s a tragedy. When a million die, it’s a statistic.” But, to Professor Sir Michael Marmot, a million deaths is not just a statistic.

A million people have died prematurely in just the last five years in Britain, according to the renowned epidemiologist Michael Marmot, author of The Health Gap,1 who has spent a lifetime trying to counteract such cynicism. For him, the deaths of millions worldwide from the same cause, inequality, are millions of tragedies which could and should be prevented.

Marmot was a medical student in the ‘60s when he realised that illnesses were not just isolated problems for the doctor to solve but symptoms of something bigger. Sitting in with a psychiatrist in a Sydney hospital, he recounts seeing a woman enter, a “picture of misery”. She said “Oh doctor, my husband is drinking again and beating me, my son is back in prison, my teenage daughter is pregnant, and I cry most days, have no energy, difficulty sleeping. I feel life is not worth living.” It seems that she was depressed (Marmot describes his mood dipping also)! The psychiatrist told her to stop taking the blue pills and try some red ones, telling her to come back in a month’s time. Marmot felt that this seemed somewhat inadequate but the psychiatrist explained that there was very little else he could do.

But it wasn’t just mental illness that resulted from people’s living conditions: immigrant workers would come into his Sydney hospital with “a pain in the belly,” be prescribed antacids and sent home. What seemed obvious to Marmot, that conditions of life contributed to both mental and physical illness, was then not generally accepted and he lacked the evidence to prove it. He has devoted the rest of his career to gathering that evidence.

The young doctor Marmot felt that his profession were treating illnesses as fires that needed putting out, but the fires kept recurring. What about some fire prevention? The doctors didn’t seem to have the time or tools for that. When he expressed these views, his consultant suggested that Marmot go into epidemiology, the study of the connections between illness and the conditions of people’s lives.

Learning his trade as an epidemiologist in California, he looked at how the health of Japanese immigrants changed. He found that their rate of heart attacks went up but their rate of strokes went down, in both cases approaching that of the host American community. This was probably linked to their diet becoming more “American,” but they still maintained some health advantage from their previous lives in Japan, probably linked to their more supportive family and social networks.

Later, Marmot worked on two large studies of the British civil service, the Whitehall studies, following the health of some 27,000 government employees from the most senior down to unskilled manual workers. Contrary to received wisdom, it was not the top civil servants who had the highest rate of heart attacks but the lowest status ones. The lowest level workers had higher rates of nearly all diseases. In case you thought this was because they tended to drink and smoke more and have unhealthy diets, Marmot’s team corrected the data for this and found that two thirds of the health difference was due to the position or status of the workers in the hierarchy. Furthermore, the risk of ill health rose as you went down the levels – there was a social gradient to mortality for many diseases and everyone was somewhere on the gradient.

Briefly, it seemed that it was not poverty as such that disadvantaged people but low social status, and somehow this was making them ill. This brings us back to the million premature deaths every five years in Britain. The calculation comes from applying the death rate of university-educated people to the whole population. Once again, there is a gradient relating the amount of education to greater life expectancy. Marmot sees this as an aspect of the gradient of social status and refers to studies showing that stress hormones are generally higher in those with less control over their lives: “Inequalities in health arise from inequalities in society.”

These social gradients exist in all countries, superimposed on a gradient between countries. Thus, infant mortality in Mozambique is 12% compared with 0.2% in Colombia. But even in Mozambique there is a gradient, with the most educated mothers experiencing an infant mortality rate of less than half that of the least educated.

On the basis of average income (GDP per capita), Mozambique is one of the poorest countries while Colombia is in the middle. In general, average income is related to life expectancy but some countries buck the trend. The USA is the richest large country and yet average life expectancy is the same as for Cuba with about a fifth of the income. The difference is in the extent of inequality in these countries. We also find that within Europe, the Scandinavian countries have the least inequality and the greatest life expectancy.2

The gradients within countries can be staggering. In the UK, life expectancies can vary by nearly thirty years between neighbourhoods in the same city. In run-down Calton, Glasgow, male life expectancy, at 54, is less than the average for India (62) while in more affluent, higher status Lenzie, it is 82. It seems paradoxical that the income of a low status Glaswegian is much higher than that of the average Indian but Marmot quotes economist Amartya Sen saying it’s “not only how much money you have that matters for your health, but what you can do with what you have.”

Of course, you can find causes for ill health among the poor, smoking, poor nutrition, alcohol and drug abuse, respiratory disease from air pollution and so on but Marmot is more interested in the “causes of the causes.” These lie in lack of control over one’s life, high demand, isolated, low status work, lack of correspondence between effort and reward, as Marmot exemplifies with the case of a warehouse “picker” who works long shifts fulfilling orders for online shopping. The picker walks over 10 km per shift, lifting hundreds of heavy objects, not seeing a fellow worker, subject to discipline for trivial faults, and paid a pittance.

Communities, in Glasgow, Cuba, USA, are an important part of inequality – or equality. Marmot gives the example of Mary, a First Nations (native American) Canadian teenager, who killed herself. This individual tragedy had several contributory factors, home circumstances, community, welfare services, but it was not isolated. Many young First Nations Canadians also commit suicide, the rate being five times that for all young Canadians. But this is not just a sad statistic. First Nations people are organised into about 200 ‘bands’ of which half had hardly ever had a suicide while 90% of the suicides occurred in 12% of the bands. Poverty, low education, unemployment, poor health and low life expectancy are common in all bands – the difference was in the degree that bands were able to hold on to their cultural history and promote their collective future. Officials blamed the child welfare services but Marmot quotes a Canadian psychologist saying that, rather than target suicide, the aim should be to make communities healthier places for youth to live.

Marmot’s message is that to reduce health inequity we need fairer societies. This message comes from WHO’s Commission on Social Determinants of Health,3 chaired by Marmot, and from his review in England, Fair Society, Healthy Lives.4 The determinants of health are not so much the medical treatments people receive as they are the characteristics of their societies. Improving living conditions and working conditions, building supportive communities, reducing income inequality, reducing air pollution…are some of the factors that will help. This sounds like it would require a socialist society but a lot can be done right now. Many councils in Britain are trying to implement Marmot’s proposals (Coventry calls itself a “Marmot city,”5 while Lancashire, Chichester, Durham, Worcestershire, Barnsley and Walsall are introducing aspects of Marmot).

Crucially, working conditions, as well as wages, are better where trades unions are active. Not only that but workers themselves can have creative ideas to make their work more effective and fulfilling. Marmot gives the example of the Merseyside fire-fighters who started visiting people’s homes to encourage use of smoke detectors and found themselves sorting out housing problems, counselling people on how to give up smoking, inviting pensioners to use their gym and helping children take part in sport. There is also the West Midlands fire service who have explicitly responded to the Marmot review by trying to help the poor and needy in their community. One example was an octogenarian contacted about fire safety when he was found to be burning rubbish in his living room for warmth as his gas had been cut off. It took the fire officer three weeks to be allowed in: she asked the man what he did all day – nothing, apart from trips to local shops for food, since his electricity had been cut off 26 years earlier. He saw no one. “The fire officer brought him clothes, Christmas dinner, located his sister, and finally got him on needed medication and into sheltered accommodation.”

Marmot’s lesson is that the health of all of us is affected by inequality and we need to work together to reduce inequality and improve our health. Marmot doesn’t say it but this is best done through collective action of the sort discouraged by our present capitalist system.


1 The Health Gap: The Challenge of an Unequal World. Bloomsbury 2015. ISBN: 978-1-4088-5799-1

2 A wealth of animated graphs and other information about health, life expectancy, income etc. is available on this website:

3 WHO Commission on Social Determinants of Health report (2008):

4 Fair Society, Healthy Lives (UCL Institute of Health Equity, 2010):

5 Coventry: a Marmot City


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