Philadelphia Reflections

Unequal Health in an Unequal World

Sir Michael Marmont

In 2007, the Sonia Isard Lecture was delivered at the College of Physicians of Philadelphia by Professor Sir Michael Marmot on the topic of Health in an Unequal World . Sir Michael is the Director of the International Institute for Science and Health, and MRC Research Professor of Epidemiology and Public Health, at University College, London.

His starting point is the commonly accepted view that the richer you are, the better your health. The life expectancy of the poorest level of society is almost everywhere seen to be shorter than the local average. In less developed countries and in children, the excess mortality is concentrated in infectious diseases. However, in more affluent nations, it is obesity, diabetes, hypertension which seems to account for it. Regardless of the cause, the common denominator everywhere is poverty, which leads to a general opinion that the alleviation of poverty contains the solution to the health gradient. There is even another logical presumption, that improved health care will directly remedy the problem, without necessarily addressing a more daunting obstacle, the elimination of poverty. Although the provision of equal access to quality health care may be almost more than we can accomplish, in this analysis of causes, it is a short-cut.

Sir Michael is not so sure. Great Britain has had a national health service for fifty years, but it is still clear to British physicians that the class distinction persists in health if not in health care. Mortality statistics confirm the professional opinion. The conclusion is general that the British health system must be flawed, or underfunded, or poorly run. Not necessarily correct, not necessarily correct. Buried in a mountain of data from the Whitehall Studies of British civil servants, Dr. Marmot teased out the fact that a striking inverse gradient of mortality and morbidity existed in a highly educated group that had essentially equal health care and, while not rich were certainly not poor. The gradient persisted at all levels; the higher you rose in the bureaucracy, the longer you were destined to live after retirement.

Evidently a huge amount of statistical work followed this insight, confirming its thesis in a wide variety of situations. The caste system in India provided a confirming example that was unrelated to education or occupational strivings. Marmot's observation is a gradual gradient, not a two-part, either/or. Not rich versus poor, but richer versus less-rich, less-rich versus even-less rich. Every occupational, social or financial step up makes you live a little longer.

I wish he had stopped there. But the pressure to explain has generated the hypothesis that what we are looking at maybe progressive degrees of empowerment. Others who have contemplated Professor Marmot's observations suggest it is due to progressive degrees of happiness. Sorry, but that's a little too touchy-feely for me. I don't know what empowerment is, or how to measure happiness. The monk in his cell may have achieved serenity, not necessarily happiness, certainly not empowerment. The prisoner in his cell has no serenity, happiness or empowerment. I prefer to believe it is premature to speculate publicly about the mechanisms which produce these observations.

Meanwhile, it seems to be true that if you aspire to be rich you may not become happy, but you will probably live longer. If you want to rise in the hierarchy and still live longer, you need not be afraid to strive. For at least a little while longer, that's going to have to suffice as a definition of wisdom.

Originally published: Monday, March 19, 2007; most-recently modified: Wednesday, May 29, 2019