Best and fairest
By Fran Molloy
Professor Sir Michael Marmot, the recently appointed President of the British Medical Association, is a world-leading social epidemiologist who says he was greatly influenced by his undergraduate education at the University of Sydney.
Though he didn’t set out to change the world, Marmot has certainly had a huge impact on its health; he’s just completed a groundbreaking review of health inequalities in Britain, after chairing the 2008 WHO Commission into social determinants of health. Marmot is presently also the Director of the International Institute for Society and Health and a Medical Research Council Research Professor of Epidemiology and Public Health at University College London.
And while he may have taken on Britain’s centuries-old class structures in his quest to overturn the social determinants of health, Marmot’s reputation and experience stood him in good stead, with few questioning his sometimes startling findings. In his review of public health in Britain, Marmot pointed out that while a man from the wealthiest London borough of Kensington and Chelsea had a life expectancy of 88 years, just 16 kms away in Tottenham Green, male life expectancy was 71 years.
His parents were poor imigrants
Marmot, now 65, has three adult children and has lived in London for many years, leaving Australia to complete his PhD at the University of California, Berkeley in 1972. Born in North London, Marmot moved with his family to Sydney at the age of four. His parents were poor immigrants who had both left school at a young age, and he says that when he grew up, great value was placed on education.
On leaving Sydney Boys High School, he went straight into an undergraduate medical degree, but after four years of medical studies, he took the opportunity to spend a year doing an intercalated BSc in pharmacology. “I spent a year in the lab, which was wonderful.”
During that year, he had time to do his own research – but also met people outside medicine, attended lectures in English literature and befriended students of sociology and political science. “I suddenly discovered the University,” he says. “Until then, I had been a medical student – but that year, I became a university student.”
Marmot’s exposure to literature and politics at such a seminal time clearly influenced his career path. “Being interested in social determinants of health and inequalities in health means you need to draw on a wide array of influences and knowledge and understanding,” he says.
He followed that year with a junior residency at Royal Prince Alfred Hospital in Sydney when, despite working around 100 hours a week, he completed first-year English Literature. The following year, he was offered a year in thoracic medicine, combining clinical work with some research interest. But thoracic medicine wasn’t the path he wanted to follow.
“Without quite knowing what it was I wanted to do, I was concerned about why people got ill in the first place and how it related to the circumstances in which they lived and worked. I hadn’t articulated it very well, but that was certainly where my interests were heading.”
He looked at rates of heart disease in men of Japancese ancestory
As a young intern, Marmot had noticed that Greek and Italian immigrants living near the hospital, struggling to integrate into the community partly due to language barriers, would present with a variety of problems that he started to think were the physical manifestations of some of the problems in their lives. He approached sociologist-turned-epidemiologist Leonard Syme with his ideas, leaving Australia in 1971 for UC Berkeley, under Syme, where he looked at rates of heart disease in men of Japanese ancestry living in Japan, Hawaii and California.
“Japanese culture was cohesive and gave protection against the stresses of daily life, but as the Japanese became more westernised in California, they lost those protections. Among the Japanese in California, regardless of smoking, diet or blood pressure, those with a more westernised culture and social structure had more heart disease than those where their culture was more traditionally Japanese.”
Marmot conclusively demonstrated a link between social environment and disease rates – setting the stage for all his subsequent research. Offered a position at the London School of Hygiene and Tropical Medicine, a major centre of epidemiology, he began his famous Whitehall studies, researching rates of heart disease in British public servants. The only social measure available for him to investigate was people’s employment grade – and this delivered Marmot with a striking observation of the social gradient in health.
Contrary to the popularly held opinion that high-status people experienced greater stress and were therefore at higher risk of heart attacks, Marmot found that the lower a person was in the hierarchy, the higher their mortality from heart disease, and a range of other diseases. “It wasn’t just about poverty,” Marmot says. “It was a finely graded relation between where you were in the hierarchy and risk of disease.”
While some commentators blamed Britain’s class structure, the Whitehall studies have since been reproduced all over the world, showing an inverse gradient between social status and health. Marmot’s 2004 book, The Status Syndrome: How Social Standing Affects Our Health and Longevity, further expanded on these findings.
Above a certain threshold of material well-being
Despite equal access to quality food, good housing and full employment, Marmot found that above a certain threshold of material well-being, another kind of well-being is central. The circumstances in which we live and work and our place in the social hierarchy affect our health and our longevity. The degree of control that each person has over their work and their life, and their level of social participation, will dictate their place on the gradient of health.
Marmot says that he has spent the past 33 years trying to understand why it was that the higher a person’s social status, the better their heath – and to develop policy to deal with this. Chairing the WHO Global Commission on the Social Determinants of Health, Marmot says that the Commission’s most striking discovery was that non-communicable disease dominated in almost every region of the world except the very poorest. It was a critical finding.
“This means that, if you think that the causes of disease are roughly the same wherever we find them, we’ve got to look for a set of common causes and common actions across the world.”
A critical global health threat is obesity, now officially an epidemic, with over one billion people worldwide overweight, and around 300 million clinically obese. Seventy per cent of women in Egypt are overweight or obese, says Marmot, while in Mexico, the problem of obesity far outweighs problems of stunting and under-nutrition.
Yet while obesity (which directly causes diabetes, heart disease and other health problems) is clearly part of a major global health crisis, it’s the causes of obesity that are the real issue – and breaking these down is complex.
How people make food choices
“It relates to the nature of our food supply, the nature of opportunities for physical activity, the changing nature of physical activity at work and how people make food choices,” says Marmot.
In the poorest countries, more educated women are more likely to be obese because in these countries, women with little education are so poor they don’t have enough calories to eat. But in countries with a GDP higher than $2700, there’s an inverse association, where women with more education are less likely to be obese.
“We can speculate on why it’s the case that more educated women in high income countries are less likely to be obese, and it’s presumably in part cognitive; it’s about fashion and the ability to control your circumstances, what you eat, going to the gym and so on,” Marmot says.
Marmot was then asked by the British government to conduct a review of these findings and make recommendations to reduce health inequalities in Britain – and in February 2010, his report, “Fair Society, Healthy Lives” was published.
“It was a statement that if we put fairness at the centre of all decision making, health would improve and health and inequalities would diminish,” Marmot says.
World changing, indeed.