Michael Marmot: Status Syndrome. Bloomsbury £7.99
Sir Michael Marmot is Professor of Epidemiology and Public Health at University College, London. The author is not a socialist – if anything he is something of an establishment figure, a doctor working as an epidemiologist (that is a medical statistician) – but he is very much concerned with health and how it is affected by the kind of society we live in. And he makes his case with polished logic, humanity, and humour. This is not a dry-as-dust book of statistics, but a critical examination of the relationship of society to health.
The basic premise is that matters of disease and mortality follow a gradient that has been statistically proven to be hierarchical. Those at the top of the hierarchy have less illness and live longer and as we go down the hierarchy illness increases and life gets shorter. No surprise there, One would immediately conclude that this is purely a matter of economics: the rich live better than the poor. But there is more to it than that. For instance in a Whitehall study of English civil servants, at the ages of forty to sixty-four those at the bottom of the hierarchy have four times greater risk of dying than those at the top.
Taking it as read that absolute poverty has very definite effects on health, Marmot puts the question in true socialist style, ‘what is poverty?’, and quotes Adam Smith’s definition that poverty is relative to the standard of what is considered necessary to exist in the society in which you live. The level of what can be considered as poverty is changing all the time and varies from country to country, between rich and poor nations. Therefore the state of health of the absolute poor in say North America may be better than that of the absolute poor in Gambia. But as you go up the ladder health and mortality also vary in direct relationship. In other words those at the top in a rich country will live longer and have less disease than those at the top in a poor country, and this applies to all the gradients in between. Why? Are there other factors than money involved?
Marmot answers this question by identifying the missing factor as that of control. It is the amount of control you have over your life. He illustrates how this can vary by whatever position you occupy on the social ladder. He then shows how this is related to the amount of stress you are under and backs this up with medical expertise from his training as a doctor to show how physiological and neurological stress can affect health. This is especially connected with heart disease, one of the biggest killers of all.
To quote, “The importance of money for health depends on how much money you had to begin with. If you have little to begin with more money will improve health by meeting basic needs of food, shelter and sanitation. Above that level, when the problems of privation have been solved how much money you have is not as important as how much you have relative to others in society. It is this relative income that determines what you can do with what you have. We need a richer understanding that poverty and wealth are not only about money.”
Marmot raises all the objections that could be raised to his arguments and knocks them down one by one. On the genes versus environment battle he demonstrates how environment can shape genetic influence, and he is particularly scathing on the pro-genetic argument that the rich are where they are because they are genetically programmed to be successful, and demonstrates conclusively that advantage comes from social background, i.e. that where you come from largely governs where you end up. He punctures the league table myth of school results, and demonstrates that league tables are a very accurate indicator of where the school is situated in society. All of this is backed up with statistical evidence.
Neither does he think that poverty and social hierarchies are inevitable. They can be changed. Well, it seems that he thinks there will always be a hierarchy of some sort, but that the gap can be narrowed. At heart he is a reformer who thinks that the answers come with government action, but then he wouldn’t be a sir if he was a socialist, would he? Never mind, this is a cracking book and a very good read, which backs up the socialist case from an impeccable source. Reading this book, you are left in no doubt that capitalism is bad for your health.
Cyril Evans
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