The Status Syndrome
How Social Standing Affects Our Health and Longevity
By Michael Marmot
Henry Holt and Company Copyright © 2004 Michael Marmot
All rights reserved.
Some Are More Equal than Others
Of all the hokum with which this country [America] is riddled the most odd is the common notion that it is free of class distinctions.
W. Somerset Maugham
In La Bohème, Puccini's wonderful operatic tearjerker, after the most brilliant pickup line in all opera, Rodolfo and Mimì fall in love. He is the bohemian poet, she the poor embroiderer; he in freely chosen happy poverty with his educated bohemian friends, a "millionaire in spirit," she in lonely isolation and destitution. She has consumption (tuberculosis) and Rodolfo, recognizing that she is dying, complains to his friend, that she is "blighted by poverty. To bring her back to life, Love's not enough." Mimì, in her turn, says that "to be alone in winter is death!" Mimì, of course, dies. Rodolfo weeps, and so do we, and go home uplifted.
Apart from creating surpassing beauty, Puccini and his librettists, Giacosa and Illica, were kindly providing an introduction to the essential themes of this book. Mimì and Rodolfo are both poor, in that neither has any money and both live in a freezing apartment, but it is no accident that it is she who dies, not he. (Quite apart from the fact that, in the opera, her death guarantees more tears.) What is the difference between her poverty and his? Poverty is more than lack of money. He and his educated bohemian friends — poet, artist, musician, and philosopher — are in control. They live the way they do by choice, in a way that the unfortunate embroiderer does not. The opera goes further. Love could save lives; isolation could end them. Important as love and isolation are, their effects on health are moderated by other influences: isolation is worse in the harsh environment of winter; love may be life-enhancing but cannot overcome the blight of poverty.
The important things of life, control over your life, love and important social relationships, riches that are not measured by money, are related to when, and how, we die. I cannot pretend to match Puccini's power to move, but the scientific findings that I shall review move me in their own way as much as Puccini does in his. These findings suggest that Puccini got it about right. The circumstances in which we live — that foster autonomy and control over life, love, happiness, social connectedness, riches that are not measured by money — affect illness. It is precisely because these benefits of life are doled out unequally in society that we have inequalities in health and in death. Life and death are not opposites; they are intimately related.
For most of us, life and health are in separate spheres. We think that health has to do with genetics, health care or lack thereof, or our own personal lifestyle and habits: whether we are following this week's advice on which vitamins to eat and which to avoid or which exercise regime is currently in vogue. Then there is life: education, family, career, friends, getting and spending, spiritual and cultural life, and the nature of the society in which all this takes place. Whenever health researchers raise their gaze from the microscope and look around, they find the evidence that health and life are not two separate spheres. It is not that genes, medical care, and lifestyle are unimportant for health, but they miss out on the major influences on health of the way we live our lives in society. The circumstances in which people live and work are intimately related to risk of illness and length of life.
Nowhere do we see this connection more clearly than in the social hierarchy. Imagine that we are witness to a grand parade. Everyone in the population is classified by their formal education and ranked from least to most. Starting with those who have the fewest years of education, they file past us. The parade begins with the unable and the unwilling, continues with those who did not complete primary school, goes on to the high-school dropouts, those who completed high school, and up through various stages of college or university education. As the parade progresses we note the changes in style and demeanor, of comportment and confidence, and of increasing affluence. We notice something else: a healthy glow increasing in radiance with those going past.
If we could but measure this glow, it would show us that this sorting of people according to their education has also, in a remarkably precise manner, sorted them according to their health and length of life. The higher the education, the longer people are likely to live, and the better their health is likely to be. It is not just that the people who come first, those without education, have poor health and those who come last, the Harvard and Oxbridge graduates, have good health, but our parade sorts everyone in between. This is the social gradient in health played out across the whole society. In general, a few more years of education translates into longer and healthier lives. The big question is why.
Before I jump to the conclusion that education for all would lead to good health for all, let's repeat the parade. Take everybody back to the starting point, forget their education, and this time sort them according to income. We have a new ranking system — lowest income first — but, remarkably, the finding is the same. The lower the income, the worse is people's health status and the shorter their lives. It is again a graded phenomenon, running from the poorest all the way up to the richest. Should I now jump to the conclusion that more money for all would improve their health? No more readily than I should conclude the same about education. I am nervous: which is it, money or education? Now let's repeat the parade with parents' social class: we find the same thing. It's a bit more difficult to give people higher-class parents in order to prevent premature death. They should have thought of that before they chose their parents. Try occupation as the ranking system. It should not be too hard to assign some sort of prestige score to occupations — doctors and judges come higher than shop assistants, who are higher than unskilled workers. There it is again: the higher the prestige of the job, the better the health. As we cannot make everyone into judges and doctors, thank goodness, one might really like to know if there is something about the job that is important in causing this gradient in health.
I conducted this parade four times, each time using a new ranking system and ignoring the previous one. But there is overlap in the rankings: for example, people with university degrees have higher incomes in general than those without; people with higher-class parents are more likely to have a college education than those without; those in top jobs have more education and income. There is overlap, but the rankings are not identical. The professor of divinity is above the plumber in education but way below in income; the trader in the bond market has several times the income of the priest but lower occupational prestige.
At the heart of my inquiry is an investigation of which ranking system is most important in determining the health gradient. Not because I am interested in rankings for their own sakes, but because I want to understand what education, income, parental background, and occupation can tell us about how life circumstances affect health. By understanding whether it is money or education, for example, that is most closely related to inequalities in health, we shed light both on causes of the differences and what we could do about them. As I indicated, La Bohème got it about right: love, happiness, riches that are beyond money, lack of money and, indeed, the education of Rodolfo and his friends may all be important to the social gradient in health. Much as I am moved by Puccini, I would like to put some scientific precision on this inquiry. The first step is to look for the health gradient in different times and places.
WHERE DO WE SEE THE HEALTH GRADIENT?
Pretty well everywhere. As one example, Figure 1.1 shows for the United States that the higher the household income, the lower the mortality rate. Figure 1.1 makes clear that poverty is bad for health but it is at the end of a spectrum. Those in the poorest households have nearly four times the risk of death of those in the richest — which in any case are not fantastically rich. It also drives home the point that the relation between income and health is a gradient — people in the second-highest income group have higher mortality than those in the highest; those in the third-highest have worse health than those in the second-highest.
Figure 1.1 illustrates the problem that our parades threw up. Income and education are correlated: the higher-income groups are more likely to include people with more education. Income predicts health as the figure shows, but so does education; is the relation between income and health because high-income people have more education? Figure 1.1 says yes, in part, but not completely. The "adjustment" for education examines the relation of income to mortality after taking into account the fact of education's ability to predict mortality. When this was done it showed that the apparent effect of income on death is reduced. This means that this study confirms that there is a social gradient in mortality, but it is difficult to be sure whether it is more closely related to income or education, or to something else that was correlated with both of them. The question of whether it is income, education, or something else that is responsible will run through the book.
I have been working with colleagues to study the health gradient in different segments of the population of rich countries: the United Kingdom, the United States, Canada, Finland, Japan, France, Sweden, Germany, Italy, Belgium, Australia, and New Zealand. It is quite remarkable that wherever you look you find a gradient. Something equivalent to Figure 1.1 could be produced for each of these countries. For years, no one really paid much attention to what should have been obvious from the data. Perhaps they were too concerned with the effect on health of absolute material deprivation that results from lack of clean water or adequate nutrition. This understandable concern got in the way of seeing that rich and poor are the ends of a spectrum — in between, health follows a gradient.
The gradient is the issue. For reasons that are not entirely clear to me, people want to see things in binary terms: poor/nonpoor, deprived/nondeprived. Recognition of a gradient changes the problem socially, scientifically, and politically.
· Socially, because health inequalities are not confined to the poor and the nonpoor but affect all of us, whether rich, poor, or somewhere in between. The status syndrome is about how you and I, neither rich nor poor, live our lives, and how that affects health and length of life.
· Scientifically, because were it the case that the poor had bad health and everyone else had good health, we would focus on which of the multiple disadvantages associated with poverty might be most responsible for the damage to health. Absolute deprivation means the basics of food and sanitation are lacking along with adequate noncrowded housing, lack of medical care, or other amenities. The status syndrome is not only about absolute deprivation. It is about inequality, but not only that between top and bottom. The scientific question has as much to do with why people in the middle of the hierarchy have worse health than those at the top, as with why those at the bottom have worse health than those in the middle.
· Politically, because it changes the way the problem is addressed. Politicians appear to be able to count up to two, actually zero and one: you are in or you are out, with us or against us. They can understand poverty as a discrete state and no politician is going to extol it. Many politicians, however, preach the virtues of inequality (set the wealth producers free). If bigger social and economic inequalities, that is, a steeper social gradient, are related to bigger health differences, this might give the politician pause. A policy pursued for one reason — increasing inequalities as an economic policy — might have undesirable consequences for health. The gradient in health has the potential to change views of what constitutes the aim of social policy.
There is a strong tendency for scientific questions to get bound up with the political question of how the implications of the science might be implemented. As we go through the scientific evidence, the implications will be evident. We should, nevertheless, try to hold back the political question of what we would do with the findings until it is clearer what the science shows. The science is the place to start.
I said that we see the health gradient everywhere. When the environment is harsh and life-threatening, the socially advantaged fare better than the less advantaged; when the environment reeks of affluence and privilege, we still see a health gradient. I will illustrate with two dramatically contrasting situations: the South Pole for extremes of hardship and Hollywood for extremes of affluence.
As a schoolboy I was thrilled by the story of Captain Scott of the Antarctic: the tragedy of heroic English gentlemen failing to complete an expedition to the South Pole in 1911 trapped by a blizzard, and lying in their tents, running out of food, out of hope and out of luck, a mere eleven miles from their food depot. The weakest, Captain Oates, struggles to his feet and stumbles out of the tent into the blizzard, with the memorable words: "I am just going outside and may be some time." His self-sacrifice is to save rations for the others. Scott records in his diary: "We knew that poor Oates was walking to his death, but though we tried to dissuade him, we knew it was the act of a brave man and an English gentleman." Scott suggests in his diary that all four of them in this tent will be deemed to have died like English gentlemen.
How does this illustrate the status syndrome? It certainly shows that if conditions are severe enough, anyone will succumb, whatever his social class — even an Edwardian English gentleman. There is a "but." On the final trek of Scott and his comrades, there was a fifth man, Seaman Evans. He was of a lower class than the "gentlemen," a petty officer in the Royal Navy, chosen for his strength. Evans, the big man, was the first to weaken in the appalling conditions. He did not reach that final act of the drama in the tent. He began losing heart sooner. Why should the man who was apparently the strongest of the five be the first to succumb? Evans was, as Scott's diary records: "nearly broken down in brain, we think." His companions found him in the snow with a wild look in his eyes. The "gentlemen" did what they could. They sledged him to the next camp where he died. Scott and his remaining three men struggled on.
The second is that Scott was right in his diagnosis — he describes Evans as being broken down in brain. I shall argue that the brain is a crucial organ in generating the social gradient in health. To put the whole expedition in context, Scott was determined to be the first to reach the South Pole. He was second — beaten to the prize by Roald Amundsen, a Norwegian. Bitterly disappointed, Scott and his four companions had an eight-hundred-mile march back toward safety that destroyed body and soul. These explorers had made a massive effort without appropriate reward. Imbalance between effort expended and reward gained is psychologically damaging and hence damages physical health. As winners, they might all have had a greater chance of survival. My speculation is that what Evans, in particular, lacked was control over his own destiny. It was this lack of control that made him especially susceptible to the appalling conditions. The expedition was Scott's, not Evans's, in the sense that Scott was the one with control over who did what, when — to the extent that the environment allowed. I cannot say in Evans's case that it was his low control and not something more prosaic like the loss of a glove that did him in, but I will show you evidence that people of lower social position have less control over their lives and are more likely to be socially excluded, and that these two factors are important aspects of the status syndrome and play a big part in their worse health. (Continues...)
Excerpted from The Status Syndrome by Michael Marmot. Copyright © 2004 Michael Marmot. Excerpted by permission of Henry Holt and Company.
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