Published: 30/09/2004, Volume II4, No. 5925 Page 21
Status Syndrome , by public health academic Professor Michael Marmot, was the surprise hit of the summer. Championed by influential policy commentators such as Will Hutton, the book argues that a person's social standing has a direct effect on their health.Here the author talks to Nick Edwards
Status Syndrome How your social standing directly affects your health and life expectancy By Professor Michael Marmot Publisher: Bloomsbury.
You have been researching and writing as an academic on the effect of rank and status on health for more than three decades.What prompted you to write a 'popular' book?
I wrote it in a different way consciously - I wanted it to be accessible to an intelligent nonspecialist.When I spoke at conferences, directors of public health often told me they wanted something that would communicate these ideas to people like NHS chief executives or the local authority. They felt people didn't understand social determinants of health and how it worked as a gradient.Also, I had never put my thoughts of health relating to where you are in a hierarchy and what was going on, down in one place.
The unexpected thing was what a joy it was to write.And in the process, I felt I understood certain things a lot better. For example, you witness hierarchies of health in all forms of society - totalitarian, communist, capitalist and indeed in non-human primates. So one might easily conclude: this seems inevitable, what can we possibly do about it?
I had worried about that for years.
During the writing of the book, I came to realise something which may seem obvious. Reducing the inequalities - the differential between people's status - seemed like a worthy aim, but I couldn't see it happening tomorrow. It is far better to understand the link between positions in a hierarchy and health - and interrupt it.
There will always be relative differences, but It is not what you have or what you do, It is what you can do with what you have.
How can you interrupt those links?
An example is paying attention to the organisation of work.One of the things that marks out hierarchies in the workplace is how much control you have.We have evidence that one of the things that leads to worse health for people with low status is that they have less control over work and indeed life in general.Now, you can change that.
There is also the balance between effort and reward - whether what you put in is reflected in things such as money, promotion and self-esteem. That is something that people working in the health service understand - the idea that no matter how hard you work, you will not get rewards.
Another area is where people live - we could do something about neighbourhoods, patterns of residential segregation and about crime. People higher up on the scale will always have better housing but we can make the differential less.
You must have seen the political popularity of such ideas ebb and flow over the years.Do you feel like the tide is in now?
The change in 1997 was quite remarkable - people were starting to move this way in the last years of the Conservative government but in general they didn't want to know about inequalities in health. Since the Acheson inquiry, which I sat on, a lot has been put in place.
There is a huge amount that has happened, certainly in the first few years - healthy schools, health action zones and so on.We are still looking at whether it has made any difference.
But when the government talks about public health as a matter of choice, they are forgetting their commitment to health inequalities. I would like to hear the words social justice a bit more often - the rhetoric has changed in the centre.
The debate about the nanny state versus individual freedom is just misplaced.We all believe in government action and we all believe in freedom. The extent to which the government is fearful of the nanny state - I would like them to change the debate, look at the role of a responsible state and talk about a fairer society, like they did right at the beginning.
What areas would you want the next Labour government to focus on?
First, is the early child and education. The government has been doing things in this area, with initiatives like Sure Start. But there is still much more to do to raise educational standards, but just as importantly to improve the readiness of children for education before they go to school.You can see the tight relationship between deprivation and school performance.
Second, is the role of work and work/life balance.We have heard a lot about the importance of work, people not being on welfare - now we have got to look at the quality of the work. Does it make sense to induce a single mother to go into the workplace and have someone else look after her children when that work is lowpaid insecure, unsatisfying and stressful?
Third, is neighbourhoods - Labour did a lot in the first term but There is more to be done.
Fourth, is the place of older people in society - the effect of areas like social isolation and public transport is something we identified in the Acheson inquiry.
Were you surprised by the amount of attention it got in the national press?
Reviewers tended to ask why all of this wasn't being talked about a lot more. I wanted to start a public discussion, and to some extent, this seems to have happened.
What are you working on next?
Most work on health inequalities that has been carried out - and work that I have been involved in - is about working age people.
I am now interested in looking at older people and consequently, we have a longitudinal study of the country's ageing population going on at the moment. It involves looking at the shadow cast by work and other circumstances such as finance, residential issues and family circumstances.
While what happens to people early in life is clearly important, I do not take the view that there is nothing you can do about the over-70s. I think there is plenty you can do about the social gradient of health as it affects older people.