This is an interesting book that looks at the factors effecting health; in particularly factors affecting health within countries. Marmot refers to this as a social gradient or ‘status syndrome’, and explains that this is not just just between the rich and the poor, but also between the rich and the very rich. An example quoted in the book is that Academy Award winning actors and actresses lived four years longer than the co-stars and the actors nominated who did not win.
Once a country has basic clean water, sanitation, and sufficient food a larger national income doesn’t provide better health for the country as a whole. Once a country has solved its basic material conditions for good health, more money does not buy better health. When comparing whole countries, there is no gradient in the relation between income and health.
The following example from the United States exemplifies the health disadvantage in the United States. Consider two typical American teenagers of fifteen: a young white man in an urban area of Michigan, and a young black man living in Harlem in New York City. Michigan is about as close as you can get to the statistical average of life expectancy in the United States. The white teenager has a 77 percent change of still being alive at age 65. The black teenager has a 37% change. Two out of three black fifteen-year-olds on the streets of New York will not see their sixty-fifth birthday. Three out of four white fifteen-year-olds in Michigan will.
Relative deprivation in the space of incomes can yield absolute deprivation in the space of capabilities.
The reason that people with higher incomes are more likely to have better health is due to a matter of resources; they have the resources to take control of the situation, rather than have events control them. These resources may be knowledge – how to operate the system; financial – the ability to bear the cost of the solution without pain; psychological – the confidence to know that they can do what is required and people respond to the confidence.
There is a large body of evidence now exists that supports the demand/ control model: people whose jobs are characterised by high demands and low control have a higher risk of developing coronary heart disease than those in other jobs with more control. The lower in the hierarchy you are, the less likely it is that you will have full control over your life and opportunities for full social participation. Autonomy and social participation are so important for health that their lack leads to deterioration in health.
The book also talks about the fact that those who participate more in social networks have better health. This is because of four primary pathways:
- Provision of social support;
- Social influence;
- Social engagement and attachement
- Access to resources and material goods.
In New York city the life expectancy drops by 15 years from Fifth Avenue to Harlem.The major contributors to premature loss of life in the deprived areas are coronary heart disease, violent deaths and the consequences of HIV infection.
The league tables for school performance are a a remarkably good indicator of deprivation of the area in which the school i located. The more deprived the area the worse the average school performance. If you look up a school to see how it is performing, you are actually reading off an exquisitely sensitive indicator of depuration. The league table is telling us something, but if it is sol closely linked with deprivation, it may not be telling us much about schools.
There will always be inequalities in society but the magnitude of their effects on hearth is in our control. Why not make things better? It is in all our interests.