Book Review by Francesca Ramondetti
“Socioeconomic differences in health are not confined to poor health for those at the bottom and good health for everyone else. Rather, there is a social gradient in health in individuals who are not poor: the higher the social position, the better the health. I have labeled this ‘the status syndrome.’ ” *
Sir Michael Marmot, a British physician who has been studying health inequalities throughout the UK and the rest of the world and who also is a Professor of Epidemiology and Public Health at University College of London has been gathering evidence for the past 30 years that offers the possibility of improving our understanding of health, happiness, and how to make a good society. He argues that autonomy, meaning how much control you have over your life, and the opportunities you have for full social engagement and participation, are crucial for health, well-being, and longevity. Marmot points out that it is inequality in these areas that plays a large part in producing the social gradient in health, and that degrees of control and participation underlie the phenomenon that he calls the “status syndrome”.
What is that, exactly? Status syndrome is a disparity in health that brings discrepancies in social standing, money, power, influence, and level of self-esteem. However, money is not the only issue: apparently, Nobel prize-winners live a few years longer on average than nominees. Independent of salary, higher educated individuals live longer than less educated people. So it seems there is something else, something intangible, yet familiar to all of us that is embodied in the idea of “status” or social worth. In order to understand Marmot’s point of view, we need to stop thinking of wealth, and how wealth disparities impact health, simply in material terms. As social status rises, so do health prospects and life expectancy.
Marmot pioneered this understanding with his studies of Whitehall civil servants, in which he discovered a steady gradient in the risk of heart disease from the lowest grades to the topmost. The first Whitehall study (1) started in 1967, included 18,000 men in the British Civil Service. It showed that men in the lowest employment grades were much more likely to die prematurely than men in the highest grades. Furthermore, these socio-economic inequalities in health did not appear to be fully accounted for by differences in well-known risk factors, such as smoking. The Whitehall II study (2) was started by Marmot in 1985 to determine other factors that might contribute to this social gradient in death and disease, and to include women as part of the study population.
Elsewhere, similar effects to the Whitehall studies have been observed in baboons (3), leading to predictable amusement as well as a theory of how status is related to health. Low status in baboons was found to lead to emotional and physiological stress, forcing the individual into permanent crisis mode: this induces physiological changes that can lead to heart disease. According to Marmot, control is at the heart of the matter. He asserts that the more control you feel able to exert over your situation, the more likely stress is to be stimulating rather than corrosive. Having a sense that one is supported by relationships with others, rather than oppressed by them, is also very good for health. Another researcher exposed study volunteers to cold viruses, after having quizzed them about their relationships with friends, family, and colleagues. The more numerous and varied the relationships, the less likely the volunteers were to catch colds.
In light of social justice, but written for ordinary readers, through Status Syndrome, Marmot brings ideas that should have been coursing through public health debate for years now. This book should stimulate each of us to further consider the implications of how our society functions and the relationship to health.
*Quote available from the book “Status Syndrome: How your social standing directly affects your health”, published in 2004 by Bloomsbury Books.
1. Marmot MG, Rose G, Shipley M, Hamilton PJ. Employment grade and coronary heart disease in British civil servants. Journal of Epidemiology and Community Health. 1978; 32 (4): 244–249.
2. Marmot MG, Smith GD, Stansfeld S. et al. Health inequalities among British civil servants: the Whitehall II study. Lancet. 1991; 337(8754):1387-93.
3. Sapolsky RM, Mott GE. Social subordinance in wild baboons is associated with suppressed high density lipoprotein-cholesterol concentrations: the possible role of chronic social stress. Endocrinology.1987; 121(5):1605-10.
Published: January 2012