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History > 2015 > UK > Health (I)
‘The richer you are,
the better your health –
and how this can be changed’
Friday 11 September 2015
08.00 BST
The Guardian
Michael Marmot
A boy living in the poorest part of Westminster or Glasgow,
Baltimore or Washington can expect to live 20 years than a boy living in the
richest part; girls fare slightly better. But most of us do not live in the
poorest part of cities and can surely take comfort that this kind of thing
doesn’t apply to us. We are wrong. Such comfort is misplaced.
There is a remarkably close link between where you are on the socioeconomic
ladder and your health – the higher the rank, the better the health. I call this
the social gradient in health. You and I, not the richest or the poorest, can
expect to live for fewer years than the richest and more years than the poorest.
The average Brit can expect eight fewer years of healthy life than the person at
the top. Unhealthy life means an earlier death and, while you are alive, your
hand grip weakens, your mobility declines, your memory and other cognitive
functions decline, and various illnesses accumulate. All of these happen at a
progressively faster rate the lower down the social hierarchy you are. Those of
us in the middle are not immune. We are part of the social gradient in health.
And the scale of the problem is enormous.
Just counting premature deaths, before the age of 75, there would be about
202,000 fewer deaths each year if everyone in Britain had the low level of
mortality of those with university education (which was less than 10% of the
population when the people dying today were of student age). That is about 500
deaths a day. It is a calamity for each of us, potentially, and a tragedy for
the nation. If this toll resulted from a pollutant, people would take to the
streets demanding action.
We should demand action. The cause is inequality in the conditions in which
people are born, grow, live, work and age; and inequities in power, money and
resources that give rise to this inequality.
The good news is that we now know how to reduce this toll of premature deaths,
and to live healthy lives. First, experience from round the world shows that
although the link between where a person is on the social ladder and ill‑health
is widespread, the magnitude varies greatly. Some countries are already doing
what’s needed. Second, we have the evidence of what can be done. It entails
lifting our gaze from the immediate concern of pressure on the NHS or unhealthy
lifestyles and focusing on the causes of ill-health. It starts with the nature
of early child development, continues through school and employment, and ends
with the conditions in which elderly people live out their lives.
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The gradient changes everything. Suppose for a moment that the problem of health
inequalities were confined to poor health for the poor. It could be a political
litmus test. If we were a certain sort of rightwinger we might think that the
poor are architects of their own misfortune, shirkers, and thus we would have
little sympathy for the inequalities in health associated with poverty: if poor
people want good health they should become like us, strivers. Alternatively,
elsewhere on the political spectrum we might care … a bit. But we still comfort
ourselves that it is “them”, the poor, who are suffering; social disadvantage
does not affect “us”.
But the gradient means that all of us below the top should make common cause,
creating the conditions for good health. There is a clear social gradient in
measures of early child development: the more deprived the family, the worse the
scores on cognitive, social and behavioural development. Yes, the poor have the
worst scores. But, in the middle of the social range, only 52% of children
reached the level certified as ready for school. We need action across the whole
social gradient. Our society needs to do two things: improve services for
parents and children – closing Sure Start children’s centres is not a good idea
– and reduce the proportion of people who have insufficient income. The Joseph
Rowntree Foundation uses the criterion of a minimum standard of living in
Britain today. It includes food, clothes and shelter. It is about having what
you need in order to enjoy the opportunities and choices necessary to
participate in society. In 2010, 31% of households with children were below the
minimum income threshold. Three years later that had risen to 39%. Paying
attention to the bottom 39% involves far more people than “the poor”.
Work, of course, should be a way to achieve the minimum income necessary to
participate in society, but it isn’t. Of “couple households” that were below the
minimum income standard in 2013, only 19% had no one working. In more than 80%
of households with low income, at least one adult was working. The problem is
neither that benefits are too generous, nor that people are feckless. The
problem is that work does not pay well enough. Neither do benefits. Evidence
from across Europe shows that countries that spend more generously on benefits
have better health and narrower health inequalities. Interestingly, countries
with better benefits also have better employment conditions.
I have been gathering inspiring examples, from rich countries and poor, of how
communities are taking action necessary to improve lives and reduce health
inequalities. The most significant factors are social cohesion and empowerment.
Rather than divide society into two great classes – either the categories of
Marx or the shirkers and strivers of a different political language – we do
better to think of gradients. We should pursue the aim of levelling up. It is a
reasonable judgment that all social groups could have the good health of the
best off. But this will take action, based on sound evidence, across the whole
of society.
• Michael Marmot’s The Health Gap: The Challenge of an Unequal World is
published by Bloomsbury.
‘The richer you are, the better your health – and how this can be
changed’,
G,
11 September 2015,
http://www.theguardian.com/books/2015/sep/11/
health-inequality-affects-us-all-michael-marmot
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