From Publishers Weekly
With 30 years of research and a catchy name for his theory, epidemiologist Marmot gives a wake-up call to those of us in the wealthy industrialized world who think our social status has no impact on our health: whether you look at wealth, education, upbringing or job, health steadily worsens as one descends the social ladder, even within the upper and middle classes. Beyond a simple explanation of how the deprivation of extreme poverty leads to disease, Marmot shows that life expectancy declines gradually from the upper crust to the impoverished. The odds are that your boss will live longer than you and that Donald Trump will outlive us all. Marmot bases his conclusions on his study of British civil servants, but backs up his theory at every turn with mountains of other research, from experiments on rhesus monkeys to studies of cigarette factory workers in India. For a book based on statistics, the text contains only a few graphs, but Marmot still provides a comprehensive overview of the current understanding of how our health depends on the society around us, and particularly on the sense of autonomy and control one has over one's life. As an adviser to the World Health Organization, Marmot has had the opportunity to make policy recommendations based on his theory. The Status Syndrome
may not be a page-turner, but it will make readers look at the rat race in a whole new way.
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From The New England Journal of Medicine
Michael Marmot's book offers a drink from the fire hose of social epidemiology. If you want to understand why the health of people living in the United States, the richest and most powerful country in world history, lags far behind the health of people in other rich nations, then be prepared to wet your whistle here. Marmot, a British doctor who received his epidemiologic training in the United States, directed the Whitehall II studies of British civil servants. His Whitehall research was built on earlier studies that had examined health disparities among various occupational grades of civil servants. Marmot found that in nearly all settings, the lower in a socioeconomic hierarchy a person is ranked, the worse is that person's health. And that maxim holds for almost any disease or health risk factor. Those who stand higher up on the ladder of life are always healthier than those even a few steps below. This health "gradient" has become accepted in public health circles during the past two decades, thanks in no small part to Marmot's work. (Marmot even received a knighthood, a rare accolade for a public health researcher.) However, the health-gradient concept remains largely unfamiliar in the United States. Americans speak about health disparities but typically are referring to differences in health outcomes between whites and minority groups. Conventional wisdom considers these disparities a consequence of unequal access to health care -- or a product of unhealthy personal behavior. But in this book, Marmot demonstrates clearly that this myopic view significantly limits what we see about our society. The Status Syndrome explores a wide range of instances in which differences in status generate differences in health outcomes. Although average incomes serve as a useful predictor of who is healthy and who is not, Marmot shows us that a health gradient even shows up among successful actors and actresses who have won Oscars and those who haven't. Here, Marmot distinguishes between poverty and inequality. Poverty, he explains, deprives people of the capabilities to lead the lives they would wish to lead. If you have little money, "more money would benefit health, but if you have more of it, then it is how much more you have compared to other people in your society that is more important for health." Poverty doesn't drive ill health, he writes. Inequality does. In rich countries, Marmot continues, most people have the basic resources necessary for life. But they do not have, as the Whitehall II studies demonstrated, control over their lives -- the power to live as they want. The lower that people stand in the hierarchy, the less they have a sense of controlling their own destiny. Low control leads to chronic stress. High-status work, on the other hand, tends to be associated with greater control, more power, and better health. Stress, of course, isn't always a bad thing. Our quick response to a short-term stressor -- our flight from an attacker, say -- may sometimes save our lives. But studies of other primates have helped researchers understand how chronic stress overwhelms our systems and leads to most of the diseases of modern life. And the chronic status dynamics that Marmot unveils start their overwhelming early in life. Our well-being, he shows, is directly related to where our parents stood on the ladder of hierarchy. In this area, Marmot considers intergenerational phenomena surrounding mothering behaviors that are transmitted nongenetically and influence our health -- and presents data showing that divorce is bad for children's health. In one of the book's lighter moments, he describes a judge asking a 95-year-old couple who want to separate, "Why divorce now?" The couple's reply: "We had to wait till the children died, your Honor." Marmot, as a member of the Scientific Advisory Group, helped produce the Acheson Report, which described inequalities in health in the United Kingdom. Although the group laid out 39 recommendations for reducing health inequalities, only 3 of them actually pertained to health care. The rest all involved enhancing people's status and narrowing the gaps that leave some of us considerably farther behind than others. Margaret Thatcher and Ronald Reagan, Marmot notes, turned "individualism" into a political credo. We now live amid the greed this credo has nurtured. Is that greed good for us? In this book, Marmot presents the general public with all the information it needs to answer that most important of questions. Stephen Bezruchka, M.D., M.P.H.
Copyright © 2005 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.