So, I jumped in with both feet and went off to Berkeley to do a PhD with Leonard Syme. And Syme said to me fairly early on, just because you studied medicine doesn't mean that you understand the causation of disease. You need to understand something about society. Well, I was very susceptible to that message. That indeed was why I traveled from Sydney to Berkeley to study with him, and that's what I've been doing ever since.
Welcome to the Stress Puzzle, where we explore the latest in stress science and consider how the science may translate to our daily lives, or where we might have missing pieces for actually making that connection. I'm your host, Ryan Brown, and I'm a social health psychologist working with the stress measurement network, which is a team funded by the National Institute on Aging and includes internationally
recognized stress experts from UCSF, UCLA and Yale. I'm excited to welcome you to the first of two complimentary episodes on social status and health. Today, I'm joined by Dr Michael Marmot, whose critical work on health inequalities has been recognized at every level of science and society. He's advised the World Health Organization, and was knighted by Her Majesty Queen Elizabeth for services to epidemiology and the
understanding of health inequalities. I'm particularly grateful to have the opportunity to speak with someone whose work has been so impactful for both global health and city level policies. We discussed his foundational research on social status and health the importance of addressing fundamental causes of health inequities like poverty and housing conditions, and we also talked about how he's approached translating the
science into policy. In next month's episode, we'll hear from Dr. Jenny Tung, who earned a MacArthur Fellowship for her critical work in primates, extending the epidemiological work of folks like Dr. Marmot and Dr. Nancy Adler to demonstrate causality between social status and health. I hope you'll tune into both episodes to see why we need researchers working with humans and primates to improve our understanding of how social environments affect our health and even the health of our children.
I am joined today by Professor Sir Michael Marmot, who is a Professor of epidemiology at University College London, Director of the UCL Institute of Health Equity and a past president of the World Medical Association, he's led multiple longitudinal cohort studies that have massively impacted our understanding of how social conditions influence aging, including the Whitehall studies of British civil servants and
the English Longitudinal Study of Ageing. Professor Marmot has also chaired the Commission on Social Determinants of Health for the World Health Organization, and has conducted a strategic review of health inequalities in England to produce evidence based policy recommendations to support population health. He's also the author of books such as The
Status Syndrome and The Health Gap. He is truly unique in the scope of impact that he has had in translating health equity science to policy recommendations that are actually being used by governments at every level. And so it's fitting that he was recognized as a global health hero at the World Health Assembly in 2019 welcome Professor Marmot, and we're so grateful you could join us for an episode of The Stress Puzzle.
My pleasure.
Now you're such a pioneer in the field of social epidemiology, and especially with respect to social determinants of health, or, as we often call it, in the US health disparities. Could you talk us through how the early work on social determinants of health began, and anyone who particularly influenced your thinking?
Well, there was a match that made in heaven. But I didn't quite realize it at the time, as a young doctor working in Sydney, I was very much concerned that the patients I was seeing coming into an inner city hospital were coming with illnesses that I perceived were influenced by the kind of lives they were able to lead. We had a lot of recent immigrants living difficult lives, and their health seemed to be a product of that. And a consultant chest physician in Sydney said, you
know, you can study that. Said, really? He said, Yeah, there are people like Len Syme in Berkeley, John Castle in Chapel Hill, North Carolina, who study how the kind of society in which people live influences their health. I thought, My goodness,
really, you could actually study that. I'd never heard of Chapel Hill and I had heard of Berkeley, so I jumped in with both feet and went off to Berkeley to do a PhD with Leornard Syme and Syme said to me fairly early on, just because you studied medicine doesn't mean that you understand the causation of disease. You need to understand something about society. Well, I was very susceptible to that message. That indeed was why I traveled from Sydney to Berkeley to study
with him, and that's what I've been doing ever since. And it was interesting that both Len Syme in Berkeley and Jeffrey Rose, who I came to work with in London, both in a way, saw the world in somewhat similar ways, namely, saying the cause of why one individual gets disease and not another might be different from why one population has a higher rate of disease than
another. And there was Jeffrey Rose and Len Syme, in a way, saying the same thing, and I was working with both of them, and that got me very much thinking about what I then came some time later to call social determinants of health.
That line of understanding health through understanding societies and how you're connecting the difference between population health on average and individual health behaviors. I've really appreciated throughout your career on how you focused on the importance of empowerment and control over one's life, especially with respect to
health behaviors. And so I'm curious if you could speak a little bit to how we can use social policy to empower individuals and support better health behaviors at the individual level.
Well, working in global health, and particularly working in this field of social determinants of health and health equity, there are two equilibrium positions that one has to resist all the time. The first is that inequities disparities in health must be due to inequities in access to health care. People in the health field naturally think about health care, and if you talk about inequities in health. They assume you're talking about inequities in healthcare.
Inequities in healthcare are very important, but they're not
Those principles are very powerful, and I think that the major cause of inequities in health. So that's one equilibrium position to which people return. The second is,
well, it must be due to individual behaviors. Oh, yes, you've convinced us prevention is important, so we'll tell our patients not to smoke, or we'll tell them to eat sensibly and not put on weight, not get overweight, or to run round the block and do exercise, and that what somebody has called lifestyle drift, that return to individual behaviors again is
something that I've resisted. We can't, for example, take the United States and readily understand why obesity has increased to such a dramatic extent in the US by examining individual differences, What have people suddenly become irresponsible and stop eating sensibly, looking after their diet? How do you explain the dramatic rise in obesity? That way, it's got to be and it's not genes, so it's got to be something else, the food environment, both food and
exercise. Now that's readily understandable when we start to talk about social determinants, more generally, poverty, housing, inequalities in opportunities, neighborhoods, community relations and coming further upstream inequities in power, money and resources, then you're moving away from the comfort zone of most people who work in the health sphere, because it's not health care and it's not individual behaviors.
You're talking very much about the nature of society to come back then to your question, how can we make a change for the better? We have to start addressing these fundamental
causes, what we call the social determinants of health. To give you one very tangible example after the WHO Commission on Social Determinants of Health, I was asked by the British government, how could we apply the recommendations of your global commission to one country, England and I produced what became known As The Marmot Review, fair society, healthy lives. And building on the knowledge we'd synthesized for the global commission and a fresh set of experts, we had six
domains of recommendations. Give every child the best start in what you're speaking to and what you've spoken to in various life, education and lifelong learning, employment and working conditions. Number four, everybody should have at least the minimum income necessary for a healthy life. Number five, healthy and sustainable places in which to live and work, including housing and environment. And number six,
taking a social determinants approach to prevention. So to answer your question, how could we get change act on what became known as the Marmot six? And the evidence suggests you will get change in a good direction.
texts previously, along the lines of it being the best of times and the worst of times in terms of best of times in terms of health technology and understanding and increasing global averages in life expectancy, but worst of times in terms of the inequalities and so many, if not most or all of
these parameters. And so when you touch on sort of what's more uncomfortable for health professionals or folks advocating folks, kind of in the middle of Health Research and Policy, that inequity and power seems to be a huge driver of each effect you're speaking about.
Very much so, and in the UK, I've maintained the fiction that I'm not party political. I say maintain the fiction because, based on the evidence, I've been sharply critical of government policy, but I'm not critical of government policy because I have a dislike of a particular political party, I have a critique of government policy because it's damaging health it's making health inequalities worse, and it's leading to poor health for the poorest people.
That's the nature of my critique. Now it so happens we've had a conservative led government for the last 14 years in Britain who have perpetrated these policies. And so that's why I say I maintain the fiction that I'm not party political because indeed, it's a particular political party that has pursued these policies of austerity with scant regard for the impact on people's lives. So it then becomes party political.
And you know, I have this naive view that I'd like politicians speak to be talking about child poverty, about the fair distribution of opportunities for people to lead flourishing lives, to talk about health and health equity. Why isn't it the stuff of political debate all the time, the fact that life expectancy in the US fell 2016 2017 2018 it went up a little bit in 2019 and then fell again in 2020 and 2021 it's been dramatic. You know, this means something's going really wrong,
and that's what we would like. I would like, naively, politics to be about, how can we make that different? And instead, it's, well, I won't go further with US politics, that's what I'd like to be the nature of the political debate for us all to agree that health and the fair distribution of health are desirable outcomes of the political process, and we'd like to know how the politicians who would like to lead us are going
to achieve those good outcomes. And my big critique of what's been happening in Britain is things have been getting worse from the point of view of health, not as bad as the US, but getting worse from the point of view of health inequalities. So in Britain, the kindest I can be is that the
It is remarkable, especially on the early childhood side of things, how robust, how high quality of government, the conservative led, firstly, coalition evidence we have that that is such a key part of population government and Conservative government, had other health. And so I'm right there with you that it seems like a priorities. That's the kindest I can be they didn't see reducing huge part of a politician's agenda should be ensuring and looking at the evidence on health of our populations,
child poverty as important. They do actually acknowledge its rather than just the economic health or something like that, which I again, I appreciate how you've resisted connecting the importance, though, in words, because they boast that they've two in many cases, because health should sort of stand on
its own. I'm wondering where you see the biggest breakdowns in taken hundreds of 1000s of children out of absolute the translation of science, you know, especially in the domain of something like early childhood education and early poverty. Now the problem was, so that's good that they recognize childhood opportunities, where we have so much strong evidence, so biggest breakdowns in the translation. Science to reducing that would be a good thing to do. The problem is it isn't
social determinants. For example, is it a lack of political will or lack of effective policies? true, and the measure of absolute poverty that they use is really bananas. So the relative poverty measure that OECD international organizations Britain uses is children living in households at less than 60% median income, and that's been going up. The absolute poverty measure they use, sorry for getting technical now, is they take relative poverty in 2010
Got it. So, taking it back a little bit in your career, I am and they ask how that's changed. What it makes no sense to me. Let me take a different measure destitution. The Joseph Rowntree Foundation published figures at the end of last year on destitution in the UK in 2020 and they defined destitution as doing without two or more of six essentials, housing, heat, light, food, clothing and toiletries, soap, toothpaste and
the like. In 2022, 3.9 million people were in a state of destitution, 1 million children, and that 1 million children was a 2.9 fold increase in five years. So for the government to say we've taken hundreds of 1000s of children out of absolute poverty. It suggests they know it would be important had they done it. Regrettably, the evidence suggests they're wrong. They haven't. You know, I'm being kind. Now, I didn't use the word lying, but they haven't done it. The truth is at
odds with what they're saying. So then you ask to come back to your question, well, what's the problem? Is it political world? I said, Well, to be kind, they've had other priorities, austerity. The problem is that austerity caused real damage.
Real damage. There was a recent piece in The New Yorker looking at what had happened in Britain. The UK is not okay, he said, and you can see the damage it's done to the criminal justice system, to local government, to health, to education, to preschool, to every aspect of life, to housing, every aspect of life has been damaged by austerity. The government would claim they took the right decisions because we had problems after the global
financial crisis. Well, they're wrong. They took the wrong decisions, because the growth of the economy was worse in the UK than in other G7 countries, we did worse than most European countries. So they had the wrong policies, even to get economic growth or productivity, and their policies led to real damage in health and health equity. So you've asked me, is the problem political will? Well, I don't know what you describe that, it's wrong headedness as well as lack of political will.
reminded over and over again how striking it is that the Whitehall Social Gradient results were so contrary to conventional wisdom of the time. So, I'm curious if you could speak to how the conversation has shifted with respect to research or policy or both, since you began your career. I mean, what to me is quite remarkable is how common the term social determinants of health now is, and when I started using it, and I laid no claim to originality, I didn't
pretend to have invented it. But when I do literature searches or look at Google, it keeps coming back to my colleague's and me, so we started using social determinants of health, and we published an book by Oxford University Press on social determinants of health. People said, social determinants of health. What does that mean? That'll never take off. Nobody even knows what you're talking about. That was the first issue.
The second, was when looking at heart disease, everybody knew, quote, unquote, that heart disease was linked to stress, and stress was more common in people in high status jobs. And what we showed in the first white horse study, and again, in the second white horse study, was that the lowest the status, the higher the mortality from heart disease. It was the opposite of what quote, everybody knew, unquote. And people said, Oh, it's just civil servants. But when we looked at
national data, in fact, we saw the same thing. The greater the level of deprivation, the higher the mortality from heart disease. And when I talked earlier in this conversation about two default positions, thinking that inequalities in health are all about inequalities in health care or inequalities in lifestyle, when people do accept the evidence on social determinants of health and health equity, they're likely to want to talk about poverty. It's a shorthand. It's
easy. We can all think of reasons why people living in absolute or relative poverty should have worse health. The gradient is not just about poverty, certainly not absolute poverty. It's saying, the lower you are in the hierarchy, the higher your mortality from heart disease and a whole range of
other diseases. And that's got very different policy implications, because we can talk about child poverty, the US has just about the highest child poverty level of all the rich countries, even higher than the UK and ours is pretty disastrous, but yours is higher, taking less than 60% median
income, but then we've got inequalities. Is not just dealing with people below the threshold, there's the gradient, and that led me to talk about proportionate universalism in Britain and to some extent in the US, the default position of social policy is means testing. Focus on the worst off by some kind of means testing and tailor programs for them. And there are a couple of problems with that. One is a health care system for the poor is a poor health care system. An education system for
the poor is a poor education system. A second problem with that, is the whole issue with labeling, administrative issue of trying to figure out who's eligible for these means tested benefits and labeling people? Well, there's something about you. You're below some threshold. You're socially excluded. So I was very attracted to the more Nordic approach of Universalist policies. We don't exclude you.
We try and include you in the same kind of policies, the education system, the healthcare system, the environment and so on that are aimed at everybody. We want you to be part of the mainstream Universalist policies. So I tried to get and the grade that's much more appropriate for the gradient, because if you've got means tested benefits targeting the poorest, then the people who are just above that threshold have worse health than people above them, but they're not in receipt
of those benefits or special programs. So we said proportionate universalism, let's have Universalist policies and programs, but with effort proportionate to need. We want everybody to be housed appropriately. But for the
homeless, we've got to work harder to make that happen. But for people who are not homeless but are living in substandard homes that are hard to heat because of poor insulation quality in poor neighborhoods or the like, we want to improve it right across the gradient proportionate universalism. It brings everyone into the fold, because it
affects us all. It really is a brilliant way to translate what the research actually means into policies that have the greatest impact with the least stigmatization of the people who might need them the most, while acknowledging that this is something that we can really all be focused on because it affects at every level, like you're like you're saying, turning a little
bit more towards the future. For last couple questions, I'd really be curious what areas of research you see as being needed now, and what you would advise current trainees or early career researchers to go towards or to avoid? If there are any areas that might fall into like a file drawer effect that you could speak to?
Although I take the view that we have quite enough evidence to make recommendations, I also take the view that in none of the areas where I'm confident making recommendations is the research of the quality that I would
like. So I would say that these various reports that I've done and I laid out my six domains of recommendations in the English report, these various reports could be seen as a research agenda, early childhood and health, education and health, employment, the work, environment and so on, relative poverty, housing, all of them vitally important. And a second major stream is, well, do any of these interventions make a difference? So, for example, in the UK, the city of Coventry
said, we're going to be a marmot city. We take your six domains of recommendations and we're going to make them the basis of our work at the city, not just the health and care system, not just public health, but the city then Greater Manchester, for people, Americans who watch the English Premier League, you'll know some of these names because they got famous football teams, soccer teams as then Greater Manchester said, well, if Coventry can do we can do it. Then Liverpool. So you know
about Liverpool. And on we went. We've now got 40 plus places in England and Wales that have declared themselves Marmot places. I really want to know what works. What works? Is it making a difference? I remember one of my visits to the US pre pandemic. Somebody said to me, you really need to come to Lexington, Kentucky to see what we're doing there on social terms of health pandemic. I haven't been but what I'd like to know, okay, that's terrific. Is it making a difference? What
are you doing in Oakland, California? Is that making a difference? What's happening in Baltimore? You know, many of these high status universities are working in their local areas. Boston University, School of Medicines, working in South Boston. I'd like to know, are they really making a difference? So there's a whole research agenda there more on the determinants and how they work. And then the second whole stream are the actions that are being taken improving health and
health equity. What can we learn from them?
Absolutely So higher quality research in all of these domains, and then especially intervention evaluation and knowledge of scalability and how generalizable these interventions may be to really move the needle locally or regionally or even beyond.
That's right. And you know, at some point we need to be influencing the politicians. I mean, as we're finishing, I'll tell you a little story I was I had coffee with a former government minister in the Conservative Party in Britain, and he said, this was last year. He said, You know, the current government doesn't like you. And my first response was, Well, I kind of knew that, but to hear it put quite so boldly is a bit shocking. My second thought was,
well, at least they'd noticed. They know what they're avoiding
Absolutely.
So they and then my third thought, I said to this very senior former conservative Minister, I was given a big award nationally by in the king's New Year's honors list, January 2023, so called companion of honor. It was called, and I said, How come, if they don't like me, how come they let it go through? Were they just too incompetent to
block it? And then I thought, That's unkind. It says something good about Britain that I c an be sharply critical of the government based on evidence, sharply critical of the government, but still be rewarded for the work that I do, and that's pretty valuable. There are a lot of countries in the world where that would not be the case.
Yes. So it definitely changes your ability to do the work that you're doing and feel safe in the environment that you're doing it in, it with career prospects and everything else. I'm glad you mentioned that also not fun to be told to your face that.
Well, it just shows a that the work is is political, even if you don't want it to be. That's why I said earlier, I maintain the fiction that I'm not party political, but be to be told point blank, the current government doesn't like you. That makes me political.
You're like I would have put it nicely.
That makes me political, whether I like it or not.
Quick conversion to politicality. So, wrapping up, I really appreciate how you've noted that you're an evidence based optimist, and that this is often fueled by how quickly health can improve. And I'm curious if you can help us all feel a little bit more like evidence based optimists as well. So I'm curious what you think is our best shot at rapidly improving the health of a global population at this moment in history?
Well, I can cite examples from all over, but let's take Brazil, for example, the Bolsa Familia, the conditional cash transfer schemes to children, significant proportion of poor families in Brazil are given cash. What a remarkable idea. One way to reduce poverty is to give people money. Gosh, who'd have thought that? And guess what, despite the prejudices of some people that if you give poor people money that waste it well, they do give it to the women, not the
men. So there may be some some consistent thinking here, but the evidence shows that the greater the coverage of these conditional cash transfer schemes, the better the outcomes for children. Better growth, lower inequalities in childhood growth, reduction of inequalities in infant and child mortality. Hey, that's pretty good. Now that got interrupted by Bolsonaro having President Lula back. People are picking up the traces again. So it's not that one can be complacent, but
look at the Marmot cities, Marmot places in the UK. I never dreamed in a million years. I mean, if I'd been a young researcher listening to a point, well, they weren't podcasts, but listening to an older researcher and say, you know, get your ambition right of what you want to achieve. Not nowhere in a million years. Would I have thought, gosh, wouldn't it be good if there were Marmot places? I wouldn't have thought that a dozen years ago, until Coventry said we're going to
become a marmot city. Oh, that's pretty optimistic, really. That's evidence based optimism. The fact that I just read some one of my colleagues, you know, another city in the local newspaper in Brighton, in Southern England, they said they were going to become a marmot city. They didn't bother to ask us yet. I guess that'll happen, but it's pretty exciting. It could really happen.
That's beautiful, the impact, and being able to feel that impact through so many local governments. I really appreciate how you've highlighted the impact that local governments taking up these policies can have, because I do think we often focus further away from the places
that we can most easily influence. And so just because you you mentioned this, I guess I'm wondering if there's any advice you would give to researchers who are more junior now, but who are wanting to do more work translating their science or others to policy recommendation?
One approach that I've taken is I push on a door, and if the door doesn't open, I don't bang my head against it, I find doors that will open, and one of the reasons we're working locally is because the doors are opening locally. They're ready, acceptance, in fact, inviting us in to come and help them. It's not that we don't want change at a national level, we do, but that's not my particular expertise. You know, I don't know how to get that kind of
political change. And again, to come back to the US. You know, were I sitting with you in California? Now, I've got no expertise at how to change the national vote for President or Senate or Congress in the five states that are going to decide the election. I've got no idea what I could do on that. So that's not a door that I'd be hammering on, that I personally would be hammering on. I might be trying at the state government level, and I'd certainly be trying at the city government level
Absolutely. Well, thank you so much. I am really happy to take away on knowing which doors we can knock on, knowing which doors are worth putting our effort into, and also having a little bit more of that feeling and toolbox to feel like an evidence based optimist. I really think it's something we all need at this moment. So, thanks for joining us today, Professor Marmot, and thanks for all the work that you've done and continue to do. Thanks for tuning in to this episode of the
stress puzzle. We'd love to hear your thoughts and feedback on any issues we've covered today. You can email us at [email protected] and you can also send requests for topics or guests for future episodes. The best way you can support the show is by leaving five star reviews wherever you listen to our podcast and sharing with your friends or your collaborators. And until next time, we're wishing you good stress and opportunities for rest.