The Health Gap: The Challenge of an Unequal World
Bloombury Press, 2015
Reviewed by Johny Van Aerde, MD, PhD
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Dr. Marmot argues that health is directly related to societal issues, that inequities in power, money, and resources give rise to inequities in the conditions of daily living which, in turn, result in health disparities. His decades of research have generated shocking findings, which are described in individual chapters of The Health Gap on child development, education, employment and working conditions, and the situation of older people. The poorer you are, the more likely you are to live a shorter, less healthy, and probably less happy life. This is true between and within countries.
The Health Gap explores why this might be the case. First Marmot looks at the impact of early childhood development, at how maternal depression rates are highest among the poor, leading to less reading, encouragement, and social interaction for an infant mind. This leads to challenges in education, and evidence suggests that good schooling benefits health. After education comes work. It comes as no surprise that unemployment is bad for mental health and it even raises the risk of earlier death. However, for those who have a job, evidence shows that jobs that combine high demand with little control and much effort with little reward increase our risk of heart disease and mental illness.
Dramatic differences in health are not a simple matter of rich and poor; poverty alone doesn’t drive ill health, but inequality does. Indeed, suicide, heart disease, lung disease, obesity, and diabetes are all linked to social disadvantage. In every country, people at relative social disadvantage suffer health disadvantage and have shorter lives. Within countries, the higher the social status of individuals, the better their health.
These health inequalities defy the usual explanations. Conventional approaches to improving health have emphasized technical solutions and changes in the behaviour of individuals, but these methods only go so far.
What really makes a difference is creating the conditions for people to have control over their lives, to have the power to live as they want. Although poverty plays a significant role in health, Marmot makes it clear that empowerment is vitally important and that it is essential to reduce health inequality and improve health. Lack of control is key, according to Marmot. He knows this, bizarrely, because of his study of the British civil service, an extreme example of a stratified organization. In the civil service, decreasing rank is a perfect indicator of lower life expectancy and greater ill health.
Marmot also gives possible solutions and, in the last few chapters, he demonstrates that a great deal can be done about the problem. He describes development of resilient communities, where changes would reduce health inequalities. It all seems rather obvious, but spending more money on society — financial and material support for parents, comprehensive education, good wages, job creation, a strong social security safety net — does the trick. That upfront investment results in less illness to be financed by the health care system later on and longer, productive lives.
With the moral authority of a physician, Marmot, who is the president of the World Medical Association, diagnoses an ill in society and proposes a remedy. As Canadians, we expect that treatment for the sick is a basic right we all pay for through universal health care. Why then should we as a society not fund the foundations for a life that minimizes the chance of becoming sick in the first place? And as physicians, is it our duty to advocate as much for those rights as we advocate for the one patient who needs rare gene therapy? This book is an eye opener.
Johny Van Aerde, MD, MA, PhD, FRCPC, is past president of the Canadian Society of Physician Leaders and editor of the Canadian Journal of Physician Leadership.
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