This is a guest post by Linda French, MD, who is Chair of the Department of Family Medicine at the University of Toledo School of Medicine.
In a recent blog (Keeping
immigrants and all of us healthy is a social task), May 19, 2013), my good
friend Josh Freeman wrote about the social determinants of health. When I
commented that arguably the most important determinant was missing from his
list he suggested that I write this book review blog as his guest. While I had long
ago read quite a few papers on the topic of social determinants of health and
health disparities that addressed the material that Josh covered in his blog,
for me it was an eye-opening experience to read a book a few years ago by
Michael Marmot (2004), The Status Syndrome: How Social Standing Affects Our
Health and Longevity[1].
I found Professor Marmot’s explanations to provide a unifying idea that
resonated with me.
Everyone knows that wealthier people are on average
healthier than poorer people. However, it doesn’t follow that wealthier
countries, including the United State (US), are necessarily healthier than
poorer countries. For example, three countries that I am rather familiar with,
Chile, Costa Rica, and Cuba, have life expectancies and other population health
statistics that are as good or better than ours despite huge differences in
average wealth.
Professor Marmot’s thesis is that, after a minimal threshold,
it is not so much absolute differences in material means that makes wealthier
people healthier, but rather their perceptions of their social status within
their reference group. To quote him,
“The remarkable finding is that
among all of these people [i.e. the
groups he studied], the higher the status in the pecking order, the healthier they are likely to be. In other
words, health follows a social gradient. I call this the status syndrome.”
Professor Marmot is a British physician and epidemiologist
from University College, London. His book carefully presents the evidence that
it is the psychological experience of how much control you believe you have and
your opportunities for full participation in society that is at the heart of
social determinants of health. He
presents evidence from many countries and comparisons between them, and evidence
related to individuals within different types of social hierarchies, and
finally ends with evidence that countries with less inequality are healthier
than those with more.
One example that he discusses in detail is that British
office workers at the bottom of the office hierarchy have a higher risk of
heart attacks than senior managers at the top, while just a generation ago
popular wisdom was that highly successful “type A” personality people in stressful
jobs were more prone to coronary artery disease.
Before reading his book I had seen some documentaries on
primates that suggested that lower status animals had poorer health and
reproductive outcomes and shorter lives on average compared with high status
animals that was relatively unrelated to sufficient access to resources such as
food. In addition I lived for a number of years in Chile as a young adult; my
middle class income by Chilean standards was dire poverty by US standards. I was
an American expatriate, a status that was
highly regarded in Chile, and also during some of those years I was a medical
student. Despite the fact that I was really poor by US standards I was happy
and healthy and my children also seemed as happy and healthy as US kids. After
returning to the US I read some papers that included data to show that the
generation of newly arrived Hispanic immigrants enjoy relatively good health
outcomes, which deteriorate in subsequent generations despite the fact that the
families have acquired more material wealth in absolute terms. No good
explanations were included for the findings in those papers. After reading The
Status Syndrome it made sense to me. The initial immigrants were probably
using their country of origin as the social reference and subsequent
generations had a US social frame of reference. I concluded that minority
groups in this country have health disparities in large part due to the
experiences of inequality and discrimination relatively more than due to absolute
access to material means or even specific services - including health services.
In the latter part of his book Professor Marmot demonstrates
that the countries with the best health statistics in the world are those that
are both relatively wealthy and more equal. Examples of such countries
are Sweden and Japan. On the other hand, countries at the other end of the
spectrum present a reaffirming contrast. He spends the latter part of the book
arguing for a political agenda in favor of reduction in social inequality.
If you haven’t figured it out by now, I highly recommend
this book. It will transform how you think about the social determinants of
health.
[1]
Marmot, Michael. The Status Syndrome: How Social Standing Affects Our Health
and Longevity. Owl Books. Henry Holt and Company. New York. 2004.
