Expert: Middle-class = middling health

Citing a host of studies, surveys, and statistics, a British health expert made a compelling case last week that the link between low social status and poor health is not just a problem for the poor, but for people at all levels of society.

Michael Marmot, director of the International Centre for Health and Society at University College, London, told about 90 faculty and students at the Harvard School of Public Health (SPH) that a recently completed study shows that the wealthy are not only healthier than the poor, they’re also healthier than the middle class.

What this means, he said, is that government policies – including those not directly aimed at the poor – in everything from taxation to education ought to be drafted with an eye to the health effects they may have.

“If you focus only on the deprivation, only on the worst off, you’re focusing on a small part of the problem,” Marmot said. “One has to deal with this as a middle-class problem as well as one of the lower class.”

Marmot is the author of two important epidemiological studies: Whitehall, in the 1960s, and Whitehall II, in 1985. Both studies examined the health of members of the British Civil Service and showed a clear decline in health with each decrease in job grade.

Marmot also worked on the Acheson report, issued in 1998, which made 39 recommendations to the British government on how to reduce the social inequalities that impact health.

Marmot centered his talk on 10 public health messages he was asked to draft for the World Health Organization for eventual use in a public health advertising campaign. Marmot said there was remarkable agreement among fellow researchers as to what the messages should be:

• The social gradient of health: People’s social and economic circumstances affect health throughout their lives.
• Stress harms health: Studies show that subordinate monkeys and baboons develop heart disease sooner than dominant monkeys and baboons. Marmot’s own results show the same pattern in civil servants.
• Early life affects a lifetime: A variety of studies have examined the long-term effects of a person’s start in life, showing high correlation between early nutrition, health, and education and a person’s health and status in later life.
• Social exclusion creates misery and costs lives: An examination of suicide by social class shows much higher rates for people in lower levels of society.
• Social cohesion and trust is important to good health: The perceived friendliness of a person’s neighborhood and workplace are important to a person’s overall well-being. A high correlation has been demonstrated between a worker’s sense of control over his or her job and the prevalence of heart disease among those workers.
• Unemployment: Job security increases health and well-being. A 1990 study of men in Finland showed highest mortality among those who were unemployed for more than 12 months.
• Social support is important: Having a strong network of friends and family helps people live longer. Studies of mortality by marital status shows that married people live longer than unmarried people.
• Addiction: The use and abuse of drugs, alcohol, and tobacco are influenced by social status, with higher usage among those on society’s lower rungs. People who do use and abuse drugs, alcohol, and tobacco suffer because of it.
• Healthy food: Healthy food is important for good health. The poor tend to eat lower-quality foods and foods higher in salt, which has been linked to high blood pressure.
• Transport: Healthy transport is important, meaning reducing the amount a person drives and increasing the amount they walk and use public transportation.Lisa Berkman, Norman Professor of Health, Social Behavior, and Epidemiology and chair of the School of Public Health’s Department of Health and Social Behavior, said Marmot’s work has attracted attention at SPH so she expected a good turnout.”There’s an enormous amount of interest in this topic at the school,” Berkman said.

  One sign of that interest, she said, is the numerous offices and organizations that sponsored his talk. In addition to the Department of Health and Social Behavior, the event was also sponsored by SPH Dean Barry Bloom, the School’s Departments of Health Policy and Management and Epidemiology, as well as the John F. Kennedy School of Government’s Multidisciplinary Program in Inequality and Social Policy.

  “I think it’s a real reflection of Michael’s work that it spans so many departments,” Berkman said.

  Lisa Bates, a student at the School of Public Health, said she found the link between Marmot’s work and government policy interesting. The United States, she said, could use a similar commitment to reducing health inequalities.

  “Why isn’t there a health inequality impact being done on [President George] Bush’s tax policy?” she asked. “I don’t think the policies [here] are driven by the science.”