BioMed
Michael Marmot charts health across every social rung: doctorate holders outlive those with master’s degrees, while greater control and universal services can narrow gaps.
A poor man in a rich city can have far more money than the average person in a poor country and still die years sooner. Disadvantage in a rich country brings its own diseases, such as violent death, suicide and heart disease, rather than the infections of absolute poverty. What drives ill health is inequality, not poverty alone.
Medical treatment that sends people back into the conditions that made them ill leaves the cause in place. Lasting gains come from changing the social conditions people live in.
A health difference between social groups becomes an injustice, an 'inequity', when reasonable means could narrow it. Because evidence from around the world shows what reduces these gaps, failing to act is a choice rather than bad luck.
A child's development in the first years strongly shapes later health and how fairly health is shared across society. High-quality early childhood services make a large difference.
The argument over whether poor parenting or social disadvantage harms children is a false choice. Both matter, because social and economic conditions shape how parents are able to parent.
A working society depends on genuine fellow-feeling among its members. When people at the top, middle and bottom live separate, sealed-off lives, that empathy and connectedness wear away.
In rich countries the main causal arrow runs from low social position to poor health, not from sickness to low income. Unequal access to medical care explains only a small part of the gap.
Health worsens step by step at every rung down the social ladder, not only below some poverty line. Even among the highly educated, people with doctorates outlive those with master's degrees. People in the middle of the hierarchy can expect years less healthy life than those at the top. These are patterns across populations, not forecasts for any one person.
Treating disease and urging people to change habits only go so far. What makes the larger difference is whether people have control over their own lives. Disempowerment harms health in absolute terms, not just in comparison with others.
Services aimed only at the poor tend to become poor services. Better to give everyone universal provision, then add effort in proportion to need, an approach called 'proportionate universalism' that keeps society cohesive.