8/22/2019 Profile: Professor Michael Marmot

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HEALTH SCIENCE

NOV 2010 SAM

BEST

ANDFAIREST

Professor Sir Michael Marmot,

the recently appointed

President of the British

Medical Association, is

a world-leading socialepidemiologist who says he was greatly

influenced by his undergraduate education

at the University of Sydney.

Though he didnt set out to change

the world, Marmot has certainly had

a huge impact on its health; hes just

completed a groundbreaking review

of health inequalities in Britain, after

chairing the 2008 WHO Commission into

social determinants of health. Marmot

is presently also the Director of the

International Institute for Society and

Health and a Medical Research Council

Research Professor of Epidemiologyand Public Health at University College

London.

And while he may have taken on

Britains centuries-old class structures

in his quest to overturn the social

determinants of health, Marmots

reputation and experience stood him

in good stead, with few questioning his

sometimes startling findings. In his review

of public health in Britain, Marmot pointed

out that while a man from the wealthiest

London borough of Kensington and

Chelsea had a life expectancy of 88 years,

just 16 kms away in Tottenham Green,

male life expectancy was 71 years.Marmot, now 65, has three adult

children and has lived in London for

many years, leaving Australia to complete

his PhD at the University of California,

Berkeley in 1972. Born in North London,

Marmot moved with his family to Sydney

at the age of four. His parents were poor

immigrants who had both left school at a

young age, and he says that when he grew

up, great value was placed on education.

On leaving Sydney Boys High School,

he went straight into an undergraduate

medical degree, but after four years of

medical studies, he took the opportunityto spend a year doing an intercalated BSc

in pharmacology. I spent a year in the lab,

which was wonderful.

During that year, he had time to do

his own research but also met people

outside medicine, attended lectures in

English literature and befriended students

of sociology and political science. I

suddenly discovered the University, he

says. Until then, I had been a medical

student but that year, I became auniversity student.

Marmots exposure to literature andpolitics at such a seminal time clearly

influenced his career path. Beinginterested in social determinants of healthand inequalities in health means you need

to draw on a wide array of influences andknowledge and understanding, he says.

He followed that year with a juniorresidency at Royal Prince Alfred Hospitalin Sydney when, despite working around

100 hours a week, he completed first-yearEnglish Literature. The following year, hewas oered a year in thoracic medicine,combining clinical work with some

research interest. But thoracic medicinewasnt the path he wanted to follow.

Without quite knowing what it was Iwanted to do, I was concerned about why

people got ill in the first place and how it

related to the circumstances in which theylived and worked. I hadnt articulated itvery well, but that was certainly where my

interests were heading.As a young intern, Marmot had noticed

that Greek and Italian immigrants livingnear the hospital, struggling to integrate

into the community partly due to languagebarriers, would present with a variety ofproblems that he started to think were thephysical manifestations of some of the

problems in their lives. He approachedsociologist-turned-epidemiologist LeonardSyme with his ideas, leaving Australia in

1971 for UC Berkeley, under Syme, wherehe looked at rates of heart disease in menof Japanese ancestry living in Japan,Hawaii and California.

Japanese culture was cohesive and

gave protection against the stresses ofdaily life, but as the Japanese becamemore westernised in California, they lostthose protections. Among the Japanese

in California, regardless of smoking, dietor blood pressure, those with a morewesternised culture and social structurehad more heart disease than those where

their culture was more traditionallyJapanese.

Marmot conclusively demonstrateda link between social environment and

disease rates setting the stage forall his subsequent research. Oered aposition at the London School of Hygieneand Tropical Medicine, a major centre

of epidemiology, he began his famousWhitehall studies, researching rates ofheart disease in British public servants.The only social measure available for him

WORDS

FRAN MOLLOY

8/22/2019 Profile: Professor Michael Marmot

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HEALTH SCIENCE

SAM NOV 2010

to investigate was peoples employment grade andthis delivered Marmot with a striking observation ofthe social gradient in health.

Contrary to the popularly held opinion that high-status people experienced greater stress and were

therefore at higher risk of heart attacks, Marmotfound that the lower a person was in the hierarchy,

the higher their mortality from heart disease, and arange of other diseases. It wasnt just about poverty,

Marmot says. It was a finely graded relation betweenwhere you were in the hierarchy and risk of disease.

While some commentators blamed Britains classstructure, the Whitehall studies have since been

reproduced all over the world, showing an inversegradient between social status and health. Marmots2004 book, The Status Syndrome: How Social StandingAects Our Health and Longevity, further expanded

on these findings.Despite equal access to quality food, good housing

and full employment, Marmot found that above acertain threshold of material well-being, another kind

of well-being is central. The circumstances in whichwe live and work and our place in the social hierarchyaect our health and our longevity. The degree ofcontrol that each person has over their work and their

life, and their level of social participation, will dictatetheir place on the gradient of health.

Marmot says that he has spent the past 33 yearstrying to understand why it was that the higher a

persons social status, the better their heath and todevelop policy to deal with this. Chairing the WHOGlobal Commission on the Social Determinants ofHealth, Marmot says that the Commissions most

striking discovery was that non-communicabledisease dominated in almost every region of the world

except the very poorest. It was a critical finding.This means that, if you think that the causes of

disease are roughly the same wherever we find them,weve got to look for a set of common causes andcommon actions across the world.

A critical global health threat is obesity, now

ocially an epidemic, with over one billion peopleworldwide overweight, and around 300 millionclinically obese. Seventy per cent of women inEgypt are overweight or obese, says Marmot, while

in Mexico, the problem of obesity far outweighsproblems of stunting and under-nutrition.

Yet while obesity (which directly causes diabetes,heart disease and other health problems) is clearly

part of a major global health crisis, its the causes ofobesity that are the real issue and breaking thesedown is complex.

It relates to the nature of our food supply, the

nature of opportunities for physical activity, thechanging nature of physical activity at work and howpeople make food choices, says Marmot.

In the poorest countries, more educated women

are more likely to be obese because in these countries,women with little education are so poor they donthave enough calories to eat. But in countries with

a GDP higher than $2700, theres an inverseassociation, where women with more education areless likely to be obese.

We can speculate on why its the case thatmore educated women in high income countriesare less likely to be obese, and its presumably inpart cognitive; its about fashion and the ability tocontrol your circumstances, what you eat, going tothe gym and so on, Marmot says.

Marmot was then asked by the Britishgovernment to conduct a review of these findingsand make recommendations to reduce healthinequalities in Britain and in February 2010, his

report, Fair Society, Healthy Lives was published.It was a statement that if we put fairness at

the centre of all decision making, health wouldimprove and health and inequalities woulddiminish, Marmot says.

World changing, indeed.