It’s a generally known fact that poverty makes sick, but in our modern Western world people usually don’t fight for mere survival every day and poverty doesn’t equal penury any longer. In Austria, for instance, the net of social security is so densely-knit that everybody can get health care – unless for one reason or another, a person prefers to go underground and therefore doesn’t appear in the system. Nonetheless, data show that those with by comparison fewer material resources, less high education and lower standing have poorer health than those who are better off in these aspects. In his book The Status Syndrome. How Your Place on the Social Gradient Directly Affects Your Health first published in 2004 epidemiologist and public health expert Michael Marmot summarises the results of over thirty years of research and draws his conclusions with regard to what is needed to close the health gap.
With immense expertise and with a dash of English humour now and then Michael Marmot presents chapter by chapter the different aspects that, as he discovered in decades of research, account for the health gap in rich countries. Quite naturally his focus is on the UK and the USA where he made his own studies, most importantly the two Whitehall ones about the health of public servants, or participated in studies of other public health experts, but he also keeps an eye on the situation in countries “across the world from Finland to Tierra del Fuego, and parts in between” that turns out to be by and large the same. Starting point is the finding that according to available data, life expectancy and health seem to be related to household income. Nonetheless, it’s not just a question of having money or not as Michael Marmot states referring to the opera La Bohème by Giaccomo Puccini. Statistics reveal that among countries that have to be considered poor by Western standards there are some – like Costa Rica and Cuba – with higher life expectancy than can be expected judging from the GDP (gross domestic product). Evidence doesn’t allow to attribute the fact to genetic determinants and environmental circumstances in these countries. Thus more important than income seem to be “capabilities” in comparison to others, i.e. relative wealth or poverty. And then other aspects connected to relative rank in society come into play. There’s power or rather control over your own life for one that is essential and that like income shows a clear relation to the level of education, but also opportunities to participate fully in society influence health. Who stands alone to face all the ups and down of life is more at risk to fall sick or to commit suicide as Michael Marmot points out using Joseph Conrad’s Nostromo as a literary example. There are, however, interesting differences with regard to how much social bonds improve the health of women and men. If the environment encourages the individual to trust others and the general level of social cohesion are crucial points also. For instance, it’s quite understandable that in a shabby neighbourhood with a high crime rate it isn’t easy to muster up the courage to go out, mix with people and make friends to rely on in hard times. The same goes for societies that have been turned upside down by historical events, notably Russia and the countries of the former Soviet Union after the breakup. Finally, Michael Marmot deals with the question if and how the family background, i.e. descent and upbringing, determines where on the social gradient an individual ends up and what impact it has on future health, if it has one. The book’s appendix reprints the Recommendations from the Independent Inquiry Into Inequalities in Health that the Acheson Group to which the author belonged as scientific advisor submitted to the British Government in 1998.
Overall, The Status Syndrome. How Your Place on the Social Gradient Directly Affects Your Health by Michael Marmot gives a highly interesting and sometimes even entertaining insight into the workings of society with regard to health. Since the author is a physician, moreover a scientist his language (as was to be expected) tends to be rather technical and I found that sometimes it was even a bit difficult to follow for a layperson and non-native speaker of English like me. However, I liked the read very much and not least for the many references to literature and music, but also to history that Michael Marmot included into his book.