Sir Michael Marmot – Conversations with History

(mid-tempo reserved music) – Welcome to a Conversation with History. I’m Harry Kreisler of the Institute of International Studies. Our guest today is Sir
Michael Marmot, who is head of the Department of
Epidemiology and Public Health and Director of the International Center for Health and Society at
University College, London. He is the 2002 Hitchcock
Lecturer on the Berkeley campus. Dr. Marmot, welcome back to Berkeley. – Thank you very much. – Where were you born and raised? – I was born in North London, but at age 4 1/2 I went
to Sydney, Australia, and so I was raised in Sydney. – Do you remember the
place that you were born, or just you were too young? – Well, I now live about five
miles from where I was born. – [Harry] (laughs) oh, I see. – So I have dim memories
which I charged up again by going back to visit it. – Looking back, how do you think your parents shaped your character? – Well, my parents, the family
image, the family tradition, was my parents were poor
immigrants into East London, and that they thought that
education was vitally important. But they both left school at 14. And so I grew up with the idea that, but for the opportunity, my parents would have been educated. And they were giving me this opportunity, and by golly, I better
take advantage of it. So that was one thing, the
importance of education, and I suppose the
importance of opportunity to allow you to receive that education. I think the second thing was that, again, the family image, and I can’t give you pounds,
shillings, and pence, or dollars and cents, but the family image was
that however much or little my father earned, some part
of it was always for charity. And the image in the family was that that was really very important. You didn’t earn money just for yourself, it was important that some
part of that went to charity. And both my parents
were very much involved in communal activities, so
that I grew up with a notion that education was important, that individual earnings should be shared, and that communal activities
were vitally important. – And what was conversation
like at the dinner table, all of the above or something else? – No, I don’t think it was
very intellectual, in a way. You know, so this wasn’t spelt out. It was very argumentative, particularly as my two
brothers and I got older, and particularly when
I went to university, and then, of course, questioned everything
my parents believed in. And so we had really quite
vigorous argumentation at the dinner table about everything. And I thought that it was like the Mark Twain view of your father, you know that’s what I
thought about my parents. – Do you remember any books that you read as a young person that
really made an impression? – Well, there were books in our household, but I wouldn’t say that I
had the image of it being a very intellectual, cultural household. But my parents always had books on the go, there were books in the household, but I couldn’t say that
my parents gave us this and inculcated a
particular way of thinking. But I suppose one part
that I can’t ignore was that after school three afternoons a week, and Sunday morning, I
went to Hebrew school, so that whatever else was going on, I was doing all that extra. So my playing of cricket
and rugby in the street was before or after, well,
usually after, Hebrew school ’cause I had school and
I had Hebrew school. – Did any teachers, either at
Hebrew school or public school that had an influence
on you at a young age? – Not teachers so much, in a way. They were okay, nobody
particularly outstanding. But one or two friends that
were really rather important. One friend, particularly, whose father was a professor
of organic chemistry. And somehow, almost by default,
through his father and him, he introduced me to the idea that one ought to think a
little bit more intellectually. – Where and when did you
do your undergraduate work? – So I did, in the Australian
system at that time, you went straight from
school to medical school. – [Harry] I see. – And there wasn’t a general
undergraduate degree. – [Harry] Okay. – So I went to medical school
at the University of Sydney. And I had one, for me,
very important year there. It was a rather conventional
medical undergraduate training, there was nothing particularly
remarkable about it, but you had the opportunity to do a so-called intercalated BSc,
a Bachelor of Science Medical, which was a year spent in
a lab, which was wonderful. It was the most enjoyable
part of my university. Firstly, I could do some research and you could follow your nose a bit, you had a bit of time to read literature, think about things. But certainly, I met
people outside medicine. So, for example, during that year, I attended lectures in English literature, and I met friends who were involved in political science and sociology. And so until that point, I’d been a very conventional
medical student, and suddenly my eyes were open. So I could do research,
I could follow my nose, and there was a whole world out there. – And so with the medical
degree, then, do you have, did you practice medicine actually or? – Well, I did a couple of
years, I did my house jobs. And in fact, during my first house job, I knew I had to get something extra, so despite working a hundred hours a week, I went off and finished
first year English. So I used to go with my
bleeper to English lectures and while on-call, waiting to be called– – So, almost a separate degree in English literature, is that? – Well, I just did the
first year, I did one year, but it was great fun. It was enormously interesting to do that, to get this extra dimension. And then my second year, again, I didn’t want to do just
straight house jobs, and so I did a clinical research year. And that, again, was
really rather important. I was working in thoracic
medicine, asthma. But the fact that I was
looking after patients, but I was starting to pursue
my own interests in research. And in a way, that’s what’s convinced me to go into epidemiology, public health. I mean the one very important
person was a chest physician in Sydney at Royal Prince Alfred Hospital. I mean I really wasn’t terribly
intellectual, in a way. I was not well read, but I used to walk
around the hospital wards and I’d say we saw this
chap three months ago. He came in in acute cardiac
failure, we treated him, or chronic respiratory
failure, we treated him. Sent him home, here he is back again. And I used to think you know, medicine and particularly surgery
is just failed prevention. If we could treat these
people quote, properly, and particularly, if we could
do something about prevention, we could empty the hospital wards. That’s probably false, but
that’s what I used to think. And this chest physician,
a man named Peter Harvey, I guess he was interested
in the idea that I had some of the thoughts to me other than just straight
clinical medicine. And he went off, he had a friend named
Ian Prior in New Zealand, and they used to do studies of blood pressure in Polynesian islanders, looking at different
prevalence of blood pressure in different Polynesian island groups. And Ian Prior had a meeting in New Zealand that Peter Harvey went to, and he came back from
this meeting, he said, “I’ve got just the thing for
you, it’s called epidemiology.” I said what’s that? (Harry laughs) And he said, well, these guys, they’re doctors and anthropologists and statisticians and biologists, and they all work together
to try and understand why disease varies in different places. And he said I met these
two terrific people there. One was named Len Syme, who was a professor of
epidemiology in Berkeley, and the other was named John Cassel, who was professor of
epidemiology at Chapel Hill, University of North Carolina. And he said, “Would you
like me to write to them?” So I said, yeah, please. So he wrote, and they
both wrote back, and said, you know, we’d like to
see your CV, and right. I found not long ago the letters I’d written at the time, and it was slightly embarrassing, really. (Harry laughs) It was embarrassing for two ways. One, this sort of naivete of a young man, but secondly, that my
ideas haven’t changed much, that I actually said in these letters that I thought that
health was a manifestation of the way we organize society. And that by asking
about health in society, we’re asking about society itself. And where I got that idea
from, I haven’t a clue, but that’s what I’ve been
doing for the last 30 years. Well, I’d had never heard of Chapel Hill, and I had heard of Berkeley,
so I came to Berkeley. – So in looking back now, do you have any better sense of the roots of that broader picture, that need for locating what you were doing in a larger social context,
or was it just curiosity? – I think it was curiosity. I think it came from one
or two fellow students. I suppose I had read a little
bit more than I’ll admit. But I can’t honestly say it came from my medical teachers in Sydney, I don’t think it really did. And, in fact, when I was
planning to come to Berkeley, and I remember one particular day when the deadline for applying
for a residence position, a training position in internal medicine, the deadline was five
o’clock Friday afternoon– – [Harry] This would be in Australia? – In Australia, yes. So the usual thing was if you could train in internal medicine, of course, you would. Who wouldn’t? So if you could get a job at
the premier teaching hospital, that’s obviously what
any sane sensible person would want to do. And five o’clock Friday afternoon came, and I hadn’t put in an application. And I didn’t yet know whether I’d be able to go to Berkeley, but I felt this wonderful
sense of liberation. And one of the older physicians said, “It’s a big mistake, you know. “You’ll get off the ladder and
you may never get back on.” And it felt wonderful. So I think it was more a reaction to conventional medicine than
it was that I could point to a particular teacher who influenced me. – On the one hand, in
conventional medicine, you were able to help
people, be sympathetic, but I guess there’s also a
lot of rote work in that. What was at the root of, was it that you were dissatisfied, or was it that you saw something better? – I loved clinical medicine, I liked dealing with patients,
real people, real problems. So I loved clinical medicine. I liked the problem-solving aspect of it, and I liked the science of it, and I liked the human
warmth and contact of it. So I really loved it. Whether I would say that 30 years later, after doing it for 30 years, I can’t say, but I really loved it. So it wasn’t any dissatisfaction with the actual practice
of clinical medicine, which was very satisfying. It was much more this feeling that this wasn’t the
right way to go about it. We really needed to think how to stop those unfortunate people coming back again and again and
again every three months. It felt to me like we
were putting Band-Aids on. And I also remember at the
time talking to a friend about the experience working in casualty and the emergency room. And the teaching hospital I was at was at the inner-city part of Sydney, and there were a lot of
Italian and Greek immigrants. And some people, as you might
expect, were slightly rude. Some of the staff were slightly rude about patients coming in who couldn’t speak English properly, and it always seemed
to me at the time that what these patients were
expressing was a problem in living. When people would come in
with nonspecific problems and we never quite got to the
root of a medical diagnosis, it always seemed to me they were expressing problems in living, and that one needed to look
at their problems in living, and how they manifested
themselves in physical problems. So to the extent that I understood what Len Syme and John Cassel were doing, that seemed to me exactly
what they were doing. And that’s why I jumped readily, and said, yep, that’s what I want to do. – So how did Berkeley affect and shape the directions of your thinking? – It had an enormous impact, really. As I’ve already said, I came
out of a rather conventional, straight up-and-down, high-quality but conventional
medical education. And I used to say at the time when I came to Berkeley
that it seemed to me that it was one big
department of social concern. (Harry laughs) My wife was a graduate student in architecture and city planning, and she was being given
the same books to read that I was being given. You know, we were all
reading Thomas Kuhn’s, Structure of Scientific Revolutions, and we were thinking
about systems analysis. And so it didn’t seem to matter which department you were in, you were reading the same books and thinking the same thoughts. – In political science too. – And presumably political science, it was one big department
of social concern. The second thing was
that Len Syme said to me, “Just ’cause you’ve
read some medical books “doesn’t mean you have
any particular insight “on the determinants of
health in societies.” That was pretty shocking. I thought, I mean, who would know about determinants of
health other than doctors? I was a doctor, by golly, and
if I didn’t know, who would? And the idea that sociologists,
economists, psychologists, biologists who weren’t doctors, might all have something to
say about this was shocking, and illuminating, I
mean just mind-opening. And you know, the pluses and minuses of the American educational system, the minuses are you do a lot
that’s a bit superficial, the pluses are you do a lot
that’s a bit superficial. And so, going around
the campus and sampling in anthropology, and
sociology, and economics, and the philosophy of science, I had a wonderful time
in philosophy of science. And the fact that there were
so many good people around really was mind-expanding, and just changed the way
I thought about research and about my subject. And the other thing, of course, is that this was the early ’70s, and the ’60s were not really yet over, certainly not at Berkeley. – Before we talk about the ’60s, so, in a way, what was
fertile and creative about Berkeley at that time was kind of an interdisciplinary, comparative, global perspective that
got you out of the box of the thinking that you were doing. But you were heading in that direction before you came to Berkeley,
you seem to be suggesting. – Well, I suppose I was, which is why I was poised to
take advantage of it here. I mean if I hadn’t been
thinking about that, I could have come to Berkeley
and studied epidemiology and statistics and health planning, and then I could have gone away again. But so at Berkeley, I was poised, I mean, it’s gene/environment
interactions. I’m not suggesting my
interest was genetic, but you know what I mean, I had a predisposition, but
there was an environment that allowed my
predisposition to flourish. – So how did the ’60s affect you, being in Berkeley in the ’60s? – Well, I only came to Berkeley at the beginning of the ’70s, but still, Australia was
in the world in the ’60s. – Yeah, so first tell us what happened in the ’60s in Australia, and then how that was reinforced when you came here, if at all. – Well, you know, Australia,
I think was influenced by this worldwide epidemic of thinking. And there was a sense
that all the old canons were open to question, and one didn’t necessarily accept things just ’cause they’d been accepted before. Now, within a medical education, that didn’t change anything very much, but within the wider society
and on student campus, that was all around. And it was a wonderful
sense, not terribly analytic, I have to say, but there
was a wonderful sense that anything is possible. There was a sense that a focus on material goods was inappropriate. There was a sense that you didn’t have to follow a conventional route. And I suppose, in a way,
my going off to Berkeley and stepping off the
conventional ladder was a manifestation of that
because anything was possible. More money was being put
into the universities, things were opening up,
and that affected Sydney, as it did Berkeley and
London and Berlin and Paris. And maybe it wasn’t quite as
exciting as Paris in 1968, but we knew about it, and we
understood it, and we felt it. – So what does an epidemiologist do? – Lots of things. But essentially, the thing
that distinguishes epidemiology is the study of disease in populations. So to contrast what I did as a clinician, in clinical medicine, and
what I do in epidemiology, clinicians are trained to
treat individual patients, that’s what they do
first, last, and always, they treat individual patients. What I was doing in my own
primitive way in Sydney of asking why are these kids getting
asthma again and again? Why are they coming back? What is it in the environment
in which they live that’s causing these kids to come back and back with asthma? It was thinking like an epidemiologist. It was thinking about causes
out there in the population. So what epidemiologists do is
study disease in populations, and they study the causes
of disease in populations. Now, my own view is to
do that effectively, they need to do it in collaboration
with other disciplines. So although epidemiology
has its own set of methods, we tend to do large population studies, we follow large groups
of people, and so on, but ideally, to try to
understand the problems that we’re seeking to understand, we need to do it in concert with others. And what are the sources of the paradigms, let’s use Kuhn’s words, that guide you in the
things that you look at? We can move into talking
about the Whitehall Study, which is a body of data that you’ve done extensive work with. But what I guess I want to get at is, well, what shall we
look at given this data? Well, I think one important paradigm, one important understanding, is that the causes of
individual differences in disease may be different from the causes of
population rates of disease. Now, I could generalize it
and say that all disease is a combination of genes in the environment. But let me illustrate. In England and Wales last year, there were about 150,000 deaths
from coronary heart disease, and the year before there
were about 150,000 deaths, and this year there’ll be slightly fewer ’cause the rate’s going down. But there won’t be 100,000
and there won’t be 200,000. If it’s not 149,400, it will be 149,300. Now, the people who died last year won’t die again this year. So we can ask why did those individuals who died last year die, and
other individuals not die? That’s one sort of question. Or we can ask why is
the rate such as it is? Why do men have a higher rate than women? Why is the rate in Hungary
higher than in England? Why is the rate in Scotland
higher than in England? And why is the rate in
Italy lower than in England? And do people who migrate
from Italy to England get higher rates when they
migrate from Italy to England? And we could know that’s the
case without knowing very much about any individual Englishman
or Scotsman or Italian, but we know these general patterns. Now, it’s crucial to know something about the individual Englishman,
Scotsman, and Italians, or Hungarians to really
understand the problem properly, but these determinants of population rates of disease are different, potentially, from the determinants of
individual difference. Or they may be different,
one should not assume that they’re the same. And that’s really difficult for somebody who’s trained in looking
at the individual patient to come to grips with initially. And they say, but if you tell me that somebody who migrates from Italy to England is subject to
a higher risk of disease when he gets to England, but doesn’t it depend on
which individual he is? And the answer is, of course it does. But standing back, and you see
this general pattern relating the characteristics of societies to those characteristic
societal rates of disease, that’s terribly important. And so then when we come to
look at inequalities in health, differences between
different social groups, we don’t necessarily
understand why differences between different social
groups comes about only by studying individuals. – Now, in a way, one
could say that this is a radical perspective, is it not? Because when you think about, thinking about an individual patient, then there is a whole
panoply of organization that will provide you with
drugs to treat this individual, and not go back to the question of how did this group of
individuals come to me. – Yeah, oh, it’s quite different. I mean I had two very important teachers, when you were asking
about early influences and I was drawing a blank, (both laugh) but I had two very important teachers, Geoffrey Rose in London, and before him, Len Syme at Berkeley, and they both had a big influence. And you know, a funny way, coming from very different backgrounds and very different perspectives and really, very different
approaches to the world, in a funny way they had a
rather consistent message. Geoffrey Rose said that
when he started teaching medical students about
epidemiology and public health, he used to say the medical
student should ask the question, why did this patient get
this disease at this time? And he then later in his life decided that that was a rather restricted question. That was the question
about this individual, and that’s an appropriate
question for a clinician to ask. But to ask, why am I seeing
so many more patients from this part of the city
than that part of the city is a different sort of question. Why is the rate of disease different is a different question. The way Len Syme used to put it was that there are three
questions one should ask. If somebody got sick,
what disease would he get? The second question is, why would one individual
get sick and not another? And the third question is, why is the rate of disease higher under these circumstances and not another? And so they were really very
similar perspectives coming from very different angles, but asking the same sort of questions. So it is quite a radical question. It’s looking at the
determinants of illness, and that leads you into looking at the societal determinants of illness. – Now, tell us a little about
what the Whitehall Study is and what you found, especially
in the second study. – Well, the first Whitehall
Study was set up as a rather conventional
study of risk factors for cardiovascular and
respiratory disease. It was in British civil servants. Why civil servants? ‘Cause there’s such a
large number of them, and there they were easily accessible. And Professor Donald Reid,
who started the study, had close connections with
the chief medical advisor in the civil service. So they set up this study, and they looked at blood pressure, and cholesterol, and
smoking, and other things. And when I arrived in London,
Geoffrey Rose said to me, you know, as a matter
of good housekeeping, we’ve just been looking
at what grade men were, these were all men, at what grade men were
in the civil service, where they were in the hierarchy. And he said, “You’re interested “in social and psychosocial things. “Would you like to look at this?” And that’s all we had, essentially, that was social and psychosocial, was just what grade they were. And so I spent quite a
lot of time looking at it in the first Whitehall Study,
and the remarkable finding, which ran counter both to
my expectations at the time, and I think most other
people’s, was firstly, just looking at heart disease, it was not the case that people in high stress jobs had a
higher risk of heart attack, rather it went exactly the other way. People at the bottom of the hierarchy had a higher risk of heart attacks. Secondly, it was a social gradient. The lower you were in the
hierarchy, the higher the risk. So it wasn’t top versus
bottom, but it was graded. And, thirdly, that social gradient applied to all the major causes of death. I’d come out of the model of well, if you want to
understand heart disease, look for the cause of heart disease. We know something about
cholesterol and blood pressure and overweight and diabetes, let’s look for these things. But it applied to all the
major causes of death, to cardiovascular disease, to gastrointestinal disease, to renal disease, to stroke, to accidental and violent deaths, to cancers that were
not related to smoking, as well as cancers that
were related to smoking, all the major causes of death. And this finding of a gradient, not only did it run counter to thinking at the time about heart attacks, that high-status people were supposed to get more heart disease. But secondly, it ran
counter then and still does to the way most people think
about inequalities in health. So in the United States,
disparities in health. We tend to think of them, the
poor, that have poor health, and us, the non-poor,
who have better health. And most social policy is about the underserved or the served, the underclass or the rest of us. It’s not about a gradient, it’s not about something
that runs from the top all the way to the bottom, and that health follows
that social gradient. And that’s kept me exercised
for the last 25 years, trying to understand that, and
its implications for policy. Now, the first question is well, maybe civil servants are atypical. Maybe a top-grade civil
servant hasn’t a clue what it means to have a stressful job because he’s protected and so on. Well, then when we
looked at national data. There was, indeed, a shallow gradient in mortality in national data in Britain. It wasn’t as steep as in Whitehall, and that bothered me a bit. Why not? And one of the answers I gave myself was that the civil service was better at classifying people
than the national data, the national social classes. But in practice over the last 20 years, we’ve seen the social gradient
get steeper and steeper in the national data, so that it’s certainly not the case that Whitehall is atypical, it’s typical. And we see similar findings
in the United States, in Canada, in Australia, in New Zealand, and most European countries
that have looked for it. So that was first thing, it’s not ’cause Whitehall is atypical. Secondly, people say, well, look, we’ve gotten rid of the problem
in infectious disease now. In fact, we haven’t,
we have HIV and so on, but people would say we’ve
got rid of the problem of infectious disease, we’re not dealing with dirty water and
poor sewage and so on. We’re now in the age
of lifestyle diseases, it’s ’cause people behave badly. So we looked at the usual risk factors, the one believes that
are related to lifestyle, smoking prime among them,
but plasma cholesterol, things related in part to fatty diet, overweight, sedentary lifestyle. And we asked how much
of the social gradient in coronary disease could
be accounted for by smoking, blood pressure, cholesterol, overweight, and being sedentary. And the answer was, somewhere between a quarter and a third, no more. And people said, oh, you didn’t
measure smoking properly. Well, we looked at never smokers, and we found the same
gradient in never smokers as we found in smokers. And I had to reassure people, I was not saying that
smoking was unimportant. Whitehall confirmed how
vitally important smoking is. It’s just that smoking
wasn’t the prime cause of the social gradient in disease. It was, for example, a
very important contributor to the social gradient in lung cancer. And in fact, asking is
there a social gradient in lung cancer in non-smokers
is a non-question, ’cause almost all the lung
cancers occur in smokers. So that I was by no means
saying smoking was unimportant. But I was saying when we
look at coronary disease, and accidental and violent deaths, and gastrointestinal and
renal deaths and so on, smoking was only some part of the story, but there was a lot else. And similarly, with cholesterol,
there was no difference in cholesterol levels
by grade of employment. So we published data from
the first Whitehall Study and said 2/3, at least, of
this gradient is unexplained. And we said at the time that there were two candidates
for the explanation, psychosocial factors and
other aspects of nutrition apart from dietary fat
related to cholesterol. And we set up the Whitehall II Study to test those hypotheses. This was a new cohort, we
included women as well as men, Whitehall I was only men, and so they were not the same
people in the first study. We set this up in the mid-1980s, 20 years after the
original Whitehall Study. And the first finding was
that the social gradient in health was as steep as it
had been 20 years previously, hadn’t got any less, and that
fitted with national data. And then what we saw was there
were clear social gradients in smoking and lack of physical activity, and so on, as we’d found in Whitehall I, but in addition now, we showed
very clear social differences in people’s experience of the workplace, how much control they had at work, how fairly they were treated at work, how interesting their work was. We found clear social gradients in people’s participation
in social networks. We found social gradients in psychological
attributes like hostility. – So in the end, what
you’re saying is you don’t, and I’m coming at this as a layman now, that it’s not about eliminating hierarchy so much as finding the factors that can be changed even if the hierarchy might remain the same. So what you’re finding is
a gold mine of information about possible changes that really nobody had been looking at, and that were very important in the different rates of death. – That’s right, ’cause as
I’ve been thinking about it over the years, and more
recently, particularly thinking about the Hitchcock Lectures at Berkeley, and struck by the fact that when you look at non-human primates you,
of course, find hierarchies, but hierarchies in disease. The subordinate monkeys in captivity or baboons in the wild
appear to get more disease than the dominant ones. And so that gives me pause. If you think about this social hierarchy and this relation to disease, there are at least two possible
ways of thinking about it. The first is, we could
abolish hierarchies. Well, that doesn’t sound very promising. – [Harry] No (laughs). – I mean if the baboons have hierarchies and the cynomolgus macaque
monkeys have hierarchies, and the civil servants have hierarchies, and everywhere we look
there are hierarchies, that doesn’t sound very promising. The idea of some egalitarian society, where everybody is exactly the same, doesn’t seem to be the way to go. So then the question is, what is it about position in the hierarchy that determines different
rates of disease? And given that, the hierarchy
in disease does change. All societies may have hierarchies, but we know that the social gradient in disease is not fixed. It’s bigger in some places than others, and it can change over time. And that could be because the magnitude of the hierarchies change, but
there’s always hierarchies. But, more importantly, it suggests what is it about where you are in the hierarchy
that’s related to disease, and can we do something about that? So you ask, is it money? Is it prestige, self-esteem? And, in fact, what I think is, is has much more to do with how much control you
have over life circumstances, and the degree to which you’re
able to participate fully in society, what Amartya
Sen calls capabilities. – So it leads you back
to overall human values about how we organize the way we work. – Well, human values, but in the end I’m a British empiricist, so human values, I think,
are absolutely crucial here. But I’m also interested
in empirical demonstration of how they translate into pathology, ’cause in the end people go and get sick, and a value sounds like
something rather abstract, that it’s the mind, where, in fact, what happens in the mind
has a crucial impact on what happens in the rest of the body. The mind is part of our
biological makeup as well. And so the empirical study is how do sets of values translate into people’s perception of
reality, and that, in turn, changes physiology and
leads to risk of disease. So we’re trying to deal in a crude way with a mind/body question of how the one translates into the other. – And this is interesting, because this is the
new phase of your work, trying to find this biological link. So the output, in a way, is disease, and the input is this
hierarchy, the social gradient. And the intervening variable is changes in the body basically, over time, and the way stress operates on
the hormonal system, is that? – Yes, although there are
one or two other intervening, so that if we’ve got
position in the hierarchy, then we’re asking what does that mean in terms of relationships
in the workplace, in the wider society, control
over events and participation. And how that, the
satisfaction of those needs, or the frustration of those needs for control and participation, how that translates into
physiological changes. And you used the word stress. I didn’t, although I
think it is a useful word. The reason I didn’t use the
word stress is people say, oh, stress, you can’t define
it, you can’t measure it. – You can’t do away with it. – You can’t do away with it. You know, one person’s stress
is another person’s happiness. And all the usual things
around the stress paradigm. But, in fact, it is a useful
way to think about it. And the way we’ve approached
the measurement issue is not to say is he or she under stress? But to ask, let’s try and characterize, can we characterize
their work circumstances? Can we characterize their
social life in measurable ways? And then ask is that related
to physiological changes, to endocrine changes, and, in turn, to other bodily changes that we can see, that we think are linked
to risk of disease? – And this is why actually,
as I listen to you, why your base in empirical
data becomes very important because it avoids entering into a realm of sort of general
discussion about these issues without making it very concrete. How does the comparative
perspective enter into this? I know that you’re involved
in studies in Europe, you’ve looked at populations from the former Soviet
Union and Eastern Europe. What does that bring to the table in furthering the insights
that you’re already making? – Well, it brings at least
two rather important things. The first is just a methodological
point, but a crucial one. When I show, and it’s happened from the very beginning
of the Whitehall Studies, when I show that people rank them according to their social position and that’s linked to their health, then one of the early questions, I’ve already mentioned two, you know, is it ’cause of civil servants? And is it ’cause of behaviors? The next question people ask is yeah, but people aren’t randomly allocated to their positions in society. Maybe people who are
genetically predisposed to be superior end up superior, and those same genetic predispositions to being superior leads to better health. Or, alternatively, a variant on that is that people’s health status determines where they end up socially, it’s not where they end up socially that determines their health. That I’ve got the cart before the horse, and that my whole argument
about social causation collapses because it’s simply genetic
differences determining health, and health determining social position. And that’s not a straw man, by the way. It doesn’t sound very politically correct, but there are a lot of people out there who believe that to be the case. Well, there are a number of ways of trying to answer to that. But one is, well, look at what’s happened to Central and Eastern Europe. Whole societies change
radically, incredibly quickly. If we look at life expectancy
in Central and Eastern Europe, let’s say 1970, so 15 years, sorry, 25 years after the end of World War II, and we look at the countries in Central and Eastern Europe compared with the countries of Western Europe, the democratic countries, then life expectancy was
fairly similar, east and west. It was always a bit lower
in the former Soviet Union, but fairly similar. And then what happened? Over the last two decades
of the Communist period, life expectancy for men, particularly, actually declined in
Central and Eastern Europe, actually got worse, whereas it got better year-on-year in the West. So the gap between east
and west increased. And then post-1989, things
changed dramatically. Life expectancy took a tumble, got very much worse, very quickly in the former Soviet Union, particularly in Belarus, in
the Ukraine, and in Russia. And life expectancy after
the initial drop started to improve in the Czech
Republic, in Poland, and then a bit later in Hungary. So you’ve got this splaying out. Now, whole countries don’t
get changes like that because of changes in
genetic predisposition. I think it’s just not
credible that changes in health status determined
the changes in the economy and the economic fortunes
of the former Soviet Union. It’s just ludicrous, it
clearly was not the case. And so that it doesn’t, by itself, argue that the determinants of
the social gradient in health within a country can’t be genetic or can’t be determined by health just because you can’t see it. But given that we think that some of the same causes are operating, and this is my second point now, the first one being the technical one, that we do think some of the
same causes might account for the differences in
health across Europe as account for the social gradient in health within a country, why? Because, in general, those
European countries were all above the threshold of
absolute deprivation. Infant mortality was low. There’s a prima facie case
that during the ’70s and ’80s they were not suffering from poverty. We know, for example, the
Czech school children, we studied this, their
growth was at least equal to Western European school children. So it looked like the
children were well nourished there was investment in children, there wasn’t absolute poverty. And yet heath suffered,
particularly in middle aged men. And that’s what led me to ask maybe the same set of
factors are going on. And the whole idea that lack
of control over your life, lack of opportunity to
participate socially in a meaningful way, could affect whole
societies, not just people, depending on where they were within the gradient within a society, was really rather powerful. And it suggested that
the way we ought to think about health policy should change. – Now when you were in that hospital as a young medical doctor,
and you saw this person, you say hey, he’s been here before. You know, why am I seeing so many people? That led you in this life’s
journey to actually focus on the relationships
that the data revealed. But now you’re moving really
to another step, which is, well, once we know that, if we truly know this and it
can be proved scientifically, then we can go about changing things. What insights have you garnered about how this scientific
information can contribute to a process of changing society, its view of public health, and
actually making a difference? – Well, the line that I’ve pursued, and this is not necessarily the right way, other people can do it different ways, is not to use the evidence as a soapbox. So I didn’t think by
standing on volumes of data I could then shout louder,
and that would work. The line that I’ve pursed is that we need lots of
people to make changes. We need people who are good
at standing on soapboxes and formulating ways
to change politically, but we also need the evidence. And given that during the time that I’ve been working in Britain, for the first 18 years, nearly the first 18 years, I went back to England in 1976. We had an intensely
conservative government, from 1979 to 1997. And so to bang on about how
health and equalities were immoral and unjust would
not have reached much favor. But to say, this is
what the evidence shows, this is what the evidence shows, that if we want to do something about improving health
for the whole population, we need to focus on the people whose health is not improving to the same extent as those who are, and ask how can we do something about it, and this is what the evidence shows. So I’ve always tried to
stick close to the evidence, to say that we need to help the people whose business it is to formulate policy, we need to help them, but we need to help them in
the light of our judgment of what the evidence shows. Now it’s not simply saying
here are some facts. Of course, it’s trying to achieve a synthesis of the evidence and present it in a way that
will help the policymakers. But I think it’s important, in my view, to try and present it to governments of the right as well as the left, so that when we had a change
of government in Britain from a Conservative to
a Labour government, they were more ready to acknowledge that inequalities in health existed, they were more ready to apply the label inequalities in health, and they were more ready to
try to do something about it. We could then feed our
evidence into that process. And say, in fact, they
set up something called the Independent Inquiry
into Inequalities in Health, under the chairmanship of a
former chief medical officer, Sir Donald Acheson. And I served on that inquiry, and so the evidence that
people like me and others had been accruing over the
years then fed into it. And we could say here are 39 areas for policy development that
we think, based on evidence, we can recommend to you as a government. And now, in fact, I’m involved in another government committee that’s trying to take
those recommendations and formulate specific
policies based on them. So how did I get involved in the policy? By sticking close to the evidence and saying this is what I think it shows, and this is what I think it means. – In this odyssey, has your definition of public health changed in your own mind? – Yeah, very much. I mean see, when I was a medical student, I thought public health
was to do with drains. – [Harry] What again, I’m sorry. – Drains. – [Harry] I see. – We had lectures from somebody
who’d been very important in public health in New Guinea, and he drew diagrams of how
you dig a deep pit latrine. – [Harry] Okay, oh I see. – I’m sure it’s very important to know how to dig a deep pit latrine in New Guinea, but that’s how public
health was taught to us. And then when I went a bit further, I thought well public
health was about preventing these individual patients
from coming back, and then I started to
think more about society. So even when I was in Berkeley, we were doing studies
of Japanese migrants, the fact that when Japanese change from one environment to another, their health rates changed. But I still didn’t quite think
about societal organization. I thought this was to do with their culture and their behavior. It was only when I
looked at this gradient, by grade of employment. As a fairly ignorant person, I thought what on earth does this mean? And it was this simple
finding of the gradient that got me to thinking
about what does it mean, and set me off on this odyssey about the social determinants of health. And that, of course, you have your own form of a midlife crises of saying, well, maybe the
purpose of doing this research is not to publish one more paper, important as that is, maybe the purpose of the research is to try and change things. And so you would implement it. – In something that you wrote or said, you pointed out that where
this all leads you is to a view of a larger
picture, so that, for example, the idea of sustainable development actually comes to have
a public health meaning. For example, I think you were talking about relating transport systems to the general health of the public. Help us understand that. – Well, this was partly an attempt by me to bring different bits
of my life together. I spent six years on Her
Majesty’s Royal Commission on Environmental Pollution. And I didn’t know anything
about environmental pollution, and you know I guess that’s the
nature of royal commissions, that you get people who
know about something, and then you ask them to
deliberate on something else. And everybody around the
table was expert in something, but not necessarily what
we were deliberating on. But spending six years on this, I tried to think what did it have to do with the things that I was interested in. And if you think that
sustainable development, people criticize it in a bit
the way they criticize stress. You know, what is it? You can’t define it, you
can’t measure it, and so on. The original Brundtland definition was that the needs of something like if the next generation
shouldn’t be compromised by what the present generation should do. But if you think that
sustainable development implies three legs of a three-legged stool, economic, social, and environment, physical, biological environment, then suddenly, that spoke to me. I thought ah-ha! That’s the link between
what I do in my day job, think about inequalities in health, and what I do on this very
time-consuming royal commission. And sustainable development
is a way of thinking about the economic, the
social, and the environmental. Now, I’d like to include, although the sustainable development folks tend to think of the environmental as physical and biological environment, I’d like to muddy the waters and say well, social and economic, well, the environment is
also social and economic. It’s not just physical, but still. So if you look both the problems, environmental problems and the solutions, they clearly have a
social/economic dimension. Take the example, should we tax fuel? Should we tax fuel? In the United States, you don’t quite understand
what taxing fuel means, you should come to Britain and
see what taxing fuel means, how much we pay for a liter of gasoline. Should we tax fuel? Well, there’s a case to be made, and I think the evidence
would probably support it, that if you really tax fuel, you’d have to have a swingeing tax, really, to change consumption because the elasticity demand related to the price of fuel is rather shallow, it’s not very elastic. ’cause in the end, if people
need to use their cars, they need to use their cars. But if you really taxed it to the extent that you change behavior, it’s highly likely that richer people would change their behavior
less than poorer people. So there would be a real
equity dimension to this. By taxing fuel to a really high extent, such that it would change behavior, you might actually make it much harder for poorer people to get about. So if you’ve said that moving about is a right in our society, that would be a right that
would be unequally distributed, because richer people would be
able to drive their big cars and they’d get the riffraff off the road, so that they wouldn’t
have the roads clogged up with all these old bangers. And the poor people, unless you had good public transport, would have their mobility restricted. So doing something for good
environmental reasons has a clear equity dimension to it, a clear fairness dimension to it. And I don’t think we should think about the one without the other. Take the issue of fuel poverty. We know in Britain that
if you define fuel poverty as spending something
like 10% of your income on home heating, then the estimates vary, but it may be several hundred
thousand, if not more, households are suffering
from fuel poverty. Well, as a royal commission, we’ve been recommending a carbon tax. What would be the impact of a carbon tax? That poor people would find it even more difficult to heat their homes because the price would go up. And rich people could heat their homes to their heart’s content because they’d be less
sensitive to that price rise. So that thinking about a carbon tax, and this is a point I made
in our own discussions on the royal commission, we need to think about
the equity dimension, so we don’t make life harder for people. And, particularly, if we didn’t think it would
change consumption very much, why would you want to belt
poorer people around the head and punish them for
being poor even further? And so without addressing
their general living standards through the tax and benefit system, I would be most uncomfortable
with a flat tax, which is, in the sense,
what a consumption tax is. So that there are a couple of examples. Now, broadening it, of how sustainable development and inequalities in health
come together, broadening it, we want to look at what
constitutes living environments. We were asked by the
World Health Organization a few years ago to try
and summarize our work on the social determinants of health in a way that might be
amenable to policymakers. And as I look at what we came up with, we called it The Solid Facts, what we came up with and
what people who were talking about sustainable
development come up with, thinking about sustainable communities in which people live and work, there’s a high degree of overlap, that people need to be able to get about, they need to have air
that they can breathe, water that’s free of chemical pollution, and so on, as well as a
habitable social environment. So I think these two
agendas come together, whatever rude words people
say about the imprecision of the sustainable development concept. – Dr. Marmot, on that
note, our time has run out. Thank you very much for
sharing with us this journey, both of your thinking
and of your life’s work, it’s been quite fascinating. – Thank you. – And thank you very much for joining us for this Conversation with History. (mid-tempo reserved music)

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