A challenge to medicine

The poor have poor health.

At first blush that is neither new nor surprising. Perhaps it should be more surprising than it is.

In rich countries, such as the United States, the nature of poverty has changed - people do not die from lack of clean water and sanitary facilities or from famine - and yet, persistently, those at the bottom of the socioeconomic scale have worse health than those above them in the hierarchy. Even more challenging is that socioeconomic differences in health are not confined to poor health for those at the bottom and good health for everyone else. Rather, there is a social gradient in health in individuals who are not poor: the higher the social position, the better the health. I have labeled this "the status syndrome." …

This article … argues that what researchers have learned about causes of illnesses and death and what society could do about them has great relevance to health in the United States and other rich nations. Conventional explanations for noncommunicable disease - lack of access to medical care, unhealthy lifestyles - at best only partially explain the status syndrome. Rather, the lower individuals are in the social hierarchy, the less likely it is that their fundamental human needs for autonomy and to be integrated into society will be met. Failure to meet these needs leads to metabolic and endocrine changes that in turn lead to increased risk of disease. …

The United States spends more on health care than any other country - around 15% of a large gross domestic product. Yet the United States ranks 29th in the world in life expectancy. Something is not right. And that something is the gross inequalities in health seen within US society. These inequalities are in turn related to features of society that meet basic human needs to vastly varying degrees depending on socioeconomic position or degree of social exclusion. Research on inequalities in health suggests that there is much that can be done from early life, childhood, among adults of working age, and older individuals that would reduce these inequalities. More research is needed, but much could be done with current knowledge. To this end, the World Health Organization has set up a Commission on Social Determinants of Health that will marshal the evidence and promote action across the whole of society to reduce inequalities in health.

The medical profession should take a lead in promoting such action. Using one analogy, smoking rates declined in countries such as the United States and the United Kingdom not simply because physicians told patients not to smoke, but because the medical profession took the lead in bringing governments to see that action was necessary across a broad front: taxation to increase price, restrictions on advertising, restrictions on availability in public places, labeling, and more. Reductions in the gradient in health and disease will require action across a broad front, starting with women of childbearing age, early child development, education, skills training, better working and living conditions, and support for older individuals.

Who will be the agents to bring to the attention of policy makers the need for such action on the social determinants of health? Why not the medical profession? Who cares more about the tragedy of lives blighted by premature ill health than do we in the medical profession? If we care, we should be leading the charge for action across a broad front to reduce inequalities in health.

Professor Sir Michael Marmot (UCL International Insitute for Society & Health), 'Journal of the American Medical Association', 15 March 2006