MM 2001: Health - Research

December 21, 2000

Connections between poverty and health
You are what you earn

Poverty and ill health are linked. A truism. The last serious political attempt to obscure the connection came with the Thatcher government's cack-handed efforts to sink the Black report on inequalities in health.

The game has now moved on. But its present focus is even more alien to Thatcherite thinking. Among the 25 richest countries, poverty is not related simply to gross domestic product per head. What really counts, according to Michael Marmot and Richard Wilkinson, is relative inequality.

Marmot, director of the International Centre for Health and Society at University College London, has long been researching the health of civil servants. The original study, known as Whitehall One, involved looking at heart and respiratory disease in relation to employment grade. "The social class differences we found were large - threefold between the top and the bottom."

Conventional risk factors - smoking, exercise and the like - could explain only part of the gap. A second study, Whitehall Two, was founded on Marmot's hypothesis that the remaining differences were psychosocial in origin. They were. He found that what predicted coronary disease, in particular, was the extent to which people were in control of their lives. An imbalance between effort and reward was similarly predictive. Nor is the effect confined to the working population; those who do not work, or who are retired, show a similar pattern.

The link is particularly clear in American research. There is almost no relationship between mortality and the average income of each US state - but there is a link between mort-ality and the distribution of income. The larger the gap between rich and poor in each state, the higher the mortality rate. The big factor in studies of this kind, says Richard Wilkinson - a professorial research fellow at the University of Sussex - is social status. "And we need to stop thinking about it simply in individual terms. Levels of trust or violence or hostility or stress are not simply to do with individual psychology, but to do with society as a whole."

Having reviewed reams of epidemiological data, both Marmot and Wilkinson want to find biological explanations. "What I think is happening is that more unequal societies have more stressful social relations, which feed into the biology of chronic anxiety, increasing vulnerability to all sorts of conditions," Wilkinson says.

Depending on your view, work such as this uncovers the price we pay for the benefits of a hierarchical, competitive society - or demonstrates a need to reform the social order.

Unless, of course, you believe in the Labour Party's third way. "My problem with the third way is that it is trying to deal with the poverty question, not the inequality question - which still applies even when you've risen above the poverty threshold," Marmot says. And then he laughs. "Maybe reconstructing the social order wouldn't be such a bad idea."

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