I need the critical review done by Sunday(April 11). I will upload an example of how it should be done and the instruction(rubric). the critical review is on chapter  (8) of the pdf book I also uploaded. you will use the book and an outside source as a reference for the critical review. the critical review should be more than one page.

Critical Review Grading Rubric

KINE 3353: Health and the Human Condition in the Global Community

Fall 2020

Criteria

Ratings

Overview of the chapter	2 pts Excellent Reflects a full understanding of all key concepts and discusses main arguments. Takes about 1/3 of the page. Ends with a strong thesis that acknowledges both strengths and limitations.	1 pts Satisfactory Reflects a moderate understanding of all key concepts and arguments. Takes about 1/3 of the page. Thesis does not acknowledge both strengths and limitations.	0 pts Needs Improvement Overview is either too long or too short and does not accurately summarize the text. Does not end with a thesis statement or does not acknowledge either strengths or weaknesses.
Evaluation of Strengths & Weaknesses	2 pts Excellent Critically evaluates the text’s arguments and assumptions, discussing its strengths and weaknesses using appropriate evidence and examples. Synthesizes information and does not merely list. About 1/3rd of a page.	1 pts Satisfactory Adequately evaluates the arguments made. Discusses strengths and weaknesses but does not synthesize the information (instead listing) and provides adequate examples. About 1/3rd of a page.	0 pts Needs Improvement Does not evaluate either the strengths or weaknesses of the text. Too long or too short.
Conclusion: General Impressions or Recommendations	2 pts Excellent Discusses the text’s contribution to public health and any recommendations for improvement. Proficiently supports recommendations made and closing arguments.	1 pts Satisfactory Concludes with only either public health contributions or recommendations. Adequately supports recommendations for improvement and closing arguments.	0 pts Needs Improvement Does not discuss the text’s contribution to public health nor makes any recommendations for improvement.
Two Key Questions	2 pts Excellent At least two thoughtful questions are posed which provoke further thought AND at least one relevant external source is cited.	1 pts Satisfactory Only one thoughtful question is posed which provokes further thought, no external sources are cited, or one external source is cited with no questions posed.	0 pts Needs Improvement No questions are posed nor are any external sources cited.
Writing, Grammar & APA Format	2 pts Excellent Written in APA style using Zotero, in 11-point Times New Roman font, one-inch margins, double-spaced, and paginated with no errors. No spelling or grammar mistakes. 1 page or more.	1 pts Satisfactory Written in APA style using Zotero, in 11-point Times New Roman font, one-inch margins, double-spaced, and paginated with a few errors. A few spelling or grammar mistakes. 1 page or more.	0 pts Needs Improvement Not written in APA style, in 11-point Times New Roman font, one-inch margins, double-spaced, and paginated or with many errors. Does not use Zotero. Many spelling or grammar mistakes. Less than 1 page. An assignment with 30% or more in Unicheck will automatically receive a grade of zero.

1

Chapter 5: Education and Empowerment.

Chapter 5 addresses various aspects of health and how inequality plays out. In chapter five, the focus is on Education and Empowerment across multiple subjects. The author seeks to deconstruct and demystify education’s perception regarding its roles, gender perspectives, and relation to health and well-being. The chapter is structured on how education creates empowerment through the concept of gender, empowerment, health, and addressing the several forms of inequality. The author understands the structural myths that have overtaken gender-based education inequalities and how misconceptions override education regarding better pay and wealth accumulation. The chapter is structured in terms of health, gender, education, fertility reduction, especially in developing countries, and child survival (Marmot, 2019). Education and empowerment are closely interrelated. According to the author, an educated child enhances its survival, improved health and awareness, and self-protection initiatives. Marmot also proposes the measures of addressing structural inequality, with the Finland model being proposed.

The author has a clear outline, structure, and model of addressing education-based misconceptions attached to gender and its roles regarding the chapter’s strengths. Marmot’s pertinent question is on the importance of education to parents, children, and society concerning their health. Thus, the article uses typical case studies in Finland to benchmark the understanding of inequality methods and strategies. The author also creates an objective approach to how education is related to health, gender, and inequality across different aspects of society. Marmot’s chapter on education and empowerment has an insightful, simple, and detailed assessment of various factors associated with education and health. Education is viewed as a tool that is more than just improved pay. The author appreciates its role concerning awareness of risk factors, gender biases, and inequalities.

However, the chapter has shortcomings regarding the complexity of the correlation between education and health in terms of gender. There is no clear clarity on which models the author uses in comparing Finland’s approach to addressing inequality to any other specific country. Thus, the vagueness creates confusion in connecting the variables. The weakness is also in the more extended similarities of the issues discussed through a language that is not smoothly comprehensive in most aspects (Marmot, 2019). These components create a lack of clarity, and the readers might lose track of what is expected of them by the author (Wiggins, 2012)There is a thin line between the chapter objectives and the prolonged narratives in the book’s chapter. These negative attributes constitute weaknesses, characterized by vague reference to claims and concepts that the author seeks to pass across. Two questions that I believe should be considered for further studies are 1. How is education creating health-related empowerment in developing countries during global pandemics such as coronavirus? 2.How make differences in educational curriculum and models impact health inequalities among developed countries?

A reflective conclusion is that it forms the benchmark on the argument between education’s roles about empowering people about their health status and well-being. The author has the masteries of various case studies on the correlation between these concepts, which underline their relevance in the modern health setup. The gap in understanding education and its implications on health and empowerment is addressed throughout the chapter. Therefore, a recommendation on the role of education on cultural empowerment should be undertaken to achieve the desired outcomes.

References

Marmot Michael. (2019). The Health Gap: The Challenge of an Unequal World. Bloomsbury Publishing.

Wiggins, N. (2012). Popular education for health promotion and community empowerment: A review of the literature. Health Promotion International, 27(3), 356–371. https://doi.org/10.1093/heapro/dar046

THE HEALTH GAP

THE HEALTH GAP
The Challenge of an Unequal World
MICHAEL MARMOT

For Alexi, Andre, Daniel and Deborah

CONTENTS
Introduction
1. The Organisation of Misery
2. Whose Responsibility?
3. Fair Society, Healthy Lives
4. Equity from the Start
5. Education and Empowerment
6. Working to Live
7. Do Not Go Gentle
8. Building Resilient Communities
9. Fair Societies
10. Living Fairly in the World
11. The Organisation of Hope
Notes
Acknowledgements
Index
A Note on the Author
By the Same Author

Introduction
Why treat people and send them back to the conditions that made them
sick?
The woman looked the very picture of misery. Her gait almost
apologetic, she approached the doctor and sat down, huddling into the chair.
The dreariness of the outpatients clinic, unloved and uncared for, could not
have helped. It certainly did nothing for my mood.
‘When were you last time completely well?’ asked the psychiatrist in a
thick middle-European accent. Psychiatrists are supposed to have middle-
European accents. Even in Australia, this one did.
‘Oh doctor,’ said the patient, ‘my husband is drinking again and beating
me, my son is back in prison, my teenage daughter is pregnant, and I cry
most days, have no energy, difficulty sleeping. I feel life is not worth
living.’
It was hardly surprising that she was depressed. My mood dipped further.
As a medical student in the 1960s I was sitting in Psychiatry Outpatients at
Royal Prince Alfred Hospital, a teaching hospital of the University of
Sydney.
The psychiatrist told the woman to stop taking the blue pills and try these
red pills. He wrote out an appointment for a month’s time and, still a picture
of misery, she was gone. That’s it? No more? To incredulous medical
students he explained that there was very little else he could do.
The idea that she was suffering from red-pill deficiency was not
compelling. It seemed startlingly obvious that her depression was related to
her life circumstances. The psychiatrist might have been correct that there
was little that he personally could do. Although, as I will show you, I have
come to question that. To me, that should not imply that there was nothing
that could be done. ‘We’ should be paying attention to the causes of her
depression. The question of who ‘we’ should be, and what we could do,
explains why I discarded my flirtation with psychiatry and pursued a career
researching the social causes of ill-health and, latterly, advocating action.

This book is the result of the journey that began in that dreary outpatients
clinic all those years ago.
And it was not just a question of mental illness. The conditions of
people’s lives could lead to physical illness as well. The inner-city teaching
hospital where I trained in Sydney served a large immigrant population, at
that time from Greece, Yugoslavia and southern Italy. Members of this
population, with very little English to explain their symptoms, would come
into the Accident and Emergency Department with a pain in the belly. As
young doctors we were told to give them some antacids and send them
home. I found this absurd. People would come in with problems in their
lives and we would treat them with a bottle of white mixture. We needed
the tools, I thought, to deal with the problems in their lives.
A respected senior colleague put it to me that there is continuity in the
life of the mind. Perhaps it is not surprising that stressful circumstances
should cause mental illness, he said, but it is inherently unlikely that stress
in life could cause physical ill-health. He was wrong, of course. I did not
have the evidence to contradict him at the time, but I do now. The evidence
linking the life of the mind with avoidable ill-health will run right through
this book. Death, for example, is rather physical, it is not just in the mind.
We know that people with mental ill-health have life expectancy between
ten and twenty years shorter than people with no mental illness.1 Whatever
is going on in the mind is having a profound effect on people’s risk of
physical illness and their risk of death, as well as on mental illness. And
what goes on in the mind is profoundly influenced by the conditions in
which people are born, grow, live, work and age, and by the inequities in
power, money and resources that influence these conditions of daily life. A
major part of this book is examining how that works and what we can do
about it.
The more I thought about it at the time, the more I thought that medicine
was failed prevention. By that I mean most of medicine, not just pain in the
belly in marginal groups or depression in women suffering domestic
violence. Surgery seems a rather crude approach to cancer. Lung cancer is
almost entirely preventable – by eliminating smoking. I didn’t know it at
the time, but about a third of cancers can be prevented by diet. Heart
disease – surely we would want to prevent that, rather than simply wait for
the heart attack and treat. Stroke ought to be preventable by diet and
treating high blood pressure. We need surgery for trauma, of course, but

could we not take steps to reduce the risk of trauma? That said, having had
a bad bicycle accident, I am very grateful for high-quality surgical care, free
at the point of use (thank you, National Health Service).
As for prevention, it seemed to me then, and I have evidence now, that
taking control of your life and exercising, eating and drinking sensibly,
having time off on happy holidays, was all very well if you were
comfortably off financially and socially (and going to the private clinics,
not the public hospital where I was then working). Were we going to tell the
woman in Psychiatry Outpatients that she should stop smoking and, as soon
as her husband stopped beating her, she should make sure that he and she
had five fruit and vegetables a day (we did know about healthy eating then,
even if we didn’t have the ‘five a day’ slogan)? Were we going to tell the
immigrant with a marginal, lonely existence to stop eating fish and chips
and take out membership in a gym? And for those who assert that health is
a matter of personal responsibility, should we tell the depressed woman to
pull her socks up and sort herself out?
The thought then occurred that a preponderance of the patients I was
seeing were disadvantaged socially. Not in desperate poverty: the husband
of the depressed woman was working; the migrants, like probably most
migrants, were working hard to get a toehold in society. But they were at
the lower end of the social scale. In fact, all the things that happened to the
depressed woman – domestic violence, son in prison, teenage daughter
pregnant – are more common in people at that end of the scale. I was seeing
social disadvantage in action; not poverty so much as low social status
leading to life problems that were leading to ill-health.
She had an illness. The fire was raging. Treating her with pills might help
put out the fire. Should we not be in the business of fire prevention as well?
Why treat people and send them back to the conditions that made them
sick? And that, I told myself, entails dealing with the conditions that make
people sick, not simply prescribing pills or, if interested in prevention,
telling people to behave better. At that time, and since, I have never met a
patient who lost weight because the doctor told her to.
As doctors we are trained to treat the sick. Of course; but if behaviour,
and health, are linked to people’s social conditions, I asked myself whose
job it should be to improve social conditions. Shouldn’t the doctor, or at
least this doctor, be involved? I became a doctor because I wanted to help
people be healthier. If simply treating them when they got sick was, at best,

a temporary remedy, then the doctor should be involved in improving the
conditions that made them sick.
I had a cause. I still do.
It was not a cause, though, that many of my seniors in medicine were
prepared to endorse. They were too busy putting out fires to expend effort
improving the conditions that promoted these fires.
While thinking these thoughts and working as a junior doctor in the
respiratory medicine ward, I had a Russian patient with tuberculosis. When
I ‘presented’ the patient to my seniors, I didn’t start with his medical history
but, I now blush to recall, said that Mr X, a Russian, was like a character
out of Dostoevsky. He had stubbed his toe on the highway of life (cringe).
He had been a gambler down on his luck, an alcoholic, unlucky in love, and
now, as if in a Russian novel, had developed TB.
A few days later the consultant chest physician drew me aside and said: I
have just the career for you, it’s called epidemiology. (Anything to get me
out of his hair.) He said that doctors, anthropologists and statisticians all
work together to figure out why people have different rates of illness
depending on where and how they live. I was dispatched with a fellowship
to the University of California Berkeley to do a PhD in epidemiology with
Leonard Syme.
The idea that one could actually study how social conditions affected
health and disease was a revelation. Walking round the hospital wards, I had
been saying to myself that if social conditions caused physical and mental
illness, then perhaps the rate of illness of a society could tell us something
about that society. I know, it sounds obvious, but I was trained in medicine,
not in thinking. It meant that the term ‘healthy society’ could do double
duty. A healthy society surely would be one that worked well to meet the
needs of its citizens, and hence would be one where health was better.
In Spanish they say Salud (health); in German prosit (may it be good for
you); in Russian Vashe zdorov’ye (for your health); in Hebrew L’Chayyim
(to life); in Maori Mauri ora (to life). In English when we are not saying
Cheers, Bottoms up or Here’s lookin’ at you kid, commonly we say: Good
health. People value health. Even when they get together for something not
favourable to health, alcohol, people remember to wish each other good
health. Health is important to all of us.
But other things take priority.

I asked some people in a poor part of London, forty or so years after the
experiences in Sydney, what was on their mind. They talked about the
importance of family and friendships; concern for their children – safe
places to play, good schools, not getting into trouble with unsuitable
friends; having enough money to feed the family and to heat the home, and
perhaps for the occasional indulgence; having adequate housing; living in a
neighbourhood with green space, good public transport, shops and
amenities, and freedom from crime; having reliable and interesting work,
without fear of losing their job; older people not being thrown on the
scrapheap. Actually, had I asked people in a well-heeled part of London, the
answers would have been little different.
Then I asked what they thought about health. I was told that in poor
countries, ill-health is the result of unsanitary living conditions and lack of
health care. In rich countries, now that we all have clean water and safe
toilets, they told me that ill-health is the result of difficulty getting to see the
doctor and our own indulgent behaviour, we dreadful feckless drinkers,
smokers and overweight sloths (I am translating slightly), or just plain bad
luck in the genetic lottery.
My point in writing this book is that my informants were not wrong
about what is important for health, just too limited. The depressed woman
in outpatients, the migrants with pain in the belly, the Russian with TB –
they are the rule, not the exception. We now know that the things that really
matter to us in our lives, minute to minute, day to day and year to year, have
a profound impact on our health. The conditions in which people lead their
lives, all the things my London informants told me were on their minds, are
the main influences on their health.
The central issue is that good conditions of daily life, the things that
really count, are unequally distributed, much more so than is good for
anything, whether for our children’s future, for a just society, for the
economy and, crucially, for health. The result of unequal distribution of life
chances is that health is unequally distributed. If you are born in the most
fortunate circumstances you can expect to have your healthy life extended
by nineteen years or more, compared with being born into disadvantage.
Being at the wrong end of inequality is disempowering, it deprives people
of control over their lives. Their health is damaged as a result. And the
effect is graded – the greater the disadvantage the worse the health.

Finding this out has been not only wonderfully interesting, thrilling even,
but it turns out that the evidence provides us with answers. How to improve
the conditions of our lives and improve health is the substance of the
chapters that follow. The knowledge that we can make a difference is
inspiring. The argument that we should make a difference I find utterly
convincing.
My Damascus moment may have been in Sydney, but the journey of
compiling the evidence began in Berkeley. As Len Syme, still in Berkeley,
puts it, they sent me off from Sydney because I was asking too many
awkward questions and thought that Berkeley, soon after its experiences of
the student rebellions of the 1960s, was a better place to ask awkward
questions. A great place, actually!
Syme, in Berkeley, shocked me by saying: just because you have a
medical degree it doesn’t mean that you can understand health. If you want
to understand why health is distributed the way it is, you have to understand
society. I have been trying ever since.
An American colleague enjoys scrambled eggs for breakfast. He studies the
impact of stress on health but he doesn’t rule out the importance of fatty
diet, so limits his egg indulgence to Sunday mornings. One day he opened
his carton of eggs and found a printed insert, a bit like a box of pills. Poor
desperate souls, we addictive readers, we’ll even read package inserts in
egg cartons. On the insert he was intrigued to discover that Marmot’s study
of Japanese migrants in California, reported in the 1970s, proved that
cholesterol was not bad for the heart. Stress was important, not diet.
Not quite.
I am, of course, delighted that academics in Massachusetts can learn
about my research over breakfast simply by reading what’s in the egg
carton. I would be even more pleased if the advertising copywriter had got
it right. Admittedly, it is just a tad complicated; it entails the ability to hold
two ideas in your head at the same time – but writers of egg-carton inserts
should be able to manage that.
As Japanese migrate across the Pacific, their rate of heart disease goes up
and their rate of stroke goes down.2 Would I like to work on this for my
Berkeley PhD? Would I! It was a brilliant natural experiment. If you were
trying to sort out genetic and environmental contributions to disease, here
were people with, presumably, the same genetic endowment living in

different environments. Japanese in Hawaii had higher rates of heart disease
than those in Japan, Japanese in California higher rates than those in
Hawaii, and white Americans higher rates still.
This was terrific. You couldn’t have designed a better experiment to test
the impact on health of ‘environment’, broadly conceived. Most likely, the
changing rates of disease are telling us something about culture and way of
life, linked to the environment. Simple hypothesis: Americanisation leads to
heart disease, or Japanese culture protects from heart disease. But what does
that mean in practice?
Conventional wisdom at the time was, and still is, that fatty diets are the
culprit. Indeed, I have chaired committees saying just that.3 Japanese-
Americans had diets that were somewhat Americanised, with higher levels
of fat than a traditional Japanese diet, and as a result had higher levels of
plasma cholesterol than did Japanese in Japan.4 Diet and high levels of
cholesterol were likely to be playing a part in the higher rate of heart
disease. What’s more, the higher the level of plasma cholesterol, the higher
is the risk of heart disease. So much for the egg-package insert. It missed
idea one. It grieves me to say it, but conventional wisdom is not always
wrong.
Now for idea two. Japanese-Americans may be taller, fatter and more
partial to hamburgers than Japanese in the old country, but their approach to
family and friends resembles the more close-knit culture of Japan more than
it does the more socially and geographically mobile culture of the US.
That’s interesting, but is it important for health? A Japanese-American
social scientist with the very Japanese-American name of Scott Matsumoto
had speculated that the cohesive nature of Japanese culture was a powerful
mechanism for reducing stress.5 Such a diminution could protect from heart
disease. I particularly liked the idea of turning the study of stress on its
head. Not looking at how being under pressure messes up the heart and
blood vessels, but how people’s social relationships were positive and
supportive. We humans gossip and schmooze; apes groom. If, whether
human or non-human primate, we support each other it changes hormonal
profiles and may lower risk of heart attacks.
If this were true, I thought, then perhaps the Japanese in Hawaii had more
opportunity to maintain their culture than the Japanese in California – hence
the lower rate of heart disease in Hawaii. It seemed a reasonable
speculation, but I had no test for it.

I had the data to test the hypothesis much more directly among the
California Japanese. Men who were more involved with Japanese culture
and had cohesive social relations should have lower rates of heart disease
than those who were more acculturated – had adopted more of the
American way of life. That is what I found. And this research result,
perhaps, is where the egg cartons got their ‘news’. The apparent protection
from heart disease among the California men who were more ‘Japanese’
culturally and socially could not be explained by dietary patterns, nor by
smoking, nor by blood pressure levels, nor by obesity. The culture effect
was not a proxy for the usual suspects of diet and smoking.6
Two ideas then: conventional wisdom is correct, smoking and diet are
important causes of heart disease; and, while correct, conventional wisdom
is also limited – other things are going on. In the case of Japanese-
Americans, it was the protective effect of being culturally Japanese.
Everything I will show you in this book conforms to that simple
proposition – conventional wisdom is correct, but limited, when it comes to
causes of disease. In rich countries, for example, we understand a good deal
about why one individual gets sick and another does not: their habits of
smoking, diet, drinking alcohol, physical inactivity, in addition to genetic
makeup – we could call that conventional wisdom. But being emotionally
abused by your spouse, having family troubles, being unlucky in love,
being marginal in society, can all increase risk of disease; just as living in
supportive, cohesive social groups can be protective. If we want to
understand why health and disease are distributed the way they are, we have
to understand these social causes; all the more so if we want to do
something about it.
The British Civil Service changed my life. Not very romantic, a bit like
being inspired by a chartered accountant. The measured pace and careful
rhythms of Her Majesty’s loyal servants had a profound effect on
everything I did subsequently. Well, not quite the conservatism of the actual
practices of the civil service, but the drama of the patterns of health that we
found there. Inequality is central.
The civil service seems the very antithesis of dramatic. Please bear with
me. You have been, let’s say, invited to a meeting with a top-grade civil
servant. It is a trial by hierarchy. You arrive at the building and someone is
watching the door – he is part of the office support grades, as is the person

who checks your bag and lets you through the security gate. A clerical
assistant checks your name and calls up to the office on the fifth floor. A
higher-grade clerical person comes to escort you upstairs, where a low-
grade executive officer greets you. Two technical people, a doctor and a
statistician, who will be joining the meeting, are already waiting. Then the
great man’s, or woman’s, high-flying junior administrator says that Richard,
or Fiona, will be ready shortly. Finally you are ushered in to the real deal
where studied informality is now the rule. In the last ten minutes you have
completed a journey up the civil service ranking ladder – takes some people
a lifetime: office support grades, through clerical assistants, clerical
officers, executive grades, professionals, junior administrators to, at the
pinnacle, senior administrators. So far so boring: little different from a
private insurance company.
The striking thing about this procession up the bureaucratic ladder is that
health maps on to it, remarkably closely. Those at the bottom, the men at
the door, have the worst health, on average. And so it goes. Each person we
meet has worse health, and shorter life expectancy, than the next one a little
higher up the ladder, but better health than the one lower down. Health is
correlated with seniority. In our first study, 1978–1984, of mortality of civil
servants (the Whitehall Study), who were all men unfortunately, men at the
bottom had a mortality rate four times higher than the men at the top – they
were four times more likely to die in a specific period of time. In between
top and bottom, health improved steadily with rank.7 This linking of social
position with health – higher rank, better health – I call the social gradient
in health. Investigating the causes of the gradient, teasing out the policy
implications of such health inequalities, and advocating for change, have
been at the centre of my activities since.
I arrived at Whitehall through a slightly circuitous route, intellectual as
well as geographic.
You couldn’t be interested in public health, or even just interested, and
not be aware that people in poor countries have high rates of illness and die
younger compared with those in rich countries. Poverty damages health.
What about poverty in rich countries? It was a niche interest in the US of
the 1970s. After all, the USA thought of itself as a classless society, so there
could not be differences between social classes in rates of health and
disease, right? Wrong – a piece of conventional wisdom that was
completely wrong. The actual truth was handed around almost like

Samizdat literature in the former Soviet Union in the form of a small
number of papers, one of which was written by Len Syme and my colleague
Lisa Berkman, now at Harvard.8 People with social disadvantage did suffer
worse health in the USA. It was, though, far from a mainstream
preoccupation. Race and ethnicity were dominant concerns. Class and
health was not a serious subject for study. Inequality and health was
completely off the agenda, bar a few trailblazers, writing about the evils of
capitalism.9
If there was a country on the planet that was aware of social class
distinctions and had a tradition of studying social class differences in health,
it was the United Kingdom. And if there was a place in Britain that excelled
at social stratification it was the British Civil Service, familiarly known as
Whitehall.
From Berkeley, then, I came home. It had taken a while. Born in North
London, I went to Australia with my family when I was four years old and,
after a few years playing cricket in the street and declaiming in the school
debating team, studied medicine in Sydney, then went off to Berkeley.
Donald Reid, Professor of Epidemiology at the London School of Hygiene
and Tropical Medicine, offered me a job with the encouragement that if I
wanted a position of low pay, limited opportunities for research in different
places (such as Hawaii, for example), low research funding, but high
intellectual activity, London was the place for me. How could I turn down
such an attractive offer? Donald Reid said he was worried about me in
‘Lotus Land’, i.e. Berkeley. It was too much fun. He was a Scottish
Presbyterian and thought a bit of hard living would be good for me. London
provided it. The British economy in 1976 had just been bailed out by the
IMF. A sense of doom prevailed, and the Labour government, staggering its
way to a dismal end, was cutting public expenditure like there was no
tomorrow. We wondered if that might well be the case. But, after being in
London for about six months (I had arrived at end October 1976), I saw the
sun come out, people shed their woolly sweaters, the roads dried out, the
flowers bloomed, I stopped writing daily letters to friends back in
California, and started to enjoy what Donald Reid promised. It was
privilege, not hard living.
At first experience, London’s Whitehall was as much of a culture shock
as San Francisco’s Japantown. Whitehall is home to the British Civil
Service, and it looks it. To the east, in ‘the City’, financial giants now flaunt

their hubris in soaring glass constructions, reaching for the skies, like their
occupants. Whitehall’s buildings, heavy and stolid, proclaim stability. Even
in the newer buildings, the corridors of power feel as though unchanged
from the days of Empire. It is certainly a place to study class distinctions,
but not poverty. There are no poor in Whitehall.
The Whitehall Study, a screening study of 17,000 men, had been set up
by Professors Donald Reid and, another great teacher of mine, Geoffrey
Rose. Why civil servants? A little more culture shock. Donald Reid had
lunch at the Athenaeum Club with one of his friends who was the chief
doctor for the Civil Service, and the study was born. Athenaeum Club?
Think Gentlemen’s Club, with a classical façade and an Athenian-style
frieze at the front, in a lovely setting not far from the Royal Parks in
London, a stuffy dining room and overpadded armchairs.
Twice is a coincidence, three times a trend. In the 1970s I had done only
two big studies, Japanese migrants and now Whitehall civil servants, and
both had flown in the face of conventional wisdom. At the time, everyone
‘knew’ that people in top jobs had a high risk of heart attacks because of the
stress they were under. Sir William Osler, great medical teacher from Johns
Hopkins University and the University of Oxford, had, around 1920,
described heart disease as being more common in men in high-status
occupations. Osler fuelled the speculation that it was the stress of these jobs
that was killing people.
We found the opposite. High-grade men had lower risk of dying from
heart attacks, and most other causes of death, than everyone below them,
and as I described earlier, it was a social gradient, progressively higher
mortality going hand in hand with progressively lower grade of
employment.
Further, conventional explanations did not work. True, smoking was
more common as one descended the social ladder, but plasma cholesterol
was marginally higher in the high grades, and the social gradient in obesity
and high blood pressure was modest. Together, these conventional risk
factors accounted for about a third of the social gradient in mortality.10
Something else had to be going on. In that sense, it was similar to my
studies of Japanese-Americans. The conventional risk factors mattered, but
something else accounted for the different risks of disease between social
groups. In the Japanese case we thought it was the stress-reducing effects of
traditional Japanese culture.

You may think: stress in the civil service? Surely not! My colleagues
Tores Theorell in Stockholm and Robert Karasek, the man who was eating
eggs in Massachusetts, had elaborated a theory of work stress. It was not
high demand that was stressful, but a combination of high demand and low
control.11 To describe it as a Eureka moment goes too far, but it did provide
a potential explanation of the Whitehall findings. Whoever spread the
rumour that it is more stressful at the top? People up there have more
psychological demands, but they also have more control.
Control over your life loomed large as a hypothesis for why, in rich
countries, people in higher social positions should have better health.
I have written about the Whitehall Studies at length in a previous book,
Status Syndrome, and will not rehearse all the evidence here.12 More recent
evidence will make its way into chapters of this book. Suffice it to say that
the social gradient that we found in the Whitehall studies has been found in
British national data, and now all over the world. There is much effort
going into understanding it. In this respect, if no other, British civil servants
do still lead the world!
More than that, some social scientists from Oxford beat a path to my
door. They said that they had a view of how work, not just in the civil
service but more generally, should be classified into hierarchies. They
thought that the span of control was central: higher status, more control.13
The second Whitehall Study showed that span of control was important for
health.14 They loved it: evidence that their theorising was important for
people’s lives.
At the start of this section, I went a bit over the top and said Whitehall
changed my life. The social gradient and ‘control’ certainly changed my
approach to health and inequalities in health. It says we should focus not
only on poverty but on the whole of society. Poverty is bad for health.
There are good reasons for wanting to do something to reduce poverty, and
among them is the harm it does to health. The gradient, though, is different.
All the way, from top to bottom of society, the lower you are the worse your
health. The gradient includes all of us below the topmost 1 per cent. You are
thinking, perhaps, that we will always need people to watch the doors and
staff the front desk, to serve the great man. Hierarchies are inevitable. Does
that not mean that health inequalities, the social gradient in health, are
inevitable?

Read on. The evidence shows that there is a great deal that we can do to
reduce the social gradient in health, but it will take committed social action,
and political will. But before we get to that, we will need to consider the
huge amount of work that has been done in connecting our understanding of
these social determinants of health in rich countries to the global picture of
health and health inequalities.
A remarkable thing happened in 2012. According to the World Health
Organization (WHO), life expectancy in the world was seventy, a biblical
three score years and ten. Regrettably, that statistic is nearly totally useless.
It tells us that China and other countries with life expectancy greater than
seventy are balanced by India and other countries, mainly in Africa, with
life expectancy less than seventy. The more relevant figure is the spread of
thirty-eight years: from life expectancy of forty-six in Sierra Leone to
eighty-four in Japan – in Japanese women it is eighty-six.
My first experiences of life expectancy at the wrong end of the scale
were in New Guinea and Nepal. To be sure, there was little medical care
available in remote villages, but one could hardly start there in looking for
causes of ill-health. Dirty water and inadequate nutrition seemed a much
better place to start. In the lowlands of New Guinea, particularly, malaria
was also a problem, but prevention with impregnated bed nets and mosquito
control, even then, seemed better options than waiting for people to get sick
and then treating them. In the highlands, everyone had a cough, mostly
because of open fires inside their huts to keep warm in the chilly highland
nights. Safe cooking stoves would make a difference.
In the early 1970s it seemed a bit hopeless to think that health could
improve in such unpromising circumstances. Not so. In Nepal, life
expectancy improved by about twenty years, to sixty-nine, between 1980
and 2012. This is astonishing. Let us assume that the figures are more or
less correct. Twenty years of improvement in thirty years means two-thirds
of a year of improvement for every calendar year. That is sixteen hours of
improvement every twenty-four hours. In rich countries, now, the rate of
improvement is only(!) about six to seven hours every twenty-four hours.
My point is twofold. First, there are huge differences in health and life
expectancy across the world, not just Sierra Leone and Japan but every
shade of light and dark in between. Second, health can improve really

quickly. Such rapid improvement fuels what I call my evidence-based
optimism.
Some time around 2008, I gave a lecture in San Francisco. After it, a friend
said to me: ‘I have heard you lecture many times, but that is the first time
I’ve seen you wagging your finger. There is something else going on. Not
just scientific evidence but an urgency, a demand for action.’
He was right. I had been studying social causes of ill-health, having a
fascinating time doing research and writing papers, but underneath there
was a low, insistent rumble: it is not right that social conditions should be so
unequally distributed across the world, and between social groups within
countries. It means that much of the inequality in health that we see is
unfair. The rumble grew louder. Research is immensely rewarding, but
shouldn’t we, and that includes me, be trying to do something about it?
At the end of every scientific paper there is a familiar coda: more
research is needed, more research is needed. What, I wondered, if we added
a new coda: more action is needed. It need not be discordant with the first.
Around this time, the turn of the millennium, Professor Jeffrey Sachs,
now at Columbia University, and a great advocate for development aimed at
the world’s poor, had led a Commission on Macroeconomics and Health
(CMH) set up by the World Health Organization. The CMH concluded that
there should be major investment, globally, aimed at reducing killing
diseases. The resultant improvement in health would lead to economic
growth.
My thought was that investment in reducing the global burden of
tuberculosis, HIV/AIDS and malaria had to be applauded. Much better than
global expenditure on armaments, for example. If arguing that disease
control would lead to economic growth helped get action, well done. There
is a ‘however’, however. From my standpoint, they got it upside down.
Health should not be a means to the end of a stronger economy. Surely the
higher goal should be health and well-being. We want better economic and
social conditions in order to achieve greater health and well-being for the
population.
As an idealistic young student, I did not decide to study medicine out of a
wish to further economic growth. I studied it because I wanted to help
individuals get healthier. I went into public health, and social determinants
of health, because I wanted to help societies become healthier. I discussed

this with the economist and philosopher Amartya Sen, then of Cambridge,
England, now of Cambridge, Mass., and suggested we get a group together
to say that it was important to improve social conditions to improve health.
Not to criticise the CMH, but to say that we needed action, globally, on the
social determinants of health. Amartya Sen agreed.
One thing led to another, and in 2005 the Director-General of WHO, J.
W. Lee, set up the Commission on Social Determinants of Health (CSDH),
with me as chair and Amartya Sen as a distinguished member. We had
consultations before the Commission started properly. One prestigious
academic said that he had served on commissions where the report was
essentially written before the commission met. He said that would not be
true here, because: ‘Michael doesn’t know enough.’
Absolutely right. I ran the CSDH as a mutual learning exercise. I learned
from the former heads of government, government ministers, academics
and representatives of civil society who made up the global commission,
and we all learned from global knowledge networks that we set up. The
learning that came from the CSDH, and two subsequent exercises that I will
mention below, informs this book.
You produce a commission report. Is anyone listening, or will its fate be
that of most such reports – worthy dustiness on shelves? The CSDH was a
global report. We were concerned with health inequalities within and
between countries from the poorest to the richest. A recommendation is
going to look somewhat different in Gujarat and in Glasgow, in Nigeria and
New York. We made a virtue of necessity and recommended that countries
set up mechanisms to ‘translate’ our recommendations in a form suitable for
that country. Brazil set up its own Commission on Social Determinants of
Health. The CSDH met the Brazilian commission and shared emerging
findings. Chile got active, as did the Nordic countries.
In the UK, the Labour government, under Prime Minister Gordon Brown,
invited me to conduct a review of health inequalities in the light of the
CSDH report. The aim was to translate the CSDH’s recommendations into a
form suitable for Britain. To inform the review we set up nine task groups
involving scores of experts who contributed their knowledge in each of our
key domains. The Marmot Review, as it was known, was published as Fair
Society, Healthy Lives in 2010.15

More international task groups, more knowledge synthesis, more
deliberation informed the production of the European Review of Social
Determinants and the Health Divide, which we published in 2014. The
European Review was commissioned by Dr Zsuzsana Jakab, the Director of
the European Office of WHO. The so-called European Region contains, in
addition to Europe, all the countries of the former Soviet Union. It stretches
all the way to the Bering Strait, practically to Alaska. It means that we are
getting social determinants of health on the agenda in many countries. The
CSDH report was not forgotten.
Society and health, by its nature, is a highly political issue. When we
published the CSDH report, one country labelled it ‘ideology with
evidence’. It was meant as criticism. I took it as praise. We do have an
ideology, I responded: health inequalities that can be avoided are unjust – a
case I will make later in the book. Putting them right is a matter of social
justice, but the evidence really matters.
The Economist weekly newspaper said what it thought of our
commitment. It gave a full two pages to covering the Commission’s report,
thank you, and ended with: ‘it would be a pity if the new report’s saner
ideas were obscured by the authors’ quixotic determination to achieve
perfect political, economic and social equity.’16 I particularly liked
‘quixotic’. In Cervantes’s masterpiece, Don Quixote woke up one morning
and, imagining himself to be a medieval knight, rushed round doing
chivalrous deeds – tilting at windmills, slaying wine gourds – while
everyone chuckled at him. I told the Spanish Minister of Health – Don
Quixote being part of the Spanish psyche – that the cap, or rather the tin
helmet, fitted me rather well: a knight idealistic in a faintly ridiculous way,
wanting to make the world a better place, and no one quite taking him
seriously. Ah, said the Minister, we need the idealism of Don Quixote the
dreamer, but we also need the pragmatism of Sancho Panza. I call that
ideology with evidence.
In presenting the CSDH we made clear that we were driven not by the
economic case for action, but by the moral case. We even put on the back
cover: ‘Social injustice is killing on a grand scale.’ That sounds rather
political. Yet we were criticised for being insufficiently political in our
analysis.17
Health is political, yes. I have tried, though, to steer clear of party
politics. As far as is possible I want the evidence to speak for itself. As

societies indulge in the very real debates between the role of the state and
freedom of the individual, I want to foreground the implications for health
and health inequity. Since wandering around hospital wards in Sydney, I
have maintained the view that the scale of health inequalities in society and
the world tells us a good deal about the quality of our society and the way
we organise our affairs.
I left clinical medicine because I did not think that the causes of ill-health
and of social inequalities in health had much to do with what doctors did.
We had to improve society. I was therefore surprised, to say the least, to be
invited to be President of the British Medical Association for the year
2010–11. I thought they had the wrong person.
I had to make a speech when I was installed. I thought that since there
were a lot of doctors in the audience, I could pick up some useful advice. I
told the doctors that while doing the work described in this book, I had
developed three medical conditions. Perhaps they could help.
The first is optimism. I feel unreasonably optimistic all the time. Despite
all the doomsayers, the people who argue that all has been ruined, I judge
that the evidence shows that things can improve. There must be some pills I
can take for this condition.
The second, related to the first, is that I have developed selective
deafness. I don’t hear cynicism. If people say that no one will ever do things
differently, it won’t happen, people don’t change, and the like, it bounces
off. I no longer hear it. Realistic yes, but not cynical.
Third, I have developed a watery condition of my eyes. We were having
a CSDH meeting in Vancouver. At the end of it, Pascoual Macoumbi,
former PM of Mozambique, who was a member of the CSDH, said: ‘I
haven’t felt so energised since my country got independence.’ The watery
condition of my eyes developed. When we were in Gujarat, and saw how
the Self Employed Women’s Association was working with its members,
the poorest, most marginalised women in India, to triumph over adversity, I
found my eyes watering. As they did when seeing young people developing
self-esteem in the slums of Rio, or Maoris finding dignity in New Zealand.
This watery condition seems to come on not when seeing people in distress,
so much as when seeing them triumph over difficult conditions.
My purpose in writing this book is to let you know about the evidence of
what we can do to improve people’s lives – be they the poorest in the world

or the relatively comfortably off. When we launched the CSDH in Santiago
de Chile, I quoted the Chilean poet Pablo Neruda. Let me do so now, and
invite you to join me and: ‘Rise up . . . against the organisation of misery.’

1
The Organisation of Misery
It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of
foolishness . . . it was the season of Light, it was the season of Darkness, it was the spring of
hope, it was the winter of despair . . .
Charles Dickens, A Tale of Two Cities
I have a one-track mind. I see everything through the prism of health. It is
indeed the best of times. Health is improving globally. In many countries of
the world we are much healthier and living much longer than we would
have been when Dickens was writing. It is the worst of times. This
enjoyment of good health is most unequally spread. For some countries
their health is nearly as bad as if they were still languishing in Dickensian
squalor. Currently in the world the unhealthiest country has a life
expectancy nearly forty years shorter than the healthiest. That is the same as
the gap between Dickensian and modern-day London. Within many
countries, too, inequalities in health are increasing – the health of the best
off is increasing more rapidly than that of the worst off. The best and worst
of times coexist.
It is the age of wisdom. Advances in medical science and knowledge of
public health give us the tools to make dramatic health advances.1 It is the
age of foolishness – I would have preferred it if Dickens had written hubris.
Knowledge of medicine and public health is not so much wrong, as too
limited. Health is too important to be left solely to doctors. Health is related
not only to access to technical solutions but to the nature of society. We are
being foolish in ignoring a broader array of evidence, which shows that the
conditions in which people are born, grow, live, work and age have
profound influence on health and inequalities in health in childhood,
working age and older age.

It is the spring of hope. We may be foolish to ignore such knowledge, but
we do now understand how society influences health – my purpose in
writing this book – and there are inspiring examples from around the world
of how such understanding is transforming lives and improving health. It is
the winter of despair. When the 1 per cent and the 99 per cent have
diverging interests and the head of the US Federal Reserve Bank says that
inequalities of income and wealth have gone too far,2 when banks in Europe
and the US have, since 2008, been fined a total of £100 billion for banking
crimes and misdemeanours which damage their customers’ interests,3 when
rich countries compete to make the most of Africa’s resources, when people
of ill will misuse race and religion to spread chaos, when in functioning
democracies people’s faith in their governments is at a low ebb, and in other
countries governments seem to have little interest in the well-being of their
populations, then despair may set in.
In this first chapter, I want to show why, in terms of health, it is the best
and worst of times. Wisdom and foolishness, hope and despair, will make
their appearance to introduce the topics for the rest of the book. I am an
evidence-based optimist. Armed with knowledge, we can transform a
season of darkness into one of light. It will take commitment and political
will, but the knowledge and experience is there that can make a huge
difference.
A TALE OF TWO CITIES . . . AND THEY ARE BOTH IN
GLASGOW
‘I know you have been contrasting shockingly poor health in Calton with
the estimable health of Lenzie [areas of Glasgow]. We talk about it in
Glasgow. Even in the pub. Especially in Calton, as people raise their glasses
to the memory of drinkers past, so many of them gone. I live in Lenzie and
drink regularly in the pub with a friend who lives in Calton. We were
chatting the other night and it turned out that my friend had no plans for
pension or other retirement arrangements. When I asked him why not, he
said: “Because I’m fifty-four.”’ So said a Scottish professor to me at a
meeting.
My response: oh dear! That’s not what I wanted at all. It is great to have
one’s research discussed, in Scottish pubs, and elsewhere I hope. I did

publish data on life expectancy in Calton and Lenzie.4 The point was for
discussion to lead to change, not to fatalism.
If a man dies in his prime in Calton, a down-at-heel part of Glasgow, it
may be a tragedy, but it’s not a surprise. Actually, the question of what
constitutes his ‘prime’ in Calton is moot. Life expectancy for men, when I
first looked at figures from 1998–2002, was fifty-four. In Lenzie, a much
more upmarket place a few kilometres away, ‘in his prime’ has an
altogether different meaning: life expectancy for men was eighty-two.5 That
converts to a twenty-eight-year gap in life expectancy in one Scottish city.
Calton is an unlovely place. Its residents say: ‘Nowhere to walk, really
bad’, ‘Can’t let granddaughter out’, ‘Side streets, terrible prostitution’.
There might be a park with some green space but it has ‘prostitutes,
alcoholics and druggies at night’, there is ‘usually a man parked on a bench
with a bottle’.
Calton is the environment in which Jimmy, a typical resident, lives. In
truth, Jimmy has always been something of a rascal. He was born in Calton
in an unstable home, was in trouble in school, and delinquency problems
led to trouble with the police as a teenager. Jimmy was enrolled in an
apprenticeship but dropped out; he has never had a ‘proper’ job, but had
short-term temporary manual work. As with his subculture, any money
Jimmy gets goes into drink and drugs; his diet, if you could call it that,
consists of pub food, fast food and alcohol. Jimmy has had a series of short-
term girlfriends, but there is a question of alcohol-fuelled violent behaviour.
He is known to the police for his various gang-related violent activities.
It is men like Jimmy who can expect to live shorter lives than men in
India. Average life expectancy for men in India was sixty-two at the time
that it was fifty-four for men in Calton. Jimmy’s poor health prospects will
not be improved by telling the adult Jimmy to pull his socks up and behave
better. We should have started a bit earlier in his life.
The twenty-eight-year gap in life expectancy in Glasgow was as big as I
could find anywhere within one city that gathers good data.6 The current
figure is probably closer to twenty years.7 Twenty years is ridiculously
large. Twenty years is the gap in life expectancy between women in India
and women in the USA. We can see differences in life expectancy as big as
twenty years within London, too – even within the London borough of
Westminster, one of the richest spots on the planet.8 In the US, if I said that

a poor part of the city, in Baltimore or Washington DC for example, had life
expectancy twenty years shorter than a rich part, many Americans would
think ‘race’. Perhaps they would be less quick to think ‘race’, whatever that
means, if they knew that London and Glasgow have a twenty-year gap in
life expectancy that cannot be attributed to ethnic differences. We need to
go beyond simple categories such as race and social class to find out what is
going on.
Perhaps you are thinking: I am not the richest, and I am not the poorest.
If I were in Glasgow I would be living neither in an elegant Georgian town
house nor in a tenement. Similarly, in the London borough of Westminster
where the gap is nearly twenty years I would be neither in the fanciest parts
of Mayfair and Knightsbridge nor in the run-down area of Church Street. If
living in a rich area corresponds with good health, and in a poor area with
poor health, where do I fit in to all of this, you might ask.
You and I, dear reader, fit right at the heart of all this. If we live in a
neighbourhood that is somewhere between the humblest and the most
exalted, our life expectancy is somewhere in between the low level in the
poor areas and the higher prospects in the richer. The richer the area, the
better is our health, on average, as illustrated in Figure 1.1.9
FIGURE 1.1: ALL THE WAY FROM TOP TO BOTTOM

Here every neighbourhood in England is ranked according to level of
deprivation. In the top line, each dot represents life expectancy for one
neighbourhood. Suppose you live in a neighbourhood with middling levels
of deprivation (or affluence), your life expectancy, on average, is middling.
If you live in a neighbourhood that is right up there, but not quite at the
most affluent level, your life expectancy is near the highest. The link
between deprivation and life expectancy is remarkably graded: the greater
the deprivation, the shorter your life expectancy.
The social gradient in life expectancy runs all the way from top to
bottom. It doesn’t just feel better at the top. It is better. At the top, not only
do you live longer but the quality of life is better – you spend more years
free from disability, as the bottom line in the graph shows. The social
gradient in disability-free life expectancy is even steeper than it is for life
expectancy. ‘Disability’ here is quite broadly defined: any limiting long-
standing illness. Talk about adding insult to injury: the more deprived
people spend more of their shorter lives with ‘disability’. On average
people at the top live twelve years of their lives with disability, people at the
bottom twenty years.
A similar graph could be reproduced in any number of countries round
the world. The social gradient in health is a widespread phenomenon.
A decade or so ago, I wrote that if you caught the Washington Metro from
the southeast of downtown Washington to Montgomery County, Maryland,
life expectancy rises about a year and a half for each mile travelled – a
twenty-year gap between ends of the journey.10 Since then, colleagues in
London have said that if you catch the Jubilee tube line, for each stop east
from Westminster in central London, life expectancy drops a year.11
The point of these exercises is to make vivid the social gradient in health.
Subtle differences in neighbourhood, or more importantly in other
conditions affecting the people who live there, have grave import for health
and length of life.
The first reaction of most of us to the social gradient in health is: hey, this
is about me. ‘Health inequalities’ is not only about poor health for poor
people, it covers gradations in health, wherever we are on the social ladder.
It is not about ‘them’, the poor, and ‘us’, the non-poor; it is about all of us
below the very top who have worse health than we could have. The gradient
involves everyone, rich, poor, and in-between.

A sampling of the popular press demonstrates a huge variability in
attitudes to the fact that the poor have worse health than everyone else. For
some, the poor are poor and sick because they are feckless. This
fecklessness extends to not looking after themselves and their children.
Elsewhere, a more sympathetic view might be that you do care about the
poor health of the ‘poor’ in your own country or ‘over there’ in another
country. It is a concern, it says something about your sense of what you
think a society should be for, but it does not touch you more than that. The
social gradient in health, though, affects all of us. We are not just interested,
we are engaged. This is my life and yours. You and I are neither feckless (I
am making an assumption) nor deserving of sympathy because of our
poverty, yet all of us below the very top have worse health than those at the
top.
The gradient changes the discussion fundamentally. The gradient implies
that the central issue is inequality, not simply poverty. As we will see,
poverty still remains hugely important for health, but relief of poverty is
conceptually simple, even if politically and practically difficult. Inequality,
on the other hand, implies that not only is having enough to make ends meet
important, but so too is what we have relative to others.
Inequality puts us into entirely different terrain. In many countries,
economic inequality has been seen as a good thing. Lowering taxes on the
rich, for example, a policy that has the clear and predictable effect of
increasing economic inequality, is justified as being good for the economy.
Set the wealth producers free and we will all benefit, runs the argument. But
what if such a policy made health inequality worse? In Britain, a senior
Labour politician said that he was ‘intensely relaxed’ about how much the
rich earned.12 Governments of the centre-right and centre-left have both
contrived to do very little to reduce economic inequality. The centre-left
wants to reduce poverty; the centre-right appears to believe that if they get
the incentives right, and the economy grows, poverty will look after itself.
But neither has seen economic inequality as a problem, although that is now
changing.
We should change our focus. We should focus on the rich, not only on the
poor. I do not mean social workers calling on the rich to see if they are
managing their money all right. Of course, we still want to solve the
problem of poverty and health, but if all of us below the top have worse

health than those at the top, surely we should aim to improve everybody’s
health towards the high level of those at the top.
The potential gains are enormous. I once calculated that if everyone in
England over the age of thirty had the same low mortality as people with
university education there would be 202,000 fewer deaths before the age of
seventy-five each year – almost half of the total. This equates to 2.6 million
extra years of life saved each year.13 Health inequalities are not a footnote
to the health problems we face, they are the major health problem.
Common sense tells us that if we want to solve a problem we should
focus on it. I am arguing that the problem of health inequalities within
countries is the social gradient – from top to bottom, the lower our social
position the worse our health. Focusing on the problem of the health
gradient implies improving society. But what about the poor at the bottom
who have the worst health? My answer is that improving society, improving
everyone’s health up to that of the best off, does not preclude extra effort on
improving health for the poor. Rather than ‘them’ and ‘us’, we need to
expend extra effort where it is needed: improve society and effort
proportional to need. The point is made even more clearly if we look at a
broader range of countries.
SOCIAL GRADIENTS? FOCUS ON THE RICHEST? DON’T
POOR COUNTRIES HAVE TO WORRY ABOUT POVERTY?
Some health workers in sub-Saharan Africa believe that the social gradient
in health is an effete concern of rich countries. In the most deprived parts of
the world, they argue, we should focus on the poorest of the poor. That is
not what the evidence shows. It is difficult to obtain figures for inequalities
in adult mortality from most countries – they are simply not available.
Many countries do have figures for mortality rates of children under age
five, and those for a few selected countries are shown in Figure 1.2.14
FIGURE 1.2: ALL RIGHT FOR THE FEW

These figures reinforce the importance of concentrating not on the
poorest, but on the richest. We should be asking not only how can we
improve things for the poor, but how can we get everyone’s health up to the
standard of the richest? Were we to focus only on the ‘poor’ of Uganda, we
would miss the fact that the most affluent 20 per cent have a higher child
mortality than the poorest of Peru. If you are in India, would you be happy
if only the child mortality rate of the poorest fifth were reduced? Wouldn’t
you want everyone to have child mortality as low as the top fifth? For that
matter, surely if you are in the best-off fifth in India you would want to get
the child mortality of people like you down to the low level of the top fifth
in Peru, who would want to get theirs as low as the average for high-income
countries – 7 deaths per 1,000 live births.
In other words, the implications of the gradient in Uganda, India or Peru
are the same as in Glasgow, London or Baltimore. Yes, it is important to
improve the lot of the worst off, but the gradient demands that we improve
conditions, and hence health, for everyone below the top. Not only do we
need to reduce poverty, we need to improve society and have effort
proportional to need.
You may be thinking that a social gradient in health in Glasgow and in
India are quite different. Thinking about Jimmy in Calton, described above,
destitution does not come to mind. He has clean water and shelter and does
not suffer from malaria, or dysentery. Surely in India it is different, where

the basics are lacking. The basics are wanting, but in other respects it is not
so different. Here is Gita.
Gita sells vegetables on the street in Ahmedabad in the state of Gujarat in
India. She has no formal education, lives in an ‘informal settlement’ (a slum
made of makeshift housing) and has two children who sit with her by the
roadside as she sells her vegetables, and an older girl who helps with the
vegetable trade. To keep her business going Gita takes out short-term loans,
at 20 per cent a month interest, to buy vegetables from the middle man in
the wholesale market. Her husband is a migrant worker who is living in
another state and sends a few rupees back each month. Gita was just about
making her tight budget work, but it was time for her daughter, aged
fourteen, to marry, and instead of paying off her debts she put money into a
dowry and a wedding party for her daughter. Some aid workers are tearing
their hair out at what they see as this ‘irresponsible’ waste of money, as her
interest payments have gone up.
What links Jimmy and Gita is disempowerment. They simply have little
control over their lives. This disempowerment is linked to ranking low in
the social hierarchy. Until they are in a position to take control of their lives
it is going to be very difficult to improve their health. Yet the evidence
shows that this is far from hopeless. It is to capture the season of light that I
have written this book.
In saying at the start that it was the worst of times, I pointed to two types
of inequality in health. We have just been looking at inequalities within
countries – the social gradient in health. There is a second type of
inequality. Figure 1.2 shows big differences between countries as well as
within them. It implies that poorer countries have worse health. They do, in
general. To see that that is not the whole story, however, I want to turn to
the US.
RICH COUNTRIES, GOOD HEALTH?
You are a fifteen-year-old boy in the USA. I’ll call you Andy. You are
secure in the notion that you live in nearly the richest nation on the planet.
Life will be good. Like all fifteen-year-olds you have many preoccupations,
some linked to your quick mind and wild enthusiasms, others to your
growing body and raging hormones. Apart from being a bit overweight and
prone to the occasional bout of hypochondria – it’s acne not cancer – health

is not a concern. You live in a rich country and everyone says that rich
countries have good health because of good medical care and public health.
Poor countries have poor health because they lack those things. Anyway,
you think, when a country’s health suffers it is babies and young children
and older people who die. Fifteen-year-old boys are practically
indestructible. Given what you get up to, that is a welcome notion. If you
reach the vigorous age of fifteen you can almost guarantee you will reach
sixty. Reassuring, but not quite right.
Go into a typical American school and count one hundred boys aged
fifteen. Thirteen of you will fail to reach your sixtieth birthday. Is thirteen
out of a hundred a lot? The US risk is double the Swedish risk, which is less
than seven. The UK looks more like Sweden, but not quite as low. Yes,
thirteen out of a hundred is a lot. It may also be the tip of the iceberg. If so
many young people are dying, there may be a good deal more that are
suffering non-fatal illnesses and injuries.
You and your family might be shocked to find out that the survival
chances of a fifteen-year-old boy in the US are about the same as in Turkey
and Tunisia, Jordan and the Dominican Republic. The US figure is worse
than Costa Rica, Cuba, Chile, Peru and Slovenia. In fact, in the US the
likelihood that a fifteen-year-old boy will survive to celebrate his sixtieth
birthday is lower than in forty-nine other countries. The US ranks around
fifty on what is called male ‘adult mortality’. There are 194 member states
of the United Nations. Fifty out of 194.15 Not looking good. The US is a
very rich country. Rich countries are supposed to have good health. What
happened?
I have lost count of the number of Americans who have told me that they
have the best health care in the world. Let us, for the moment, assume it is
true. Why, then, would young adults in the US have less chance of
surviving to sixty than young adults in Costa Rica, Cuba or Slovenia,
let alone Sweden, the UK and most other European countries?
The answer is because medical care, and even public health, has little to
do with it. The high mortality of young men comes from homicide, suicide,
car crashes, other accidents, drugs, alcohol and some other disorders. To
blame homicide or other violent deaths on lack of medical care is a bit like
blaming broken windows on a lack of suppliers of new window panes. If
someone heaves a rock through your window, it is quite helpful to have
someone to call who can come and fix it. It wasn’t difficulty in finding

someone to call that led to the rock being thrown . . . or not directly. (There
is a broken windows hypothesis which suggests that if you don’t fix the
windows it encourages rock throwers.) Could the relatively poor survival
chances of young men be linked to the nature of society?
For American readers here is a little consolation, albeit not much for
Russian readers. Russia does dramatically worse. If you are one of a
hundred fifteen-year-old boys in Russia, look around and take note: a third
of your group will be gone by the age of sixty. In Russia you simply cannot
assume, as you can in Sweden, that if you are alive and kicking at fifteen
you will still be breathing at sixty. On this particular health measure, Russia
would not look out of place in sub-Saharan Africa. Its figure is the same as
in Guinea-Bissau, and only marginally better than Sierra Leone.
This second type of health inequality – the first is the social gradient
within countries – is the dramatic variation in health between countries,
even among relatively rich countries: Sweden, the US and Russia.
Perhaps you are thinking that Sweden and the US is not a fair
comparison. Perhaps, Sweden being a more homogeneous country, the
Swedes are genetically programmed to be healthier young adults than the
ethnically and racially diverse US. Or is it misleading to compare a country
with a population smaller than New York with the whole of the US?
What if I told you that twenty years ago, the survival chances of fifteen-
year-old Swedes were worse than now and looked a lot like that of
Americans today? Sweden was more homogeneous twenty years ago than it
is today – there has been a great deal of immigration – so the homogeneity
explanation does not hold much water. Put simply, if Sweden could improve
its health from a US level of health to a Swedish level, so today could the
US improve its health to the new Swedish level. After all the US, too, has
improved over the last twenty years. It just hasn’t caught up. There is no
good biological reason why you, fifteen-year-old Andy in the US, should
not have the same health prospects as fifteen-year-old Johan in Sweden.
Why don’t you, then? Read on.
Obviously, it is not simply about rich and poor countries. National
income per head is a third higher in the US than in Sweden, but health is
poorer in the US.16 The US is richer than almost all of the forty-nine
countries that rank ahead of it in the survival stakes. Russia’s national
income per head (adjusting for purchasing power) is twenty times Guinea-
Bissau’s, yet boys in the two countries have the same poor survival chances.

OK, not simply rich and poor, but we know, don’t we, why people get
sick and die. Isn’t it lack of health care? And if not that, in poor countries it
is destitution that leads to death from communicable diseases. In rich
countries it is smoking, drinking, obesity and general failure to look after
ourselves that cause diabetes, heart disease and cancer. We will look at
these explanations and see that they are not so much wrong, as too limited,
and they scarcely apply to the life prospects of fifteen-year-old boys.
I rather ruled out of hand the idea that differences in medical care could
explain the differences in survival among fifteen-year-old boys – broken
windows are not caused by lack of window fixers. Perhaps such quick
dismissal is inappropriate when it comes to the more robust gender.
Differences in medical care might provide a readier explanation for
international differences in fifteen-year-old girls. Women have to face
something special before they reach sixty: pregnancy and childbirth. We
visited a boys’ school. Let’s visit a girls’ school.
Go into a school in Sierra Leone, and count twenty-one fifteen-year-old
girls. One of those twenty-one will die during her childbearing years of a
cause related to maternity. In Italy, one school would not be enough. You
would have to count 17,100 fifteen-year-old girls to be fairly sure than one
would die of a maternal-related cause. I was shocked by the differences
among boys. I am horrified by the differences among girls.17
My horror comes not just because of the magnitude of the difference
between Sierra Leone and Italy, but because it is all so unnecessary. This
loss of young lives should not happen. Medical science knows how to make
pregnancy and childbirth completely safe for the mother. One maternal
death in all the reproductive years of 17,100 women is as close as we can
get to completely safe. Conventional explanations suggest that we know
what to do to prevent this tragedy.
Skilled birth attendants present before, during and after labour can make
a dramatic difference to survival. Lack of access to health care, then, is the
beginning of an answer to the differences in risk of maternal deaths. It is
only the beginning because the obvious question is, why is there lack of
access? Do countries not know what is needed? Do international donors not
know what is needed? When I say that conventional explanations are not
wrong, they are just too limited; this is part of what I mean.
If it were simply a ‘medical care’ issue then the US would have the
lowest maternal mortality in the world, wouldn’t it? The US spends more

than any other country on health care. Arguably, it has the best obstetric
care in the world, but it does not do very well. In the US, you would have to
count 1,800 fifteen-year-old girls to get one maternal death in their
childbearing years. One in 1,800 is enormously better than one in twenty-
one in Sierra Leone, but significantly worse than Italy, at one in 17,100. In
fact, sixty-two countries have lower lifetime risks of maternal deaths than
the US. Let that one sink in a bit. No woman should die during pregnancy
and childbirth, yet in one of the richest countries in the world, which spends
the most on medical care, the risk is higher than in sixty-two other
countries.
It is possible that some countries don’t count maternal deaths properly
and there may be some error in the calculations. For this purpose I will
adopt a ‘northern’ bias, cut out the global south, and limit the comparison to
Europe, by which I mean the fifty-three countries that make up the
European Region of the World Health Organization, including all of the
former Soviet Union, Turkey and Israel. Were the US a European country
then it would have only forty-six countries ranking ahead of it in lifetime
risk of maternal death. The US would rank forty-seventh among these
‘European’ countries, and be on a par with Armenia, just ahead of the
republic of Georgia.
Invited to address a meeting of the American Gynecological and
Obstetric Society, I told them this home truth about US maternal risks
equalling Armenia, congratulated them on being ahead of Georgia, and said
that I was willing to accept that the US has the best obstetric care in the
world. I was also willing to guess that if I asked them to jot down on a piece
of paper which US women died of a maternal-related cause, all their notes
would say much the same thing: the socially excluded, the very poor, illegal
immigrants, people with chaotic lives in one form or another. Some of the
good doctors might have mentioned ‘race’. I take race as a proxy for other
forms of social exclusion, but I’ll come back to that.
When people get sick they need access to high-quality medical care.
Medical care saves lives. But it is not the lack of medical care that causes
illness in the first place. Inequalities in health arise from inequalities in
society. Social conditions have a determining impact on access to medical
care, as they do on access to the other aspects of society that lead to good
health.

I don’t have it in for the US: some of my best friends . . . If you are a
young person in the US, though, it is reasonable to ask why your prospects
for a healthy life are no better than in Armenia and worse than in Costa
Rica, Chile or Cuba, quite apart from most high-income countries.
I assumed that you, Andy, are a typical American fifteen-year-old. But
there isn’t, is there, a typical fifteen-year-old. There are rich and poor, urban
and rural, inner-city and suburban, immigrants and descendants of
immigrants, indigenous and others, different ethnic groups, red states and
blue states. Often, inequalities in health within countries are as big as the
differences among countries. We need to get behind the averages, to unpick
them. In other words, we need to keep both types of inequalities in focus:
those between countries, and those within countries – the social gradient.
Before we go on, there is something that may be nagging at you, as you
read this. How can I make such generalisations? You and I are unique.
There has never been in the history of the planet another you or another me.
Even if you have an identical twin, who is the same as you genetically, the
two of you have somewhat different life experiences that mark each of you
out as unique. However, if you thought that your uniqueness meant that we
could not make any generalisations about you, I would advise against going
to the doctor when you get sick. All she could say in that case would be that
she had never seen another person quite like you; research data didn’t
apply; treatment was out of the question. Your doctor doesn’t say that. She
says people with your symptoms and signs have disease of the heart, or
lungs, or toenails. We have good experience of treating people like you; we
will therefore recommend the following. It turns out that the treatment has
more or less the same effect on you as it has, on average, on other unique
individuals with the same medical condition that you have. You may be
unique but you share characteristics in common with others of our species .
. . and other species. Those common characteristics allow us to learn from
experience.
The same reasoning applies to all the social facts in this book. Each
American is unique; so is each Swede, and each Russian. Yet consistently
Russians have higher adult mortality than Americans, who have higher
mortality than Swedes. They did last year; they did the year before; and in
all probability they will again next year. Unique as you are, your shared
experience with your fellow countrymen and women changes your risk of
health and disease, and of life and death; and marks you out as different, on

average, from people in other countries. Similarly, if you are rich and in
professional employment, you share characteristics with others in those
groups that mark you out as different, on average, from people who are
poor and not employed professionally. Health and disease vary with these
characteristics of groups, as they do with characteristics of countries.
MONEY – DOES IT MATTER OR NOT?
In the previous section, when discussing American Andy’s poorer health
prospects than Swedish Johan’s, I said that it was not about rich and poor.
The US is richer than almost all of the forty-nine countries that have lower
chance of death of fifteen-year-old boys. Similarly, I pointed to Russia’s
‘African’ level of mortality despite having much higher national income
than Guinea-Bissau. What I did not say is that the 144 countries with higher
adult mortality than the US are poorer countries.
It is not as contradictory as it sounds. Among poor countries, higher
national income is associated with better health. Among rich countries,
getting richer does very little for health. Other things are more important.
Figure 1.3 illustrates these two phenomena, by plotting the span of
countries’ life expectancy against their national income in dollars. A dollar
in a poor country can buy much more than a dollar in a rich country, so
national incomes are adjusted for purchasing power. This adjustment brings
up the figures for national incomes in poor countries.
If you have little of it, money is crucial to your life and your health. For
poor countries, small increments in income are associated with big
increases in life expectancy. It makes sense. A country with a per capita
national income of less than $1,000 can afford little in the way of food,
shelter, clean water, sanitation, medical and other services – relief of what I
have called destitution. With a small increment in income, more things are
possible.
FIGURE 1.3: RICHER AND HEALTHIER – UP TO A POINT

Even more money, though, does not guarantee good health. Above a
national income of about $10,000 there is very little relation between
national income and life expectancy. When describing the fate of fifteen-
year-old American Andy, I pointed out that he does worse than Swedish
Johan. Here, taking a slightly different measure of health, life expectancy at
birth, we see that Cuba is doing as well as the USA, and Costa Rica and
Chile are doing somewhat better, though they all have lower national
incomes. Russia does remarkably poorly: much lower life expectancy than
would have been expected from their national income.
The conclusion is that money does matter if you are in a poor country
and have little of it, less so if your country is relatively well off. Other
things are important.
NOT JUST INCOME, SOCIETY!
I have three simple ideas that animate this book – only the third of which
needs some explanation. The first, as I said when comparing Andy and
Johan, is that there is no good biological reason for most of the health
inequalities that we see within and between countries. Health and
inequalities in health can change rapidly. Second, we know what to do to

make a difference. Arguing for what can be done is the purpose of this
book. The third relates to the relatively flat part of the curve in Figure 1.3 –
the fact that above a national income of $10,000 there is little relation
between income and life expectancy.
This third proposition is simply that health is related to how we organise
our affairs in society. Currently, we measure a society’s success by an
economic metric – the growth of Gross Domestic Product. There is
recognition that GDP captures only one aspect of what the good society
means.18 A measure that gets closer to people’s lives is happiness or life
satisfaction.19 Health is another. We all value health, probably more than we
value money. The argument for health as a measure of social success goes
further. Many of the other things we value are related to health of
individuals and society: good early child development, education, good
working conditions, a cohesive society – all are linked to better health, as
subsequent chapters will show.
I will make the case that our social arrangements are crucial to the level
of health of our society. The US is doing better than Russia, but not as well
as Sweden, or forty-eight other countries. My case does not rest on whether
I personally would rather live in the US or Sweden, UK or Russia; it rests
on the data. If I say that the US ranks fiftieth, and is therefore doing badly
by its citizens, it is not because I start out liking, or not, the way the US
does things. My case rests on the data on health. I know Russia is doing
badly, not because of prior views that I hold, whether about communism,
post-communism, Putin-ism or some other -ism. I say Russia is doing badly
by its citizens because its health is disastrously poor. I knew that
communism in Russia was a disaster in the post-war years because health
suffered. Post-communism was worse. But we’ll come to that.
So close is the link between the nature of society and health that you can
use it both ways. By which I mean the level of health, and magnitude of the
social gradient in health, tell us about how well the society is doing. And if
you are concerned about improving health, then the conditions of society
that influence health – its social determinants – loom large.
POVERTY: ABSOLUTE OR RELATIVE?

Two of the ways that societies can affect health are the level of poverty and
the magnitude of inequalities. They are linked. Absolute poverty is of clear
importance in explaining the close link between national income and life
expectancy in the steep part of the curve in Figure 1.3, for countries with
national income less than $10,000 per head, adjusting for purchasing power.
Degrees of absolute poverty are also likely to be important in explaining the
gradient in child mortality in India or Uganda, for example. The higher up
the wealth scale, the more likely that people have the basic necessities of
life.
Think, though, about the gradient in health in rich countries, the subway
rides, and Figure 1.1. It is odd to think of people in the middle of the
distribution as being somewhat in poverty, yet they have worse health than
those at the top. We need to look for something other than absolute poverty
to explain their worse health – perhaps relative deprivation, or being the
wrong side of inequality.
What about poverty in Glasgow? Most people visiting Calton would have
no hesitation in calling it poor, and yet it is fantastically wealthy by, for
example, Indian standards. A third of Indians live on $1.25 a day. No one in
Glasgow lives on so little. Average income per person in India, adjusting for
purchasing power, is $3,300. That is way below the poverty line in
Scotland. There are a few rough sleepers in Glasgow, but almost everyone
has shelter, a toilet, clean water and food. Yet life expectancy for men in
Calton was eight years shorter than the Indian average.
A clear implication of this contrast is that the meaning of poverty differs
with the context. While $3,300 a year is not considered poor in India, it
would count as remarkably poor in a high-income country. It is not simply
the money in your pocket that defines poverty, or determines health risks.
In the 1980s Amartya Sen and Peter Townsend, two distinguished social
scientists concerned with poverty, had a vigorous debate as to which was
more important: absolute or relative poverty. It makes for amusing reading
as they aimed respectful, elegant, courtly even, academic blows at each
other. But rereading it now, I am struck by how little difference there seems
to have been between them.20
Which is more important for health, absolute or relative poverty? Surely
the answer is both. The people of Calton are deprived relative to the
standards of the UK, but the absolute amount of money they have matters
too. It is reasonable to suppose that if they had more money their lives

would change, and if the community had more cash, conditions in Calton
would also change.
Amartya Sen resolved the debate by saying that relative inequality with
respect to income translates into absolute inequality in capabilities: your
freedom to be and to do. It is not only how much money you have that
matters for your health, but what you can do with what you have; which, in
turn, will be influenced by where you are.21 If the community provides
clean water, and sanitation, you don’t need your own money to ensure these
solutions. If the community provides subsidised public transport, health
care free at the point of use, and public education, you don’t need your own
money to access these necessities.
Poverty, then, takes different forms depending on the context. There is,
though, something that links poverty in countries at all levels of income and
development, that links Jimmy and Gita. For its 2000–01 World
Development Report, the World Bank interviewed 60,000 people in forty-
seven countries about what relief of poverty meant to them.22 The answers
were: opportunity, empowerment and security. Dignity was frequently
mentioned. Indeed, dignity has strong claims for consideration by those of
us concerned with society and health.23 A similar exercise in Europe
showed that people felt themselves to be poor if they could not do the
things that were reasonable to expect in society: for example, entertaining
children’s friends, having a holiday away from home, buying presents for
people.24 In other words, in Europe the ways of doing without have
changed – no longer lack of clean water and sanitation, but not having the
means to participate in society with dignity.
POVERTY? INEQUALITY? EMPOWERMENT? DON’T WE
KNOW THE CAUSES OF ILL HEALTH?
A massive and truly impressive study, the Global Burden of Disease, looked
at the causes of everything, everywhere.25 I am exaggerating only slightly.
The study really did look at all diseases in every region of the world in 2010
and, heroically, came up with estimates of the major causes of ill-health
globally. The list was, starting at the most important and working down in
order: high blood pressure, smoking, household air pollution, low fruit
intake, alcohol use, high body mass index, high fasting plasma glucose

level, childhood underweight, ambient particulate matter pollution, physical
inactivity, high sodium intake, low nuts and seeds, iron deficiency,
suboptimal breastfeeding, high total cholesterol, low whole grains, low
vegetables, low omega-3, drug use, occupational injury, occupational low
back pain, high processed meat, intimate partner violence, low fibre, lead,
sanitation, vitamin A deficiency, zinc deficiency and unimproved water.
Three things strike me about this list. First, where are the causes of
infectious disease? Sanitation, vitamin A and zinc deficiency and
unimproved water bring up the rear of the list. Childhood underweight,
which makes children more vulnerable to infection, comes in at rank 8,
after high body mass index, i.e. overweight. Today, considering all
countries, high-, middle- and low-income, the major diseases affecting
people are similar – so-called non-communicable diseases: heart disease,
lung disease – note the importance of indoor air pollution, a cause of
chronic lung disease in low-income countries – cancers, diabetes. AIDS,
Ebola, TB and malaria remind us that there is still a long distance to go in
eradicating major infectious disease epidemics. That said, already in
middle-income countries, and increasingly in low-income countries, the
causes of suffering and death are similar to those in high-income countries.
Second, the list contains a mix of physiological risk factors: high blood
pressure, high blood glucose, high total cholesterol; behaviours: smoking,
diet and alcohol consumption; and environmental exposures: air pollution,
lead. There is no causal analysis in the sense that diet can cause high blood
pressure and high plasma cholesterol. Think about two ways to control high
blood pressure: pharmacologically, or through changing diet and
environmental factors. The pharmaceutical industry may not like me for
saying it, but my preference is for seeing how we could deal with the causes
of high blood pressure, high cholesterol and high blood sugar, rather than
simply wait for them to get raised and then treat.
Third, and related to the last point, there is no social analysis.
Overwhelmingly, most of these risk factors are related to people’s social
circumstances. We might call these the ‘causes of the causes’. Diet, indoor
air pollution and high blood pressure are potent causes of disease globally.
We need to ask why, increasingly, these risk factors are linked to social
disadvantage. Remember the discussion of maternal mortality? We may call
lack of access to medical care a cause of a mother dying in childbirth. We
need to look at the causes of lack of access – the causes of the causes.

My argument is that tackling disempowerment is crucial for improving
health and improving health equity. I think of disempowerment in three
ways: material, psychosocial and political. If you have too little money to
feed your children you cannot be empowered. The material conditions for
well-being are vital. The psychosocial dimension can be described as
having control over your life. We will look at evidence that people have
difficulty making the decisions that will improve their health if they do not
have control over their lives. Further, disempowering people in this way,
depriving them of control over their lives, is stressful and leads to greater
risk of mental and physical illness. The political dimension of
empowerment relates to having a voice – for you, your community and
indeed your country.
My approach to empowerment and the causes of the causes has a history.
Over a century ago, Robert Tressell, describing the foul living conditions in
which poor labourers in Britain slept, wrote in The Ragged Trousered
Philanthropists:
The majority of those who profess to be desirous of preventing and curing the disease called
consumption (tuberculosis) must be either hypocrites or fools, for they ridicule the suggestion
that it is necessary first to cure and prevent the poverty that compels badly clothed and half-
starved human beings to sleep in such dens as this.26
Tressell was a novelist and polemicist and not a scientist, but he is still bang
up to date. Should we, as much of modern medicine tries to do, at great
expense, look for technical solutions and educate people and patients about
healthy behaviour? Or should we, in the tradition of Tressell, seek to create
the conditions for people to lead fulfilling lives, free from poverty and
drudgery? In my view we should do both.
For an illustration of the potent health effects of disempowerment we can
return to Glasgow. Sir Harry Burns is a remarkable man. He was a
practising surgeon in Glasgow. He concluded that treating people surgically
was too late in the course of their illness. His own clinical observations led
him to the clear insight that the illnesses he was seeing resulted from
people’s social conditions. He wanted, then, to treat those conditions to
prevent illness rather than wait for the illness to occur. We met in the early
1990s when he made the shift from surgery to public health. His clinical
insights led him to the view that the way social conditions got into the body
was through the mind. As I was doing research on how psychosocial factors

affected heart disease we had a great deal to talk about. When Harry Burns
was appointed Chief Medical Officer of Scotland he brought these insights
with him – a force for good.
Harry Burns and his colleagues from Glasgow compared mortality rates
in Glasgow with rates in Manchester and Liverpool in England.27 All three
cities are post-industrial, in the sense of having lost their heavy industry,
and have similar levels of poverty and of income inequality. The causes of
death with the biggest relative excess in Glasgow were: drug-related
poisonings, deaths associated with alcohol, suicide and ‘external’ causes,
i.e. accidents and violence apart from suicide.
The causes that show the biggest relative excess in Glasgow are all
psychosocial. Harry Burns says that to understand Scottish, and in
particular Glaswegian, health disadvantage, you have to understand that
people feel they have little control over their lives – they are disempowered.
This will be most evident for the poorest people in Glasgow, but it will not
be an all-or-nothing phenomenon. It gives us a way to link poverty and the
gradient. The lower they are in the socio-economic hierarchy the less
control people have over their lives.
All over the world, babies that would have died had they been born a
generation ago are now surviving. Middle-aged people can expect to live
longer. Older people are healthier. In terms of health, it is the best of times.
Unfortunately, there are dramatic inequalities in health, life chances and
length of life. There are steep social gradients in health within countries and
stark inequalities in health between countries. It is the worst of times. The
knowledge we have of the causes of the global burden of disease, and of
advances in medical care, qualifies us for an age of wisdom. Age of
foolishness is putting it a bit strongly, but it is ignoring the social
determinants, the causes of the causes, that accounts for our lack of success
in reducing health inequalities within countries and, in some signal cases,
between countries.
Money is important for health if you have little of it, but it is not only
absolute income that matters. The amount of money you have relative to
others influences your degree of empowerment, your freedom to be and to
do. Empowerment, or freedoms, in their turn are related to better health. As
we shall see, there are ways of contributing to empowerment, or freedoms,
other than money.

I want to finish this chapter on what sounds like pedantry, but is actually
fundamental. I have used two terms, health inequalities and health
inequities. From now on, I am going to use the term health inequities to
refer to those systematic inequalities in health between social groups that
are judged to be avoidable by reasonable means. Such an approach does not
cut off debate. There is ample disagreement as to what are ‘reasonable
means’. But it focuses the argument. Why is this fundamental? Because if
people are suffering from ill-health in ways that could be remedied but are
not, that is quite simply unjust.

2
Whose Responsibility?
Dost thou think, because thou art virtuous, there shall be no more cakes and ale?
William Shakespeare, Twelfth Night (Act II, Scene iii)
Here are ten top tips for health. This list was published in 1999 by
England’s Chief Medical Officer, but it differs little from the kind of advice
you would receive from any public health source in a high-income country.
1. Don’t smoke. If you can, stop. If you can’t, cut down.
2. Follow a balanced diet with plenty of fruit and vegetables.
3. Keep physically active.
4. Manage stress by, for example, talking things through and making time to relax.
5. If you drink alcohol, do so in moderation.
6. Cover up in the sun, and protect children from sunburn.
7. Practise safer sex.
8. Take up cancer-screening opportunities.
9. Be safe on the roads: follow the Highway Code.
10. Learn the First Aid ABC: airways, breathing, circulation.
Two questions: do you find the list helpful? Is it likely to change your
behaviour, or that of others?
With that in mind, here is an alternative ten top tips for health compiled
by David Gordon and colleagues at University of Bristol.
1. Don’t be poor. If you can, stop. If you can’t, try not to be poor for long.
2. Don’t live in a deprived area. If you do, move.
3. Don’t be disabled or have a disabled child.
4. Don’t work in a stressful, low-paid manual job.
5. Don’t live in damp, low-quality housing or be homeless.
6. Be able to afford to pay for social activities and annual holidays.
7. Don’t be a lone parent.
8. Claim all benefits to which you are entitled.
9. Be able to afford to own a car.
10. Use education to improve your socio-economic position.

Hard to argue with any of the first, public health, list; it is all very worthy,
well-meaning, based on sound science . . . and unlikely to make much
difference. ‘I was about to drink and drive and have unsafe sex and then,
just in time, I remembered the Chief Medical Officer’s advice.’ ‘I was about
to feed the children takeaway chips, but remembered the one about fruit and
vegetables, so gave them a salad and fresh fruit instead.’ ‘I’m worried about
losing my job, which probably means losing my flat, pretty stressful, but I
made time to relax, so it’s all right now.’
The problem with the public health list is not that it’s wrong – it is not –
but that simply conveying advice is unlikely to lead to change in those who
have most to gain. Here are three possible reactions to that list:
‘I know all that. I take the trouble to get informed and look after myself
and am already doing what the advice says.’
‘Smoking and too much alcohol are bad for me? Fancy that. Who knew?
That makes everything different.’
‘I knew that, but so what? It won’t change what I do. I have other things
to worry about.’
In relation to these possibilities, there is good evidence that most people
in countries such as the US and UK do know that smoking harms health,1
and, in England, a majority of people who are obese claim to be on a diet.2
The reasons that people continue to smoke and that obesity continues to
spread do not stem from ignorance. In other words, advice is useful, but it is
not how much people know that determines whether they behave as the
advice suggests.
And the second, David Gordon’s, list of tips? It too is based on sound
science. There is good evidence to support the proposition that each of the
ten items in the list is related to health, although that is less widely known.
The issue that the Gordon list highlights so effectively is that even if people
did know that these things were bad for health, there is very little that they
could do about them.
The question that I wish to explore in this chapter is: whose
responsibility is health? When we published the report of the Commission
on Social Determinants of Health, Closing the Gap in a Generation, one
senior politician asked: where is personal responsibility in all this? A
leading economist and public policy expert based his critique on the fact
that Closing the Gap mentioned ‘social’ many more times than it did
‘individual’. It was the report on social determinants, why was he

surprised? My response was, and is, that personal responsibility should be
right at the heart of what we are seeking to achieve. But people’s ability to
take personal responsibility is shaped by their circumstances. People cannot
take responsibility if they cannot control what happens to them.
The second list of ten top tips, quite obviously, contains advice that is
outside the control of the individual to follow, although some commentators
think that unemployment is a lifestyle choice and suspect that poverty
results from laziness. Less readily appreciated is that the first top ten list is
also, to some extent, outside individuals’ control. At the very least,
individual behavioural choices are influenced by where people find
themselves. Smoking, diet and alcohol are causes of disease and contribute
to the social gradient in ill-health. We may think of the determinants of
these causes as the ‘causes of the causes’.3
Trying to influence behaviour by addressing the causes of the causes
evokes strong reactions. On one side of the argument, public health activists
demonstrate that big business has too much influence on health policy – in
relation to tobacco, alcohol and food, for example. The other side alleges
that any government interference is an intolerable erosion of liberty, that
letting business have a say is not lobbying against government policy, it is
simply democracy. Citizens and public health people can have a say, too.
The fact that a multi-billion-dollar corporation may have a louder
megaphone than individual citizens is beside the point, they claim.
An exchange between two commentators on alcohol policy is revealing
and typical. A journalist, Jonathan Gornall, wrote a piece in the British
Medical Journal saying that big business had been instrumental in changing
government policy on alcohol and health. Gornall pointed out that it had
been the stated policy of the Conservative-led coalition government in
Britain to introduce a minimum unit price for alcohol. After all, the data
show what economists would predict: raise the price of alcohol and
consumption declines. At the time the policy was announced, I publicly
praised the Conservative Prime Minister, David Cameron, for taking this
step that would benefit the public health. The government then reversed
itself. Jonathan Gornall claimed that it was pressure on government from
the alcohol industry, the dreaded big business, that led to the policy
reversal.4
A rejoinder from the Institute of Economic Affairs (IEA), a free-market
think tank, was strongly critical of Gornall and others who pressed for

government action on public health. The author, Christopher Snowdon,
found it hard to doubt that raising the price would reduce consumption but
said that the policy was misguided and based on sloppy science, because a
minimum price for alcohol might have other bad effects – people might pay
more for alcohol and stop feeding their children.5 He accused Gornall of
‘personal attacks and grubby insinuations’.
Gornall’s riposte was robust. His scientific objectivity was being
criticised by an Institute whose stated policy was summed up in these words
from its director-general: ‘Through detailed research, we will be seeking to
show that free market mechanisms produce better outcomes than heavy-
handed and restrictive state regulation.’6 If you already know that the
outcome of your research will favour free markets before you do it, claims
of objectivity are ludicrous. Further, the claim that the IEA is an
independent voice is undermined by its refusal to disclose its funding
sources. When the same Institute opposed steps for tobacco control,
including plain packaging, detailed research in tobacco industry documents
revealed that the industry had given funding to the Institute of Economic
Affairs.
I could report scores of such exchanges. They make clear that discussions
of how to address the ‘causes of the causes’ of behaviours relevant to health
involve both political views of the role of the state and vested interests. The
overlap makes for a distorted debate.
The fact is that the conditions to which we are exposed influence
behaviour. Most of us cherish the notion of free choice, but our choices are
constrained by the conditions in which we are born, grow, live, work and
age. How far we accept constraints on behaviour varies.
With smoking, for example, most people nowadays do not find steps
society may take to limit tobacco consumption particularly troubling. Most
people accept restriction of smoking in public places, bans on advertising
and warnings on labels. As a result of these measures, smoking rates have
declined in many countries, with consequent benefits to health. Even with
smoking, though, a proven toxic practice that kills up to a half of regular
smokers, there is a hardy bunch that claims that steps towards tobacco
control are an erosion of their freedom.7 One would be more inclined to
listen to the viewpoint of those not funded by the tobacco industry.
For smoking, the healthiest amount is zero. Diet is different. We all eat.
More than half the world’s population live in cities and do not grow their

own food. The food industry plays a crucial role, as do governments and
others, in getting food to people. If you are critical of markets, as I am when
it comes to health care and education, spend a moment imagining how a
Soviet minister of food in Moscow might have ensured that 10 million
people and their food were matched up every day, without the help of
markets. The market works amazingly to match people to food. That said,
there are market failures. Some people have too little food to eat, and some
too much. The type of food we eat influences obesity, heart disease and
cancer. As a result there have been ‘food wars’ – the Economist labelled one
in which I was an unwitting combatant as the ‘Battle of the Bulge’ – over
healthy eating. These food wars illustrate the issue of whose responsibility
is healthy eating. In addition, the food wars are highly relevant to health
inequities because diet can influence and determine levels of non-
communicable disease, which in turn contribute to health inequities.
FOOD AND FASCISM
It is diverting to find yourself described in the Daily Mail, a national
newspaper, as a health Nazi. When it happened to me, in 2007, I
commented to a journalist friend that I thought Joseph Mengele was a
health Nazi. Why me? My friend told me not to take it so seriously; the
writer did not mean I did ghastly experiments on humans in concentration
camps. Just that I was a health fascist. That was not terribly reassuring,
especially as the newspaper in question described my pronouncements as
‘grotesque and increasingly irresponsible’. Another national newspaper, the
Telegraph, fulminated that I was leading ‘an unholy alliance of puritans,
health fascists and nanny-state control freaks’. For good measure, another
national daily chimed in with ‘Fat lies of the food fascists’. One or two of
the tabloid headlines were clever. The Sun had: ‘Save our bacon’ and
‘Careless pork costs lives’.
What might have led to so much frothing at the mouth? Who were my
gang of fascistic liars that a perceptive press uncovered?
Our camouflage was good. I had chaired a panel convened by the World
Cancer Research Fund, to review the evidence on Diet, Nutrition, Physical
Activity and Cancer.8 The panel consisted of more than twenty
internationally acclaimed scientists. Ingenious fascists, covering our tracks

by having day jobs as professors from the UK, US, Japan, China, India,
Chile, Mexico, Africa, New Zealand and Australia. The strength of our
report was that the recommendations were based not on one study but on
7,000 scientific papers. More than 200 scientists were involved in the five-
year process of assembling the 400-page report, and UNICEF and the
World Health Organization were among the observers – hardly Mein
Kampf.
Our conclusion, based on all the quality scientific evidence, was that
people who were overweight had higher risk of cancer, so it was important
to be as lean as possible within the normal body-weight range. We reported
that processed meat increased risk of cancer and should be avoided if
people wished to reduce their risk; and red meat consumption above 500 g a
week increased risk of cancer.
As a way of framing our conclusions we made recommendations. It was
these scientific conclusions, reached after a painstaking process, that were
labelled as ‘fat lies of the food fascists’.
I had been here before a dozen years previously: that time about dietary
prevention of heart disease.9 Then the sober reflections of my committee of
scientists and professors were described as ‘the food Leninists’ latest
onslaught . . . The nanny state is going to tell you what to eat for breakfast,
lunch and dinner.’10 Leninist or Nazi? The point is that anyone who seeks to
influence individual behaviour in the interest of the health of the public is a
totalitarian.
WHAT IS THE ARGUMENT – SCIENCE OR SOMETHING
ELSE?
What is going on? How can sober scientific conclusions generate such
hostility? Drawing conclusions on the basis of careful review and debate of
7,000 scientific papers was lying? Spending five years culminating in
careful formulation of meticulously worded recommendations that were
subject to seemingly endless debate was irresponsible? Reporting that
people could, if they followed our advice, reduce their risk of cancer was
fascist?
The clue is in the fact that it was only the populist press with a libertarian
streak who thought we were lying fascists. Acceptance of our scientific

conclusions – that there were steps that could be taken that might reduce the
risk of cancer – should lead to a serious debate: whose responsibility is it to
prevent disease and promote health? Somewhere beneath the hyperbole
and, indeed, lies of the journalists was an argument that ran along the lines
of: if people want to make themselves sick by their freely chosen
behaviours, that is nobody’s business but their own.
There is an intellectual smokescreen working here. If he can claim that
our scientific conclusions are incorrect the commentator does not have to
face the difficult question of what to do about them. It’s easier to label us
liars than to grapple with the matter of whose responsibility it is to prevent
disease, or where the balance of responsibilities should lie between the
individual and the community. Or again, and relevant to my core concern,
to consider whether social disadvantage renders some people less able to
make healthy choices.
It is reasonable to disagree about evidence. Scientists disagree frequently,
and vigorously, because the evidence is never as firm as we would like. It
does not mean that because there is disagreement no conclusions can be
drawn. Some ‘scientists’ think the earth is flat, and some don’t, so can we
draw no conclusions? Some think creation science is a more valid theory
than evolution, so should we present both theories equally? Of course not.
We must distinguish between situations where most scientists, with only a
few exceptions, conclude that evidence points a certain way – man-made
climate change, for example – and those where it is genuinely more
uncertain.
When I first started doing research on determinants of the health of the
public I noted a division even among scientists in their view of the evidence
on diet and disease. Rather than views of the evidence determining
scientists’ willingness to take action to improve the public health, the
reverse was true: willingness to take public health action was determining
views of the evidence. Scientists who were inclined to want to take public
health action found the evidence more convincing than those who were
philosophically averse to action.
Let us assume, as the evidence shows overwhelmingly, that increased
body weight does increase risk of cancer. What should we do? The answer
from the political right is that ‘we’ should do nothing. It is up to the fully
informed individual actor, in possession of all the information, to make his

individual choice. If he chooses to be fat it should be of no concern to
anyone else.
RATIONAL OBESITY?
Gary Becker, Nobel Prize-winning economist from the University of
Chicago (sadly, he died in 2014), applied rational choice theory to everyday
life. We weigh up the costs and benefits of different actions and make
rational choices to maximise our utility, roughly our satisfaction. In general,
people value the present more than the future, so future consequences of our
actions will weigh less heavily than present benefits, argue rational choice
theorists. Becker and his University of Chicago colleague Kevin Murphy
write on rational addiction.11 In their view, addiction, not just to alcohol,
tobacco and cocaine, but to television, work and food, can be explained by
rational choice theory. The more people discount the future the more can
rational choice account for addiction. Simplifying (following Lord Byron):
wine and women, mirth and laughter, now, count for more than sermons and
soda water the day after. Eat, drink and be merry because the future, well, is
in the future. They argue that it is precisely because some people do value
the future that we are not all addicts.
The theory is brilliant and creative and has influenced large numbers of
economists, but I wonder if a rational totting up of benefits and harms,
discounted at the market rate of interest or some other suitable rate, is what
really determines our behaviour. It assumes perfect information which will
of course be lacking much of the time.
I have asked rational choice theorists why someone overweight and
worried about it might eat a huge slice of chocolate gateau. The
conversation goes like this.
RATIONAL CHOICE THEORIST: It is because the utility of doing so is greater than the utility
of abstaining.
ME: How do you know that?
RCT: Well, they wouldn’t have done it otherwise.
ME: Even if they enjoyed it for five minutes and spent the rest of the waking day in an agony of
self-loathing? Is that maximising utility?
RCT: Steep discounting; they value the present ecstasy of chocolate gateau more highly than
avoiding the future agony of self-loathing.
ME: Would you ever conclude that someone is not rationally maximising utility?

RCT: No, why else would they do the behaviour?
Having read Dostoevsky, let alone Freud, as a medical student, I thought
behaviour was a little more complicated than that. But if you never have to
measure utility, simply infer it from the behaviour, it is always perfectly
consistent: whatever people do maximises utility, by assumption. Danny
Kahneman, psychologist and winner of the Nobel Prize in Economic
Sciences, showed that all kinds of things influence our choices, other than
simple rational calculation of utility – what we remember, how the evidence
is presented, and a whole slew of biases to which we are all subject.12
At a meeting, an economist lecturing on rational choice theory as applied
to obesity was asked by someone, rather unkindly I thought, why he was
obese. His response: because I choose to be. I have to say: I doubt it. It is
most unlikely that he gets up in the morning and says: I think I shall spend
the day making myself fatter. I presume his answer was shorthand for: the
utility I get from my present pattern of eating outweighs the disutility in the
future from the effect of obesity on my health. I value health but that’s in
the future and, right now, I value a quarter-pounder, fries and a large Coke
more.
Even if it were the case that, in his model, obese people chose to be so
rationally, how then does he account for the prevalence of obesity rising in
the USA and elsewhere? And why are more Americans obese than
Frenchmen? Telling me that it is because more and more Americans choose
to be obese has no explanatory power at all. It simply shifts the question:
why are more Americans choosing to be obese?
Rational choice theory is probably implicit in the oft-stated notion that
people are responsible for their own health. Growing obesity is a result of
people increasingly valuing present consumption more highly than future
disbenefits; or, in more everyday language, growing more irresponsible. But
if increasing fecklessness accounts for increasing obesity, why have rates of
smoking declined dramatically? Why are we responsible when it comes to
smoking and feckless when it comes to eating? Even were it true that
people value present consumption more highly than the future effects on
health, why has the balance changed? Or, if the balance hasn’t changed, and
people always valued the present more highly than the future, why is that
balance more likely to cause obesity now than it did in the past?

With the rise in obesity in mind let’s return to the question of whose
responsibility is health. A dispassionate view of the evidence would surely
acknowledge that the rise in obesity was the result of more than individual
choice – it was due to changed circumstances. Why then assume that any
attempt to change circumstances is fascism and that it must be left to the
individual actor to change things for himself? Yet, if social actions caused
the problem, surely it must be legitimate to discuss what social actions we
are willing to take to solve it.
INEQUITIES IN HEALTH AND ‘LIFESTYLE’ – THE CAUSES
OF THE CAUSES
The smaller the dress size the larger the apartment. This received wisdom
in New York sums it up: there is a social gradient in obesity. Particularly
among women in middle-income and high-income countries, the lower the
status, the greater the obesity. But why?
My concern is with inequities in health within and between countries,
and the role of social determinants. ‘Social determinants’ is a language
unfamiliar to many epidemiologists and others who are more concerned
with individual risks. Relative deprivation, social relationships, conditions
enabling a life of dignity, empowerment and the items in David Gordon’s
top tips are not the bread and butter, or even the five a day, of traditional
health concerns. Where, I am challenged, are smoking, alcohol, obesity?
Social determinants do not exclude these health behaviours. When
considering inequities in non-communicable disease, smoking, alcohol and
obesity are right at the centre. One way the social environment is causally
linked to health inequity is through these behaviours – hence this chapter.
Another way is through stress pathways which will feature in later chapters.
I argue that central to improving people’s health and well-being is
empowerment of individuals and communities. At first blush, the language
of personal responsibility would seem to be consistent with empowerment,
with people taking control over their lives and freely making health choices.
Certainly individuals must make the choice to smoke or not, how to drink
and to eat. But when we see regular social patterns of behaviours it suggests
that there are broader, social, causes.

I can illustrate with data on the development of these unhealthy
behaviours. With colleagues at UCL and the National Centre for Social
Research, I was at one time involved with the Scottish Health Survey. I was
catching the flight from London to Edinburgh to present the findings and
reviewing my PowerPoint presentation on the plane. The data showed that
as girls went through the age of puberty, smoking rates rose dramatically. It
was almost as if smoking, along with the bodily changes, was another sign
of puberty. Participation in exercise went down as girls passed through the
puberty years, and girls also started to experiment with alcohol. A woman
flight attendant looking over my shoulder said: I did all that, and more
besides. I showed her the social gradient in these behaviours, which starts
early: the lower the status the more unhealthy the behaviour patterns. ‘Yup.
That was me, too,’ she said, ‘modest background like my friends.’
All young people experiment. But we see social gradients in obesity, and
smoking already appearing in childhood and adolescence. It is too narrow a
view to see this as simply each single one of these young people making an
individual choice and ignoring the social pressures on them to behave in
certain ways.
I have been asked by a concerned public health doctor: unemployed
young people are hanging around in downtown areas, smoking, drinking
too much, doing drugs and getting into trouble. What would I suggest? My
response, not helpful, is that I would not start from here. I would start with
early child development and education. Empower young people, help them
develop the attributes that will give them control over their lives and a stake
in the future, and they will have more interesting things to do than hang
around street corners smoking and drinking too much.
Knowledge is but one step to empowerment. As described above, in
Britain the whole population understands that smoking is bad for health –
yet there is a social gradient in smoking. Poverty and inequality are deeply
disempowering. People with little control over their lives do not feel able to
make healthy choices.
Which may be part of the reason that health advice, if effective at all, can
act to increase inequalities in unhealthy behaviours. So it was with
smoking. A habit that did not discriminate among socio-economic positions
has become increasingly distributed along the social gradient. Now in
Britain only 9 per cent of adults in higher professional households smoke,

compared with 31 per cent in manual households.13 Smoking is a cause of
illness and death. We must address the causes of the causes.
OBESITY AND OVERWEIGHT – GENES OR EDUCATION?
Obesity and overweight illustrate well the interaction of individual and
social determinants. Individuals make choices about what to eat and how
much, what exercise to take and how much, but those choices are
influenced by the environment in which they find themselves. Part of the
individual propensity to obesity will be genetic. Studies of twins provide
one way of sorting through the contribution of genes and environment to
any condition. Identical twins are identical genetically, but they also share
environments. Fraternal twins share half their genes, on average, but also
share environments. Twin studies suggest that obesity is 50–90 per cent
heritable – a big genetic component.14 But note: twin studies are, in general,
performed in a restricted range of environments. The assumption that
fraternal twins share environments to the same extent as identical twins
could also be questioned. But that is not my main point here. It is: how do
we reconcile the results of twin studies with results from other types of
studies?
I have been interested in the health of migrants to the UK from the Indian
subcontinent. A study in West London of men of South Asian background
showed a mean body mass index (BMI) of 28. BMI is a widely used
measure of healthy weight and adjusts weight for height (squared). Given
that the desirable range of BMI is 20–25, and that anything over 25 is
defined as overweight, and over 30 as obese, an average of 28 means a
great deal of overweight, not to say obesity. A study in rural Punjab, the
area of India from which these men originated, showed a mean BMI of 18.
The average was underweight. Assume an average height of 1.72 m (5 feet
8 inches) in both places. A difference in BMI of 10 corresponds to a
difference in average weight of 29 kg (64 pounds). That is enormous.
Unless the Punjabi men with a genetic predisposition to put on weight were
more likely to become immigrants, which seems unlikely, the men in the
Punjab and the men in London of Punjabi origin are likely to be similar
genetically. Which means that, in this case, overweight is chiefly
environmental.

A standoff. Twin studies say it is predominantly genetic. Migrant studies
say it is predominantly environmental. The environmentalists can criticise
the twin studies as understating the environmental component, as I have
done; the geneticists can criticise the migrant studies as not controlling the
genetic component adequately, and they do. The point should be that if
there is a restricted range of environmental exposure, all the variation will
be genetic. If there is the environmental equivalent of a tsunami, individual
differences in susceptibility, genetically determined, will make less
difference – the environment predominates. To explain emaciation in India
and overweight in London we have to appeal to ‘environmental’
explanations. To explain the differences between identical and fraternal
twins exposed to very similar environments, we appeal to differences in
genetic susceptibility.
In Figure 2.1 I have copied three maps from the US Centers for Disease
Control and Prevention (CDC) on obesity levels by state using the years
1985, 1997 and 2010 to show the progression. The maps show each US
state shaded according to the prevalence of obesity. As the years roll on, the
colours get deeper and deeper, as the rate of obesity rises. When I present
these graphs, the reaction of the audience is similar to mine when I first saw
them. They are jaw-droppingly shocking. As the colours go from pale blue
to deep red, the audience gasps in unison. It is amazing how rapidly the
genome can change in the USA! I am being ironic. Whatever genetic
contributions to obesity there may be, these will be stable over two or three
decades. They most certainly don’t run riot within a generation. Increases in
obesity such as these have to be ‘nurture’, not ‘nature’.
Not just in the US, though. The waistline of the planet is expanding. In
Egypt and Mexico 70 per cent of women are overweight. This has been
labelled coca-colonisation. Rational choice, perhaps, but growth in
processed foods and decline in opportunities for physical activity are more
potent explanations.
For some decades in high-income countries, we have seen that, in women
particularly, the lower the education the greater the prevalence of
overweight and obesity – a social gradient.
FIGURE 2.1: GOING, GOING, GONE!

Worryingly, obesity levels in children have been rising. With children the
discussion about personal responsibility is more complicated. Even parents
who are ideologically opposed to the nanny state will have no compunction
in saying to children: don’t eat that chocolate bar now, it will spoil your
dinner; if you don’t eat your broccoli, no dessert for you. We are probably
biologically programmed to like sweet things. It is only by exerting will that
we do not subsist on a diet of sugary drinks and ice cream. Rising obesity in
children, then, reflects the diets to which they are exposed, not the
likelihood that children have changed their economic calculus and started
valuing the pleasures of present consumption more highly than future
health. In England, now, the rise in childhood obesity has levelled off in
children from families of intermediate and higher social position, but the

rise continues in children from less advantaged families.15 In the future, the
social gradient in obesity may be steeper than it is now.
By contrast, in low-income countries women with more education are
more likely to be overweight than women with less education. This may
reflect two linked phenomena: women of low education in low-income
countries are simply too close to the absolute poverty line to have sufficient
calorie intake to get fat. The obverse is that getting fat may give a public
sign that you have risen above the destitution margin.
As countries get richer, the social gradient shifts towards the familiar
pattern in high-income countries: high education, less overweight. Amina
Aitsi-Selmi, working with me, examined this trend in Egypt and other
countries. She found that richer women were more likely to be overweight –
a worrying finding. Worrying, because I do not want to be the Jeremiah
who says that rising above absolute poverty will bring punishment in the
form of obesity and its complications such as diabetes. Amina found
further, however, that the link between wealth and obesity was not seen in
women with more education. Now I display my own prejudices: I like this
finding. Women with more education are not punished with obesity for
rising out of poverty.16
The social distribution of obesity and overweight within and between
countries should give pause to those who think of health only in terms of
personal responsibility. Why should it be that personal responsibility should
follow the social gradient? Is personal responsibility an exclusive preserve
of the better off? The idea is absurd. Rather, as I would put it, create the
conditions for people to have control over their lives – spread the
advantages of education more broadly, for example – and women and men
will have the tools, and concern, to do something about their own body
weight.
ALCOHOL – JUST PERSONAL RESPONSIBILITY?
Alcohol is an obvious example of a health behaviour influenced by social
conditions. Male mortality rates rose dramatically in Russia after the
collapse of the Soviet Union. It is estimated that there were 4 million excess
deaths in the first decade after 1990. It is clear that heavy alcohol
consumption played a role in this increased mortality. The scale of its

contribution is debated, but binge drinking was deeply implicated in the
frequency of violent deaths and possibly in sudden deaths. Alcohol is a
cause, but we need to ask why more Russian men than before were killing
themselves with drink. Can drinking fatal amounts of alcohol be described
as a rational choice to maximise utility? This would only be helpful as an
approach if it helped us understand the changes and what to do about them.
Of course, I am making the assumption that 4 million extra deaths should
be a concern. That we should not stand by and say that if individuals set
their minds on behaving as they did, they should reap what they sow: it’s
their fault for behaving so irresponsibly. Rather we should say that changes
in circumstances accounted for changes in behaviour on a mass scale.
These changes include sharp declines in social and economic conditions.
Following the collapse of the Soviet Union there was a dramatic fall in
national income (GDP), which translated into a 60 per cent drop in real
incomes for average families. Faced with poverty, with difficulties finding
work, with a steep rise in inequality, Russian men turned to drink, including
toxic alcohol substitutes, with dire consequences.
In Britain the patterns of alcohol consumption, and harm endured, are
different. Take the question of who drinks more on average in Britain: high
status or low. Contrary to popular opinion, survey after survey shows that
average alcohol consumption is higher in people of higher socio-economic
position, and especially women. Women with more education and higher-
status jobs drink more on average than those with less education. Similarly,
in the US, the higher the education the more likely are people to be
drinkers.17 By contrast the pattern of alcohol-related harm shows a clear
social gradient the other way: more alcohol-associated hospital admissions,
and alcohol-associated deaths, the lower one stands in the social hierarchy.
The mismatch between average drinking and harm is striking. It may arise
because the pattern of drinking differs. If high-status people have half a
bottle of burgundy with dinner each night, they may have a higher weekly
consumption than someone who gets blind drunk on a Friday night. The
latter may do more harm. Other factors may also contribute to the increased
risk associated with being low-status: poor nutrition, risky behaviour and
smoking are all likely contributors to risk of harm.
In the case both of European East–West differences in alcohol-associated
harm and of the social distribution in Britain, we must not only understand
the causal connection between patterns of drinking and ill-health, but the

causes of the causes: what determines the pattern. Broadly speaking we
understand three types of causes affecting population patterns of alcohol
consumption: price, availability and cultural influences. I illustrate one of
these causes of population fluctuation in alcohol – price – in Figure 2.2.
FIGURE 2.2: THE THEORY WORKS: THE CHEAPER THE DRINK THE MORE IS DRUNK
Alcohol became progressively cheaper between 1960 and 2005. As the
price dropped, so consumption rose. One of my economist colleagues saw
this graph and said: ‘I teach this stuff – how price changes demand – and I
have never seen such a clear real-life demonstration.’ If as a society, we
think lower alcohol consumption might be beneficial, we should raise the
price. As I discussed earlier in the chapter, this offends some free-
marketeers.
Note that, as well as price, availability and culture influencing population
trends in alcohol consumption, there are individual determinants, which
may include genetic predisposition, personal history, personality and
subculture. Individual-level determinants may need counselling and
treatment. Population determinants require social action. It doesn’t help
simply to say that it is up to the individual.
WHOSE RESPONSIBILITY?

As I was cycling home after a dinner at the Royal College of Physicians,
still wearing my dinner jacket and bow tie, my bicycle swerved and went
over, and left me lying in agony and unable to move off the road. The
ambulance came promptly. The ambulance man took one look at my fancy
dress and said: ‘’E’s ’ad a few!’ I’d had one glass of wine between 7 and 11
p.m., I protested, but wondered what that had to do with anything. Was he
somehow not going to look after me if he thought I had been drinking,
because he would have held me responsible for my own downfall –
literally?
As it was I received excellent care, including a titanium pin to hold the
ends of my fractured femur in place – again, thank you NHS. But I was still
mulling over the ‘’E’s ’ad a few’ when a Conservative member of
Parliament said that, in his view, people who suffered from lifestyle
diseases should pay for the cost of their treatment. I wonder if, in this
parliamentarian’s view, had I had three glasses of wine, not one, I should
have been liable for the cost of treatment of my fractured femur. Was the
politician suggesting that any down-and-out who fell over in a stupor and
banged his head should be left lying in the gutter where he belonged,
because he couldn’t afford to pay? Was that the kind of society he
envisaged?
I’m being melodramatic. The MP might have been referring to diabetes
linked to obesity. As I described, obesity is more common the lower in the
social hierarchy you are. As a result, diabetes prevalence also shows a
social gradient – higher in lower-status groups. The proposal, then, is that
poor people should be held liable for the cost of their diabetes treatment.
There may be three reasons why this proposal has been made:
• Disincentive. Forcing people to pay for the cost of treatment would encourage them to adopt
healthier lifestyles, not get obese, and thereby avoid diabetes.
• Punishment. If people behave badly they should incur a cost as a penalty for their bad behaviour.
• Cost saving. Lower the costs to the health service by offloading the cost onto irresponsible people.
The evidence to support the first argument, disincentive, is completely
lacking. People become overweight and obese over a lifetime. The idea that
a slice of chocolate gateau would be forgone at age twenty-five in order to
avoid the burden of having to pay for diabetes care at sixty-five is
completely fanciful. If there were evidence of such a deterrent effect, we

could then have a debate as to whether we agreed with the principle of a
sick individual having to pay – I do not – but there is no such evidence.
I speculate that most of us would deem the second view, punishment, as
unworthy. The objection is a moral one. The whole principle of a universal
care system, free at the point of use, is that it treats all comers according to
need, not according to some third party’s idea of moral virtue. Not only
should we treat the drug addict who has got HIV from using unclean
needles, there is a good case to be made for medicalising drug addiction
precisely to reduce harm. In other words, to go out of our way to use
society’s resources to improve people’s lives, even those labelled by some
moralists as unworthy.
Given that poor people are more likely to suffer ‘lifestyle’ diseases than
rich, but the rich pay more tax than the poor, the third argument, reducing
costs in the health system, would have the effect of transferring money from
poorer people to richer. That form of anti-equity redistribution, too, has no
place in a civilised society.
This discussion of whether we should hold people responsible for their
own misfortune leads in two directions. First is the moral case for taking
action on social determinants of health and health inequity, which will be
the substance of the next chapter. Second, I argue that empowerment –
having freedom, in Amartya Sen’s terms, to lead a life you value – is crucial
to good health. The question then is how can society achieve conditions that
will enable people to take control of their own lives, including fostering
healthy behaviours? Or, to put it differently, how can we take action against
David Gordon’s top ten list, the social conditions one, with which I began
this chapter? The rest of the book will address that question.
DON’T PEOPLE HAVE POOR HEALTH BECAUSE THEY
DON’T HAVE HEALTH CARE?
You might be thinking: if he is concerned with health, surely he should be
discussing health care. Give everyone access and health inequalities would
go away.
Here’s a choice. What would you prefer: not to suffer a heart attack, or to
have access to high-quality treatment when you had one? For heart attack I
could substitute stroke, cancer, diabetes, mental illness. As with most of my

questions, the appropriate answer is: probably both. You’d like to avoid a
heart attack, but if the calamity struck you would want access to best-
quality health care.
Access to high-quality health care for everyone would be a good thing,
but health inequalities would not go away. Health inequalities arise from the
conditions that make people ill; health care is what is needed to treat people
when they get sick. Lack of health care is no more a cause of ill-health than
aspirin deficiency is the cause of headache. We should not add the insult of
lack of access to health care to the injury of getting sick in the first place.
It is common to equate health and health care. Ask the average person
her views on health and she might talk about how wonderful the nurses
were when her grandmother was in hospital, or the difficulties of seeing a
doctor on weekends. You are unlikely to get the Chief Medical Officer’s top
ten list, and almost certainly not David Gordon’s top ten. I hear people talk
about investing in health when they mean investing in health care. Policy
wonks discuss how much a country spends on health, when they mean
health care. I would argue that most of what a country spends affects health:
transport, education, social protection, environment, foreign affairs,
overseas development – sometimes positively and sometimes adversely.
That is in addition to expenditure on health care.
In the US much of the discussion of ‘disparities’ – the American term for
health inequalities or health inequity – is indeed about health care. Such
concern is hardly surprising given that although the US spends more on
health care than any other country, about one-sixth of its population lack
health insurance, and hence have had difficulties in access to care. This
should change with the Affordable Care Act, Obamacare. Well-meaning US
colleagues have urged me not to talk about social determinants of health in
the US because it might detract attention from inequities in access to care.
An example of why they might be concerned was given to me by a US
colleague. Medicaid pays for health care for the poor. Its director in one US
state said he was against expansion of Medicaid coverage because
insurance was less important than social determinants of health like income,
education and housing conditions.18 As the colleague who sent me this
remarked wryly: the devil can always quote the scriptures for his purposes.
The fact that a Medicaid director is talking about social determinants of
health, and even using the phrase, is great encouragement to those of us

promoting this agenda. The fact that he is using social determinants as an
excuse to discourage people from having health insurance is indefensible.
The US spends 17 per cent of its gross domestic product on health care.
The UK spend per person is about 40 per cent of the American spend. What
does the US get for all this outlay? Not much. We compared the health of
white Americans and white English men and women aged fifty-five to
sixty-four and showed first, that among Americans with health insurance
there was a social gradient in health, related to income and education, and
second, that even though 92 per cent of Americans in our sample had health
insurance, the Americans were sicker than the English.19 Richer Americans
were sicker than richer English; poorer Americans were sicker than poorer
English. And in case you were wondering, in one or two cases richer
Americans were sicker than poorer English.
Bad news has legs. The good news that the English were healthier than
Americans caused a momentary flutter in the airwaves in the UK. The bad
news that Americans had lost the health wars to the English was on US
headline news for at least two weeks after the original news hysteria. The
finding led to at least two National Academy of Science Reports asking
why the US was doing so badly.20
Some US economists have argued that spending on health care is a good
thing, and spending more on health care would indeed lead to better
health.21 My response is one of curiosity. The US spends more on health
care than any other country, yet, as I worried in Chapter 1, it ranks 50th in
the chances of a fifteen-year-old man surviving to sixty.22 Likewise in that
chapter I pointed out that the US ranks sixty-third in the world in lifetime
risk of a maternal death.
In Britain we have a national health service; the evidence shows that low
income is mostly not a barrier to access. Yet we still have inequalities in
health.
Two lessons emerge from this contrast. First, it is likely that provision of
medical care interacts with social determinants. Given how much richer the
US is than Greece, for example, and how much more it spends on health
care than any other country, maternal mortality in the US should be as low
as in Greece, 2 per 100,000 live births. So we should ask why some women
are not saved. It is highly likely that the women who die are poor, black, ill-
educated, often migrants.23 Women who for other reasons would be at

increased risk of ill health are put at higher risk by their lack of access to
health care. According to the Centers for Disease Control and Prevention,
over half of maternal deaths in the US are preventable.24 The second lesson
is related: the question should not only be how much medical care there is,
but how it is distributed. We need to ensure that provision of health care
does not increase health inequalities due to inequitable access.
It has proved very hard to calculate the contribution that lack of access to
medical care makes to health inequality. The answer will depend on
context. Health inequities persist in the UK, despite a health-care system
that is free at the point of use, and where cost is not a barrier to care. It is
likely then that differential access to care does not make a huge contribution
to generating health inequities. Likewise the fact that Americans with health
insurance and their generous health-care spending are sicker than English
with their more modest levels of expenditure suggests that it is not
differences in health care that account for big differences in health status.
That said, there is potentially much that health and medical people can do
about social determinants of health.25
Much of public health in high-income countries, and increasingly in
middle- and even low-income countries, focuses on behaviours thought of
as lifestyle. Were we told by an overweening state that we absolutely had to
eat French fries and drink fizzy sugary drinks daily we would take this as an
intolerable erosion of our freedom. We decide what we eat, whether to
exercise, whether to smoke, how much alcohol to drink. It is our choice and
therefore our responsibility.
But, and it is a big but, the evidence I have reviewed in this chapter
shows that our choices are influenced by circumstances beyond our control:
price, availability, not to mention billions spent on advertising and
marketing seeking to influence our choices. Do food, drink and tobacco
companies sponsor sporting events because they just happen to like sports?
One way we see the operation of these forces beyond our control is the rise
in obesity; another is the social gradient in smoking and obesity.
Such observations suggest two approaches to promoting healthy
behaviours. First, the time-honoured ‘make healthy choices the easy
choices’.26 If fresh fruit and vegetables are less readily available and cost
more than fast food full of saturated fat, salt and sugar, that will act as a
barrier to consumption.

A second approach is to empower people to take the decisions that will
positively influence their health and well-being. In Amartya Sen’s words: to
create the conditions for people to have the freedom to lead lives they have
reason to value.27 If an experienced doctor, knowing the risks, chooses to
cycle home after a dinner late at night, it is his choice. If his bicycle slips on
wet leaves and he injures himself, he has no one to blame but himself. But
David Gordon’s top ten list of tips for health is outside the control of the
people it most concerns. We should be seeking to improve the social
environment and take the steps to give people the freedom to lead lives they
have reason to value.
In my view we should take the steps just summarised because it is the
right thing to do – a matter of social justice. If I am arguing that we should
act in a spirit of social justice, it is well to understand what we mean. I turn
to that key question in Chapter 3.

3
Fair Society, Healthy Lives
PICKERING. Have you no morals man?
DOOLITTLE [unabashed]. Can’t afford them, Governor . . . What am I? I ask you, what am I?
I’m one of the undeserving poor: that’s what I am. Think what that means to a man. It means
that he’s up agen middle class morality all the time. If there’s anything going, and I put in for a
bit of it, it’s always the same story: ‘You’re undeserving: so you can’t have it.’ . . . I don’t need
less than a deserving man: I need more. I don’t eat less hearty than him; and I drink a lot more.
I want a bit of amusement, cause I’m a thinking man. I want cheerfulness and a song and band
when I feel low. Well they charge me just the same for everything as they charge the deserving.
What is middle class morality? Just an excuse for never giving me anything . . .
HIGGINS. Pickering: if we were to take this man in hand for three months, he could choose
between a seat in the Cabinet and a popular pulpit in Wales.
DOOLITTLE. Not me, Governor . . . Undeserving poverty is my line.
George Bernard Shaw, Pygmalion (Act II)
In Puccini’s opera, candidates for Turandot’s hand are given a fair choice:
correctly answer three riddles and gain marriage to the princess; fail and be
executed. No male, however ardent or focused on the main chance, is
forced into it – he can choose, so one could argue that the process is fair.
The outcome, as distinct from the process, is anything but: a trail of dead
suitors and one chaste princess (until, of course, the tenor arrives, which in
opera usually spells the end of the soprano’s chastity). On this evidence –
fair process versus fair outcome – would we deem the society in which
Turandot was a princess to be a just society?
Obviously not. We have become a little squeamish about executing
unsuccessful suitors for the royal hand. We rig things in more subtle ways.
Some philosophers argue that process is the thing. If the process is fair, the
outcome is fair whatever it may be, wrote John Rawls, the doyen of liberal
political philosophers.1 To see if the Rawls thesis holds, try this experiment
with two young children. You have two ice creams, one vanilla and one
chocolate. They both want the chocolate. You explain carefully that they

can both have ice creams but there is only one chocolate. Do they agree that
a fair way to decide would be to toss a coin? Yes, they agree. The coin is
tossed and Peter gets the chocolate and John the vanilla. And the first thing
John says? Unfair!
You try to explain to John that we all believe in equality of opportunity.
He had an equal opportunity to get chocolate ice cream. Things just didn’t
work out. John is totally unconvinced by such theory. It wasn’t the
opportunity he wanted but the chocolate ice cream. He is focused on
equality of outcomes, not equality of opportunity.
I haven’t done the research to know what the age cut-off is beyond which
John would learn to live with his disappointment and acknowledge that
although he’s unhappy he had an equal opportunity and it was a fair
process. But for a younger child, and I suspect for all of us, the outcome
matters too. The principle of tossing a coin may be better than some other
way of deciding – primogeniture for example, or who’s better-looking – but
in the end, they both wanted the chocolate and Peter got it and not John.
Can you imagine a politician on his soapbox declaiming: ‘I am of the
firm belief that we should deny some people the opportunity to succeed,
simply on the basis of the accident of their birth’? No. I can’t either. It
would be difficult to find a social commentator or politician who is against
equality of opportunity – even if their policies deny such opportunity. But
our discussions of social justice should not stop there.
Certainly as a doctor I care not only about opportunities and process but
about outcomes. Outcomes really matter. Not at any cost or to the exclusion
of all else, but they are important. If the doctor offers you chemotherapy –
that will go on for months, make you sick and leave you bald – for your
disease, the first thing you ask is how it will affect the natural course of the
disease. You may be prepared to put up with an uncomfortable process if
there is a good prospect of your health being better at the end. Conversely,
if the likely improvement in survival is marginal, you may decide that the
game is not worth the candle.
Outcomes matter in many domains. One of the objections to capital
punishment, not the only one, is that even though the trial may have been
‘fair’, whatever that may mean in a particular jurisdiction, there are well-
known examples where a person subsequently shown to be innocent has
been executed. There are also good examples where a ‘fair’ judicial process

is open to question. If the accused has been killed, sorry executed, there is
no redress. The outcome matters as well as the process.
In the Introduction, I described the WHO Commission on Social
Determinants of Health. On the cover of the Report we declared: social
injustice is killing on a grand scale. In my English Review, so as not to
frighten anyone in case social justice sounded like socialism we used the
term fairness, and called it Fair Society, Healthy Lives. Colleagues from
different European countries have since told me that ‘fairness’ sounds like
the English playing cricket. I am going to use the terms fairness and social
justice as if they amount to much the same thing.
Ethical debates about justice and health used to revolve around access to
health care.2 Recognising that health is strongly influenced by social
determinants changes the ethical debate to the just organisation of society,
in order to achieve better health. Amartya Sen once wrote that all moral
social systems require equality of something, the question is equality of
what?3 And the philosophers really do disagree about the ‘what’.
Immodestly, I think we can help the philosophers. In Chapter 1, I said
that we can use health, and inequities in health, as a measure of how we are
doing in society. I follow that approach here by exploring which approach
to social justice is most likely to increase health equity. If a libertarian says
that he is right, or an Aristotelian, or a Kantian, I’ll ask which approach, if
followed, would lead to a diminution of health inequities. That, surely, is
one worthy goal on which we can all agree.
To help resolve this, I want to look at the reality of the lives of people
that I have been studying and writing about – people whose health is worse
because of their social conditions, worse, that is, than it would have been
had they grown up and lived in more favourable social conditions.
SOCIAL JUSTICE AND AVOIDABLE HEALTH
INEQUALITIES = INEQUITIES
Three examples of people at the wrong end of health inequities
We met Gita and Jimmy in Chapter 1. To repeat: Gita sells vegetables on
the street in Ahmedabad in the state of Gujarat in India. She has no formal
education. Gita lives in an ‘informal settlement’ (a slum made of makeshift

housing) and has two children who sit with her by the roadside as she sells
her vegetables, and an older girl who helps with the vegetable trade. To
keep her business going Gita takes out short-term loans, at 20 per cent a
month interest, to buy vegetables from the middle man in the wholesale
market. Her husband is a migrant worker who is living in another state and
sends a few rupees back each month. Gita was just about making her tight
budget work, but it was time for her daughter, aged fourteen, to marry, and
instead of paying off her debts she put money into a dowry and a wedding
party for her daughter. Some aid workers are tearing their hair out at what
they see as this ‘irresponsible’ waste of money, as her interest payments
have gone up.
Jimmy was born in Calton in Glasgow, was in trouble in school, and
delinquency problems led to trouble with the police as a teenager. Jimmy
was enrolled in an apprenticeship but dropped out; he has never had a
‘proper’ job, but did short-term temporary manual work. As is common in
his subculture, any money Jimmy gets goes into drink and drugs; his diet, if
you could call it that, consists of pub food, fast food and alcohol. Jimmy has
had a series of short-term girlfriends, but is liable to alcohol-fuelled violent
behaviour. He is known to the police for his various gang-related violent
activities.
Rachel is an executive officer in the British Civil Service. She finished high
school, but university was not the done thing in her school, so she took a
low-level job in the British Civil Service; it’s taken twenty-five years but
she has slowly worked her way up from clerical assistant, through clerical
officer to low-ranking executive officer. Rachel’s salary is above the
national median income, just, and she will retire on a pension that amounts
to half her salary. She is divorced and lives alone. She sees her daughter
two or three times a year. When council housing was being sold, she bought
her flat and has nearly paid off the mortgage. Given that she lives alone she
doesn’t bother much about preparing elaborate meals.
Rachel is not poor but she feels that her life is somewhat impoverished,
in the sense of being restricted by lack of money. When she and her
husband were both earning modest salaries they could go out and do more
things. She does not really have the money for foreign holidays that she

sees work colleagues enjoying and, while she puts a brave face on her
single life, were she to admit it, she is lonely.
What Gita, Jimmy and Rachel have in common is that their health is worse
than those around them in more favoured social and economic positions.
All three are on the downside of health inequalities, and I am arguing that
putting these health inequalities right is a matter of social justice.
There are strong and possibly irreconcilable views among political
philosophers as to what constitutes social justice. If there is simply no
solution to the philosophers’ disagreements then I do not expect to devise
one. My approach is as a doctor. I am concerned with health and avoidable
health inequalities – health inequity. I want to know, therefore, which
approach to social justice helps provide the framework for understanding
and the impetus for action on health inequities.
My guide has been Professor Michael Sandel, although he doesn’t know
it.4 He teaches a philosophy class at Harvard which apparently is regularly
oversubscribed. Having seen him in action at my own university, I can see
why. He uses everyday problems and controversies, examined in lucid
Socratic dialogues with his audience, to draw out principles of political
philosophy. He does not provide me with an answer to social justice and
health but he provides a framework for thinking about it.
Sandel distinguishes three approaches to social justice:
• maximising welfare,
• promoting freedom, and
• rewarding virtue.
It illuminates the cause of social justice and health to see how each of these
might apply to avoidable health inequalities.
MAXIMISING WELFARE
Jeremy Bentham, a great philosopher whose auto-icon – his skeleton
dressed up in his own clothes with a wax face – sits in a case outside the
office of the Provost and President of UCL where I work, is the founder of
utilitarianism. Simply put, he argued for the greatest good for the greatest
number, where good was measured as utility, on a scale of pain and

pleasure. Given that my concern is with health more than with happiness,
the same utilitarian principle could be applied: the greatest level of health
for the greatest number.
A big advantage of simply adding up everyone’s utility, or health, is that
prince and pauper are counted the same. Given my focus on health, equal
utility implies that a sick prince and a healthy pauper add up to the same
societal level of health as do the healthy prince and the sick pauper.
Predictably, healthy prince and unhealthy pauper are more common.
What if we want to value health against some other desirable good?
Economists will often choose money as a universal measure. As, for
example, in the following exchange that I had with a Chicago economist at
a meeting. The economist said:
‘If you want to know how much people value a television set, see how
much they are willing to pay for it. So it is with human life. See how much
people are willing to pay for another year of life and, ergo, you have the
value of a year of human life.’
Setting aside the temptation to invoke Oscar Wilde’s definition of a cynic
(someone who knows the price of everything and the value of nothing), and
some questions about the economist’s stunningly simple methodology, I
wondered about the incommensurability of human life and televisions.
Provoked, he said: ‘What’s the difference between a life and a television?
You can’t answer that, can you!’
I mulled over this telling point. Of course, our students are motivated to
go off to Africa to improve the dire situation of suffering televisions. The
continued violence to female televisions is unacceptable. We could have the
Millennium Television Goals, easier to meet than the Millennium
Development Goals. Interrupting this silent riff I was moved to ask: if a
poor person were willing to pay less for another year of life than a rich
person, did that mean that a poor person’s life was worth less than a rich
person’s? Absolutely, was the answer. Bangladeshi lives all worthless?
Pretty much. Well, at least that’s clear.
About this time I read a headline in the Financial Times: Economists are
from Mars, Europeans are from Venus. Not all economists, I should add.
It has been put to me that I simply cannot turn my back on such
economic calculations. For example, is it a good idea to introduce a new
health programme, say, breast screening? Tot up the life years saved in

dollars, set that against the cost of the programme, and you know how much
society has benefited from the breast-screening programme.
I have two problems with this utilitarian calculus: the first is that it
measures life years on the same scale as television sets. It is superficially
attractive to measure everything the same way, to make comparisons. With
a limited pot of money, should we invest in curbing global warming or in a
programme of breast screening? Measure the relevant outcomes in dollars,
compare them with the costs, and the decision is made.
Except it isn’t. The methods of assigning dollar values to very different
benefits are problematic. Which would you rather have: a 20 per cent
reduction in your risk of dying from breast cancer, the benefit of screening,
or have the polar ice cap melt at a slower rate? The inherent difficulty in
answering that question is not solved by the superficial attractiveness of
measuring them both in terms of dollars. Many have written on this
subject.5 I have resisted translating lives saved into a price for any of the
reports on health inequalities for which I have had responsibility.
The second problem, which exercises me more, is one of distribution.
Think of Gita in Ahmedabad. Suppose we are part of a team that goes into
two Ahmedabad communities with a programme to improve nutrition of
two-year-old children. When the programme is implemented, the children
in both communities grow, on average, 6 cm in height in the next year. The
benefit is the same in the two communities; they are equivalent in
maximising welfare.
The difference is that, in the first community, the growth of all the
children was actually between 5 and 7 cm, average 6. In the second
community, there was a group of children of the poorest families, Gita and
her fellow vegetable-sellers, who were discriminated against and excluded
from the nutrition programme, one-third of the whole, and their average
growth was only 2 cm. The other two-thirds leapt ahead with an average
growth of 8 cm – average for the community 6. Simply by adding up the
greatest good for the greatest number, the two communities are equivalent,
average childhood growth in a year 6 cm. Should we leave it there? Which
community is really doing better, the one where two-thirds of the children
are growing rapidly, leaving one-third behind; or the other where all the
kids are growing at about average rate? What I would not conclude is that
the two communities were equivalent.

The outcome of the discussion may depend on whether all the children
were valued equally. If, for example, you thought that the children left
behind were somehow less valuable, then the community with two-thirds of
children growing at 8 cm is clearly doing better.
Are some people’s lives less valuable than others?
Kevin Murphy is a much-respected economist at the University of Chicago.
Widely admired within his profession, he has won prizes and is tipped for
more. He and Robert Topel use willingness-to-pay methodology to work
out the value of a human life.6 They ask, as with televisions, how much is
someone willing to pay for another year of life? I am profoundly uneasy at
the willingness-to-pay methodology in principle, and in particular at the
way they use compensation levels in various occupations to infer ‘revealed
preferences’. Their methodology says that the societal value of life is
greater:
(i) the higher the lifetime income
(ii) the less illness people have
(iii) the closer in age people are to the onset of illness
As I read this: the lives of older, richer, healthier people are more
valuable than the lives of poorer, younger, sicker people. If I believe that,
what am I doing caring about poor, sick, Indian children? Their lives are
worthless. And if you believe it, do not waste a moment more on this book.
I was invited to a meeting at the RAND Corporation in Santa Monica
California with a group of economists to discuss valuation of life. The
starting text was the Murphy–Topel paper. I went next. I began by saying
that I had had lunch with an Indian historian recently and I told him that the
news from Chicago was that he did not value his life – he was willing to
pay far fewer dollars for another year of life than an American. Ergo, he
didn’t value his life very highly.
Some of the Chicago economists in the room had expressions on their
faces that said: that is what we think but would rather you had not put it so
bluntly. I told them, to little effect, that my Indian lunch companion told me
that Indian villagers were willing to give up food for their families for two
days in order to be vaccinated against smallpox, so highly did they value
their lives. But dollars, man, where are the dollars! My historian colleague’s

point is fundamental. Where people do not have money, money is the
wrong unit of measurement to assess value. And where they do have
money, it still may be the wrong unit. In discussing this with one economist,
who I knew was devoted to his daughters, I showed him an SMS text I had
just received from my daughter: ‘Happy birthday, Daddy. You are the best.
Love you. xxx’. I asked him how much that was worth in dollars. He
couldn’t answer because of the lump in his throat.
If you use the valuation of life to make allocation decisions, you spend
the money where it will yield the greatest result, measured in dollars. It is
inefficient to care for the poor, the sick and the young. If social justice
demanded attention to the young, the sick and the poor, I must be paying a
price to do this. Economists could work out the price and then ask me if it
was worth it to use the money in this inefficient way.
To say that I was uncomfortable with this approach would understate it. I
was aghast. At the meeting, I showed the Whitehall mortality graph – the
lower the position in the hierarchy, including low-grade civil servants such
as Rachel above, the shorter the life. I understood that the high-grade civil
servant, Rachel’s superior, would get a higher pension than Rachel in a
relatively low grade, but if they each had renal failure Rachel and her boss
had an equal right to dialysis and renal transplant. The economists disputed
that, vigorously and all at once. First was the Murphy–Topel argument: the
senior civil servant’s life was worth more. Another suggested that the high-
grade civil servant contributed more to society, so society would be better
off if we treated her and let the low-grade woman die. Yet another
suggested that we offer Rachel some money as compensation for not getting
the treatment. Not a lot of money, because if we had a lot, we would give
her the treatment. That amounts to bribing someone to accept a slow,
uncomfortable death, rather than treating her.
There will always be less medical care to go around than we might like.
Choices will always have to be made. Rachel may be less ‘deserving’ of
high pay than her boss, but she has the same right to treatment for her
chronic renal disease as her boss.
Women tend to have more illness than men, although they live longer,
and are paid less than men for the same job, so are likely to be less rich than
men. Does that mean we should give priority to treating men rather than
women because the women are sicker and poorer? I wouldn’t vote for any
government that proposed that. Regrettably, such gender discrimination is

all too common in parts of the world. Social injustice kills, and the
utilitarian calculus does not capture or rectify this.
Do ‘we’ in rich countries, owe anything to ‘them’ in poor countries,
whose poverty renders their lives worthless? I do not pretend for a moment
that the answer to that question is simple. In this book I set out what could
be done if the global community took seriously social determinants of
health and health equity. The question of what should be done is, in my
view, not answered by taking the view that the poorer you are the less
valuable your life.
If the utilitarian calculus means the greatest good for the greatest number
it runs up against other principles of action that take distributions into
account. This was brought home to me by a conversation with an Irish
minister of health. She spoke out in favour of targeting her limited
resources on the poor and the needy and said:
‘I want to spend the money where it will do the most good.’
‘In that case’, I replied, ‘spend it on the middle classes.’
She was shocked.
‘The evidence shows,’ I continued, ‘that people of higher socio-economic
position have better cancer survival after treatment than people of lower
position. If you have limited resources, and who doesn’t, spend it where
you’ll get the most health gain: on the middle classes. That would serve the
principle of the greatest good for the greatest number.’ (I didn’t think her
tolerance would stretch to my telling her that, in addition, economists say
that saving a rich person’s life is more valuable to society, measured in
euros, than saving a poor person’s.)
‘But that’s not what I came into politics to do,’ she said, ‘I want to help
the poor and disadvantaged.’
‘Ah, then you have an equity principle, as well as an efficiency one. I
would vote for you.’
It is clear that for her, as for me, a principle of equity was more important
than simply the greatest good for the greatest number. I am presenting it as
if it were a straightforward choice. It is anything but straightforward. If you
were Rachel’s boss you would not like to be told that because of your
privileged place in society your chronic renal disease was not going to be
treated because poor Rachel took priority, even though she was less likely
to benefit than you.

If choosing who got treatment between Rachel and her boss, I would not
choose on the basis of their income or seniority. I further enraged the
economists at the RAND valuation of life meeting by saying that Canadians
had made the case that it was wrong for rich people to buy more health care
than was available to the poor. Now the economists were really screaming
at me: ‘Would you not let anyone have a Mercedes unless everyone could
have one?!’
As I shall say, when we get to section three on rewards, I do not think
everyone should have the same income – we should reward some sort of
virtue, problematic as that is – but I do not think motor cars and health care
are equivalent. Rich people have more money to spend, fine, within the
limits that society deems acceptable. But that should not mean that they get
better health care than people who have less to spend.
There is no easy answer to such dilemmas, which is why there are such
vexed debates about allocation of scarce resources. For many of the actions
I propose in this book, the dilemmas are less intense. For example, all over
the world children from less advantaged backgrounds have less adequate
pre-school education and care and less opportunity for quality education
than do children from more privileged backgrounds. It is entirely feasible to
work towards bringing the levels of pre-school education and care up
towards the standard available to the best-off. As I shall show in the chapter
on early childhood, there is even a good economic case for doing it. Would
anyone seriously argue that it is morally wrong to give all children the best
start in life?
PROMOTING FREEDOM
In a democracy, it is not easy to find someone to argue that freedom is a bad
thing, and rightly so. Barring a few authoritarians, most people are in
favour. I thought of writing a justification of why democracy is a good
thing, and then remembered that the late Oxford philosopher G. A. Cohen
wrote that in Oxford, as opposed to Harvard, they choose their deepest
normative convictions pre-philosophically. To a non-philosopher, that
means they start from some deeply held beliefs and then reason, rather than
reason their way towards these beliefs. Democracy, then, is a good thing. If
I had to have a ‘because’, I would say: because it has at its heart more
freedom than other systems of government. What then is the issue? Surely

any approach to social justice that has as an aim to promote freedom has to
be the correct one.
The challenge is to rescue ‘freedom’ from a polarised political debate.
Commentators of the political ‘right’ prize the freedom of the individual
over the controls of the state. The economist Milton Friedman called his
influential book calling for free markets and freedom from state
intervention Free to Choose. Putting a more negative slant on a similar idea,
Friedrich von Hayek called his book The Road to Serfdom. Once the state
gets involved in economic decision-making, individual liberty is eroded and
we are on the road to serfdom. When neoliberalism is looking for
intellectual flag-bearers these two fit the bill.
Libertarians, articulately represented by Robert Nozick in his Anarchy,
State, and Utopia, argue that only a minimal state limited to protecting
people against force and fraud and enforcing contracts is justified. Anything
else is an intolerable erosion of freedom.
What freedom do Jimmy, Gita and Rachel enjoy? On the surface you
might think that Jimmy in Glasgow has the most freedom to change his
situation. He could stop being a scallywag, lay off the drugs and alcohol,
stop abusing his girlfriends, put away his knife, leave the gang, pull his
socks up, find a job and get on with it. Beneath the surface, though, Jimmy
is not simply a tearaway. There is more to his biography, which is based on
a case history brought to me by Detective Chief Superintendent John
Carnochan, the top policeman who was head of the homicide unit in
Glasgow until 2013. Jimmy never knew his father. His mother had a
succession of male partners, most of whom abused Jimmy physically, if not
sexually. He and his mother moved house about every eighteen months. By
the time Jimmy entered school he already had behavioural problems and
difficulty concentrating, and was subject to outbreaks of aggression towards
other children and teachers. As soon as he was old enough, he was in
trouble with delinquency problems, and later was well known to the police
for a series of possibly drug-related thefts, and for violence. At various
times, psychiatrists labelled him as having personality disorder, anxiety,
depression and antisocial tendencies. Jimmy has this in common with men
in prisons, over 70 per cent of whom have two or more mental disorders7 –
fourteen times more than among the general population.8
I’ll try and get inside the head of a libertarian. Jimmy is free, when he is
not in prison. He has the freedom to live a life of relative poverty, be

arrested and, if he survives the battles of the gangs, die at age fifty-four of
heart disease, if not alcohol-related causes or drug poisoning. The role of
the state should be limited to locking him up whenever he gets caught for
one crime or another. My response: is the freedom that allows the heads of
corporations to have multi-million-pound salaries the selfsame freedom that
Jimmy enjoys to lead a life of intermittent depression, violence, drugs and
alcohol? Perhaps it is a comfort to Jimmy to know that his miserable
situation is what libertarians call freedom.
But what if, a libertarian might ask, Jimmy chose to live this way? My
response is: ‘chose’ to be unemployable, fall out with his friends, be tossed
out by his girlfriends, and to be angry, depressed or drunk most of the time?
Karl Marx said: ‘Men make their own history, but they do not make it as
they please; they do not make it under self-selected circumstances, but
under circumstances existing already, given and transmitted from the past.’9
I do not think you have to be a Marxist to recognise that Jimmy is a product
of circumstances. To describe him as having the freedom to change his life
is to ignore the imprint on him of his appalling conditions from early in life.
Please remember I am speaking of averages. There will be some individuals
who emerge from the circumstances that bred a Jimmy who do well, by
their own lights as well as society’s.
As I shall show in the chapter on early childhood, the evidence is clear
that state-provided services such as family–nurse partnerships could have
helped with Jimmy’s early child-development. In turn, fewer social,
emotional, behavioural and cognitive problems would have meant a better
chance to flourish in school. In its turn, better school performance means
better chances of decent employment and reasonable income. Then, I would
argue, Jimmy would have far greater freedom to make his life choices. If at
that point he chooses the Glasgow equivalent of sitting under the yum-yum
tree, rather than pursuing a more conventional route, that is his choice.
John Carnochan, the policeman in Glasgow, said: ‘When I began my
career as a police officer back in 1974, I don’t think anyone would have
imagined one day a police officer would be standing on stage talking to a
conference full of midwives about the importance of cuddling your child
when it comes to preventing violence.’10 Carnochan said that, given the
choice, he would rather have more health visitors than more officers on the
beat, in order to prevent violence.

What of Gita? How can she be free when she lives in dire poverty in the
slums of Ahmedabad? Freedom to wallow in poverty, to see your children
on the edge of starvation, and to lack both education and prospects, is not a
freedom many would prize.
But freedom does give us a good way to think about Gita’s life. It may
not be the freedom of the libertarian, but the freedom to be and to do what
she values. Such freedom does not come by eliminating social action, as the
libertarian might argue. It requires social action. Let’s explore this
alternative concept of freedom.
A key feature of the lives of Gita, Jimmy and Rachel is that they are
disempowered; they lack basic freedoms. Things have been happening to
them all their lives over which they have little control. One thing that marks
out relative social advantage is the opportunity to shape your life more than
the Gitas, Jimmys and Rachels can do. I think of disempowerment as
having three dimensions: material – if you cannot afford to feed your
children you cannot be empowered; psychosocial – having control over
your life; political – having a voice.
My model is of health equity being built on creating the social and
environmental conditions that make empowerment a possibility. Gita’s life
can be transformed if she has access to the basic necessities.
The second, psychosocial, dimension of empowerment is having control
over your life, and taking your place in society without shame. Having little
control over your life is central to the mechanism by which the social
environment influences health. Rachel, who spent a career in the lower
reaches of the Civil Service, has material conditions for good health, such
as Gita and her fellow slum dwellers could scarcely imagine. What she
lacks is control over her life, at work or at home. The empirical basis for my
concern with lack of control came from our Whitehall II study of British
civil servants.11 Men and women whose work environment was
characterised by little control over the circumstances of work – what they
did, when they did it, and with whom – had increased risk of heart disease,
mental illness and sickness absence.12 We also asked a simple question
about degree of control at home. Particularly among women, more than
men, people who reported little control at home had increased risk of heart
disease and depression.13
‘Basic freedoms’ is a concept of the inspiring economist and philosopher
Amartya Sen. He emphasises freedom to lead a life one has reason to

value.14 Freedom to be and to do has a central place. Sen, like most
contemporary philosophers, is a great admirer of John Rawls. His
divergence from Rawls, highly significant, arises because Sen is not
searching for an ideal institutional arrangement that would constitute the
good society. Rather, he wants to evaluate social arrangements by their
effects on actual lives – whether people have the freedom to lead the lives
they choose.15 This resonates with my health-centred approach. I said that if
philosophers could not settle their theoretical differences on what
constituted social justice, I most certainly could not. I want to use the
impact of our set of social arrangements on health equity as my criterion of
social justice. Empowerment, freedom to choose a life you have reason to
value, would transform the lives of Gita, Jimmy and Rachel and improve
their health. How we achieve empowerment – meaningful freedoms – is set
out in the chapters that follow.
Sen’s approach to human rights is that they embody important freedoms.
A human rights framework has much to recommend it in seeking to
promote action on social determinants of health. The British philosopher
Onora O’Neill reminds us that simply claiming rights is not enough. For
rights, there are corresponding duties.16 In other words, if I claim that
people have rights to good health, there is the implication that they have
rights to the social determinants of health – pre-school education, good
education, housing, a decent paid job, social protection. Whose
responsibility is it to meet those rights? It is a good question. We cannot say
simply that parents have the duty to provide good schools for their children.
My purpose in bringing the evidence together is to show what we need to
do. In a democracy, it is up to all of us to determine what we want to do
about this evidence, and how to go about it.
Equality of opportunity?
I began this chapter by saying that the suitor for Turandot’s hand who was
about to lose his head because he wasn’t good at riddles, little John who
wanted chocolate ice cream and had to make do with vanilla, and I as a
doctor were all concerned about fair outcomes as well as fair process. And
Gita, Jimmy and Rachel are each on the wrong end of health inequalities
that could have been prevented – unfair outcomes.

What I have said so far may sound perfectly reasonable: it is not just I, as
a doctor, who believe this, but most people who care about their health. It is
less reasonable than it sounds. While politicians of left and right, and the
people who support them, can agree on equality of opportunity, many will
argue against equality of outcome. If equality of outcome demands equality
of income, of education, of living conditions, this will be several steps too
far for many.
John Rawls recognised that equal opportunity was a chimera because
people’s basic starting conditions varied so greatly. Opportunity is heavily
influenced by inequalities in power, education and resources – all socially
determined – quite apart from inequalities based on the natural lottery that
deals some a luckier genetic hand than others. In the Rawls schema, to
achieve equality of opportunity a just society guarantees every citizen
access to basic or primary social goods, including basic liberties,
opportunity, powers and prerogatives of office, income and wealth, and the
social bases of self-respect. For Rawls fairness rests on a fair procedure by
which these primary social goods are distributed. It is the process that
decides justice, not the ultimate allocation.
Rawls acknowledges that his principles for distributing primary social
goods will not eliminate inequality. He is, however, concerned with the fate
of those worst off. Therefore, his ‘difference principle’ says that, while
guaranteeing equal liberties to all, inequalities in the distribution of the
remaining primary social goods are allowable only when the inequalities
work to make those who are worst off as well off as possible compared with
alternative arrangements.
One strand of Amartya Sen’s criticism of Rawls is that it is too much
about process, not enough about outcome. Suppose in Ahmedabad there
was a new programme of education available to all children in the slums. A
child who had been malnourished from birth and was sickly would perhaps
benefit less from the educational opportunity than a child who was thriving.
The first child’s ill-health would limit her opportunity to convert education
chances into better education. For Sen, the freedom to be and to do is not
guaranteed by getting the distribution of social goods right. A fair
distribution of social goods that does not take account of differences in
health, skills, needs and vulnerabilities will therefore not be enough.
Note that Sen is arguing that ill-health limits the conversion of
opportunities into meaningful outcomes, such as more educational

achievement. I agree, but am also arguing that more educational
achievement, better occupational opportunities and better conditions in
general will transform the lives of Gita, Jimmy and Rachel and lead to
better health.
There is a particular dilemma with which Rawlsians, and the rest of us,
have to deal. Going back at least to Adam Smith, economists have argued
that allowing some people to have a larger slice of the economic cake may
lead to the whole cake enlarging. In other words, set the wealth producers
free and, although they will benefit the most, people at the bottom will be
somewhat better off – trickle-down economics. I hear the distant rumble of
self-interest promoting this view. What does Rawls say, given that his
difference principle states that greater inequalities are fairer provided that
the worst off are better off than they could be under any alternative
arrangement? Does that mean that greater health inequalities might be fairer
provided those at the bottom have improved more than they could have
under alternative arrangements?
This is, after all, close to what has happened in many countries over
recent decades. Health has improved for everybody but it has improved
more for those in more privileged social and economic positions. Health
improving for everybody has to be a most welcome social achievement, but
so would flattening the health gradient by levelling up – bringing
everyone’s health up to the standard of the best.
What this suggests to me is that Rawls’s focus on fair distribution of
opportunity, even given his difference principle, does not provide the
framework for approaching a just distribution of health. The Sen idea of
freedom to lead a life one has reason to value comes much closer.
Michael Sandel’s third approach to social justice, after maximising
welfare and promoting freedom, is:
REWARDING VIRTUE
If you want to know what God thinks of money, just look at the people he gave it to.
Dorothy Parker
‘The important thing in life is not the triumph but the struggle, the essential
thing is not to have conquered but to have fought well,’ said Baron Pierre

de Coubertin, founder of the modern Olympics in 1896. It is often quoted
as: it’s not the winning but the taking part that counts.
That is not how it looks. Contests reward winners. Taking part? Yes, very
worthy. But winning? Winners deserve their rewards, we think. In Britain
we remember the sailor who won gold at four successive Olympics, and the
rower who won gold at five successive Olympics. To keep up that level of
performance over twelve to sixteen years . . . we feel they deserve all the
fame, money and admiration that is heaped on them. No doubt each country
has a similar story: praise for the wonderful winners, rather than respect for
the plucky losers for turning up.
As with sportsmen, so with bankers and others: is it justified that the
winner takes all? Ask the highly paid banker or hedge-fund manager why
they get paid as much as they do, and the answer comes back in some
version of: ‘Because we’re worth it.’ How do we know you’re worth it?
‘Because that’s what we get paid.’ Hardly faultless logic. It is ‘willingness-
to-pay’ methodology. How much is something worth? Whatever someone is
willing to pay for it.
At the other end of the income scale, the same circular reasoning applies.
Low pay is a sign of being less worthy; if people were worth more they
would be paid more. When, in the English city of Nottingham in 2013, one
of the coffee chains advertised eight jobs as baristas it received 1,701
applications, despite offering less per hour than the ‘living wage’. By the
logic of price equating to worth, people who applied presumably realised
that they did not deserve to be paid enough to live a healthy life, else they
would not have applied. Or might it have had something to do with the
Great Recession, high unemployment in Nottingham and lack of
alternatives?
It is not just the problem with what passes for logic in this argument that
bothers me, it is that the level of inequalities in income and wealth has been
rising in many countries. The US and UK stand out. Such inequalities may
have profound effects on health in at least three ways.
First, if some people have ‘too much’, others may have too little. If
‘rewards’ to hedge-fund managers, bankers and the top 1 per cent mean that
people living in the shadows of Wall Street or the City of London have too
little for a healthy life, the system has gone awry. In the US it has been
estimated that almost all the income growth between 2010 and 2012, 95 per
cent of it, went to the top 1 per cent.17 At the same time, 24 per cent of the

population were in poverty – taking an OECD (Organisation for Economic
Co-operation and Development) definition of poverty as less than 60 per
cent median income, after taxes and transfers.18 By contrast, in Denmark
and Norway, with much lower levels of income inequality, 13 per cent of
the population are in poverty, using the same definition. Despite living in a
rich country some people simply do not have enough to lead a healthy life –
we call that the Minimum Income for Healthy Living.
Second, if too much of the money is being sequestered at the top, local
and central governments may have too little to spend on pre-school
education, schools, improving services and amenities for neighbourhoods –
reproducing, two generations later, what in 1958 J. K. Galbraith called
‘private affluence and public squalor’.19
Third, too much inequality of income and wealth damages social
cohesion; increasingly the rich are separated from everyone else: separate
neighbourhoods, schools, recreation, fitness centres, holidays. Lack of
social cohesion is likely to damage health and increase crime.20 We used to
hear that what was good for General Motors was good for America. Perhaps
it was. It is a good deal harder to make the case that what is good for
Private Equity Asset Strippers International, or Get Rich Quick Hedge
Fund, or United Short Sellers, and the billionaires who lead them, is good
for America.21 We will look in more detail at how communities and whole
societies impact on health equity.
For these three reasons we should be concerned about distribution of
income. Were you a market fundamentalist you would now be horrified, or
ignore me because I’m not an economist, so what could I know. The market
is a sacred thing: it allocates income according to worth. Markets are
infallible, and here am I saying that if avoidable health inequalities are the
result, it represents market failure.
I have been asked often: we hear your message on how inequities in
power, money and resources are bad for health equity; why are
governments apparently not listening? Or, if they are, why are there are
such inequities in power, money and resources that health is being
damaged?
Are there good reasons for the inequalities in income that we have?

There may be a sharp conflict between a distribution of income that can be
justified in some other way and the distribution that is optimal for health
equity. Allocating rewards based on merit or virtue goes back to Aristotle,
and may be blind to the likely effect on people’s lives and hence on their
health. But how are we to decide virtue?
The philosopher Stuart Hampshire considers that a just distribution of
society’s resources might reward individual virtue and excellence and
conform to the kind of society we want, but he then writes: ‘Conceptions of
the good, ideals of social life, visions of individual virtue and excellence,
are infinitely various and divisive, rooted in the imagination and in the
memories of individuals and in the preserved histories of cities and
states.’22 If conceptions of the good life and what people deserve are
‘infinitely various and divisive’ there will not be one answer to the question
of the just distribution. Hampshire then goes on to distinguish two kinds of
evils of injustice. First, the evil of injustice in the distribution of goods
needs to be revealed and certified by argument as evil before it can be felt
as evil. Agreeing what makes up the right way to allocate goods needs a fair
process of negotiation and debate. The outcome will vary with time and
culture.
Hampshire continues: ‘On the other hand, the evils of great poverty, and
of sickness and physical suffering, and of the misery of bereavement are
immediately felt as evils by any normally responsive person.’ I find that
extremely helpful. There is no answer to the question of the just distribution
of goods. There will and should be negotiation, probably helped by rational
argument. But the ‘evil’ of avoidable health inequality should garner much
more immediate attention and concern. To the extent that the uneven
distribution of goods, including income, causes inequalities in health, it is a
legitimate object of concern. Where the two questions – what is a just
distribution and what kind of distribution might damage health – come
together is in the question of relative inequalities and perceptions of
unfairness.
If we take money as the index of how much we value someone’s
contribution, we think top-level basketballers and footballers are quite the
most wonderful thing on the planet, and jobbing B-grade movie actors more
valuable than professors of mathematics. Nurses? Worth about one two-
hundredth of a banker. Unemployed single mothers? Beneath contempt.

Contempt brings out the worst in people. In the US, Governor Mitt
Romney distinguished the 47 per cent somehow dependent on the state as
those who would never vote for him. It was almost as if being dependent in
some way on the state marked you out as a lesser person. In Britain we have
had politicians dividing the population into strivers and scroungers. The
scroungers are not closely defined but seem to include people on benefits of
various kinds. We have the unedifying spectacle of politicians presiding
over high unemployment rates and then asserting that unemployment is a
lifestyle choice. One might have thought that George Bernard Shaw’s sharp
wit, quoted at the head of this chapter, might have skewered the language of
‘undeserving poor’ a century ago. My objection to this rhetoric is not only
moral, it is factual. For example, in Britain, the majority of people living in
poverty are in households where at least one person is working.23 In fact of
all adults in low-income working households, three-quarters were in work.
For most poor people, the problem is not being undeserving, it is low pay.
The idea that the market accurately represents worth, and thus justifies
the high incomes of the top 1 per cent, is a self-serving illusion. In Jacob
Hacker and Paul Pierson’s Winner-Take-All Politics, they put the
convincing case that the level of income inequality that we have has more
to do with grubby politics than the logic of the market and rewarding
virtue.24
What, then, would a fair distribution of income look like? See what the
population think is fair. The British Social Attitudes Survey in 2009 asked a
representative sample of the population what they thought various people
earned, and what they thought they should earn.25 Averaging the answers,
respondents thought that chairs of large corporations earned fifteen times as
much as unskilled factory workers. Respondents thought that the big boss
should earn £100,000 and the factory worker £16,000 – a ratio of six times.
I draw three interesting conclusions from this simple survey. First, the
population is not egalitarian when it comes to income. It is a reasonable
guess that the general public hold the view that skills, training and
responsibility should be rewarded. Perhaps scarcity, too. A higher salary
might be necessary to attract people who are in demand elsewhere.
Second, the public take the view that income inequalities are too big. In
fact, the British Social Attitudes Survey shows that since 1983, consistently,
more than 70 per cent of the population think the income gap is too large.

Third, they have no idea how big it is. The true ratio of top to bottom
salaries is more like 340 than 15. I am not even for a millisecond
entertaining the proposition that we set salaries by polling the population on
what they think they should be. It is clear, though, that the population take
the view that we have a grossly unfair distribution of income. We could
summarise by saying that in our democracy the majority think that ‘virtue’
should attract rewards, but within limits.
Will Hutton has explored this territory in Them and Us.26 He reviews the
interesting evidence that we are programmed, by evolution, to be sensitive
to unfairness. We welcome people being rewarded for achievement, but not
unfairly. Both the biological/psychological evidence, and people’s attitudes
in a country like Britain, suggest that not only are we comfortable with
inequalities in income, we think it is the right thing to do, provided it is
done fairly. It would be hard to argue, though, that if some people are paid
less than the minimum they require for a healthy life, then the distribution
of income is fair.
Undeserving because it’s their own fault
Are the poor architects of their own misfortune?
George Bernard Shaw has Arthur Doolittle, the dustman, claim that he
has chosen his undeserving poverty, but only after a catalogue of
complaints about how demeaning he finds it – ‘think what that means to a
man’. Shaw’s intent is clear: people do not choose their poverty. But, even
if they do not choose poverty, might the decisions they make account for
their poverty and the ill-health associated with it?
Given the history of Gita in Ahmedabad it would be difficult to say that
she is somehow poor of her own volition. She, and perhaps a billion men
and women like her, are poor because of lack of both material conditions
and the opportunity to do better.
Jimmy in Glasgow is different. He certainly has poverty of material
conditions, compared with those prevailing in Glasgow, but as we have
said, they are wonderful compared with Gita’s. His poverty has more to do
with his choices. Actually, that should probably be ‘choices’, given the
disastrous family history that left him psychologically scarred. The
circumstances of his background make social mobility – going up the social
ladder – unlikely.

Rachel, the low-grade civil servant, is not poor, but she is relatively low
in the social hierarchy, which constrains her choices. Rachel, compared
with higher-status women, is more likely to be obese, and to smoke, less
likely to pursue physical activities, has fewer social connections,27 and
when her daughter was young and Rachel was a single mother, she was less
likely to have read to her, or to have cuddled and played with her,28 as she
juggled the demands of work, motherhood, childcare and making ends
meet. These ‘choices’ were bad for her, Rachel’s, own health and played a
role in limiting her daughter’s opportunities.
Two US-based researchers, Sendhil Mullainathan, an economist at
Harvard, and Eldar Shafir, a psychologist at Princeton, looking at the
Rachels, the Jimmys and even the Gitas of the world, asked, why do the
poor appear to make decisions that are not in their own interest?29
Summarising the evidence, they say that the poor use less preventive health
care, fail to adhere to drug regimens even when the costs are covered, are
less attentive parents and worse managers of their finances. In low-income
countries, they are less likely to weed their plots of land even though that
would increase productivity. I would add that it is not just the poor versus
the rest, but the evidence shows there is a social gradient in adopting
preventive behaviours or adhering to drug regimes.
So self-defeating do some of these decisions seem to be, that some
speculate that it is the very fecklessness of the poor that leads to their own
misfortune and ill-health. Mullainathan and Shafir’s view is that this is
precisely upside down. Rather than poor decision-making leading to
poverty, they argue, it is poverty that leads to poor decision-making. Their
book, Scarcity, brings together evidence that scarcity narrows a person’s
working memory, to use a computer analogy. Someone starving starts to
focus on food, to the exclusion of other concerns; someone time-poor
focuses on deadline pressures rather than on long-term planning; and,
crucially, the poor focus on short-term survival rather than on more
strategic decision-making.
In various experiments, they show that being relatively poor makes
people less insightful, and diminishes forward planning and sense of
control. The effect of poverty on cognitive function is equivalent to the
effect of going without sleep for a night. Their experiments and studies
show that this diminished cognitive function is not a permanent state – it
gets worse as poverty worsens and improves as it lessens.

The implication of this effect of scarcity is that the poor need not only
money – they do need money – but also the security of mind that allows a
fuller range of mental functions to flourish. For example, if when Rachel
was a single mother she could have had access to subsidised childcare, it
would have reduced not only her financial burden but also her cognitive
load as she juggled the tasks and the finances involved in being a single
mother. In low-income countries, where employment and income are
insecure and inconstant, short-term low-interest loans might be valuable in
relieving intolerable mental burdens.
My entrée into political philosophy was to help understand the links
between social justice and health. A simple adding-up principle, enshrined
in utilitarianism, does not do it, because we need to take distributions into
account.
An approach to social justice that maximises freedom is much closer to
my concerns, provided that we recognise that we need to create the
conditions for people to have control over their lives, to have meaningful
freedoms. Such an approach to freedoms recognises human rights to health
and to the social determinants of health. Understanding how to realise those
rights is the task of the chapters that follow.
Rewarding virtue will be an important principle for deciding the
distribution of resources. My concern is with the impact of these allocation
decisions on people’s lives, and hence on health inequities.
IDEOLOGY AND EVIDENCE
If everyone agreed on the meaning of social justice and there was only one
conception of the good society, political philosophers would have to think
of something else to do. They are kept busy because as Stuart Hampshire
wrote, there is no agreement. Libertarians do not convert to Kantian
philosophy, or vice versa, simply on the basis of reasoned argument. We are
dealing with ideology, although the arguments are revealing.
One might have thought that, in science, where ideology has to come up
against hard facts, the ideological debates would give way to debates about
evidence. All too often, that is simply not the case. I described above my
debate with utilitarian economists at the RAND meeting. Their views were
anathema to me. I admired the intellectual coherence of putting a dollar

value on people’s lives and apportioning care only to the most worthy, but
wanted no part of it. The culmination was what I called bribing people to
die. And I would certainly speculate that not a one of them changed his
mind – I think they were all men – as a result of my point of view. I am
guessing now, but they may have thought that my concern for human
suffering led to an intolerable degree of intellectual sloppiness. Heart
getting in the way of head. What we have though is conflicting principles,
ideologies, one of which is efficiency versus equity.
As I will also say later, there is great disagreement among economists
when it comes to discussing macroeconomic policy. There are devotees of
austerity and Keynesians, and they argue their positions with religious
fervour. My own view, as a non-economist, is that data really should settle
it. In practice, it does not. Alan Blinder, a self-declared liberal Keynesian
economist at Princeton, quoted a Chicago economist, John Cochrane, as
saying that Keynesian economics is ‘not part of what anybody has taught
graduate students since the 1960s. [Keynesian ideas] are fairy tales that
have been proved false.’ Blinder comments: ‘The first statement is
demonstrably false; the second is absurd.’ Blinder then goes on to call this
dismissal of Keynes’s ideas ideological. That said, and despite the heavy
interplay of ideology and evidence, economic evidence is important.30
When I come to discuss early child development I will touch on the long-
standing debates on nature and nurture. Here, I think that thought and
evidence can help penetrate the ideological positions, even if it does not
change them completely. Environmental determinists will not issue a mea
culpa and convert to genetic determinists; nor vice versa. But evidence
matters.
Economists and public health people disagree, too. Recently, I proposed a
screening test to detect an economist: if someone comes across the social
gradient in health and assumes that health leads to socio-economic position,
rather than social circumstances lead to health, then he is an economist.31
Like all screening tests there are false positives and false negatives, but the
typical economist starting position is that people’s health determines what
happens to them. The public health starting position is that what happens to
people affects their health. When economists analyse birth cohort data they
find evidence that health in childhood influences adult socio-economic
position. When public health people analyse the same data they find

evidence that childhood socio-economic circumstances influence adult
health. Each concludes that their pathway is more important.
One economist was furious with me for pointing out this alleged bias. He
said that any sensible person would conclude that the pathway can go both
ways – from wealth to health and from health to wealth; I give too little
credence to the possibility that ill-health causes low social position. I agree.
I do give too little credence to it. Not because it cannot happen. For
example, ill-health can lead to inability to work. Particularly where there
are no safety nets, of the type described in Chapter 9, inability to work will,
of course, lead to lack of income. But, in my view the evidence is
overwhelming that social condition, acting through the life course,
influences health and health equity. No, my concern is the tendency of
many economists to emphasise this health-to-wealth pathway – I would call
it reverse causation – to the exclusion of a focus on the social determinants
of ill-health of the type that this book has addressed. That is not prejudice
on my side, it is an empirical observation. More or less every time I have
given a lecture and someone has asked if I have considered the possibility
that everything I have said is wrong, because ill-health leads to low social
position, that someone has been an economist.
This is not just a polite, or even testy, academic debate. The policy
implication of these two positions is quite different. If the main causal
direction goes from health to wealth the appropriate intervention is to
control illness in order to improve an individual’s social and economic
fortunes or, indeed, eradicate illness to improve the economy of a whole
country. If, as I conclude, the main causes of health inequalities reside in the
circumstances in which people are born, grow, live, work and age – the
social determinants of health – then action to reduce health inequalities
must confront those circumstances and the fundamental drivers of those
circumstances: economics, social policies and governance.
When we published Fair Society, Healthy Lives, the Marmot Review of
health inequalities in England, Social Science and Medicine, an academic
journal, invited eight commentators to give their reactions to our report.32
Six of the commentaries are in little doubt that we have enough evidence
to take action, although all, like us, want a stronger evidence base. Some
commentators thought we put too much emphasis on income, some said too
little. Some thought we had made great strides politically, some that we
were not political enough. Absolutely fine with me. Exactly what you

expect when you ask for comments. The comments were a constructive
contribution to the debate.
What of the other two commentators? They were economists. As
expected, their starting position was that people’s health determines what
happens to them. The Marmot Review’s starting position was that what
happens to people has a cumulative effect throughout their life course,
progressively affecting their health.
This issue of reverse causation has been examined extensively in the
epidemiological literature. The debate has been around for a long time. I
reviewed it, in extenso, in my book Status Syndrome,33 where I concluded
that there was strong and conclusive evidence for social causation – social
conditions cause health. When the Social Science and Medicine debate
surfaced I happened to be reading Dickens’s Hard Times. Here is Dickens
on housing: ‘In the hardest working part of Coketown, . . . where Nature
was as strongly bricked out as killing airs and gases were bricked in.’ He
also describes the terrible working conditions in Coketown.
Should we really assume that these dark satanic mills and airless places,
rather than causing terrible illness and shortened lives, selectively employed
and attracted as residents sick people and those whose backgrounds
accounted for all their subsequent illness? That subsequent improvement in
living and working conditions, thus abating Victorian squalor, and
associated improvements in health, were correlation, not causation? That
while medical care improved health, housing also got better, and an
intellectually slack public health profession mistook the improvement in
housing and working conditions for causes of improved health?
If proponents of this set of assumptions dropped their guard for a
moment and accepted the evidence that air pollution, crowded living space,
ghastly working conditions and poor nutrition were causes of ill-health in
Victorian times why, a priori, do they start from the position that living and
working conditions are not a cause of ill-health in the twenty-first century?
Of course, this disagreement between commentators is not just about
evidence. It is also about ideology. Talking to a senior economist, Anton
Muscatelli, Principal of Glasgow University, I said that you can explain
why we in public health may emphasise the wealth-to-health pathway. We
want to improve health and the evidence suggests that improving social
conditions is an important way to get there. Why do economists take the
reverse position, I asked, do they not want to improve society? Professor

Muscatelli’s response: economists are taught that health is a contribution to
wealth, rather than the other way round, because it is easier to model in
their equations. Not a very exalted ideology, then.
What I can say is that not all economists take the same view. Amartya
Sen was a member of the Commission on Social Determinants of Health,
and Sir Tony Atkinson was a Commissioner of the Marmot Review. Each
signed up to the conclusions in the respective reports. Jim Smith, whose
work showing how health affects income is quoted, also showed elegantly
the powerful influence of education on health; such that income drops out
of the model.
The fact that ideology, of various degrees of fervour, infuses debates
about evidence does not dim my respect for the evidence. All of the
conclusions and recommendations in this book are based on evidence. But I
will assert that I do have an ideology: avoidable health inequalities are
unjust. We need the best evidence that will help us take steps to make
society more just, and reduce health inequity.

4
Equity from the Start
So we beat on, boats against the current, borne back ceaselessly into the past.
F. Scott Fitzgerald, The Great Gatsby
In Aldous Huxley’s dystopia Brave New World there were five castes. The
Alphas and Betas were allowed to develop normally. The Gammas, Deltas
and Epsilons were treated with chemicals to arrest their development
intellectually and physically. The result: a neatly stratified society with
intellectual function, and physical development, correlated with caste.
That was satire, wasn’t it? No relation with real life. We would never,
surely, tolerate a state of affairs that stratified people, then made it harder
for the lower orders, but helped the higher orders, to reach their full
potential. Were we to find a chemical in the water, or in food, that was
damaging children’s growth and their brains worldwide, and thus their
intellectual development and control of emotions, we would clamour for
immediate action. Remove the chemical and allow all our children to
flourish, not only the Alphas and Betas.
Yet, unwittingly perhaps, we do tolerate such a state of affairs. The
pollutant is poverty or, more generally, lower rank in the social hierarchy,
and it limits children’s intellectual and social development. We should want
that removed as if it were any other toxin so that children can develop their
potential, to flourish across the whole social gradient, not only at the top.
What happens to children in the early years has a profound effect on their
life chances and hence their health as adults. At the heart of it is
empowerment, developing the capacities to enjoy basic freedoms that give
life meaning; and early child experiences have a determining influence on
that development. Early child development is influenced in part by quality
of parenting or caring from others; which in turn are influenced by the
circumstances in which parenting takes place.

Perhaps the thought crossed your mind that removing the toxin of
poverty or social disadvantage would still leave some children with greater
intellectual and social flourishing than others. Of course. Which is why I
use the words ‘develop their potential’ and ‘flourish’. If we remove the
damaging effects of social disadvantage, the fact will remain that
individuals vary in dexterity, chess-playing, mathematics, creativity, athletic
potential, sociability. There are many ways to flourish. Long live diversity.
Recent books address this question.1 Nor would I call this diversity unfair,
other than in the ironic sense that the gods are unfair. The unfairness comes
if children, by dint of circumstances acting over years, are deprived of the
opportunity to flourish.
There is a great deal to celebrate in the revolution in child survival. All
over the world, child mortality has been coming down, albeit there are still
huge inequalities, as shown in Chapter 1. In its way there is an even bigger
tragedy that is the subject of this chapter: for each child that dies
unnecessarily, there are twenty-five or more who survive but do not develop
to their potential.2
As I shall show in this chapter, social conditions in which parents bear
and raise their children have a big influence on the quality of their
development. And children who survive and develop to their potential will
become healthier adults with reductions in inequalities in health. The case
for social action is compelling.
Not in the minds of some. It was put to me by one minister of health in
Europe that the whole notion of social determinants of health is wrong-
headed. It is no business of governments, health practitioners or the World
Health Organization to meddle with society. Health is a matter of personal
responsibility.
My response was: you might blame adults for their absent-mindedness in
being poor, let alone what you see as their disgraceful behaviour in risking
their health by eating cheap food and being too ground down and poor to
join a gym or Pilates class. Fecklessness, it has been called, or being one of
the undeserving poor – but don’t blame the children! They do not choose
their parents; they do not choose to be born in poverty.
Holding adults responsible for their own misfortune is one thing.
Condemning children because of their parents is to take a rather primitive
biblical approach: the parents have eaten sour grapes and the children’s
teeth are set on edge.3 Ensuring the health and well-being of children,

regardless of how blameworthy you judge their parents to be, might even
cut across prior political beliefs. Once, a bit overwrought, I declared to
colleagues at the American Medical Association: Republicans, Democrats, I
couldn’t care less. This is our children we are talking about. Would there be
a politician in America who said they didn’t care about the children? ‘You’d
be surprised,’ was the response.
This chapter will lay out the evidence that position on the social gradient
affects parenting, which in turn affects cognitive, social and emotional, as
well as physical development of children, which in turn is related to
inequities in mental and physical health in adulthood. We have then a model
of causation. There are at least two pieces missing from this model. First,
what goes into the mix I have summed up as ‘position on the social gradient
affects parenting’; second, how do these social and psychosocial influences
affect bodily processes, how do social influences get under the skin?4
But first, let’s look at why it matters. Experiences in childhood are vital
for adult health, and for crime. We can then go on to examine the causes of
the social gradient in early child development, and see how equity from the
start is strongly linked to health equity at later ages.
CHILDHOOD EXPERIENCE AFFECTS ADULT HEALTH . . .
AND CRIME
Two great Canadians, Fraser Mustard and Clyde Hertzman, did as much as
anyone to emphasise the relevance to adult health and health inequities of
the circumstances in which children are born, grow and develop. Fraser
Mustard, a charismatic figure, was a cardiovascular scientist whose research
led to the recognition of aspirin in preventing cardiovascular disease, an
innovative medical educator at McMasters University, and founder
President of the Canadian Institute for Advanced Research (then CIAR,
now CIFAR). His mission at CIAR was to bring the best people together,
regardless of discipline, to work on a particular topic. He got the medical
scientists to engage with economists, educators, psychologists and
sociologists in pursuing population health.
Fraser Mustard turned up in my room at UCL in about 1986 because he
wanted to hear about the Whitehall studies of British civil servants. The
Whitehall II study had just been launched as a study of men and women in

the Civil Service aged 35–55 at entry to the study. As Fraser told it, the
Whitehall social gradient in mortality from cardiovascular disease, and a
range of other diseases, convinced him of the importance of social
determinants of health. I was simply trying to do good science, but Fraser
wanted to focus on the profound policy implications of the gradient.
‘There are no policy implications,’ I told him. ‘Mrs Thatcher has
declared that there is no such thing as society. And the Department of
Health has ruled that health inequalities are not a matter for discussion. All
of which means that I am doing pure science with no policy implications.’
Fraser assured me that there were policy implications in Canada.
He then asked if I had considered early life influences on the social
gradient in health in adults. I tried to explain that I was studying civil
servants. They sprang into adulthood, fully formed, clutching umbrellas.
They had no childhood. Fraser was totally persuaded by the evidence that
early life experiences shape children’s development, and indeed their
brains, and change the development of health and ill-health in adult life.
Civil servants and others, he said, come to their adult lives with the
experiences of early childhood impressed upon them. Now, I am persuaded
too. There is abundant evidence. Hence this chapter.
Clyde Hertzman was – he died tragically early, aged fifty-nine – a young
doctor spotted by Fraser at McMasters as a future star. He picked up on the
importance of early life, both synthesising the science and taking out into
the community measures of early child development and what can be done
to improve them.5 I invited Clyde to convene the knowledge network on
early child development for the WHO Commission on Social Determinants
of Health. Clyde’s inspiration runs right through the relevant chapter of the
final report of the commission, Closing the Gap in a Generation, and this
chapter.
Clyde, and his collaborator Chris Power, identified ways that childhood
experience can influence adult health. We can group these into two. First is
accumulation of advantage and disadvantage through the life course. Poor
early child development leads to worse performance in school, which
means a lower-status job, less money, worse living conditions in adult life –
all of which can damage health. Not only can where you start off influence
where you end up, but advantage and disadvantage accumulate. Second are
the effects of events in early life on health in later life: events at one time of
life exert bad effects on health later on – latency effect.6

Accumulation of disadvantage through the life course leads both to ill-
health and to crime
The City of Baltimore in the US state of Maryland is marked by stark
inequalities. A young man, let’s call him LeShawn, has grown up in the
Upton/Druid Heights neighbourhood in Baltimore’s inner city. Bobby has
grown up in Greater Roland Park/Poplar. Life expectancy in Upton/Druid is
sixty-three; in Roland Park, eighty-three. This is of the same order as the
gap we now see in Glasgow.
LeShawn’s was a single-parent family, like half the others in
Upton/Druid Heights. Their household income in 2010 was $17,000, the
median for the neighbourhood. At school, in common with four out of ten
of his classmates, he scored under the ‘proficient’ mark in reading in the
third grade; and in high school he was one of the more than half of his
neighbourhood who had missed at least twenty days of school a year.
LeShawn completed high school, but like 90 per cent of his neighbourhood
he did not go on to college. It was during the school years that he gave his
mother the most worry. It seemed as if everyone his age was getting
arrested. In fact, each year, in Upton/Druid Heights, a third of youngsters
aged ten to seventeen were arrested for some ‘juvenile disorder’. A third
every year means that there is little chance that LeShawn would get to the
age of seventeen without a criminal record, with everything that means for
the future. In Upton/Druid, in the period 2005 to 2009, there were 100 non-
fatal shootings for every 10,000 residents, and nearly forty homicides.
You can write the script for the contrast with Bobby in Roland Park.
Bobby, and all but 7 per cent of his neighbours, grew up in two-parent
families, median income $90,000. Bobby was one of the 97 per cent of his
neighbourhood to achieve ‘proficient or advanced’ in the third grade
reading. He was not among the 8 per cent who missed at least twenty days a
year of high school, and he was one of the three-quarters who completed
college. When it comes to juvenile arrests, there are no guarantees of
immunity, but the figure for Roland Park is one in fifty each year, compared
to the one in three in Upton/Druid. Another stark contrast with
Upton/Druid: there were no non-fatal shootings in 2005–2009, and four
homicides per 10,000 – one-tenth of the Upton/Druid rate.
Writing from England, I cannot help but comment that had guns not been
freely available there would have been far fewer non-fatal shootings and

homicides in either area. Deprivation leads to crime, but without ready
access to guns, at least your violent behaviour toward your neighbours does
not end up with someone getting shot. As a reminder, the differences in
lifetime experiences between neighbourhoods are not just in crime.
LeShawn and others like him from the deprived part of town face twenty
years’ shorter life expectancy than Bobby and his neighbours from classy
Roland Park.
I have ignored the fact that the population of Upton/Druid is almost
exclusively black and that of Roland Park nearly uniformly white. The
determinants of health, and crime, are not blackness or whiteness, but
accumulation of disadvantage through the life course. The perspective of
the ‘causes of the causes’ recognises that advantage and disadvantage are,
in the US, closely linked with race, largely because of widespread and
institutional discrimination.
The link between crime and ill-health was brought home by the riots that
scarred London in the summer of 2011. The year before, I had been citing
Tottenham as containing a ward, Tottenham Green, that had the worst male
life expectancy in London, eighteen years shorter than Queens Gate Ward in
Kensington and Chelsea. No surprise that the riots should have started in
Tottenham, and not in Kensington and Chelsea.
As just shown in Baltimore, there is a close correlation between the
geographical distribution of ill-health and of crime. Not that one causes the
other, but that they have common causes. A British newspaper pointed out
that in the Tottenham riot one handler of stolen goods had a job, and
another parked his VW round the corner. Hence, the paper concluded, there
was no link between poverty and urban unrest. A politician said that this
was criminality pure and simple. To misquote Oscar Wilde, the riots were
not very pure and their causes are certainly not simple. But relative poverty
and disadvantage play a role. The Guardian newspaper reported that of
1,000 rioters going through the magistrates’ courts only 8.6 per cent were in
employment or training, i.e. 91.4 per cent were not. Nationally, NEET (Not
in Employment, Education or Training) is about 10 per cent. No link
between social disadvantage and being hauled in for crime in the rioting?
The link is astonishingly strong: 91 per cent of rioters were NEET versus 10
per cent of non-rioters. With a few exceptions, people in jobs or education
did not take part in, or strictly were not caught for, committing crimes
during the riots.

That which does not kill us makes us . . . more vulnerable. Events in
childhood influence adult health – latency effect
There is a second way in which early childhood may matter for adult health.
The thrust of physician David Barker’s work was to show that growth in
utero and in the first year of life was important to the risk of heart disease
and diabetes when these infants became adults.7 Poor nutrition in this early
period can change subsequent risk of disease. The risk will be affected by
later events, but an episode or period of malnutrition can have a lasting
effect.
What David Barker showed for the effects in adult life of poor nutrition
in infants may also apply to social and psychological – psychosocial –
experiences. We should have long known this, but a study that put it on the
map in 1998 was done in California and is known as the ACE, Adverse
Childhood Experiences, study.8 Just over 8,000 people living in San Diego
were asked if, during their first eighteen years of life, they had experienced
any of three categories of childhood abuse: psychological – being
frequently put down or sworn at, or in fear of physical harm; physical; and
sexual – four questions about being forced into various acts. They were also
asked about four categories of household dysfunction: someone they lived
with a problem drinker or user of street drugs; mental illness or attempted
suicide of a household member; mother treated violently; criminal
behaviour in the household.
The first striking finding is that if people reported one of these adverse
experiences they were likely to report at least one other; and more than half
reported at least two others. Adverse experiences tend to cluster. The
question is what happens when these individuals reach adulthood.
People love to quote Nietzsche: that which does not kill us makes us
stronger. Well, it doesn’t actually. It makes us more likely to get sick. If we
think of those who report no adverse experiences as the reference group,
compared with them, the more different types of adverse experience a
person had, the greater the risk of depression and attempted suicide. People
who had four or more different types of adverse childhood experience had
nearly five times the risk of having spent two or more weeks in depressed
mood the previous year, and twelve times the risk of having attempted
suicide.

In general, the more types of adverse childhood experience, the more
likely people were to describe themselves as alcoholic, to have injected
drugs, to have had fifty or more partners in sexual intercourse.
When I first read this study I objected that perhaps people with mental
illness or behavioural problems as adults were more likely to ‘recall’
adverse childhood experiences – memory of such things is notoriously
unreliable. In other words, the relation with mental illness might not be
causal but be biased by people with mental illness searching their
background for reasons and coming up with blameable events in their
childhood. But – and this is a big objection to my objection – the more
adverse experiences, the higher the risk of diabetes, of chronic obstructive
pulmonary disease (bronchitis or emphysema), stroke and heart disease. It
is a good deal less likely that people with physical illness were spuriously
blaming their childhood for their diabetes or heart disease.
A notable feature of the ACE study is that the study participants were all
enrolees in a prepaid Health Maintenance Organisation (a type of health
insurance) in San Diego. They were not a down-and-out population. As
well as having health insurance, 94 per cent had graduated from high
school, and 43 per cent were college graduates.
The ACE study was not a one-off. A review of 124 studies confirmed
that child physical abuse, emotional abuse and neglect (they did not study
sexual abuse) are linked to adult mental disorders, suicide attempts, drug
use, sexually transmitted infections and risky sexual behaviour.9 The
authors of the review concluded that this is more than simple correlation but
represents causation.
The graded nature of the relation between abuse and adult mental, and
perhaps physical, ill-health – the more types of abuse the worse the adult
health – suggests that we should not be looking only at exceptional episodes
of abuse but, more generally, at quality of early child development. Indeed,
further evidence supports this. Britain has been blessed by a series of long-
term studies of people born at a particular moment and followed through
their lives. One of these, the 1958 British birth cohort study, followed a
national sample of people born in the first week of March 1958. It showed
that children who were not read to daily by their parents, who did not adjust
easily when first attending school, and whose height increased slowly, an
indicator of poor nutrition, were far more likely to have poor health at age
thirty-three than people who were more ‘advantaged’. This impact on adult

ill-health was independent of all other influences from subsequent periods
of their lives that could be studied.
It all sounds like common sense. Childhood experiences matter. But the
fact that it sounds reasonable does not make it true – as I argued with
Nietzsche’s evocative declaration. Geneticists would argue that nurture
matters little, it is nature that determines outcomes – I will come back to
this idea a little later in the chapter. Of course, genes matter. But the
evidence shows that what happens in early childhood has a powerful effect
on health and disease in adult life through the causal pathways discussed.
The long-term effects of early exposure and the accumulation of advantage
and disadvantage through life, whereby childhood experiences determine
education, employment, income and, more generally, empowerment in adult
life, are responsible for determining inequalities in health.
INEQUALITIES IN EARLY CHILD DEVELOPMENT – THE
SOCIAL GRADIENT STARTS EARLY
Here is a novelist’s perspective on socio-economic differences in attitudes
to rearing young children, contrasting a low-income area of North West
London (Caldwell) with its ‘other’: ‘Caldwell people felt everything would
be fine as long as you didn’t actually throw the child down the stairs. Non-
Caldwell people felt nothing would be fine unless everything was done
perfectly and even then there was no guarantee.’10 I would add, and there is
a gradient between these two extremes. The evidence shows that what
happens to children does make a profound difference, and it differs by
social circumstances.
With that in mind, let’s consider four children: Alex, Beth, Claire and
Debbie, or A, B, C and D for short. When measured at twenty-two months,
Alex and Beth, A and B, are in the top 10 per cent on a measure of
cognitive performance, something akin to intelligence; Claire and Debbie,
C and D, are in the bottom 10 per cent. If we follow these four children
until they are ten years old, what is likely to happen to their cognitive
scores?
Figure 4.1 gives the answer, and it is one that should give us pause.
Looking first at A and B, the ‘clever’ ones, Alex is raised in a family of
higher socio-economic position and her scores remain high over the period

up to ten years of age. Beth’s family is of lower socio-economic position,
and her relative ranking on cognitive scores plummets over time. Now look
at Claire and Debbie, the ‘not-so-clever’ ones at twenty-two months. Claire
is raised in a family of higher socio-economic position, and her scores shoot
upwards as she approaches age ten. Debbie is raised in a family of lower
socio-economic position and her scores remain low. These four children are
emblematic of what occurs on average in Britain and in other wealthy
countries.
(The convergence of the curves between time one and time two – the first
and second measurements – results from regression to the mean and need
not detain us here.)
FIGURE 4.1: JUST HANG IN AND NORMAL SERVICE RESUMES
Returning to our four children, the effects are dramatic. Assume for a
moment that all the differences in cognitive function at twenty-two months
are biologically determined – genetic endowment, experiences in utero,
nutrition – and that all the changes that occur after twenty-two months are
to do with social environment, broadly conceived. The social trumps the
biological! Beth may be clever at twenty-two months, but her family is low-
status; her cleverness will diminish as she approaches ten years of age.
Claire may not be the brightest at twenty-two months; she just needs to
hang in and her scores will go up, as she is blessed with a family of high

socio-economic position. Debbie loses both ways – low score at twenty-two
months and having a family at the low end, socially.
I have simplified. Not all the differences at twenty-two months are
biological in origin; not all the differences associated with social level of
family will in fact be social – genetic effects may make a late appearance.11
What are LeShawn in Baltimore and Jimmy in Glasgow missing out on?
Quite a lot, it would seem. The political right would say that they suffer
from poor parenting and the left that it is poverty. They are both correct.
What is not correct is to conclude that there is nothing we can do about the
social gradient in early child development.
Figure 4.2 is my gift to both the political left and right. It shows the
proportion of children in each local authority in England rated as having a
‘good’ level of development at age five. Local authorities are ranked on
their degree of deprivation, or lack thereof, from 1, the most deprived, to
150, the most affluent. First, then, is the gift to the left. The graph shows
that the greater the degree of deprivation the smaller the proportion of
children who have a good level of development at age five. It is a gradient.
One message from the graph is that if the more deprived areas had their
socio-economic circumstances improved, there would be a higher
percentage of children with a good level of development. Reduce poverty
and you reduce inequalities in early child development. Poverty is
important.
FIGURE 4.2: A GOOD START? BETTER FOR SOME

But poverty is not destiny. A second message derives from the variation
around the line. At any given level of deprivation, some local authorities are
doing better than others. If we can find out what is happening in the ‘good’
areas to weaken the link between deprivation and poor early child
development, there is the potential for great advance.
There is actually a third message contained in Figure 4.2: the median is
under 60 per cent. Translated, that means that fewer than 60 per cent of
children nationally, in England, were rated as having a good level of
development aged five. Our most recent figures, 2013, put the figure at 52
per cent of children having a good level of development.12 Can it really be
true that in an advanced country like England, more than 40 per cent of
children do not have a good level of development?
Well, yes it can. Periodically, UNICEF (the UN children’s organisation)
publishes a report card, the results of which are shown in Figure 4.3.
When UNICEF examined four measures of child well-being, the UK
ranked sixteenth out of twenty-one. I tease my US colleagues that I do like
visiting the US – it’s the only big country that makes me feel better about
my own. The US ranks bottom of twenty-one rich countries. The poor
performance in child well-being in the US and the UK underlines the

importance of improving it across the whole of society, for the whole social
hierarchy (or gradient), not just for the poor.
FIGURE 4.3: THE PROBLEM WITH RANKINGS IS THAT SOMEONE HAS TO BE BOTTOM
There is another message from Figure 4.3, and that is that rankings can
change relatively quickly. Between the early and late 2000s, Sweden
slipped from 1 to 4. The UK went from equal 20th to 16th. The US
languished at the bottom. Changes in ranking suggest that changes in policy
and practice can have effects relatively quickly. We see this in local areas
where concerted action can change rankings in early childhood
development.
The challenge

The evidence shows us clearly the importance of the mind. It is not that the
material conditions of life are unimportant, but those conditions shape the
input children receive from parents and other carers.
We want our children to be bright, to be good at language, to learn how
to get on with other children and adults and control their emotions, and of
course to develop normally physically. Put more formally, we want children
to achieve their potential on cognitive development, development of and
use of language, social and emotional development, and physical
development. The chances of children achieving healthy development in all
these domains diminish progressively the lower their parents’ income. Why
is this? And what can we do about it?
Some parents do more
By the time children get to school, those from lower-status backgrounds
have fallen behind in their language development. In a remarkable study in
Kansas, researchers went into a number of family homes at set times over
the first four years of a child’s life and counted the amount of speech
addressed to the child. The results are staggering. The higher the socio-
economic level of the family the more words were addressed to the children
over the first forty-eight months of life. Children of professional parents
had 30 million more words addressed to them than children of families on
welfare.13 That’s more than an extra 20,000 words a day. Even if the
absolute numbers are exaggerated, it is not a surprise that children of
professional parents possess more highly honed verbal skills than children
of parents on welfare.
When the researchers studied the type of comments addressed to the
children, they found that discouragements were more common in the
families on welfare. It is not hard to paint the picture. In the US as in
Britain, welfare is hardly sufficient to eke out a living. Frazzled parents,
possibly a single parent, juggling multiple demands, perhaps depressed,
ground down, and, in the language of the authors of Scarcity, with reduced
band width, are more likely to scold their children and to want to keep them
under control.
To test out the contribution of parenting to the social gradient in child
development a group of us at UCL, led by Yvonne Kelly, analysed data
from the Millennium Birth Cohort Study, a national study in England. We

asked mothers of children aged three: was it important to talk to and to
cuddle their children? About 20 per cent of mothers denied that these
activities were important. We asked about reading, singing, playing; and
found that the lower the income the lower the scores on these parenting
activities. In fact, our analyses suggested that about a third of the social
gradient in linguistic development and about half of the social gradient in
social and emotional development could be attributed to differences in
parenting.
So who won the political argument?
Earlier in this section, I implied that worse child development scores among
the poor could serve as a political litmus test. The political left would blame
poverty, the right would blame individuals for their poor parenting. The
evidence shows that they are both correct, in part. ‘Good’ parenting is not
randomly distributed. It follows the social gradient – there is less of it lower
down the social hierarchy. When we see regular patterns such as these it is
hardly a complete explanation to blame individual parents. To be sure, it is
individuals who make the decisions whether to read to their children, or
engage them in conversation or play. But the freedom of those individuals
to make those decisions is shaped by the influences on them. For example,
maternal depression also follows the social gradient, more frequent lower
down. I would not blame a depressed woman for not having the energy to
read to her children. Short of depression, if a parent lower in the hierarchy
is ground down by misery, poverty and living in cramped conditions,
playing with children may become a luxury too far. The nature of parenting
is shaped by the context in which it takes place.
This is tricky terrain. It was reported to me that one woman living in
poverty complained: ‘That man Marmot is accusing me of being a bad
mother just because I’m poor.’
Difficult. My response is threefold, which means I’m almost certainly
bound to lose the public argument – a good sound bite would be better – but
it is based on the evidence I have just presented. First, good parenting is
important and is less common among the poor. Second, blame is unhelpful.
The context in which parenting takes place is really important. Third,
poverty is not destiny. The message of Figure 4.2 is that for a given level of
deprivation some children are doing better than others.

The general message from the scientific evidence is that there are good
grounds for intervening at two levels: reduction of poverty and supporting
parents in their parenting activities. We shall come to the policy
implications in a moment. First, though, if parents matter, how do they deal
with the work–life balance? Should they be home addressing an extra
20,000 words a day to their offspring, or should they be grinding maize so
the family can eat, toiling in a factory to eke out a living, or pursuing an
interesting career which might also be of benefit to their children? It is hard
to make those choices sound neutral.
EARLY CHILD DEVELOPMENT – WHERE SHOULD
PARENTS BE?
Two answers to that question are supplied by heart-felt testimonies from
mothers. The first is from England, but it could come from any rich
country:
There is a presentation of women who look after their own children full-time as air-headed,
spoilt and dowdy. However, there is also a prejudice against women who look after their
children but aren’t dowdy (yummy mummies); women who go back to work after having had
children; women who stay out of work but also employ nannies; women who work part-time
and look after their children the rest of the time.
I think the only way you could gain approval for your time-management, as a mother, would
be to look after your children all the time as well as working full-time but for some socially
useful enterprise (ideally voluntary work), while never relying on a man for money, yet never
claiming benefits either, but God forbid that you should have a private income.14
The second is from Ahmedabad, India, from the Self Employed Women’s
Association (SEWA):
According to the mothers, the immediate benefit of the crèche service is they can go to work at
ease and with peace of mind. Formerly, if there was no one at home to care for a young child
and the ‘khali’ or tobacco factory owners did not allow them to bring younger children to work,
the mothers would remain at home and forfeit the day’s wages. Only the husband would go to
the ‘khali’ [tobacco factory] and a single salary of Rs 8 to 10 per day was not enough for
covering daily household expenses. In such circumstances, the families could not afford to buy
even the basic necessities like food and just had to do without.
Mothers said that the crèches had resulted in increase in income because they could go out to
work. One of the mothers in Vanoti village expressed her satisfaction lucidly: ‘First, sister, we
had “rotlo” [thick bread] to eat only once a day. Now we can eat twice a day and have enough
money to buy vegetables also. I pray that this crèche will remain – it has been such a support to
me and my family.’15

It is difficult being a mother. Whether you are ten rupees away from
starvation or struggling with work–life balance in a rich country, it is not an
easy ride – the poorer you are the tougher the ride. The SEWA experience
makes it clear that, if the alternative is destitution, it is better for mothers to
work. Being able to feed your children is not bad compensation for missing
time with them.
In richer countries there has been much debate, and no little angst among
mothers, on whether the family is better served by a mother being in paid
employment or staying home with her children. In the UK, there has been a
problem for women on low pay that the economic benefits of work do not
make up for the cost of childcare. The economic incentives to work are not
there.
In focusing on mothers, I am not diminishing the role fathers might, or
even should, have. I am simply reflecting the usual.
Facts do not always count with ideologists, but it may be helpful to know
if there is evidence that young children are damaged by their mothers going
out to work. The Millennium Birth Cohort, as its name suggests, was started
in 2000. Colleagues of mine at UCL, led by Anne McMunn, noting the
controversy over mothers of young children combining work and childcare,
examined the impact of different household arrangements on social and
emotional development of children aged five.16 The most favourable
outcomes for the children, the best scores on socio-emotional behaviour, are
in families where both mothers and fathers are living in the same household
and in paid work. This outcome was evident even after taking account of
parents’ education and of family income.
The worst situation for children was to be in a household with no parent
working, particularly a single mother with no paid employment. Much of
this is because of poverty and maternal depression. Grim findings. Girls, in
particular, seem to suffer from their mothers not being in paid employment.
A tantalising finding that was not explained by the study, it sparks
speculation about gender roles. I am not sure what it means.
The finding that for parents to be working is, at the very least, not bad for
the child is not to deny the importance of maternal and paternal bonds with
the child. As we saw above, they are vital, particularly in the early months
of a child’s life. Paid maternity (and paternity) leave enables these bonds to
develop while reducing financial disadvantage. Jody Heymann, at UCLA,
has looked at the arrangements for paid maternity leave globally.17 The

USA stands out as providing no – I repeat no – state-guaranteed paid
maternity leave. It is not alone, however: neither Surinam nor Papua New
Guinea provide state-guaranteed paid maternity leave. Every other country
does.
DO PARENTS REALLY MATTER OR ARE THEY JUST
BYSTANDERS?
I do have one piece of advice for worried parents. Read the literature on
behavioural genetics.
Behavioural geneticists believe that what parents do with or for their
children matters little for their children’s cognitive and behavioural
development.18
If you believe this, all that reading to children, all the love, warmth and
attention that you bestow on them, is for naught – it makes little difference.
That does seem to be in direct contradiction to the evidence of profound
effects of parenting, and the circumstances in which parenting takes place,
on the physical, cognitive and linguistic, social and emotional development
of children. Above, I only touched on a vast scientific literature that shows
parental effects on children’s development.
How do we reconcile the research I reviewed above with the research of
behavioural geneticists? One answer, not the only one, is that we are asking
different questions. My primary concern is the regular patterns of
differences between countries and between social groups – why children
from the families of insecurely employed unskilled workers are less likely
to do well than children from the families of well-paid professionals.
Behavioural geneticists ask the question of why one person differs from
another – why, if you have two children, they are so different, the one from
the other.
Surely this is a false debate. To think that genes do not count in children’s
development would be to think nonsense. To deny the importance of
environment would be to turn a blind eye to the evidence. The balance
between genes and environment, and how they interact, will differ for
different characteristics. How tall you are is largely genetic – tall parents
have tall children, on average. Genes, however, do not explain why Dutch
men in 1858 had an average height of 163 cm (5 foot 4) and 140 years later

had reached 184 cm (over 6 foot).19 Improved nutrition accounts for that. In
other words, in a given environment where most people have good
nutrition, genetic differences will play a big part in determining why one
person is taller than another. Where there is marked environmental
variation, over 140 years in the Netherlands for example, genetic
differences will not tell us why there has been such spectacular growth in
average height.
The same principles apply to early child development. In twin studies, for
example, genetic variations are important for IQ and a range of other
characteristics. If the environment is largely controlled – twins come from
the same family – what else is there but genes? Twin studies do not address
the question of why you and your partner, both with university education,
are more likely to have children who go to university than is a couple
neither of whom graduated from high school. Genes may play a role here,
too, but so may the kinds of input that I review above.
When we turn to differences among countries, those in Figure 4.3 for
example, let alone differences between those OECD countries and countries
of South Asia, Africa and Latin America, it is very unlikely that we can
explain differences in early child development on the basis of genetic
variation. These country differences arise because of the different
circumstances in which children are raised.
HOW THE SOCIAL GRADIENT GETS UNDER THE SKIN –
BIOLOGICAL EMBEDDING
Early in this chapter I sketched out a causal pathway: position on the social
gradient affects parenting, which in turn affects cognitive, social and
emotional, as well as physical, development of children, which in turn is
related to social inequalities in mental and physical health in adulthood. I
said that there are at least two pieces missing from this model of causation.
First, what else goes into the mix I have labelled as ‘position on the social
gradient affects parenting’. I have attempted to fill in that gap. Second, how
do these social and psychosocial influences affect bodily processes – or, as
Clyde Hertzman and others have put it, get under the skin?20 The two are
linked. By understanding biological mechanisms we may get a better grasp

of what it is in the environment that influences the social gradient in
children’s development and subsequent health.
The brain has proved to be an active battleground for theories of how we
humans got to be as we are. The acclaimed evolutionary psychologist
Stephen Pinker wrote a whole book critical of the idea that the brain –
actually the mind, but you can’t have one without the other – was a blank
slate to be written on by experience.21 Of course. The way we see, speak,
exercise executive functions, think, feel emotions, and behave with others,
and the neurological pathways by which these happen, are similar for all of
us. Patterns of neurological wiring are common to us as a species. And we
share some of these wiring patterns with other primate species. Disorders in
the genetically determined wiring pattern can lead to psychological
disorders. Most experts who study autism, for example, think it can be
traced to biological inheritance of some form. Parents are not to blame.
However, the brain can be sculpted by experience. The word ‘sculpted’ is
important. If one child is easily distractible and another concentrates with a
fixity to be admired – this too follows the gradient: more distractibility in
more deprived children – it is hardly surprising to find that there may be
different neurological pathways involved. But sculpting implies changes to
the brain’s architecture, consequent upon experience.
Clyde Hertzman has summarised the elegant neurological research on
critical periods.22 The idea is that the developing child needs to be exposed
to the appropriate environmental inputs during the critical period. If not,
certain pathways never get developed.
Hearing, vision and emotional control all need appropriate input in the
first two to three years of life to develop normally. Language, numbers and
peer social skills can all start to develop a little later. You can learn a
foreign language after age ten or so, but you may never quite speak it with
the same accent-free facility that you would if you learnt it earlier. The key
point is that the environment needs to provide the right input.
The lower down the social hierarchy are children’s families, the less
likely are the kids to get the right input. Poor nutrition, both before birth
and after, stress, and appropriate cognitive stimulation are all vital. We have
dealt with cognitive stimulation above. Stress affecting the mother, which
becomes more common with increasing social disadvantage, has
demonstrable effects on the function and structure of the developing child’s

brain. Part of the effect of stress may be that it limits the parents’ cognitive
stimulation of their child. But there may be other pathways too.
Clyde Hertzman and his colleague Tom Boyce identify four biological
systems by which social disadvantage may get under the skin. First, the
HPA axis (hypothalamic pituitary adrenal cortex), by regulating the output
of the stress hormone cortisol, is one way the brain communicates a
response to stress to the rest of the body. Second, the autonomic nervous
system is an essential part of the body’s fight-or-flight mechanism. Third,
the development of memory, attention and other executive functions in the
prefrontal cortex of the brain may underpin the cognitive development that
we discussed above. Fourth are the systems of social affiliation involving
other parts of the brain, amygdala and locus coeruleus, mediated by
serotonin and other hormones.
There are exciting and rich pickings here for scientists investigating the
impact of social environment on mind and body, treated together. One of
the best worked out comes from the studies of Michael Meaney at McGill
University in Montreal. He has been peeling back the layers of
incomprehension to reveal a remarkably coherent picture, not only of how
the environment influences the brain and stress pathways, but how it
changes the function of genes – epigenetics.23
Mother rats nurture their pups in not so very different ways from those
enjoyed by human infants. The rats do it by licking and grooming their
offspring. One way to increase mother rat’s attentiveness is to handle the rat
and remove the pup from Mum for a brief period. On her pup’s return,
mother engages in extra licking and grooming. It turns out that this
especially attentive licking and grooming programmes the pup’s HPA axis.
The pup produces cortisol on cue when faced with a stress, but for the rest
of its life, the rat that has had this extra attention puts out less cortisol, on
average. Less cortisol, on the whole, is thought to be linked to less stress-
related illness. This conditioning effect has to take place in a short time
window, a critical period, in the first few days of life. Outside that window,
all the extra maternal attention has little effect.
It gets more interesting. The chronic overproduction of corticosterone,
the ratty equivalent of human cortisol, damages neurones in the brain of the
rats who did not get the mother’s special attention, leading to cognitive
deterioration. People are not rats, but some of the potential parallels with
humans should be intruding themselves. Over time, the rats who got less

attention from their mothers had faster deterioration in memory and in other
cognitive performance tasks.
For too long, we have been arguing over nature versus nurture; genes
versus environment. I was at it again a few moments ago. It’s the wrong
debate. Nurture can sculpt nature, and nature can influence the
environment. The long-term effect of maternal licking on the HPA axis is an
elegant example of environment affecting genes. DNA is the material that
constitutes genes. Simply put, genes dictate the production of proteins,
which do just about everything. Maternal attention during the appropriate
window of opportunity modifies DNA, and thus affects its function and
subsequent manufacture of proteins. A region of DNA that regulates HPA
axis function is altered (it is methylated), and that changes its function.
Over the next few years this already growing scientific literature is set to
expand rapidly. It is likely to provide a richer understanding of how the
social environment acting through the brain has long-term impact on
development, bodily function and disease risk.
WHAT CAN WE DO ABOUT PROBLEMS OF EARLY CHILD
DEVELOPMENT?
I described Figure 4.2 as a gift to both the political left and right. It
suggested there were two strategies to improve early child development:
reduce deprivation; and, for a given level of deprivation, apply knowledge
as summarised above to improve early childhood development.
Reducing deprivation
Poverty is neither simply an act of God nor something people do, or don’t
do, to themselves. The level of child poverty in a society is under a great
deal of political control. It is a choice made by the political system.
Figure 4.4 looks at child poverty in different countries before and after
taxes and social transfers.
Child poverty is a relative measure. For each country, the cut-off is less
than 50 per cent of median income.
Before social transfers, the levels of child poverty in Spain and France
were 19 per cent in each country. After taxes and transfers, child poverty
was reduced to 17 per cent in Spain but to 9 per cent in France. In Slovenia,

not a rich country, it is even lower at 6 per cent. The minister of finance, by
deciding what the level of child poverty should be, is probably having a
bigger effect on child development than the minister of health.
In the US, after taxes and transfers, child poverty is higher than in
Lithuania – 23 per cent compared with 15 per cent – despite having similar
levels of poverty pre-tax. I challenge my American colleagues: you live in a
functioning democracy. This must be the level of child poverty you want,
otherwise you would do something about it. Once again, I argue that this
should be above party politics. We are talking about our children, and their
future blighted by poverty.
FIGURE 4.4: THE MINISTER OF FINANCE COULD REDUCE CHILD POVERTY IF SHE
WISHED

We can see why it might be part of a consistent world view for the
political left to blame poor early child development on poverty and the right
on parenting. If you are of the persuasion that tax is theft, you will be
intolerant of using the tax system to reduce poverty. But if you are of that
persuasion you might find it uncomfortable to acknowledge that your tax
preferences are damaging children’s lives by failing to reduce poverty.
The evidence that early child development follows the social gradient
cannot be disputed. In my view, the evidence is persuasive that the material

conditions in which children grow up have a profound effect on how their
minds develop. While the precise contribution of parents or others can be
debated, it is a reasonable conclusion that poverty reduction will be good
for children’s physical, psychological, social and emotional development.
Breaking the link between poverty and poor early child development
I was invited to visit the English city of Birmingham. They have a set of
plans to implement my English Review, Fair Society, Healthy Lives.
Birmingham is more deprived than the average for England as a whole. As
expected from everything shown above, the proportion of children aged five
who were ranked as having a good level of early child development was
worse than the English average. That was in 2007. By 2010 they had closed
the gap. In only three years they had closed it. They could not have
abolished deprivation in that time, but they broke the link between
deprivation and poor early child development.
‘What did you do?’ I asked. They focused: they made good early child
development a priority. There are some well-evaluated programmes for
improving early child development, with the input of trained staff: Family
Nurse Partnership, Incredible Years Parenting Programme, Promoting
Alternative Thinking Strategies (PATHS), Triple P Parenting Programme.24
Children’s services applied these programmes and in three years they closed
the gap. When parents need help, providing it can make a huge difference.
What I have described is not a carefully controlled experiment. One should
be cautious of over-interpreting. The data do show, however, that rapid
improvement is possible.
More generally, provision of high-quality services for early childhood
makes a huge difference. Evidence suggests that after two years of age,
spending some time each week in stimulating and high-quality group care
benefits all children, and helps children from poorer backgrounds to gain
more. Provision of high-quality services is also a major poverty-reduction
strategy, enabling parental employment and so increasing family income.
Ideal provision includes multiple uses for childcare centres, such as advice
and support on parenting, health and diet. In the UK, wider community use
is supposed to occur in children’s centres, but often does not.25
The idea that provision of universal services helps to reduce the gradient,
by helping the worst-off more, is supported by evidence from France. Pre-

school has existed in France since the 1880s but enrolment rose
dramatically in the 1960s and 70s so that around 90 per cent of three-year-
old children are enrolled. An evaluation found that all children had some
benefit in cognitive scores, but poorer children benefited more, thereby
narrowing the gap with children from better-off families in subsequent
school performance.26
EQUALITY OF OPPORTUNITY?
In Chapter 3 I posed the question of whether it is enough to aim for equality
of opportunity in society, which must include the opportunity for children to
grow and develop to their full potential. I said that, as a doctor concerned
with health equity, outcomes mattered, too.
It’s easy enough to be in favour of equality of opportunity; doing
something about it is a good deal more challenging, especially as, in the
US, UK and other countries, increasing inequalities that are affecting adults
are also influencing life chances of the next generation. A telling illustration
is given by the Great Gatsby Curve. In 2012, Alan Krueger, Chairman of
the President’s Council of Economic Advisors, demonstrated the correlation
between inequality and social immobility between generations, which has
been dubbed the Great Gatsby Curve – perhaps not only referring to
accumulation of great wealth, but to the influence of one’s past history on
present circumstances (see the quote at the opening of this chapter). The
graph in Figure 4.5 shows that the growth of income inequality is not just
inequitable for the present adult population, it diminishes life chances for
the next generation – it diminishes equity between generations
(intergenerational equity).
FIGURE 4.5: INEQUALITY IS NOT JUST BAD FOR MUM AND DAD

The term ‘intergenerational earnings elasticity’ plots the resemblance
between the earnings of parents and the earnings of their adult children. To
explain: if the next generation’s earnings were exactly the same as their
parents – rich parents → rich children, middle-income parents → middle-
income children, poor parents → poor children – then a country would
score high on intergenerational earnings elasticity and would have low
social mobility between generations. For example, in Denmark there is only
a relatively small relation between the earnings of parents and the earnings
of their offspring – rich parents are only a little bit more likely to have rich
children than are poor parents. There is a great deal of social mobility, so
Denmark scores under 0.2 on this metric. By contrast the US and UK have
scores in the 0.45–0.5 range. How rich your parents are has a profound
influence on how rich you will turn out to be. Poor parents tend to have
poor children – social mobility is much lower.
The graph shows that the greater a country’s income inequality the lower
the social mobility. In other words, the greater the distance between the
rungs of the ladder, the harder it is to get from one rung to the next. Going
by the curve, Finland, Denmark and Norway experience high social
mobility between generations and low inequalities within generations. The
US and the UK are up at the other end. We might conclude that there is

genuine equality of opportunity in the Nordic countries, and a good deal
less in the US and UK. For the US, the Great Gatsby Curve is damning
evidence of the decline of the American dream.
The message of this chapter is that early child development matters
hugely for subsequent health and health equity, and that good early child
development is shaped by the environment in which children grow and
develop. Equity from the start is possible, but it will take action at all levels,
from the magnitude of income inequalities and social mobility, to levels of
poverty, to the quality of services and the care parents and others give to
their children. The developing mind of the child is key. He or she will
benefit more from school if he or she has had a better early child
development. It is the issue of education to which we turn next.

5
Education and Empowerment
We want to provide only such education as would enable the student to earn more. We hardly
give any thought to the improvement of the character of the educated. The girls, we say, do not
have to earn; so why should they be educated? As long as such ideas persist there is no hope of
our ever knowing the true value of education.
Mahatma Gandhi
You are a young girl sitting outside a rude shelter, humble but home, in a
Bangladeshi village, watching your baby brother play in the dirt – your
parents are both at work – and daydreaming. The fairy godmother appears
and asks: ‘How would you like a more secure future, better nutrition, a paid
job, control over the decision if and when to get married, defence against
being beaten by your husband, control over your sexuality and childbearing,
increased chance that children you choose to have survive and grow in good
health? Oh yes, and you can have an inside toilet, too – none of the
embarrassment and indignity your mother has of having to “go” outdoors.’
No belief in fairies is required. The remedy is called education. Not only
would it deliver all the good things the fairy godmother promised, it would
enhance your capacity to live an informed life, enable you to learn the
values of your culture and society, to participate in the wider community
and in the political decisions that affect your life, to exercise your freedoms
and claim your rights.1 There’s more: education can be fun; more fun than
starting a life of back-breaking menial toil at age ten or eleven, and being
married off to an older man at thirteen.
Sitting outside the hut, minding your little brother, you may give little
thought to public goods. You may not, but we should. Education is not just
good for the individual; it is good for all of us. A more educated society is
likely to be a healthier society. Education can do all that. In rich countries as
well as poor.

When we published the report of the Commission on Social
Determinants of Health, Closing the Gap in a Generation, with its list of
recommendations through the life course, I was asked by one journalist:
‘What’s the one thing you would recommend to the US President?’
‘One thing? . . . Read my report.’
Annoying perhaps, but had I thought we only needed to make one
recommendation, I would have made only one. That said, if I had to choose
one among all of our recommendations about daily life and social and
economic inequalities, it would be education, and in a global context,
education of women. It is central to women’s empowerment. Of course, by
education I don’t mean just years spent in a classroom, but the outcome of
education: knowledge, skills, opportunity and control over your life, and
gender equity and social inclusion. Were I Dickens, I would add: ‘graces of
the soul’ and ‘sentiments of the heart’.
Education is at the centre because it captures so much of everything else
that is in this book. Looking backwards through the life course, inequalities
in education are caused, in part, by inequalities in early child development.
Looking outwards from the individual to the society, inequalities in society
cause inequalities in education. Schools matter too – radical thought. And
good education in its turn leads on to all the good things promised by the
fairy godmother. It is worth repeating: at a stroke, a focus on educating girls
is the best single contributor to empowerment of women, with
improvements in national and community development and health for
women and their children.
EDUCATION IS GOOD . . . FOR CHILD SURVIVAL
Rightly, there has been much emphasis on improving access to primary
education, globally. It is scandalous, in any country, that children of either
gender should be deprived of the opportunity to attend primary school. That
problem is on its way to being solved. Crucial, now, is secondary and
tertiary education. Figure 5.1, with data from low- and middle-income
countries, shows how beneficial secondary education of mothers can be to
the next generation’s chance of taking up the struggle of life.
Figure 5.1 shows three things: first, the dramatic differences in infant
mortality between these low- and middle-income countries, from just over
120 per 1,000 live births in Mozambique to just over 20 in Colombia.

Second, within each country, women with secondary education, or higher
(the lower end of the vertical bars), have babies who are more likely to
survive than those of women with no education (the top end of the vertical
bars). Not shown is the gradient within countries, the fact that women with
primary education are in the middle: their babies have a better chance of
survival than those of women with no education but worse than those of
women with secondary education. Third, having a secondary education
reduces dramatically the disadvantage of having your baby in a poor
country with a high toll of infant deaths. In Mozambique, for example, the
infant mortality of the offspring of the educated women is a good deal
closer to the Colombian level than is the figure for those of uneducated
women.
FIGURE 5.1: GET EDUCATED OR MOVE
In Chapter 4, when discussing the social gradient in early child
development, the data suggested to me two strategies: reduce deprivation,
and break the link between deprivation and poor outcomes. So it is with

these data. Mozambique is more deprived than Colombia. One strategy for
reducing the high infant mortality in Mozambique is to reduce deprivation:
improve nutrition, sanitation and provision of medical care. A second
strategy is to educate women. Being educated will reduce the disadvantage
associated with living in a country with high average levels of deprivation
and infant mortality. And the effect is really big: in Mozambique going
from no education to secondary education is associated with infant
mortality falling from 140 to 60 per 1,000.
The effect of education of women in overcoming the disadvantage of
having babies in a poor country is so potentially worthwhile that we have to
ask if it is education itself that is so beneficial, or something correlated with
it. This question will recur, as we look at the link between education and
adult mortality in high-income countries. In the case of infant mortality,
education is almost certainly causal for all the reasons the fairy godmother
promised: better nutrition and sanitation, and mothers know more about
what to do to protect their children. The mother’s education is a much
stronger predictor of infant mortality than is household income or wealth.
So convinced by these findings are the authors of the United Nations
Human Development Report, that they conclude that development policy
should be focused more on education of women than on household
income.2 Two propositions overlap: that one way of increasing household
income is education of women, and that one way of making education more
likely is to increase household income. All of this is made more possible
with good policies.
In rich countries, now, infant mortality rates are under ten per 1,000 live
births. It is a dramatic result of strategy one: improving conditions and
access to care for all in society. But even here, we find that mothers with
more education have better child survival than mothers with less. The
differences may be 2.5 compared with 7.5, rather than 60 compared with
140 in Mozambique; but they remain important.
. . . AND FOR REDUCING FERTILITY
In high-income countries, we stopped worrying that if all babies survive
their entry into our chaotic world we would suffer overpopulation. France
has had a long concern with fertility below replacement rate. In Italy, too,

the number of children per woman is 1.4. I tease my Italian colleagues:
‘Italy is a Catholic country, contraception is proscribed, if you’re not having
babies it must mean you’ve given up sex.’ They reassure me they like sex,
but in Italy women are educated and know how to exercise the choice of
when, and how often, to reproduce.
So it is in low-income countries. Birth rates have not fallen below
replacement, at least not yet, but educated women are in control of their
reproduction. There have been welcome declines in child mortality rates
globally. Fewer babies dying does not necessarily mean an overstocked
planet. Fertility rates, the number of births per woman, have been declining,
particularly for more educated women. Figure 5.2 shows that in action.
I have only shown four countries, but could show one hundred and the
point would be the same. Women with more education have fewer children.
In Ethiopia it is particularly dramatic. The more educated women have two
children, compared with an average of more than six for their uneducated
sisters.
The problem for Ethiopia is shown in the ‘overall’ column. The country
as a whole has a fertility rate of 5.4 births for each woman – higher than the
fertility for women with primary education. Why? Because very few
women in Ethiopia have secondary education. No education or primary is
the norm. The likelihood is that if all women in Ethiopia had secondary
education, the fertility rate would be nearer to two births for each woman
rather than more than five.
FIGURE 5.2: KNOW WHEN TO SAY NO?
It is precisely lack of education that has led to fertility rates actually
rising between 1970 and 1990 in Sub-Saharan Africa, when they declined
in every other region of the world. A great deal has been written about
structural adjustment programmes.3 The International Monetary Fund
(IMF), when asked for help by countries in dire economic straits, had a

formula which required structural adjustment. That sounds neutral, but in
practice it meant the state spending less on public services and putting
things out to the market.
In Africa in the 1980s large cuts in public expenditure may have satisfied
those who equate government expenditure with waste and economic failure,
but such cuts meant that real expenditure on education per person fell by
nearly 50 per cent on average in Sub-Saharan Africa.4 In some countries
there was an actual decline in school enrolment; in others the previous
growth in the proportion of girls being educated slowed down.
This ‘natural experiment’ – that is being kind to structural adjustment:
others would use sharper descriptions – disempowered women. Cuts in
education meant that more women were denied the possibility of having the
knowledge, the skills, the freedoms to control their own reproduction. This
effect on fertility of reductions in education spending is a clear example of
damaging a public good: education does not only help individual women, it
is good for society. Because fertility rates went up in the 1980s, the number
of people reaching childbearing age twenty years later is high, so that
population increase will continue for longer than it might have done,
putting huge strains on already poor countries.
How does it work? Education leads to lower fertility rates in many of the
ways the fairy godmother promised. A more educated woman has access to
information, she can get access to contraception and service, and is more
likely to be an economic participant in the wider economy. So is her
husband, which reduces the incentive to have more children. They have
jobs and careers to pursue and will be less likely to see children as
insurance for their old age. Education gives women more control of both
their sexuality and their reproduction. And, of course, if education leads to
more babies surviving it reduces the incentive to have more, just in case.
. . . AND FOR YOUR OWN HEALTH
The US is an attractive destination both for highly qualified people, and for
those who are desperate, economically or politically. It has many good
features. Good health is not among them. In Chapter 1, I drew attention to
the US’s remarkably poor health for men and women – worse than would
have been predicted by that country’s income and wealth. A study by the

US National Academy of Science reaches similar conclusions, and points
out that the health disadvantage in the US, compared with so-called peer
countries, is biggest for Americans who are most disadvantaged.5
One group who are disadvantaged is African Americans. Another is
people with little education. They overlap. Black Americans have shorter
life expectancy than do white Americans, by 4.7 years for men and
3.3 years for women.6 The US reports much of its health statistics by race.
My own view is that skin pigment has little to do with health. So-called
racial differences in health are related to degrees of social disadvantage and
discrimination.
If the argument about social disadvantage is correct, we might see that
Black Americans have worse health than whites because of less education.
This does seem to be largely true for women, less so for men. Figure 5.3
gives figures for life expectancy by education for blacks and whites.7
Much of the health disadvantage among black women is linked to the
fact that they have less education, on average, than do white women.
Among men, there are two ways to describe what we see. Either white men
get more health advantage from their education than do black men – six
years’ black–white difference for men with a bachelor’s degree or higher –
or something is going badly wrong for white men with little education. In
fact, it is likely to be the latter. White men with little education have seen
their health decline over the last two decades.
FIGURE 5.3: IT DOESN’T JUST SEEM LONGER. . .
I cannot resist drawing attention, yet again, to the gradient. It is not
simply that people with little education have poor health – they do – but
there is a graded relation between years of education and length of life. We

see it even at the top. People with less time in college have shorter life
expectancy than those who went even further with sixteen or more years of
education.
Explanation for health disadvantage must include the gradient. We have
to explain not only why it is bad for your health to be uneducated in a poor
country, and to be relatively uneducated in a rich country, but also why the
more education you have the better your health.
We also have to explain why the strength of the link between education
and health varies. My colleagues and I at UCL in London were invited by
the European Commission to put together a group report on health in
Europe, focusing mainly on the European Union. Figure 5.4, from that
European Report, shows how dramatic are the health inequities both within
and between countries.8
It can be read in a similar way to Figure 5.1, which shows infant
mortality. Look, for example, at Estonia. The average life expectancy for
men at age twenty-five is only forty-five more years, ten years fewer than
Sweden. Now look within Estonia. Twenty-five-year-old men with the
lowest level of education have life expectancy of another thirty-six years, a
staggering seventeen years fewer than for men with the highest level of
education, at fifty-three more years. Adding the figures, that means that if
today’s death rates applied, a twenty-five-year-old with the lowest
educational level could only expect to survive to sixty-one, on average. By
contrast the twenty-five-year-old who has been to university or other
tertiary education can expect to be alive at seventy-eight. In Sweden,
everyone is doing better and the gap in life expectancy between the least
and most educated is about four years – not seventeen as in Estonia.
FIGURE 5.4: EUROPE: NOT ALL THE SAME THEN

In general, all the countries with the largest inequalities in life expectancy
are in central and eastern Europe. They are the poorer countries of the
region, with lowest national income, and they also tend to be those with the
lowest average life expectancy. But we see something else – another gift for
those who think that our health is mainly determined by the choices we
make. If you are going to have the lowest level of education you’d be well
advised to have it in Sweden, Italy or Norway, rather than in Estonia,
Hungary or Bulgaria. Putting it the other way: if you have the lowest level
of education, it really matters which country you live in. For those with the
highest level of education, it matters far less. We saw something similar
with infant mortality and mothers’ education in poor countries in
Figure 5.1. I call this ‘choice’. It is a grim mockery of choice. People have
no control over where they are born, and only some control over how much
education they get.
I hasten to add that length of life, life expectancy, is not all there is to
health. In our comparison of European countries, we also looked at whether
people felt themselves to be in poor health, and whether they had a long-
term illness. We found clear social gradients in these measures of ill-health
too – the lower the level of education the worse the health.
I started this book by emphasising that a combination of material
deprivation and disempowerment is responsible for many of the health
inequalities we see within and between countries. At lower levels national

income is important as a guide to material deprivation; and education is not
a bad proxy for empowerment. Are these really two separate influences or
can the apparent link between education and health shown in Figure 5.4 be
accounted for by the fact that less educated people are more likely to live in
deprived conditions?
In order to answer that question, we have to think what deprivation
means in Europe. In Sub-Saharan Africa and South Asia deprivation means
lack of basic conditions for health: water and sanitation, food and shelter.
More or less everyone in Europe has those things, yet we still see dramatic
inequities in health. To measure European deprivation we have used an
index constructed from responses to questions on the ability to afford:
• to pay rent or utility bills
• to keep the home adequately warm
• to face unexpected expenses
• to eat meat, fish or a protein equivalent every second day
• a week’s holiday away from home
• a car
• a washing machine
• a colour TV
• a telephone
The data show clearly that for individuals in Europe the greater the
material deprivation, in terms of the list above, the worse their health.9 It is
an interesting list. Deprivation in Bangladesh means having no bathroom,
watching your little brother grow too slowly because of too few calories to
eat, or catching infections because of having to drink dirty water.
Deprivation in Europe means no holiday, no car or colour TV, as well as
having to choose between eating and heating.
What happened to education? Education and material deprivation
overlap: in general, the less the education, the greater the deprivation. They
only overlap. They are not measuring all the same individuals. Both
material deprivation and education, independently, are linked to the social
gradient in health.
In sum, then, it is likely that even in rich countries the fairy godmother
got it about right. We can build a life-course picture. Inequalities in early
child development lead to inequalities in education. Educational outcome is
related to the kind of job you get, or whether you have a job at all, if you

have enough money to get by, and the choices you make about smoking,
drinking and lifestyle. All of these will have an impact on health and health
inequalities.
. . . AND FOR PROTECTING YOURSELF
I find these next figures almost too awful to contemplate. Demographic and
Health Surveys are conducted in many low- and middle-income countries.
One question asked women if they agreed that it was acceptable for a
husband to beat his wife if she refused to have sex with him.10 What would
be your guess as to how many women would endorse that proposition? The
answers for two countries are shown in Figure 5.5.
In Mali, just over half of women with primary education agreed that it
was all right for the husband to beat his wife. It had been higher. The
glimmer of hope is that the proportion agreeing was under 40 per cent
among women with secondary or higher education. In Ethiopia, 33 per cent
of women with primary education thought a beating was acceptable in
return for exercising control over their bodies; down from 45 per cent. The
figure was 11 per cent for women with secondary education or higher. And
so on, in country after country, education makes a difference. One
interpretation of these figures is that lack of education renders women more
vulnerable. Those in power, be they husbands or dominant ethnic groups or
tyrannical authorities, prey on the vulnerable. Education reduces women’s
vulnerability.
FIGURE 5.5: HE CAN DO WHAT?!

The first lesson when getting involved in global health is to be culturally
sensitive, to respect the reality that ‘they’ do things differently ‘over there’.
Very important, but respect does not supersede women’s rights. It is wrong
for one half of humanity, men, to have licence to batter the other half.
Women’s right to control their own bodies must surely trump cultural
sensitivity. If that is how ‘they’ do things, then they are wrong. The fact that
education of women makes this clear underlines the message. The
improvement over time, i.e. declining percentages, fuels my evidence-based
optimism.
Education may play a further role in women protecting themselves. It
helps women to gain paid employment. Being economically self-sufficient
reduces the chances of intimate partner violence.
. . . AND FOR YOUR COUNTRY’S DEVELOPMENT
‘Development’ is an evocative word. We used to talk about ‘developing’
and ‘developed’ countries. Was that supposed to imply that developed
countries had done it – it was all over, finished? Someone once defined an
optimist as one who thinks the present organisation of society is the best
that could possibly be. A pessimist is one who fears that that may very well
be true. Most of us would probably want our societies to continue to
develop, in the sense of getting better. Even those who think everything was
better before, and progressives wrecked everything, probably want
‘development’ in the sense of going back to a better time, whenever that
was. I cannot muster too much enthusiasm for a rose-tinted past.
The United Nations has a whole agency devoted to Development, the
UNDP. I find their reports invaluable. Pioneered by Mahbub ul Haq, and
influenced by Amartya Sen, UNDP recognises that development involves
much more than economic growth. It uses a Human Development Index,
HDI, that includes measures of national income, of education, and of life
expectancy. Further, rather than divide the world into developed and
developing it ranks countries on their HDI. In the 2013 Report Norway
ranked number 1 on HDI, and Democratic Republic of Congo and Niger
ranked joint bottom at 186.
Health and education are vital components of lives that people value. A
fundamental assumption underlying this book is that people value health.

The fact that the UN privileges these, and does not rely solely on national
income as the measure of development, is excellent.
While questions might be raised as to whether the planet could stand
continued growth in national incomes, putting sustainable development
under threat, improvements in health and education are considered by most
to be good things. Therefore, on the whole, growth in HDI is a good thing.
Such growth is damaged by inequality. According to analyses presented in
the UNDP’s 2013 Human Development Report, it turns out that inequalities
in education and health have a big impact on the HDI, but inequalities in
income do not. In fact more equal achievements in education and health
counteracted increases in income inequalities in their effects on human
development.
Even taking a narrower approach, and considering economic growth as
an outcome, public education was vital to economic development in Japan
in the Meiji era (1868–1912), and latterly to South Korea, Taiwan,
Singapore, Hong Kong and China.11
The fairy godmother might take note: improving equity both in education
and health is vital not just for a young girl in a village but for development
of the whole society. I don’t find any need to believe in fairies to believe
that the world can be made a better place, is being made a better place, by
improvements in education. Progress is never without its hitches and
glitches, inequalities chief among them, but the evidence is clear. When we
make a difference in improving education, improved health equity is likely
to follow.
UNDERSTANDING AND ADDRESSING INEQUALITIES . . .
BY LEARNING FROM FINLAND
All Finnish primary school children seem to look particularly fresh-faced,
healthy and actively engaged – a bit like their teachers, actually. The head
teacher tells me that the pupils at Ressu comprehensive school in Helsinki
are not from particularly privileged backgrounds. The catchment area has
three groups: academics, artists and working class. The head teacher is
polite, well informed, generous with her time, and very indulgent, given
that I am not the first to come to pray at the shrine of Finnish education.
Ever since the PISA (Programme of International Student Assessment)

showed Finland’s fifteen-year-olds scoring particularly well compared with
other European countries on standard tests, people have been wondering
how they do it. PISA is a study conducted regularly by the OECD, the rich
country club. It tests fifteen-year-olds on mathematics, science and literacy
using standardised tests – in so far as such things are possible in cross-
country research. Its results are pored over when they come out, as
countries examine how they fare.
The UK made a reputation as being a brainy country – a great many
discoveries, wonderful creative arts, brilliant universities. Despite that, we
don’t do very well on PISA tests. The US is no slouch either, when it comes
to innovation and skills. Why do the Finns do so brilliantly and the British
and Americans so badly on internationally standardised tests? It’s quite a
neat natural experiment, because the UK and Finland do things so
differently.
The current approach in the UK to improving education for our children
is for the relevant government minister to take central control, abolish
meddlesome local authority control of schools, set the national curriculum,
set out a programme of school visits by inspectors to make sure they are up
to scratch (the schools, that is, not the inspectors), and lay down the criteria
for what children should be able to achieve at various stages of their school
career. Central government will examine at each of these stages, publish
league tables of school performance to name and shame schools, and
abolish minimum qualifications for teachers so as to stimulate creativity.
Education and standards of education have become intensely political.
Finland has followed pretty much the reverse. There is a national
curriculum but teachers have a great deal of autonomy in deciding what
they teach; schools are under the control of local authorities; and there are
no tests to see if children have reached the relevant competency at various
ages. There is one national test at the end of nine years of basic education in
comprehensive schools, but the results are not published, not fed back to
pupils, and are used by the schools for statistical purposes so that they can
see how they are doing alongside other schools. All teachers have a
master’s degree – unthinkable to have less; teaching is highly prized and
teaching jobs are much sought; teacher training is research-based, so
teachers are encouraged to develop an enquiring approach to sort out
solutions for children who are having difficulties.

The Finnish system is based not on managerial control of teachers but on
both teachers and students taking responsibility. The lack of emphasis on
national exams represents a judgement not only that they are not necessary
for high levels of performance – witness the high PISA scores – but that
they represent too narrow an approach to education. Finland is interested in
educating future citizens who know how to work with people from diverse
backgrounds, are educated in music and culture, have learnt traditional
Finnish skills such as working with wood and textiles, and know how to
cook.
I put two contradictory hypotheses to my hosts – the head teacher and an
official from the teachers’ union. One is that school reduces the effect of
social disadvantage on educational performance. The other is that school
amplifies the effects of social advantage and disadvantage because the kids
from more stimulating backgrounds are better placed to take advantage of
what schools have to offer. No question in the teachers’ minds: Finnish
comprehensive schools reduce the effect of social disadvantage on
educational performance. Children who are having trouble – up to 30 per
cent of pupils – get special attention. Equality is the most important word in
Finnish education.
I suggested that if educational performance follows a bell-shaped curve,
their special attention to the children in trouble may have reduced the
prevalence of dumb-bells, but it may also have reduced elite performance,
fewer Nobels.* They were not having any of that. The teachers work not
only at helping the slower kids, but at challenging and extending the more
able.
Might it not be the case that Finland’s good performance educationally
may have less to do with schools and more to do with a relatively
homogeneous population with low levels of child poverty? This was a
typical academic’s question, wanting to isolate relevant variables. They
chided me gently. You cannot separate the performance of the schools from
the society and culture in which they are embedded. Schools are influenced
by culture and society, and their mission is to contribute to society and
culture in a positive way.
There are lessons to draw from the Finnish experience that are applicable
globally.

. . . AND, ALTHOUGH THERE ARE SOCIO-ECONOMIC
DIFFERENCES IN EDUCATION, POVERTY IS NOT
DESTINY!
In Finland, as in all other countries in the PISA Survey, the higher the
socio-economic and cultural level of the family, the better their fifteen-year-
olds perform on standard tests. Examples are shown in Figure 5.6. Please
forgive me if I remark, yet again, that it is not just children from poor
families that do poorly, but it is a social gradient in all the countries shown
here – shallowest in Macau and Finland, steepest in the Slovak Republic
and intermediate in the US and UK. Given everything in the first part of this
chapter, it is entirely reasonable to suggest that if we in the US and UK, and
much of Europe, want to catch up in educational performance with the
Chinese and the Finns, we have to take active steps to reduce the social
gradient in educational performance.
FIGURE 5.6: GETTING IT ALL TO ADD UP. . . FOR EVERYONE. KEEPING UP WITH THE
CHINESE.

I presented results such as these at a meeting convened to discuss
growing up in Tower Hamlets, a particularly deprived area of East London.
The Director of Education in Tower Hamlets challenged me:
‘Your results are out of date,’ she said.
That was hitting me where it hurt. What did she mean?
‘We tell ourselves every day, poverty is not destiny. We have broken the
link between deprivation and school performance.’
She sent me their results and, indeed, they had broken the link between
deprivation and outcome of education. That too is what the PISA results
show. Poverty, or more accurately, low scores on PISA’s measure of
economic, social and cultural status (ESCS), is not destiny. While all
countries show the socio-economic gradient, many young people perform
better than predicted by their ESCS background, and some perform worse.
PISA talks of resilient people who do well despite their social and
economic disadvantages. Schools and families matter. The Tower Hamlets
case shows that dedication on the part of teachers can make a huge
difference, making Tower Hamlets schools more like Finnish ones.
Disadvantage can be destiny, under the wrong circumstances. A
particularly telling, and upsetting, example of how economic, social and
cultural background can influence educational outcomes comes from
India’s caste system. Researchers for a World Bank Report on Equity gave
Indian children aged ten to twelve a set of puzzles.12 They had to solve
mazes in a fixed period of time, and were rewarded on the number of mazes
they solved. The children were from high-caste and low-caste backgrounds.
In the first part of the experiment, their caste background was in no way
made obvious. Under these conditions the lower- and higher-caste children
performed equally well on the intellectual task. It is the next part of the
experiment, when the children’s caste was revealed, that is upsetting. Under
these conditions, the lower-caste children performed significantly worse
than those from more privileged backgrounds – the lower-caste children
solved 25 per cent fewer mazes compared with when their caste was not
announced. One interpretation is that this is disempowerment in action.
Once the lower-caste children knew that the authority figures knew about
their background, they knew the game was rigged. No matter how hard they
tried, no matter how well they did, they would not get due reward for their
efforts.

There is a clear message: create the conditions so that caste is not destiny,
and children will do better regardless of their background. After one lecture
in the US, in which I featured these results, an African-American member
of the audience came up and gave me a big hug. ‘Now you know what it is
like to grow up black in the ghetto in the US,’ he said.
Putting these results together, we see socio-economic gradients in
educational performance more or less everywhere. The magnitude varies.
Evidence suggests that there are three sets of influence on these gradients:
the family, the wider socio-economic conditions and the school. One of the
predictors of school success is the readiness for school when children start.
As was laid out in the previous chapter, early child development, and hence
readiness for school, is influenced in part by parenting. Parents may have a
continuing influence in the school years. Peer effects, connected with the
socio-economic environment, will also be important. We saw in Baltimore
that in the more deprived part of the city the absence rates from school were
dramatically higher than in the ritzier parts of town – if everyone is at it,
why not me? The Finnish and the Tower Hamlets experiences suggest that
schools can really make a difference.
. . . AND FOR MOVING TO GENDER EQUITY
In Finland, now, not only has gender equity been achieved in primary and
secondary education – participation of girls and boys is 100 per cent – but
more women than men go on to tertiary education. Finland is not alone. The
figures suggest that there is a threshold globally for this phenomenon, and it
is related to national income in a clear-cut way (no gradient here). Below a
national income of around $10,000 (adjusted for purchasing power) fewer
women than men participate in tertiary education. Above that level, in most
countries, more women than men go on with their education. Gender isn’t
destiny either.
We see this in PISA scores. Study after study reports that girls are better
at language, boys at mathematics. Not in Finland. Girls are better at
reading, as they are in all countries, but girls do better at maths than do
boys – likewise in Sweden and Iceland.
Gender equity remains a problem for the rest of the world. The good
news, really good news, is that enrolment in primary education has
increased dramatically in all parts of the world in the last forty years,

despite hiccups, with improvements in gender equity. As Figure 5.7 shows,
the last forty years have also seen dramatic increases in enrolment in
secondary education.
FIGURE 5.7: SCHOOL’S OUT EARLY. . . IN SOME REGIONS
Continuing the good news, in Latin America, and East Asia and the
Pacific, girls’ participation overtook the boys’. But as Figure 5.7 shows,
gender equity remains a huge problem for secondary education in Sub-
Saharan Africa and South Asia. As we shall see in a moment, this should be
an intensely soluble problem. Put simply, gender equity in education is
likely to be a reflection of gender equity in society.
WHAT CAN BE DONE TO IMPROVE EDUCATION?
A great deal, it would seem. The problems are clear. In low-income
countries there are too few children in school, standards are indifferent, and
absentee rates are high. In countries poor, middle and rich, there are social
gradients in educational performance.
Don’t start from here

The best intervention to improve education is to start before school age. All
over Europe, children who were enrolled in formal pre-school programmes
have better performance on PISA scores at age fifteen. Important as it is to
increase participation in primary, secondary and tertiary education, we
should not forget pre-school. The principles of what constitutes good pre-
school education are well understood and were reviewed in the previous
chapter. It is not necessary to live in a rich country to have access to quality
pre-school. For example, the Mwana Mwende project in Kenya involves the
whole community in providing support, education and childcare for the
youngest children. The project trains parents in child and youth
development, community development and participatory processes. The
Mwana Mwende Child Development Centre, which set up the project, also
trains pre-school teachers to a professional level.
In Latin America the countries that have high enrolment in pre-school are
the same countries that do well on reading at school. Cuba and Costa Rica
have nearly 100 per cent attendance at pre-school, at ages three to five, and
have top reading scores in Latin America in sixth grade. Paraguay and the
Dominican Republic have low pre-school participation and low reading
scores in sixth grade. Argentina and Peru are somewhere in between. I
should beware of jumping to conclusions, but I do note that people in Cuba
and Costa Rica have remarkably good health (life expectancy at birth over
seventy-nine); Dominican Republic and Paraguay relatively poor health
(around seventy-three); and Argentina (seventy-six) and Peru (seventy-four)
come somewhere in between.
Money matters but is not everything
Education brings money and money brings education. This seems to work
for both poor countries and families within those countries. To be more
precise, among low-income countries, the greater their national income the
more they spend on education. For low-income families in those countries,
in general the higher their income the more they spend on education. But it
works the other way as well. Education of individuals, in general, brings
higher incomes; and education, as we have seen, has proved one route for
economic growth of countries.
Breaking into this cycle has proved quite possible. Many countries have
done it. In India 63 per cent of adults are literate. By contrast, in Vietnam

and Sri Lanka – the first a little poorer than India, the second a little richer –
more than 90 per cent of adults are literate. India’s economic growth at 6–8
per cent a year is the envy of the rich world, but it is likely that the benefits
of that growth would reach further if education were more widely spread.
One way countries have helped families to break out of the cycle of low
income→low education→low income is with help from outside.
Conditional cash-transfer schemes, first in Mexico and Brazil, were
developed as a way of reducing poverty AND producing long-term change.
Poor families are targeted and receive regular cash subsidies, provided they
meet certain conditions such as taking young children to nutrition and
health clinics, and keeping older children in school. The Mexican scheme,
originally known as Progresa, subsequently as Oportunidades, covered
5 million low-income households by 2004.13 The largest part of the cash
transfer came for children in school; more for older children and more for
girls.
I visited one Oportunidades location in a rural area outside Mexico City.
One young member of our party commented that the people queuing to
receive their benefits were all women, short, and looked ‘Indian’. Accurate
observation. Women, because giving cash to women is a more reliable
proposition than giving it to men. The money is more likely to be used to
support the family than if men chose its uses. Short, because poverty is
linked to malnutrition and hence to short height. ‘Indian’, because
indigenous groups are more likely to be in poverty.
These schemes work. In general, participants in a conditional cash
transfer scheme are more likely to have their children in school.14 The
conditionality element makes some of us uncomfortable. In effect, the
government is saying to poor families: we’ll give you cash, provided you do
what we tell you; take young children for check-ups and keep older children
in school. A recent review of seventy-five reports from thirty-five studies
compared schemes that gave cash without conditions with those that
imposed conditions. The unconditional schemes did increase school
enrolment, but the more the conditions were applied and monitored, the
greater the positive impact on school enrolment.15 That said, there are
examples, Malawi is one, where unconditional cash transfers had as big an
effect on girls staying in school as transfers with strings attached.16
The report highlighted the obvious but vital point. Keeping children in
school is one thing. Teaching them something is another. There was no

evidence that conditional cash transfer schemes improved test scores. The
implication is clear. You cannot get the benefit of school if you don’t turn
up, but real effort has to be put into improving quality of education as well
as the mere fact of it.
Improving quality is a concern for all countries, whether low-, medium-
or high-income. That a country does not have to be rich to get there is
shown by the staggering results on PISA scores by Macao-China, shown in
Figure 5.6, and similarly excellent results from Shanghai China.
Delivering good education
I have had my differences with economists over the years, but as my
economist friends tell me, they pale compared with the differences
economists have with each other. Two MIT economists, Abhijit Banerjee
and Esther Duflo, have carried out a programme of research on reducing
poverty.17 They use hard evidence to adjudicate the arguments among their
fellow economists. In particular, one set of views suggests that top-down
provision of education, from central or local government, will deliver good
education. The opposing view is leave it to the market: people will demand
good education and be willing to pay for it; the private sector will come in
and provide it.
Beware of ideology here. If one suggested to Finland that what they most
needed was a private sector in education with parents paying school fees,
rather than having schools funded from taxation, they would (politely,
because they are Finnish) show you the door. They have among the best
results outside Asia because of the way they run their affairs. On the other
hand, as Banerjee and Duflo point out, people do not trust state provision of
education in India, with some good reason based on experience. The private
sector is mixed in quality and the fees are out of reach of the poor. But
certain non-governmental organisations are providing high-quality
education that is making a difference. The message is that simple nostrums
such as public good/private bad or vice versa are too limited. We need to
take account of circumstances.
Countries like South Korea show us the way. It is possible from a
standing start to make dramatic improvements in educational performance.
In South Korea, success is due in part to significant investment in
education. The budget for the ministry of education is six times what it was

in 1990, and now represents 20 per cent of central government expenditure.
Teaching in Korea is a respected and competitive occupation – teachers are
well paid (ranked tenth in the world), and are rewarded after fifteen years of
service. The curriculum has been significantly revised over the last fifty
years, and now emphasises individuality, creativity and knowledge of
Korean and other cultures. There is a 93 per cent high-school graduation
rate, compared with 77 per cent in the USA.
Education is an important part of the life course, which highlights
education’s importance but also shows the difficulties in isolating its effects
on health. The picture so far is that the circumstances in which children are
born and grow have a profound effect on what happens to them in school.
The ‘outcome’ – skills, knowledge, ability to control their lives – will
determine what happens next in the world of work and in general living
standards as adults. Both the effects from earlier life and what happens
when young people leave school are important for health equity.
Improving education will take good schools, of course, but as the Finns
taught me, education takes place in a context. To achieve good educational
results, we also need action to reduce poverty and socio-economic
inequality and to improve the family and community context in which
children’s education takes place. One aspect of both redressing socio-
economic inequalities and improving family lives is work, the subject of the
next chapter.
* I am grateful to Helena Cronin for this terminology.

6
Working to Live
. . . all the melancholy-mad elephants, polished and oiled up for the day’s monotony, were at
their heavy exercise again . . . Every man was in the forest of looms where Stephen worked to
the crashing, smashing, tearing piece of mechanism at which he laboured.
Charles Dickens, Hard Times
Alan was a picker. In a vast warehouse. You order goods online. Alan goes
to the shelf where they are stored, ‘picks’ them, places them in a trolley and
takes them to the packer, who puts them in a box, sticks on a label, and you
have them a couple of days later. It’s so neat: you click, he picks, she packs
and sticks. It’s convenient for you; less so for Alan. Alan was a picker. He
was fired for collecting three penalty points, which he explained to me
when we met as part of a BBC Panorama programme.*
When on nights, a typical shift lasted ten and a half hours, punctuated by
two fifteen-minute breaks and one half-hour break – i.e. nine and a half
hours of work. On arrival for his shift, Alan was handed what was in effect
his controller and conscience: a hand-held electronic device that directed
him to Row X to pick up item Y and put it in his trolley; then to Row P to
pick up item Q, and so on. When his trolley contained about 250 kg his
device would direct Alan to the packers. Then he’d be off again for another
load. His target was 110 large items an hour (more for smaller items), two a
minute. That was the job, for nine and a half hours, plus the hour of breaks.
His hand-held electronic gizmo was not just his controller, it also fed
back what he had done, so his performance could be monitored to see how
he did against his target. He was warned when he did not keep up the pace.
If he fell too far behind he would incur half a penalty point; more, a whole
point. ‘Did you ever,’ I asked Alan, ‘in all the time you worked there, meet
your target and finish a shift with a sense of achievement?’ Not once, was

his answer. Hour after hour, day after day, and feeling always that he had
fallen short.
‘Did you feel that once you got used to it, at least you knew that you had
secure employment?’ No, he always felt he was on borrowed time because
of the penalty points.
‘How did other employees feel about the job?’ Alan didn’t know. He
rarely spoke to anyone but his line manager, whose job it was to warn him
about his failure to meet targets. There was no time to talk to other
employees while the shift was on. During the break, the walk from one end
of this aircraft hangar of a warehouse to the canteen took so long, plus the
security going in and out of the warehouse, that there was simply no time to
chat with anyone while taking a few minutes to eat and drink.
Alan told me that he used a pedometer one night and he clocked up
eleven miles (18 km). Bone-weary, his feet blistered, he had never felt more
exhausted in his life. When, on one shift, he went off sick he incurred
another penalty point. Doing a job like Alan’s, the employer is at some
pains to ensure you do not take work home with you – security at the door.
What Alan did take home with him was the beeping of his miniature
malevolent gizmo that echoed through his mind.
One day he turned up late for a shift, about three minutes, and added to
his penalty points. It took about eight weeks to accumulate the three penalty
points, but he did, and was summarily dismissed.
My reaction to Alan’s experiences was that it was as if his employers had
taken everything we know about damaging aspects of work, concentrated
them in a syringe and injected them into Alan. Added to the heavy physical
demands, Alan’s work was characterised by high demand with no control
over the work task, by high effort and little reward, by social isolation at
work, by job insecurity, by organisational injustice, and by shift work – all
of which, as I will lay out below, have been shown to damage health. About
the only ‘good’ thing about Alan’s work was that it wasn’t sedentary. That
would have been fine had his activity not involved physical strain and
heavy lifting.
In the 1930s film Modern Times, Charlie Chaplin pitted the little tramp
against the implacable will of the production line – to the detriment of the
little tramp. What’s changed since then is that we now have much more
evidence as to when, and under what circumstances, work is bad for health.
People in high-status jobs do not have working conditions like Alan and the

little tramp. People in low-status jobs don’t have to have such working
conditions either but, all too commonly, they do. Poor working conditions
make a major contribution to inequities in health.
Charlie Chaplin and Alan both illustrate the key theme of this book:
inequities in power, money and resources are the fundamental causes of
inequities in health. All three of these inequities stand out in the workplace:
the lower the position in the hierarchy, the more disempowered, the less the
money, and the worse the physical, psychological and social resources.
Worse health ensues. Work is a breeding ground for disempowerment.
Let’s expand on the disempowerment. Not only was Alan’s work full of
the bad things work can do to your health, it lacked the positives that we
look for in work. We go to work to get money – he was not well paid. Work
helps define our social status and identity, who we think we are and what
society thinks we are – Alan said he felt like a drone; the only reason he
was not actually replaced by a drone is that he was a little more flexible –
his intelligence had little to do with it. Work can provide opportunities for
self-fulfilment and personal growth – not so for Alan in his work as a
picker. Work is a place for developing social relationships – not if your
target is 110 heavy items an hour, up to 240 small items, and you are
averaging 80. Work and life have to be in balance. Alan’s shift work and
sheer exhaustion were hardly conducive to work–life balance.
Work is fundamental to security and to empowerment. Without work we
can be lost, insecure, restricted and in poverty. If your reaction to Alan’s
experience is that, bad as it is, he would be worse off without work, you
may well be right. Unemployment is bad for health. But we should not
simply contrast work with no work: the quality of work really matters. All
of which means we need to consider not only working conditions but also
employment status – the nature and existence of employment contracts.
Both have an impact on health.
Work like Alan’s does not come about by accident. It is planned and
requires certain general societal conditions: low unionisation – or else
working conditions would be better; lack of alternative employment –
people would go elsewhere; relentless attention to the profit margin; and
tolerance, or even fostering, by the society of this type of employment. If
work and employment can be a cause of ill-health, we need, as elsewhere,
to look at the causes of the causes – why work and employment are the way
they are. Is Alan’s work a grim predictor of the future of work, divided into

high-paid, high-skilled work at the top, drone-like work at the bottom, and a
diminishing middle?
We will examine the evidence on work and health in a moment, but first .
. .
IF YOU THINK ALAN HAD IT BAD . . .
Lalta was a human scavenger. Her occupation, and that of a million or so
others like her in India, was to clean human excrement out of dry latrines by
hand, pile it in a reed basket, carry it on her head to a dumping place and
deposit it. Can you imagine a line of work more foul? Lalta couldn’t either.
As she said: ‘All I missed was my dignity . . . I felt like the dirt I carried on
my head.’1
Lalta lived in Alwar in Rajasthan in India, but she might have been in
one of several states. Most of the latrines built in India in the twentieth
century were of the dry type, largely because of water shortage. The
tradition of this most demeaning of work was passed down through Dalit
(outcaste) families for centuries or, in Lalta’s case, she married into it at age
seventeen. Parenthetically, about one-sixth of India’s vast population are
Dalit. There are a lot of people in demeaning occupations.
The scavengers had to reach in through a tunnel and retrieve the human
waste by hand. The problem with work like Lalta’s is a double burden: as
well as the physical and biological hazards, there is the gross lack of
dignity, the threat to self-worth, the appalling stress of such an occupation.
Lalta felt there was no way out. She was told this was her fate. Not that
there was calm acceptance of it: ‘There was no happiness in our lives. It
actually had no meaning. All the time it was either people’s filth on the
head or its thought in the heart.’
I have never been more inspired by toilets than when I heard someone
from Sulabh International, a non-governmental organisation set up to deal
with this issue, describe what happened next. Lalta herself could not solve
her problems, but an organisation could. There were two parts to the
solution. Sulabh International installed low-cost, safe sanitation systems in
villages. Public toilets replaced dry latrines. Villagers had to pay a small
cost to use the public toilets, so that the enterprise of installing toilets paid
for itself. Since 1970, Sulabh International has installed more than

1.4 million household toilets and maintains more than 6,500 public pay-per-
use facilities.2 They even set up an international museum of toilets.
More interested in people than in porcelain, I am inspired by what
happened to the scavengers in the areas where Sulabh has been working.
They were retrained. In the case study I was shown, they were retrained as
beauticians. Wonderful image. Instead of toiling beneath the surface of
human dignity, dealing with the waste we would all rather not acknowledge,
they were working to enhance others’ dignity and their own, by working to
help women look more beautiful. Pictures of these graceful former
scavengers in white saris gladden the heart. Other scavenger women have
also been trained to make pickles, have various jobs in food processing, do
office jobs, and have received micro-credits for small businesses.
Lalta saw her pay go from 600 rupees a month to 2,000 rupees. More, she
says: ‘From a heap of humiliation to the heights of self-respect and self-
confidence, I believe life has turned out miraculously for the good. I don’t
ask for more, for today I can stand and face the world with respect.’
When I hear people in rich countries lament appalling working or living
conditions with no apparent way out, I remind them of Lalta and people like
her in demeaning work all over the world, and the power of group action
and vision to transform people’s lives. It is worth bearing in mind, as we
examine the evidence on work and health, that if the working conditions of
India’s scavengers can be improved by concerted action, all working
conditions can be improved wherever we find them.
WORK AND HEALTH
We owe a great deal to a great Italian
Our understanding of the influence of work on health owes much to
Bernardino Ramazzini. When I meet Italian colleagues I soon turn the
conversation to Ramazzini. The usual reaction is: who? Bernardino
Ramazzini was the father of occupational medicine. Born in Carpi in
northern Italy, near Modena, he became professor of medicine in Modena,
where he published his great book De Morbis Artificum Diatriba, Diseases
of Workers, in 1700. Ramazzini instructed the physicians of his day that if
they wished to understand what made workers ill they had to stop holding
their noses and enter the workplace: ‘I hesitate and wonder whether I shall

bring bile to the noses of the doctors . . . if I invite them to come to the
latrines.’3
Doctors belonged to one class, sufferers from occupational diseases to
another. Ramazzini attracted the derision of other physicians by suggesting
they might learn something from crossing the class barrier: ‘and have not
thought it beneath me to step in workshops of the meaner sort now and
again and study the obscure operations of the mechanical arts’.4 He
suggested actually talking to people of the humbler orders to find out about
their work, and hence their health. Talk to patients? Whatever next!
I would like to think that with modern epidemiological and toxicological
science we know more now about work and health than Ramazzini did in
1700. Not a lot more, I have to admit. He observed, he recorded, and he
linked workers’ ailments to their work. His concern with working
conditions did not imply neglect of the influence on health of other things in
workers’ lives.
INEQUITIES IN POWER, MONEY AND RESOURCES COME
TO THE WORK PLACE – NOT JUST PHYSICAL AND
CHEMICAL EXPOSURES: THREE WAYS WORK CAN
DAMAGE HEALTH
Inequities in power, money and resources as causes of health inequity – it
was the language we used in the report of the Commission on Social
Determinants of Health. With only a little adaptation, it is a good
description of how work can affect health. In general, the lower the social
position, the greater the hazards – hence the contribution of work to
inequities in health.
Ramazzini drew attention to physical and chemical hazards of work.
Regrettably such hazards still prevail in many parts of the world, in
agriculture, in mines, factories and construction sites, and in service work.
We could, with a touch of poetic licence, call these inequities in physical
resources. As the nature of work has changed in a post-industrial world, of
even more concern are inequities in power in the workplace – the
psychosocial conditions – features of Alan’s workplace, but also rife in
office-based and service work. And third, work can influence health by the
obvious mechanism of money. Work can make people rich or keep them

poor, and much in between. Both how much money you have in absolute
amounts and how much relative to others affects health and health
inequalities. The tragedy of Lalta’s work as a scavenger was that she was
subject to all three at the same time – inequities in power, money and
resources.
Physical
It is tempting to believe that we have sorted out the first type of hazard,
physical and chemical, in high-income countries with their high standards
of occupational health. Tempting, but wrong – especially if we include
ergonomic hazards. Here’s the testimony, via an email to me, of someone
from the US, I’ll call her Emily, working in a job similar to Alan’s:
I was injured many times in the warehouse but was forced to continue working or risk losing my
job . . . My friend and many others, including myself warned safety personnel that the weight of
totes [the goods the picker carried to the packer] were exceeding the limit according to safety
standards. This was ignored and people were expected to meet the same rate [number of goods
per hour] by lifting totes that were three times heavier than safety standards. My friend bent
down to grab one off the bottom shelf of a cart when she felt something snap in her back. She
now suffers from a crushed disk in her back.
A European-wide panel survey on working conditions indicated that in
2005, every sixth worker was exposed to toxic substances at their
workplace and many were subject to noise, at least intermittently.5 Twenty-
four per cent reported exposure to vibrations, 45 per cent were working in
painful, tiring conditions and 50 per cent were confined to repetitive hand
or arm movements, mainly due to computer work. Clear social gradients
were observed in these adverse conditions.6
Don’t we have occupational standards to deal with these kinds of hazard?
Here’s Emily’s answer to that question, in the same email:
I have many friends who still work there because there are very little jobs to be found here.
They feel trapped and therefore will keep subjecting themselves to the harsh conditions because
they have no other choice. These people want a UNION and want to be heard, but fear if their
names are released that they will either lose their job or be relocated to harsher conditions until
they can’t take it anymore and just quit.
No alternative employment; no union to represent workers’ interests;
inadequate or poorly enforced health and safety regulations. The history of
improving working conditions makes it abundantly clear: trade unions and

health and safety regulations played a vital role. Do you want the pilot of
your commercial flight falling asleep over the controls, or drinking on the
job? We expect entirely reasonable health and safety regulations to be
followed. (As the grim joke has it: I want to die in my sleep like my dad;
not screaming in terror like his passengers.) Yet, read certain sections of the
press, and favourite hate objects are trade unions and ‘health and safety
gone mad’. It is certainly true that in Britain in the 1970s, had the trade
unions hired public relations people with the explicit instruction to ensure a
bad press, they could hardly have trumped what actually happened. In
Britain, we have only to remember the so-called ‘winter of discontent’ of
1978–9, when one trade union after another struck to the great discomfort
of the public, to think that we do not want a return to unbridled power of
trade union bosses. But that does not mean that we should revel in
unbridled power of corporation bosses. It is entirely possible, and desirable,
to run profitable companies that do not pursue profit at the expense of the
physical and mental health of employees. Experience shows that it is not
wise to rely on the altruism of company owners. Both health and safety
regulations and effective trade unions make a difference.
Difficulty enforcing health and safety standards in high-income countries
is as nothing compared with the problems in low- and middle-income
countries. It should not take the collapse of a garment factory in Bangladesh
with the death of more than 1,100 workers to remind us of lax standards.7 In
large parts of the world most workers are in ‘informal’ employment, which
means it is extraordinarily difficult to impose standards of occupational
health.8 But, do not despair. If Lalta’s life can be improved, so can Alan’s
and Emily’s.
Psychosocial
One way to describe Alan’s work is disempowering. More specifically, I
described it in six ways: high demand and low control, imbalance between
effort and rewards, social isolation, organisational injustice, job insecurity,
shift work. Each of these increases risk of illness. Together they are a toxic
cocktail.
These concepts, each backed by evidence, change the way we think about
stress at work. Conventional wisdom had it that the demands work placed
on high-status people increased their risk of heart disease and other

ailments. Conventional wisdom is not always wrong, but it should not
always be automatically trusted, especially if it asks us to reserve our
sympathy for highly paid, high-status individuals. There are not vast
numbers of high-status individuals striving to swap the boardroom for a
quieter life in the open-plan office.
If you were going to study stress at work your first thought might not be
the British Civil Service. It turns out it is quite a good real-life laboratory to
study the effects of stress on health. Several years ago, the government’s tax
office (now Her Majesty’s Revenue and Customs) was concerned because
higher-grade tax officers had a high rate of suicide. Men and women doing
this job told us that their in-tray was not their friend. On arrival at work, the
first thing was to see quite how unfriendly the in-tray looked. The challenge
of work became not to detect tax avoiders but to stem the in-tray tide that
threatened to engulf them. The greater the height of the in-tray, the greater
the threat of feeling like you could never get your head above water. They
would start on the in-tray pile, work all day, and at the end of the day the
pile was higher than it was at the beginning. Holidays made them unhappy
because the tidal wave of paper would build up so that, on return, they
would be engulfed. It wasn’t just the ineluctable flow of work that did them
in, but the lack of control. No matter how steadily, how hard, they worked,
they fell further and further behind.
To make matters worse, the better they did their job, the more they were
hated and the worse they felt. No member of the public thanked them for
having been assiduous in pointing out ‘mistakes’ in their tax return. High
effort, low reward and lack of control have the same effect in the office as
they do in the warehouse.
My colleagues and I at UCL looked at the question of stress at work in a
systematic way in the Whitehall II study of British Civil Servants. In the
introduction I described the social gradient in death rates from heart disease
and other diseases – the lower the grade of employment the higher the
mortality – that we observed in the Whitehall study.9 I think of it as ‘life
and death on the social gradient’, and we saw similar gradients in the
Whitehall II study of more than 10,000 men and women working in the
Civil Service in and around London.10
In the Whitehall II study we showed that men and women whose work
was characterised by high demands, low control and imbalance between
efforts and rewards had increased risk of heart disease,11 and of mental

illness.12 Further we asked a few questions about how fairly they felt the
organisation treated them. We called this organisational justice. People who
reported a lack of organisational justice had high rates of mental and
physical illness.13
Just in case the thought occurred that there might be something atypical
about civil servants, think about your own life. When does work, or life in
general, feel most stressful? When you lose control. Most people can cope
with being busy. If they are working parents, usually mothers, they can cope
amazingly well with juggling work and life. When it all gets too much is
when one cannot control what is happening. Trouble paying bills, pressure
at work when you are worried about a sick child, demands from the
landlord that cannot be ignored, then the heating fails, and the partner gets
laid off and becomes morose. All contribute to a feeling of being unable to
control events.
There have been several reviews of the evidence on what has been called
the job-strain model: high demands, low control. A review of twenty-one
studies of many thousands of people working in a variety of conditions
shows that people whose jobs are characterised by high demands and low
control have a 34 per cent increased risk of developing coronary heart
disease compared with people without job strain.14
The second source of stress at work is effort without appropriate reward.
To me, one of the most distressing aspects of Alan’s work as a picker is that
day after day his rewards were minimal – whether financial, or in terms of
self-esteem, esteem in the eyes of others, promotion, or just about any form
of reward one could think of. It is not only people low in the industrial food
chain who need rewards; we all do. I was once in a meeting with a Nobel
Prize winner, justly feted as one of the world’s great thinkers. I quoted
sentences from his work, and said how it had changed thinking. The great
man grinned with pleasure. Even he, garlanded with recognition, needed the
reward of knowing his contribution had been recognised. Rewards give life
meaning, and help make the effort worth it.
Am I really alleging that failure to have someone say ‘Thank you’, and
mean it, when you put in effort could increase risk of disease? That is to
oversimplify. The reciprocal exchange of effort for money, status,
recognition and self-esteem is vital. Its lack is stressful. Indeed, the
evidence shows that effort–reward imbalance is associated with increased

risk of heart disease, mental illness and sickness absence.15 Similarly,
organisational injustice and shift work increase the risk of ill-health.16
I could call this section the loneliness of the long-distance warehouse
picker . . . and bureaucrat. Work can connect us socially, or isolate us, and
everything in between. Social isolation is bad for health. It is one more
indignity that follows the social gradient – not just more adverse things
happening, but fewer potential social supports coming from a variety of
sources. Whitehall II is but one example of several studies that show the
lower the social position, the fewer social ties people have with friends,
with co-workers, with neighbours, with clubs and organisations. The only
category of social contacts that was more frequent at the bottom of the
gradient was contact with family. This seems not to make up for lack in the
other spheres.
My colleagues at UCL, Andrew Steptoe and Mika Kivimaki, conducted a
review of nine studies, each of which followed people free of disease at the
start of the study. Summarising all the data, they showed that men and
women who were socially isolated and/or lonely at the beginning of the
study had a 50 per cent higher risk of developing coronary heart disease
during the subsequent follow-up compared with those who were not lonely
or isolated.17 We cannot, of course, lay social isolation at the door of work.
But work is one way people develop their social relations. Isolation at work
cuts off one route to relief from loneliness.
Financial
During the Second World War the British economist William Beveridge
produced a report with the unpromising title Social Insurance and Allied
Services.18 It is no exaggeration to say this report had a worldwide effect. It
laid the basis for the welfare state in Britain, and influenced its development
in many countries. Beveridge identified the importance of lack of income,
which he called ‘want’, and then wrote: ‘Want is one only of five giants on
the road of reconstruction and in some ways the easiest to attack. The others
are disease, ignorance, squalor and idleness.’
We are still dealing with Beveridge’s five giants, in countries of low,
middle and high income. Translating Beveridge into modern concerns:
ignorance we can say is lack of education; squalor is the kind of destitution
that causes babies to die in low-income countries, or people to live in cold

homes in rich countries; idleness is lack of work. Given that I am concerned
with the causes of health inequalities, my perspective is that four of the
giants – want, ignorance, squalor and idleness – can lead to the fifth,
disease. But the giants are interrelated. Lack of education can lead to
unemployment; lack of employment to poverty.
Regrettably, work may not be the way out of poverty if the rewards of
work are unequally distributed. In Britain, for example, Figure 6.1 shows
alarming trends.
Poverty is defined as having income less than that needed for a healthy
life. The number of people in poverty in workless households, including
retired people, has declined. Good. But there has been an increase in
poverty among those who work: by 2011/12 the majority of people in
poverty were in working families. Not good.
FIGURE 6.1: WORK IS NO LONGER THE WAY OUT OF POVERTY
In Britain, as elsewhere, our politicians speak in clichés that often are a
barrier to both thought and communication. The simple account of
economic trends is that the world is divided into hard-working families,
strivers, and those dependent on state handouts of various forms,
scroungers. One of the many problems with this rhetoric is that it clouds the
fact that most of the people who do not have enough money to live on are in

work.19 In fact about three-quarters of working-age adults in low-income
working households are in work. If work were the route out of poverty, state
handouts would be unnecessary for these households. The problem is not
lack of interest in work, it is low pay.
In the US, we have seen something similar. Figure 6.2 shows what has
been happening to incomes of men and women in full-time employment.20
Men and women are sorted according to their income: P10 is the bottom
10 per cent of earners; P90 is the top 10 per cent (the 90th centile). Over a
twenty-five-year period incomes for men and women in the top 10 per cent
of incomes, P90 on the graph, grew handsomely. But the lower the starting
income the lower the growth in incomes. In fact for men in full-time
employment, the lower 50 per cent of earners had a fall in real income (i.e.
adjusted for inflation).
FIGURE 6.2: TO THEM THAT HAVE SHALL BE GIVEN. . .
You won’t have forgotten that I am concerned with the gradient, as well
as with poverty. The fortunes of the middle groups are therefore also of
concern. The US is getting richer but the benefit is going overwhelmingly
to the richest 10 per cent. As Figure 6.2 shows, not much of it reaches the
bottom 80 per cent.
Simplifying and summarising, there are three ways to address low
incomes of people of working age: improve the incomes of the working

poor, get more people into work, and improve the incomes of people who
for whatever reason are unable to work. Each of these is likely to reduce
health inequalities.
Before we move from conditions in the workplace to employment
conditions, we should ask an important question: is it work or the worker
that is damaging health?
I argued in the previous two chapters on early life and education that it
was not genes that determined the quality of early child development and
educational achievement, but the nature of the social environment. But what
if I were wrong, and it was the genes? What if it was genetic differences
between people that decided who left education for an interesting well-paid
job, and who ended up in work hell as Alan did; who found a good stable
job and who went to no job at all? Even if all that were true, genes would
not let work and employment off the hook.
It is the work that determines health outcomes, not just the worker.
Whatever the process of getting into the job – whether fixed by the
connections of your rich parents, earned by the sweat of your brow,
allocated randomly by a throw of the dice by the great gambler in the sky,
or determined by your genetic endowment – it is still reasonable to ask
whether the nature of work, and of the employment contract, influences
health.
Improve Lalta’s working conditions, or Alan’s, and their health is less
likely to suffer, whatever their genetic makeup.
EMPLOYMENT CONDITIONS AND HEALTH
We have just been considering what happens at work and what it means for
health. There are two aspects of what we may call employment conditions
that are also relevant for health: unemployment and job insecurity. Let’s
start with unemployment.
Young people have been out on the streets of Madrid. They are angry and
have styled themselves indignados. They are angry with good reason.
Society’s implied promise to them has been broken – grow up, go to school,
study, prepare, and then it will be your turn to embark into the world of
work, earn your living and do what every generation has done before. But
not for them, it would seem. Unemployment among fifteen- to twenty-four-
year-olds in Spain is 58 per cent. This figure may look worse than it is, as

some young people might be in ‘informal’ employment – registered as
unemployed but working in the grey or black economy. Even so, there is
still a major issue of youth unemployment. In Greece the figures are even
higher, 60 per cent of young people unemployed; in Italy more than 40 per
cent.
This youth unemployment does not strike randomly: the higher the level
of qualifications a person has, the more probable that they will enter
employment when they leave education. So we can see the life course
operate: the lower the level of early child development, the worse the
educational attainment, and the greater the likelihood of unemployment.
Globally, the great recession has been disastrous for employment. The
International Labour Organisation (ILO) estimates that in 2013 there were
over 200 million people unemployed in the world. The global recession that
began in 2008 has led to an increase of unemployment of more than
60 million over and above an already large figure.21 As in Europe, so
around the world young people aged fifteen to twenty-four are
disproportionately affected – the unemployment rate in the young is three
times higher than in older working-age people. An economic crisis begun in
Wall Street and the City of London is depriving young people of work in
North Africa and the Middle East, parts of Latin America and the
Caribbean, as well as Southern Europe.
Elsewhere, the real unemployment is hidden. In a country like India,
more than 80 per cent of working people are in the ‘informal’ sector. If the
economy turns down, they do not go and register with their unemployment
office – there is no such thing. They pick up rubbish, clean latrines, take
whatever demeaning work is available. The alternative to work is not
unemployment benefits. It is starvation if they do not do whatever it takes
to earn a tiny amount of money.
Not usually given to hyperbole, I have described this youth
unemployment as a public health time bomb. Unemployment is bad for
health and it blights lives. Young people who leave school for the scrapheap
are in danger of never getting the habit of work – potentially, they face a
lifetime on the margin. Bad work may be bad for health; unemployment
may be worse.
In the economic downturn in Britain in the 1980s, unemployment rose
sharply. There was debate at the time as to whether this was bad for
health.22 Some economists argued that sick people are more likely to

become unemployed, not that unemployment leads to sickness. The debate
generated some heat, because there was little argument that government
policy had put people out of work. If putting people out of work damaged
their health, killed them even, then it was tantamount to saying that
government policy was killing people. One British chancellor of the
exchequer said: ‘Rising unemployment and the recession have been the
price that we have had to pay to get inflation down. That price is well worth
paying.’23 It is somewhat less likely that he would have said: rising
unemployment and consequent damage to people’s health have been the
price we have had to pay to keep inflation down. That price is well worth
paying. Not even a minister of finance would say that. At least, not publicly.
Hence the government’s desire to play down the links with ill-health.
It is scarcely credible when the number of unemployed goes from under
1 million to more than 3 million in about three years to claim that sickness
is causing unemployment. My colleagues Peter Goldblatt, Kath Moser and
John Fox were centrally involved in that debate. In the end, the evidence
settled the issue. They followed a 1 per cent sample of people identified in
the 1971 national census in England and Wales and showed the same social
gradient in mortality that we had seen in civil servants: the lower the social
class, based on occupation, the higher the risk of dying. But for each social
class, those who were unemployed in 1981 had about a 20 per cent higher
mortality rate than those who were employed.24
Among other studies that confirm that unemployment damages health are
those grouped under the acronym HAPIEE (Health, Alcohol and
Psychosocial factors in Eastern Europe) which my colleague at UCL,
Martin Bobak, and I set up with partners in the Czech Republic, Poland and
Russia; Lithuania joined subsequently. The purpose of these studies was to
investigate the reasons why health in the former communist countries of
central and eastern Europe has been lagging far behind that in ‘western’
(using the term loosely) Europe. The hypotheses under test are contained in
the title of the study, HAPIEE. We did medical examinations of nearly
30,000 people in the first three countries and have been following them
since. After six years of follow-up the risk of dying in men and women who
were unemployed at the start of the period was more than double that in the
employed. Some of the reasons for this higher rate of mortality are that
unemployed people are more likely to drink and smoke than those in
employment. What else is there to do? Allowing for the fact that the

unemployed had lower socio-economic positions, and were likely to have
markers, such as smoking and poor diet, that put them at higher risk of
dying, there was still a 70 per cent increased risk of dying.25
Unemployment is particularly bad for mental health. Some of our
politicians claim that unemployment is a lifestyle choice. If so, it is an odd
one as it puts people at increased risk of depression and suicide.
One way of examining the effects on health of unemployment is to
follow employed and unemployed individuals and compare them. A
different, more complex way is to see what happens to a country’s health
when the unemployment rate goes up.
David Stuckler from Oxford University looked at figures for Europe and
showed that a rise in a country’s unemployment rate was correlated with a
rise in that country’s suicide rate.26 For me, a dramatic finding was that the
size of the effect varied according to how generous a country was in its
spending on social protection – which included unemployment benefits,
active labour market programmes, family support and health care. If there
were no spending on social protection a 3 per cent rise in unemployment
would be associated with a 3 per cent rise in suicide. Eastern European
countries spend on average US$37 a head on social protection. In these
countries, a 3 per cent rise in unemployment was associated with a 2 per
cent rise in suicide. In Western European countries, which spend on average
about US$150 a head on social protection, a 3 per cent rise in suicide was
associated with less than 1 per cent rise in suicide.
The conclusion from such complex analysis is straightforward:
unemployment damages mental health so severely that it can even lead to
suicide, but government policies can make a difference. The toxic
combination is what Eastern European countries have done and what
Southern European countries are being forced to do: have a high rate of
unemployment and reduce spending on social protection.
To be clear about this, I do not know anyone who thinks Greece managed
its finances well before the great recession. When I heard a figure that few
Greek doctors in private practice declared an annual income greater than
10,000 Euros, I asked a Greek medical colleague: are the Greek tax officials
corrupt or incompetent? His reply: in Greece it’s hard to tell the difference.
Greek government officials were either cooking the books or not keeping
them, and the Greek population was practising tax avoidance on a grand
scale. All that said, the policies thrust on them by the troika of the European

Commission, the European Central Bank and the IMF are damaging the
health of the Greek population.
Job insecurity and health
Job insecurity is supposed to be a good thing. It’s called labour market
flexibility. Jobs for life? Stultifying, for the individual and the firm. At least
that is the conventional wisdom. If workers are insecure they will be kept
on their toes, work harder. I saw a cartoon at one workplace: ‘The beatings
won’t cease until morale improves.’
When I presented evidence at a meeting that, in Spain, workers in
insecure jobs had higher risk of mental illness than those in secure jobs I
was greeted with the inevitable question: have you thought about causation?
That is code for: it may be that people with mental illness are more likely to
find themselves in insecure jobs. In other words, mental illness is causing
job insecurity, not the other way round.
I do have an answer and it comes from the European Review on Social
Determinants of Health and the Health Divide, which I led on behalf of the
WHO Regional Office for Europe. Among the task groups we set up to
review the evidence on social determinants of health was one on
employment and working conditions. This task group summarised sixty-
five studies of job insecurity with overwhelming evidence that it damages
health, particularly mental health.27 Particularly convincing are those cases
where job insecurity is thrust on people by circumstances, by threatened
closure or downsizing of an activity.
MAKING THINGS BETTER . . . BY GETTING CONDITIONS
OF EMPLOYMENT RIGHT
Fair employment implies a just relation between employers and employees
that requires that certain features be present: (1) freedom from coercion; (2)
job security in terms of contracts and safe employment conditions; (3) fair
income; (4) job protection and the availability of social benefits including
provisions that allow harmony between working life and family life, and
retirement income; (5) respect and dignity at work; (6) workplace
participation; and (7) enrichment and lack of alienation.28

What world am I living in? you might think. I want employers and
employees to treat each other with dignity. Before you dismiss me as living
in some fairyland, let us return to India for a further example of how, with
squalid starting conditions, change is possible.
In Ahmedabad, more than 30,000 women worked picking paper and
rubbish from the roads. For working in the dirt of the streets, carrying loads
of paper of up to 20 kg for twelve hours a day, they received 5 rupees. They
had no legal protection, no control over the unsanitary nature of their
working conditions, and no job security. The Self Employed Women’s
Association got involved in organising these women. Several organisations
were formed. One example was the Soundarya Cleaning Cooperative,
which negotiates contracts with clients, individual households, residential
tower blocks, offices and institutions including academies. There is now
control over working conditions, more job security, and the pay is better:
5,000 rupees a month rather than 5 rupees a day. For weddings and Divali
festival it is 300 rupees a day.
To repeat what I said when discussing the pickers in the warehouse: one
way of improving working conditions is to have organised labour. There
was a time when ‘trade union’ was a respectable label, rather than a term of
derision, as it now is in some circles. Another is to enforce health and safety
regulations.
. . . AND PURSUING POLICIES THAT CREATE JOBS, NOT
DESTROY THEM – THE CAUSES OF THE CAUSES
I implied above that the worldwide problem of unemployment in the wake
of the Great Recession, particularly of young people, was first caused by
irresponsible behaviour of whizz kids in financial institutions whose greed
led to financial collapse. If in doubt read Michael Lewis’s book The Big
Short.29 Second, I stated that policies of austerity put in place in the wake of
the Great Recession made unemployment worse. If the second is true, why
would governments pursue policies of austerity?
In fact, faced with the economic problems of the Great Recession
economists and politicians seem to have taken up one of two positions. One
side thinks we have to reduce the national debt to get economic growth; the
other that we have to get economic growth in order to reduce the national

debt. Amplifying a little, expansionary austerians believe that imposing
policies of austerity, reducing the annual deficit and paying down national
debt will enhance the confidence of the private sector and restore economic
growth. Keynesians are of the view that with demand depressed,
households and businesses are reluctant to invest and consume – Keynes’s
‘paradox of thrift’. Government must step in and, despite high levels of
public debt, spend to stimulate the economy – counter-cyclical investment.
Paul Krugman, Nobel Prize-winning Keynesian, characterises expansionary
austerianism as belief in the confidence fairies. Austerians sneer that the
Keynesian solution to high debt is more debt.
Before asking who’s right, it is worth noting that views about the
economic remedy appear to be correlated with positions on the ideological
spectrum: austerians to the right, Keynesians to the left (although Keynes
himself was not of the left and was concerned to save capitalism). Why is
this so? Naively, one might have thought that it was an empirical question
as to which policy ‘worked’. It is likely, however, that austerians tend to be
more suspicious of government solutions and less concerned with
distributive effects of policies – harming the poor. Keynesians have a
readier acceptance of the importance of government policies and practice,
and are more concerned with inequality – more so, perhaps, than was
Keynes himself. Because of this political alignment, it is hard to debate
about the evidence. As so often, what should be an informed debate about
evidence is a none-too-veiled contest about prior political beliefs, or short-
term low-level politics.
It is difficult for a non-economist to penetrate the argument and form an
independent judgement. It can be noted that the intellectual case for
austerity has suffered a couple of recent blows. Austerians have cited,
among others, the Harvard economists Carmen Reinhart and Kenneth
Rogoff, who set out to show that when national debt climbs above 90 per
cent of GDP, economic growth slows.30 They showed it, except that a
graduate student checking their figures found elementary errors that cast
considerable doubt on their conclusions.31
Second, the IMF, which arguably has wreaked great havoc globally with
its universal prescription to cut government spending, has published new
estimates that austerity has a bigger effect on slowing economic growth
than it used to think.32 In Britain, the Office of Budget Responsibility says
that it subscribes to the widely held assumption that fiscal contraction

damages growth. The intellectual argument is under threat, but austerians
are still winning the political and public relations argument across Europe
and in the USA.
There is another objection to this debate: the main criterion of success of
economic policy appears to be growth of GDP. But what if we had a wider
set of considerations? We want economic and social policy to do more than
deliver economic growth. Policies should also be evaluated for their
impacts on people’s lives. An important way of doing that is to look at the
health impacts of policy. My entry into the debate is that if austerity leads to
unemployment, particularly of young people, it has to be tempered by
judicious investment and active labour market programmes.
Working locally
Earlier in the chapter, I agonised over the huge problem of young people
leaving school to go straight to the unemployment scrapheap, of being ‘not
in employment, education or training’ – NEET. Think what that means to a
young person, now and in the future. In the previous section I concluded
that answers to the big macroeconomic questions will have an important
influence on the availability of jobs. While these debates are happening,
what should the young people on the streets of Madrid or Athens be doing?
It turns out that local action can make a difference. Consider these two
examples from the Welsh city of Swansea.
Gareth and Derek are typical of young people growing up in the less
affluent parts of Swansea. They went to their local state schools. School
was not much to Gareth’s liking. He had been in trouble for bad behaviour,
had some minor truancy problems, and he and his teachers engaged in
mutual disregard, but he got 5 Cs in his General Certificate of Secondary
Education exams. To explain, at age fifteen–sixteen every young person in
Britain takes so-called GCSE exams. The benchmark of success the
government uses is the proportion of young people who gain five GCSEs at
C or above. Nationally, the average is 68 per cent. But five Cs is not
outstanding. The average scores of people who go on to Oxford or
Cambridge is eight A*s and two As.
Gareth, then, was a just-average student, hadn’t found a subject he
wanted to pursue, and he left at age sixteen rather than trying to get into the
local sixth form college to do A-levels. He would have liked to find

employment, but wasn’t sure where to go or what to do. He applied for a
couple of jobs but they went to people who had more experience or better
qualifications. When he turned eighteen he signed up for unemployment
benefits, and as a consequence, after six months got enrolled in some short-
term training courses. These didn’t lead to sustainable employment. By the
time he was twenty-one, Gareth had spent most of the last four years not in
employment, education or training. He wanted to leave home, but could not
afford rent. He tried living with a girlfriend but that didn’t work out. She
was employed in the local supermarket and did not appreciate paying rent
for Gareth. He was back home with his parents, who he regularly argued
with. He claimed unemployment benefits and supplemented this income
with small-time drug dealing. Gareth’s story is typical of those termed
NEET.
Derek went to a different but similar school in Swansea. He was also on
track to get mostly Cs in his GCSEs. However, before he sat his exams, at
the start of Year 11, he was identified by the school as someone at risk of
becoming NEET. As a result, he was offered a range of support by Careers
Wales, the local council and his school. While he was still in school, Derek
was offered a work experience placement at the local authority. He was also
assigned a personal adviser with whom he could discuss the options and
opportunities open to him, and the school worked with him to reduce his
truancy. Derek did not particularly like school, so it helped that his adviser
was not a member of the school staff, and they met outside school. Derek
left school at sixteen, but support was maintained, particularly over the
summer right after he finished. This helped him to enrol in a six-month
training course starting in September, which included employability skills
and placements in a local manufacturing company. The training course also
included a discretionary fund for staff, some of which they allocated to
Derek to enable him to buy tools and interview clothes. At the end of his
six-month training course, the local company interviewed Derek and then
offered him a one-year apprenticeship. Now he has a permanent full-time
position at the company as a technician.
Derek’s experience is typical of what Swansea and another Welsh town,
Wrexham, achieved as shown in Figure 6.3.
FIGURE 6.3: GETTING INTO WORK IN SWANSEA AND WREXHAM

By focusing on the problem in a strategic way, working with young
people, giving them access to information, and perhaps above all, caring,
authorities in these towns lowered the toll of young people not in
employment, education or training.
There was an unexpected benefit. Youth offending in Swansea fell from
over 1,000 incidents a year to fewer than 400.33 Correlation is not
causation. One cannot say that the reduction in NEETs was responsible for
the reduction in youth offending, but it is certainly possible.
Unemployment harms health and work is vital. When work is of ‘good’
quality it is empowering. It provides power, money and resources – all
essential for a healthy life. The ‘good’ characteristics of work tend to follow
the social gradient: greater empowerment and better conditions go with
higher status. Not always, but the highly paid lawyers and hedge-fund
managers have considerable compensation for the ridiculous hours that they
work. Bond traders, who Tom Wolfe called ‘Masters of the Universe’, may
feel stressed, but they are in control.34
In low-income countries, the nature of working life too often resembles
the Dickensian conditions that high-income countries have put behind them.
Further, with the export of undesirable jobs from high-income countries to
low, the problem is not so much solved as transferred. Solutions to
improving working conditions should be applied globally, but examples of

local action show how working life can be transformed – witness the
scavengers of India or the young unemployed of Wales.
A worrying trend is that work will increasingly be stratified into well-
paid empowering work for people with education and skills and the reverse
for those without. Global competition can lead to a race to the bottom.
Worse working conditions and cheaper labour costs make a country more
attractive for transnational corporations. Highlighting the problem is a step
towards addressing it.
I said in Chapter 5 that education was central because it provided the key
connection between early life and the grown-up world of work. I could say
the same here. Work is central because it provides the crucial link between
earlier life and those older years, beyond working age, that are stretching
ever further. It is those years of later life that claim our attention next.
* I met ‘Alan’ (not his name) as part of this programme broadcast in 2013.

7
Do Not Go Gentle
Fool: If thou wert my fool, nuncle, I’d have thee beaten for being old before thy time.
Lear: How’s that?
Fool: Thou shouldst not have been old till thou hadst been wise.
William Shakespeare, King Lear (Act I, Scene v)
Older age is a terrible time. Poverty, misery, social isolation, declines in
intellectual and physical function, no social role and, old age being a kind
of evolutionary accident, there is little wonder that older people get all
kinds of illnesses. As well as being a misery to themselves, older people
add to everyone else’s misery by being a drag on society.
Like most stereotypes the description I have just given is not completely
wrong, it is simply inadequate and misleading. It does not capture the rich
variety in the lives of older people as they are actually lived in different
countries and, given my central theme, in people living in different social
circumstances. The inevitable declines that come with age pose challenges
for health and social care. It can be done well, and it can be done badly. The
Harvard surgeon and writer Atul Gawande asks, in a sensitive way, what the
appropriate response of a caring, compassionate health-care system should
be – neither neglect nor heroic over-treatment in attempting futilely to stave
off the inevitable.1
Important as it is, health and social care for the elderly is not my topic
here. I want to explore what happens before people need their final episodes
of care. Consistent with my general theme, I will look at inequities in the
conditions that lead to health and effective functioning. For some, older age
is one stop before the scrapheap. But it does not have to be. For others it is a
time of personal flourishing and contributions to family and the wider
society. Here is the testimony of Maria, a ninety-year-old Brazilian woman:

The situation has changed for older people in my country since the Law for the Rights of Older
People [Estatuto do Idoso] was approved [in 2003]. Even after the Policy for Older People was
adopted, older people abandoned their sandals and their rocking chairs and started having a life.
Now we are supported by the law. We can demand our rights.
Overall, there has been a change in the way society sees older people . . . Now what we need
are jobs and respect in the streets. Holes in the street are the biggest enemy of the older person.
That is why falls prevention classes are so important. I used to have terrible falls, I even bruised
my face. After going to classes I’ve never fallen again. Another thing is that the bus drivers are
not prepared. The buses should always stop at the kerb but they don’t – the companies are not
worried.
Now we are better respected. It is good to be able to buy half-price tickets for the theatre and
concerts. Before, we couldn’t go because it was too expensive. Now it is affordable and the bus
pass is free too. Even buses between cities are free. I feel fortunate to have this life, I realize not
everyone is so fortunate.
I used to avoid going to the bank. I kept my money at home. We older people did that because
we couldn’t face waiting at the bank for hours. Sometimes we just gave up and went home
because the lines were too long, but now there are priority lanes for older people.
We need to end the separation between older and younger people. We can share experiences
with each other, which is very exciting. Younger people are starting to better understand older
people. They are learning that we also have the right to sing, to dance, to talk.
There are still many things left to do, but a lot has improved.2
Obviously, this woman was misinformed – she didn’t realise that older
people, stuck in their misery, destitution and sickness, were supposed to be
grateful for whatever crumbs a charitable society bequeathed them. She
thought that older people should have enough money and resources to be
able to do things – material empowerment. She wanted the conditions to
enable her to control her life and participate, be they repairing the holes in
the street, accessible transport, affordable tickets or respect and jobs –
psychosocial empowerment. She demanded rights and support of the law –
political empowerment.
Her lucid prose makes me wonder whether she is no ordinary older
person. But then, should that not be the message: recognise that older
people, just like people at all other ages, have the capacity to be
extraordinary as well as ordinary. Social action will further that capacity.
Recognising the rights of people of all ages will improve all our lives.
My theme through the book is that inequities in society lead to inequities
in health. In this chapter, I will focus on inequities in health and functioning
of older people between countries and inequities between social groups
within countries. By doing so, I hope to address a further challenge to a
moral society: inequities between older people and the rest of society. Year
on year, as age creeps on, I become less tolerant of these age-based

inequities. Maria from Brazil is my heroine, along with the novelists,
orchestra conductors, the Rolling Stones, charity organisers and local
volunteers who in their later decades make society just a little better.
OLD IN THE GLOBAL NORTH, YOUNG IN THE GLOBAL
SOUTH?
Perhaps the question should be, not what is Maria aged ninety in Brazil
doing demanding her rights, but how come there are Marias aged ninety in
a middle-income country like Brazil, part of the global south? Isn’t the issue
that there are lots of young people in the south, lots of older people in the
north? It was, but it is changing very rapidly.
In France in 1865, 7 per cent of the population were aged sixty-five or
over. By 1980, 115 years later, that proportion had doubled to 14 per cent.
By contrast, what took France 115 years is predicted to take Brazil twenty-
one years – going from 7 per cent elderly in 2011 to 14 per cent in 2032 –
and South Korea about eighteen years.3 As my Brazilian colleague Alex
Kalache, retired head of ageing at WHO Geneva, says: the North grew rich
before it grew old, the South is growing old before it grows rich. Put
simply, rich countries have the money to enable people beyond working age
to have a reasonable standard of living, if they are so inclined. By ‘they’, of
course, I mean the countries. It is a reasonable bet that most older people
would themselves be inclined towards a reasonable standard of living.
Increasingly, in democracies, that inclination is becoming a powerful
political force.
The world is indeed ageing rapidly, as shown in Figure 7.1. By 2020 the
balance will have shifted from young to old. There will be a higher
percentage of people aged sixty-five or above than children aged younger
than five.
An ageing population is a reason to rejoice, to celebrate, for two chief
reasons. First, populations are ageing because people are not dying young.
In low-income countries the probability that a child will survive into
adulthood has improved dramatically. How many adjectives may I be
permitted: this achievement is astonishing, wonderful, remarkable, and its
speed was probably a great deal more rapid than most experts predicted. In
short, it is a cause for celebration.

FIGURE 7.1: MULTIPLE SHADES OF GREY
The second reason to celebrate an ageing population is that older age can
be a wonderful time of life – just think of the testimony of Maria from
Brazil. People over sixty-five can be creative, productive, carers, lovers,
voters, citizens, consumers and enjoyers of what a society has to offer. They
receive, certainly, but they contribute a great deal, too.
We cannot think about ageing without thinking about gender. Sex, too,
probably, but here I am concerned with gender. As the world ages, it grows
more female. Towards the end of his life, close to his ninetieth birthday, my
father voluntarily moved from his apartment into sheltered
accommodation – his own apartment with communal meals. Having lunch
with him there one day I watched an elderly lady, white hair beautifully
coiffured, shuffle past with her Zimmer frame. My dad smiled and said: she
is one of my favourites. The elderly lady looked wistful, with just a touch of
mischief, as she said: he has a lot of favourites here. Indeed, there was a
choice for the men in this residence for elderly people: three men and forty-
five women.

Women are hardier than men. Unless there is egregious discrimination
against them, women can expect to live longer. As a result, today, for every
hundred women over sixty worldwide there are eighty-four men. For every
hundred women aged eighty and above, there are sixty-one men. The
implications are that the greater the discrimination against women in
education, jobs, owning property, receiving financial assistance, and general
place in society, the worse will be the lot of the older population.
There is ample reason to adjust our angle of vision when concerned with
inequities in global health. We know how to prevent child deaths and,
increasingly, that knowledge is being applied. But globally the much bigger
problem is going to be deaths at older ages. By 2025–30, the UN predicts,
62 per cent of all deaths globally will occur among the over-sixty-fives.4 Of
course, dying at a great age is a good deal more socially acceptable than
deaths in childhood. It is the inequities in death at older ages that concern
me here.
GREAT INEQUITIES IN LENGTH OF LIFE . . . BETWEEN
COUNTRIES
Here’s a question: you have reached age sixty and want to know your
prospects for further survival. Are they better if you had to fight off all sorts
of hazards to survive to age sixty and could therefore class yourself as a
hardy survivor? Or are they better if you had a cushy ride to age sixty, most
people in your society get there, and had little to contend with?
I can make the choice more tangible. In Japan 92 per cent of fifteen-year-
old boys and 96 per cent of fifteen-year-old girls can expect to reach the age
of sixty. By contrast, in Russia, only 66 per cent of boys and 87 per cent of
girls will get to sixty. Who will have better prospects for survival after sixty,
Japanese or Russians?
The Japanese win it by a large margin: healthier before age sixty, they
can expect to live many more years after that age.
Figure 7.2 gives the figures plus a few more examples. It is a remarkably
close fit. I have listed the countries in order of the healthiest male survival
to age sixty. There are exceptions, but in general, the worse the survival
before age sixty, the fewer years you can expect to live after sixty. It is

staggering that men in Russia should have worse health than men in India,
but we will take that up in a subsequent chapter.
FIGURE 7.2: HEALTHIER BEFORE 60, HEALTHIER LATER
To remind you, a few years of life expectancy may not seem much, but it
matters a lot. Japanese women have the longest life expectancy in the
world. A Japanese woman of sixty can expect, on average, to live a further
twenty-nine years. An American woman can expect to live a further twenty-
four years. Is the difference between eighty-nine and eighty-four much to
write home about? First, it is if you’re eighty-four, and have tickets to hear
Bob Dylan next month. Second, we calculated that abolition of coronary
heart disease from the population, removing it statistically, would add just
under four years to life expectancy. If I said that we were moving to abolish
the major cause of death, that would sound revolutionary. That is what four
years of life expectancy means. One year is impressive and worth having.
Four years is enormous. And nine years, the difference between Russians
and Japanese, is, well, staggering.
In Chapter 4 I took up the question of whether what does not kill us
makes us stronger. I said that was not true when it comes to the adverse
effects of early child experiences. What does not kill us harms us. That, I
think, is what is going on here. There is no hardy survivor effect to be seen:
less healthy on average before age sixty, fewer years of life still in store.
The two likely explanations are first that similar hazards affect each age
group. Drinking dirty water or sleeping on the street is bad for your health
whatever age you are. So too are relative deprivation, social disadvantage
and unhealthy lifestyle. Second, health at older ages is affected by the prior

life course. Health and well-being in later life is affected by experience
along the way. By no means does this mean that it is all over for today’s
older people if their mothers didn’t cuddle them when they were babes in
arms. Both life-course influences and contemporary circumstances, the
kinds of things that Brazilian Maria finds so important, are linked to health
inequities in later life.
. . . AND WITHIN COUNTRIES
Here is a remarkable finding. You finish your education in your teens or
early twenties and the level of education you achieved predicts your
chances of surviving four, five or more decades later. Figure 7.3 shows a set
of figures for life expectancy at fifty – in Chapter 5 we saw something
similar for life expectancy at twenty-five.
The figures shown are for the lowest and highest education, but
intermediate levels of education have intermediate levels of life expectancy.
It is a gradient.
FIGURE 7.3: CAN EDUCATION HAVE SUCH LONG–LASTING EFFECTS?

There are, though, big differences between countries, particularly for
those with the lowest level of education, ISCED 0–2 (ISCED is the
international social classification of education). As a result health inequities
are much bigger in Hungary and Estonia than they are in Sweden, Italy,
Norway and Malta.
Suppose you were in Hungary and were trying to use these figures to
convince your child to get serious about school – evidence-based parenting.
The following conversation might take place:
YOU: You must work harder in school.
CHILD: But I’m having fun being a child, nourishing my soul and gladdening my heart,
smelling the flowers and revelling at the crisp blue of a sparkling spring . . . [a very lyrical
child]
YOU: If you go to university you’ll have a longer life.
CHILD: I am a child. Why should I care about a longer life?
YOU: A longer life is not just good in itself, it is an indicator that you have enjoyed better social
conditions throughout your life.
CHILD: If you were so concerned about my having a long life, or a better life, why didn’t you
arrange for me to be born in Sweden instead of Hungary? People with little education in
Sweden have a better chance to survive after age fifty than people with tertiary education in
Hungary.
YOU: Be quiet and eat your Brussels sprouts.
CHILD: Pulling rank is the last refuge of a scoundrel.
YOU: OK. We are in Hungary. Not too much we could do about that. But look at the figures in
7.3. Remember, we are using life expectancy not just as a good thing in itself but as an
indicator that life has treated us better. It is worse to be in Hungary than in Sweden, true, but
you can reduce the disadvantage by having more education. The gap between Sweden, Italy
and Norway on the one hand, and Hungary, Estonia and Bulgaria on the other, is much bigger
for people with little education. Go to university and you get closer to closing the gap.
CHILD: Hmm. So, education is important everywhere, as a predictor of a longer and, if you say
so, a better life. But knowing what a subjunctive clause is can’t be everything. Why should
being good at grammar make a bigger difference to life in Hungary than in Sweden?
YOU: Good point, well made. Education probably is good in itself. It gives you life skills, puts
you more in charge of what happens to you in life; but in addition, in most countries, more
education gets you a better job, more income, a better place to live. If social conditions are
pretty good for everybody, in Sweden for example, then having the special advantage of more
education perhaps matters a little less. In Hungary it will matter more.
CHILD: So, having more education in Hungary gets me metaphorically halfway across the
Baltic to Sweden, while staying right here in Hungary.
YOU: You’re there already!
INEQUITIES IN QUALITY OF LIFE

Before we ask what it is about education that seems to have such long-
lasting effects, it makes sense to consider not just length of life, but quality
too. At younger ages we feel immortal. Young people can abuse their
bodies in all kinds of interesting and exciting ways and appear to get away
with it. Who knows, perhaps Maria in Brazil at nineteen was concerned at
how many hours she could dance the night away and for how many days on
end. At ninety, her life can be transformed if the bus stops closer to the kerb
and the potholes are filled in. She can then enjoy the advantage of cut-price
theatre tickets and the company of friends.
At older ages, we want to be alive but, more important, we want to be
‘alive’. If the stereotype of older-age misery with which I began this chapter
were true, a few more years of life would not be such a bargain. I said
above that the difference between living to eighty-four and eighty-nine is
highly significant if you are eighty-four. Possibly. If you are severely
disabled another five years of life may seem a lot less attractive than
another five years of golf, opera and luxury travel.
Golf at eighty? Really? It does appear so. In England, at age eighty-plus,
more than 60 per cent of people describe their health as ‘good’, ‘very good’,
or ‘excellent’. These figures come from the English Longitudinal Study of
Ageing (ELSA), which follows a representative sample of the English
population. We look not only at how they feel but what they can do – their
functioning. A good measure is walking speed – how fast is one’s normal
pace. Walking speed is highly correlated with reports of difficulty with the
ordinary activities of daily life. At age eighty to eighty-four, nearly three-
quarters of women and more than 80 per cent of men have no difficulty
with walking speed.5
Golf is manageable by most people in England at eighty, except that it
isn’t, because only the more privileged play golf. Ditto opera and luxury
travel. I choose them advisedly. If you have wealth not only will you have
the money for golf, opera and travel, you are also more likely to have the
health, physical and mental function needed to enjoy them. There is a sharp
social gradient in health and functioning at older ages. In ELSA men and
women of high status, measured by wealth or education, had the same level
of reported good health as people of low status who were fifteen years
younger. A seventy-five-year-old in the highest education group had the
same likelihood of good health as a sixty-year-old in the lowest. In these
years of mid- to later life, high status means not getting old so quickly.6

It may be that people of high status and those of low have similar rates of
decline, but the high-status start from a higher level. I heard of a chess
grand master who complained that he used to plan nine moves ahead. Now
in his dotage he was reduced to five moves ahead. When he died, soon after,
he was found to have the pathological picture of advanced Alzheimer’s in
his brain. He noted marked decline in his cognitive ability, yet he was still
functioning at a level most of us could only dream of. The point is that if
you start from a high level, even with the inevitable toll of age you can still
function at a high enough level not only to lead an independent life, but to
flourish.
I am not for a moment suggesting that nothing changes at older ages, but
we should think of gains as well as losses.7 Joints are stiffer, everything is
slower – getting about, recovery from injury, remembering names – but
some things get better. Knowledge, experience, reasoned solutions to
problems, all improve with age. Wisdom is not a bad word for it. These,
too, follow the social gradient.
At older ages, particularly then, reducing inequities in health means
reducing inequities in physical and mental functioning as well as in
mortality and length of life. In the first figure in this book, Figure 1.1, I
showed that the social gradient in health was steeper for disability-free life
expectancy than for life expectancy. The lower the position in the hierarchy
the more years of life spent in disability – shorter lives with more pain and
discomfort. Happily, there is good news to report on what can be done.
Empowering older people and recognising their rights to a continued place
in society is key.
ACHIEVING HEALTH EQUITY AT OLDER AGES
The great affairs of life are not performed by physical strength, or activity, or nimbleness of
body, but by deliberation, character, expression of opinion. Of these, old age is not only not
deprived but, as a rule, has them in greater degree . . .
Cicero on Old Age
We can wring our hands at the ageing of the world’s population, subscribe
to the miserable stereotype with which I began this chapter, and . . . then
what? Then nothing. It is a counsel of despair. The world’s population is
ageing, and growing older will happen to all of us. Let’s embrace it and

recognise that, as I have just described, in many countries significant
proportions of the older population are flourishing, but there are marked
social inequities. The challenge is, as it is at earlier stages of life, to bring
everyone up to the level of health and functioning of the most privileged –
to reduce the social gradient in health by levelling up.
The best way to reduce social inequities in health at older ages is
undoubtedly to start at the beginning of life. Arrive at age sixty or sixty-five
with better cognitive function, better physical functioning and better health,
and the future looks rosier than if you are lower on these measures – fifteen
more years of rosiness for those in the top income, wealth or education
group than for those in the bottom.
There is, though, much that can be done at later ages and for all social
groups. Strong evidence comes from the United Nations. Some UN reports,
by the time they have been through the political wringer of approval by
member states, come out looking wrinkled and shrunken. Not all do. Ageing
in the Twenty-First Century: A Celebration and a Challenge is a
remarkably robust report from the UN Population Fund (UNFPA) and Help
Age International, a charity.8 At its heart it puts ageing with dignity and
security and enjoying life through the full realisation of human rights or
fundamental freedoms. The report appeals not only because it has good
analyses of practical actions but because it has dignity and freedoms at its
heart and makes the explicit link between dignity and economic security.
When I lecture to first-year medical students, I explain to them the
concept of Minimum Income for Healthy Living.9 A minimum income
includes not only what is necessary for food and shelter, but what is
required to live a life of dignity and to take one’s place in society. An older
person needs money for transport, to enable social engagement, and to buy
presents for the grandchildren. I say to these brilliant young medical
students who have performed extraordinarily well to get into medical
school: you came to UCL to learn about genomics, and proteomics, and
metabolomics, and here is a professor telling you that if your granny has too
little money to buy you presents she is denied a life of dignity, which will
be damaging to her health. The students love it!
This paragraph is a diversion. Indulge me, please. The concept of
Minimum Income for Healthy Living was developed by Professor Jerry
Morris. Jerry was a pioneer in what was then called Social Medicine in
Britain. He was the one who put exercise and health on the map. He had

showed that conductors on London’s double-decker buses had lower rates
of heart disease than drivers. Wiry, short, energetic, he would grab your
elbow in an iron grip and order you to have lunch with him. Then would
follow the rare privilege of ranging with him across his intellectual terrain
from biochemistry to social welfare policies. After his ninetieth birthday, he
was publishing papers on this ‘new’ concept he had developed: minimum
income for healthy living. In 2008, after we published Closing the Gap in a
Generation, the report of the WHO Commission on Social Determinants of
Health, Jerry rang me at home one Saturday afternoon and said:
‘Michael! Your report has transformed the debate.’
Praise indeed. But, panic. Had I remembered to quote his work on minimum income? I had
the report on my desk, thumbed quickly through it, and . . . Aha!
‘We quoted you on page ninety,’ I said.
‘And on page seventy-nine,’ said Jerry.
He was ninety-eight when that conversation took place. But still, he did
what academics will: did they cite my work? That is healthy ageing. I have
acknowledged one of my great teachers. Diversion over.
Ageing in the Twenty-First Century reports that, worldwide, the two most
frequently mentioned concerns of older people are income security and
health. They are closely linked.
I have stated already that the social gradient in health in older people has
its origins in the life course. The time to start is before birth. Yet I am about
to lay out evidence that there is much we can do at older ages to improve
health and functioning and reduce social inequities. The evidence is of
variable quality. Yet I reach conclusions. Suppose some of the evidence is
not correct. Suppose empowering older people to lead lives of dignity and
independence did not improve their health, and that being physically and
socially active did not slow the rate of cognitive decline. Have we done
damage by pursuing these ends? Is it a bad thing that older people should
not have to choose between heating their home and eating, that they should
be able to use public transport and make use of cut-price tickets to concerts
and theatre, that the environment should make it easier for them to see
friends and family? My own view is that these interventions will make a
difference to health equity. But even if I am wrong, even if they won’t
improve health, they will make a significant contribution to the well-being

of older people and their chance to lead lives of dignity. That, surely, is
justification enough.
EMPOWERMENT: MATERIAL, PSYCHOSOCIAL AND
POLITICAL
Hearken to Maria from Brazil. I described her needs as empowerment:
material, psychosocial and political. They overlap. I think of social
participation as psychosocial, but having enough money enables Maria to
participate in a way that otherwise she could not. Fixing the potholes is
‘material’, but doing so enables her to get out more with confidence.
Having rights is political, but may lead to action in the other domains.
Material empowerment . . . through wealth
You have reached retirement age, no more income from work. Now what do
you live on? One aristocratic luminary in British public life described his
parents as being members of the idle rich. Some fathers were richer, he said,
but none was idler. The first possibility then is that some tiny percentage of
the world’s population can live on returns from their wealth. They are, in
effect, members of the rentier class. Even in rich countries, though, most
people have at most two assets, their dwelling and their pensions, and many
do not have even that. Thus, even in high-income countries income from
capital is not a route out of old-age poverty for most people.
. . . and work
A second possibility is to keep working beyond the formal retirement age,
or for societies to change the retirement age. Here we have the twin issues
of gender discrimination and socio-economic inequalities. In Chapter 6 I
described the lot of Lalta, a human scavenger in India. Even when she was
retrained as a beautician she was in informal employment – no job security,
low pay. If a younger woman comes along, she is easily dispensable. Even
were she fit enough to keep working beyond sixty or sixty-five, there may
simply be no work for her to do.
Globally, women are more likely than men to be in the informal sector, to
have less education, to be discriminated against when it comes to work

opportunities, and to have been paid less than men doing the same job.
They are also likely to outlive their husbands, hence be single, and to be
important in family caring. All of these combine to make it more likely that
older-age poverty is female poverty. In the future this will change, as
women’s education catches up on men’s and, we hope, gender
discrimination becomes less widespread.
Suppose a country said that it would delay retirement age from sixty-five
to sixty-eight, so that people could work longer to keep themselves out of
poverty, or at least relative poverty. Step forward employers and potential
employees. What happens next? Employers are likely to want people with
skills and education. And potential employees, if they are to seek work,
have to be fit enough to do it. Both of these mean that continuing in work to
later ages is a possibility that tracks the socio-economic gradient.
England serves as a modal example. As we saw in Figure 1.1 (p. 26),
there is a striking social gradient in disability-free life expectancy: the lower
the socio-economic level the shorter is disability-free life expectancy. For
people at the most deprived end of the scale, disability-free life expectancy
is about fifty-five; at the upper end about seventy-two. The most affluent
could do physical work but probably wouldn’t want to; the least affluent
might want to, but couldn’t do it. Not a good match.
Working longer is, and should be, a possibility, but why do we find it so
hard to build in flexibility? For some, in privileged occupations, stopping
work is anathema. A friend, a professor at a prestigious US university, tells
me that half the full professors in his school are over seventy and some are
in their eighties. It seems obvious that the old should step aside to make
way for the young. There are only so many jobs to go around, and if the old
won’t move the young can’t have them. Obvious, but wrong. The idea that
older people are blocking jobs for younger people – the ‘lump of labour’
hypothesis – has been debunked as a myth.10 The flaw is to assume that
there is a fixed number of jobs. The evidence shows that, in general, the
higher the participation of older people in the labour market the higher the
employment rate of younger people – more jobs for the old and more jobs
for the young. Yes, there may indeed be circumstances when the old should
make way for the young – new brooms, fresh ideas, and so on – but not
because if old people remain working young people cannot. Roles can and
should change with age.

People whose work is their pleasure, such as many academics, are only
too pleased to stay on working. More generally, the nature of work affects
people’s desire to want to keep doing it. In Chapter 6 I reported that jobs
characterised by high effort and low reward were particularly stressful and
increased risk of disease. My colleague Johannes Siegrist from Düsseldorf,
who developed the effort/reward concept, has looked at how this relates to
retirement across Europe. A study of fifteen European countries found that
the more that jobs are characterised by imbalance between efforts and
rewards, the more likely are people to declare that they intend to retire.11
Attempts to raise retirement age in France led to mass strikes and Paris
grinding to a halt. Keep the jobs lousy and it is hardly a surprise if people
are not keen to keep doing them.
Anecdotal evidence from a large British retailer suggested that older staff
see the advantage of staying in work not only in financial security, but in
maintaining friendships and, being more experienced, having something
special/extra to offer customers.12
The fact that the terrain is tricky does not mean that it can’t be
negotiated. One path out of older-age poverty is to work for longer. For
those with education and skills in interesting jobs, surely what we need is
some flexibility. The idea that people work to a certain age and then fall off
a cliff into non-work seems bad for them personally, and a loss for others of
the skills, experience and wisdom that some embody. Part-time work at
older ages? Easing into retirement? These should be options. The ground is
tricky because we then have to think about people in physically demanding
jobs that are boring or worse. Would it be such a boon to Alan or Lalta to
keep working longer? They may need the money but they do not need the
indignity and stress. If the adverse impact on health is a reason for
addressing the nature of work at younger ages, all the more is it a reason for
improving working conditions at older ages – to provide the conditions and
flexibility to enable older people to continue at work.
Academics, orchestra conductors and novelists may want to keep
working for ever, but most people do not. Even Philip Roth, novelist, who
wrote some of his greatest novels to great acclaim in his sixties and
seventies, declared at eighty that it was time to stop. After work finishes,
and if there is little private wealth, pensions or some form of social security
and family support become vital.

. . . and pensions
‘Annual income twenty pounds, annual expenditure nineteen [pounds] nineteen [shillings] and
six [pence], result happiness. Annual income twenty pounds, annual expenditure twenty pounds
ought and six, result misery.’
Mr Micawber in Charles Dickens, David Copperfield
A few years ago in Finland, I was told that they had designed their social
security system on the assumption that people would work for forty years
and die soon after they stopped. With longer spent in education, the mean
age at entry to the workforce was then twenty-six, and the mean age at exit
was then fifty-two – time in the work force twenty-six years. Life
expectancy at sixty continued to rise. Finland was heading for Mr
Micawber’s unhappiness.
An ageing of populations entails political choices. Pensions are
complicated. Some combination of workers themselves, their employers
and the government put money into a scheme. It may be you notionally
putting money aside for your own non-working future, or today’s workers
supporting today’s older people. If the money is invested, the performance
of the market will of course be important.
If there seems to be too little money for today’s retirees, society has three
choices: people can work longer, pensioners be poorer, or workers be
poorer as they put more money aside for their own or others’ old age. There
may be some other more complicated choices to do with manipulation of
money, but those three will do to demonstrate that societies can choose how
they want to manage things.
Indeed societies do make different choices. Figure 6.1 (p. 184) in the
previous chapter showed that in Britain the number of workless households
in poverty has been declining while the number of working households in
poverty has been on the increase. Figure 7.4 shows more generally for the
rich country club, the OECD, the choices countries make.
Compare Ireland and Poland, for example. Both have a poverty rate in
the general population of about 15 per cent, but in Ireland the poverty rate
for older people is around 30 per cent, in Poland it is about 5 per cent.
Poland has organised its affairs, or been subject to historical accident, so
that older people are better off than the general population. In Ireland the
opposite is true. In Sweden and Austria the poverty rate is low both
generally and in the elderly. Clearly the best is to have low poverty rates,

but if poverty is defined relative to some standard, 60 per cent of median
income for example, someone has to be poor. Society has a good deal of
discretion as to where the hardship should fall.
Figure 7.4 covers rich countries, most of which have well-developed
social security or pension systems of one sort or another. It is worth asking
if such a thing is even conceivable in a middle- or low-income country. The
answer is yes.
FIGURE 7.4: ARE OLDER PEOPLE MORE LIKELY TO BE POOR THAN THE REST OF THE
POPULATION? NOT NECESSARILY. . .
Bolivia is one of the poorest countries in Latin America. Nilda at sixty-
eight had no source of income. She heard that there was a state pension:
older people could receive an annual payment of about $217. She lived in a
rural area and the pension was available from a bank in an urban area.
About to make the trek to collect it, she was told she needed an
identification document to register for the pension, but she didn’t have one.
About one-sixth of older Bolivians, almost all rural-born indigenous people,
had no birth certificate or identity document. Without it they did not exist in
the system. HelpAge International, an NGO, supports legal centres in
Bolivia that help people obtain birth certificates. For Nilda the steps were,
first – birth certificate, second – pension, and then transformation of her
life. The pension was way below average income for the country, but it was

enough for household expenses and basic medications. For some of Nilda’s
neighbours the pension was a lifeline of another sort. It provided a small
amount of capital for income-generating activities or to help their children
do the same.13
Bolivia is not alone among poorer countries. When we were conducting
the Commission on Social Determinants of Health we were given evidence
of pension schemes in low- and middle-income countries from A to V,
Argentina to Vietnam, including among others Bangladesh, Botswana,
Nepal and Uruguay. That said, only about 65 per cent of people in Latin
America are covered by pension schemes, 20 per cent in South Asia, and
less than 10 per cent in Sub-Saharan Africa. Where contributory pension
schemes, to which the employee and employer contribute, fall short, some
form of social scheme, provided by the state, is necessary. Now, more than
100 countries have social pension schemes.14
If a country is poor the prevalence of poverty among the elderly will be
high. But even for a low-income country there is ample precedent for
schemes that make a qualitative difference to the lives that the elderly are
able to lead, to their empowerment.
Psychosocial – empowerment as control and participation with dignity
I have two approaches to empowerment at older age of the psychosocial
variety. The first is impact on health behaviours, or lifestyle. The second is
social participation. Starting with health behavior, a friend put it to me: I
have devoted my life, studiously and conscientiously, to avoiding physical
activity of any kind. Why in my sixties should I change? It is true that when
standing upright he has some difficulty seeing his toes, let alone stooping to
touch them, because of a generous midriff. But he takes that as a modern
equivalent of Shakespeare’s fifth age of man: ‘In fair round belly with good
capon lined’. It goes along with being ‘Full of wise saws and modern
instances’.15 My friend has a poetic, indeed Shakespearean, turn of phrase,
and can bring a tear to the eye with descriptions of his Falstaffian
enjoyment of a roast running with fatty juices, and roast potatoes glistening
with their oily covering. Saturated fat? Bring it on. He tried green
vegetables once, but couldn’t see the point. His description of his
enjoyment of rich puddings would make ‘Shall I compare thee to a
summer’s day?’ read like a legal letter.16

At least my friend has his high socio-economic position going for him in
the survival stakes. Given that position, I argue that he should take control
of his life and enjoy healthy food and physical fitness, and moderate alcohol
consumption, in addition to continuing not to smoke. Echoing Woody
Allen, my friend wants to know what the point is of living to a hundred if,
to do it, you have to give up all the things that make you want to live to a
hundred. He has a prior question, though. He wants to know, given that he
has been deliciously wicked as far as diet and exercise go from childhood
into the latter part of his seventh decade, whether it would make any
difference to change now.
His question is a good one. It underlies the premise of this whole chapter.
If health and health inequities at older ages are determined by what
happened through the whole of the life course before people were elderly, it
may not matter what the elderly do, or what they have to endure. I have just
been arguing that it does matter if the elderly are in poverty. It may matter,
too, how they behave.
One powerful piece of evidence comes from a European study of people
aged seventy to ninety in eleven European countries.17 People who
consumed a Mediterranean diet – lots of olive oil, legumes, nuts and seeds,
grains, fruit and vegetables, fish, relatively little meat and dairy, alcohol in
moderation – were physically active, and had not smoked for fifteen years
appeared to derive great health benefits. Over ten years of follow-up they
had less than half the mortality rate of the people who, like my friend, were
doing the ‘wrong’ things. But they had presumably been doing, or not
doing, these things for most of their lives before they reached seventy. The
study does not quite tell us if contemporary behaviour matters. It almost
certainly does for smoking. People who give up smoking gain health
benefits after a lag period. There are also probably contemporary benefits in
physical activity, not only for mortality but, as we shall see in a moment, for
cognitive function.
If all it took was evidence of benefit then everyone could be healthy. As I
laid out in Chapter 2, there are constraints on healthy behaviours, which
apply in the elderly as they do at earlier ages. In the elderly, as at other ages,
two of these four behaviours, physical activity and smoking, follow the
social gradient as, in some countries, does healthy diet.18 It is likely that
they are contributing to the social gradient in health. One form of
psychosocial empowerment, then, is taking control over behaviours.

There is significant evidence relating to cognitive function and dementia.
Researchers are divided into two camps: those who subscribe to ‘use it or
lose it’ and those who do not. Both camps have evidence to support their
view. The question is: if you stop doing the sudoku, will your cognitive
powers decline; or do your cognitive powers decline, which is why you stop
doing the sudoku?
Several studies have looked at this question.19 One in the Bronx in New
York interviewed and examined generally healthy people aged seventy-five
to eighty-five.20 These people were asked about their physical activity
patterns and how often they participated in six ‘cognitive’ activities:
reading books or newspapers, writing for pleasure, doing crossword
puzzles, playing board games or cards, participating in organised group
discussions, and playing musical instruments. In this study physical activity
was not protective of cognitive decline or dementia, but cognitive activities
were. The question was, which came first – the dementia or the lack of
cognitive activities? The researchers’ way of answering it was to use a
cognitive test at baseline that satisfied them that they were ruling out the
possibility that pre-clinical dementia was leading to lack of activities.
Participation in cognitive activities was protective – it linked to less
cognitive decline.
Other studies have found moderate physical activity to be protective
against cognitive decline, again taking into account the possibility that
cognitive decline precedes lack of interest in physical activity.21 A study of
former US nurses aged seventy and above assessed habitual physical
activity nine years before looking at the rate of cognitive decline, and still
they found that physical activity, even just walking, was protective.22
I have shown my bias by not giving the other side of the story of which
comes first: whether decrease of activity or cognitive decline. One
longitudinal study of the elderly, the Victoria Longitudinal Study, shows
evidence that the relation between activity and cognitive performance goes
both ways.23 Certainly, people who were active socially, cognitively and
physically had less subsequent decline in cognitive performance, but there
was also clear evidence that it goes the other way too. Decline in cognitive
performance can lead to reduced participation in activities. Hardly
surprising, really.

This controversy of which comes first, use it or lose it, is not over. That
said, it seems likely that there is some protective effect on physical and
mental functioning of cognitive, social and physical activities. Given that
such activities follow the social gradient, they will contribute to a social
gradient in healthy ageing.
After health behaviours, the second approach to empowerment is social
participation. As we have just seen, lack of activity can be bad both for the
brain and for the body. Loneliness makes things worse, but can be ‘cured’.
Mr. O, a 68-year-old amputee (due to diabetes), was wheel chair bound; a longtime smoker;
lived in – and hadn’t left – his senior high rise apartment building in 5 years. A new project,
Experience Corps, enrolled elderly volunteers to spend time with young children in school. Mr.
O volunteered and came to school three or more days per week for 15 hours a week. The School
Principal saw him in his wheel chair, and told me she went back to her office and wept because
she was afraid she had agreed to having to baby sit old people as well as lead a challenging
school. One month later, she described to me the following scene: three children were arguing in
front of the elevator and around Mr. O and his wheelchair. She listened and found that they were
arguing about who would get to push Mr. O onto the elevator. They resolved it: one pushed, one
pressed the elevator button, one sat on Mr. O’s lap. Two months later, the Principal asked for
sixty volunteers – an addition of 45 over what she had.
Linda Fried, geriatrician, gerontologist, epidemiologist
Lack of social integration can be fatal. If Mr O. had the choice of giving up
smoking or being more enmeshed socially, it is a close thing: both are
potentially life-saving, but social integration is marginally better for his
health.
A ‘meta-analysis’ combined results from 148 studies of men and women
with an average age of sixty-four at the start of the study. It found that over
an average 7.5 years of follow-up, people who were socially engaged had a
50 per cent lower chance of dying. Being socially integrated in a variety of
ways was more protective than simply being married or not living alone.24
The protective effect was similar in men and women. This lack of gender
difference is interesting. It has long been known that married people have
lower mortality than those who are single, widowed or divorced. It never
failed to raise a chuckle when someone would report that marriage was
good for men and not for women. Not difficult to think of an explanation
for that one. What this study shows, however, is that when men and women
are involved with society and organisations in a variety of ways, it is
equally protective for both genders.

You do not have to be an African-American in Baltimore, like Mr O. to
be socially isolated in your older age. In the English Longitudinal Study of
Ageing, the evidence shows clearly that it is not lonely at the top, but at the
bottom.25 As usual it is socially graded. People in the study were classified
according to their wealth: the lower their wealth, the more likely not to
belong to clubs or organisations, to be socially disengaged, to have less
contact with friends, and to feel lonely.
Social isolation is not just a matter of personal choice, but is influenced
by the environment broadly conceived. For older people, working, caring,
subsidised transport, age-friendly cities that remove the physical barriers
against the elderly, crime-free neighbourhoods, having enough money to
engage, are all ways of reducing the problem of social isolation. Chapter 8
will look at the question of building healthy communities.
A particularly exciting way of involving older people in society,
Experience Corps, was devised by Linda Fried, quoted above, who was a
professor in Baltimore and is now Dean of the School of Public Health at
Columbia University.26 Her concern was with the Mr O.s of Baltimore –
elderly people, socially isolated, with no useful role in society. Could she
and her colleagues solve the social isolation, give people a useful role, and
improve their health and well-being all at the same time? The useful role
they chose was working with young children in schools in deprived areas. It
was a strategic choice. Older people could satisfy their need to give
something back to society, and young children would benefit.
Conventional wisdom in US cities was that upper-income white women
are the volunteers for good causes. Experience Corps tapped into wells of
enthusiasm among men, as well as women, who were of low income, and
African-American. Preliminary evidence from controlled trials of
Experience Corps point in a good direction: children have improved reading
scores and fewer referrals for behaviour problems. The elderly volunteers
have higher levels of social integration and sense of generative
achievement; have modest increases in intellectual and physical activity;
and feel, in the words of participants, like they had ‘dusted off the cobwebs
in their brains’.
Political empowerment

What if you are old and don’t feel it? More than 60 per cent of people in
England over the age of seventy-five said they did not feel ‘old’.27
Interesting. My first reaction to these figures was: that’s good. In fact, that’s
great that seventy-five does not mean feeling old. My second reaction: oh
dear! I am trapped in the negative stereotype of what ‘old’ means. That is
not great at all.
Here’s an alternative thought. What if the word ‘old’ conjured up images
not of frailty, decrepitude and dependence but the wisdom of Cicero, the wit
of Woody Allen, the sparkle of a mischievous grandparent, the love that
only grandparents can have for their grandchildren and vice versa? With
this in mind, we would lament that only 40 per cent of seventy-five-year-
olds felt old – sparkling, witty, wise, mischievous and loving to their
grandchildren – rather than rejoice that 60 per cent do not feel old.
Changing the cultural meaning of ‘old’ is not to deny the inevitable
physical and mental declines. But as I showed above, society is defining old
as sixty or sixty-five, and many people’s minds and bodies are not behaving
‘old’ until fifteen or twenty years later – earlier if you are relatively socially
disadvantaged, later if your life has been more privileged.
I am not sure which comes first, change of culture or change of laws and
regulations. Clearly we need both when it comes to ageing populations. I
began the chapter with Maria from Brazil saying that her life had been
changed by a law guaranteeing her rights, her entitlements. Certainly, in
democracies, governments can no longer ignore the rights and other claims
of older people. There are so many voters who are older. In the US, the
AARP (it used to be the American Association of Retired Persons) has
37 million members – a force that cannot be ignored.
As each stage of the life course has come to prominence I have argued that
now this is the really important stage. Early child development sets the
stage for the rest of life. Education determines whether a promising
beginning will translate into better life chances all the way, right into the
oldest age. Working age is of vital importance. We spend so long in work
that it matters what work does to our health and well-being and whether
work gives the economic security to guarantee good life chances for the
next generation. And now, I have argued that older age is where we really
see the effects of the whole of life. As childhood mortality declines, as the
world ages, and as non-communicable diseases come to dominate the global

health picture, then health inequities at older ages become increasingly
important. The evidence is clear that what happens through the whole of the
life course impacts on the health and well-being of older people. So too do
the conditions in which older people live out the remaining ten, twenty or
thirty years of their lives. What happens in the wider society affects older
people as it does people at earlier ages. The aspect of the wider society that
we turn to next is the communities where people are born, grow, live, work
and age.

8
Building Resilient Communities
There’s nothing ill can dwell in such a temple.
If the ill spirit have so fair a house,
Good things will strive to dwell with ’t.
William Shakespeare, The Tempest (Act I, Scene ii)
In May 2011 Mary hanged herself.* She was found in the yard of her
grandparents’ house on a First Nations Reserve in the province of British
Columbia in Canada. She was fourteen. She was a First Nations, aboriginal,
Canadian.1
Her story has particulars. All suicides do. She had been physically and
emotionally abused at home and in her community, and possibly sexually
abused. Her mother was mentally unstable and heard voices telling her to
‘snap’ her child’s head. Officials attributed the suicide to a dysfunctional
child welfare system, and to the fact that no one took her complaints of
abuse seriously or acted on them.
There is another way to look at Mary’s sadly foreshortened life, and that
is to realise that though her personal tragedy was unique, there are many
young aboriginal Canadians who experience similar tragedies. In fact, the
aboriginal youth suicide rate in British Columbia is five times the average
for all young Canadians.2 One cannot understand fully why Mary saw no
way out without also asking why so many other young aboriginal people in
British Columbia reached the same desperate point.
Christopher Lalonde, a professor of psychology at the University of
Victoria in British Columbia, says: ‘There are media reports of an epidemic
of youth suicides among First Nation communities, but half the
communities we studied had not had a youth suicide in twenty-one years.’
Lalonde and Michael Chandler, now an emeritus professor at the University
of British Columbia, studied aboriginal youth suicide from 1987 to 2000 in

British Columbia. They found that although the Province had about 200
aboriginal ‘bands’, in the first six years of their study more than 90 per cent
of the suicides occurred in 12 per cent of the bands.
What features distinguished communities where suicides occurred from
others that were not so scarred? The starting point for Chandler and
Lalonde was poverty, what they call bone-grinding poverty. They say: ‘The
aboriginal population of North America is known to be the most poverty-
stricken group on the continent, to have the highest unemployment rates, to
be the most undereducated, to be the shortest lived, and to suffer the poorest
health.’3 Poverty had to be part of the explanation, but only part. All the
aboriginal communities were poor, almost without exception. There had to
be something that put some poor communities at higher risk than others.
According to Lalonde, ‘communities that were able to hold on to their
cultural history and promote their own collective future’ were the ones with
low rates of suicide. To measure this they collected six markers from each
community that assessed cultural continuity. These included participation in
land claims; aspects of self-government; community control over education,
police, fire and health services; and establishment of ‘cultural’ facilities.
The results were clear: the greater the cultural continuity and community
control over their destiny, the lower was the youth suicide rate. Poverty is
bad but, to echo the schoolteacher from Tower Hamlets, poverty is not
destiny.
The officials’ account is that the provincial child welfare system failed to
prevent Mary’s suicide. Lalonde puts it differently: ‘Don’t target suicide;
what you should target is making the community a healthier place for youth
to live.’ And the way to do that is to empower the community, to use my
language. In Lalonde’s language: communities should be able to hold on to
their culture and promote their collective future.
The grim picture played out to deadly consequences in Canadian
aboriginal populations is also present in Native American,4 Australian
aborigine5 and New Zealand Maori communities.6 Social exclusion and
disempowerment can kill.
Social exclusion is not an all-or-nothing phenomenon. Degree of social
exclusion and disempowerment can contribute to the social gradient in
health – not just in aboriginals but in all our communities. The
environments where people are born, grow, live, work and age pose

material and social hazards to health. At the same time, communities can be
resilient in the face of hazards, and can be health-enhancing.
What happens at the local level can contribute to crime, alcohol-related
deaths, obesity, road traffic injuries, depression, health problems linked to
pollution of air and water, problems with housing. On the plus side, the
local level can improve health through a high level of social cohesion and
social participation, security and low fear of crime, active transport,
provision of green space, walkability, availability of healthy food, good
services.
The best is not to have bone-grinding poverty. But even in the face of
such poverty communities can flourish to a greater or lesser extent with
profound consequences for health equity. There are encouraging stories of
community developments in the face of grinding poverty. Local influences
are important all the way up the social gradient and at all ages. I want to
begin with social hazards and resilience, then move on to material hazards.
MAKING COMMUNITIES SOCIALLY HABITABLE
The distinction between social and physical that I am making is somewhat
arbitrary. Good urban design allows social interaction. Affordable public
transport enables people old and young to be socially active. That said, the
more obviously social is a good place to start.
Crime is a public health issue . . . fear of crime
‘De folks wid plenty o’ plenty got a lock on de door,’ sang Porgy in George
Gershwin’s Porgy and Bess. Someone with ‘plenty of nuttin’ needed no
lock on the door. The implication was that crime happened to the rich. But
thinking you need no lock because if you haven’t got much would-be
robbers will look elsewhere suggests that Porgy had not been reading the
figures from the Department of Justice in the US.7 These show that the
lower the household income the higher the risk of property crime. We have
a similar situation in the UK: the more deprived the area the higher the
crime rate. One civil servant said, sardonically: that’s joined-up
government. The public transport is so bad, the poor have to rob where they
live.

Bank robber Willie Sutton may have explained his penchant for robbing
banks as because ‘that’s where the money is’, but more property crime takes
place in the US and the UK where the money isn’t.8 The same is largely
true for violent crime: higher rates in low-income areas. Both theft and
violence lead to fear of crime.
As we saw at the start of the chapter, suicide is an individual act, but the
suicide rate is a property of the community. So it is with crime. An
individual gets attacked or robbed. But the crime rate becomes a
community characteristic. One way we see this is fear of crime, which is
influenced by the actual crime rate, but may not change as fast as the rate of
crime changes.9
With my colleagues Mai Stafford and Tarani Chandola we demonstrated
the link between fear of crime and ill health in the Whitehall II study of
British Civil Servants, aged fifty to seventy at the time of this particular
study.10 As I have reported in earlier chapters, we used the employment
grade of civil servants to mark out their position in the social hierarchy. The
results were astonishing. There was a steep social gradient – lower grade
more fear – in fear of mugging, burglary, car crime and rape. A third of the
lower grades were worried about mugging, 7 per cent of the high grades; a
third of the lower grades were worried about robbery, a sixth of the higher
grades were.
The greater the fear of crime the worse was the mental health and the
worse the general level of physical functioning. Fear of crime, as well as
directly influencing anxiety and stress, seemed to be isolating people – they
spent less time visiting friends, participating in social activities, walking
outside or exercising. This reduction in activities was a clear part of the link
between fear of crime and ill health.11 The social gradient in fear of crime
was part of the explanation for the social gradient in health. If fear of crime
leads to social isolation of older people they become indirect victims of fear
of crime as a community characteristic.
. . . dealing with grievous bodily harm
Saturday nights are busy in Cardiff, capital of Wales, not least in the
accident and emergency rooms. Youngsters, usually men, get to hospital in
various states of disrepair. A typical case would be a brawl in a pub,

smashed beer glasses used as weapons, jagged gashes to the face and body
of a drunken young man.
Jonathan Shepherd, an oral and maxillofacial surgeon, spent his Saturday
nights stitching up these torn young and sometimes not so young men, and
wondering. He wondered, in the words of the standard public health
metaphor, why no one was looking upstream at the causes of these violent
injuries. Surgeons are supposed to stitch people up, not ‘do’ prevention and
public health. I’ll display my prejudice if I say that the best do public health
alongside their clinical duties. Jonathan Shepherd in Wales is a shining
example.
Professor Shepherd was not surprised to note that violence was not
randomly distributed through the city, but there were violent hotspots. The
problem was that the police did not know about the majority of violent
incidents, so had not identified the hotspots. Only a quarter to one-third of
the violent incidents that are treated in accident and emergency departments
in the UK are reported to the police. There is similar low reporting in the
US and other countries. The victims of violence are reluctant to report the
crime because they fear reprisals, they may not know the identity of the
assailant – ‘a drunk bloke in a pub’ hardly narrows it down – and are
concerned over having their own circumstances closely scrutinised.
In order to prevent violent harm, Shepherd set up and led a partnership of
health practitioners, police, city alcohol-licensing authorities, education,
transport and ambulance services. A key element was the accident and
emergency departments’ reporting of violent incidents to the police,
anonymised – that is, the identity of the victim was withheld but the
location was reported so that the police could identify hotspots.
One issue is displacement. If the police actively target a high-risk area,
will the violence simply move somewhere else? The answer appears to be a
clear no, which is interesting – a ‘yes’ answer, it does move, would not have
surprised. One might speculate that if violence is a property of society, then
young people unable to create mayhem in one place would do it somewhere
else. Apparently not. Perhaps the people who get into drunken, broken-
glass-wielding brawls are not thinking quite so rationally. They are hardly
evaluating their options, the risks and benefits of slashing someone round
the face with a makeshift weapon, and maximising their utility.
The prongs of the prevention strategy, in addition to targeted, high-
visibility policing in hotspots, included pedestrianising streets in high-risk

areas, providing late-night public transport, and working with staff in the
taverns and pubs where violence was frequent. It seems to have worked.
Over a four-year period, Cardiff had a 42 per cent reduction in hospital
admissions related to violence compared to similar cities without such
intervention.12
Broadening his approach to the whole of England and Wales, Shepherd
and colleagues sought to explain the greater than threefold difference in
rates of violence-related injuries across regions. They found higher rates of
violence in areas that were both poorer and had higher rates of youth
unemployment; rates were higher in the summer, and when major national
sporting events took place. In addition to all of that was the price of beer:
higher beer price, lower violence-related injury.13 Simple, really. As we saw
in Chapter 2: raise the price of alcohol and consumption goes down. I have
been a bit critical of overly simple, not to say simplistic, applications of
rational choice theories of economic behaviour, but if raising the beer price
reduces violent behaviour it can make a contribution to communities
becoming more liveable.
. . . combating gangs
It is likely that most violence-related injury involving gangs comes from
them fighting each other. It is unlikely, but just possible, that someone
might argue: let them do each other in. I have two objections, practical and
moral. Practical, in that the rest of us can get caught in the cross-fire,
literally or figuratively. Crime-ridden neighbourhoods engender fear of
crime, see above, and they may sweep innocent people up in the net of
violence.
Second, on the moral objection, it is core to the beliefs and practice of
doctors to help the sick and injured. Doctors do not, nor should they, make
moral judgements about people and treat or not depending on those
judgements. Just as I argued in Chapter 3 that we would treat people even
though they were ‘responsible’ for their own illness, we do the same if
people are harmed by violence in which they were willing participants.
Gang-related violence is widespread. On the US–Mexican border there
have been thousands killed in warfare between drug cartels in the last seven
years or so. There are approximately 6,700 licensed firearms dealers in the
US along the border with Mexico, and only one legal firearms retailer in

Mexico itself. Approximately 70 per cent of guns recovered from Mexican
criminal activity come from the USA.14 Tackling that might be a way to
reduce gang violence.
Organised violence in favelas in Brazil plagues these informal
settlements with some of the worst murder rates in the world. Colombia’s
drug-related violence is legendary.
The US has been in the lead in developing approaches to combatting
gang violence.15 The US approach has been adapted in Glasgow. Police
officers bring gang members who have offended to a meeting. They treat
the gang as a unit rather than as individuals and they say that if any of the
members of the gang – including those not present in the meeting – commit
a crime after the meeting, the police will pursue the whole group rather than
the individual. The police make the message clear: we know who you are
and if you continue offending, we will come down on you, hard! Imagine
that line delivered in a tough Glaswegian accent. The threat to punish the
whole group also encourages gangs to police their own behaviour.
A mother of a victim comes to the meeting and talks movingly of what it
is like to have a son knifed in gang violence, what it means to a mother. An
A&E consultant describes having to treat injured gang members, and
community members describe the damage that the gang is doing to their
local communities. There follow group discussions. At one of these, one
young man spoke up angrily and said: I’ve been fighting them for years
(pointing at members of a rival gang), and I want to know why!
The warning is the stick. The carrot is crucial. The opportunity to
develop skills and be trained for employment offers visions of an alternative
future. Here, the cooperation of potential employers in both the public and
private sectors is vital. Gang members are given the phone number of a
‘one-stop shop’ where they are able to access education, health services,
careers advice and social services, and once they have signed up to the
programme, their needs are assessed and they are put on relevant
programmes, such as anger management and conflict resolution, or training
in employment skills. The violence reduction unit (Community Initiative to
Reduce Violence: CIRV) of the police that runs this programme reports a
near-50 per cent reduction in violence among the 400 or so gang members
who have been through it.16 These programmes cost money, but the benefit
is not only in the short-term reduction in violence: the potential long-term
gains are large.

BUILDING SOCIALLY SUSTAINABLE COMMUNITIES AND
RESILIENCE
. . . with community groups
While conducting my English Review of Health Inequalities, I talked to
community groups in the English city of Liverpool.17 They listened, went
away and discussed what they heard, and came back with the following
challenges – my summary:
• We do not want an outside expert telling us what to do. Our values should determine our goals.
• Nor do we want an expert telling us what to measure. Our value-driven goals should determine
how we measure success.
• The journey is important as well as the destination. How we get there is important, as is where we
want to get.
• We thought that the problem was poor-quality programmes. Now we recognise that the problem is
the nature of society. But there is still much that we can do.
I felt a bit confronted by ‘We do not want an outside expert telling us
what to do.’ Having just caught the early train from London, I was the only
outside expert in the room. They must mean me. Good Liverpudlian stuff.
They folded their arms, metaphorically.
I folded mine and came back: ‘So, it is more important that an
intervention be designed locally than it be effective? After all, I would only
recommend what the evidence shows is likely to work.’
Now we had a standoff.
‘OK,’ they said, ‘tell us what has been shown to work, but we will do it
in our own way.’
Sounds to me like a good principle. The community should take control,
but it will be helpful to know what has worked elsewhere to build socially
sustainable communities. There are two issues here: preventing bad things
happening, and building the capacity to bounce back from adversity. We
could call this latter ‘community resilience’ – a property of socially
sustainable communities.
These community groups in Liverpool eloquently described
empowerment, the community taking control in its efforts to build
resilience. They also pointed to the fact that although the problems they
faced, specifically health inequities, were attributable to the wider society,

there was much that could happen to reduce these inequalities at community
level.
A good example of a well-evaluated community intervention comes from
Seattle: Communities that Care. They make the entirely reasonable
assumption that the time to get the community mobilised is while children
are in school, and suggest a menu of proven interventions that a community
can adopt. Central to the approach is assembling a coalition of community
people to work with families and schools. The interventions can take place
right through the school years. A recent evaluation in seven US states
focused on ten- to fourteen-year-olds and showed that youths who had been
through the programme were significantly less likely to be using drugs,
tobacco, or alcohol by grade 12, and were less likely to have been involved
in delinquent behaviour and violence.18
An earlier study from Seattle has followed young people until age thirty-
three and shown that the ‘Seattle Social Development Project’ involving the
community helps young people to develop bonds to their school and
community. Over the long term, in addition to less use of drugs, alcohol and
tobacco, there was less history of multiple sexual partners, greater use of
contraception, less involvement in crime, and lower incidence of mental
illness.19
It may be objected that Seattle is not the nastiest place in the US, and that
the Communities that Care project was in medium-size cities rather than in
the most deprived and crime-ridden of places. However, these programmes
still show that involving communities in developing more socially
appropriate behaviours in young people can work. There is proof of
concept. Indeed, it could be harder to apply in large cities, but it is worth
working to make it succeed.
There is a different aspect that worries me. If gross inequalities in income
and associated social conditions are driving inequalities in outcomes, as in
Baltimore, is it really sensible to be struggling to make communities more
resilient? It is analogous to my argument in Chapter 4 that there are two
ways to reduce inequities in early child development: reduce the level of
economic and social deprivation; and implement proven programmes that
have been shown to work. We need to do both: reduce hazards associated
with poverty and exclusion and promote resilience.
. . . and surprising bedfellows

On a visit to Liverpool I found myself in a fire station. A fire chief from the
Merseyside Fire and Rescue Service explained:
We are all macho men. We would come back from fighting a fire in which someone had died
and say to ourselves: that is so unnecessary; they should have done something to prevent that
death. Then we said: why ‘they’? Perhaps ‘we’ should do something about preventing deaths by
fire. We spend six per cent of our time fighting fires, the rest is preparing, and so on.
So, we went into people’s homes – everyone likes fire fighters and we were welcome – to talk to
them about fitting smoke alarms. But people said to us: smoke alarms! What about my leaky
roof? We told them how they could get help from the council in fixing their roof. In effect, we
became social workers, we burly macho men.
We counselled people not to smoke in bed. Then we thought: while we’re up why don’t we
counsel people on giving up smoking.
We worked with Liverpool Football Club to get the kids off the streets and playing sport. We
gave pensioners cards to get free access to our gym. We brought the kids into the fire station and
got them growing vegetables. Better than creating mayhem on the streets.
I now get asked to talk to fire officers in various parts of the country. It is
fun being met at the railway station by a fire service vehicle – regrettably
not a real-life red fire engine. That ambition is yet to be realised. I can now
say to general practitioners and other health professionals: ‘This is what the
fire-fighters are doing to improve health in deprived communities. What are
you doing?’
The more general point is that improving the lives of members of
communities is likely to have positive effects on health equity. It is not only
those whose statutory duty includes health that can be active players. In our
English Review, Fair Society, Healthy Lives, we emphasised proportionate
universalism: universal solutions with effort proportional to need. It is not
only ‘middle-class’ communities that can benefit from community action,
but the more effort put into developing communities that are more
disadvantaged, the more they too are likely to benefit.
. . . including everyone in Australia
If you have come to help me, you are wasting your time. But if you have come because your
liberation is bound up with mine, then let us work together.
Aboriginal activists group, Queensland, 1970s
I was sitting at lunch in Darwin, capital of Australia’s Northern Territory,
with two aboriginal men, leaders of the Aboriginal Medical Service. They
said: we use your reports all the time.

Now that is success. It is unseemly to boast, I know, but I could not have
been more pleased.
To put Darwin in context, think Australia. Sydney, with its iconic Opera
House and Harbour Bridge, played host to a universally acclaimed Olympic
Games. Australia ranks second, after Norway, on the UNDP (United
Nations Development Programme) Human Development Index, which
combines life expectancy, education and literacy, and national income.20
Now travel more than 3,000 km from Sydney to Darwin, in the Northern
Territory at Australia’s top end – a frontier town that has got richer with
nearby mining, and some tourism, but otherwise a world away from the
boulevards of Sydney and Melbourne. Not so much in Darwin, itself, but in
scattered communities all around, are aboriginal settlements. I visited
Gunbalanya, a ‘large’ aboriginal town of about 1,200 people in West
Arnhem Land. The local languages are Kunwinkju and English. You have
to cross the East Alligator River – mistakenly named after the crocodiles
that are so numerous, and impressive – and the town is inaccessible by road
from Darwin in the wet season. Two first impressions: the awesome beauty
of the landscape, and the put-together third-world-style convenience store,
made this feel more like New Guinea than the Australia of opera houses and
Melbourne Cricket Ground.
Australia may rank second on the human development index, but . . . if
Australian aborigines were considered as a separate country, they would
rank 122 (out of 187 countries).21 A few years ago, the figures were
Australia 4, Australian aborigines 104.22 Getting more unequal? I would not
jump to that conclusion before being sure about changes in methodology.
The health problems are considerable. In 2010–12, life expectancy for
aboriginals in the Northern Territory was 63.4 for men and 68.7 for
women – 14.4 years shorter than for non-indigenous men and women.23
The life-expectancy gap signals that there is a substantial difference in the
conditions in which people are born, grow, live, work and age – the social
determinants of health – between indigenous and other Australians.
No one is in any doubt that most Australian aborigines live in bone-
grinding poverty. Their health problems, though, are not those we associate
with countries in the lower half of the human development index ranking.
We know what third world poverty does to health: babies die. Infant
mortality in Sierra Leone is 117 per 1,000 live births. In Iceland, the lowest
in the world, it is 2. On a global scale, from 117 to 2, Australian aborigines,

at 9.6 per 1,000, look a great deal more like Iceland than like Sierra Leone.
True, for non-indigenous Australians it is 4.3.24 But the illnesses leading to
a bigger than fourteen-year gap in life expectancy are occurring mainly at
ages twenty-five to sixty-four. They are precisely those diseases that, as we
have seen earlier, follow the social gradient: heart disease, diabetes,
respiratory disease, cancer, as well as accidents and violence.
The differences are huge. Australian aboriginal men are six times more
likely, and aboriginal women eleven times more likely, to die of ischaemic
heart disease than non-indigenous men and women.25 For diabetes, the
differences are more alarming. The diabetes death rate is nineteen times
higher in aboriginal men, and twenty-seven times higher in aboriginal
women, than in the non-indigenous population.
We need to be thinking, then, not of aboriginal poverty as third-world-
style destitution but as disempowerment, community disruption, the kind of
conditions that lead to aboriginal youth suicide in British Columbia.
Diagnosing the problem is relatively straightforward, dealing with it less so.
Starting with the diagnosis. More typical than Gunbalanya, to which we
will return in a moment, is a rural town described by one aboriginal leader
as:
Screams of pain and fear piercing the night. Children roaming dark streets afraid of home where
sexual assault awaits. Parents taking money to let their children be abused.
A snapshot of Aboriginal life in several small towns in north western New South Wales
overwhelmed by hopelessness, alcoholism, drug abuse, domestic violence, child crime – you
name it, we’ve got it.26
In Australia, the indigenous population is 2.5 per cent of the whole but 30
per cent of the prison population. In the Northern Territory, the indigenous
population is 30 per cent of the whole but 83 per cent of the prison
population.27 Some of that shockingly high prison population represents
high crime rates and some comes from discrimination in the justice system.
It is a long way from Gunbalanya or a benighted country town in New
South Wales to Liverpool or Baltimore, but remember that the diseases, and
accidents and violence, that carry you off in a deprived English or
American community are the same that are killing Australian aborigines.
Diseases and violence are likely to have the same causes wherever we find
them. It follows that the remedies should, in principle, be similar. In Fair
Society, Healthy Lives, the report of my English Review of Health

Inequalities, we emphasised six areas both as explanations of the social
gradient in health and as solutions.28 They are:
• Early child development
• Education and lifelong learning
• Employment and working conditions
• Minimum income for healthy living
• Healthy and sustainable communities
• A social determinants approach to prevention
Basic are inequities in power, money and resources.
The causes of the extreme health disadvantage of Australian aborigines
are not different in kind from the causes of the social gradient in health in
Liverpool, London or Baltimore, but in degree. If you have a social
gradient, someone or some groups will be at the bottom. That is what we
have with Australian aborigines: high levels of child neglect and domestic
violence, low levels of education, unemployment and poor working
conditions, little money, lack of adequate housing, high levels of smoking
and drinking, and poor diet. All are causes of the gradient that we
highlighted in the English Review, building on the Commission on Social
Determinants of Health (CSDH). They are seen to a chilling level in
indigenous populations that are socially excluded.
The problems are so entrenched, have been there for so long, one can be
forgiven for wondering if things can change. You will know by now that I
am not given to counsels of despair. Education illustrates.
Whatever pleasure I feel at my reports being taken up by aboriginals in
Darwin does not make up for my feeling ashamed, doubly so, at prior
history. Charlie Perkins graduated from the University of Sydney in 1966.29
He was the first Australian aborigine to graduate from university. The
university was founded in 1850. It took 116 years for the first original
Australian to graduate. I feel ashamed, because I spent twenty years of my
young life going to school and medical school in Sydney and, though my
passport is British, I feel implicated.
Doubly ashamed, because at the time, 1966, I was a medical student at
Sydney University and I am ashamed, now, at my own lack of outrage then.
What was I thinking? Or, more to the point, not thinking. But whatever
people, including me, were thinking then, things have changed, rapidly.
Twenty-five years later, in 1991, it was estimated that there were more than

3,600 Indigenous Australian graduates, and this number had risen to over
20,000 in 2006.30
In 1998 there were twenty aboriginal medical graduates. At last count
there are 150, and every year now in the Northern Territory another dozen
or so aboriginals enrol in medical training. The problems are huge but
progress can be rapid. If, despite the odds against them, aboriginals can be
doctors, teachers and administrators they can be role models. It is not
straightforward. I travelled with one aboriginal doctor who told me that
angry young people thought that he had sold out, because he talks to the
white man and sits on their committees.
The young men’s anger does, though, illustrate a problem. Improving
social conditions takes national action, but solutions to such problems that
have been devised in Canberra, Melbourne or Sydney have most certainly
failed. The question is what would success look like for aborigines: to
abandon traditional culture and become carpenters, nurses, bank clerks and
teachers, or to live as hunter-gatherers in traditional fashion? What is clear
is that no one thinks alcoholism, unemployment and child abuse, diabetes,
renal disease and dying early, count as success.
The lesson from Canadian British Columbia with which I began the
chapter is that there is another way. Cultural continuity and communities
taking control over their futures is vital. It is possible to be a teacher or
nurse and maintain important elements of the cultural heritage.
Back across the East Alligator River in Gunbalanya there is an
experiment going on that involves a good attempt to put these insights into
action. It is too early to tell if it is working, but there are some good signs.
Gunbalanya is one of twenty-nine remote indigenous communities across
Australia where there is a local development plan in which the local
indigenous community is heavily involved.31
The school in Gunbalanya is impressive. It has now become part of West
Arnhem College – combining schools in Gunbalanya and Jabiru. West
Arnhem College has a programme called Strong Start Bright Future. It
certainly sounds right. I met John, the director, Esther, the long-standing
aboriginal head teacher of Gunbalanya school, and Sue, the (white) co-
principal of the school. The picture Esther painted before the advent of
West Arnhem College in 2010 was of high levels of non-attendance, poor
completion rates, and no jobs for those who did complete school. A
depressing account.

Now comes the new regime. Esther has a whole new programme of work
in the school. The transition cannot have been easy. There is likely to have
been some blood on the carpet, but the stains had been removed by the time
I visited, and all appeared harmonious. Significantly, the government says it
will guarantee a job for any student who completes year 12.
One example of the attempts to resolve the conflict between traditional
culture and training for a place in modern society is seen in the flexible
school year. Students were being taken out of school at the time when it was
traditional to go hunting and fishing with family members. Instead of
scolding parents, an exercise in futility, the school adapted and changed the
term timetable to allow for these excursions to happen.
Does the new school regime work? Too early to tell. But there is a spirit
of optimism in and around the college. This time things are going to get
better. Let’s hope so.
. . . and in New Zealand
The Marae is a Maori communal centre. I visited the Kokiri Marae Health
and Social Services Centre in Lower Hutt, a down-at-heel area outside the
main city of Wellington. The story we were told was one of Maoris being
encouraged off the land into the cities to find work and finding not so much
work but marginality and social exclusion – a regrettably familiar tale of
gangs of young males getting into trouble, alcohol and physical abuse of
women and children.
Kokiri Marae was started by and is run by women. They get a variety of
government grants to run services. The one man that we met, and it was he
who did the traditional Maori greeting, told us the story of how the Marae
was founded by his grandmother.
The story of Grandma and the gangs is the stuff of movies. In short,
Grandma was in Lower Hutt in the same poverty as all the other Maoris, but
wanted to provide a community centre for the young men who were getting
into all sorts of trouble in gangs. Every day, with whatever ingredients she
could find, Grandma made a tureen of soup. She invited the gang members
to come and eat, but it had to be on her terms: shoes off, respect, no
violence. No respect, no soup. For two months the standoff between
Grandma and the gangs continued. They wouldn’t meet her terms and she

threw the soup out at the end of the day. At last they took their shoes off and
came and ate.
‘Hollywood ending?’ I asked. ‘The gang members all became lawyers
and members of parliament?’ Not quite. There was still a lot of mayhem
and family violence, but Grandma’s vision flourished.
Among the programmes of the Kokiri Marae is one called ‘Whanau Ora’.
The CSDH and the Marmot Review highlighted empowerment, dignity,
participation in society, and the Amartya Sen concept of freedom to lead a
life one has reason to value. I was therefore entranced to read the following
description of enhancing whanau (extended family) capabilities:
• To become self-managing
• To be living healthy lifestyles
• To be participating fully in society
• To be confidently participating in Te Ao Maori (the Maori world)
• To be economically secure and successfully involved in wealth creation
• To be cohesive, resilient and nurturing
Terrific. This is putting into practice the kind of principles espoused by
the CSDH and Fair Society, Healthy Lives. Does it work? We had a highly
nuanced discussion about the need for evidence of what works, but also
about the difficulties of doing the right kind of evaluation and their
miserable experience in the past at the hands of researchers whose interest
was much more in research than it was in the welfare of the community.
They painted a realistic picture of continuing processes of exclusion, of
family violence and young men getting into trouble. But they have hope and
commitment and it gives grounds for optimism.
It is tempting to believe that the kinds of initiative that I saw in the Marae
outside Wellington, bringing together Maori traditions, social programmes
and adaptations to the wider society, will bear fruit. Certainly, the gap in life
expectancy between Maori and non-Maori is narrowing, but there could be
other reasons for that.
IMPROVING THE MATERIAL ENVIRONMENT
Environmental quality . . . indoors

It cannot be that everyone in the New Guinea Highlands has a cough, but it
seems like it, particularly the women and children. There is a lot of it
about.32 Some of the lung disease that the cough represented is linked to
infection but a great deal can be traced to indoor fires. Highland huts have a
distinctive odour. For warmth in the cold highlands night, and for cooking,
indoor fires are common. As a result, so is indoor smoke.
It is estimated that 3 billion people in the world cook on open fires or
rudimentary cooking stoves that burn coal or solid biomass such as wood.33
Such cooking methods are not good, in almost any way you look at it. They
are bad for the planet and inefficient. For a given amount of heat you need
to burn more fuel than a simply designed alternative cooker, hence increase
output of greenhouse gases.
There is a shortage of fuel in great swathes of the world, particularly in
South and East Asia. Picture Indian women going further and further from
home to gather what fuel they can. In addition to the physical burden of
carrying wood or manure, they are at increased risk of sexual violence.
Cooking over open fires, and indoors in smoky badly ventilated
dwellings, is also bad for health. The World Health Organisation estimates
that in 2012, globally, 4.3 million deaths were attributable to indoor air
pollution, almost all of them in low- and middle-income countries. We
have, then, a significant contributor to health inequities between countries.
The pity of this problem is that it is soluble, and quickly. Global poverty
is soluble too, but will take a little longer. The Global Alliance for Clean
Cookstoves is one among many organisations that are committed to helping
hundreds of millions of families escape the unnecessary toil of having no
cooking stove or only a rudimentary one. The strategy involves technology
of both fuel and efficient stoves, and innovative approaches to delivery.
. . . and outdoors
There are pleasures to be had in Beijing. Going for a walk in the early
morning sunshine is not among them. Peering through the gloom I can
make out that the elderly people doing t’ai chi are wearing face masks.
Same the next day. Beijing has a smog problem.
Concern over air pollution has a long history. In 1661 the diarist John
Evelyn, determined to draw attention to the foul air in London, wrote a
pamphlet called Fumifugium: or, The Inconveniencie of the Aer and Smoak

of London Dissipated. Two years later an anonymous satirist reported that
Evelyn:
Shows that ’tis the sea-coal smoke
That always London does environ,
Which does our lungs and spirits choke,
Our hanging spoil, and rust our iron.
Let none at Fumifuge be scoffing
Who heard at Church our Sunday’s coughing.
We can say that Evelyn’s activism was successful . . . if you take the long
view. Britain passed the Clean Air Act in 1956. It took less than 300 years
to take John Evelyn seriously. It would help if we could act a little faster
this time, given the scale of the problem. The World Health Organization
estimates that in 2012, globally 3.7 million deaths were attributable to
outdoor air pollution. As with indoor air pollution, the big problem is in
middle- and low-income countries, thus contributing to global health
inequity.
Richer countries have done much to reduce the burden of air-pollution-
related deaths, suggesting that it is entirely feasible to have cleaner cars,
cleaner factories, restrictions on urban pollution. In high-income countries,
not surprisingly, the issue is who is exposed. Mostly, if there is something
bad going, society tries to organise so that those lower down the hierarchy
get more of it. So it seems to be with environmental quality generally, and
air pollution specifically.34
Nitrogen dioxide, NO2, is mainly emitted by combustion in vehicles and
power plants.35 A US study looked at variation in air concentrations and
found that average NO2 concentrations were 38 per cent higher among non-
whites than among whites; 10 per cent higher for people in poverty than
among those above the poverty line. In contradiction to my general theme,
there was no clear gradient – in this case non-whites and people in poverty
were particularly exposed. The authors of this study asked themselves if 38
per cent higher matters, whether it is a lot or a little. Their answer was that
38 per cent matters a great deal. They calculate that if the non-white
exposure to NO2 were reduced to the exposure levels of whites, there
would be 7,000 fewer deaths each year from ischaemic heart disease. A
different way of achieving a reduction of 7,000 deaths would be to get

16 million people to increase their physical activity from inactive to 2.5
hours a week.
. . . and by going green
I read that green ‘is the color of balance and harmony. From a color
psychology perspective, it is the great balancer of the heart and the
emotions, creating equilibrium between the head and the heart.’ I can’t
quite put my finger on it, but given that I read it on a website called
‘empower-yourself-with-color-psychology.com’ I want a little more
evidence. It turns out that there is evidence in abundance that living near
and using green space is good for mental health. The key issue is urban
green space, as a majority of us, worldwide, now live in cities.
One study, among many, examined the population of England and
showed that people living near green space had better mental health and
greater well-being than those with poorer access.36 The effect was not
enormous, about a tenth of the positive effect from being employed
compared with unemployed, but it was worth having.
In later research these same investigators showed that moving to a
greener area enhanced mental health, whereas the very thought of going the
other way seemed to suffice to lessen mental health – it got worse before
those destined to go to more built-up areas made the move.37
If the thought occurred that ‘I’m just dying for a bit of green space’, it
may well be true. Lack of access to urban green space may make a
contribution to the social gradient in deaths from heart disease.38 Richard
Mitchell in Glasgow and Frank Popham at St Andrews in Scotland have
conducted research that addresses whether access to green space might be
protective against the negative impact on health of low income. Indeed, that
is what they found. For people with the least access to green space, the
lowest income group had 2.2 times the mortality from circulatory disease
compared with the highest income group. For those in the greenest areas,
the lowest income group had 1.5 times the risk. It seems as though living
near green space can diminish the negative effect of poverty on health.
Green space did not abolish the social gradient in mortality, but it appeared
to have a big impact. Why?
Mitchell and Popham found no difference in lung cancer mortality
between areas ranked on green space. That ruled out smoking. The two

most plausible pathways for the green-space effect on reducing the social
gradient in mortality were reduction of stress and promotion of physical
activity. Both are plausible and both may be playing a role.
Either way, making access to green space a priority for urban
environments should be a priority. In Britain the Commission for
Architecture and the Built Environment estimates that if the budget for new
road building were diverted, it could provide for 1,000 new urban parks at
an initial capital cost of £10 million each. Creating 1,000 new parks would
save around 74,000 tons of carbon from being emitted.39 Options are
available that would create a greener and more health-equitable urban
environment.
Active transport, usually travelling by bike or foot, but also including any
form of transport that involves exercise, should be the complement to
spending more on parks and less on roads. In the US, the love affair with
the automobile is responsible for much of the urban pollution that I
described above when discussing NO2 concentrations. It may also be
contributing to obesity. Active transport is not only good for the planet, it
may be good for health and for the social gradient.
In Britain, the nation was diverted for a while by an altercation between a
rather posh Conservative government minister with a bicycle, and the police
guarding No. 10 Downing Street. The image of a toff on a bicycle is not far
from what the evidence shows: the higher the social position, the more
likely are people to have used a bicycle in the previous week. People at the
top make more trips of all types than those at the bottom and more by
walking and cycling.40
Happily, some in urban planning are putting their talents to designing
cities with a view to walkability and active transport. I want to highlight
two issues. First is the safe journey to school – taking steps to encourage
children to walk or cycle to school. To achieve this will take concentration
on the second issue: making cycling and walking safe. In Copenhagen, 36
per cent of the journeys to work or education are by bicycle.41 Cycle travel
is relatively safe because of the separation of cars, pedestrians and cycles.
Even were there the political will to change, it would take a long time to
change the design of cities to encourage active transport. That said, some
changes can happen quickly. Introducing 20 mph speed limits in areas of
cities has been shown to reduce traffic-related injuries and death.42 Traffic

calming has been shown to reduce the social gradient in traffic-related
deaths of children.
AGE-FRIENDLY CITIES
If I challenged you, the reader, to come up with a set of criteria for the age-
friendly city, you would not feel baffled. Conceptually, it is not hard to do.
Practically, it is not too hard to do. We just have to do it.
Alex Kalache, a Brazilian who I have mentioned earlier, has devoted his
career to improving the lot of older people globally. While at the World
Health Organization he developed a guide to the Age-Friendly City.43 It is
so sensible, so right, that one wonders why all cities are not doing it. There
are two major reasons why it is so sensible. First, it is based on the principle
of active ageing, the same principle that animated my discussions in
Chapter 7: older age is not a time to be put out to pasture. Second, the
practical recommendations were developed bottom up: by listening to the
voices of older people round the world who said what they needed, and to
service-providers who have experience from the coal face.
The guide has eight topics: outdoor spaces and buildings, transport,
housing, social participation, respect and social inclusion, civic
participation and employment, communication and information, community
support and health services. Seventy-six pages of common-sense advice as
to how to make cities more habitable for older people should be on the
reading list of every urban planner and local politician.
HOUSING
Closing the Gap in a Generation is the title we gave the report of the
Commission on Social Determinants of Health. We referred to a forty-year
gap in life expectancy between countries, and as much as twenty-eight
years within countries, and we want to close those gaps in a generation.
What are we thinking? I claim that we have both the knowledge and the
money to close the gap in a generation. The question is whether we have the
will.
I admit it is a bold claim, particularly with respect to the money. We said
in Closing the Gap that a billion people live in slums. Further, we said that

it would take $100 billion to upgrade the slums, to make them decent
housing. One hundred billion dollars sounds enormous. No one will take us
seriously, I thought; who would find $100 billion for anything? Last time I
looked, ‘we’ had found $11 trillion to bail out the banks. For less than one-
hundredth of the money we found for the banks, every urban dweller could
have clean running water. We have the knowledge, we have the money. Do
we have the will?
Of course, I am oversimplifying, but not by much. A key part of having
the will is getting the players aligned: governments, funders and people.
There are many ways to do it wrong. An academic in Kenya, for example,
wanted to raze to the ground the slum of Kibera, close to the centre of
Nairobi, and transfer to new-build housing, out of town, the half-million
people who currently live in Kibera. He had no idea if that was what the
people of Kibera wanted, but he knew that the land thus liberated was
potentially valuable real estate that, in his view, could be put to ‘better’ use
than housing poor people. And the poor people? They should be grateful for
what they ended up with. I wish I were caricaturing.
To put it in context, Kibera, reportedly the biggest urban slum in Africa,
has a lot wrong with it. It is a makeshift settlement, with makeshift housing
and substandard or no services. People pay more for a litre of water,
collected in a jerrycan, than a litre of water would cost in London. That
said, ‘high streets’ have developed. Shops with advertisements for mobile
phones are next to food shops and convenience stores, medical clinics and
pharmacies. Kibera is a hotbed of crime, to be sure, but it has aspects of
community, too, that would take great effort to reproduce elsewhere, in
rows of breeze-block new housing, for example.
One way to do it better is shown by what the Self-Employed Women’s
Association (SEWA – we met it earlier) has done in Ahmedabad in Gujarat.
SEWA members, living in shanties, gathered together and said what they
wanted to improve their housing. The first thing they said was: we do not
want to be moved! We want to stay right where we are, but we would like a
place to cook, a bathroom and running water. SEWA negotiated loans
equivalent to $500 for each household. The women themselves had to
contribute $50, a great amount if you are living on $2 a day.44
The results are impressive: same streets, same modest houses, but
spruced up, made pukka, and the required additions made. It feels cared for.
I don’t know whether it would lead to less crime. It feels like it might, if

there is anything to the broken windows theory.45 What is clear, though, is
that women no longer have to stand in long queues to collect water, there is
less water-borne disease, and as a result children lose fewer days of school.
In Bonfire of the Vanities, the novelist Tom Wolfe talks of his obscenely
rich banker achieving ‘isolation’ from the chaos of New York. He could
have been living in New York, London or Frankfurt for all the contact he
had with people who were not in his rarefied stratum. For people with less
money and privilege, and particularly for families, community is where life
happens, death too. Communities can be a place of social, physical and
biological hazards, but the social and physical attributes of the places where
people are born, grow, live, work and age can have a profoundly positive
effect on the lives they are able to lead and hence on health equity.
Local government, in partnership with civil society and with community
residents, has a key role to play in promoting health equity. That said,
central government sets the context and determines the power, money and
resources that are available to communities, individuals and families. It is
that broader sphere, social influences, to which we turn in Chapter 9, and
global influences on health equity in Chapter 10.
* Mary is not her real name. Her name is withheld for legal reasons.

9
Fair Societies
Many Americans are well aware that something is seriously amiss. They do not live as well as
they once did. Everyone would like their child to have improved life chances at birth: better
education and better job prospects. They would prefer it if their wife or daughter had the same
odds of surviving maternity as women in other advanced countries. They would appreciate full
medical coverage at lower cost, longer life expectancy, better public services, and less crime.
However, when advised that such benefits are available in Western Europe, many Americans
respond: ‘But they have socialism! We don’t want the state interfering in our affairs.’
Tony Judt, Ill Fares the Land1
In January 2010, Haiti’s earthquake wreaked havoc and 200,000 people
died. Less than two months later a quake 500 times stronger hit Chile and
the death toll was in the hundreds. Haiti was underprepared in every way
imaginable; Chile was well prepared, with strict building codes, well-
organised emergency responses and a long history of dealing with
earthquakes. True, the epicentre of the Haitian earthquake was closer to
population centres than that of the Chilean quake, but that was only part of
the explanation for the different scale of devastation.2 Here is one indication
of the differences in response: in Chile, President Bachelet was out within
hours giving minute-by-minute reports in the middle of the night. People
were reassured by the well-organised emergency response, as well as by the
secure buildings. In Haiti, most people did not know if the president was
alive for at least a day after the quake. The National Palace and the
president’s residence – like most government buildings – had collapsed.3
What turns a natural phenomenon into a disaster is the nature of society.
The number of people who died had more to do with Haiti’s societal
readiness and response than with the strength of the quake.
Here is another societal contrast. I received an email from an American
colleague: ‘I woke up this morning to learn that my country had lost the
health wars to England.’ This was his response to the news coverage of the

paper I discussed in Chapter 2 which showed that middle-aged Americans
are sicker than their English equivalents.4 One of the two themes with
which I began this book was the surprisingly poor health of Americans at
younger ages, from ages fifteen to sixty. The health wars were lost at ages
fifty-five to sixty-four, too.
The National Academy of Science (NAS) pursued the issue.5 Its report
compared health in the US with that of sixteen other high-income ‘peer’
countries. The US comes out of this badly. Compared with the average of
its peers it ranks near or at the bottom of the league for nine health domains:
adverse birth outcomes, injuries and homicide, adolescent pregnancy and
sexually transmitted infections, HIV and AIDS, drug-related mortality,
obesity and diabetes, heart disease, chronic lung disease, disability. Given
that the US spends more on health care than each of the peer countries in
the study, and given the nature of the health problems, the authors of the
report did not look to health care for explanations. They say that there is no
single cause of the US health disadvantage, but they do attribute it in part to
the nature of US society.
A third societal contrast comes from South Asia. India is richer than
Bangladesh, yet Bangladesh has had more rapid improvement in infant and
child mortality. The Indian state of Kerala runs its affairs rather differently
from most other Indian states, with higher status for women and a more
communal orientation. The fabled good health of Kerala, compared with
other Indian states, again points to the importance of society.6
A fourth striking contrast is that between eastern and western Europe.7
During the communist period there was marked divergence in health as
measured by life expectancy. In the Soviet Union and the other communist
countries of Central and Eastern Europe, life expectancy stagnated. In
western Europe, life expectancy improved year on year. Life was bleak in
the communist countries, but was improving yearly for people in western
Europe. After communism collapsed, countries such as the Czech Republic
and Poland saw marked improvements in life expectancy. Russia has been
on a roller-coaster ride, with dramatic increases in mortality, fall, rise and
now fall again. But life expectancy for men in Russia is still a massive
eighteen years shorter than the best in Europe: Iceland. The nature of
society is crucial.
I could go on. Cuba, Costa Rica and Chile have better health than other
countries in Central and South America. Japan beats us all – good health

and relatively narrow health inequalities.8
Looking at these health contrasts between societies leads us to consider
what constitutes the good society. When discussing theories of social justice
in Chapter 3, I quoted Stuart Hampshire saying that there was no answer to
that question. Philosophers disagree. I made the bold claim that health
equity could decide the question. The good society is one where health and
health equity are high and improve over time.
Some of the ways countries achieve better health than others will come
from the specific things they do – provide universal access to high-quality
medical care, for example, regardless of ability to pay. Each of the
preceding five chapters dealt with specific changes that would improve
health and reduce health inequity: early child development, education,
employment and working conditions, conditions for older people, and
development of resilient communities. A society that ensures that all of
these are well supported is likely to have good health and health equity.
There is more. Societies have cultures, values and economic
arrangements that set the context for conditions through the life course that
influence health. We talk of community resilience, but the nature of society
will influence the hazards to which individuals and communities are
exposed. This chapter, then, is about our social arrangements in society, and
how they influence health equity. To repeat, my general theme is that
inequities in power, money and resources give rise to inequities in the
conditions of daily life, which in turn lead to inequities in health.
SOCIETY: RIGHT AND LEFT
In Britain, the standard view has been that Conservatives come to power
and improve the economy while reducing social spending. After a while,
the population tires of shoddy public services and miserly support for the
needy, and votes Labour in. Labour proceeds to raise social spending and
improve the public realm while messing up the economy. The population
tires of the economic problems and votes Conservative . . . who reverse
things . . . and so on. It is something of a caricature, especially now with
multiple political parties, and some of our leaders seem able to mess up
both the public realm and the economy at the same time. That said, there is
continued debate between the public realm and individual freedom, the

latter perceived as the route to economic success. The US is slightly more
complicated because there may be a Democratic president with a
Republican Congress, which ensures that not too much happens to the right
or the left, or at all. At least in the US and Britain we play out these tensions
through the ballot box. For a long time in Argentina, for example, the same
kinds of tension between populism and the ‘needs’ of the wealthy for a
robust economy led to periodic military coups alternating with episodes of
democracy.
I asked a Chilean colleague, on the left politically, who was a refugee
from Pinochet’s junta and only returned to Chile when democracy was
restored: ‘Quite apart from Pinochet being a right-wing dictator who
trampled on human rights, the political right would say that Pinochet was
good for the economy. What do you say to that?’
‘Unfortunately, the right are correct,’ said my colleague.
‘Why did Pinochet submit himself to an election [which he lost] after all
those years of military rule?’ I asked.
‘To lie about the society you have created is very bad,’ said my
colleague. ‘But to believe your own lies is really stupid.’
There, in extreme form, we have the same debate I described in Britain:
the idea that the far ‘right’ are good for the economy but terrible for other
things that people care about, such as human rights, social cohesion, and
tolerance of diversity of views.
One thing is fairly certain. You have your own set of views, prejudices
even, about this political terrain of the state versus the individual. If of one
persuasion, you are on the alert in case I trot out old leftie solutions that rely
on the state to do this, that and the other, all at great expense to the taxpayer.
Am I not aware that bureaucracies are inefficient, ineffective, and create
dependencies? If I am in favour of empowerment, do I not realise that
people need to be set free from a controlling state? Do I want to create
European socialism, which terrifies the Americans described by Tony Judt?
If of a different persuasion, your antennae may be waving in case I seem
too soft on capitalism. When we published Closing the Gap in a
Generation, historians at UCL convened a conference to discuss the
Commission’s report in light of the history of social determinants of
health.9 One critic, from the political left, said he had gone through the
whole of Closing the Gap and found only one mention of neoliberalism. I

apologised. I thought I had removed them all. One must have slipped
through my net.
‘Does that mean you support neoliberalism?’ he asked, aghast.
‘No, of course not. If you read the report, you would see that we are
highly critical of unbridled markets in education and health care, and the
kind of inequality that neoliberalism brings in its train. We called for sound
institutions and market responsibility and saw a vital role for the state.’
‘If you are against neoliberalism, why didn’t you say so?’ he and others
wanted to know.
Once you start to sign up for or against ‘isms’ there is the danger of
joining clans and stopping the analysis. Communism in Central and Eastern
Europe did not deliver continued good health. By contrast, health did
improve under communism in China, and continued to improve under
whatever we call the current mix of Chinese communism and capitalism.
Capitalism brings with it great problems of inequality which, in their own
turn, can damage health and well-being. Rather than ride to the barricades
waving ‘ism’ banners, we need to examine the evidence of how the rights
of the individual and the requirements of the public realm can be balanced.
Jean Drèze, a Belgian/Indian economist, and Amartya Sen have
collaborated on important books on India. In their most recent, An
Uncertain Glory, they write that when India began its economic reforms in
the early 1990s it faced ‘two gigantic failures of economic governance. The
first was a failure to tap the constructive role of the market.’ The second
was a ‘resounding failure to harness the constructive role of the state for
growth and development’.10 It could not be clearer: both markets and state
institutions are vital.
The critique of neoliberalism is correct. The idea that unbridled free
markets in everything (the so-called Washington Consensus) is the way for
countries to grow, develop and ensure better health and greater health equity
is contradicted by the evidence. Equally, market dynamism is a route to
greater productivity and economic growth. The question should no longer
be capitalism or not, but what kind of capitalistic society do we want to
have.
LEARNING

. . . from what is working
Suspending ideological predispositions, as far as is possible, where could
we find societies that combine economic success, a profitable private sector,
a constructive role for the state, and a record of good health? Picking up
data from earlier in the book, Norway ranks top in the Human Development
Index, Sweden is near the top in life expectancy, Finland has the best
education scores on the PISA index in Europe, Denmark the best social
mobility – but not, interestingly, the best health. The Nordic countries seem
to be a good place to look.
First, though, it is necessary to scotch a rumour. In 1960 President
Eisenhower made a speech in which he claimed that Sweden’s socialist
policies lead to ‘sin, nudity, drunkenness, and suicide’. I’ve been a bit too
preoccupied to investigate sin or nudity – although the teenage pregnancy
rates are low in Sweden – but the latter two are wrong. Despite that, the
rumour has persisted: people are so unhappy with their socialist ‘paradise’
that they kill themselves. It is a pity to spoil a good story, but it is simply
untrue. Sweden’s suicide rate per 100,000 is lower than the OECD average
and marginally lower than in the US.11 Norway’s is about the same as
Sweden’s, Finland’s is higher, and Denmark’s is lower. There is no
consistent story of social democracy and high suicide here.
When I was chairing the Commission on Social Determinants of Health,
with my Swedish colleague and fellow commissioner Denny Vågerö, we
approached the Swedish government to ask if they would fund a Nordic
network of scholars to ask what we could learn from the Nordic Experience
of the Welfare State – they called themselves the NEWS group.12 Meeting
with the group, I said that the rest of the world thinks that the Nordic
countries are on another planet: good health, low crime, high degrees of
gender equity, thriving social welfare. Are there some general lessons we
can learn that could be applied elsewhere?
The NEWS group’s review of the evidence suggested that the following
were important in producing good health in the Nordic countries:
• Universal social policies rather than reliance on targeted, means-tested selective policies
• Reducing poverty through welfare state redistribution policies
• Relatively narrow income inequalities
• Emphasis on equality of opportunity and outcomes according to class and gender, and for socially
excluded groups

• A broad scope of public services with provision of services mainly by the public sector at local
level
• Social spending and social protection are important
• No one single policy solution but an accumulation of policies across the life course, each with its
specific effects
. . . and from what is not working
If that is what the Nordic countries are doing right to gain good health, what
is the US doing wrong? Above, I quoted the US National Academy of
Science Report that showed that the US did particularly badly on health as
compared with sixteen other ‘peer’ countries. The US health disadvantage
was particularly strong among socially disadvantaged groups, but the better
off were not doing wonderfully. In contradiction of President Eisenhower’s
concern about ‘sin’ in Sweden, the NAS notes that US adolescents are more
likely to become sexually active at a young age, to have more sexual
partners, and are less likely to practise safe sex than adolescents in other
high-income countries.
The US had poor health compared with other rich countries in every age
group under seventy-five – it ranked 16 or 17 out of 17 for most age groups
(1 out of 17 is the healthiest), until it ‘soared’ to 16th or even 14th at age
groups after fifty. One way of expressing health disadvantage is to examine
the years of life lost from birth to age fifty. Around 1900, in the US and
Europe, a newborn could expect to live about thirty-four years. This can be
expressed as ‘losing’ sixteen years before age fifty. Today, not many people
die before the age of fifty. Nevertheless the US ranks bottom on this
measure as shown in Figure 9.1. In addition to this difference in years of
life lost there is a great deal of non-fatal illness and suffering.
The National Academy of Science authors describe the reasons for the
poor health of Americans as follows:
Adverse social and economic conditions also matter greatly to health and affect a large segment
of the U.S. population. Despite its large and powerful economy, the United States has higher
rates of poverty and income inequality than most high-income countries. U.S. children are more
likely than children in peer countries to grow up in poverty, and the proportion of today’s
children who will improve their socioeconomic position and earn more than their parents is
smaller than in many other high-income countries. In addition, although the United States was
once the world leader in education, students in many countries now outperform U.S. students.
Finally, Americans have less access to the kinds of ‘safety net’ programs that help buffer the
effects of adverse economic and social conditions in other countries.13

It is almost a mirror image of the report of the NEWS group: poverty,
inequality, and less access to social safety nets – in particular income
support in times of need.
FIGURE 9.1: A CANDIDATE FOR RELEGATION FROM THE TOP LEAGUE
MONEY AND OTHER THINGS THAT MATTER
The Nordic and US reports highlight income inequality and poverty as
major causes of ill health. Through the book so far I have flirted with

money. I condemned countries for not being more active in reducing child
poverty, but then veered away and talked about parenting and the quality of
the environment in which children are raised. I said that one of the main
things we look for in work is monetary reward, but then talked about the
quality of working life. I worried about poverty in retirement but then
discussed social relationships and age-friendly cities.
At a more fundamental level I said that inequity in power, money and
resources drives the inequities in daily life that cause health inequity. One
key dimension of empowerment is ‘material’ – having the resources to lead
a decent life. Which led me to quote, approvingly, Jerry Morris’s pioneering
work on minimum income for healthy living. Being able to afford the basics
and lead a life of dignity and participate in society will take money, but
much more than money.
If money is important, even if only part of the story when it comes to
health inequity, we need to consider inequalities in income and wealth. We
will also need to consider inequities in features of society, other than
money, that are important for generating health inequities, but let’s start
with money.
Two of the most important recent contributions to the analysis of
economic inequality come from the economists Joseph Stiglitz14 and
Thomas Piketty.15 Neither is centrally concerned with health, but their
analyses have much to say on the kind of society we are creating, and
provide a context to Tony Judt’s cry of anguish with which I began this
chapter.
PATRIMONIAL CAPITALISM – PIKETTY STYLE
‘It is illusory to think that social success can be achieved through study,
talent and effort’ is the essence of a lecture given by Vautrin to an
impoverished nobleman, Rastignac, in Balzac’s novel Père Goriot,
published in 1835. Vautrin says (I am paraphrasing): there is no point
pursuing your law studies. If by dint of great success and a deal of political
scheming you become one of only twenty prosecutor-generals in France
you could earn 5,000 francs a year. By contrast, marry the rich heiress
Mademoiselle Victorine, who has eyes for you, and you will immediately
have an income ten times that, of 50,000 a year.

For Vautrin’s advice to be correct, the financial return from capital had to
be greater than earnings from work (labour), the inequality had to be large,
and a major source of capital had to be inherited, as distinct from what
could be saved from earnings. Those conditions undoubtedly applied in
nineteenth-century France, as they did in Britain of the time. Try to think of
a Jane Austen hero or heroine who worked for a living – difficult. The
income from inherited wealth had to be substantial. For a Jane Austen
character to lead a dignified life, the material and psychological threshold
was about thirty times the average income of the day. The unfortunate
young Dashwood women in Sense and Sensibility, reduced to an unearned
income of barely four times average income per head, have their marriage
chances drastically reduced. Perish the thought that they should work.
(Jane Austen writes about the rich and scarcely notices anyone else. I
have long harboured a wish to adapt her most famous opening line, and
write: ‘It is a truth universally acknowledged that a single man not in
possession of a good fortune must be in want of a life.’ Single, poor, his
prospects for life expectancy are not good.)
Large inequalities of wealth and income and a preponderance of inherited
wealth characterised nineteenth-century Britain and France. These insights
and the concern that we may be heading that way again are the message of
Thomas Piketty’s Capital in the Twenty-First Century. For a 685-page
economics book, published by a university press, to become a best-seller –
it sold out within days, and was likely to have sold 200,000 copies within
three months – and for its author, a serious French economics professor, to
become a superstar, Capital must be tapping in to something important. It
is.
There are two issues that Piketty highlights: growing inequalities of
wealth and income and the fact that, in the future, much of the wealth will
be inherited rather than earned. The first issue, growing inequalities, is of
particular concern for health inequalities; the second, a preponderance of
inherited wealth, is of concern for society as a whole, not only for health. I
want to start with Piketty’s concern over the way wealth is being
accumulated. The bulk of the chapter will then deal with health inequalities.
Piketty’s central point is that the return on capital is higher than the
growth of income. Therefore capital accumulates. Prior to Piketty’s
painstaking collection and analysis of data, economists were not so
concerned with distribution. Simon Kuznets, a distinguished US economist,

observed that in the US and some other countries, as their economies
developed and grew, up t0 the mid-twentieth century, inequality diminished.
Inequality was just a stage of development, no need to worry about it, no
politics involved.
Piketty, drawing on detailed study of the data over a longer period of
time, points out that the period Kuznets was observing, roughly 1914–70,
was an aberration. The shock of two world wars with an intervening
depression did indeed lead to a marked reduction in inequalities of both
income and capital. During that time, the return to capital was less than the
growth of incomes. From about 1970 on, and continuing into the twenty-
first century, we seem to be returning to the Belle Époque inequalities of the
nineteenth century. Piketty’s simple measure is capital as a ratio of national
income. In Britain, for example, in 1870 the capital:income ratio was about
7. It went as low as 3 in 1950, and began to climb from about 1970, rising
to above 5 by 2010. The US did not have such concentration of capital in
the nineteenth century, but its capital: income ratio is now at the 5 level and,
Piketty fears, is rising.
In the US, and to a lesser extent in other Anglophone economies, the
growth in inequality is fuelled not only by increasing capital: income ratios
but by the growth of top incomes. In 1928, the top 1 per cent of US income
earners had 23 per cent of total household income. This lion’s share
tumbled if not to a kitten’s, at least to a cat’s share, of less than 10 per cent,
after the 1929 crash. It had a rapid increase again, starting in the 1970s, so
by 2007 the top 1 per cent had again 23 per cent of total household income.
After the 1928 peak came a crash; similarly after the 2007 peak. Correlation
or causation? Piketty is in no doubt that the concentration of income led to
instability in the US economy, not least because the bottom 90 per cent had
income growth of less than 0.5 per cent a year in the thirty years up to 2007.
They had to either stop consuming or borrow. Increased inequality, then,
can damage the economy in addition to other ills.
What are the top 1 per cent of earners going to do with all that money?
How many yachts and houses can one family own? What they will do is
save it and pass it on to the next generation. Says Piketty: ‘It is all but
inevitable that inheritance (of fortunes accumulating in the past)
predominates over saving (wealth accumulated in the present) . . . the past
tends to devour the future.’ We will reproduce the kind of inherited wealth
that we saw in the nineteenth century – the patrimonial society of Balzac

and Austen. As we shall see, accumulating so much income and wealth at
the top will not make the rich healthier, but it may slow the health
improvement of those lower down.
Piketty’s concern is not only with the size of the inequalities in wealth
and income, but how they come about – the shift to inheritance. As Piketty
says: ‘Our democratic societies rest on a meritocratic worldview, or at any
rate a meritocratic hope, by which I mean a belief in a society in which
inequality is based more on merit and effort than on kinship and rents.’ He
continues: ‘In a democracy, the professed equality of rights of all citizens
contrasts sharply with the very real inequality of living conditions, and in
order to overcome this contradiction it is vital to make sure that social
inequalities derive from rational and universal principles rather than
arbitrary contingencies’ such as inheritance and ‘rent’ (shorthand for
income received from capital, which equals wealth in the Piketty schema).
To summarise, then, Piketty thinks the rise of income and wealth
inequalities, and the return of patrimonial capitalism, are bad for the
economy, contravene our sense of what is just in the world, and have the
potential for social unrest.
As I read Piketty, it is clear that societies do have political choices. If
they want to increase inequalities of wealth and income they should do the
following: transfer publicly owned assets into private hands; be complicit in
low general rates of income growth, but engineer the economy so there are
runaway salaries at the top; make taxes on income and spending less
progressive; reduce taxes on capital, including corporation tax, capital gains
and inheritance tax. Sounds rather familiar. It is what we have been doing in
the US and the UK. It is hardly surprising that we are having trouble
reducing health inequalities.
Bringing his vast knowledge and penetrating mind to the rise of
inequalities in the US, Joseph Stiglitz similarly makes the point that moving
money from the bottom to the top of the income distribution, as has been
happening, lowers consumption. Those at the top save 15–25 per cent of
their income, those at the bottom spend all of theirs. The resultant
dampening of aggregate demand leads to unemployment. I would add: and
unemployment leads to ill-health and worsens health equity.
Stiglitz says we know what extremes of inequality can do, we have seen
it in Latin America: threats to social cohesion, crime, social instability, civil
conflict. Stiglitz writes: ‘Of all the costs imposed on our society by the top

1 per cent, perhaps the greatest is this: erosion of our sense of identity in
which fair play, equality of opportunity, and a sense of community are so
important.’ I would add that the ills that Piketty and Stiglitz have so clearly
identified bring in their train another concern.
INEQUALITIES IN SOCIETY LEAD TO INEQUALITIES IN
HEALTH; MONEY MATTERS
. . . because money makes the poor less poor
What do Tanzania, Paraguay, Latvia and the twenty-five top-earning US
hedge-fund managers (combined) have in common? They all have annual
income of 21–28 billion dollars.16
The first way that massive inequalities of income and wealth can lead to
health inequalities is that if the rich have so much, there is less available for
everyone else. I don’t imagine that anyone has in mind asking the twenty-
five top-earning hedge-fund managers to donate a year’s earnings to
Tanzania, but if they did they would hardly notice, as they would collect
their $24 billion the next year, and it would double Tanzania’s national
income. This could potentially improve the health of Tanzanians in two
ways: make individuals a bit richer and improve the public realm. Such
money could pay for sewage plants and toilets, provide clean running water
and clean cooking stoves, even fund a few school teachers’ salaries. No,
total fantasy. The critics of aid would say that the money would end up in
Swiss bank accounts. I will revisit this question in the next chapter.
For some, it would be no less fanciful to imagine that some of that
combined ‘earning’ of $24 billion could be redistributed within the US.
There is an argument, in the past taught to economics students as if it were a
fact, that it didn’t matter if the top 1 per cent took an increasing slice of the

cake, because they are the wealth producers, and setting the wealth
producers free enlarges the cake.
Joseph Stiglitz says clearly that is not what the evidence shows. The
International Monetary Fund (IMF) is hardly known as a champion of
redistribution, but they back Stiglitz.17 Examining evidence across
countries, OECD and non-OECD, the IMF researchers conclude that ‘lower
net inequality (i.e. after taxes and transfers) is robustly correlated with
faster and more durable growth’. There are not even any ‘maybes’ here.
The IMF authors also conclude that redistribution is ‘benign’ in its effect on
growth, so that, in sum, redistribution is pro-growth.
A related argument put out by apologists for inequality is that a rising
tide lifts all boats. Swamps, more like. Stiglitz has no patience with this
argument either. As quoted above, in the US in particular, the small boats
are leaking or capsizing, while the luxury yachts have the freedom of the
seas. In Chapter 1, and throughout the book, I laid out why low income was
bad for health. In poor countries low income is linked to destitution. In rich
countries it is something a bit different. In Chapter 5, when discussing
income from work, I said that we had measured deprivation in Europe on
the ability to afford:
• to pay rent or utility bills
• to keep the home adequately warm
• to face unexpected expenses
• to eat meat, fish or a protein equivalent every second day
• a week’s holiday away from home
• a car
• a washing machine
• a colour TV
• a telephone
This has the air more of deprivation relative to the standards of the
society – why otherwise should lack of a colour TV be bad for health? –
than to some absolute standard. I said in Chapter 1 that Amartya Sen
resolved the debate of absolute or relative poverty by saying that relative
inequality with respect to income translates into absolute inequality in
capabilities: your freedom to be and to do. It is not only how much money
you have, but what you can do with what you have; which, in turn, will be
influenced by where you are.18 If the community provides clean water and

sanitation, you don’t need your own money to ensure these solutions. If the
community provides subsidised public transport, health care free at the
point of use and public education, you don’t need your own money to
access these necessities. The way to understand the importance of income
for health is to enquire what people are able to do with the income they
have. This relates to the income both of the community and of the
individuals within it.
How will this understanding help LeShawn in Baltimore, whose story I
told in Chapter 4? To remind you, many of LeShawn’s problems arose from
his mother’s poverty, and the stressful life he had from birth through early
childhood, adolescence and young adulthood. One way to intervene in
LeShawn’s family’s poverty is to increase their income, by improving
employment prospects and supporting a living wage. Where this is not
feasible, in the short term, the state has a clear role to play.
Health warning: I am going to discuss welfare and benefits. Politicians in
the US and the UK seem convinced that to reduce welfare spending is self-
evidently a good thing. What if every time a politician said he was going to
cut benefits to the poor, a little bird whispered in his ear: lower welfare
spending means making people’s health worse, if not killing people.
One of the NEWS group’s conclusions was that good health of the
Nordic countries is dependent, in part, on social spending and social
protection. As a step in showing this they examined poverty levels before
and after taxes and social transfers of various kinds. The benchmark for
poverty, as with child poverty in Chapter 4, was having an income less than
60 per cent of the median income. Figure 9.2 illustrates the point.
FIGURE 9.2: WHAT WOULD YOU LIKE THE POVERTY LEVEL TO BE?

The height of the bars shows poverty levels in different countries from
income gained in the marketplace. The dark bars show poverty after taxes
and transfers. First, compare the US and UK. Pre-tax, poverty levels are
higher in the UK than in the US – the bar is higher. The effect of taxes and
transfers is to reduce poverty level by 50 per cent in the UK, and by only 24
per cent in the US (that is what the per cent figures are in the bars on the
graph). US poverty rates, post-tax and transfers, are therefore higher than in
the UK. If being below the poverty line means not being able to afford
items on the list I gave above, health will be damaged and health inequities
will be worse. The Treasury Secretary has it in his power to influence the
magnitude of health inequities.
In Figure 9.2, look at Finland, Norway and Sweden, where the impact of
taxes and transfers is to reduce poverty by more than 70 per cent.
The NEWS group then addressed the question of whether social welfare
spending of a country was related to better health. They did this in two
ways. First, they used the concept of ‘social rights’ – legislated social
provisions aimed at guaranteeing citizens’ welfare and security. They
examined two characteristics of social spending to meet social rights,
generosity and universality – does it cover everybody? Both were related to

good health. The more generous the social spending of a country, and the
more universal, the lower is the national mortality rate.
FIGURE 9.3: SHOCKING NEWS: WELFARE SPENDING IMPROVES HEALTH AND
REDUCES INEQUALITIES
The second way was to examine the impact of social spending, not just
on the average health of a country, but on health inequities. My Swedish
colleague Olle Lundberg reasoned that we should not simply be asking:
Nordic, good or bad? If addressing the social determinants of health means
empowering people, then one way of giving people more control over their
lives is to improve income when it is needed. Therefore look at what is
known as social protection – spending by the state on support for old age,
bereaved persons, incapacity, health, family, active labour market
programmes, unemployment and housing. Then adjust all this for tax breaks
and the amount of direct and indirect taxes paid. Once they had this
measure they looked at its relation to inequities in health in fifteen
European (EU) countries, shown in Figure 9.3, for women – the results are
similar for men.19
Women with only primary education are more likely to have poor health
than women with tertiary education; everything else I’ve shown you should
mean that is not a surprise. But the greater a country’s social spending the
narrower the gap in ill-health between those with least education and those

with most. The graph shows the relative health disadvantage of having only
primary compared with tertiary education. There was a big absolute
difference as well.
Greater welfare spending improves overall health and narrows health
inequities. There is no question in my mind that it is better to work than to
subsist on benefits, but where work is not possible, or is not a way out of
poverty, spending on social protection makes a difference to people’s lives.
The graph shows how much more likely to be in poor health are people
with primary education compared with those with tertiary education. It
shows that the higher a country’s social expenditure, the lower is the health
disadvantage of having primary education.
In some Latin American countries, notably Mexico and Brazil, the
government’s approach to reducing poverty includes conditional cash-
transfer schemes, such as Oportunidades in Mexico and Bolsa Familia in
Brazil. These schemes are interesting, exciting and problematic. As their
name suggests they transfer cash to poor people on certain conditions: that
they take their children to health clinics, that they attend health education
classes, that older children attend school regularly. I said that cash is given
to ‘people’. The people are usually women. The assumption is that if the
money is given to women it is more likely to be used to support the family’s
needs than if it is given to people of the male persuasion.
The schemes are exciting because there is little doubt that they have
contributed to poverty reduction, in Brazil, for example,20 and to improved
nutrition in Mexico.21 They are problematic for two reasons. First, it is all
very well to insist that girls be in school as a prerequisite for receiving the
monthly cash. But what if the schools are hopeless? Transferring cash to
poor women is not a substitute for investing in improving institutions and
services, such as the health clinics and schools where attendance is
required. Second, conditionality is authoritarian. Authorities are saying to
women: ‘We know what is good for you; we’ll give you the money
provided you do as we say.’ It leaves a bad taste. There is now a move to
evaluate whether removing the conditionality component allows the
schemes still to function.22
. . . because money can be spent in ways that will improve lives

A second way money can improve the lives of LeShawn and his mother is
that the community can spend it in ways that meet their needs while
reducing their burden. Transport will serve as example. LeShawn’s mother
has household income of about $17,000. She spends 23 per cent of that on
running a car.23 Why, you might ask, if you have such low income, would
you spend such a vast sum on running a car? I tease my American
colleagues that they think public transport is when two people travel in a car
at the same time. If public transport is inadequate how else is LeShawn’s
mother to get to her part-time job, to take her children to hospital, or
generally to get about?
We took some visitors to see a Children’s Centre in Newham, a deprived
part of East London. Childcare provided by the community was charged at
£850 a month. How, I wondered, could a woman in a deprived part of
London possibly afford to pay that out of her earnings, assuming she could
find work? In Britain, for a family with two children in full-time care, the
annual cost of childcare is £11,700 ($20,000).24 Tax credits help, but if their
value is being reduced, work is not a way out of poverty. Subsidised
childcare might be. A Swedish colleague on the visit pointed out that in
Sweden, childcare is state-subsidised. The most you pay per child is £113 a
month, £1,356 a year ($2,300).25 State provision is making working
families less poor, and enabling both parents to work.
Similarly, if the community provides the kinds of services for early child
development, education, job training and unemployment benefits discussed
in earlier chapters, people will not have to pay for them out of their pockets.
There is no free lunch, agreed. It takes money. Taxation is a good source of
such money. To show that there is a great deal of money about, one-third of
the $24 billion income of the top twenty-five hedge-fund managers could
fund something like 80,000 New York schoolteachers.
The rich are intolerant of taxation. As mentioned above, when discussing
Piketty, in the US and Britain we have made our taxation systems less
progressive. The rich, in general, have disproportionate political power.
They use it to ensure they pay less tax. If the rich buy their own health care,
education, transport, even security, they argue, why should they pay taxes to
provide those things for other people? Virtually no one in public life in the
UK and US is prepared to have a grown-up discussion in public about
whether a more progressive taxation system, with a higher overall tax take,

is a price worth paying for improving the quality of people’s lives to match
that of the Nordic countries.
Before we leave the Nordic countries, it is important to say that there is
not an agreed view as to whether health inequalities are narrower there than
in other countries less committed to social democracy. The graphs I showed
in Chapter 5 and 7, on life expectancy by education, do show overall good
health and relatively narrow inequalities in the Nordic countries. Yet other
reports dispute this.26 Our Nordic colleagues point out that overall health is
high in Nordic countries, and the health of the most disadvantaged is high.
These are major societal advances, while we continue to debate which
evidence to believe on the size of the social health gap.
Proportionate universalism
It was the evidence provided by our Nordic colleagues that led us, at the
UCL Institute of Health Equity, to come up with the ugly neologism
‘proportionate universalism’. Let me explain.
When the British government was planning its Sure Start policy for early
child development, I went to a meeting at Her Majesty’s Treasury to discuss
the proposed programme. It turned out that the initial plans for Sure Start
were to target it at the most deprived communities. I showed the group the
social gradient in literacy of young people according to parents’ education
and pointed out that at the top, parents with the highest levels of education,
our young people’s literacy levels were on a par with Sweden and Japan.
But the gradient was steeper in Britain than in Japan and Sweden; the result
was that the lower you go in the social hierarchy the worse our young
people score compared with Sweden and Japan. The implication was that
Sure Start should be for everyone, not only for the worst off (see
Chapter 4).
The senior Treasury official, the wonderful Norman Glass (deceased
sadly), said:
‘Don’t come to me with that Scandinavian nonsense about universal interventions. We’re
Anglo-Saxons. We target and focus on the worst off.’
Anglo-Saxon? Norman was Irish–Jewish, but the point was well made.
The default position of British social policy is to target interventions on the
worst off. It seems to make sense. Why spend money on those who don’t

need it? The problem with such ‘common sense’ is that it ignores the
gradient. All the social and related health problems that we see follow a
social gradient. The disadvantage of focusing on the worst off is that you
miss those, say, in the middle who have worse health than those at the top,
albeit better than those beneath them on the ladder.
It is not just from the Nordic countries that we learned the importance of
universalist policies. In Chile they talk of Chile Solidario. The aim is to
bring the most socially excluded into the mainstream of society, to
emphasise their rights and entitlements, not to see the state as a charitable
institution handing out help to a grateful poor. Proportionate universalism is
an attempt to marry the obvious need to work hardest on behalf of those in
greatest need while preserving the universalist nature of social
interventions. Services for the poor are poor services. We should want
everyone to gain the benefits of universal policies while putting in effort
proportionate to need. A key principle is social cohesion.
. . . because inequality damages social cohesion
I was at a meeting in Japan having coffee with a Hungarian colleague. He
and I had tried to pursue collaborative research in Hungary, alongside our
investigations into poor health in Central and Eastern Europe in the Czech
Republic, Poland, Russia and Lithuania. The research did not get going in
Hungary, and my colleague was explaining why – personal relations
problems. He then passed the comment that Japan was a very stressful
country. My reaction was: you have just spent half an hour telling me that
things aren’t working in Budapest because A is having an affair with B, and
her husband is not on talking terms with C, who simply won’t work with D
and E. You are all pulling against each other. I have the impression that in
Japan they are all on the same team. There is, in Japan, a shared
commitment to success. We see it in relatively narrow income inequalities,
low rates of poverty, low rates of crime, care for older people – and the
longest life expectancy in the world.
Richard Wilkinson and Kate Pickett captured public imagination with
their book The Spirit Level.27 It contains a simple and powerful idea:
inequalities of income damage the health and well-being of all of us, rich,
poor, or somewhere in between. I have co-edited books with Richard
Wilkinson, and co-written a paper defending his ideas against some of his

critics. I agree that social and economic inequalities are bad for health
inequalities. There is a ‘but’. The evidence that income inequalities are bad
for the health of everyone in society was seen only among richer countries,
and that evidence is weaker now than it was. In Chapter 7 I included a
graph (Figure 7.3, p. 207) showing life expectancy in different countries
according to education, and imagined a conversation with a child in
Hungary. There were big differences in life expectancy among European
countries. But the size of the difference was much smaller for people with
university education than it was for people with only primary education. If
inequality were damaging the health of everybody you might have
imagined big differences between countries for everybody, not only for the
most disadvantaged. Inequality damages the health of the poor more than it
damages the health of the rich.
That said, I am entirely sympathetic to Wilkinson and Pickett’s focus on
psychosocial factors. When social and economic inequalities are large,
people lower down the social hierarchy are disempowered. Similarly big
inequalities mean that we tend more and more to see the poor and socially
excluded inhabiting a different world from people in the middle, and the
rich inhabiting a different world from everyone else: separate schools,
living arrangements, transport, gyms, holidays and attitudes.
Key to living in society is empathy and connectedness – genuine feeling
for our fellow members of society. The separate, compartmented lives of
people at the top, middle and bottom damage this vital ingredient of society.
The previous chapters spell out, in detail, how this lack can damage health
through the life course and in communities.
SOCIAL HIERARCHIES AND HEALTH ARE ABOUT MUCH
MORE THAN INCOME
Robert Sapolsky and I had to get together. We had been introduced by
proxy by Robert Evans, a Canadian economist who said in print that he
wanted to make comparisons between two long-term programmes of
research on primates. They were Sapolsky’s studies of baboons in the
Serengeti ecosystem and Marmot’s studies of civil servants in the Whitehall
ecosystem. Both sets of primates, baboons and civil servants, revealed clear
social gradients in biological markers of illness and of ill-health.

I met Robert first at his lab at Stanford. His own room there looks a bit
like he does, that is if a lab could be described as having scraggly long hair
and beard, ruffled, warm, engaging, intellectual and socially committed.
Robert and I have reviewed the evidence on social gradients in human and
non-human primates to ask what we can learn about human societies and
inequalities in health. In primates of the human variety we can speculate
whether the social gradient in health might be attributed to lack of access to
medical care, to disreputable consumption of fattening foods or alcohol, or
to smoking. None of these applies to the baboons, nor is any baboon signed
up either to neoliberalism or to social democracy. What does apply,
potentially in humans as in baboons, is stress and its physiological effects.28
We gave ourselves a caution: apes can be Machiavellian, but no ape was
ever Machiavelli; humans are not apes in pinstripe suits; we should not be
too literal in reading across from apes to man. That said, the variation
among species of non-human primates is instructive for understanding how
hierarchies in human societies translate into inequalities in health.
To start with Sapolsky’s studies of baboons, there are clear dominance
hierarchies, and the major stresses that subordinate animals’ experience are
psychosocial rather than physical. Food is plentiful and, in the absence of a
drought, comes with no more cost than foraging. Luxuries, ‘kills’, are more
available to the dominant animals, but these make up a small proportion of
the diet. Dominance in males is seen in access to preferred resting sites,
grooming opportunities and access to females. The aggression to which
low-status animals are subject is more usually symbolic threats, rather than
actual fights. I have in mind the high status baboon, with a leather jacket
and a bike chain, cigarette out of the corner of his mouth saying: this piece
of savannah ain’t big enough for the both of us. The subordinate male beats
a hasty retreat, leaving food or female to be enjoyed by the alpha.
We shouldn’t jump too quickly to conclusions, but high ranks that enjoy
a high degree of social control and predictability, better-developed social
relationships (grooming) and access to luxuries, while basics are relatively
abundant at all levels of the hierarchy, and aggression symbolic rather than
actual, is not a world away from human social hierarchies. In these animal
surveys in the wild the ‘endpoints’ studied have not been disease, or even
life expectancy – the numbers involved have simply been too small for
precise calculations – but physiological markers of stress. The most
frequently studied has been the stress hormone cortisol, which we think is

relevant in humans as it is in non-human primates. (You may be wondering
how you measure plasma cortisol in a baboon. You hide, then shoot it with
an anaesthetic dart, and hurry to get the blood sample before the cortisol
level changes. While you go to the field lab, the baboon wakes up and goes
about his business.)
Studies of baboons, other than Robert Sapolsky’s, have replicated his
finding that subordinate males have higher levels of basal cortisol. There is
an interesting exception, in conditions of instability. The very top-ranking
baboon may engage in real fights to keep his position, as number 2 works to
make his move for the top spot. Under these conditions, basal cortisol may
be higher in number 1 than in number 2. Even if you are a high-status
human male, finding out that you are about to be kicked out of the
boardroom or the Cabinet can be stressful.
In some primate species low status is not characterised by frequent
episodes of social stress, as described above. In these species the higher
cortisol levels in subordinate animals are less marked.
Culture seems important, as well as species differences. Sapolsky and a
colleague observed a troop of baboons where, because of historical
accident, living too close to humans, 50 per cent of the high-ranking male
baboons were killed. What developed next was interesting: a troop emerged
that had markedly less aggression related to hierarchy and a greater degree
of affiliative behaviour – such as grooming. As with all baboon troops,
adolescent males join from outside. Usually the new entrants fight for a
place in the hierarchy. In this special troop the new males learned caring
behaviour, even treating females without aggression. In this ‘caring’ troop
low status was not associated with higher levels of cortisol.
As I said at the start of this section, we should not overstate the read-
across from non-human to human primates. That said, it is entirely plausible
that low status in humans, as in apes, is associated with higher levels of
stress and its physiological correlates. Affiliative behaviour moderates the
harmful effects of stress. Social cohesion means trust and social supports
from others, or from caring services and institutions, or, as I said in relation
to Japan, feeling that you are on the same team. To link back to the
discussion on economic and social inequalities, the bigger the inequalities
the greater is the threat to social cohesion and hence the greater threat to
health equity.

HEALTH OF SOCIETIES IS ALSO ABOUT MORE THAN
INCOME
Quoting Amartya Sen, I said it is not so much what you have that is
important for health, but what you can do with what you have. Way back in
Chapter 1 I pointed to countries that enjoyed good health despite not having
high national income. By contrast, in this chapter we have been considering
a country, the US, which has relatively poor health, despite high national
income.
Let us visit three Latin American countries that have achieved good
health despite relatively low national incomes, and in the case of Costa Rica
and Chile, strikingly high levels of income inequality.
I start with Cuba. If you’ve not visited, what do you imagine it is like?
Full of Soviet-era apparatchiks dressed in standard-issue Russian clothes?
People anxious, poor and afraid, careful about who they talk to, and about
what?
It did not look like that to me, on a recent visit. Among other activities I
was invited to give a lecture at the Ministry of Public Health. Not even civil
servants looked standard-issue. The women had nail varnish on their
fingernails and toenails, and highlights in their hair. They looked like
middle-class Latin American women. The men, all dressed appropriately
for the hot climate, looked slightly more casual (and fashionable) than an
Englishman on his summer holiday – at least they were not wearing sandals
with socks.
At one point in my lecture on social determinants of health I described
research showing that stress at work was associated with increased risk of
heart disease. One way of measuring stress at work, I said, was imbalance
between effort and reward. High effort and low reward: has that ever
happened to one of you? A titter ran round the audience that rose from a
hum to an excited babble. Indeed it had happened to them, and they didn’t
mind letting me know. And when I showed them the evidence from Europe
that the lower the status in the workplace the more common was imbalance
between effort and reward, again there was excited acknowledgement. They
recognised the phenomenon.
Not a socialist paradise, then, nor lacking social hierarchies.
Cuba could be a Rorschach test. For some, it is a communist pariah. For
others, Cuba represents a different model of development: a country that

has been able to turn its back on neoliberalism and avoid many of the gross
income inequalities that scar Latin America. The political right will frown
at this: if there is equality in Cuba, it is because it is uniformly ghastly.
FIGURE 9.4: SOMEONE IS DOING SOMETHING RIGHT
I see it as neither socialist paradise nor communist pariah, but as a poor
country with remarkably good health. As when considering Europe, we
need to go beyond the ideological battles of the Cold War and try to see
what is happening. To see, that is, what we can learn from understanding
how Cuba achieved such good health, despite an economy that even its
staunchest defenders have to admit has been a sorry mess. It was dependent
on the USSR for everything imported. When the Soviet Union collapsed, so
did Cuba’s economy. Without petrol for the cars and farm machinery, they
went back to using horses and carts and bullocks in the fields – hardly the
white heat of modern development.
Despite all this, health flourished. The graph in Figure 9.4 shows life
expectancy for Cuba and for three comparison countries from the Americas:
Argentina, Uruguay and the USA. Argentina and Uruguay were a good deal
more developed in the 1950s than pre-revolutionary Cuba – the
revolutionary government of Fidel Castro fought its way to power in 1959.
In 1910, Argentina was the eighth-richest country in the world in national

income per head, just behind Canada and Belgium, and ahead of Denmark
and the Netherlands.
What has happened is simply dramatic. Cuba’s life expectancy was ten
years shorter than the US in 1955, but by 2011 both countries had the same
life expectancy. It had outstripped the two comparison Latin American
countries.
The question is: what has Cuba been doing? Cubans tell me that it has
much to do with their highly developed health-care system. It is also likely
to connect with their emphasis on education and social protection.
Costa Rica’s health record looks a great deal like Cuba’s, and Costa Rica
is not a communist country. I asked the Costa Ricans why their health is so
good – life expectancy, like Cuba’s, similar to the US. The first thing they
told me was that they abolished their armed forces in 1948. Why should we
have an army? they said. Most countries in this part of the world have
armies to suppress their own population; we used the money to invest in
education and health care – priorities similar to Cuba’s. Figure 9.5 tells an
interesting story. It compares Latin American countries in terms of pre-
school enrolment and reading scores at 6th grade. Cuba has the most
children enrolled in pre-school, and the best reading scores in 6th grade.
Next comes Costa Rica, followed by Chile. My ‘developed’ country
examples, Uruguay and Argentina, come lower down on both measures.
Paraguay and Dominican Republic do badly.
FIGURE 9.5: GETTING TO THE CHILDREN EARLY

The truth is that I do not know precisely why Cuba, Costa Rica and
Chile, with their remarkably different political histories, all have health up
at the same level as the US, despite having only a fraction of the US’s
income per head. My speculation is that Chile Solidario, with its
universalist approach to including the poor, high investment in pre-school
and education, and provision of health care, is important. Something similar
is at work in the other two countries.
Societies matter. The ‘causes of the causes’ perspective is relevant. We have
a good deal of evidence that we could improve health and health equity by
including everyone in society in the implications of Chapters 4–8: early
child development, education, work and employment conditions, good
circumstances for older people, resilient communities. But we have to want
to. Large inequalities of income and social conditions may be a cause of
lack of social cohesion, but they may be a symptom, too. Why do we
tolerate the incomes of the 1 per cent soaring ever upwards, while
apparently not caring that vast numbers of our populations live in poverty?
A more socially cohesive society would not want that. To quote Piketty
again: ‘In a democracy, the professed equality of rights of all citizens
contrasts sharply with the very real inequality of living conditions, and in
order to overcome this contradiction it is vital to make sure that social
inequalities derive from rational and universal principles rather than

arbitrary contingencies.’ Inequalities exist in all societies. That is how it is.
The magnitude and extent of those inequalities, how they come about, and
what they mean for the less privileged, is vital to a sense of social justice
and to health. We have good evidence that we can do things better.

10
Living Fairly in the World
Gross National Product counts air pollution and cigarette advertising, and ambulances to clear
our highways of carnage. It counts special locks for our doors and the jails for the people who
break them. It counts the destruction of the redwood and the loss of our natural wonder in
chaotic sprawl . . .
Yet the gross national product does not allow for the health of our children, the quality of their
education or the joy of their play. It does not include the beauty of our poetry or the strength of
our marriages, the intelligence of our public debate or the integrity of our public officials. It
measures neither our wit nor our courage, neither our wisdom nor our learning, neither our
compassion nor our devotion to our country, it measures everything in short, except that which
makes life worthwhile.
Robert F. Kennedy, University of Kansas, 18 March 1968
At the crowded dinner table of my mind, I have an anarchic Icelandic
mayor sitting down with some angry young Greeks, an Irish professor
struggling to make ends meet, a Brazilian woman juggling children and
poverty, a healthy and well-educated South Korean, a woman from Kerala
in South India, a suicidal Indian cotton farmer, a Bangladeshi teenager who
loves sweatshops, a Zambian whose children cannot go to secondary
school, an irritated Argentinian, an obese Egyptian woman, a young
Kenyan chain-smoker and a few randomly chosen Americans and
Europeans. The dress is traditional, and/or smart casual.
What the dinner guests all have in common is that their lives, and hence
their chances for good health, are all influenced by their country’s
participation in globalisation. It’s my fantasy, so I can structure it how I
want. The people serving the food, and listening to moving tales of failure
and success, are officials from the International Monetary Fund and the
World Bank, the European Commission and the US State Department, and
executives from tobacco corporations, food-marketing giants, retail clothing
chains and national aid agencies.

Were I Chaucer, and we had a poet’s time, each would tell their tale in
detail, with brio and wit. But I am not, and we don’t, so let’s start with the
anarchic Icelander. The others will make their appearance in this chapter, as
will their clothing and the food on their table. It’s a non-smoking
environment so the Kenyan chain-smoker has to refrain for a bit.
In 2010, Jon Gnarr was elected mayor of Reykjavik, the capital of
Iceland. He was a professional comedian with an anarchist streak. He’d
never had anything formal to do with politics, but he formed the ‘Best
Party’ to contest the mayoral election, and campaigned on a promise to
break his election promises, which included installing a polar bear in
Reykjavik Zoo, free towels at the public swimming pools, and fighting
corruption by indulging in it in public.1 He drove his political opponents
bananas by smiling at any and all attacks. We sometimes think our
politicians are clowns. Here was a clown who became a politician. He
started campaigning as a joke and found himself with a real political job. I
met him in June 2013, when I was invited to Iceland by the government to
talk to them about social determinants of health. The mayor did what
mayors do: he hosted a reception at a special venue in the city and delivered
a speech of welcome, albeit you couldn’t help feeling that his tongue kept
straying towards his cheek. His political adviser told me that they had to
take the job seriously and work with City Hall in a responsible way – that
was no joke. They did, however, do something very un-politicianlike:
decide that one term was enough.
Two pieces of background are relevant. Iceland is a country with a
population of just over 300,000, more than a third of whom live in the
capital. In Britain, we jest that our country is run by members of an old
boys’ club who were all at Oxford together. (It’s not true; some were at
Cambridge.) In Iceland, to say everyone really does know everyone is only
a slight exaggeration. Gnarr’s wife was a friend of Björk (the singer), and
his campaign manager was at university with . . . who knows . . . who is a
neighbour of . . . Even if you’re an outsider like Gnarr, you have
connections all over the place. To illustrate, I was sitting at a fish restaurant
outside Reykjavik on a Saturday evening with the Chief Medical Officer
and asked him what is the prison population of Iceland. Just a moment, he
said, made a quick call, and in three minutes he had the answer: 50 per
100,000. All right, you might expect the Chief Medical Officer to be well
connected, but one phone call on a Saturday evening? Incidentally,

50/100,000 is very low, roughly the same as Japan. In the UK the figure is
just under 200 per 100,000, and in the US close to 800. In Iceland, if you
commit a crime the probability is that the victim will tell your mother next
time she sees her in the supermarket. It may be the very cohesiveness of
Iceland that is responsible for their low crime rates and remarkably good
health.
The second piece of background, more relevant to globalisation and
health, is that Iceland had suffered a catastrophic economic meltdown in
2008. It had gone from being a well-organised society based on fishing and
huge supplies of geothermal energy – hence aluminium smelting – to
housing three private banks that represented everyone’s worst nightmare of
what reckless cowboys can do when let loose on the global economy.
In Chapter 6, I referred to the debate around the work of Harvard
economists Carmen Reinhart and Kenneth Rogoff who showed that when
national debt climbs above 90 per cent of GDP, economic growth slows.2,3
At its peak, Iceland’s debt was 850 per cent of GDP! Icelandic banks
bought assets round the world, as though all curves go ever upwards
without a day of reckoning. The butterfly that flapped its wings might have
been the collapse of sub-prime mortgages in the USA, but it caused a
hurricane in Iceland and, predictably, the castles in the air were reduced to
rubble. The economic collapse was a profound shock to the economic
livelihood of Icelanders, not to mention to their self-esteem and to the sense
of being part of a small close-knit society. It was against this background
that the citizens of Reykjavik, thoroughly fed up with the politicians who
had presided over this catastrophe, elected a self-confessed clown.
What happened next?
Iceland appealed to the IMF, who offered help in return for their usual
policies of stringent austerity. The general population of Iceland were asked
to pay off the debts of a few bankers through taxes and submitting to
austerity. In a referendum, they refused – much to the chagrin of those in
other countries who had, wittingly or otherwise, found their finances to be
tied up with the fate of these lasso-twirling Icelandic bankers. Spending on
social safety nets and health care was maintained. Electing a funny man as
mayor of Reykjavik was perhaps the population’s way of saying that they
rejected ‘business as usual’, including IMF-style economic orthodoxy.
Iceland’s response was in sharp contrast to what happened in Greece,
Ireland and some other countries. That, and a high degree of social

solidarity, were perhaps the reason why Iceland did not see adverse health
effects in response to its financial cataclysm, as other countries did.4
The first area of globalisation and health that I want to examine, then, is
global finance, in various aspects. We will then move on to look at trade;
markets and the behaviour of corporations; and at alternatives to the pursuit
of economic growth. Each can have a profound impact, for good and ill, on
health and health equity.
Asking if globalisation is good or bad is akin to asking if the weather is
good or bad. It can be both. A key question is the degree to which
globalisation leads to shared knowledge and resources and creates
opportunities on the one hand, or is disempowering of individuals and
communities on the other.
FAIR FINANCE: THE GLOBAL FINANCIAL CRISIS AND
AUSTERITY
The contrast between my anarchist Icelander and angry young Greeks is
instructive. Both were disempowered by the global financial crisis, but the
response differed markedly. In Chapter 6 I referred to debates between
macroeconomists as to whether Keynesian stimulus or austerity was the
appropriate response to the global financial crisis. Naively perhaps, I think
that economic evidence should determine the outcome of the debate. It
turns out that interpretation of the evidence tends to split along political
lines – the right embracing austerity, the left more disposed towards
Keynesian stimulus. The first is cyclical – when things are tight, cut
spending. The second is counter-cyclical – when things are tight, spend.
Cross purposes. Politicians then appeal to which interpretation of evidence
suits their purpose. Reinhart and Rogoff were quoted by the British
chancellor as intellectual justification for the severity of his austerity
package. Paul Krugman, a Keynesian economist, tends to be quoted by
those who would like to follow a less severe path.
There are several questions here, of which we can isolate three. Which
course of action is most likely to lead to the return of economic growth?
What is the impact of the different policy choices on people’s lives across
the socio-economic spectrum? And, related, what do the people want? All
could have an impact on health, and on health equity.

On the first, Reinhart–Rogoff say that too much debt slows growth. The
IMF, reviewing global experience, says that other things being equal,
austerity slows growth.5 The Reinhart–Rogoff argument was weakened by
the mistakes in their spread sheets, but not fatally so. Although a
comparison of the two does not settle this issue, it is of interest that the US
indulged in a fiscal stimulus, and the UK experimented with austerity. The
US economy recovered GDP faster from the 2008 crisis than did the UK.
Actually, even that comparison is simplistic, because in the UK the
government realised that they were cutting too deeply, so they quietly, with
no fanfare, eased off on the austerity after a couple of years of savage
squeezing, and gave themselves more time to pay down the debt.6 A
commentator in the conservative Spectator magazine said that the
chancellor was spending like a ‘drunken Keynesian’.7 One suspects that
perhaps there is only one evidence base here: cutting spending in time of
recession reduces aggregate demand and delays economic recovery. One
cannot but think that enthusiasm for austerity, which has been manifest all
over Europe, flies in the face of the evidence, and is pursued for reasons
other than presumed economic benefits.
I visited Athens at a time when young Greeks, more than half of whom
were unemployed, took to the streets to vent their anger at economic
austerity. It was an intense experience. Even the more organised political
march was scary, given Greece’s history of military coups. Greece had got
into a painful muddle with its finances, over years if not decades. Its fellow
members of the Eurozone appeared to ignore the mess. The muddle was
exposed and inflamed by the global financial crisis. Greece’s debts soared
and the ability of its government to borrow money plummeted. The country
was told that the price of remaining a member of the global financial
community in general, and the European currency in particular, was to take
the medicine – a powerful cocktail that included drastic cuts to public
spending. Public spending sounds abstract. It is not. It may include the
indefensible such as early retirement on large pensions for civil servants,
but public spending is also jobs and salary levels for teachers and nurses,
postal workers and street cleaners. Public spending is also nutrition clinics
for children and social care for older citizens, it is health care,
unemployment benefits and subsidies to public transport. Predictably, the
whole economy suffered under this ‘orthodoxy’ and spiralled downwards.

The response of many disempowered Greeks was to take to the streets and
protest.
As Greece was coming up to an election, one German politician watched
the unrest on the streets of Athens and mused that perhaps this was not a
good time for an election. Wonderful, I thought. Not only are the Greek
population to have ‘remedies’ thrust upon them, they should be deprived of
a say. What do Greeks know about democracy, they don’t even have a word
for it. Oh, they do: δημοκρατία (dēmokratía). Democracy, of course, comes
from two Greek words meaning people and power. In Ancient Greece,
democracy was an antonym to another word, aristokratia, rule of an elite.
Rather than the people, the European Central Bank, the European
Commission and the IMF were to dictate what Greece had to do. Here, in
the twenty-first century, were European politicians musing that aristocracy
was safer than democracy. Safer for whom?
There is already evidence from Greece that the people had legitimate
grounds for protest – austerity has damaged health. One obvious
mechanism is through unemployment, which, as summarised in Chapter 6,
has an adverse impact on mental illness and on suicide rates. It also has an
impact on the homicide rate. It is not too melodramatic to say that policies
of austerity are leading people to take their own lives, and also to kill each
other.
Terminal 2 at Dublin airport is somehow symbolic of what Ireland has
been through. The terminal is a wonderful testament to a once booming
economy, built to be suitable for a Celtic Tiger, an economy that was going
places. When I travel through Terminal 2 now, its echoing halls seem to
represent the downside, the hollowness of the promise that the people of
Ireland could be rich by lending each other money they didn’t have.8 A taxi
driver shakes your hand, so pleased is he to have any business. In Dublin
itself, ‘To Let’ signs on empty office buildings, deserted restaurants and
pubs half full are signs of what happens when a growth economy collapses.
In Ireland, as in Iceland, the banks got into all sorts of trouble because
they overreached themselves in the apparent belief that there would never
be a downturn. Remarkably, the government took the decision to pay the
banks’ debts. The government, of course, is the taxpayers. The people had
to pay the banks’ debts, which translated into enormous salary cuts for
employed people and damages to employment. The Irish professor at my

dinner table found her salary cut by 40 per cent. Cuts in standard of living,
cuts in social programmes: the impact on health is likely to be adverse.9
Icelanders decided to do things differently from the Irish. I cannot claim
that the doctors, academics, civil servants and politicians who talked to me
are typical of Iceland, but, to a person, they asked the question: why should
all Icelanders be made to pay for the wild excesses of irresponsible
bankers? The IMF’s remedy was that the Iceland government should
assume liability for the bank’s losses (as happened in Ireland), which would
have resulted in 50 per cent of the national income between 2016 and 2023
being paid to the UK and Dutch governments, holders of much of the
debt.10 The President put it to the people in a referendum and 93 per cent of
the population rejected the package. Why did Iceland’s health apparently
not suffer as a result of their economic crisis? Here is a plausible account:
First, Iceland ignored the advice of the IMF, and instead invested in social protection. This
investment was coupled with active measures to get people back into work. Second, diet
improved. McDonald’s pulled out of the country because of the rising costs of importation of
onions and tomatoes (the most expensive ingredients in its burgers). Icelanders began cooking at
home more (especially fish, boosting the income of the country’s fishing fleet). Third, Iceland
retained its restrictive policies on alcohol, again contrary to the advice of the IMF. Finally, the
Icelandic people drew on strong reserves of social capital, and everyone really felt that they
were united in the crisis. Although extrapolation to other countries should be undertaken with
care, Iceland, by challenging the economic orthodoxy at every step of its response, has shown
that an alternative to austerity exists.11
As Iceland’s economy recovers, it is now repaying its debts.
The IMF has a history. I was a member of The Lancet–University of Oslo
Commission on Global Governance for Health, chaired by Ole Petter
Ottersen, Rector of Oslo University.12 The starting point for the governance
commission was the Commission on Social Determinants of Health
(CSDH). The governance commission said in effect: the CSDH has pointed
to the causes, and the causes of the causes, of health inequity. We now need
to look at what can be done to improve governance at a global level so that
effective action can be taken on the social determinants of health.
In light of the experience in Europe with austerity we, the governance
commission, went back to an older literature to look at the effect of IMF
policies of structural adjustment in low-income countries. It does not make
happy reading. In the 1980s the IMF made loans contingent on
governments accepting IMF recommendations on how to manage the

economy. It was mainstream Washington consensus: reduce public
spending, markets as the default option for public services, economic
deregulation, privatise public assets. We concluded:
the effects of these programmes have been disastrous for public health . . . structural adjustment
programmes undermined the health of poor people in sub-Saharan Africa through effects on
employment, incomes, prices, public expenditure, taxation, and access to credit, which in turn
translated into negative health outcomes through effects on food security, nutrition, living and
working environments, access to health services, education.13
When discussing the battle between austerians and Keynesians I said that
a key criterion should be impact on the lives people are able to lead.
Structural adjustment, there is little doubt, led to a great deal of pain in the
short term. As an economic policy adviser, how convinced do you have to
be that, in the long term, it is worth it, before inflicting such short-term pain
on other people?
A SOCIAL PROTECTION FLOOR?
As shown in Chapter 6, unemployment increases national suicide rates. But
the greater the spending on social protection – unemployment benefits,
active labour market programmes, health care – the more the harm inflicted
by unemployment is reduced.14 Further, when examining the Nordic
countries, the message is clear: greater spending on social protection is
linked to narrower health inequities.
I have to confess that when I began my involvement as chair of the
CSDH, I thought social protection was something that only rich countries
could afford. Based on the evidence presented to us, I changed my mind.
We made the clear recommendation for universal social protection systems
in low-income countries, as in middle and high. These should include
people in informal employment. Totally fanciful? The answer is: a bit
fanciful. First, the bad news. Currently, globally, only 27 per cent of people
are comprehensively covered by social security systems.15 This means that
73 per cent of people have only partial coverage or none at all. Essentially,
lack of coverage means no protection from low income that may arise in a
variety of ways: lack of work, sickness or varieties of social exclusion.
The more encouraging news is that the global community wants this to
change. The International Labour Office (ILO) convened an Advisory

Group on a Social Protection Floor, chaired by Michelle Bachelet, then the
former, now the current, President of Chile. Some clarity of language might
be helpful. The ILO uses the terms social protection and social security
interchangeably, and treats social security as a human right. The term
encompasses a broad variety of policy instruments, including social
insurance, social assistance, universal benefits and other forms of cash
transfers, as well as measures to ensure effective access to health care and
other benefits in kind aiming at securing social protection.
The recommendation made by Bachelet’s group for a social protection
floor was endorsed by 185 countries. The key point for a chapter on
globalisation and health is that although social protection is an issue for
countries themselves, the global community can play a role in at least two
ways: showing what is possible, and using global resources to help
countries establish a minimal level, a floor, of social protection for each
country. The ILO has weighed into the debate on austerity with a clear
statement that social protection systems must be protected and enhanced.
The ILO praises the European social model (as described in the previous
chapter) but says austerity is putting that under threat to the detriment of the
population in Europe – not just Greece and Ireland, but many other
countries. It looks with approval at the expansion of social protection in
middle-income countries such as Brazil and China. The big question is
whether voices such as those from the ILO can be heard above the austerity
clamour, and a social protection floor be extended to low-income countries,
in addition to preserving social protection in higher-income countries.
ECONOMIC GROWTH, INEQUALITY AND SOCIAL
INVESTMENT
Growth is good, isn’t it? We scour our daily newspapers to see the GDP
figures. If GDP sank by 0.1 per cent in the last quarter it invalidates the
government’s whole economic rationale; and if it grew by 0.1 per cent the
government is triumphant. It’s silly. It stretches reason. This is not to deny
that growth matters for low-income countries. There is no question that if
India’s economy is growing at 7–9 per cent a year it has the possibility to do
things socially to the benefit of its population’s health that it could not when

it was a poor country and had sluggish growth. There is also no question
that if the whole world grew at that rate, the planet would choke.
Economic growth, though, is no guarantee of development, by which I
mean the kinds of social goal identified by Robert Kennedy at the head of
this chapter, particularly education and health. For the well-being and health
of people to be enhanced we must ask how economic growth is used and
how equitably it is distributed.
We turn now to the Brazilian and South Korean at my dinner table.
Jean Drèze and Amartya Sen refer to Brazil’s growth in the 1960s to
1980s as ‘unaimed opulence’.16 Brazil had rapid economic growth but
deplorably low living conditions for large swathes of the population. The
Brazilian woman at my table, had the dinner party happened in the 1980s,
would have been struggling to raise children in conditions of extreme
poverty. By contrast South Korea’s growth was more equitably distributed
and the proceeds were used for education and the widespread improvement
of living conditions.
Since then, say Drèze and Sen, Brazil has changed course. The adoption
of a democratic constitution, washing away the vestiges of military
dictatorship, the building of social institutions, commitment to free and
universal health care, social security programmes, including the conditional
cash transfer scheme, Bolsa Familia, which I described in the previous
chapter, improved the quality of people’s lives and was accompanied by
rapid improvements in health. As one indication of how life improved for
the Brazilian woman and her children, we can look at stunting – failure to
grow adequately in the first year of life. Figure 10.1 illustrates the social
gradient.
In 1974–5 that gradient was steep and plain to see: the higher the income
the lower the prevalence of stunting. As the years go on, not only does the
prevalence of stunting go down for all groups, but the social gradient
becomes progressively flatter. By 2006–7 there is hardly a gradient to be
seen. The changes in Brazil improved the lives of children.
FIGURE 10.1: POVERTY IS NOT DESTINY – THINGS CAN GET BETTER

Each year the United Nations Development Programme (UNDP)
produces a Human Development Report (HDR). The HDR for 2013
expands the insights of Drèze and Sen and identifies what it calls:
unwelcome types of growth: jobless growth, which does not increase employment opportunities;
ruthless growth, which is accompanied by rising inequality; voiceless growth, which denies the
participation of the most vulnerable communities; rootless growth, which uses inappropriate
models transplanted from elsewhere; and futureless growth, which is based on unbridled
exploitation of environmental resources.17
The HDR contrasts the Washington Consensus, which argues for getting
the economic fundamentals right, with UNDP’s own approach, which puts
human development first. I love it. Of course I do. This UN agency says
that improvement in poor people’s lives – and hence, their health – cannot
be postponed while the economic fundamentals start to work. It is actually
stronger than that. The Washington Consensus, neoliberalism by another
name, is likely to make inequalities wider in addition to neglecting the need
to build people’s capabilities and ensure their meaningful freedoms. Further,
consistent with Joseph Stiglitz’s arguments outlined in Chapter 9, social
protection and enhancing people’s capabilities are likely to be good for
economic growth and economic productivity.
A way that the UNDP measures progress is with a human development
index, and the important thing about this HDI is that it includes health,

national income and education. Moving beyond the ideology of whether
public spending is good or bad is the evidence shown in Figure 10.2.
FIGURE 10.2: YESTERDAY’S SPENDING LEADS TO TODAY’S BENEFITS.
Each point on the graph represents a country. It shows that the greater the
public expenditure on health (care) and education in the year 2000, the
higher the score on the human development index (HDI) twelve years later.
If I showed this graph to a class of graduate students they would argue over
cause and effect and could come up with any number of competing
explanations for this correlation. One of them, though, is the obvious one: if
yours is the kind of society that spends more of its public money on schools
and health care, yours is likely to be the kind of society that scores better on
education, health and income – the components of the HDI.
The HDR 2013 refers to countries that privilege social development
rather than simply economic growth as ‘development states’ and says:
The recent literature on developmental states has grown out of the experiences of the East Asian
‘miracle’ economies: Japan before the Second World War and Hong Kong, China (SAR), the
Republic of Korea, Singapore and Taiwan Province of China in the second half of the 20th
century. Recently, China and Viet Nam (as well as Cambodia and Lao PDR) can be seen as
developmental states. Common traits include promoting economic development by explicitly
favouring certain sectors; commanding competent bureaucracies; placing robust, competent
public institutions at the centre of development strategies; clearly articulating social and
economic goals; and deriving political legitimacy from their record in development.18

Economic development, yes, says the UNDP, but high levels of economic
growth alone do not suffice to build a state that is characterised by high
levels of health and education. From the 1990s on, Brazil’s progress in
human development was faster than in the period described as ‘unaimed
opulence’, even though its growth of GDP was slower.
It is the turn of the woman from Kerala, the South Indian state that stands
out in relation to India’s performance in human development. Life
expectancy for women in India has improved, and the improvement is
impressive: from fifty-eight in 1990 to sixty-eight in 2012 – although that is
still nearly twenty years behind the international top scorer, Japan.19 In
Kerala it is more impressive than in the rest of India. At seventy-seven, it is
the one part of India that is up with China and Brazil. The lesson from
Kerala is similar to those countries: emphasis on human development,
investment in human capabilities . . . and no fear of state intervention. A
few comparisons between Kerala and the average for India are instructive
(see chart on following page).20
When Kerala’s good health record first came to attention, thirty or so
years ago, one of the puzzles was that if education was so high, why was it
one of the poorer states of India? It fuelled speculation that there is a trade-
off between involvement of the public sector in human development and
economic success. That scepticism is no longer valid. Kerala has had rapid
economic growth since then, improvements in living conditions and
increases in health, all with a vigorous involvement of the public sector.21
At the beginning of this section, when saying that economic growth
might be helpful in improving development and health, I stressed that we
had to ask both how growth is used and how equitably it is distributed.
Much of the debate in the development literature concerns whether growth
is a cure for poverty. Inequality is relevant here in at least two ways. First,
in the previous chapter I quoted Joseph Stiglitz, backed up by the IMF,

saying that too much inequality hinders growth. If growth is one route to
poverty reduction, then too much inequality hinders that reduction. Second,
the impact may be much more direct. If reduction of poverty was the main
outcome, reduction of economic inequality has a much bigger impact than
simply growth of GDP.22 I don’t think this is mysterious. Redistribution in
the direction of the less well off will of course benefit the less well off,
whether or not the economy is growing. But growth will only benefit the
less well off if its benefits are inclusive.
Too much inequality is bad for growth and bad for poverty reduction.
You might be thinking that the way a country chooses to develop is its
business: why is it in a chapter on globalisation and health? The answer is
twofold. First, bodies like the IMF and the European Central Bank are
dictating to countries what they must do if their economies are to be
supported. Second, what happens to their economies is heavily affected by
global forces. A financial crisis that began in Wall Street and the City of
London had profound effects round the world.
There is a further answer. What one country does in relation to trade and
aid is a potentially powerful driver of its own and other countries’
development.
TRADE
Dying to trade
Next as we go around the table we come to the Indian cotton farmer. He is
pleased to be with us. With good reason. Every half an hour an Indian
farmer commits suicide, in excess of 16,000 per year. Cotton farmers seem
to be particularly vulnerable – 270,000 suicides since 1995.23 India is so
enormous that any statistic sounds large. There are about 3,000 births every
hour. Are two suicides an hour a lot? It turns out that they are. In one
contiguous group of states – Maharashtra, Karnataka, Andhra Pradesh,
Chhattisgarh and Madhya Pradesh – the suicide rate among farmers is
nearly three times the average rate for all India (farmers and non-farmers).24
Our Indian dinner guest is all in favour of globalisation – well, mostly.
He attributes his children’s improved chances of survival to advances in
Western medical science that India enjoys. He watches World Cup football

on television and, poor as he is, he uses a mobile phone, which he loves.
Always in debt, though, our farmer is on the edge of disaster. Drought, and
resultant crop failure, can do him in. There is a question of whether
variability in the climate, a feature of climate change, is making both floods
and drought more common. Not much that he, or any one government, can
do about that – although all of us together could.
There is another kind of shock, much more amenable to change:
subsidies to US cotton farmers. US cotton farmers, many of them giant
corporate farms, receive substantial subsidies from the US government –
more than $3 billion in 2008–9 – to support their economic livelihoods.25
The effect of these subsidies is to lower the world price of cotton. In turn, a
lower world price undercuts the ability of cotton farmers in India and Africa
to sell their produce at an economic price. The US may be subsidising
domestic producers for good political reasons, but the removal of these
subsidies would allow the world price of cotton to rise by 6–14 per cent. Is
it stretching the causal chain implausibly to suggest that subsidies of US
cotton producers are leading to suicides of Indian cotton farmers? It is
entirely plausible that US subsidies are making a difference to the
livelihood of Indian cotton farmers. It is also entirely plausible that
inescapable debts are leading Indian cotton farmers to take their own lives.
A newer feature that is affecting Indian cotton farmers is the marketing of
genetically modified cotton crops. Sold to farmers on the grounds of
increase in yields, because of resistance to boll worms, these seeds raise
costs in a variety of ways: increased, not decreased expenditure on
pesticides to control other parasites; the seeds cannot be propagated, so
farmers have to buy new seeds every year; costs that are higher than
conventional seeds – the company claims the high prices are necessary to
cover the costs of meeting regulatory standards.
Brazil, India, China and several West African countries have appealed to
the US to remove their cotton subsidies and allow free trade. The lack of
success of this appeal led to Brazil pursuing the US through the World
Trade Organization. The US did not budge.26 One might respect the
argument for free trade somewhat more if those who argue for it obeyed its
rules.
Not just the US, and not just cotton: subsidies to European agriculture in
one week equal subsidies to African agriculture in one year.27 In a
globalised world, we should want all countries to develop economic self-

sufficiency. One should not rig the conditions so that they always favour the
rich and disempower low-income countries.
Trading to live
Next to the – thankfully not suicidal – cotton farmer sits the Bangladeshi
teenager who likes sweatshops. She looks around the table at the Americans
and Europeans wearing clothes – smart casual, remember – from Benetton,
Primark, C&A, Mango and others and she says: I made those garments.
Well, perhaps not literally those very garments, but ones very much like
those were made in the factories where my friends and I work.
Cue guilt feelings on the part of the Americans and Europeans. It is
difficult not to feel that our liking for cheap clothes is somehow linked to
the collapse, in April 2013, of the garment factory at the Rana Plaza
complex that killed 1,100 people and injured 2,500 more. Cheap clothes in
London and New York mean rotten factory conditions and low pay in
Dhaka, in Bangladesh. Like it or not, we are involved.
The simple version of this is that we, in high-income countries, export
low pay and sweatshop working conditions to Bangladesh and Bangladesh
exports affordable clothing to us – globalisation at work. It is not, though, a
simple case of good and evil.
First, Bangladesh as a country is a willing participant. It has in excess of
5,000 garment factories. The industry earns $20 billion a year in exports
and it is the second-biggest exporter of garments after China. Second, what
about the people? My mantra is: put health equity at the heart of all policy-
making. The garment industry employs 4 million people in Bangladesh, 90
per cent of them women. Dangerous factory conditions, low pay: is this just
another way to do women in? Are these not precisely the sort of working
conditions that I described as disempowering in Chapter 6?
The answer is that they are, but young Bangladeshi women consider the
alternative available to them. The alternative, so far, is not better working
conditions. These young women, coming from the countryside, have
swapped a life of early marriage and rural poverty for earning their own
money, controlling the decision of when and if to marry, and having a
desirable skill.28 Shaina Hyder, while a young scholar in the Law Faculty of
the University of California Berkeley, interviewed Bangladeshi garment
workers. Hyder reports that 90 per cent of her interviewees thought that

working was better than being a housewife, and could see the opportunities
it brings. One garment worker, a woman in her forties from a rural
background, saw her daughter go to college. Three generations: rural poor,
urban factory worker, college graduate.
That is not to say that any of us who has bought a garment made in
Bangladesh should be relaxed about the working conditions in which it was
produced. The Rana Plaza incident brought much-needed attention to the
question of working conditions in Bangladesh’s garment industry. There are
power asymmetries at work here. If Bangladesh starts to get more organised
about pay and working conditions, multinational corporations can simply
shift their business elsewhere, to the detriment of Bangladesh’s economy
and of the women who gladly see the work as empowering them. There is
not a well-developed mechanism for enforcing global working standards,
although ILO is trying to help. Shaming individual corporations into
acceptable practice can only go so far. That said, there are signs that a
concerted effort is being made by the government in Bangladesh to
recognise trade unions and pay attention to working conditions.29
Winners and losers
As my two examples show, there are winners and losers from international
trade – Indian farmers suffering, Bangladeshi women having the chance to
transform their lives. I led a European Review of Social Determinants and
the Health Divide.30 As part of that Review we invited Ron Labonté of the
University of Ottawa to update the work he did for the CSDH on
globalisation and health. Ron commented that the relationship between
trade policies, poverty and inequalities is a huge field of policy research,
but two significant pointers emerged.31 The first relates to the long, and I
mean very long and protracted, Doha development round negotiations
conducted under the auspices of the World Trade Organization. Assuming
the talks ever reached a conclusion, analysts modelled four different
outcomes. Their work suggested that there would be annual real income
gains of between $6 and $8 billion each for Japan, the USA and the EU 15
group of countries, and losses of about $250 million for Sub-Saharan
Africa. Free trade sounds like a good thing. As we saw above, when it
works against the interests of Europe and the US, the rich countries have no
compunction in discarding it. If it is to the benefit of the rich countries at

the expense of the poor, we hear pious exhortations on how free trade
benefits everyone. But not equally.
Ron’s second observation was that if trade liberalisation does occur, and
there are adverse impacts on income and employment in rich countries and
in poor, the kind of safety nets that I alluded to above, with a social
protection floor, are viable options.
Should there be a ‘should’?
Running through the discussion above there is an implicit concern that
decisions taken for one reason may have adverse impacts on the health of
disadvantaged people in other countries. The purpose of the original
decision may have been entirely admirable. If you are an elected politician
for a rural community in Europe or the US, you may take a view that your
primary responsibility is to your constituents. If subsidies to your farmers
hurt farmers in India or Africa, that is unfortunate, but not your chief
concern. If you are the leader of a country you may well say that your
motivation is not in being ‘fair’ to other countries but in pursuing your
country’s national interest. I explored in Chapter 3 what social justice meant
for health inequities. I didn’t say it, but I was in a sense assuming that if we
are a big interconnected globalised world community, then concerns with
social justice should be global rather than simply national. It slipped out, I
just used ‘should’.
If I enjoy cheap clothes, I should care, shouldn’t I, if workers are
benefiting or suffering in providing them. After all, if I were the factory
owner, I should have a responsibility for the health of my workers,
shouldn’t I? If they go home happy and well fed because of their work with
me, I can feel I am doing the right thing. If I get rich on the back of their ill-
health, do I not have some sense of responsibility? If I am not the factory
owner but the user of the products that the factory produces, my sense of
responsibility is weakened, probably rightly, but should it disappear all
together?
The reason for coming back to this discussion here, is because I want to
talk about aid, overseas development assistance. Is there a ‘should’ we can
recognise? Should the money of taxpayers in high-income countries be used
to help the livelihood of people in low-income countries? If aid were
ineffective, there cannot be a ‘should’. There can be no obligation on us to

do something that is useless or even harmful. We’ll come to that in a
moment.
DEBT AND AID
Paying one’s debts
Our Zambian dinner guest is angry, and the Argentinian thoroughly fed up.
The first feels let down by everyone, from his own government to the
international community; the second is profoundly annoyed that just when
he was getting his self-esteem back, he has been undermined all over again.
What unites these dinner companions is concern over their countries’ debt.
They would like us to put aid in the context of debt, which is what I do in
Figure 10.3 overleaf. The figures come from before the global financial
crisis.
The first observation, looking at this graph, is that when it comes to aid,
development assistance, the amounts of money are trivial in the context of
the economies of rich countries. An agreed benchmark was 0.7 per cent –
rich countries would give 0.7 per cent of their GDP to overseas
development assistance.32 We are way below that. For example, the US
economy turns over about $13 trillion a year; 0.7 per cent of that is about
$90 billion a year. If we add Japan, and the richer European countries . . .
the sum comes to a good deal more than the amounts currently going out in
aid.
Second, in every region of the world, except Sub-Saharan Africa, the
amount coming back to rich countries in debt repayment far exceeds
receipts of aid. Latin America and the Caribbean are a cash cow for the rich
countries. Some of these debt repayments are entirely reasonable. Countries
need to borrow to make their economies work. Some are not.
As an example of unreasonable debt repayment, take Zambia. In the
1980s, when the cold war was still in progress, Zambia borrowed from
Romania for agricultural equipment and services. In 1999 Zambia was
having difficulty paying its debts, and was in the process of renegotiating its
loans. Enter vulture funds – hedge funds that behave like vultures. A
vulture fund registered in the British Virgin Islands and run by a US
businessman bought Zambian debt at the knockdown price of $4 million.
How is this possible? Let’s say a bank has loaned Zambia $50 million.

There can then be a secondary trade in that debt. One bank ‘sells’ that debt
to some other kind of investor, who trades it further, and so on. When it
turns out, what a surprise, that Zambia is having difficulty paying its debts,
the price of the debt on this secondary market tumbles. It could be, for
example, that $50 million of debt gets sold for $4 million. The owner of
$50 million of Zambian debt calculates that he is never going to be repaid,
so he gets rid of his ‘worthless’ holding for any money at all. The buyer of
this ‘worthless’ debt makes the calculation that, eventually, he will make a
killing. Our Zambian guest wants to know how any of these financial
shenanigans is going to make it easier for his children to go to secondary
school.
FIGURE 10.3: WHO IS HELPING WHOM

A decade later, having paid $4 million for Zambia’s debt, the vulture
fund claimed debt repayments from Zambia of $55 million and, when it
refused, pursued it through the courts.33 Morality? Candy from a baby,
more like. Selfish to take candy from a baby? Not a bit of it. I’m doing it for
the baby’s own good: bad for its teeth, laying the seeds of bad habits that
would lead to obesity. I’m not a greedy vulture, I’m a public benefactor,
saving babies everywhere from themselves. What’s more it is perfectly

legal, and the corrupt leaders who rule Zambia would probably have stolen
the money – it is much better off in the hands of the businessmen who
control the vulture fund.
Happily, in this particular case, the Royal Courts of Justice in London
took a different view, not so much on the morality or legality of the claim,
but on the nature of the evidence presented. ‘Put at its kindest . . . some of
the witnesses [for the fund] were less than candid,’ said the judge.
I remember the feeling I had after the Gleneagles Summit in 2005. Tony
Blair was UK Prime Minister and hosted the G8 summit. Shamed into it by
rock stars, perhaps, the world’s leaders declared that they would give debt
relief for the poorest countries as a significant step in abolishing world
poverty. Zambia was a recipient of debt relief. In theory, at least – I know,
there is a great deal of corruption about – instead of paying interest on
debts, Zambia could use the money for education and health care. But along
comes this vulture fund, which voluntarily bought the debt for a pittance,
pursuing Zambia for more in debt repayment than it would receive in debt
relief.
It is not only the poorest countries that have got into trouble with their
debt. As I write, Argentina is at the mercy of a vulture fund. Its case is
different from Zambia’s because Argentina is not one of the poorest
countries that qualify for debt relief, but its ability to solve its problems is
strongly affected by debt. I do not for one moment suggest that there is only
one side to this story and that Argentina was a model of good financial
management before it defaulted on its debt in 2001. But Argentina’s virtues
or otherwise do not justify the role of a vulture fund. Prior to its default in
2001, Argentina’s debt was being traded as if it were sardines. It is hard to
think of a way that any one Argentinian benefited by having one person in
The Hague buy a chunk of Argentinian debt from another in Frankfurt, but
no doubt a trader somewhere can explain why it was good for the people of
Buenos Aires. No, I wouldn’t believe him either.
When Argentina could not pay its debts in 2001, its creditors agreed, or
felt they had no other option but to write down the value of their debts by
up to 70 per cent – known in the trade as a ‘haircut’. Enter a vulture fund
that bought up some Argentinian debt cheaply, which was not subject to the
haircut, it was a holdout. Argentina’s debt in the subsequent decade was at
manageable level, and it was paying off the holders of its (reduced) debt,
the ones who took the haircut. Once again, the vulture fund entered the

scene and demanded full repayment, of the whole value of the debt – debt
that they had purchased at a bargain-basement price, but was a holdout from
the original haircut agreement. (Are you following this?)
Remarkably, a US court ruled that Argentina was not allowed to continue
to repay its creditors, the haircut crowd, on the reduced debt, unless it also
‘repaid’ the vultures on the full value of the debt at the same time, the
holdout. Argentina argued, reasonably enough it seems to me, that had they
the prospect of repaying the full value of the debt, they would not have
demanded haircuts of the rest, and they simply could not do it. The court
was adamant: pay the vulture fund at the same time, or pay nobody.
Argentina defaulted with who knows what knock-on effects in Brazil, other
Latin American countries, global finance, let alone Argentina’s ability to
spend on national programmes. And failure to spend on national
programmes has the potential to damage health, for all the reasons that I
have covered in the previous chapters.
There is a serious failure of global financial governance when the
interests of hedge funds, legally if not morally, trump the ability of nations
to decide their own future.
Does aid work?
The medieval Jewish scholar Maimonides wrote of eight levels of charity.
The lowest is to give unwillingly. Skipping through the levels, the second-
highest is to give anonymously without knowing to whom you give. The
highest is to help the needy with employment or other arrangements so that
they progress to the point of no longer needing help.
Maimonides seems to be arguing from the point of view of the donor –
give unwillingly is the donor’s perspective. But he also takes in the
recipient. While there may be a tiny proportion of people who would prefer
charity to self-sufficiency – exaggerated by the right, minimised by the
left – the highest level of charity from the recipient’s viewpoint is also to be
in a position not to need charity. Which is where we want to be as a global
community, surely: to create the conditions for the poor and disadvantaged
to be empowered to control their own destiny. With 49 per cent of people in
Sub-Saharan Africa and 31 per cent in South Asia living on $1.25 a day or
less, we are not there yet. There is little doubt that the Indian cotton farmer
would rather be able to grow and sell his cotton at a profit, than have to

subsist on a lowly government handout. The Zambian at our table would
like there to be schools for his children to attend. If, in the short term, that
takes external assistance, he accepts that as a stage in a process.
It would seem obvious that if a country lacks the resources to employ
nurses and teachers, to buy medicines and textbooks, to build latrines and a
clean water supply, to provide pensions and social protection, then
international assistance would help. Critics say of the advocates of aid that
part of what they say is obvious and part is true; unfortunately these two do
not overlap. Aid may distort a country’s priorities, create dependencies,
have much more to do with the priorities of the donor than the needs of the
recipient, act as a kind of resource curse for a country, thus hindering the
climb out of poverty. And then of course there is corruption: aid money can
end up in shady places, and not used for its intended purpose. In the end,
say the critics, it just does not work.
Banerjee and Duflo, who we met previously as the authors of Poor
Economics, contrast the positions of Jeffrey Sachs of Columbia University,
who says aid is effective, and William Easterly, New York University and
previously a World Bank economist, who says it is not.34 Princeton
economist Angus Deaton is much more with Easterly than with Sachs.35
Parenthetically, reading their views of each other is a great spectator sport,
if offering few lessons in politeness. Banerjee and Duflo say that, at heart,
this is an ideological debate between left (Sachs) and right (Easterly). They
say that there is not a BIG answer to whether aid works, but small answers
as to whether specific forms of aid work under which circumstances. Much
of the answer to when and whether, they say, will come from randomised
controlled trials. Deaton is not only critical of aid, he is critical of what he
calls randomistas who think the answer to what works will come from such
trials. It would all be good knockabout intellectual fun, were it not such a
vitally important question.
Banerjee and Duflo use the example of impregnated bed nets to protect
against mosquito bites and consequent malaria. Sachs says provide bed
nets, children won’t get malaria, and their earning power will grow by 15
per cent. Easterly says that unless people pay for the nets, they won’t value
them and will not use them for the intended purpose. It will be a waste of
money and ineffective in the control of malaria. Banerjee and Duflo don’t
quite say: a plague on both your houses. They say that Sachs exaggerates
the economic benefits. But Easterly is wrong. They point to evidence that

use of bed nets, for the purpose intended, is increased by making them
cheaper, or free to the recipient.
Whether aid can help in poverty relief and economic growth remains a
vexed question.36 Particularly so, in the context of debt repayment shown in
Figure 10.3 and trading and financial arrangements that can work to the
disbenefit of low-income countries. Aid for health care and disease control
can be effective, as Banerjee and Duflo say, under particular circumstances.
In our European Review we pointed to the fact that, in 2009, external
assistance for health made up about half of government expenditure on
health care in low-income countries.37 Were this to be summarily removed
it would create great hardship. It is vital though to be satisfied that the
money is being used to good purpose.
FOOD GLORIOUS FOOD
When, at the dinner table, we come to the obese Egyptian woman, I tell her
about my recurring nightmare. I dream that I am attending a board meeting
of a corporation whose main product is fizzy drinks. The strategic analyst
addresses the board:
‘Gentlemen [it’s my nightmare – they are all men in my nightmare]. We
are in trouble. We are in the business of selling calories – flavoured sugary
water. But globally people are doing less physical activity. They need fewer
calories. Trouble looms. [The board has a collective vision of their private
jets taking off without them.] But, I have a solution. [The private jets come
back into view.] There are two main drivers of an individual’s calorie
consumption: physical activity and body mass. In general the more an
individual weighs, the more calories they need to stay in balance. So we
promote obesity. How do we do that? Increase portion size. Offer twenty
per cent more for “free”. It costs us next to nothing. All our costs are in
processing, distributing and marketing. That way we get a fatter population
who will need more calories. [Bigger and better private jets.]’
At this point in my nightmare, I wake up screaming. Thank goodness real
life is nothing like that. Purveyors of soft drinks may not set out to make
people obese; it happens to be the effect of their products. Of all the
proposed contributors to obesity, the one for which the evidence is strongest
is consumption of fizzy drinks.38 It is highly likely that fast foods, rich in

fat and sugar, are also fuelling obesity, although the evidence is not quite as
secure as with sugary drinks.
From the time that my concern with social determinants of health came
out of the academic environment into the policy sphere, I have been told
that we must collaborate with the private sector, in food as in other areas. I
am sure we must. The problem is that we have different aims. Mine is
health equity. Theirs is profit. If they coincide, fine. But, if not, we get into
the kind of battles that I regaled you with in Chapter 2. There I produced
three graphs of the alarming increase in obesity in the US. As goes the US,
so goes the world, as the two graphs in Figure 10.4 show.
The standard for measuring overweight and obesity is Body Mass
Index – weight in kg divided by height in metres, squared. A BMI of 25 or
greater is called overweight; of 30 or over is obesity. It’s hard to see my
Egyptian dinner guest on this graph. Not so hard to see her in real life. An
Egyptian woman in her late forties has a 90 per cent chance of being
overweight, and a two-thirds chance of being obese.39 If we had a Mexican
guest at the table, the chances are the same as in Egypt. Overweight is the
norm, and obesity almost so.
FIGURE 10.4: SMALL WORLD, BIG PEOPLE

Of course, the food industry argues that it is not their foods that are
making people fat, it is people’s pattern of eating. It’s a bit like the gun
lobby arguing that guns don’t kill people, people do. It is true that if you
didn’t consume fast foods they wouldn’t make you fat. Beyond that
astonishing insight is the fact that food corporations are trying as hard as
they can to get as many of us to consume as many of their products as
possible. They are succeeding. Global sales of packaged foods grew by 92
per cent to $2.2 trillion in the decade to 2012.40 The Coca-Cola Corporation

publishes figures of sales of their beverages. Mexico tops the world league:
675 servings (of 8 US oz, 237 ml) per person per year. The US is a laggard.
It comes in fourth with (only!) 394 servings per person per year. There is
some pressure to make processed foods ‘healthier’ in richer countries, less
so in other countries. Diet sodas make up 22 per cent of Coca-Cola’s sales
by volume in Europe and nearly one-third in North America but just 6 per
cent in Latin America.41
It is not fanciful to link Mexico’s top billing on the obesity league with
their top spot in Coca-Cola consumption. To repeat, the more sugary drinks
you consume the more likely are you to be overweight or obese. To be sure,
other foods make a contribution, and the sales of highly processed foods are
growing sharply in low-middle and middle-income countries.42
What we are seeing is a globalisation of food patterns. In high-income
countries we have already seen the impact of processed foods on eating
styles. It has gone a long way in the UK. A survey in England revealed that
30 per cent of households use their table for meals barely a few times a
year. Nearly two-thirds of people eat at their table less than once a week.
Just 18 per cent of people have one or more meals a day at their table.
(Three per cent have no table.) With the growth in sales of highly processed
foods globally, we will be exporting this pattern of eating.43 The
consequence will be not only obesity, diabetes and other non-communicable
disease, but a different way for families and friends to relate to each other.
Earlier (Chapter 2), I pointed out that a majority of the world’s
population are urban, and do not grow their own food. Markets are vital in
matching people to food. Processed food will play a part in meeting
people’s nutritional needs. But, I said, there are market failures. In one
sense the growth of Nestlé, Coca-Cola, PepsiCo, Kraft, or its successor, and
the retail fast food chains is a fantastic market success. Sales grow because
these companies bring food to people. Shareholders must be happy. From
the point of view of overnutrition it has to be counted a failure.
I am not much given to wringing my hands at the lack of solutions, but if
there were a ready way to limit the reach of transnational food corporations
and reduce their impact on obesity, we might be doing it. Knowledge helps,
in two ways. The more it is recognised what a potentially profound effect
food corporations are having on global food patterns, the greater the
pressure to do things differently, and the more the spread of fattening food
and beverages can perhaps be controlled. Second, the evidence I reported in

Chapter 2 showed that other factors can prevent or mitigate the growth of
obesity. Just as in high-income countries obesity growth is becoming less
extreme in people with high status, so in low-income countries there is less
obesity among those with higher levels of education. If the Egyptian
woman at our table had gone to university, she would be less likely to be
obese than her sisters with less education.
The experience with tobacco is relevant, in part. We come at last to the
chain-smoking Kenyan, whose habit reflects the widespread activities of
tobacco companies to recruit globally to their deadly habit. With use of
tobacco products declining in some high-income countries, the tobacco
industry has shifted its focus to low- and middle-income countries where 80
per cent of the one billion smokers in the world now live.44 We actually
know a good deal about how to make progress in reducing smoking. It
involves much more than simply exhorting people to look after themselves.
Tobacco control measures include pricing, bans on advertising, restriction
of sports sponsorship, restrictions in public places and health warnings on
packets. Much of this has been enshrined in a Framework Convention on
Tobacco Control (FCTC), coordinated by WHO and endorsed by most
countries.
The FCTC ought to be showing the way for what global coordination can
do. The problem is that the tobacco industry has profits to make, and is
challenging it wherever it can. The case of Uruguay is instructive. Uruguay
signed up to the FCTC and wanted to increase the size of the health
warnings on its packets. Philip Morris challenged them through the courts.
Similarly, Australia’s initiative in introducing plain packaging is being
challenged by Philip Morris. In both cases the cigarette company is arguing
violation of trade agreements.
I think the global health community will win this one. The case of
smoking is so open and shut. Smoking could kill a billion people this
century if it is not curbed. The tobacco industry is on the wrong side of this
issue. It will be difficult for courts or arbitrators to fly in the face of public
opinion and continue to find that trade agreements mean that selling
tobacco should trump the public’s health.
That said, it will take global action, as it will with food. Until this point
in the book, despite the uncertainties that are fundamental to my life as an
academic, I have been rather sure of what the evidence shows we can do to
advance the cause of health equity. I have been clear that models of good

practice exist that show the rest of us how things could be done. With this
global terrain, I am less sure how we get from where we are now to where it
would be desirable to be. And there are many other guests I could have had
at my dinner table. The Malian nurse working in Manchester rather than
Mali, representing the flow of health workers from poor countries to rich;
the Indian with cancer who could not afford the price of the drug because
intellectual property protection did not allow a generic version to be made
and sold at a fraction of the cost; the illegal migrant from Africa, fleeing
poverty and making his way through Southern Italy and Spain into Europe,
facing uncertainty and worse at both ends of his journey. They are all
clamouring for our attention.
Our Commission on Global Governance for Health has made an
important step in the direction of identifying how to make progress. First is
to recognise the problems of power asymmetry and the fact that for global
health equity to improve, action will be needed across all the important
social areas that I have described. Second, and related, there should be
independent monitoring of progress made in redressing health inequities,
and in countering the global political forces that are detrimental to health.
Third, whatever improvement there is to be in global institutions and the
way they are governed, fundamental is a commitment to global solidarity
and shared responsibility.
Here’s one optimistic view of globalisation from Thomas Friedman:
‘Holy mackerel, the world is becoming flat. Several technological and
political forces have converged, and that has produced a global, Web-
enabled playing field that allows for multiple forms of collaboration
without regard to geography or distance – or soon, even language.’45 It is a
wonderful rosy picture. We all benefit from this global interconnectedness.
Here is a more nuanced, and I would judge a more accurate, view from
the economist Nancy Birdsall: ‘But the world is not flat. Those of us on the
top, with the right education and in the right countries, can easily overlook
the countries and the people stuck in deep craters across the global
landscape.’46 Progress will come only from recognising the peaks and
troughs and dealing with them.

11
The Organisation of Hope
I will give you a talisman. Whenever you are in doubt, or when the self becomes too much with
you, apply the following test. Recall the face of the poorest and the weakest man [woman] whom
you may have seen, and ask yourself, if the step you contemplate is going to be of any use to him
[her]. Will he [she] gain anything by it? Will it restore him [her] to a control over his [her] own
life and destiny? In other words, will it lead to swaraj [freedom] for the hungry and spiritually
starving millions?
Then you will find your doubts and your self melt away.
Mahatma Gandhi
‘You are the first white man who spoke to me in a way I could believe in;
what you said: did it include me?’ Then the Maori woman, in traditional
Maori fashion, introduced herself by saying who her grandparents and
parents were. She finished: ‘I think what you said includes me, but I want to
hear from you that it is so.’
I had just given a lecture, covering some of the material in this book, at a
big meeting in Auckland organised by the New Zealand Medical
Association. When the Maori woman spoke, the watery condition of my
eyes that I reported in the Introduction made a nuisance of itself. Finally, in
a small voice, I said that when I was at a People’s Health Assembly in
Thailand, the Thais told me about the ‘triangle that moves the mountain’.
The three corners of the triangle are: government, knowledge/academia and
the people. Get the three working together and we can move mountains.
Then I recalled how at the Thai assembly a group of children, each one
more gorgeous than the next, sang:
We are all waves of the same sea
We are all stars of the same sky
It’s time to learn to live as one.

I said to the Maori woman: if what I said did not include you, the people,
then I am doing something terribly wrong. Of course, it includes you, as it
does the people of the Kokiri Marae I described in Chapter 8.
‘We opened our minds. More important we opened our hearts.’
Who do you imagine might say something like that? A social worker? A
New Age traveller? A cleric of one or other faith? How about a Deputy
Chief Fire Officer at West Midlands Fire Service in Birmingham, England.
He was launching their report ‘Improving Lives to Save Lives – the role of
West Midlands Fire Service in contributing to Marmot objectives’. He said
that they opened their minds to the Marmot Review, Fair Society, Healthy
Lives, and they opened their hearts to what they could do to help the poor
and the needy in the communities they serve and of which they form a vital
part.1
A woman fire officer told the story of ‘David’, an octogenarian, living
alone. Fire officers had been called because he was burning rubbish in his
living room to stay warm – his gas had been cut off. The fire officer said it
took her three weeks of coaxing for David, finally, to let her in the door.
She asked how he spent his time. He didn’t ‘do’ anything. He didn’t watch
TV because his electricity had been cut off twenty-six years ago. His only
outings were to the corner store to buy a few things to eat. He saw no one.
The fire officer brought him clothes, Christmas dinner, located his sister,
and finally got him on needed medication and into sheltered
accommodation. He was in a good deal better state than when they found
him. A fire officer did that!
At my visit to the West Midlands Fire Service, it was quite something as
one burly fire fighter after another told moving stories of how they were
working with children, with older people, and those in need, to improve
people’s lives. For most of my day with the fire fighters, one or other of us
was in tears. That watery ocular condition is catching.
These fire fighters in Birmingham England had picked up on the
activities of the Merseyside Fire and Rescue Service that I described in
Chapter 8, and said: we want to use our capacity out in the community to
improve people’s lives. Their principles are Prevention, Protection and
Response. They have given an undertaking to respond within five minutes
to a call for a fire. They spend between 6 and 10 per cent of their time
responding to fires. With training, shifts and preparation, that comes to

about half their time; they have been innovative, creative and committed in
using the other half to enhance the communities they serve. They quote my
English Review in pointing out that both health and fires follow the social
gradient. Prevention of one is likely to help in preventing the other.
One important principle is Making Every Contact Count. A fire fighter
goes into a home to check fire risks and talk about making the home safer.
He sees hoarding of ‘stuff’ which contributes to risk; deprivation; isolation
of an elderly person. He doesn’t then say: bad luck, but it’s not my problem.
He either works on the problem himself or works with colleagues to figure
out who they should be working with. If the fire fighter has reason to
suspect domestic violence, for example, he contacts the relevant experts.
They have ‘Marmot Ambassadors’ who are the front-line staff whose role
is acting on the six domains of recommendations in our English Review,
Fair Society, Healthy Lives. They call them the Marmot Six. I say to
general practitioners: this is what the fire fighters are doing to prevent fires
and reduce health inequalities. What are you doing? The answer is: more
and more, we are doing quite a bit.
After my bicycle accident left me with a fractured femur, the first trip I
made was to Stockholm, in January 2013. With my walking stick (happily,
long since discarded), I struggled through the snow to the Royal Swedish
Academy of Science for a meeting on social determinants of health. Among
many others, a member of the Swedish parliament spoke about the WHO
Commission on Social Determinants of Health (CSDH). He said that most
reports of international commissions are scarcely read and mostly ignored.
Emphatically, this was not the case with Closing the Gap in a Generation,
the final report of the CSDH. He said it is much discussed, still, in the
Swedish Parliament, five years after publication.
At his invitation I went to the Swedish Parliament a few months later. I
told the parliamentarians that the Swedish Association of Local Authorities
and Regions had galvanised its members, with great enthusiasm, to take
action on social determinants of health. What were they, the Parliament,
doing? Should all the action be at local level?
The City of Malmö was the vanguard. They took Closing the Gap in a
Generation as a starting point and asked: how, using the recommendations
of the global Commission on Social Determinants of Health, can we work
together for a socially sustainable Malmö?2 Other Swedish cities are

following suit: Linköping, Göteborg, Östersund, and perhaps others. As I
write, the Swedish government has taken the decision to set up a Swedish
Commission on Equity in Health.
In Göteborg, local government set up their city Commission. The
leitmotif of this Göteborg activity is inclusion: 1,100 people, mainly
employees of the City of Göteborg, came to a conference on socially
sustainable Göteborg. I have been to meetings of various kinds in London,
but never a thousand people engaging with how to make London a more
socially sustainable place. Per capita, to match Göteborg, such a London
meeting would have to have numbered 11,000. The day after my visit, 400
of these 1,100 were to sit down to work together to plan a more socially
sustainable Göteborg, with health equity and sustainable development at its
heart.
In England, local governments now have ‘health and well-being’ boards
whose job description is in the name. The King’s Fund, a health think tank,
did a survey of their priorities. Out of sixty-five local authorities in the
survey, three-quarters said that their number one priority was ‘Marmot
Principles’ – referring to the Marmot Review, Fair Society, Healthy Lives.
I met one local councillor from Manchester who said: ‘You’re Marmot! I
didn’t realise that Marmot was a person. We talk about implementing
Marmot.’
In the US, particularly, I hear the cry of anguish that health equity is a
fine goal, and social determinants are fine principles of action, but what if
the central government seems unwilling to act, or unable, given Washington
deadlock? I point to the action at local level. Not just in the UK, but in the
US, too. Come to Lexington Kentucky, I am urged, come to Baltimore,
come to Los Angeles, and see what we are doing. We need central
government, of course, but we also need action where people are born,
grow, live, work and age – at local level.
‘We offer our patients up to one hundred different programmes. In the same
community centre where the general practice is located we have language
classes, occupation skills, how to do a job interview, a children’s centre,
counselling, and so many more,’ said Sam Everington, a GP from Bromley-
by-Bow in East London.

‘But that’s not your job,’ said the BBC interviewer. ‘Surely you are
supposed to treat sick people, not teach them how to be more employable.’
But if people can’t get a job, how can their health improve?
Building on inspiring examples, such as Bromley-by-Bow, not to
mention the fire fighters, it seemed reasonable to ask what doctors and other
health professionals can do on social determinants of health. It is not quite
as obvious as it sounds. Doctors treat sick people, they don’t address child
poverty or fear of crime. If, as I have been arguing, the key determinants of
health lie outside the health-care system, is there a role for doctors and
other health professionals in promoting health equity, apart, that is, from
their vital role of treating the sick? It is certainly the question put to me by
the doctors at the British Medical Association when I spent time there.
Working with Vivienne Nathanson at the BMA, and my colleagues at the
UCL Institute of Health Equity, we produced a report on what doctors and
others could do on social determinants of health.3 We grouped
recommendations under five headings: education and training – make sure
medical students and doctors understand the insights on social determinants
of health; seeing the patient in a wider context – don’t treat illness in the
homeless, for example, without trying to deal with their homelessness; the
health service as employer – ensure good conditions of work for health
service employees; working with others – Bromley-by-Bow illustrated the
importance of cross-sector working, as did the fire fighters; advocacy –
doctors and other health professionals advocating for policies that would
improve conditions for their patients.
Empty words? Nice document, but . . . ? Emphatically not. We got
commitments from twenty-two medical and health-care organisations:
medical Royal Colleges, nurses, midwives, physiotherapists, more or less
everyone we approached embraced these ideas. More, they worked to
incorporate practice on social determinants of health into the day jobs of
their professional groups.
Advocacy is central. I ask the doctors: who cares more about health than
we do? We should therefore be concerned about the causes of health
inequity. Remember the words of Rudolf Virchow, the great nineteenth-
century pathologist: physicians are the natural attorneys of the poor. In
Moldova, doctors told us that they are anti-poverty campaigners, so clear is
the link between poverty and ill-health.

As with the BMA, I have the same compact with the World Medical
Association: they agree to get doctors active on social determinants of
health, and I agree to stand for election as President. They did, and I did. I
appealed to doctors’ finer instincts. Remember why we went into medicine?
I asked representatives of medical associations from round the world. If any
of us have forgotten, we should spend time with today’s medical students
and imbibe their enthusiasm for changing the world to reduce avoidable
inequalities in health. We have at least a dozen National Medical
Associations, with the Canadians and British in the lead, exploring with us
what doctors can do on the social determinants of health. The first twelve
are the hardest. Doctors, too, are joining the global movement.
THE TRIANGLE THAT MOVES THE MOUNTAIN
We are on the move. The five vignettes that I have just touched on illustrate
the Triangle that Moves the Mountain. We need governments to be
involved – local, national and global. We need people to be involved. The
‘people’ include civil society groups. The West Midlands fire fighters,
employees of local government, had in effect become a civil society group,
representing and serving their local population. Yes, and we need health
professionals. And we need knowledge, involvement of academics and
experts. The review of social determinants of health for a socially
sustainable Malmö, for example, involved academics who reviewed the
evidence, as well as politicians and representatives of the city population.
The evidence in this book builds on the scores, no hundreds, of experts who
contributed their knowledge to the syntheses of evidence that were the
bases of my three reports, Closing the Gap in a Generation, Fair Society,
Healthy Lives and the European Review of Social Determinants and the
Health Divide.
I am excited and embarrassed. Excited, because at the start of the
Commission on Social Determinants of Health, we said we wanted to foster
a social movement. That movement is alive and well. To the vignettes from
New Zealand, Sweden and England, I could add Brazil, Chile, Costa Rica,
Cuba, Canada, various US cities, Slovenia, Italy, Peru, Colombia, South
Africa, Norway, Denmark, Finland, Iceland, Egypt, Taiwan . . . and many
more.

Embarrassed, because my vignettes make it sound like I am driving it –
changing the world one flight at a time. I have been not so much driving it
as being the advocate, but it is taking off. We have a movement. As one of
the members of the WHO Commission on Social Determinants of Health
said, quoting Harry Truman I think: it’s amazing what you can achieve if
you don’t care who gets the credit. People are claiming their own insight
into the effect of society on health – a good development.
The report of the global commission was taken to the World Health
Assembly, initially by the Nordic countries and Brazil. When it was
debated, representatives from thirty-eight countries spoke supporting the
recommendations of Closing the Gap in a Generation. All over the globe I
am hearing the language of social determinants of health and health equity.
When the UN Secretary-General used the language of Closing the Gap –
the conditions in which people are born, grow, live, work and age – at
Ecosoc, the Economic and Social Council of the UN in 2009, I asked the
Chair of Ecosoc if Mr Moon knew he was quoting from our report. Her
response: that language is out there.
Parenthetically, I thanked representatives of the Nordic countries and
Brazil for taking the initiative in supporting the recommendations of
Closing the Gap. Their response: we are not doing it for you; we are doing
it for the cause of a more just distribution of health in the world.
I am excited.
A BBC journalist who chaired a BBC Festival of Ideas at which I spoke
said:
‘You’re a professional optimist, aren’t you?’
‘Of course,’ I told him. ‘There are a hundred and ninety-four member
states of the World Health Organization. Suppose only twenty countries had
taken seriously Closing the Gap in a Generation. I wouldn’t be saying on
the BBC that a hundred and seventy-four countries were ignoring us. I
would say that perhaps next week there will be twenty-two countries, and
the month after that thirty. We are on the move. In fact, depending how you
count, many more than twenty countries are acknowledging the importance
of social determinants of health.’
‘What about the global level?’ he asked.
In Closing the Gap in a Generation one of our recommendations was that
there be a global meeting where all countries report on progress on social
determinants of health and health equity. Be careful what you wish for.

When our report was discussed at the World Health Assembly, the
governing body of the World Health Organization (WHO), Brazil, said, in
effect: great idea! We’ll host the global meeting. The government of Brazil
has put arrangements in place for it.
It happened. In October 2011, the First World Conference on Social
Determinants of Health was held in Rio de Janeiro, hosted by the Brazilian
government and organised by WHO. More than 120 countries were
represented, with more than sixty ministers of health. I know, you cynics,
you are thinking what minister would not want a trip to Rio. The fact is that
it happened. To be sure, it was not perfect. Not all the ministers who
attended had a keen understanding of social determinants of health. Some
could not wean themselves away from talking about medical care. Medical
care is of vital importance, but this meeting was about social determinants
of health.
It is so remarkable, that I’ll say it a third time: it happened. It is
remarkable because global health meetings have either been about control
of specific diseases – malaria, tuberculosis, AIDS, non-communicable
diseases – or about health systems. Here was a third strand to global health:
social determinants of health. We didn’t talk only about vaccination and bed
nets, about tobacco and alcohol, important as they are. We talked of
empowerment of women, of early child development and education, of
employment and work, of income and poverty. As one colleague after
another came up to me and said this could not have happened five years
ago, symbolically, we rubbed our eyes.
As with all international meetings, there was some low politics, and even
some high politics, some laughable in its triviality, some more serious.
Among the more serious was the Rio Declaration that emerged from the
meeting. It was quite bland. The Commission on Social Determinants of
Health made a clear statement that inequities in power, money and
resources were driving inequities in conditions of daily life, which in turn
were responsible for health inequities. As the International Federation of
Medical Students’ Associations pointed out, inequities in power, money and
resources were airbrushed out of the Rio Declaration – too strong for some
ministerial stomachs. That said, there was passion, excitement and
encouragement among the representatives of government, civil society and
academics who took part. Governments, and others, declared their
commitment to act.

And act they have, with enthusiasm and moral fervour.
The moral commitment is important. I was introduced to the head of one
of the large global management consultancies. I sought his help, pro bono,
in implementing social determinants of health globally. I explained what we
were about. He listened.
‘Tell me, when you visit a country, urging take-up of your
recommendations, do you have resources to offer the country?’ he said.
‘No. No resources.’
‘Do you have a large cadre of trained personnel that can be sent in to
help?’ he continued.
‘No. Not really.’
‘What can you offer, then?’ was the next question.
‘The opportunity for a country’s leaders to improve the health and well-
being of all their citizens and to reduce unjust inequalities in health. In
short, to create a more just society.’
‘You really do need help!’ he said.
THE BEST OF TIMES, THE WORST OF TIMES
Back to excitement. In Chapter 1 I quoted Dickens. It is the best of times:
the evidence laid out in chapters 4–10 shows that we know what to do to
reduce inequities in health between and within countries. Many people –
governments, civil society organisations, health professionals, international
bodies, fire fighters (!) – are listening to that evidence and acting on it.
Perhaps the worst of times is too strong. There are, though, major
challenges to health equity, prominent among them increasing economic
and social inequalities and the lack of political response to them. Jean Drèze
and Amartya Sen entitled their latest book on India An Uncertain Glory. It
was a reflection that there are things both glorious and not so glorious about
India’s progress. They identify inequality in India as a cause of major
unsolved problems. They do not, however, think that it is well captured by a
simple measure of income inequality such as the Gini coefficient (in which
everyone’s income is ranked from lowest to highest, and a calculation made
of dispersion; if everyone had the same income the Gini would be 0; if one
person had all the income the Gini would be 1; the greater the inequality the
higher the Gini in the range 0 to 1). They write:

First, when the income levels of the poor are so low that they cannot afford even very basic
necessities, the gulf between their lives and those of the more prosperous has an intensity –
indeed an outrageousness – that aggregate inequality indicators cannot capture . . . Second,
measures of private incomes miss the role of public services, in such fields as education, health
care, social facilities and environmental support.4
Banerjee and Duflo, whose work on poverty we met earlier, write that, in
effect, the poor are being asked to bear too much responsibility. The richer
you are, the more things are done for you. You can depend on clean water,
get your daily vitamins from fortified breakfast cereals, assume that your
food is microbiologically safe, that the building you work in won’t collapse
and that pension plans will be arranged for you. Individual decisions about
how to organise all of these features of our lives would be difficult for
anyone, let alone the poor. Especially so, as the poor lack information.5 I
would add that these features follow the social gradient.
As with India, so with the world. Poverty in high-income countries may
not have the intensity of poverty in India, but we need to rediscover some of
our outrage. When in Britain, the fifth-richest county on the planet, nearly a
million people have to resort to food banks because they cannot afford to
feed their families, it is time to ask how we can do things differently.
Similarly, some outrage would not come amiss when we realise that young
men in the US have less chance of surviving to sixty than young men in
forty-nine other countries. There has been outrage, of course, on the streets
of Madrid and Athens among unemployed young people, and by the 99 per
cent in opposition to the 1 per cent. Such outrage needs to be channelled
into producing fairer societies.
As with India, so with the world, inequities in power, money and
resources are working against action to promote health equity. As one
example, a 2014 report from the OECD, the rich country club, shows that
income inequality increased in almost all OECD countries – Figure 11.1.
The most unequal of the rich countries is Mexico, followed by Turkey and
the US.6
For all the reasons reviewed earlier, and reprised by Drèze and Sen
(although they think that this Gini measure doesn’t adequately capture the
ill-effects on the poor), increases in income inequality will have an adverse
effect on living standards, and hence on the health of those lower down the
social scale. But won’t redistribution of income harm economic growth?
Don’t we hear, time and again, that setting the wealth producers free is good

for everyone? The OECD is unequivocal on what the evidence shows: the
greater the income inequality, the less the growth. Why? Because if the
poor have little money, they can’t buy things. Further, the OECD
emphasises that the negative effect on growth arises not just because of the
low purchasing power of the bottom 10 per cent, but of the bottom 40 per
cent. Of course, saying that we need to pay attention to the bottom 40 per
cent, not only to the very poorest, moves towards the gradient. Music to my
ears. Even were you concerned only with economic growth, greater equality
makes sense, but as I have tried to make plain, exorbitant inequality
damages our lives, and has impact on the social gradient in health. There
are strong moral and practical reasons to be concerned.
FIGURE 11.1: GINI COEFFICIENTS OF INCOME INEQUALITY, OECD COUNTRIES, MID-
1980S AND 2011/12
If we turn from income to wealth, again we see enormous inequalities.
According to the Economist, global wealth grew from $117 trillion in 2000
to $262 trillion in 2014.7 That comes to $56,000 for each adult on the
planet. But half the people in the world have less than $3,650 each; and the
richest 20 per cent have 94.5 per cent of all the wealth.
What the figures on income and wealth show is that there are oceans of
money sloshing about. It is not easy to maintain the fiction that we do not
have enough money to do good things. The problem is that, within
countries, the concentration of wealth is becoming more extreme. That was

the message of Piketty’s Capital in the Twenty-First Century. At the same
time as wealth concentration is increasing, all across Europe and the US we
are being lectured to on the dire importance of austerity. Public services
have to be cut back because . . . because . . . we cannot afford them?
John Maynard Keynes, immediately after the Second World War, wrote:
‘The day is not far off when the economic problem will take the back seat
where it belongs, and the arena of the heart and the head will be occupied or
reoccupied, by our real problems – the problems of life and of human
relations, of creation and behaviour and religion.’8 In country after country,
too much of our public conversation is about how we can grow national
income, too little about how we can improve society.
Keynes’s message is similar to that of Bobby Kennedy, with which I
began Chapter 10. To remind you, he called for going beyond Gross
National Product as a measure of progress and emphasising: ‘the health of
our children, the quality of their education or the joy of their play . . . the
beauty of our poetry or the strength of our marriages, the intelligence of our
public debate or the integrity of our public officials. . . our wit [and] our
courage . . . our wisdom [and] our learning . . . our compassion . . .’
These are all good things, but not all are so easily measurable. My simple
proposal is that health and health inequity are good measures of how we are
doing as a society. They are outcomes and they are indicators. By that I
mean that health and health equity are valued in themselves. Given the
choice, other things being equal, most of us would choose to live in a
society characterised by general good health.We value good health. As
indicators they form another function. I have argued through the book that
health and health equity tell us something more about the quality of the
society in which we live: perhaps not directly about the quality of our
poetry, or our wit and courage, to quote Bobby Kennedy, but certainly about
the quality of our education, our social life, our institutions. Get those right,
and not only will health flourish, we are likely to reduce crime, and have a
better-functioning society.
MOVING FORWARD
Based on its health record, there are grounds to be concerned about US
society. Joseph Stiglitz, who I quoted on inequality, is concerned that

increasing economic inequality in the US poses all sorts of burdens. No
other country should be complacent that it has it right. The problem is, says
Stiglitz, that we have been pursuing economic policy that benefits the 1 per
cent. Trickle-down economics is defunct and does not work. Time is
running out, but there are solutions. He lays out an economic reform agenda
that curbs excesses at the top and invests in the rest of the population.9
While I have not addressed economic policy directly, many of his
suggestions for social protection and investing in the population are entirely
consistent with my recommendations in earlier chapters in this book.
Policies to address inequities quickly move into the political realm. I
maintain the fiction that I am not political . . . and have been criticised for
it. A criticism I accept. For example, Vicente Navarro, of Johns Hopkins
and Barcelona, praised the report of the Commission on Social
Determinants of Health. He particularly liked our phrase: social injustice is
killing on a grand scale. But then he said: we know who the killers are –
name them and shame them.10
I offer two reasons for my ‘non-political’ position, in mitigation if it were
needed. First, a political level of analysis requires research all of its own.11
For example, Jacob Hacker, American political scientist, and his
collaborator Paul Pierson have written an excellent book on how the
growing inequality of income in the US can be accounted for by the
disproportionate political power of the very rich.12 I am delighted for others
to pursue analysis of the politics. Second, I want political parties of
whatever complexion to take on the agenda that I am promoting. We are
talking about creating societies that meet the needs and create the
opportunities for flourishing of all their members. That should not be the
province of one political party. At the global level, if the CSDH report
started to name and shame presidents and prime ministers we would not
have had representatives of thirty-eight countries praising it at the World
Health Assembly and support from Africa, India, China, the USA and many
European countries.
Politics quickly departs from evidence into the realm of ideology. As I
said right at the beginning, I do have an ideology: inequalities in health that
are avoidable by reasonable means, and are not avoided, are unjust,
inequitable. But the evidence must be a key part of the conversation. We
know that ideology shapes views of the evidence, but that is not a reason to
stop arguing from the evidence and simply surrender to prejudice. If

someone ‘believes’ that the poor of India brought their ill-health on
themselves, we need to show the evidence to the contrary. My own view is
that the truth will win out against prejudice, eventually – and I would
support that view with evidence.
I am not sure how, politically, you get from here to there. But I am sure
that knowledge is an important part of the process. In case you thought that
the political leaders in your country, whichever that is, are uniquely
‘economical with the truth’, here is George Orwell: ‘In our time, political
speech and writing are largely the defence of the indefensible.’13 Or go
further back and listen to Dickens’s savage mockery of political leaders in
Victorian times.
Routinely, in surveys of who the public trusts on scientific issues,
politicians vie with journalists for the bottom rank. That gives me faith in
democracy. The public can tell when they are being lied to. But we need to
be informed. For example, in Britain in 2015 an economic recovery is being
trumpeted. We are the envy of the rich world, we are told. The actual
figures are in Figure 11.2. Real wages in 2013 in the UK were 7 per cent
lower than they were in 2007 – the worst performance of any of the rich
countries. Is there not something of a gap between the rhetoric and the
reality?
As a member of the general public, perhaps you are not given to looking
at reports from the International Labour Office, but you know that your
living standards have declined simply by doing the family shopping and
paying your energy bills.
In Britain, where there is a tradition of respect for evidence, data tend to
be used as weapons in political debate rather than for reasoned argument. If
one set of figures don’t make your political case, chose another. ‘Lies, damn
lies, and statistics’ has a long history.
FIGURE 11.2: AVERAGE REAL WAGE INDEX FOR DEVELOPED G20 COUNTRIES, 2007–13

A major reason for writing this book is to share knowledge on how the
working of society impacts on health and the unjust distribution of health
and what we can do about it.
One senior Conservative politician in Britain put it to me that my agenda
is closer to social democratic than to Conservative thinking. I have tried
studiously in public, and in this book, to make my case on the evidence, not
on prior political beliefs. My response to this politician was that avoidable
health inequality, health inequity, was the deepest injustice in our society.
Was he saying that only social democratic politicians cared? I hoped not.
Further, showing that politicians distort the evidence to suit their political
ends was not a party-political act; it should be aimed at all our political
leaders whatever their makeup. No political party has a monopoly on
purveying misleading information.
A PLANET-SHAPED HOLE
It is tempting to want to try to write about everything. Tempting but
foolhardy. I have written this book about what I know and what I have been
doing in research and policy. I am aware of a big hole here. Environment
has made only fleeting appearances, and climate change stands out for
having gone missing. The planet-shaped hole is the book that needs to be
written on bringing the environmental and social determinants of health
agendas together.
Sustainable development has taught us the importance of equity between
generations as well as within. And I would argue that discussions on

preserving the planet must take equity within this generation into account –
within and between countries. For example, congestion charging – charging
you if you drive your car into the central city – is a good ‘green’ tax. But
like all consumption taxes it tends to be regressive, in that it takes a higher
proportion of a poor person’s income than of a rich person’s. I have raised
this in environmental circles and been told: don’t spoil a perfectly good tax
by worrying about equity. I am tempted to retort: don’t damage equity with
your perfectly good taxes. We need to bring the environmental and health
equity agendas together.
Similarly, as low-income countries develop, their use of carbon increases.
Carbon trading can be seen as a way for rich countries to buy the rights of
poor countries to pump out carbon dioxide. It has the effect of allowing
people in rich countries to enjoy their lifestyles and hindering the economic
development of low-income countries – a deep social injustice. We need to
bring the environmental and health equity agendas together.
After all, sustainable development means a balance of the three pillars:
economic, social and environmental. These three pillars are vital for health
equity. Attending both to climate change and to health equity requires
acting on evidence to produce the kind of society we want – one that meets
the needs of the present generation without hazarding the lives of future
generations.
ACROSS THE SPECTRUM FROM LOW- TO HIGH-INCOME
COUNTRIES
I have argued that disempowerment, material, psychosocial and political,
damages health and creates heath inequities. Such disempowerment may
take different forms in low-, middle- and high-income countries. But the
general approach to promoting a just distribution of health is similar. When
we conducted the European Review of Social Determinants and the Health
Divide we were concerned with countries from Central Asia to Scandinavia.
We said that there was something for everyone in our recommendations. If
you are in a country with poorly developed social systems, do something. It
will make a difference. If your country is on the way, do more. And if you
are in the Nordic countries, do it better.
Do something. Do more. Do it better.

Notes
INTRODUCTION
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2 Gordon T. Further mortality experience among Japanese Americans. Public Health Report. 1967;
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3 Committee on Medical Aspects of Food Policy. Nutritional Aspects of Cardiovascular Disease.
London: HMSO, 1994. 1–186.
4 Nichaman MZ, Hamilton HB, Kagan A, Sacks S, Greer T, Syme SL. Epidemiologic studies of
coronary heart disease and stroke in Japanese men living in Japan, Hawaii and California:
distribution of biochemical risk factors. American Journal of Epidemiology. 1975; 102: 491–501;
Yano K, Rhoads GG, Kagan A, Tillotson J. Dietary intake and the risk of coronary heart disease
in Japanese men living in Hawaii. American Journal of Clinical Nutrition. 1978; 31: 1270–9.
5 Matsumoto YS. Social stress and coronary heart disease in Japan: a hypothesis. Milbank
MemFund Qtly. 1970; 48: 9–36.
6 Marmot MG, Syme SL. Acculturation and CHD in Japanese-Americans. American Journal of
Epidemiology. 1976; 104: 225–47.
7 Marmot MG, Shipley MJ, Rose G. Inequalities in death – specific explanations of a general
pattern? Lancet. 1984; 1(8384): 1003–6.
8 Syme SL, Berkman LF. Social class, susceptibility, and sickness. American Journal of
Epidemiology. 1976; 104: 1–8.
9 Navarro V. Medicine under Capitalism. Croom Helm, 1976.
10 Van Rossum CTM, Shipley MJ, Van de Mheen H, Grobbee DE, Marmot MG. Employment grade
differences in cause specific mortality. A 25 year follow up of civil servants from the first
Whitehall study. Journal of Epidemiology and Community Health. 2000; 54(3): 178–84.
11 Karasek R, Theorell T. Healthy Work: Stress, Productivity, and the Reconstruction of Working
Life. New York: Basic Books, 1990.
12 Marmot M. Status Syndrome: How Your Social Standing Directly Affects Your Health and Life
Expectancy. London: Bloomsbury Publishing, 2004.
13 Rose D, O’Brien K. Constructing Classes: Towards a New Social Classification for the UK.
Swindon: ESRC, 1997.
14 Marmot M, Bosma H, Hemingway H, Brunner E, Stansfeld S. Contribution of job control to
social gradient in coronary heart disease [authors’ response letter]. Whitehall II Study. Lancet.
997; 350: 1405.
15 Marmot Review Team. Fair Society, Healthy Lives: Strategic Review of Health Inequalities in
England Post 2010. London: Marmot Review, 2010.
16 The Price of Being Well. The Economist. 28 Aug 2008.

17 Navarro V. What we mean by social determinants of health. Global Health Promotion. 2009;
16(1): 5–16.
1 THE ORGANISATION OF MISERY
1 Deaton A. The Great Escape: Health, Wealth, and the Origins of Inequality. Princeton: Princeton
University Press, 2013.
2 Yellen JL. Perspectives on Inequality and Opportunity from the Survey of Consumer Finances:
Federal Reserve; 2014 [22/12/2014]. Available from:
http://www.federalreserve.gov/newsevents/speech/yellen20141017a.htm.
3 Hutton W. Banking is changing, slowly, but its culture is still corrupt. The Guardian,
2014 [updated 16/11/2014]. Available from:
http://www.theguardian.com/commentisfree/2014/nov/16/banking-changing-slowly-but-culture-
still-corrupt.
4 Commission on the Social Determinants of Health. Closing the Gap in a Generation: Health
Equity through Action on the Social Determinants of Health. Final Report of the Commission on
Social Determinants of Health. Geneva: World Health Organization, 2008.
5 Hanlon P, Walsh A, Whyte B. Let Glasgow Flourish. Glasgow: 2006.
6 Ibid.
7 Scottish Public Health Observatory. Comparative Health Profiles 2010. Available from:
www.scotpho.org.uk/home/Comparativehealth/Profiles/2010CHPProfiles.asp.
8 City of Westminster. Area Profiles 2013 [15/09/2013]. Available from:
http://www.westminster.gov.uk/services/councilgovernmentanddemocracy/ward-profiles/.
9 Marmot Review Team. Fair Society, Healthy Lives: Strategic Review of Health Inequalities in
England post-2010. London: Marmot Review, 2010.
10 Marmot M. Status Syndrome How Your Social Standing Directly Affects Your Health and Life
Expectancy. London: Bloomsbury, 2004.
11 London Health Observatory. Health inequalities overview 2012 [updated 13/02/2012,
22/12/2014]. Available from:
http://www.lho.org.uk/LHO_Topics/National_Lead_Areas/HealthInequalitiesOverview.aspx.
12 Peter Mandelson quoted by Michael White. The Guardian. 26 January 2012.
13 Marmot Review Team. Fair Society, Healthy Lives.
14 Gwatkin DR. Socio-economic Differences in Health, Nutrition and Population within Developing
Countries: an Overview. Washington: World Bank, 2007.
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13 Marmot et al. Health inequalities; Bosma et al. Low job control.
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20 Wilkinson RG, Pickett K. The Spirit Level: Why More Equal Societies Almost Always Do Better.
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21 Lewis M. The Big Short: Inside the Doomsday Machine. London: Allen Lane, 2011.
22 Hampshire S. Justice Is Conflict. Princeton NJ: Princeton University Press, 2000.
23 New Policy Institute, MacInnes T, Aldridge H, Bushe S, Kenway P, Tinson A. Monitoring
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24 Hacker J, Pierson P. Winner-Take-All Politics. New York: Simon and Schuster, 2010.
25 Park A, National Centre for Social Research. British Social Attitudes: the 25th Report. Los
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26 Hutton W. Them and Us: Changing Britain – Why We Need a Fairer Society. London: Abacus,
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27 Bell R, Britton A, Brunner E, Chandola T, Ferrie J, Harris M, et al. Work, Stress and Health: The
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http://stats.oecd.org/Index.aspx?DataSetCode=IDD

28 Kelly Y, Sacker A, Del BE, Francesconi M, Marmot M. What role for the home learning
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29 Mullainathan S, Shafir E. Scarcity: Why Having Too Little Means So Much. New York: Times
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30 Blinder AS. What’s the Matter with Economics? New York Review of Books. 2014; December 18:
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31 Marmot M. A continued affair with science and judgements. International Journal of
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32 Various. Fair Society, Healthy Lives Reviews. Social Science & Medicine. 2010; 71(7).
33 Marmot M. Status Syndrome: How Your Social Standing Directly Affects Your Health and Life
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5 Hertzman and Boyce. How experience gets under the skin.
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9 Norman RE, Byambaa M, De R, Butchart A, Scott J, Vos T. The long-term health consequences
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21 Pinker. The Blank Slate.
22 Hertzman and Boyce. How experience gets under the skin.
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3 Stiglitz JE. Globalization and its Discontents. London: Allen Lane, 2002.
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6 Murphy SL, Xu JQ, Kochanek KD. Deaths: Final Data for 2010. National Vital Statistics
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7 Olshansky SJ, Antonucci T, Berkman L, Binstock RH, Boersch-Supan A, Cacioppo JT, et al.
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9 UCL Institute of Health Equity. Health Inequalities in the EU – Final Report of a Consortium.
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10 Demographic and Health Surveys 2011. Available from: www.measuredhs.com/countries.
11 Drèze and Sen. An Uncertain Glory.
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17 Ibid.
6 WORKING TO LIVE
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2 Growing Inclusive Markets, UNDP. Case Study: India. Sulabh International: A Movement to
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3 Franco G. Ramazzini and workers’ health. Lancet. 1999; 354(9181): 858–61.
4 Ibid.
5 Eurofound. Fifth European Working Conditions Survey. Luxembourg: Publications Office of the
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6 Ibid.
7 Butler S. Bangladesh garment workers still vulnerable a year after Rana Plaza. The Guardian. 24
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8 International Labour Organisation. ILO Introductory Report: Global Trends and Challenges on
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9 Marmot MG, Rose G, Shipley M, Hamilton PJS. Employment grade and coronary heart disease
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10 Marmot MG, Davey Smith G, Stansfeld SA, Patel C, North F, Head J, et al. Health inequalities
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11 Bosma H, Peter R, Siegrist J, Marmot MG. Two alternative job stress models and the risk of
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12 Head J, Ferrie JE, Brunner E, Marmot M, Rydstedt L, Stansfeld S, et al. The Potential Impact on
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13 Kivimaki M, Ferrie JE, Brunner EJ, Head J, Shipley MJ, Vahtera J, et al. Justice at work and
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14 Steptoe A, Kivimaki M. Stress and cardiovascular disease: an update on current knowledge.
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15 Siegrist J, Rosskam E, Leka S. Report of task group 2: Employment and working conditions
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17 Steptoe and Kivimaki. Stress and cardiovascular disease.
18 Beveridge W. Social Insurance and Allied Services. London: HMSO, 1942.
19 New Policy Institute, MacInnes T, Aldridge H, Bushe S, Kenway P, Tinson A. Monitoring
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20 OECD. Growing Unequal? Income Distribution and Poverty in OECD Countries. OECD, 2008.
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23 Hansard. HC 6Ser vol 191 col 413 (16 May 1991). 1991.
24 Moser K, Godblatt P, Fox J. Unemployment and Mortality. Longitudinal Study. London: HMSO,
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25 The HAPIEE study, UCL, 1999–2005.
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27 Siegrist J, Rosskam E, Leka S. Report of task group 2: Employment and working conditions
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28 Ibid.
29 Lewis M. The Big Short: Inside the Doomsday Machine. London: Allen Lane, 2011.
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32 International Monetary Fund. World Economic Outlook October 2012: Coping with High Debt
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33 UCL Institute of Health Equity. Reducing the Number of Young People Not in Employment,
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34 Wolfe T. The Bonfire of the Vanities. London: Vintage Books, 1987.
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27 Banks et al. Retirement, Health and Relationships.
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2 Chandler MJ, Lalonde CE. Cultural Continuity as a Moderator of Suicide Risk among Canada’s
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3 Ibid.
4 Hummingbird L. The public health crisis of native American youth suicide. NASN School Nurse.
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5 Spirits C. Aboriginal suicide rates 2014 [26/06/2014]. Available from:
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12 Florence C, Shepherd J, Brennan I, Simon T. Effectiveness of anonymised information sharing
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18 Hawkins JD, Oesterle S, Brown EC, Abbott RD, Catalano R. Youth Problem Behaviors 8 Years
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25 Ibid.
26 Creative Spirits. Michael Anderson: Can an Aboriginal school break the vicious circle?
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vicious-circle.
27 Creative Spirits. Aboriginal law & justice 2013 [25/06/2014]. Available from:
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28 Marmot Review Team. Fair Society, Healthy Lives.
29 University of Sydney. Dr Charles Nelson Perrurle Perkins AO, Arrernte and Kalkadoon Man.
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30 Lane J. Indigenous Participation in University Education. No. 110, 27 May 2009. The Centre for
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31 Australian Government Department of Social Services. Local Implementation Plans, Gunbalanya
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32 Anderson HR, Vallance P, Bland JM, Nohl F, Ebrahim S. Prospective study of mortality
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33 Global Alliance for Clean Cookstoves. The Issues 2014 [25/06/2014]. Available from:
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34 Marmot Review Team. Fair Society, Healthy Lives.
35 Clark LP, Millet DB, Marshall JD. National Patterns in Environmental Injustice and Inequality:
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36 White MP, Alcock I, Wheeler BW, Depledge MH. Would you be happier living in a greener
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37 University of Exeter. Green spaces deliver lasting mental health benefits 2014 [25/06/2014].
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38 Mitchell R, Popham F. Effect of exposure to natural environment on health inequalities: an
observational population study. Lancet. 2008; 372(9650): 1655–60.
39 Bird D. Government advisors demand urgent shift in public investment to green England’s cities.
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41 City of Copenhagen. The Bicycle Account 2013 [30/06/2014]. Available from:
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42 Jones SJ, Lyons RA, John A, Palmer SR. Traffic calming policy can reduce inequalities in child
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43 World Health Organization. Global Age-Friendly Cities: a Guide. Geneva: WHO, 2007.

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44 Kjellstrom T. Our cities, our health, our future. Acting on social determinants for health equity in
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9 FAIR SOCIETIES
1 Judt T. Ill Fares the Land. London: Penguin Books, 2011.
2 Bajak F. Chile–Haiti Earthquake Comparison: Chile Was More Prepared. Huffington Post. 2011.
3 Ibid.
4 Banks J, Marmot M, Oldfield Z, Smith JP. Disease and disadvantage in the United States and
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5 Woolf SH, Aron L, editors. U.S. Health in International Perspective: Shorter Lives, Poorer
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6 Drèze J, Sen A. An Uncertain Glory: India and Its Contradictions. London: Allen Lane, 2013.
7 Marmot M, Allen J, Bell R, Bloomer E, Goldblatt P. WHO European review of social
determinants of health and the health divide. Lancet. 2012; 380(9846): 1011–29.
8 Marmot M, Bell R. Japanese Longevity Revisited. Journal of the National Institute of Public
Health. 2007; 56(2).
9 Cook HJ, Bhattacharya S, Hardy A, editors. History of the Social Determinants of Health: Global
Histories, Contemporary Debates (New Perspectives in South Asian History). India: Orient
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10 Drèze and Sen. An Uncertain Glory, p. 39.
11 OECD. Health at a Glance: Suicide mortality rates, 2011 (or nearest year) 2013 [28/10/2014].
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12 Lundberg O, Aberg Yngwe M, Kolegard Stjarne M, Bjork L, Fritzell J. The Nordic Experience:
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13 Woolf SH, Aron L, editors. U.S. Health in International Perspective: Shorter Lives, Poorer
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14 Stiglitz J. The Price of Inequality. New York: Penguin, 2013.
15 Piketty T. Capital in the Twenty-First Century. Cambridge, MA: Harvard University Press, 2014.
16 Vardi N. The 25 Highest-Earning Hedge Fund Managers and Traders. Forbes. 2014.
17 Ostry JD, Berg A, Tsangarides CG. IMF Staff Discussion Note: Redistribution, Inequality, and
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18 Sen A. Inequality Reexamined. Oxford: Oxford University Press, 1992.
19 Dahl E, van der Wel KA. Educational inequalities in health in European welfare states: a social
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20 Santos LMP, Paes-Sousa R, Miazagi E, Silva TF, Mederios da Fonseca AM. The Brazilian
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21 Barber SL, Gertler PJ. The impact of Mexico’s conditional cash transfer programme,
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22 Baird S, Ferreira FHG, Ozler B, Woolcock M. Relative Effectiveness of Conditional and
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23 Mahapatra L. Consumer Spending: How much of their income do poor and rich American
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24 Rutter J, Stocker K. Childcare Costs Survey 2014. Family and Childcare Trust, 2014.
25 Ferguson D. The costs of childcare: how Britain compares with Sweden. The Guardian. 31 May
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26 Mackenbach JP. The persistence of health inequalities in modern welfare states: The explanation
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27 Wilkinson RG, Pickett K. The Spirit Level: Why More Equal Societies Almost Always Do Better.
London: Allen Lane, 2009.
28 Marmot MG, Sapolsky R. Of Baboons and Men: Social Circumstances, Biology, and the Social
Gradient in Health. In: Weinstein M, Lane MA, editors. Sociality, Hierarchy, Health:
Comparative Biodemography: A Collection of Papers. Washington DC: National Academies
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10 LIVING FAIRLY IN THE WORLD
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4 Stuckler D, Basu S. The Body Economic: Why Austerity Kills. New York: Basic Books, 2013.
5 Eyraud L, Weber A. The Challenge of Debt Reduction during Fiscal Consolidation. IMF
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6 Wren-Lewis S. Mainly Macro [Internet] 2013. Available from:
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7 Nelson F. In graphs: How George Osborne learned to stop worrying and love the debt: The
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8 Lewis M. The Big Short: Inside the Doomsday Machine. London: Allen Lane, 2011.
9 Stuckler and Basu. The Body Economic.
10 Karanikolos M, Mladovsky P, Cylus J, Thomson S, Basu S, Stuckler D, et al. Financial crisis,
austerity, and health in Europe. Lancet. 2013; 381(9874): 1323–31.
11 Ibid.
12 Ottersen OP, Dasgupta J, Blouin C, Buss P, Chongsuvivatwong V, Frenk J, et al. The political
origins of health inequity: prospects for change. Lancet. 2014; 383(9917): 630–67.
13 Ibid.
14 Stuckler and Basu. The Body Economic.

http://mainlymacro.blogspot.co.uk/2013/12/osbornes-plan-b.html

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15 World Social Protection Report 2014/15. Building Economic Recovery, Inclusive Development
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16 Drèze J, Sen A. An Uncertain Glory: India and Its Contradictions. London: Allen Lane, 2013.
17 UNDP. Human Development Report 2013 – The Rise of the South: Human Progress in a Diverse
World. New York: United Nations Development Programme, 2013.
18 Ibid.
19 World Health Organization. World Health Statistics 2014. Geneva: WHO, 2014.
20 Drèze and Sen. An Uncertain Glory.
21 Ibid.
22 World Development Report 2006. Equity and Development. New York: World Bank/Oxford
University, 2005.
23 Laird L. India’s farmer suicides: are deaths linked to GM cotton? – in pictures: The Guardian,
2014 [updated 05/05/2014, 23/12/2014]. Available from: http://www.theguardian.com/global-
development/gallery/2014/may/05/india-cotton-suicides-farmer-deaths-gm-seeds.
24 Nagaraj K. Farmers’ Suicides in India: Magnitudes, Trends and Spatial Patterns. Madras
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25 Sastry P. U.S. agricultural subsidies and farmer suicide in India: Roosevelt Institute,
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26 Ibid.
27 United Nations Development Programme. Human Development Report 2005. International
Cooperation at a Crossroads: Aid, Trade and Security in an Unequal World. UNDP, 2005.
28 Hyder S. Women’s financial independence amongst female garments workers in Bangladesh:
Summary of research. Berkeley Law, 2012.
29 Ayres A. Bangladesh: Behemoth garment industry weathers the storm: Council on Foreign
Relations, 2014 [updated 20/06/2014, 23/12/2014]. Available from:
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30 Marmot M, Allen J, Bell R, Bloomer E, Goldblatt P. WHO European review of social
determinants of health and the health divide. Lancet. 2012; 380(9846): 1011–29.
31 Global Factors Task Group. Global Factors Task Group Final Report. 2014.
32 The 0.7% target: An in-depth look: Millennium Project, 2006 [23/12/2014]. Available from:
http://www.unmillenniumproject.org/press/07.htm.
33 Burkina Faso: Oxfam International, 2014 [23/12/2014]. Available from: http://oxf.am/HMZ.
34 Banerjee A, Duflo E. Poor Economics: A Radical Rethinking of the Way to Fight Global Poverty.
USA: Public Affairs, 2011.
35 Deaton A. The Great Escape: Health, Wealth, and the Origins of Inequality. Princeton: Princeton
University Press, 2013.
36 Ibid.
37 Ooms G, Hammonds R, Van Damme W. International Assistance from Europe for Global
Health: Searching for a Common Paradigm. 2012.
38 World Cancer Research Fund, American Institute for Cancer Research. Food, Nutrition, Physical
Activity, and the Prevention of Cancer: A Global Perspective. Washington, DC.: AICR, 2007.
39 El-Zanaty F, Way A. Egypt: Demographic and Health Survey. Cairo: Ministry of Health, 2009.
40 The Economist. Food companies: Food for thought 2012 [07/01/2015]. Available from:
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fight-against-flab-food-thought.

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http://www.rooseveltcampusnetwork.org/blog/us-agricultural-subsidies-and-farmer-suicide-india

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http://oxf.am/HMZ

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41 Ibid.
42 Monteiro CA, Moubarac JC, Cannon G, Ng SW, Popkin B. Ultra-processed products are
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43 Monteiro CA, Cannon G. The impact of transnational ‘big food’ companies on the South: a view
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44 Ottersen OP, Dasgupta J, Blouin C, Buss P, Chongsuvivatwong V, Frenk J, et al. The political
origins of health inequity: prospects for change. Lancet. 2014; 383(9917): 630–67.
45 Friedman TL. The World Is Flat: a Brief History of the Globalized World in the Twenty-First
Century. London: Allen Lane, 2005.
46 Kopetchny T. Centre for Global Development: Your Chance to Ask Nancy Birdsall About
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11 THE ORGANISATION OF HOPE
1 West Midlands Fire Service. Improving Lives to Save Lives. WMFS, 2014.
2 Commission for a Socially Sustainable Malmö. Commission for a Socially Sustainable Malmö,
Final Report 2013. Available from: http://www.malmo.se.
3 UCL Institute for Health Equity. Working for Health Equity: The Role of Health Professionals.
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4 Drèze J, Sen A. An Uncertain Glory: India and Its Contradictions. London: Allen Lane, 2013.
5 Banerjee A, Duflo E. Poor Economics: A Radical Rethinking of the Way to Fight Global Poverty.
USA: Public Affairs, 2011.
6 OECD. Focus on Inequality and Growth: Does income inequality hurt economic growth? 2014.
7 The Economist. Economist Espresso 24 December 2014. 2014.
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Acknowledgements
I have made clear, I hope, that the ideas, conclusions and recommendations
in this book were developed over years of collaboration. In my previous
book, Status Syndrome, I acknowledged the funding agencies in the UK,
Europe and the US that supported my research and all the people who had
contributed to my research and the ideas in that book. Those good
colleagues in helping shape my ideas were important contributors to what I
have done since. The big shift, however, was my involvement in reviews of
the evidence with a view to influencing policy and practice. Through all this
time I was supported by UCL, which provided an ideal working
environment, and the Medical Research Council, as an MRC Research
Professor.
In conducting these reviews I have been supported by a wonderful group
of colleagues at UCL, which went from being the UCL secretariat for the
WHO CSDH, to the Marmot Review team, to the UCL Institute of Health
Equity. Current members are: Jessica Allen, Angela Donkin, Ruth Bell,
Peter Goldblatt, Matilda Allen, Jillian Roberts, Dan Durcan, Luke Beswick,
Laura Grobicki, Sara Thomas, Patricia Hallam, Felicity Porritt, Elaine
Reinertsen. Past staff include: Ellen Bloomer, Mike Grady, Tammy Boyce,
Di McNeish, Ilaria Geddes, Alex Godoy, Ria Galeote. Without such
colleagues nothing would have got done.
Matilda Allen provided invaluable help with the book, initially with
research and references and then as a sensitive reader and commentator.
Jessica Allen read the book and provided wise comments as did Felicity
Porritt. I am so grateful for their input. I had a remarkable series of monthly
meetings with Rabbi Tony Bayfield. They began with my critiquing his
work in progress then shifted to his careful reading and comments on every
word of this book. He was a great reader to have. Bill Swainson, Senior
Editor at Bloomsbury, read the book twice and was extremely helpful. My
agent, Peter Robinson, was key in shaping the original proposal. During my
time at the British Medical Association, and at the World Medical

Association, I have benefited greatly from the collegiality and insights of
Vivienne Nathanson.
As will be seen below a vast number of people were involved in the
reviews on social determinants of health and health equity that I led. This
book is highly influenced by the evidence and conclusions of those reviews,
but is not a summary. The probability that each of the colleagues who
contributed so much to the reviews agrees with every one of my
interpretations and emphases is vanishingly small. It is my view of that
evidence, for which I take responsibility. That said, in our deliberations
over evidence in each of the reviews there was a high degree of consensus.
The first review, as described, was the WHO Commission on Social
Determinants of Health (CSDH), set up by the then Director-General of
WHO, J. W. Lee, and taken forward under his successor, Margaret Chan. I
am grateful to these two inspirational leaders of global health. The CSDH,
which I chaired, had a wonderful group of commissioners who contributed
individually and collectively to our report, Closing the Gap in a
Generation. The Commissioners were: Frances Baum, Monique Bégin,
Giovanni Berlinguer, Mirai Chatterjee, William H. Foege, Yan Guo,
Kiyoshi Kurokawa, Ricardo Lagos Escobar, Alireza Marandi, Pascoal
Mocumbi, Ndioro Ndiaye, Charity Kaluki Ngilu, Hoda Rashad, Amartya
Sen, David Satcher, Anna Tibaijuka, Denny Vågerö, Gail Wilensky.
To provide evidence on which we deliberated, the CSDH convened nine
knowledge networks, whose leaders were: Joan Benach, Josiane Bonnefoy,
Jane Doherty, Sarah Escorel, Lucy Gilson, Mario Hernández, Clyde
Hertzman, Lori Irwin, Heidi Johnston, Michael P Kelly, Tord Kjellstrom,
Ronald Labonté, Susan Mercado, Antony Morgan, Carles Muntaner,
Piroska Östlin, Jennie Popay, Laetitia Rispel, Vilma Santana, Ted
Schrecker, Gita Sen, Arjumand Siddiqi. In addition, we received valuable
input from the NEWS (Nordic Experience of the Welfare State) group led
by Olle Lundberg and Johann Fritzell.
The CSDH Secretariat included my close colleagues in the Chair’s office
at UCL: Ruth Bell, Sharon Friel, Tanja A. J. Houweling, Sebastian Taylor.
We worked closely with the secretariat at WHO: led by Jeanette Vega
(2004–2007) and Nick Drager (2008), and including Erik Blas, Chris
Brown, Hilary Brown, Alec Irwin, Rene Loewenson (consultant), Richard
Poe, Gabrielle Ross, Ritu Sadana, Sarah Simpson, Orielle Solar, Nicole
Valentine and Eugenio Raul Villar Montesinos; as well as, at various times,

Elmira Adenova, Daniel Albrecht, Lexi Bambas-Nolan, Ahmad Reza
Hosseinpoor, Theadora Koller, Lucy Mshana, Susanne Nakalembe,
Giorelley Niezen, Bongiwe Peguillan, Amit Prasad, Kumanan Rasanathan,
Kitt Rasmussen, Lina Reinders, Anand Sivasankara Kurup, Niko
Speybroeck and Michel Thieren. Whew! It took a huge team to synthesise
the world’s knowledge and organise a Commission that had ten meetings
and met governments in ten different countries during its three and a half
years of work.
In the wake of the Global Commission I was invited by Prime Minister
Gordon Brown to conduct a strategic review of health inequalities in
England. We published that report as Fair Society Healthy Lives, the
Marmot Review. The Commissioners were, as with the CSDH, a stellar
group: Tony Atkinson, John Bell, Carol Black, Patricia Broadfoot, Julia
Cumberlege, Ian Diamond, Ian Gilmore, Chris Ham, Molly Meacher, Geoff
Mulgan. The Marmot Review team at UCL was led by Jessica Allen. Team
members included Peter Goldblatt, Ruth Bell, Tammy Boyce, Di McNeish,
Mike Grady, Jason Strelitz, Ilaria Geddes, Sharon Friel, Felicity Porritt,
Elaine Reinertsen and Matilda Allen.
As with the CSDH, the Marmot Review was supported by Task Groups
and Working Committees who reviewed and synthesised evidence on the
review’s key areas. These groups involved: Sharon Friel, Denny Vagero,
Alan Dyson, Jane Tunstill, Clyde Hertzman, Ziba Vaghri, Helen Roberts,
Johannes Siegrist, Abigail McKnight, Joan Benach, Carles Muntaner, David
MacFarlane, Monste Vergara Duarte, Hans Weitkowitz, Gry Wester,
Howard Glennerster, Ruth Lister, Jonathan Bradshaw, Olle Lundberg, Kay
Withers, Jan Flaherty, Anne Power, Jonathan Davis, Paul Plant, Tord
Kjellstrom, Catalina Turcu, Helen Eveleigh, Jonathon Porritt, Anna Coote,
Paul Wilkinson, David Colin-Thomé, Maria Arnold, Helen Clarkson, Sue
Dibb, Jane Franklin, Tara Garnett, Jemima Jewell, Duncan Kay, Shivani
Reddy, Cathryn Tonne, Ben Tuxworth, James Woodcock, Peter Smith,
David Epstein, Marc Suhrcke, John Appleby, Adam Coutts, Demetris
Pillas, Carmen de Paz Nieves, Cristina Otano, Ron Labonté, Margaret
Whitehead, Mark Exworthy, Sue Richards, Don Matheson, Tim Doran, Sue
Povall, Anna Peckham, Emma Rowland, Helen Vieth, Amy Colori, Louis
Coiffait, Matthew Andrews, Anna Matheson, Lindsey Meyers, Alan
Maryon-Davis, John Doyle, Tim Lobstein, Angela Greatley, Mark Bellis,
Sally Greengross, Martin Wiseman, Paul Lincoln, Clare Bambra, Kerry

Joyce, David Piachaud, James Nazroo, Jennie Popay, Fran Bennett, Hillary
Graham, Bobbie Jacobson, Paul Johnstone, Ken Judge, Mike Kelly,
Catherine Law, John Newton, John Fox, Rashmi Shukla, Nicky Best, Ian
Plewis, Sue Atkinson, Tim Allen, Amanda Ariss, Antony Morgan, Paul
Fryers, Veena Raleigh, Gwyn Bevan, Hugh Markowe, Justine Fitzpatrick,
David Hunter, Gabriel Scally, Ruth Hussey, Tony Elson, Steve Weaver,
Jacky Chambers, Nick Hicks, Paul Dornan, Liam Hughes, Carol Tannahill,
Hari Sewell, Alison O’Sullivan, Chris Bentley, Caroline Briggs, Anne
McDonald, John Beer, Jim Hillage, Jenny Savage, Daniel Lucy, Klim
McPherson, Paul Johnson, Damien O’Flaherty, Matthew Bell.
I was invited by the Regional Director of WHO Europe, Dr Zsuzsanna
Jakab, to lead The European Review of Social Determinants and the Health
Divide. I had a group of senior advisors: Guillem Lopez, Zsuzsa Ferge,
Ilona Kickbusch, Johan Mackenbach, Tilek Meimanaliev, Amartya Sen,
Vladimir Starodubov, Tomris Turmen, Denny Vagero, Barbro Westerholm,
Margaret Whitehead, Ex-officio representatives of WHO, Roberto
Bertollini, Agis Tsouros, Erio Ziglio, and The European Commission,
Michael Hübel, Charles Price. The UCL Secretariat was led by Peter
Goldblatt and Jessica Allen and included Ruth Bell, Ellen Bloomer, Angela
Donkin, Ilaria Geddes, Mike Grady, David Bann, Sadie Boniface, Michael
Holmes, Akanksha Katyai, Anne Scott, Matilda Allen, Luke Beswick, Ria
Galeote and Alex Godoy. The WHO secretariat was led by Agis Tsouros,
with Johanna Hanefeld, Piroska Ostlin, Asa Nihlen, Chris Brown, Isabel
Yordi, Theadora Koller, Sarah Simpson, Erio Ziglio and Richard
Alderslade. Task group chairs/co-chairs: Alan Dyson, Naomi Eisenstadt,
Johannes Siegrist, Jennie Popay, Olle Lundberg, Anna Coote, Gauden
Galea, Witold Zatonski, Maria Kopp, Emily Grundy, Marc Suhrcke,
Richard Cookson, Harry Burns, Erio Ziglio, Ronald Labonte, Karien
Stronks, Martin Bobak, Claudia Stein.
If you have managed to get this far, I would like to make one more point.
I said we wanted to create a social movement for health equity. The good
colleagues above who have been part of compiling the evidence and
approaches that fed into our reviews, and hence this book, are part of that
social movement. The process has been immensely rewarding.
My family have lived this movement and these ideas over the decade
during which the reviews were conducted, and several decades before that.

Tolerant, loving, and contributing in all sorts of ways, they are the people to
whom I dedicate this book, with love.

Index
AARP, here
ACE study, here
active transport, here
African-Americans, here, here
age-friendly cities, here
ageing
and gender, here, here
global populations, here
and health behaviours, here
and income security, here
and political participation, here
and quality of life, here
and retirement, here
and social participation, here
Ageing in the Twenty-First Century, here
Ahmedabad, here, here, here, here, here, here
see also Self Employed Women’s Association (SEWA)
aid, here
air pollution, here, here, here, here
Aitsi-Selmi, Amina, here
alcohol use, here, here, here, here, here, here, here, here, here
and adverse childhood experience, here
and education, here
Iceland and, here
price of, here, here, here
and public policy, here, here
Russia and, here
and unemployment, here
Allen, Woody, here, here
Alzheimer’s, here
American Gynaecological and Obstetric Society, here
American Medical Association, here
Argentina, here, here, here
debt repayments, here
politics and economics, here
Aristotle, here
Armenia, here
Athenaeum Club, here
Atkinson, Sir Tony, here
Austen, Jane, here, here
austerity, here, here
Australia, and cigarette packaging, here

Australian aboriginals, here, here
Austria, here
autism, here
autonomic nervous system, here
baboons, here
Bachelet, Michelle, here, here
Baltimore, here, here, here, here, here, here, here, here, here
Balzac, Honoré de, here, here
Ban Ki-moon, here
Banerjee, Abhijit, here, here, here
Bangladesh, here, here
garment workers, here, here
improved child mortality, here
Barker, David, here
Becker, Gary, here
behavioural genetics, here
Beijing, here
Belgium, here
Bentham, Jeremy, here
Berkman, Lisa, here
Beveridge, William, here
bicycles, here
Birdsall, Nancy, here
Birmingham
and early child development, here
fire fighters, here
Björk, here
Blair, Tony, here
Blinder, Alan, here
Bobak, Martin, here
Body Mass Index, here, here
Bolivia, pension scheme, here
Botswana, here
Boyce, Tom, here
brain development, here
Brazil, here, here, here, here, here, here
and ageing population, here, here, here, here
and commission report, here
economic growth, here, here
breast screening, here
Britain, see United Kingdom
British birth cohort study, here
British Columbia, here, here, here
British Medical Association, here, here
British Medical Journal, here
British Social Attitudes Survey, here
British Virgin Islands, here
Bromley-by-Bow, here
Brown, Gordon, here

Bulgaria, here, here
Burns, Sir Harry, here
Cambodia, here
Cameron, David, here
Canada, here, here
aboriginal Canadians, here
Canadian Institute for Advanced Research, here
cancer risk, and diet, here
cancer survival rates, here
capital punishment, here
capitalism, here, here, here
patrimonial, here
carbon trading, here
Cardiff, here
Carnochan, DCS John, here, here
cash-transfer schemes, here, here, here
Castro, Fidel, here
Chandler, Michael, here
Chandola, Tarani, here
Chaplin, Charlie, here
chemotherapy, here
chess, here
child poverty, here
childbirth, here
childcare, here, here, here
childhood development
and adult health, here
and brain development, here
critical periods in, here, here
genetic and environmental factors in, here, here
improvements in Birmingham, here
measures of well-being, here
and parenting, here
social gradient in, here, here, here, here, here, here
and social mobility, here
and speech, here
children
obesity levels in, here, here
underweight, here
children’s centres, here
Chile, here, here, here, here
earthquake, here
life expectancy, here, here, here, here
China, here, here, here, here
education system, here, here, here
garment exports, here
life expectancy, here, here
cholesterol, here, here, here
Cicero, here, here

civil service, see Whitehall Studies
Clean Air Act (1956), here
climate change (global warming), here, here
Closing the Gap, here, here, here, here, here, here, here, here
Coca-Cola, here
‘coca-colonisation’, here
cocaine, here
Cochrane, John, here
cognitive function, here
Cohe, G. A., here
Colombia, here, here
Commission for Architecture and the Built Environment, here
Commission on Global Governance for Health, here, here
Commission on Macroeconomics and Health (CMH), here
Commission on Social Determinants of Health (CSDH), here, here, here, here, here, here, here, here,
here, here, here, here, here, here
see also Closing the Gap; European Review of Social Determinants and the Health Divide; Fair
Society, Healthy Lives
communism, and health outcomes, here
congestion charging, here
contraception, here, here
cooking stoves, here
Copenhagen, here
cortisol, here, here
Costa Rica, here, here
life expectancy, here, here, here, here, here, here
pre-school education, here
cotton farmers, here, here
Coubertin, Baron Pierre de, here
crèches, here
crime, here, here, here, here, here, here, here, here, here, here, here, here, here, here
fear of, here, here, here
see also delinquency; gangs
Cuba, here
life expectancy, here, here, here, here, here, here
pre-school education, here, here
cultural sensitivity, here
Czech Republic, here, here, here
Daily Mail, here
Daily Telegraph, here
Deaton, Angus, here
debt repayments, here, here
delinquency, here, here, here, here
dementia, here
democracy, and freedom, here
Democratic Republic of Congo, here
Denmark, here, here, here
social mobility, here, here
depression, here, here, here

deprivation, European measure of, here, here
development states, here
diabetes, here, here, here, here
and adverse childhood experience, here, here
in Australian aboriginals, here
Dickens, Charles, here, here, here, here, here, here
diet
and disease, here
Mediterranean, here
‘difference principle’, here
disability, and life expectancy, here
disempowerment, here, here, here, here
Dominican Republic, here, here, here
Dostoevsky, Fyodor, here
Drèze, Jean, here, here, here, here
drug regimens, adherence to, here
drug use, here, here, here, here, here, here
and adverse childhood experience, here
Duflo, Esther, here, here, here
Dylan, Bob, here
Easterly, William, here
Ebola, here
economic growth, here, here
economic inequality, see income inequalities
Economist, here, here, here
education
and cash-transfer schemes, here
and fertility rates, here
Finnish system,, here, here, here, here
gender equity in, here
and intimate partner violence, here
and life expectancy, here, here
and material deprivation, here
and measures of ill-health, here
pre-school, here, here, here, here
social gradient in, here
university education, here, here, here, here, here, here, here
women and secondary education, here
women and tertiary education, here
Egypt, obesity levels, here, here, here, here
Eisenhower, Dwight D., here
employment conditions, here
see also unemployment
empowerment, here, here, here, here, here, here, here, here, here, here, here, here, here, here, here,
here
and education, here
and health behaviours, here
political, here
and social participation, here

England, see United Kingdom
English Longitudinal Study of Ageing (ELSA), here, here
English Review, see Fair Society, Healthy Lives
epigenetics, here
equality of opportunity, here, here, here
Estonia, here, here
Ethiopia, here, here
European Central Bank, here, here, here
European Review of Social Determinants and the Health Divide, here, here, here, here, here, here
Evans, Robert, here
Evelyn, John, here
Everington, Sam, here
exercise, see physical activity
Experience Corps, here
Fair Society, Healthy Lives, here, here, here, here, here, here, here, here, here, here
fairness (definition), here
fecklessness, here, here, here, here
fertility rates, here
Financial Times, here
Finland, here, here, here, here
education system, here, here, here, here
gender equity in education, here
fire fighters, here, here, here
Fitzgerald, F. Scott, here
food banks, here
food corporations, here, here
Fox, John, here
Framework Convention on Tobacco Control (FCTC), here
France, here, here, here, here, here, here
free trade, here, here
freedom, here, here, here
Freud, Sigmund, here
Fried, Linda, here
Friedman, Milton, here
Friedman, Thomas, here
Galbraith, J. K., here
Gandhi, Mahatma, here, here
gangs, here, here
Gawande, Atul, here
GDP, measurement of, here
gender equity, move to, here
General Motors, here
Georgia, here
Gershwin, George, here
Glasgow, here, here, here, here, here, here, here
combating gang violence, here
life expectancy, here, here, here
mortality rates, here

Glass, Norman, here
Gleneagles Summit, here
Global Burden of Disease, here
global warming, see climate change
global wealth, increasing, here
Gnarr, Jon, here
Goldblatt, Peter, here
golf, here
Gordon, David, here, here, here, here
Gornall, Jonathan, here
Göteborg, here
Great Gatsby Curve, here
Greece, here, here
financial crisis and austerity, here, here, here, here
green space, here
grooming, in apes, here, here
Guardian, here
Guinea-Bissau, here, here
Gunbalanya, here, here, here
Hacker, Jacob, here, here
Haiti earthquake, here
Hampshire, Stuart, here, here
HAPIEE studies, here
ul Haq, Mahbub, here
Hayek, Friedrich von, here
health advice, here
health and safety regulations, here, here
health and well-being boards, here
health care systems, here
health inequities (definition), here
heart disease, here, here, here, here, here, here, here
abolition of, here
and adverse childhood experience, here, here
in Australian aboriginals, here
and civil servants, here, here, here
and exercise, here
and high status, here, here
and Japanese migrants, here
and job strain, here
Hertzman, Clyde, here, here
Heymann, Jody, here
high blood pressure, here, here, here
HIV/AIDS, here, here, here, here
homicide, here, here, here
Hong Kong, here, here
HPA axis, here
Human Development Index (HDI), here, here, here, here
Hungary, here, here, here
Hutton, Will, here

Huxley, Aldous, here
Hyder, Shaina, here
Iceland, here, here, here, here, here
ideology, here, here
income inequalities, here, here, here, here, here, here
India, here, here, here, here
average BMI, here
caste system and education, here
child mortality, here, here, here
cotton farmers, here
distrust of education system, here
income inequalities, here
life expectancy, here, here, here, here, here
literacy, here
scavengers, here, here, here, here
see also Kerala
infant mortality, here
inherited wealth, here
Institute of Economic Affairs, here
intergenerational earnings elasticity, here
International Federation of Medical Students’ Associations, here
International Labour Office (ILO), here, here, here, here
International Monetary Fund (IMF), here, here, here, here, here, here, here, here, here
and impact of structural adjustments, here
Ireland, here, here, here, here
Israel, here
Italy, here, here
fertility rate, here
maternal mortality, here
Jakab, Zsuzsana, here
Japan, here, here, here, here
life expectancy, here, here, here
and team commitment, here, here
Japanese-Americans, here, here
Jordan, here
Judt, Tony, here, here, here
Kahneman, Danny, here
Kalache, Alex, here, here
Karasek, Robert, here
Kelly, Yvonne, here
Kennedy, Robert, here, here, here
Kenya, here, here
Kerala, here, here
Keynes, John Maynard, here
Keynesian economics, here, here, here, here
Kibera slum, here

King’s Fund, here
Kivimaki, Mika, here
Kokiri Marae, here, here
Krueger, Alan, here
Krugman, Paul, here, here
Kuznets, Simon, here
Labonté, Ron, here
labour market flexibility, here
Lalonde, Christopher, here
Laos, here
latency effect, here
Lativa, here
Lee, J. W., here
Lewis, Michael, here
Lexington, Kentucky, here
libertarians, here, here
life expectancy, here, here, here, here
among Australian aboriginals, here
disability-free, here, here
and education, here, here, here, here
in former communist states, here
and mental health, here
and national income, here
US compared with Cuba, here
Lithuania, here, here, here
Liverpool, here, here, here
‘living wage’, here
loans, low-interest, here
lobbying, here
Los Angeles, here
‘lump of labour’ hypothesis, here
Lundberg, Ole, here
lung cancer, here, here
lung disease, here, here, here, here
luxury travel, here
Macao, here, here
McDonald’s, here
McMunn, Anne, here
Macoumbi, Pascoual, here
Madrid, indignados protests, here, here
Maimonides, here
malaria, here, here, here, here, here
Malawi, here
male adult mortality, here, here
Mali, here, here
Malmö, here, here
Malta, here
Manchester, here, here, here

Maoris, here, here, here, here
Marmot Review, see Fair Society, Healthy Lives
marriage, here
Marx, Karl, here
maternal mortality, here, here, here
maternity leave, paid, here
Matsumoto, Scott, here
Meaney, Michael, here
Medicaid, here
Mediterranean diet, here
Mengele, Joseph, here
mental health, here, here, here, here, here, here, here
and access to green space, here
and adverse childhood experience, here
and austerity, here
and fear of crime, here
and job insecurity, here
and unemployment, here
meritocracy, here
Mexico, here, here, here, here, here
education and cash transfers, here, here
Millennium Birth Cohort Study, here, here
Minimum Income for Healthy Living, here, here, here
Mitchell, Richard, here
Modern Times, here
Morris, Jerry, here, here
Moser, Kath, here
Mozambique, infant mortality, here
Mullainathan, Sendhil, here
Murphy, Kevin, here, here
Muscatelli, Anton, here
Mustard, Fraser, here
Mwana Mwende project, here
Nathanson, Vivienne, here
Native Americans, here
Navarro, Vicente, here
NEETs, here, here
neoliberalism, here, here, here, here, here
Nepal, here, here
Neruda, Pablo, here
Netherlands, here, here
New Guinea, here, here
NEWS group, here, here
Nietzsche, Friedrich, here, here
Niger, here
nitrogen dioxide, here, here
non-human primates, here
Nordic countries
and commission report, here

and social protection, here, here, here, here, here
see also individual countries
Norway, here, here, here, here, here, here
life expectancy and education, here, here
Nottingham, here
Nozick, Robert, here
obesity, here, here, here, here, here, here, here, here
in children, here, here
and diabetes, here
and disincentives, here
food corporations and, here
genetic and environmental factors in, here
and migrant studies, here
and rational choice theory, here
social gradient in, here, here, here, here
in women, here, here
Office of Budget Responsibility, here
Olympic Games, here
opera, here
Organisation for Economic Co-operation and Development (OECD), here, here, here, here, here,
here, here
organisational justice, here
Orwell, George, here
Osler, Sir William, here
Panorama, here
Papua New Guinea, here
‘paradox of thrift’, here
Paraguay, here, here, here
parenting, here, here, here, here
and work–life balance, here
pay, low, here
pensions, here, here, here, here
Perkins, Charlie, here
Peru, here, here, here
physical activity
and cognitive function, here
green space and, here
Pickett, Kate, here
Pierson, Paul, here, here
Piketty, Thomas, here, here, here, here
Pinker, Steven, here
Pinochet, General Augusto, here
PISA scores, here, here, here, here, here
Poland, here, here, here, here
Popham, Frank, here
Porgy and Bess, here
poverty, here, here, here, here, here, here, here
and aboriginal populations, here, here

absolute and relative, here, here
child poverty, here, here, here, here, here
and choice, here
and early childhood development, here, here
effect on cognitive function, here
and urban unrest, here
and work, here
Power, Chris, here
pregnancy, here
preventive health care, here
‘proportionate universalism’, here
puberty, and smoking here
public transport, here, here, here, here, here, here, here, here
Ramazzini, Bernardino, here
RAND Corporation, here, here, here
rational choice theory, here, here, here
rats, and brain development, here
Rawls, John, here, here
Reid, Donald, here
Reinhart, Carmen, here, here
reproduction, control over, here
retirement, here
reverse causation, here
Reykjavik Zoo, here
Rio de Janeiro, here, here
Rogoff, Kenneth, here, here
Rolling Stones, here
Romania, here
Romney, Mitt, here
Rose, Geoffrey, here
Roth, Philip, here
Royal College of Physicians, here
Royal Swedish Academy of Science, here
Russia, here, here, here
and alcohol use, here
life expectancy, here, here, here, here
Sachs, Jeffrey, here, here
St Andrews, here
San Diego, here
Sandel, Michael, here, here
Sapolsky, Robert, here
Scottish Health Survey, here
Seattle, here
Self Employed Women’s Association (SEWA), here, here, here, here
Sen, Amartya, here, here, here, here, here, here, here, here, here, here, here
and Jean Drèze, here, here, here, here
serotonin, here
sexuality, here, here

see also reproduction, control over
sexually transmitted infections, here, here
Shafir, Eldar, here
Shakespeare, William, here, here, here, here
Shanghai, here
Shaw, George Bernard, here, here
Shepherd, Jonathan, here
shootings, here
Siegrist, Johannes, here
Sierra Leone, here, here, here
Singapore, here, here
Slovakia, here
Slovenia, here, here
smallpox vaccinations, here
Smith, Adam, here
Smith, Jim, here
smoking, here, here, here, here, here, here, here, here
declining rates of, here, here
and education, here
and public policy, here
social gradient in, here, here
and tobacco companies, here
and unemployment, here
Snowdon, Christopher, here
social cohesion, here, here, here, here, here, here, here
social mobility, here, here
social protection, here
‘social rights’, here
Social Science and Medicine, here
Soundarya Cleaning Cooperative, here
South Korea, here, here, here, here
Spain, here, here, here
Spectator, here
sports sponsorship, here
Sri Lanka, here
Stafford, Mai, here
Steptoe, Andrew, here
Stiglitz, Joseph, here, here, here, here, here
stroke, here, here, here
structural adjustments, here, here
Stuckler, David, here
suicide, here, here, here, here, here
and aboriginal populations, here, here
and Indian cotton farmers, here
and unemployment, here, here
suicide, attempted, here
Sulabh International, here
Sun, here
Sure Start programme, here
Surinam, here

Sutton, Willie, here
Swansea, here
Sweden, here, here, here, here, here, here, here
life expectancy and education, here, here
male adult mortality, here, here
Swedish Commission on Equity in Health, here
Syme, Leonard, here, here, here
Taiwan, here, here
Tanzania, here
taxation, here
Thailand, here
Thatcher, Margaret, here
Theorell, Tores, here
tobacco companies, here
Topel Robert, here
Tottenham riots, here
Tower Hamlets, here, here
Townsend, Peter, here
trade unions, here, here, here, here
traffic calming measures, here
Tressell, Robert, here
‘Triangle that Moves the Mountain’, here, here
trickle-down economics, here, here
Truman, Harry S., here
tuberculosis, here, here, here, here
Tunisia, here
Turandot, here, here
Turkey, here, here
Uganda, here, here
unemployment, here, here, here, here, here, here, here
and mental health, here
and suicide, here, here
youth unemployment, here, here, here, here
UNICEF, here, here
United Kingdom
alcohol consumption, here
capital:income ratio, here
and child well-being, here
cost of childcare, here
and economic recovery, here, here
education system, here, here
disability-free life expectancy, here
founding of welfare state, here
health-care system, here
income inequalities, here, here
literacy levels, here
male adult mortality, here
PISA score, here

politics and economics, here
and poverty in work, here, here
poverty levels, here, here
prison population, here
social attitudes, here
and social interventions, here
social mobility, here
‘strivers and scroungers’ rhetoric, here, here
and taxation, here
unemployment, here
use of tables for meals, here
United Nations Development Programme (UNDP), here, here, here, here
United States of America
air pollution, here, here
alcohol consumption, here
capital:income ratio, here
child poverty, here
and child well-being, here
cotton subsidies, here
and economic recovery, here
education system, here, here, here
female life expectancy, here
and gang violence, here
health-care system, here, here
income inequalities, here, here, here, here
international comparisons, here, here, here
lack of paid maternity leave, here
life expectancy and education, here
male adult mortality, here, here, here
maternal mortality, here, here
obesity levels, here, here, here, here
PISA score, here
politics and economics, here
and poverty in work, here
poverty levels, here
prison population, here
race and disadvantage, here, here, here, here, here
social disadvantage and health, here
social mobility, here
suicide rate, here
and taxation, here
US Centers for Disease Control and Prevention, here
US Department of Justice, here
US Federal Reserve Bank, here
US National Academy of Science (NAS), here, here, here, here
University of Sydney, here
urban planning, here
Uruguay, here, here, here, here
utilitarianism, here, here, here

Vågerö, Denny, here
valuation of life, here
Victoria Longitudinal Study, here
Vietnam, here, here
violence, here
domestic (intimate partner), here, here, here
Virchow, Rudolf, here
vulture funds, here, here
Wales, youth unemployment in, here
walking speed, here
Washington Consensus, here, here, here
welfare spending, here
West Arnhem College, here
Westminster, life expectancy in, here
Whitehall Studies, here, here, here, here, here, here, here
wife-beating, here
Wilde, Oscar, here, here
Wilkinson, Richard, here
willingness-to-pay methodology, here, here
Wolfe, Tom, here, here
women
and alcohol use, here
and cash-transfer schemes, here

A Note on the Author
Born in England and educated in Australia, Sir Michael Marmot is
Professor of Epidemiology and Public Health at UCL. He takes up the
Lown visiting professorship at Harvard in 2015 and Presidency of the
World Medical Association. He chaired the WHO Commission on Social
Determinants of Health (2005–8), and the European Review of Social
Determinants and the Health Divide. His recommendations have been
adopted by the World Health Assembly and by many countries. The British
Government appointed him to conduct a review of social determinants and
health inequalities. The Marmot Review and its recommendations are now
being implemented in three-quarters of local authorities in England. He
lives in North London.
@MichaelMarmot

By the Same Author
Status Syndrome
Social Determinants of Health

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Half-Title
Title
Dedication
Contents
Introduction
1.  The Organisation of Misery
A Tale of Two Cities . . . And they are Both in Glasgow
Social Gradients? Focus on the Richest? Don’t Poor Countries have to Worry About Poverty?
Rich Countries, Good Health?
Money – Does it Matter Or Not?
Not Just Income, Society!
Poverty: Absolute Or Relative?
Poverty? Inequality? Empowerment? Don’t We Know the Causes of Ill Health?
2.  Whose Responsibility?
Food And Fascism
What is the Argument – Science or Something Else?
Rational Obesity?
Inequities in Health and ‘Lifestyle’ – The Causes of the Causes
Obesity and Overweight – Genes or Education?
Alcohol – Just Personal Responsibility?
Whose Responsibility?
Don’t People Have Poor Health Because They Don’t Have Health Care?
3.  Fair Society, Healthy Lives
Social Justice and Avoidable Health Inequalities Inequities
Maximising Welfare
Promoting Freedom
Rewarding Virtue
Ideology And Evidence
4.  Equity from the Start
Childhood Experience Affects Adult Health . . . and Crime
Inequalities in Early Child Development – The Social Gradient Starts Early
Early Child Development – Where Should Parents Be?
Do Parents Really Matter or are they Just Bystanders?
How the Social Gradient Gets Under the Skin – Biological Embedding
What Can we do About Problems of Early Child Development?
Equality of Opportunity?
5.  Education and Empowerment
Education is Good . . . for Child Survival
. . . And for Reducing Fertility
. . . And for Your Own Health
. . . And for Protecting Yourself
. . . And for Your Country’s Development
Understanding and Addressing Inequalities . . . by Learning from Finland
. . . And, Although there are Socio-Economic Differences in Education, Poverty is not Destiny!
. . . And for Moving to Gender Equity
What Can be Done to Improve Education?
6.  Working to Live
If you Think Alan had it Bad . . .
Work and Health
Inequities in Power, Money and Resources Come to the Work Place – Not Just Physical and Chemical Exposures: Three Ways Work can Damage Health
Employment Conditions and Health
Making Things Better . . . By Getting Conditions of Employment Right
. . . And Pursuing Policies that Create Jobs, not Destroy them – the Causes of the Causes
7.  Do Not Go Gentle
Old in the Global North, Young in the Global South?
Great Inequities in Length of Life . . . Between Countries
. . . And Within Countries
Inequities in Quality of Life
Achieving Health Equity at Older Ages
Empowerment: Material, Psychosocial and Political
8.  Building Resilient Communities
Making Communities Socially Habitable
Building Socially Sustainable Communities and Resilience
Improving the Material Environment
Age-Friendly Cities
Housing
9.  Fair Societies
Society: Right and Left
Learning
Money and Other Things That Matter
Patrimonial Capitalism – Piketty Style
Inequalities in Society Lead to Inequalities in Health; Money Matters
Social Hierarchies and Health are About much more than Income
Health of Societies is also about More than Income
10.  Living Fairly in the World
Fair Finance: The Global Financial Crisis and Austerity
A Social Protection Floor?
Economic Growth, Inequality And Social Investment
Trade
Debt and Aid
Food Glorious Food
11.  The Organisation of Hope
The Triangle that Moves the Mountain
The Best Of Times, The Worst Of Times
Moving Forward
A Planet-Shaped Hole
Across The Spectrum From Low-To High-Income Countries
Notes
Acknowledgements
Index
A Note on the Author
By the Same Author
Copyright