An Interview with Sir Michael Marmot



In August of 2008 the WHO Commission on the Social Determinants of Health concluded its work with the publication of a report entitled: “Closing the gap in a generation: Health equity through action on the social determinants of health.” The Commission’s chair, Sir Michael Marmot, was kind enough to answer our questions about the Commission’s recommendations. This interview was conducted by email in May of this year.

Social Medicine: We congratulate the Com-mission on its excellent work in bringing attention to the social determinants of health and the Commission’s call for health equity. We appreciated the Commission’s recognition that: “Social Justice is a matter of life and death.” We were also happy that the Commission included representatives of civil society in their work. This was an important affirmation of democratic values.
When thinking about health inequalities people often use the analogue of the ladder to show how the gradient of worsening health outcomes affects all people in society except (presumably) those at the very top. Thinking about the ladder leads us to pose the following question: Is making the ladder shorter (i.e. reducing inequalities) the only approach to inequalities or is it possible to imagine making the ladder disappear entirely?

Sir Michael Marmot: All societies have hier-archies. It is not conceivable, therefore, to have a society with no ladder. The conceptual framework of the Commission on Social Determinants of Health leads us to think of at least two (linked) ways to address the relation between position on the ladder and health: act at the societal level to reduce social inequalities, and break the link between position in the social hierarchy and health.

The first argues for reducing the slope of the social gradient. To see this, suppose, just for a moment, that the ladder were defined on the basis of years of education. People who had three years or fewer had life expectancy of 50 years, those who had 13 years or more had life expectancy of 80 and the rest were ranged in between in a graded way: the social gradient in health. Now if we had a societal change so that everyone had at least 10 years of education, and better health followed as a result, the magnitude of health inequity would be reduced. We have reduced inequities by making the ladder shorter. [...]


Social Determinants of Health, WHO, Sir Michael Marmot

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