Sir Michael Marmot: Most of the things that doctors treat are failed prevention

“Instead of being scared that governments would not like us, we told the truth.”

Sir Michael Marmot is Professor of Epidemiology and Public Health at University College London. He is currently the Director of the UCL Institute of Health Equity and President of the British Lung Foundation. With more than 225,000 citations, Sir Marmot is the 49th most cited living author in the world.

Additionally, Sir Marmot chaired the WHO Commission on Social Determinants of Health (2005-8) and the European Review of Social Determinants and the Health Divide. He has served as president of the British Medical Association (2010-11) as well as the World Medical Association (2015-2016). Sir Marmot holds the Harvard Lown Professorship for 2014-2017 and is the recipient of the Prince Mahidol Award for Public Health 2015. As the world’s foremost expert in the field of health equity, his recommendations have been adopted by the World Health Assembly and by a wide range of countries. Within the United Kingdom, the recommendations of The Marmot Review are being implemented by three-quarters of local authorities. He holds a PhD from Berkeley and has been awarded honorary doctorates from 18 universities. Sir Marmot has led research groups on health inequalities for over 40 years and continues to do so to this day.

In this interview, Sir Michael Marmot speaks with our Managing Editor, Christian Overgaard Wessels, about his academic inspirations, his work on the inequalities in health, and his hopes for a brighter tomorrow.

What attracted you to study health inequality and social determinants of health?

Well, I was interested in science. I would like to say that I had a vocation to do medicine, but that is not quite true. I was interested in science, but I thought if I enrolled in medicine, I could always switch to science. On the other hand, if I enrolled in science, it would be more difficult to switch to medicine. So I enrolled in medicine at Sidney University. I became interested in the basics of medical science and in the clinical side of course, but I never lost interest in doing research. One of the things that struck me, even as a medical student, was that you could see most of the things that doctors treat as failed prevention. If you did not smoke, you would not get lung cancer. If you ate healthy diets, you could avoid a third of cancers. I thought to myself, if medicine is failed prevention, we ought to do more about prevention. As a junior doctor, it seemed obvious to me that a lot of people’s health problems were related to problems in their lives. We ought to be doing something about dealing with the problems in their lives. It never occurred to me that you could study that scientifically. One of the consultants in the Royal Prince Alfred Hospital in Sydney said to me ‘I have got just the thing for you; it is called epidemiology’. These doctors, anthropologists, and statisticians work together to study how rate of disease varies depending on people’s social and living circumstances. So I went off to University of California Berkeley to do a PhD in epidemiology. I am delighted I did it and have no regrets. But in retrospect I did not know very much about what I was getting into. It just seemed like a good idea, and I jumped in with both feet.

What particular intellectual influences inspired you throughout your career, and in what way have such influences impacted your work?

My supervisor at Berkeley, Leonard Syme, did his PhD in medical sociology, and then became an epidemiologist. Part of his argument was that we need something concrete to study, and health outcomes were pretty concrete. He thought that sociologists tend to have both a rather less-than-concrete input and a less-than-concrete output. Well, let us have at least one of them concrete, and health was pretty concrete – particularly life and death. So, I think that was part of his thinking. But that meant that his input were social processes. Aspects of society. When I was voicing these vague notions that the nature of society impacts health, there was somebody at Berkeley studying these things and teaching students about these things. He ended up supervising my PhD, so we could turn what was a vague notion into scientific study. Leonard Syme had a big influence on me.

Then I came to the London School of Hygiene and Tropical Medicine. Donald Reid was the man who requited me. He would have been one of my big influences, except he sadly died six months after I got there. I do not think those two events were related. Geoffrey Rose became the head of the department. The first thing that I learnt from him was to stay close to the evidence. He really knew the numbers. It is not that Leonard Syme did not respect the evidence, but he was more interested in the ideas and the social processes. Geoffrey Rose was interested in that too, but he was very good on the numbers. That was a very important influence. As Geoffrey Rose’s thinking progressed, he sounded more and more like Leonard Syme which was really interesting. Geoffrey wrote a seminal paper called ‘Sick individuals and sick populations’. He asked why one individual gets sick and not another. That is an important question, but it is a different from asking why the rate of disease in one society is different from another. The causes of the individual differences and the causes behind group differences might not be the same. That was very much a Leonard Syme type notion. I learnt from both of these brilliant people some rather similar messages.

I also have to mention a third one which is Professor Jerry Morris. I did not work with him directly. He was at a different department at the London School of Hygiene and Tropical Medicine. One day, he caught my elbow in his iron grip, and said ‘come and have lunch with me.’ That must have been around 1976 or 1977. Over a twenty-year period having lunch with Jerry Morris was like having an individual post-graduate seminar. His intellectual capacity was huge, his interests were wide. He was very committed to fairness, justice, the nature of society. Of course, he was fascinated with his scientific research on exercise and health, but he had this genuine interest in how society works. He was a very important third influence.

You are well-known for your leading roles in the studies of British civil servants known as Whitehall I and Whitehall II. Could you please elaborate on the motivation for conducting this research and the most surprising findings?

Whitehall I was begun by Donald Reid and Geoffrey Rose, and they saw it as a British Framingham. The Framingham study in the United States was a cohort study that established relationships between plasma cholesterol levels, smoking, blood pressure, heart disease and the like. Donald Reid and Geoffrey Rose saw the Whitehall study as something like that. When I came to London, Geoffrey Rose said: ‘Do you want to work on the Whitehall study? I know you are interested in social things. Just about the only social thing we have got is people’s grade of employment.’ In other words, the purpose of the first Whitehall study was not to look at inequalities. The really surprising finding, when I started to look at people’s level in the hierarchy was, a social gradient. The lower the position in the hierarchy, the higher their mortality. I published my first paper on this in 1978. So I have been writing about this topic for a very long time, 43 years or so. You have to remember, at the time, the conventional wisdom was that stress caused heart attacks, and stress was more common in busy high-status individuals that had busy jobs such as politicians, football managers, senior executives and the like. In the study, we showed that the lower the status of employment, the higher the mortality from heart disease and from a whole range of other diseases. That really was surprising. Both the finding of this inverse social gradient that contradicted the conventional wisdom, and the finding that the lower the grade of employment, the higher mortality from heart disease, from lung disease, from gastrointestinal disease, from smoking-related cancers and non-smoking-related cancers.

It was a very general finding. I wrote a later paper from the ten-year follow-up of the Whitehall cohort in 1984, about the generality of this finding across specific diseases. Yes, we need to look at the causes of specific diseases. But we also need to ask why there should be, what I described as a social gradient, whereby people second from the top had higher mortality than people at the top. People third from the top had higher mortality than people second from the top. This was not about poverty. It was about degrees. That was why I called my first book ‘Status Syndrome’. I slightly regret talking about status because I do not think it was just about status. But certainly, it was about where you were in the social hierarchy. That influenced everything that I have done since, both in research and in policy. I described that, maybe others knew about it. But it really struck me when I found the social gradient in 1978, and it continues to do so to this day. Just before this interview, I was giving a lecture to the National Institute of Health Research about the social gradient in Covid-19 mortality. This is a disease we never heard of, and it looks exactly like the gradient in all-cause mortality. 

I set up Whitehall II to investigate this social gradient because from Whitehall I we could explain between a quarter and a third of the gradient on the basis of smoking, plasma cholesterol, blood pressure, overweight and the other usual suspects. We wanted to look at psycho-social aspects and on nutrition.

It is often said that all good things come in threes. Can we expect a Whitehall III, and what do you think would be relevant to address with such a project?

I quite wanted to set up a Whitehall III. It should be larger than Whitehall II. and include more women to be able to say something about what was influencing women as well as men. For one reason or another, I then got involved in other things instead. We set up the English Longitudinal Study of Ageing (ELSA), we launched cohort studies in Central and Eastern Europe, and then I got more involved in trying to package the research into policy and practise. So, I really wanted to do a Whitehall III but for one reason or another it did not happen.

From 2005 to 2008, you chaired the ‘WHO Commission on Social Determinants of Health’ (CSDH). The cover of the final report reads “Social injustice is killing on a grand scale”. How did you find the experience of working on a WHO commission, and how were your recommendations received?

It was extraordinarily interesting in a whole variety of ways. We did several consultations before we actually launched the commission about what we should cover, and what people thought about it. One distinguished American academic who had worked on one of the scientific groups for a different commission said that they had fun, but they did not influence the commission at all because the chair of the commission knew what they wanted to write before they set up the advisory group. He said, in the case of this commission, it will not be like that ‘because Michael does not know enough’, which was true. I did not have the report written before we started. It was an amazing learning experience. We convened nine knowledge networks, and we tried to have co-leads in each knowledge network; one from the Global South and one from the Global North to ensure a broad perspective. It was a WHO commission, so you have to have ‘regional representation’. I thought that regional representation meant that for every Cambridge professor you had an Oxford professor, and for every Harvard professor you had a Yale or Princeton professor. I thought that was what regional representation meant. Forget it. It meant we had people from different regions Africa, South Asia, Europe etc.

And we did not just have academics. President Ricardo Lagos [former president of Chile], Prime Minister Pascoal Mocumbi [former prime minster of Mozambique] were also part of the commission. I was several leagues out of my comfort zone. It was extraordinarily interesting. At one point when I got to know the commissioners, still fairly early in the process, I said what am I doing, chairing this commission with former presidents, prime ministers and heads of agencies? They said, it is okay Michael, you know something about the subject which is quite a good criterion. So, we got on remarkably well. We formed a very cohesive bond. It was a learning experience for all of us, particularly for me. These were experienced and remarkable people who knew how to do things in the big wide world. We got fresh information from our nine knowledge networks and learned an enormous amount from each other. Then there was the whole political side of the story. The experienced politicians protected us somewhat from the politics. I was able to put blinders on and ignore some of the political pressures on us, which was important. If I had been too sensitive about the politics, we never would have finished, we would have been blown all over the place. If we were under the thumb, we would never have been able to write on the cover of the report that “social injustice is killing on a grand scale”. We had the courage to discuss unfair economic arrangements and poor governance. Instead of being scared that governments would not like us, we told the truth.

In your 2015 book ‘The Health Gap: The challenge of an unequal world’, you mention that you have often been criticized for being too political. For example, the CSDH report was labelled by one as “ideology with evidence”, and The Economist weekly newspaper argued that “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”. What is your response to this critique, and in what ways have your findings met resistance throughout your career?

While “ideology with evidence” was meant as a criticism, I took it as praise because we do have an ideology; health inequalities that are judged to be avoidable by reasonable means are unfair. Hence a violation of social justice, so we do have an ideology. But the evidence really matters. It is not enough to want to achieve social justice, you can do useless things, you can do dangerous things in the name of good intentions. The evidence really matters. I quite liked “ideology with evidence”, and I quite liked The Economist’s comment about my quixotic commitment to equity. I had actually said before that I felt a bit like Don Quixote. You know, Don Quixote wakes up and imagines that he is a medieval knight. He is running around doing chivalrous deeds, and everybody is laughing at him tilting at windmills. I said this to the Spanish minister of health, and he said: “We need the idealism of Don Quixote, and we need the pragmatism of Sancho Panza.” So when I saw The Economist’s comment about my quixotic commitment to equity, I could not do anything but agree with them. But we had a whole set of practical recommendations to achieve it.

In terms of your work in the UK, in 2008, you were asked by the Labour government to chair a review of health inequalities in England. The review was published in 2010 as ‘Fair society, healthy lives: the Marmot Review’. What would you say was the essence of that report?

The essence of the report was that the evidence suggests that the magnitudes of health inequalities existing in England should not be taken as a given. The evidence suggests that we could take action to reduce them. Health inequality varies over time, and it varies among countries. The evidence pointed to six domains (early child development, education, employment and working conditions, having enough money to lead a healthy life, sustainable places and communities, and taking a social determinants approach to prevention) which fitted with the evidence from the WHO commission. We recommended that strongly. Ideology with evidence. Our ideology was that we should do something about these health inequalities, it is the right thing to do, and the evidence really matters.

Why did you choose not to prioritise the six main policy recommendations in the report?

We chose not to prioritise them because we think you need all of them, and they are linked. Having enough money to live a healthy life relates to giving every child the best start in life. But giving every child the best start in life is not only about having enough money. It is important, but it is also about parenting, support for the child, and services like pre-school education. I would never say invest in pre-school education, and let today’s older people languish in isolation, poverty, and ill-health without doing anything about it. I mean, read the front page of the newspaper for the last few days. It is all about adult social care for needy older people. I would never say let us get that right and forget about early childhood. We need to do them at the same time. Why would you focus on early childhood and adult social care for the elderly and not talk about good jobs for working aged people? I did not prioritise the recommendations because I think we need all six at the same time. And governments do that, they have departments that deal with each of these.

Much of your work has been based on empowerment and control over one’s life as a recipe for good health. The third recommendation of The Marmot Review “Create fair employment and good work for all” is particularly interesting in the rise of gig economy. There seems to be a tension between autonomy and job precarity. For example, an Uber driver or Deliveroo courier may prioritise autonomy in the sense that they are in complete control of their working hours over job security. Do you agree that there is a tension between autonomy and job precarity, and what can be done in the future to empower people in their employment?

It sounds like there is a tension between autonomy and precarity. In fact, one of the ways to deprive people of autonomy is to make their working situation very precarious. The film ‘I, Daniel Blake’ by Ken Loach demonstrates people falling casualty of the welfare system, and his film ‘Sorry we missed you’ is about someone who finds himself as a delivery driver. It is very precarious, and you would not describe what he has as autonomy. The protagonist is under stress all the time. All these questions of what if you cannot find the address, what do you do if they are not there? You have got performance targets, you are being criticised if you don’t meet your targets even though you are self-employed. You have got no security, no paid holiday, no pension arrangements, no nothing. I got horrified when I heard that people were losing their jobs, and the councillors were citing my Whitehall II study saying: Well, Prof Marmot shows you have more control if you are not the subject of big bureaucracy, and if you have more control, you have better health. Nonsense, I do not think that not knowing if you are going to be paid next week or whether you are going to have the money to pay the rent, is giving people more control over their lives. So, precarious employment is a way of depriving people.

I am privileged beyond belief to have worked in a university my whole life. I would not have thought that I had more control if I was an independent contractor. Having stability, knowing you are going to get a pay-check this month as well as the next month, getting paid holiday and pension gives you quite a bit control of your life as distinct from not knowing whether you are going to make ends meet. If you are a swashbuckling entrepreneur, I think they exist in Marvel comics if not in real life, you could say yes, I have got real control. Look what is going on with Tesla at the moment. The US government lent $465 million in Tesla over ten years ago. I am sure that Elon Musk paid it back and now has control, but the government supported what he did. Tesla also got this big contract from South Australia to provide battery power. Musk is essentially working for the government; a big support which funded developments. I think there is some illusion that being free from an organisation gives you more control. It could, but it might not.

In your 2004 book ‘Status Syndrome: How Your Place on the Social Gradient Directly Affects Your Health’, you argue that people cannot take responsibility if they cannot control what happens to them. Could you elaborate on this idea? Specifically, at what degree of material, psycho-social, and political empowerment does individual responsibility become relevant?

Well, it is an important tension, and there is not a clear dividing line. In my recent report ‘Health Equity in England: The Marmot Review 10 years on’, we have a graph from the food foundation. It asked if households followed the national healthy eating advice, how much would each household have to spend on food? The people in the most deprived ten percent would need to spend 74 percent of their income on food to meet the healthy eating advice. They have no control. If you say it is your individual responsibility to eat healthily. Well, if they eat healthily, who is going to pay the rent? If we pay the rent, how are we going to heat the dwelling? If we both pay the rent and heat the dwelling, where is the healthy food going to come from? So they have no control.

The most affluent ten percent would need to spend six percent of their household income on food to meet the healthy eating guidelines. If these people feed their children bad food, that is a shocking lack of responsibility. So you could say that rich people should exercise individual responsibility. They are in a position to do so. But for poor people, the problem is their poverty, not their lack of responsibility.

In your 2020 report, ‘Health Equity in England: The Marmot Review 10 years on’, you point out that most of the six recommendations from your 2010 report have moved in the wrong direction. Has this development affected your optimism, and how do you stay motivated to create change in the future?

It did not make me pessimistic, it made me annoyed. It made me want to use the evidence to argue for change. We have to be a bit patient. Of course, you should not be too patient as Keynes said: “In the long run, we are all dead”. Last week, I got an email from Gothenburg in Sweden. The person who wrote the email told me that Gothenburg has become the European city of literacy. He said that I had played an important part in the journey. I had given a lecture in Gothenburg some years ago where I had talked about the importance of reading to children. On a subsequent trip, a city official said in honour of your visit we wanted the standard city slogan changed from something like ‘Gothenburg. Good of business’ to ‘Gothenburg. We read to children’. The official translated a section of the Gothenburg city website where they acknowledged my contribution to their thinking about literacy and the importance of reading to children. That will keep my optimism going for a while.

When I said you have got to be patient, I did not go to Gothenburg with the idea that they would become a city that championed literacy. Nor would I have imagined that I had anything to do with that. But the idea that I went and presented the evidence, and they were convinced by the evidence which led to a process. Seven years later, there was an outcome. So you should be patient, but not too patient.

A second point I would like to make is that we have had real take-up from cities and regions. For example, Coventry declared itself a ‘Marmot city’. We produced a report on Greater Manchester. We are working with Chesham, Lancashire, Cumbria, and Gateshead. Cities and regions all around the United Kingdom. I am on the commission for Wales, I have been talking with colleagues in Scotland. So yes, my report ‘Health Equity in England: The Marmot Review 10 years on’ was critical of both what the government did do and what they did not do. But that does not mean that nothing is happening. There is quite a lot happening at a local level.

Do you think the policy initiatives at the local level presents a sustainable way to improve health, or is it necessary for national authorities or supranational organisations to step in?

Well, I have produced four reports in the past 11 months with the title ‘Build Back Fairer: The Covid-19 Marmot Review’: One for the WHO Eastern Mediterranean Region; one for England; one for Greater Manchester; and one for Hong Kong. That in a way is an answer to your question. One of the reports was supranational, two were country reports, and one was a local report. I think action has to, and can, take place at each of these levels. Ideally, all at the same time because in Greater Manchester, they cannot control child poverty in the way that Westminster can. The Chancellor of the Exchequer has the power to influence child poverty in a way that the major of Greater Manchester does not. So we do need national policies and national action but there is much that can happen at local and regional level. In Britain there is lip service paid to ‘Levelling Up’ which in theory should make it easier for cities and regions in the north of the country to act. But we will have to see what that looks like in practise.

You have mentioned in your recent ‘Build Back Fairer: The Covid-19 Marmot Review’ report that Covid-19 has exposed and amplified the inequalities in our society, and that the status quo before the pandemic hit us was not desirable. With finite resources, where should our efforts be placed to optimally prevent further inequalities?

I have two approaches to that question. One is revisiting my six domains from 2010. The second relates to the observation that the UK had a terrible management of the pandemic and so did the United States. The US was worse than us [UK] in terms of health improvement pre-pandemic, and at least initially, it was not quite as bad as we were in managing the pandemic, and then later on became significantly worse than the UK in terms of excess mortality. I think the link between doing poorly in pre-pandemic health inequalities and doing poorly during the pandemic works at four levels: Poor governance and political culture; Increasing social and economic inequalities; Disinvestment from public services; The low quality of pre-pandemic health. To build back fairer we need to take action on my six domains but simultaneously address these four issues.

On a slightly different note, COP26 finished a couple of weeks ago. How do you think actions towards improving health equity could contribute to net-zero greenhouse gas emissions?

We produced a British report last year on that topic showing two things: First, how actions to improve health equity could contribute to net-zero greenhouse gas emissions; Second, we argued that it is vitally important that you keep equity in mind while you take the actions needed for reaching net-zero emissions. So, make sure that the action taken do not increase general inequalities which could increase health inequalities. My view, based on the evidence and chairing this small group, is that it is entirely possible and desirable to put together an agenda to combat the climate crisis, and to achieve greater health equity.

In the 2009 book ‘The Spirit Level: Why More Equal Societies Almost Always Do Better’, Wilkinson and Pickett argue that the discussion of greater social and economic equality is not necessarily partisan. Reducing income inequality would benefit the vast majority of society. Do you believe we should prioritize reducing income inequality across public policy in general?

Much more than we currently do. I do not only talk about income inequality, but I think that income inequality as discussed by Wilkinson and Pickett damages social cohesion. Secondly, if rich people are accumulating vast wealth through clever ways of not paying taxes, governments will start complaining that they do not have enough money to spend on early child development or any other issues. Well, in the US, during the past 18 months since the start of the pandemic, American billionaires increased their wealth by about two trillion USD. Two trillion USD went to 752 billionaires. Jeff Bezos and Elon Musk have the same combined wealth of the bottom 40 percent of the American population. To say, well we cannot do subsidised childcare because we have do not have enough money, we cannot invest in preschool because we do not have enough money, we cannot reduce child poverty because we do not have enough money is absurd. There is a lot of money. The first argument is about social cohesion. The second, although not quite a Wilkinson and Pickett argument, is that if you allow this runaway inequality, there is just not enough money in the system to improve early childhood or to support old people who need help clipping their toenails. You know, the billionaires increased their combined wealth from three trillion USD to five trillion USD during the pandemic. I wonder what just one of those extra two trillion USD could have done for public health.

What do you think are the most interesting developments in your field right now?

From my point of view, the most interesting development is how people take up the recommendations, implement them, and try to evaluate what works. Relating to the question we discussed earlier, where is the appropriate level of action? Can multinational action, national action, city action, local action work separately, and how do they work together? It is not that I have lost interest in the science. There are a lot of scientific questions that have come out of the process of putting the evidence together, but the key question is what works. How do we get action, at what level, and what can we then recommend to others to take up?

Do you have any advice for young scholars considering a career in academia or public policy?

My first piece of advice would be that if I was so bold as to give you advice ignore it. What a terrible responsibility. If I told you what I thought you should do, and you went out and did it, oh my God. Any advice I give, ignore. That would be my first overriding piece of advice. The second thing I would say is that I did not go into the research I was doing because I thought that I wanted to change the world. I went into it because it seemed really interesting. I was intellectually curious, but what a privilege to be doing research in an area where the aim is to improve the health of the least privileged members of society, and to create fairer societies based on principles of social justice. This is not a recommendation of what anybody else should do but I say that it has been an absolute privilege to do research and to use the research to try to package recommendations for policy and practise in this area of health equity. An absolute privilege.