Sir Michael Marmot on health inequalities

Sir Michael Marmot, a prominent British social medicine scholar, health policy adviser, and principle researcher in the Whitehall studies in the UK, made the following points in his talk this evening on health disparities:

1) The gradient effect of health disparity: poor health does not just strike the poor below a certain threshold of income or education, but applies across a gradient. Anyone who is not at the "top" of society has some degree of degraded health proportional to how far they are from that "top." This was clearly demonstrated in the original Whitehall study of British civil servants, in which universal health care access made income level the only meaningful variable. The study showed that even a small difference in income correlated with poorer health, both physiological and psychological. This, in effect, makes health disparities everyone's problem.

2) On linking research on the gradient effect of health disparities to policy-making: the gradient effect of health disparities poses a challenge for policy-makers. It can generally be assumed that the government, not the private market, will ultimately need to step in to correct health inequities. However, the lack of clear benchmarks makes it difficult to use this research to identify priorities for allocation of funding and health care resources. In fact, Sir Marmot proposed that it is almost impossible for a country (such as the U.S.) that begins with a health care system in which groups of people are targeted for special treatment (elderly - Medicare; poor - Medicaid) to switch to a universal system. Such a system needs to be mindfully designed beforehand. This, of course, returns to the old theme of how cultural values shape the design and evolution of the health care system. A fragmented, targeted system assumes that public care is inferior to private care, that one person should not be responsible for the health care of another, and that government programs are only for those who are weaker or sicker than the rest. In a universal system, there is a general sense of entitlement, and thus ownership of and satisfaction with, the public system; it is something that everyone pays into and reaps the benefits of. Thus, the health system between Canada and the U.S., for example, are not just structurally different, but really reflect two very different value systems.

3) How can we meaningfully measure the effects of race? In the U.S., a country so uniquely obsessed with race and color, many studies includes race in a way that is not informative, while others do not explore in enough depth the silent effects of conscious or subconscious discrimination on minorities' health status. This is evident in the fact that within any socioeconomic stratification, people of color generally have poorer health indicators than their white counterparts. At the same time, traditional measures of socioeconomic status such as income and education level have just as clear an effect on the health of minorities, seen in the difference that these factors make in the health status among people of the same color or ethnicity. These suggest that race plays a uniquely subtle but undeniable role in health disparities, which presents complex challenges to researchers in terms of measurement.