Poverty and Health: Understanding the Complex Relationship

Through his research regarding health impacts from different childhood experiences, education levels, and working life, Michael Marmot effectively argues that today’s working society has a large impact on health and its unequal distribution.

Unraveling the Health Gap

“The Health Gap” by Michael Marmot is a stimulating and passionate narrative describing the state of health across the globe. Specifically, there are many unrelenting inequities that appear throughout different populations: this is called the “health gap.” The gap that exists between many sorts of groups is large, and not just in the United States.

It is smaller in some populations and larger in others, which is what led Marmot to take a look into the specific conditions leading to unequal health within populations. Along the way, he also investigates specific policies that have led to improvements in health along with reductions in the health gap that we see today. Marmot finds evidence from reputable journals and other sources to argue the fact that biology and access to healthcare cannot explain many of the inequities. For example, although access to quality healthcare will positively impact your life if you have a stroke, not having a stroke in the first place has a much greater impact on how long you live. Health is far too important to be left to doctors alone. It is related to the nature of society as a whole. So, besides the biological risk factors of developing a disease, Marmot finds deeper causes of diseases, the main one being socio-economic status.

The Social Gradient and Its Effects on Health

Something that Marmot often brings up throughout “The Health Gap” is the social gradient. He describes this as a hierarchy that includes everyone in society besides the top 1 percent. In explaining this hierarchy, Marmot specifically states, “All the way from top to bottom of society, the lower you are, the worse your health” (15). Hierarchies tend to be inevitable, but it doesn’t necessarily mean that health inequalities have to be. Instead of just providing facts regarding what is going wrong, Marmot goes the extra mile to explain where we can make changes to better society and this social gradient when it comes to health. First, we need to understand these social determinants that lead to health inequalities and then take serious social action to bring about change.

The Crucial Role of Childhood Experiences

When it comes to the life of a child, a major pollutant in their development is a lower rank in the social hierarchy. A child’s experiences early on have an outstanding impact on their health and well-being as adults. These experiences are influenced by the parenting they receive, which in turn is influenced by the circumstances of the lives their parents grew up with and currently live. Children need to be given the opportunity to flourish to their full potential. Even if all factors leading to social disadvantage were removed, all individuals will still vary in their abilities in areas such as math, reading, athletics, creativity, and sociability. Marmot provides thorough evidence that all over the world, child mortality has been going down. However, for each child that dies unnecessarily, there are at least twenty-five that survive yet do not develop to their full potential due to their life circumstances brought about by their socioeconomic status (CITE). Marmot provides that one’s position on the social gradient affects parenting, which then has an impact on the social, emotional, and physical development of children. This, then, is related to inequalities in health in adulthood. It all seems to come down to causation. This is something Marmot explains very well with examples of children growing up with parents in different positions on the social gradient. If a child begins low on the social gradient and has poor early child development, they tend to perform worse in school. This then often means a lower-status job, less money, and worse living conditions later in life. This all has the opportunity to damage health and create a cycle of those that start in a low position tending to stay in a low position. Childhood experiences certainly matter. Marmot effectively proves this with the facts he brings up about certain experiences in childhood leading to specific health problems later in life. For example, child physical abuse, emotional abuse, and neglect are closely linked to drug use, suicide attempts, depression, and risky behaviors. Marmot provides a graph that shows that if the more deprived areas of the world had their socio-economic status improved, there would be higher percentages of kids with better levels of development. Reducing poverty leads to reductions in inequalities in early childhood development. This, again, is causation in its purest form. Poverty certainly does matter, but it isn’t destiny. Marmot suggests that if we find out what is going on in good areas, there is potential to model that and advance. It is beneficial that Marmot does this because, without ideas for solutions, this book would not have as much importance. Yes, we would see there is a problem. However, we would be left with no direction to turn in how to improve.

Education and its Impact on Health Inequalities

Another topic where Marmot gives sufficient information on how to improve is the impact of education levels on health inequalities. Marmot does a good job setting the stage for this topic. He provides a background of education and describes how much importance it holds in today’s society, even though, unfortunately, there are still many that don’t have access to it. Education is the key to living an informed life and learning the values of your culture in order to participate in society as a whole and exercise your rights as a human being. It is not only good for you individually but for all of society. Better education means better health in rich and poor countries. Being educated in countries like Mozambique is huge. Marmot provides a graph that shows that going from no education to secondary education in Mozambique causes infant mortality to fall from 140 to 60 per 1,000. This evidence effectively proves that with education, health is improved because people are simply more informed about their health as well as the health of others, like their children. Marmot brings this full circle back to the social gradient and describes that even at the top, there is a relation between years of education and longevity. People with less time in school have a shorter life expectancy than those who furthered their education. This also goes along with long-term illnesses. Marmot brings us back to society as a whole when he discusses societal differences. In today’s society, you can’t separate the school from the society and culture they are embedded in. Their mission is to contribute to society in a positive way, yet in different countries, societal expectations get in the way. In many countries, girls are not able to go to school and get an education. In families with little money, kids often have to be working at younger ages to provide for their family. Marmot brings these ideas up multiple times, which does an excellent job of enforcing them into the reader’s mind. This gender equity issue in education is likely to reflect gender equity issues in society. The economic equity issue in education is also likely to reflect the equity issues in society. Marmot effectively brings this topic full circle once again, providing us with evidence supporting the fact that the social gradient has a profound effect on education, which in turn impacts an individual’s health throughout their lifetime. Marmot gives us an idea—backed up with reason and evidence—on how this can be changed. He provides that the best interventions are those that begin as young as possible, such as preschools. However, this is the only piece of advice he gives regarding how to make a change in the social gradient of education. Perhaps if he gave even more solutions, there could be more efficient changes. Although education is extremely important in itself, it also lays the groundwork for future employment—another key factor contributing to the health gap.

Employment and Quality of Life

When it comes to employment in today’s society, those at the bottom of the social gradient tend to be working to live, not for fulfillment, like those at the top often are. This, in turn, can lead to disparities in health and quality of life. Something Marmot does that is very powerful regarding this topic is the use of stories. He incorporates real-life experiences from people that fall in different places among the social gradient to show the actual effects of different employment situations. Those at the lower end of the social gradient tend to work multiple jobs—causing them to lose sleep and time with family—yet still coming home, always feeling like they’ve fallen short. This work is also often characterized by high demand, little control, high effort, little reward, job insecurity, as well as physical strains. Marmot simply states, “Work is the breeding ground for disempowerment” (172). People go to work to earn money, but many aren’t even earning enough to support themselves and their families. This, as well as the strain put on people during work, contributes to health inequities. In some countries in Europe and Asia, there are even more physical risks involved with work, such as chemical exposure. These are adverse conditions where the social gradient is extremely clear. As well as the impact on one’s physical health, there is also psychosocial health. Working these jobs and not having time for family and relaxing takes a toll on one’s mind. These workers experience social isolation, which can lead to higher risks of heart disease and suicide. Once again, Marmot brings this back around to the social gradient. Those at the bottom that desperately need money to survive are constantly working in sub-par conditions, which negatively affects their health. Marmot describes that a way to fix this would be to improve the relationship between employers and employees to provide better benefits, job security, safe conditions, and fair income. Work is a crucial time in one’s life and has the ability to shape one’s health later in life, so it cannot be ignored as a factor of health inequities.

Works Cited

1. Marmot, M. (2015). The Health Gap: The Challenge of an Unequal World. Bloomsbury Publishing.
2. Wilkinson, R., & Marmot, M. (2003). Social Determinants of Health: The Solid Facts. World Health Organization.
3. Marmot, M., & Allen, J. (2014). Social determinants of health equity. American Journal of Public Health, 104(S4), S517-S519.
4. Adler, N. E., & Stewart, J. (2010). Health disparities across the lifespan: meaning, methods, and mechanisms. Annals of the New York Academy of Sciences, 1186(1), 5-23.
5. World Health Organization. (2008). Closing the gap in a generation: health equity through action on the social determinants of health: Commission on Social Determinants of Health final report. World Health Organization.

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