The Health Gap

by Michael Marmot

There are dramatic differences in health between countries and within countries. But this is not a simple matter of rich and poor. A poor man in Glasgow is rich compared to the average Indian, but the Glaswegian's life expectancy is 8 years shorter. The Indian is dying of infectious disease linked to his poverty; the Glaswegian of violent death, suicide, heart disease linked to a rich country's version of disadvantage. In all countries, people at relative social disadvantage suffer health disadvantage, dramatically so. Within countries, the higher the social status of individuals the better is their health. These health inequalities defy usual explanations. Conventional approaches to improving health have emphasised access to technical solutions - improved medical care, sanitation, and control of disease vectors; or behaviours - smoking, drinking - obesity, linked to diabetes, heart disease and cancer. These approaches only go so far. Creating the conditions for people to lead flourishing lives, and thus empowering individuals and communities, is key to reduction of health inequalities. In addition to the scale of material success, your position in the social hierarchy also directly affects your health, the higher you are on the social scale, the longer you will live and the better your health will be. As people change rank, so their health risk changes. What makes these health inequalities unjust is that evidence from round the world shows we know what to do to make them smaller. This new evidence is compelling. It has the potential to change radically the way we think about health, and indeed society.

Genres: Nonfiction, Medicine, Health, Health Care, Science, Medical, Sociology

400 pages, Paperback

First published September 10, 2015

Reviews

[Liz · Rating 2 out of 5]

While I tend to agree with the overarching points Marmot makes, and think it's a very important topic, I thought the book itself could have been half the length and still make those points effectively. He says the same thing over and over and over again, or even in some ways repeatedly hints at the points but says "more on this later." I think this would be good for someone new to the topic of health disparities, or someone whose profession isn't in health care but is interested in learning about health- it's clear and straightforward, very approachable.

[Sara Budarz · Rating 3 out of 5]

One of my friends who is getting a PhD in Global Health was reading this book and then handed it over to me to read. And so I dove into it - all 400 some pages. The result? I sort of wish the editor of this book had been a bit more demanding; the information presented is fantastic, but could easily have been given in 200 pages, not 400. That said, it was an interesting read, and something I wouldn't usually have been exposed to.

The takeaway messages: when we think about health, or health outcomes, people right away want to think about medical health care, and whether it is good or not. But the truth is that the factors influencing our health, on a global and national and local scale, have much less to do with health care than with societal factors. Do you want to live a long, healthy life? Then avoid poverty at all costs. Get as much education as you can. Make sure you live in a rich area of town. Have access to green space. Live in a place where you can use public transport and bike / walk to most places, especially your school and place of employment. Have strong social ties. And most importantly, live a life in which you feel empowered.

Empowerment. It was a fascinating idea backed by a LOT of research. That all the best health advice we love to give - eat well, get rest, exercise, avoid smoking, don't drink too much - will not be followed if people do not feel empowered in their life. If they are struggling, they just will not care about other things related to health. Telling them to eat well when they can't pay their bills, or to take time for wellness and rest when they are being beaten at home - it isn't going to work. So the argument is simple and yet hard to do: change societal conditions in order for people to thrive, through better early-childhood education and intervention programs, through universal health care, through mental health services, through apprenticeship programs to avoid unemployment, etc - and health will improve.

But we readers might be sitting here thinking, yes, yes, I get it. But that isn't about me.

But this part is: health follows a gradient. Yes, you are healthier than those poorer than you. But that friend who earns a few thousand more? Statistically they are a few notches more likely to outlive you. Are you middle-class? They you fall somewhere in the middle of the spectrum of life expectancy and likelihood of living to old age without major disabilities. So caring about instituting changes matters because it is literally killing you to not. You live in lovely suburbia but have to drive everywhere? Hello sicknesses brought on by this. Petition and argue for sidewalks. For transit. For bike lanes.

And crazy as it might sound, but the gradient of health applies not on a global scale, but a local scale. You might earn what is an absurd amount of money in the global context, but if compared to your immediate world, say, the city you live in, you earn relatively little, your health suffers. If you feel disempowered compared to your immediate surrounding, you will make worse choices. Which is to say you could be earning 60k a year, but if you live in California and feel that isn't enough to let you take a vacation or live comfortably, the feeling of being disadvantaged compared to others will lead to worse health outcomes for you. (We are weird creatures, we humans.)

It really was interesting to read. And sort of made me think my PhD in literature is at least good for one thing: statistically keeping me alive longer than a BA or MA alone would have. ;) Even if apparently a PhD in a field that earned proper income would have been a better choice. Oh well. At least I will now ride my bike and hope that offsets relative lack of income.

[Douglas · Rating 4 out of 5]

Thanks to Goodreads and Bloomsbury for an advanced review copy. This was an intriguing look into global health gaps and disparities that effect overall survival and quality of life. Though it was difficult to navigate through Marmot's clear political leanings, his knowledge and ability to decipher and use data to support his theories and points make this an eye-opening and insightful read. I think my biggest takeaway is knowing that the U.S. in fact does not have the best system for ensuring quality healthcare for all. Yes, we do have the best trained physicians and medical workers and state-of-the-art facilities, we lag behind other countries in terms of survival rates and quality of life. Also, our overall health is markedly inferior. While I think the solutions Marmot puts forth are somewhat implausible given the number of opinions that vary as to how countries and governments should work, I do applaud his dedication and mission to at least put forth a plan that could work. This is an important work for anyone interested in global public health.

[Mariam · Rating 2 out of 5]

Now, did I like the content of this book? Yes, 100%. The points made were very valid and eye-opening. It approaches healthcare in a different light I’d never personally thought of until I came across this book. However, there’s waffle everywhere in this. The book could have been shortened a lot more, and would have been a lot more enjoyable to read if it wasn’t for the useless “big” words used and the repetitive rhetorical questions and explanations.

[Krishna · Rating 5 out of 5]

one of the best books I’ve ever read. really goes into depth on how health inequalities come into place

[Eitakbackwards · Rating 4 out of 5]

3.75

Took a while to read this book for non-book related reasons and also because its requires FULL attention and the writing doesn't quite flow and is a tad repetitive HOWEVER,

V glad to have read it. I have to admit, it wasn't what I expected it to be. I expected an analysis focusing more on diseases and health care and this book ISN'T THAT. Rather, it is an analysis of a series of reports commissioned on the social determinants of health inequity. It looks in details at the global state of health and what underlies health equity. LEARNT SO MUCH LMTU.

Most important point: Health inequality isn't just about the poorest people, it follows a clear social gradient. There is not an 'us' and 'them'.

It covers:

- Early child development: children with both parents in work have the best health outcomes when controlled for other factors.
- Education : education of women globally may be one of the most impactful steps of all in tackling health inequity
- Work : Lower status jobs ---> Less perception of control + poorer conditions ----> Poorer health outcomes. Contrary to the idea that people in high status jobs have poor health due to stress.
(see The Whitehall Study I and II summary: https://en.wikipedia.org/wiki/Whiteha...
- Social resilience (protection against social inequality buffers health outcomes)
- Structure of society
- Globalisation (mainly aid in the context of debt, learnt about vulture funds??? like can we get it 2gether??)

I liked that it broke down the data and real world findings related to health and tried not to politicise it because of course, the more governments that adopt the recommendations, the better. And it also made it easier to trust given the general lack of spin. It also discussed health GLOBALLY not just in Europe or in the US or whatever.

The US: it does poorly on almost all health metrics despite it's high (and often highest) per capita spending on health care (compared to 'peer' countries), but social inequality and health outcomes are very poor and haven't improved. Relatively much poorer countries like Costa Rica, have at least equal or better health outcomes than the US.
The UK: also scores poorly on metrics like child-wellbeing (only just higher than the US.) - in 2013, only 52% of children in the UK were said to have 'good development' at age 5. And of course, conditions at the start of life have a lag effect on adult health and ultimately life expectancy and perhaps more importantly: disability free life expectancy.

It really seems that the reasons for those disparities might be priorities. I.e. prioritising economic growth over social protections and wealth redistribution at the expense of health for example, with austerity policies. Health equity is definitely a good metric off which to base how 'well' a country and its population are doing given that health is directly impacted by attention to hard to argue with factors important for human flourishing (see the 7 bullet point list above.) If these are not addressed, the social gradient of health inequality is steeper.

Yeah would definitely recommend this book to interested p a r t i e s. Also like hmu would deffo do a job in global health inequality epidemiology

[Shelby · Rating 4 out of 5]

I'll start this review by saying that if you work in public health or any adjacent field (social work, medicine, etc.) where you are familiar with the Social Determinants of Health, most of the information in this book will not be new to you. Most of the statistics will not be new to you and even most of the major studies cited will not be new to you. You will likely agree with all of the author's conclusions and may, as a result, find this book a bit boring.

However, if you are someone who is not familiar with the Social Determinants of Health and/or health inequities, this book is a fantastic resource and introduction to those concepts. Marmot does a great job explaining things in a way that is thorough, but approachable, and with some humor. He uses well-known literary references throughout to make the information more relatable. He explains statistics well and only uses graphs to hammer home points, not to make them. The book is easy to understand and written in plain language. This book covers health inequities on the global scale, using examples and statistics from many different countries and comparing and contrasting how seemingly vastly different issues end up causing the same result. It covers different strategies countries implement to combat these issues and to what degree those implementations are successful.

I did end up taking one star because this book could have been 100 pages shorter while still containing all necessary information and keeping it's approachable nature. Marmot has a tendency to go on small tangents and overuse phrases ("We'll cover that in later chapters" or "I'll get to that in a bit" are two phrases that you will see a lot of), which made reading tedious at times. Marmot also does write about non-white characters in a way that is respectful, but cringe-worthy, though I did expect this given that he is an old white guy from the UK. He does make his points effectively still.

Overall, I do recommend this book - especially if you are trying to learn more about the Social Determinants of Health and health inequities on a global scale. If you are already familiar with these concepts, then this is likely one you can skip.

[Kiara Braga · Rating 2 out of 5]

Gave up on this book of the first few chapters. Although I find the topic super interesting I thought the author repeated himself ALOT without getting to the point. Also the book is not very well structured on actual advice on policies.

[Jithin Sam · Rating 5 out of 5]

The running theme in the book is this: Equality in opportunity is meaningless without equity in access to a basic set of services (health, schooling, social security to adversity, public services)

[sara · Rating 4 out of 5]

important book with a really important message but soooooo repetitive could’ve easily been a third of the length

[Noor · Rating 2 out of 5]

First of all, this book could have been a heck of a lot shorter. While Marmot does make some very worthwhile cases for a healthier society, he unfortunately lacks brevity while doing so.

Early on in the book, Marmot claims (through quoting Dickens) that we presently live in the best and worst times; healthcare and medicine have never been more advanced, yet at the same time, the social gradient with regards to public health has also never been as high. He later explains how people are a product of their circumstances.

I'll start off with the positives:

What I liked:
- The literary references. Michael Marmot is clearly well-read and starts all of his chapters with either a quote from a literary classic or a quote by a memorable historical figure.

Some things I learned:
-The United States is one of 3 countries in the WORLD not to have state-guaranteed maternity leave, alongside Papua New Guinea and Suriname!
- Economists think that health leads to socio-economic position, whereas public health people think that socio-economic position leads to health.
- Japanese culture protects against heart disease better than American culture.
- Life expectancy in Sierra Leone is of 46, contrasted to 84 in Japan (highest and lowest in the world).
- Considering what a rich country it is, the USA fares pretty poorly on health. In 49 other countries, 16-year-old boys have better prospects of living to 60 than the USA and there is also one maternal death per 1800 births (compared with 1 in 17,000 in Italy). This is surprising considering the USA spends the most on health per capita than any other country.
-Women in higher socio-economic positions are the greatest drinkers of alcohol, yet more alcohol-related harm is associated with the lower ends of the socio-economic spectrum.
-1/6 of the US population lack health insurance!
-The latency effect: contrary to popular belief, that which does not kill us makes us more vulnerable.
-Working professional parents speak 20,000 more words to their children on average than families on welfare.

And now onto the negatives:

In some places I feel as though Marmot was a bit contradictory; he says that in rich countries, getting richer does little for health. Yet he also says that within certain areas in London or Glasgow, for example, life expectancy can vary by up to 20 years depending on the area, with the richer areas having better life expectancies. For example, males in Tottenham in London can expect to live 18 years shorter than Queen's Gate in Kensington (on of the richest areas of London).

The book is filled with mostly unsurprising statistics: mental health leads to a lower life expectancy; a poor education and unemployment/low income and ill-health are determinants of poor health, which ultimately leads to a lower life expectancy; Scandanavian countries have it all figured out, etc. Perhaps I'm being a bit unfair; after all, my background is in healthcare and so a lot of these appear strikingly obvious for me.

Elsewhere in the book, I felt that Marmot showed a degree of disregard for cultural sensitivity and there were undertones of a Western imperialistic outlook. There were one too many references to poor disadvantaged Bengali (or other nationality) girls who were waiting for a liberation, lest they be trapped into a forced marriage. Not that these problems do not exist, but rather it was the tone of the author and his generaliastions that I found unnecessary.

There are too many statistics and not enough specific instruction on what should be done to overcome all of these health inequalities. Yes, we should invest in the education. Yes, we should help to bridge the gap between the rich and the poor. What else?

Mostly, I found this book to be a (rather lengthy) summarisation of Marmot's political and economic views (although he defends this point by saying that healthcare should be a priority for every politician regardless of background and that surely this is something that they should all agree on. Very idealistic, but touching nonetheless).

So... I enjoyed parts of this book, but in all honestly lost interest by about halfway through the book. Nonetheless, the topics addressed are very pertinent issues and I agree that targetting them should be a global concern.

[Ben · Rating 3 out of 5]

The author does a good job of laying out the social determinants of health and making suggestions for how he believes health for entire populations can be improved. The book is easy to read, and the author has a breezy, conversational style. My average ranking may have come from my own expectations. My big problem with the arguments the author makes in favor of improving overall health for all are that, if you already agree with the author, then you'll agree with his arguments. For those who already believe (as both the author and I do) that improving the health is a worthwhile goal, his arguments are preaching to the choir. If you don't believe that, then I think his argument would fall on deaf ears. I guess I was hoping for more arguments that could possibly convince those on the other side of the argument. A secondary problem for me is that I am already familiar with social determinants of health, and have been reading quite a bit for my MSW program. I think that those who are less familiar with the concept would enjoy this book quite a bit more than I did.

[Frida Røvik · Rating 5 out of 5]

Such an inspiring book which challenges the mainstream conception of health and treatment globally. The idea is that we always have to look at the social determinants of health, which are the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. These include economic policies and systems, development agendas, social norms, social policies and political systems. They are the forces behind the huge inequality in health we find within and between countries today. Meaning, when we manage to work with living conditions and build fair societies, the health gain is huge!

[Tess · Rating 4 out of 5]

Data-heavy but sound arguments and evidence

[James · Rating 3 out of 5]

Recommended by my boss but don’t tell him I’ve been reading on company time. Anyways considering the year the book was published (2015), the idea that social factors can lead to health outcomes may have seemed revolutionary at the time but it is a well-established and common sense notion in health psychology today. Despite being an almost 300 page book the author does reiterate various ideas more often than is necessary to the point of tedium, which makes sense when you find out the book is based on a 10 page report. Fortunately the content is illuminating more often than not and tackles societal issues such as the myth of trickle-down economics and how wealth disparity can lead to worse outcomes for society.

My only other criticism is that the author is well-intentioned in stating what needs to happen (focus on social benefits and safety nets, developing infrastructure, education and empowerment) but has done little to outline how to finance these improvements (money??). Little has been said about how to actually tackle the growing income disparity and how to (re)distribute wealth to realise these changes without restructuring society as we know it. But that is probably beyond the scope of this book.

tl;dr Address the societal factors causing health issues rather than treating the symptoms.

[Jeremy · Rating 4 out of 5]

Do you love your neighbor and want them to live to their fullest potential? Read this book. Health outcomes should not differ down racial lines, and yet they do. This book presents the data, the case, and the solutions before you. You just need to take the action.

[Grace Lewis · Rating 5 out of 5]

Incredible, very well written, funny and extremely knowledgeable author who is somehow hopefully despite what he is writing about

[Lauren · Rating 5 out of 5]

Michael Marmot is a genius and this book is incredible. A must read for anyone who cares about inequality!

[Meghan · Rating 1 out of 5]

While I think the information and data that is in this book is mostly valuable and there is some interesting content, Marmot is incredibly redundant to the point the book is almost unreadable.

The points about health equity he wants to make are drawn out way too much and the impact of the data he is presenting loses it's value. In explaining his points and dragging everything out, he dumbs down scenarios A LOT but still uses high level language to describe the said dumbed down scenario-it makes 0 sense why the information and data is presented like this.

I found Marmot's tone throughout this book to be incredibly pretentious and his constant name dropping to be absolutely obnoxious.

[Silvia Jackson · Rating 5 out of 5]

So much information that I was completely unaware of. The state of the American Medical Care was very surprising. The World has got a long way to go to become just for all.

[Saffron Snowden · Rating 4 out of 5]

I was introduced to Marmot’s work during a public health module at university. He has done some very important work in health inequalities & inequities which he discusses within this book. Quite a slow burner but I guess this type of book is never going to be an easy bedtime read. It is definitely worth the effort though, and very relevant for people that work with the public, in health and education. As a soon to be practising health professional I have found his work invaluable. You can also catch him delivering some engaging talks about his work on YouTube.

[Nuzhat]

I finally finished!! It took me a long time because I own this book and previously had prioritized my library loans. Because of the pandemic that's happened in the ensuing years since this book was published, the problems of health inequity in the United States especially were highlighted and acknowledged, but what I've seen lacking is still the action to solve the problems. We have so much money, but it's not being spent on improving lives because our politicians can't work toward a common goal of health for all.

[Janice Huang · Rating 4 out of 5]

3.5/5 - I think the biggest personal lesson I learnt from this is that I have no interest in economics whatsoever. In the context of health and how wealth correlates to it, that was bearable, but my nightmare (rather like Marmot's one) would be being stuck in a lift with economists.

My view before this book had already been health --> wealth, so it really just gave me evidence of how evident that is in common sense but oh so difficult to prove without arguing about the details of causation and correlation. It's a very self aware book; Marmot highlights all the weaknesses in his arguments (e.g. he's not making this a political argument), but pointing it out doesn't excuse the fact that it's still a weakness. Marmot is truly an optimist and an ideologist but still a sceptic but not a cynic (as he describes himself). I think that's a pretty good stance for a public health researcher but the hard thing is implementing the 'closing the gap' health strategies. Having the ideals is one thing but actually implementing them is a whole other challenge. I agree very much with him that community empowerment is beneficial and that prevention of ill health by improving living conditions to an equal is more important right now than focussing on treatment (I'm not saying good medical care isn't important, just that we need to raise awareness that factors of lifestyle that you may not be able to control is contributing to ill health).

[Immy · Rating 3 out of 5]

3.5 🌟

[Gabriela · Rating 4 out of 5]

If you’re a healthcare worker or human being fed up with the disparities of basic human rights in this world, get ready to be even more fired up. The author used many statistical facts and comparisons between countries to convey the gaps in healthcare access and how it affects people on multiple levels. He does not so subtlety drop his accolades throughout the book and sometimes jumps from one fact to another unnecessarily. Enjoyed the overall premise and learned a lot.

[Valerie · Rating 1 out of 5]

Admittedly, I gave up on this one. The author talked a lot, but it was mostly sharing his own experiences and very little actual suggestions on policy changes. He urged people to make a difference, but didn't give any specific suggestions.

[Eugenie! · Rating 5 out of 5]

A must-read for all, but easily could’ve been done in half the length of the book. Amazing statistics and visually appealing graphs, though.

[Josh Fielding · Rating 2 out of 5]

Interesting book, but not the most enjoyable read, felt a bit repetitive after a while

[Max Stone · Rating 3 out of 5]

I thought the book was very strong on its main point, which is that the social determinants of health are really important, and underappreciated. I agree with that, and with most (maybe all) of his policy views that result from that orientation.

He's not an awesome writer but he's engaging enough in style and choice of anecdote, he comes up with some powerful metaphors (like how much the expected life span of a person changes with every stop or in every few seconds if you head north from midtown manhattan on a subway), and there's plenty of data and research presented in support of his points.

Why three stars?

I thought he was generally snarky and condescending to views other than his own. And in particular he basically hates economists and the financial industry (disclosure: I work in the finance industry, and tend to like economists) and seemed to take plenty of potshots in their direction, sometimes in ways that advanced his narrative and sometimes just randomly. And his knowledge of, and accuracy in, these areas is low. E.g. when saying we could get rid of worldwide deep poverty (actually I think it was some subset; poverty in slums) for $100bn, which might seem like more than we could possibly collect, but somehow we found $11 trillion to give banks during the financial crisis. (issues: he's probably wrong on the $100bn; but less debatably, he's comparing a one-time cost to an annual cost without acknowledging it, and the $11 trillion was not given but in fact loaned or invested and ultimately made a small profit, so he's comparing gifts to loans which he inaccurately labels as gifts. Those might sound like nitpicks but actually they are really important differences, and it made me basically wonder what else was wrong in other cases where I happened to not be as familiar with the facts.

[Sarah Alamoudi · Rating 5 out of 5]

"The Health Gap" by Michael Marmot is an insightful and thought-provoking book that highlights the alarming issue of health inequalities in our world today. The author provides compelling evidence showing that individuals from lower socio-economic classes have poorer health outcomes and shorter life expectancies than their wealthier counterparts.

Marmot argues that the root cause of these health disparities lies in social inequalities and political policies that promote them. He presents a comprehensive review of the social determinants of health, including income, education, employment, and housing, and how they influence health. The book is rich with historical and contemporary case studies that effectively illustrate how social policies impact health outcomes.

The author also offers practical solutions for reducing health inequalities, such as universal healthcare, addressing the social determinants of health, and promoting social justice. He emphasizes the importance of taking a holistic approach to healthcare and understanding the social, economic, and political factors that influence it.

While Marmot's book focuses on health inequalities around the world, it's worth noting that the concept isn't applicable in Saudi, which has free healthcare. Nevertheless, "The Health Gap" remains a significant read, providing critical insights into the issue of health inequalities that will benefit readers everywhere.

Overall, "The Health Gap" is an informative and compelling book that is essential reading for policymakers and anyone interested in promoting social justice and improving the health of people worldwide.