Researcher Links Low Income to Poor Health
SCOTT SIMON, host:
Right now, health care is hot in the 2008 presidential campaign. All of the candidates have proposals, ranging from universal health care to government-mandated subsidies. But will increasing access to doctors and reducing out-of-pocket costs be enough to ease the nation's most persistent health problems, things like hypertension, heart disease and obesity?
Sir Michael Marmot is a professor of epidemiology and public health at University College of London. He joins us now from our studios there.
Thanks very much for being with us, Sir Michael.
Professor SIR MICHAEL MARMOT (Epidemiology and Public Health, University College London): It's my pleasure.
SIMON: You've done quite a bit of work on studies that linked poverty and other social environmental factors for health. What are the types of health problems you've found that are linked to those circumstances in the U.S.?
Prof. MARMOT: Well, I use the expression the social gradient in health. To make the distinction between what we know clearly, that is people in poverty have poor health, on the one hand, and on the other, the fact that where you are on the social hierarchies intimately bound up with your risk of illness.
So the people who aren't in poverty, but are still below the top have worse health than people at the top. It follows the whole social hierarchy from the top to the bottom of society. And the remarkable thing is that almost all the major causes of death, and of mental illness and suffering follow this social gradient.
SIMON: I think a lot of people will think that poor people should be more susceptible to illness seems self-evident, but explain to us exactly why that is.
Prof. MARMOT: The World Bank uses a figure of $2 a day as the benchmark of poverty. And something like 40 percent of the world's population live on $2 a day or less. No one in North America or Western Europe lives on anything like that. We know that poverty is related to ill health in Sub-Saharan Africa because people don't have enough to eat, because they don't have clean water. Those don't obtain, by and large, in the poorer areas of the United States or Britain.
A key part of it is chronic stress. And the degree of that stress rises as you go down the social hierarchy. And how that manifest in illness? We think of two major ways. One is health behavior. When people are under stress and you talk to them about giving up smoking, about healthy eating, about physical activity, about watching their weight, they say go away, I have other problems to deal with.
But the other way is direct effects from the nervous system on bodily physiology, which increases susceptibility to metabolic disturbances, which increase risk of diabetes, and, we think, to other diseases as well.
SIMON: I think a lot of people listening might be inclined to say that some of the most stress-afflicted people they know are some of the most successful and, one assumes, financially well-off.
Prof. MARMOT: No. We used to think of stress that way, but there was really a revolution in our thinking about it and, in fact, in the evidence. It's almost stressful to be at the bottom of the pile.
SIMON: I think people in the United States have learned over really the past generation how difficult it is to fundamentally, for a lot of reasons, change access to health care. Changing the social gradient would strike me as being even more politically difficult to accomplish.
Prof. MARMOT: Well, I think a simple comparison between Americans and English -and we did this, we published this last year. Take Americans and English aged 55 to 64. We were comparing basically white English, so we compared them with white Americans. In both countries, we saw the social gradient, the lower the income, the lower the education, the more illness there was in both the U.S. and England. But at every level of the social hierarchy, the Americans had more illness than the English.
It was really very striking. I mean, Americans look at Europeans and they say what? They take those summer holidays? They spend all that pleasure time? The Europeans are in no question about the fact that they'd rather have their long holidays and perhaps be a little less productive than the Americans. I wonder if all of your listeners think they've actually got their work-life balance correct.
SIMON: Sir Michael, thank you so much.
Prof. MARMOT: It's a pleasure.
SIMON: Sir Michael Marmot speaking with us from London.