The Health Gap: The Challenge of an Unequal World by Michael Marmot, book review: Medicine for a morally ailing society

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Seventy years ago, the National Health Service was set up on the understanding that good health mattered a very great deal to a society and was a right for all, not a privilege for a few. The NHS transformed the country, freeing millions from a cruel choice between disease and the penury caused by paying for the treatment of disease.

One might argue, though, that the NHS was misnamed. By health, do we not really mean how fit we are, how pain-free, how functional our bodies and our minds? And while the NHS might remedy a pain, or repair a body or a mind, it is not – or it is very rarely – there in our homes, on the street, in our schools and in our workplaces, championing our health. Wonderful as it is, really it should be called the National Treatment Service. But what if the same principles of social solidarity that created the NHS were applied not just to the treatment of ill health, but to the facilitation of good health – for all, not just for a few? It is to plea for this that Professor Sir Michael Marmot has written The Health Gap: the Challenge of an Unequal World.

The animating idea behind Marmot's life work is that social injustice is bad for our health. His research over the years has generated a catalogue of shocking headline findings, which are collected in this book to devastating effect. Page after page rams home the message that the poorer you are, the more likely you are to live a shorter, less healthy and in all likelihood less happy life.

This rings true between and within countries. Thirty-eight years separate the average life expectancy in impoverished Sierra Leone from wealthy Japan. Twenty years separate the life expectancy of the poorest citizens of Glasgow from their wealthiest near neighbours.

The Health Gap briskly and coherently explores why this might be the case. First we look at the impact of early childhood development, at how – miserably – maternal depression rates are highest among the poor, leading to less reading, encouragement and social interaction for an infant mind.

Next, education. Evidence from around the world suggests that good schooling has extraordinary benefits for health. In Mozambique, for example, infant mortality rates are halved among women with a secondary school education, compared to those with none.

Then, the world of work. Jobs that combine high demand with little control, much effort with little reward, increase our risk of heart disease and mental illness. So much for the "tough at the top" hypothesis. Unemployment, meanwhile, has been shown to be bad for mental health – plus, it raises the risk of a premature death. But Marmot is no doom-monger. Quite the opposite. Despite the bleak evidence of health inequality he sets out, this is a fundamentally optimistic book. As he demonstrates in the final chapters, there is a great deal that can be done about the problem.

After reading his evidence, it all seems rather obvious, but spending more money on society – financial and material support for parents, comprehensive education, good wages, job creation, a strong social security safety net – does the trick.

As Marmot wryly acknowledges throughout the book, this takes us firmly into the domain of politics. His argument is that the evidence base is now strong enough that the moral absolute that is health and health equity should cut through debates about the size of the state.

With the moral authority of a doctor he diagnoses an ill in society and proposes a remedy. We – well, most of us – accept that treatment for the sick is a basic right the state should pay for. So why not the foundations for a life that minimises the chance of becoming sick?

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