Elsevier

The Lancet

Volume 368, Issue 9552, 9–15 December 2006, Pages 2081-2094
The Lancet

Lecture
Health in an unequal world

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William Harvey and the Harveian Trust

William Harvey was born in Folkestone on April 1, 1578. He was educated at the King's School, Canterbury, Gonville, and Caius College, Cambridge, and the University of Padua, graduating as doctor of arts and medicine in 1602. He became a Fellow of the Royal College of Physicians in 1607 and was appointed to the Lumleian lectureship in 1615.

In the cycles of his Lumleian lectures over the next 13 years, Harvey developed and refined his ideas about the circulation of the blood. He published his

Professor Sir Michael Marmot

Michael Marmot is Director of the International Institute for Society and Health, and MRC Research Professor of Epidemiology and Public Health at University College London. He has been at the forefront of research into health inequalities for the past 30 years. He is Principal Investigator of the Whitehall Studies of British civil servants, investigating explanations for the striking inverse social gradient in morbidity and mortality. He leads the English Longitudinal Study of Ageing (ELSA) and

A lesson in the importance of environment

As physicians we are trained that the patient comes first and last. Searching out individual causes of disease, however, does not negate the importance of environmental causes. Studies of migrants show that as environments change, disease rates change. I learnt this lesson through engagement with Leonard Syme and others in a study of men of Japanese ancestry, living in Japan, Hawaii, and California. As Japanese men migrate across the Pacific, the rate of coronary heart disease rises and the

Social gradient in richer countries

My starting point is the Whitehall study of British civil servants.13 Figure 1 shows results from the 25-year mortality follow-up of men, originally aged 40–69, by age at death. The graded nature of the link between position in the hierarchy and death—the social gradient in mortality—is the challenge to understanding. The gradient is a broader issue than that of poverty and health. We have no difficulty in contemplating how dirty water, poor sanitary facilities, and inadequate nutrition and

Inequalities between countries

Life expectancy for some countries is shown in table 2, along with gross domestic product (GDP) adjusted for purchasing power. The range of life expectancy is staggeringly large: from 32·5 years (both sexes) in Swaziland to 82 years in Japan.34 This gap in life expectancy has been growing. Figure 4 has much to encourage us and much to depress.34 Life expectancy in the high-income countries of the Organisation for Economic Co-operation and Development (OECD) increased from 71·6 years to 78·8 in

Inequalities in health are not inevitable

Before diving into the question of explanations of inequalities in health and, hence, what we could do about them, I should make clear that they are not inevitable. Starting first with inequalities among countries, there is nothing inevitable about the data in figure 4. The rapid health improvements in some countries and the lack of improvement in others suggest that changes in social and environmental conditions, and in public health and basic medical care, could do much to change things for

Poverty: lack of money and more

I have set myself the task of trying to achieve a unifying explanation for health inequalities that takes in both the disastrously poor health (life expectancy below 40 years) of some extremely poor countries and the social gradient in health that we see in rich and poor countries alike. I might seem to have a steep hill to climb.

Poverty is widespread: 2·5 billion people, 40% of the world's population, live on less than US$2 a day. That they have poor health as a result is not difficult to

A framework for explanation of inequalities in health within and between countries

In both poor and rich countries, poverty is more than lack of money. For its 2000–01 World Development Report, the World Bank interviewed 60 000 people in 47 countries45 about what relief of poverty meant to them. The answers were: opportunity, empowerment, and security. Dignity was frequently mentioned. Indeed, dignity has strong claims for consideration by those of us concerned with society and health.46, 47 A similar exercise in Europe showed that people felt themselves to be poor if they

Control and social engagement as contributors to inequalities in health

I use control and social engagement as an organising principle, a way of thinking, about human needs that might relate to health on the one hand and the nature of our social arrangements on the other. They are, though, more than an organising principle since there is direct evidence to support them.

My group studied control, initially, in the workplace. The context was the Whitehall II study of British civil servants in which the lower the position in the occupational hierarchy the higher the

Pathways linking autonomy and social engagement to health

One set of pathways are those linking autonomy and engagement to resources that lead to better health. Szreter finds no mystery in the link between social capital and health in Victorian England. It led to community action to provide clean water supplies.51, 85 If social inclusion means that more people are involved in education, they will benefit from all the economic, social, and psychological benefits that education can bring. As stated above, an approach to controlling HIV/AIDS in southern

Medical care?

I have said little about medical care. There is no question that part of improving health in poorer countries, as in richer, is the provision of comprehensive primary care. In a well-organised society there should be universal access to high quality medical care. The whole principle of the UK National Health Service is universal provision and that seems a principle worth exporting. In poorer countries of the world, as in some richer ones, attempts at universal provision do not guarantee

Creating freedom and empowerment

If empowerment is so important for health, how does it arise? Stern conceives of three classes of influence.3 First are individual endowments: assets and human capital. Second are external constraints that come from the context of family, community (including caste and religion), society, and systems of governance, all of which shape people's lives. Third, individuals have internal constraints on their actions associated with their preferences and perceptions of their role. These classes of

Research as a guide to action

A mark of our civilisation is that we value scientific understanding for its own sake. The Enlightenment brought with it the idea that critical questioning was a better way to the truth than received wisdom. Hence we prize research and scholarship because they enrich us culturally. It is not against this spirit that we might want to apply our knowledge. As physicians we seek not only to understand, but also to makes things better. So, too, in public health but the sphere of action is collective

The physician and social change

Rudolph Virchow has featured many times in these Lectures. Paul Nurse, for example, quotes Virchow's understanding of cells: “that every animal appears as a sum of vital units, each of which bears in itself the complete characteristics of life”. My first contact with Virchow's writing was in relation to his studies of the blood and blood vessels that are important still for our understanding of the pathology of atherosclerosis.

As well as being a scientist who contributed so much to our

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