Skip to main content

Professor Sir Michael Marmot, Professor of Epidemiology, University College London

Published on: 9 Mar 2023
Category:

AUTHORS:  Dr Sanketh Rampes and Dr Anvarjon Mukhammadaminov 

In this series the Medspire team interviews doctors about their career, their specialty, the choices they have made and their advice for doctors and medical students.

Today, the subject is Professor Sir Michael Marmot, who is professor of epidemiology, University College London, and director of the UCL Institute of Health Equity. He is author of The Health Gap, and he has led research groups on health inequalities for nearly 50 years. He has also published The Marmot Review: 10 Years On, and Build Back Fairer: The COVID-19 Marmot Review.

A podcast of this interview is available here:

 

Tell us about the social determinants of health and your research.

One of the clear lessons from studies of migrants is their patterns of disease change when they migrate - when they change culture. In  general, this points to the importance of social, cultural, and environmental influences on health. 

The Whitehall Study - which had a huge influence on me and may have influenced some British civil servants - showed that the lower people were in the hierarchy, the higher the mortality from a whole range of causes, and that it wasn't simply explicable on the basis of the usual risk factors. 

So if you looked at smoking, you looked at plasma cholesterol levels, blood pressure, height - which were all important - but it explained less than half of the social gradient. The study suggested there was something about the place you occupy in the hierarchy, and that how you get to be a top-level civil servant, or languish somewhere lower down in the hierarchy, might start in early childhood.  

It may relate to the quality of working life. Or it may relate to the fact that the higher you are in the hierarchy, the higher the income, the more likely you are to live in better living, working conditions.

All of this points to the importance of the social environment. I started using the term ‘social determinants of health’ to describe that. I may have coined the term - I certainly don't lay claim to have coined it, but I can't find who else used it earlier.  I've been doing research for decades. 

I published my first paper on the Whitehall Study in 1978, and thought: ‘What if somebody took the implications of all the research we've been doing seriously, and one thing led to another?’ I went to the World Health Organisation, and met the then new director-general of the WHO, JW Lee. We had a good conversation, and as a result he set up the WHO Commission on Social Determinants of Health, which he asked me to chair. 

That was an important transition from having spent my whole life doing research, to now saying:  'What if somebody took the research seriously?' And of course, we went global. Whitehall civil servants are very important people, but to generalise from Whitehall to low-income countries in South Asia, or Sub-Saharan Africa, or Latin America is a bit of a stretch. So we had to do a lot of work in compiling the evidence on social determinants of health globally. 


 

Over the span of your long career, how has our understanding of social determinants changed?

The European region of the WHO approached me and said: 'We've got simple messages like: “Smoking kills”, and “Eat five a day”. Could you get equivalent simple messages from the research that you and your colleagues have been doing?' 

And that's when we started using the term social determinants of health. We produced a book, published by Oxford University Press, called Social Determinants of Health, and packaged what we thought we understood into ten solid facts. 

We looked at the social gradient, the importance of early childhood, working conditions, neighbourhoods and communities, influences on behaviour, and social isolation. We looked at all those things, and it was a much richer understanding than, for example, I had in approaching the Whitehall Study. 

It was that richer understanding that we took with us to the WHO Commission on Social Determinants of Health, and then it got much richer still. If you're dealing with low-income countries, and globalisation and health, you've got to think about politics and financial organisations, as they are affecting health and the unfair distribution of health. 

So the learning has gone on - not quite continuously - that makes it sound like it was one long linear journey - but in fits and starts. There were huge increases in learning and understanding. 

Then we would coast a bit, and then there would be another significant increment. For example, when we set up The Marmot Review in England, we did not quite start again, but we certainly built on what the WHO Commission had done. 

When we set up the WHO Commission I said we needed input from the world's experts. So we convened nine knowledge networks. It wasn't a blank slate, in the sense that I, with colleagues, decided what the topics for these nine knowledge networks should be. 

But we had scores, if not hundreds, of scientist experts from around the world involved with these nine knowledge networks, bringing to us the evidence on early child development and education, on urban settings, globalisation, employment and working conditions, healthcare, priority public health conditions, and more. 

When we set up The Marmot Review in England, I was asked how we could apply the findings and recommendations of the global commission to England. We didn't quite start again, but we set up, again, nine task groups to review the evidence applying to England. So we had the basis from the WHO Commission. 

We did it remarkably quickly - we just had a year, and we had three or four meetings during the year. One senior person said to me, 'There's so much here. How are you going to bring all this together?' I was grinning from ear-to-ear and said: 'I love it! We're wallowing in information and evidence, so yes, we'll bring it together, but I'd much rather this way.' 

We had data and evidence and recommendations ‘coming out of our ears’, so the task wasn't: ‘Do we have any knowledge about these topics?’ The task was: ‘We've got so much knowledge about these topics, how do we package them into a form that will make sense to people?’ And we did. 

We had six domains of recommendations equally from the start: the importance of early child development; education and life-long learning; employment and working conditions; having sufficient income to lead a healthy life; healthy and sustainable places and communities in which to live and work; and taking a social determinants approach to prevention. 

Those six have stood us in pretty good stead. They summarised the evidence, and we made recommendations within each of those six domains as to what to do to reduce health inequalities and achieve greater health equity.


 

Can you summarise some of those recommendations, and tell us more about the ten years follow-on that you published?

I'm not going to go into all the details of the recommendations, but take early child development. There are two kinds of influences. What we see is that early child development follows a social gradient. 

The lower the socioeconomic position, the greater the deprivation, the less likely are children aged five to be classified as ready for school, and having a good level of development. When I say there are two kinds of influences - there's positive influences, such as caring, nurturing, being a loving, caring person, parent, or important carer, or significant services that support families or replace them. 

What we find is that those positive influences are more frequent the higher you are in the social hierarchy - the less the deprivation, the more cuddling, talking, singing, playing, and reading to children takes place. The other kind of influences are negative ones: adverse childhood experiences, mental illness in the parents, physical abuse of children, psychological abuse, sexual abuse, parental separation, and drug and alcohol problems in the parents. 

They damage children, and almost all of those also follow the social gradient - the more common, the greater the deprivation. It doesn't mean that high-income families are perfect and low-income families are dreadful, but in general, the greater the deprivation, the greater the frequency of these problems. 

Then you could argue -and we did - that there are two types of interventions, broadly speaking. One is, okay, if they relate to deprivation, and reduce poverty. One recent former Chancellor increased poverty from one day to the next. He cancelled the upgrade to Universal Credit. That took £1,000 a year out of the income of poor families, and the estimate is in England that 300,000 extra children will find themselves in poverty. 

So you can increase the number of children in poverty by 300,000 between Wednesday and Thursday. If you can do it one direction, surely you can do it in the other? How about between Thursday and Friday reducing the number of children in poverty by 500,000? 

One recommendation is to use the tax and benefit system to reduce child poverty, and the second is to have services that break the link between deprivation and poor early child development. We documented that 1,000 Sure Start children's centres closed because of lack of funding, and they were designed to break the link between deprivation and poor early child development. These are the kinds of evidence we brought to bear on what you could do.


 

Can you tell us about The Marmot Review: 10 Years and some of your key findings?

We published The Marmot Review in February 2010. In February 2020, almost exactly to the day, we published The Marmot Review: 10 Years On. My simple summary was: we've lost a decade, and it shows. 

Life expectancy had been increasing about one year every four years, for about 100 years in England. In 2010/11 the rate of increase slowed dramatically, and just about ground to a halt. Wow! That's really something. To reverse a century-long trend within a very short time is quite an achievement - to make the population stop having health improvement at the same rate.

The government said at the time: 'Surely you can't be suggesting it's anything we did that could have led to this slowdown. Maybe we just reached peak life expectancy.’ So we looked at other rich countries, and we had the slowest improvement in life expectancy of any rich country except Iceland and the United States. So, no, we had not reached peak life expectancy.

Regarding the social gradient in life expectancy, the greater the deprivation, the shorter the life expectancy. That social gradient had got steeper and inequalities had got bigger, and we saw a marked regional difference. 

If you're rich, it doesn't much matter where in the country you live. The greater the deprivation, the bigger the disadvantage of living in the North East or the North West compared with London or the South East, and for the poorest 10% of people outside London, life expectancy went down. 

We had three major findings. The first was the slowdown in improvement in life expectancy; the second was the increase in inequalities; and the third was life expectancy for the poorest people outside London getting worse. 

Then we asked: 'How could this terrible situation have come about?' The government was quite proud of its mission to reduce public expenditure. It said it on every occasion: 'We're going to cut spending', and they did, but they cut it in a highly regressive way. The poorer the community, the greater the reduction in spending.

So as a policy, they increased poverty, and made inequality worse. That was government policy - they did it, and failed to fund the health service in line with historical inflation. That became very clear with COVID. There was just no slack in the system - there was huge pressure on the NHS, and reduced funding to local government. 

I've mentioned the closure of Sure Start children's centres because of lack of funding, closure of youth counselling centres, and cuts to adult social care. Just cuts, cuts, cuts. If you think that all that public money was going to waste, then why not cut it all out? Don't spend anything. But the evidence is that we probably suffered as a result. 

It's quite likely that that reduction in public expenditure led to the health picture that I've described - the slowdown in health improvement, the increased inequalities, and the fact that life expectancy in the poorest areas outside London got worse. 


 

Tell us about the follow-on report, Build Back Fairer.

We said from the beginning that COVID would expose the underlying inequalities in society and amplify them, and indeed it did. The social gradient in mortality from COVID-19 looks very similar to the social gradient in mortality from all causes, but it's a bit steeper for COVID-19. That's really important, because we think COVID is a virus. 

We don't think heart disease or chronic obstructive pulmonary disease is caused by a virus, but they showed the same kind of gradients that mortality from COVID-19 showed. So it's clear that the causes of inequalities in COVID-19 and the causes of inequalities in health more generally overlap. Then of course, the societal response to COVID, lockdown, increased inequalities. More affluent people could work from home. Poorer people had to go out and work, and frontline occupations were exposed. 

Healthcare workers were the exception, in that you had high-status doctors, surgeons alongside more humble occupations - cleaners, messengers and the like, and everybody else - all in frontline occupations. So there, it wasn't quite the same thing.

But in general, people in higher-status occupations could work from home and keep their jobs. Not only could they keep their jobs and their salaries, they had less opportunity to spend money. They may have wanted to go to fancy restaurants, or go for holidays in the Caribbean, but they couldn't spend their money because of the lockdown. 

The people who were working in the hospitality industry lost their jobs. They might have been on furlough schemes, so they got 80% of their salary. So there was this redistribution upwards. Both because of our 10 Years On Review, and because of the impact of COVID, we called the report Build Back Fairer. 

Not just build back better, but fairer. We said we want to re-establish the status quo that we had before COVID, and the societal response to COVID increased inequalities, so let's learn some lessons, and not try and re-establish what we had before.


 

What can we do, practically, day-to-day to tackle the budget and help improve it? 

We wrestle with this all the time. What can doctors, nurses, and the healthcare system do to address the social determinants of health? We produced two reports: what can doctors do? and then I've worked with nurses to produce a report on what can nurses do? - rather similar.

We said there are five things doctors can do. Firstly, education and training - so understanding the social determinants of health and health equity. Second - which a good doctor should do anyway - seeing the patient in a broader perspective. 

You don't treat a homeless person and sling them back onto the street. It doesn't make either moral, practical, or economic sense to do that. Third is the healthcare institution as an ‘anchor institution’, and this means the health service as an employer - employing nurses, ambulance drivers, lab technicians, cleaners and the like - having good standards of employment, including for doctors. 

More generally, the idea of an anchor institution is that it should have a positive impact on the community. It could employ local people. Its commissions of goods and services could have regard to, 'Will this be good for the local community?' The environmental impact. All of that's important. 

So being involved in your healthcare organisation to ensure that it acts well as an anchor institution is important. The fourth thing is working in partnership. For example, it's not a great idea to treat a homeless person and sling them back onto the street. You may say: 'But I'm a doctor. I don't provide homes for people.' 

So form a partnership with people who do provide homes for people. Paediatricians understand this. They work with people involved in early child development. Geriatricians understand this. They work with people involved in adult social care, for example. And the fifth - very important - advocacy is  standing up for the needs of our patients and our communities.


 

Are there any remaining research questions in your field that you want to answer in the future?

I did an event in Barcelona, but like all events I've done in the last few years, no matter where in the world that is, it's from my desk in London. The event in Barcelona was with a very senior economist. He said: 'We don't do anything about inequalities in health. We don't know anything. 

We've got all these variables and they're all highly correlated, and you don't know anything.' But I've spent 40 years researching it! We've got 200 experts from around the world for the WHO Commission, we've got 80 experts in the UK to give us the best knowledge they could, and what's this guy saying - as if none of that had happened? 

We didn't analyse the data that this high-level economist would have liked, in that way, so I reacted quite sharply. In fact, the organiser wrote to me afterwards and said: 'Thank you so much for the way you rebuffed this attack.' 

When I calmed down, a bit later in the conversation, I said: 'Okay, if you've got 20 brilliant PhD students, take those six domains that I laid out and do research on them. I would never say we know everything about those issues that we'd like to know. I do say we know enough to make recommendations of what action is needed. 

But that doesn't mean we know everything we need to know. If you've got researchers who want to look at the impact on the brain of adverse childhood experiences, go for it. If you've got researchers who want to see if particular programmes work, go for it.'  

So whether it's further understanding of causal processes, biology, the effect of interventions, I would say that my six domains of recommendations could also be a research agenda.


 

What advice would you offer to young researchers interested in pursuing a career in the academic field?

I'm very cautious about offering advice to young people. I have this horrible sense: what if they listened to me? What if they took my advice? That would be terrible. I don't feel wise enough to tell any young person what to do, so I'm very cautious. So my first words of advice are: 'Don't listen to what I say.' And: 'Be cautious in listening to what anybody else tells you is the right thing for you to do.' 

But let me say a negative and a positive. A negative is, in conventional research terms, you don't get much benefit from interdisciplinary collaboration. It's very difficult to earn kudos. The fact that you worked with a neurobiologist and an economist and a cognitive psychologist, you may find it very illuminating, but when it comes to evaluating your work, it doesn't get the same kudos. 

I've had: 'You want to team up with an immunologist. But you're not doing frontline immunology.' No, of course not. I'm not an immunologist. I want to use the understanding of immunology to help illuminate how your position on the social hierarchy influences your health.

I don't have to be at the cutting-edge of immunology. But people are suspicious of this kind of cross-departmental cross-disciplinary work. That's the negative. 

The positive is to understand health equity and the social determinants of health. There's no way of understanding without working with other disciplines, and it's so exciting and engaging and interesting. I feel like a bit of an amateur, but I talk to people in early child development. 

I'm a patron of groups in early child development. I talk to people in lung health. I'm a patron of the British Lung Foundation. I talk to all kinds of different groups. I don't claim to be an expert in all these different fields, but they're all highly relevant to the social determinants of health and health equity. So know how to talk to the experts.  

Any research can be interesting and engaging, so doing something that engages you and is interesting is very important. But it's an absolute privilege to know that what one’s doing in one's day job is trying to improve health for people who are relatively poor, relatively disadvantaged, relatively needy. To know that that's what you're doing in your day job is a privilege. 


 

Did you ever have setbacks in your career, and how did you deal with them?

You deal with the five stages of grief, and self-loathing, feelings of inadequacy - anger, rage, disappointment, all that normal stuff. 'Why don't they understand?' When you calm down from all that, you ask yourself the question: 'Maybe they had a point. Maybe this wasn't as good as it should have been.’ 

So I’ve dealt with setbacks like normal people deal with them - ‘never blame yourself, blame the other guy’, all of that normal stuff. You do it, but actually it’s about trying to develop the maturity to acknowledge that it may be your deficiency that's the issue, not their judgement of your deficiency that's wrong. You may be at fault. 

It takes a bit of maturity to be able to cope with that. That's very important, because you could take it too far and say: 'I'm hopeless. I'm a worthless person.’ So getting that balance right between not taking it too personally and saying, 'I'm worthless', but learning the lesson, is vital.  

Whether it's having a grant application turned down, or a paper rejected - we've all had that. But if you're committed to what you do, you try and learn the lesson, and you come back at it. And that's what I did. And I published a lot of papers.


 

Were there any role models in your life who shaped you?

I had two very important mentors early on, and then a third. I did my PhD with Professor Leonard Syme at the University of California Berkeley.  I don't know if he used the words ‘social determinants of health’, but that's what he taught me. He taught me about the importance of the social environment. 

If he didn't use the words ‘social determinants’, he should have, because he was the one who taught me about the importance of the social environment. So one question is: 'Why does one individual get sick and not another?' And another question is, 'Why is this group more likely to have illness than another?' That second question is the social determinants type question. So he was very important. 

Then there was Geoffrey Rose, who was professor of Epidemiology at the London School of Hygiene and Tropical Medicine. When I came back from Berkeley to work in the UK , and I was working at the London School of Hygiene, Geoffrey Rose was my professor. What I learnt from him was to stick close to the evidence - the data are crucial. He always knew the data, always knew the evidence. I'm not saying Len Syme didn't, but Geoffrey Rose was very close to the evidence. 

If I'm not sure if something is true, I say: 'I'm not sure if this is true. I'm speculating.' If I say something is true, then I'm confident that it is so. I may be wrong - we're all fallible - but it means I'm confident that the evidence supports me. 

I said to my colleagues, when we wrote the report of the WHO Commission on Social Determinants of Health: 'I need to be able to justify every argument in this whole report, and if we haven't got evidence, because the evidence is lacking, then I need a reasoned chain of argument to justify it.' I got that both from Leonard Syme and Geoffrey Rose. 

Towards the end of his career, Geoffrey Rose was sounding more like Leonard Syme - he wrote a very significant paper on sick individuals and sick populations, which made the same point about why does one individual get sick and not another, and why is the rate of illness different, and not another. So they were both very important. 

A third role model was Professor Jerry Morris at the London School of Hygiene and Tropical Medicine. I didn't work for him or with him, but he kidnapped me. I was walking along the corridor at the School of Hygiene and he grabbed my elbow and held on with a steely grip and said: 'Come and have lunch with me.' I did. 

When I became a professor at UCL we used to meet for a simple lunch. But every time it was like a postgraduate seminar. He would range over his intellectual territory, which was extremely broad, and he was utterly committed to social justice, using evidence in the cause of social justice, and he had such intellectual breadths. He was just wonderful. He died aged 99, just before we published The Marmot Review in 2010. 

When we published the report of the WHO Commission on Social Determinants of Health in 2008, I was sitting at my desk one Saturday afternoon and the phone rang, and it was Jerry Morris. He said, 'Michael, your report has transformed the conversation!' I had the report on my desk, and I quickly flipped through it and said: 'We quoted you on page 92.' He said: 'And on page 79.’ 

I thought: ‘Wonderful - he's 98-years old, he's got this report, and he's flipped through it to see if we quoted him, which we did. Later, I said: 'You said that the report changed the conversation.' He said: 'No, I didn't. I said your report transformed the conversation.' 

So he was a role model in his utter commitment to social justice and health, and the evidence. And also at 98-years old, he was sufficiently vain to wonder if we'd actually quoted him in this report, which was probably part of his secret of living so long - he was committed to what he did. So he was wonderful, absolutely wonderful. 


 

What's your favourite book?

I used to say I divided my life into three phases: before I read Tolstoy's War and Peace, while I was reading War and Peace - it's so long - and after I read War and Peace. It's monumental in every way. It's subtle, insightful, it reflects on philosophy and history, and there’s brilliant character formation. 

I heard this lovely debate between two distinguished intellectuals about: 'Who was the greater 19th century writer, Dickens or Tolstoy?' The one arguing for Dickens said: 'Apparently, Tolstoy, above the desk where he worked, had a picture of Dickens'. 

So it's a bit of a toss up whether I go back to read Dickens more often than I read Tolstoy. But they both have great insight into the human condition. I've read A Tale of Two Cities maybe three times, and Great Expectations at least twice, so Dickens looms large. But in the end, if I had to give one award, it would be War and Peace. 

I couldn't read it in Russian, unfortunately, but I began reading it on a train from Moscow to Kaunas in Lithuania. I pulled out War and Peace. I thought: follow Napoleon's retreat from Moscow. While I pulled out War and Peace, my companion, a Russian scientist, pulled out a bottle of vodka. He made more progress with his vodka than I made with War and Peace. I did finish it, but not on that journey.


 

Medspire podcasts are produced by Dr Sanketh Rampes and Dr Anvarjon Mukhammadaminov, both full-time junior doctors. They aim to inspire the next generation of doctors and scientists by exploring the career journeys of leading clinicians and researchers.