Intended for healthcare professionals

Education And Debate

Psychosocial and material pathways in the relation between income and health: a response to Lynch et al

BMJ 2001; 322 doi: (Published 19 May 2001) Cite this as: BMJ 2001;322:1233
  1. Michael Marmot, research professor (,
  2. Richard G Wilkinson, professorb
  1. a International Centre for Health and Society, Department of Epidemiology and Public Health, University College London, London WC1E 6BT
  2. b Trafford Centre for Medical Research, University of Sussex, Brighton BN19RY
  1. Correspondence to: M Marmot

    Much of the debate on health inequalities has centred on the damage done by poverty. However, evidence suggests that health is also related to inequality. Firstly, as the Whitehall studies of British civil servants show, there is a gradient in health among those who are not poor, indicating that the higher the socioeconomic position, the lower the morbidity and mortality.14 Whole population samples show that this gradient runs right across societies and that its magnitude varies between societies and over time. 5 6 Although absolute mortality has been falling in Britain, inequalities in mortality have increased. 7 8 Secondly, despite the health gradient within societies, there is little relation between average income (gross domestic product per capita) and life expectancy in rich countries. This suggests that absolute material standards are not, in themselves, the key. Thirdly, there is a strong relation between mortality and income inequalities. People living in countries with greater income inequality have a shorter life expectancy.911 Furthermore, a similar relation has been found for geographical areas within countries.1215

    Summary points

    Economic and social circumstances affect health through the physiological effects of their emotional and social meanings and the direct effects of material circumstances

    Material conditions do not adequately explain health inequalities in rich countries

    The relation between smaller inequalities in income and better population health reflects increased psychosocial wellbeing

    In rich countries wellbeing is more closely related to relative income than absolute income

    Social dominance, inequality, autonomy, and the quality of social relations have an impact on psychosocial wellbeing and are among the most powerful explanations for the pattern of population health in rich countries

    Importance of psychosocial pathways

    These observations support our argument that there are psychosocial pathways associated with relative disadvantage which act in addition to the direct effects of absolute material …

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