In the 1960s, a group of epidemiologists from the University of London set out to study the heart-attack rate among the civil servants of Whitehall. The scientists chose to study civil servants because they were an orderly population; like white mice or fruit flies, they seemed similar to each other in so many respects. They were all white-collar workers, mostly Anglo-Saxon, and all middle class. To Whitehall visitors such as myself it isn’t easy to distinguish a chief administrator from a filing clerk. They don’t wear bowler hats anymore, but many of them have the same dark suits and haircuts and the same courteous, inscrutable bureaucratic manner.
In the late 1960s the scientists managed to persuade about 18,000 men in the civil service in Whitehall then between the ages of forty and sixty-four to participate in the study. They began by looking at obvious risk factors for heart disease such as diet, exercise, and smoking. They weighed and measured the civil servants, compared their blood pressure readings and cholesterol levels, and interviewed them about different aspects of their lifestyles, including their exercise, smoking, eating, and drinking habits.
In 1976, a young epidemiologist named Michael Marmot joined the Whitehall study of civil servants. At first he wasn’t sure what aspect of the civil servants’ health he wanted to measure, but he was interested in the connection between social factors and disease. He was assigned to measure heart-attack rates among workers in different civil service ranks, and soon found that those in the lowest employment grades were four times more likely to die of a heart attack than chief administrators and others at the top of the hierarchy. Lower-grade civil servants were also more likely to come down with other afflictions such as strokes and certain cancers and stomach diseases.
Perhaps the most surprising finding of the Whitehall study at the time was that everyone in the hierarchy seemed to be vulnerable to the effects of social status, not just those at the bottom. Even a small increment in social status could be reflected in statistics on life and death. For example, “administrators,” those in the civil service who design policies and set the strategies for executing them, were half as likely to have a fatal heart attack as the “executives” who ran the various departments and carried out the policies dictated to them by the administrators. For the clerks, who worked for the executives, the risk of a fatal heart attack was three times as high as it was for administrators.
The risk of dying of a heart attack increased steadily, right down the chain of command. For the remaining support staff, such as assistant clerks and data processors, the risk was four times as high as for the administrators. These were middle-class people, and yet all of them seemed to be part of some mortal gradient. In his book Unhealthy Societies, the British economist Richard Wilkinson writes that if a virus or something toxic in the water were killing as many civil servants as the professional hierarchy itself seemed to be, the Whitehall buildings would be evacuated and closed down.
Marmot is around fifty, small as a jockey, with black hair and a physician’s small scrubbed hands. His uniform is the gray suit, blue shirt, and conservative tie affected by educated professional men of his class. Marmot’s father came from a poor Ukrainian Jewish immigrant family in London. He left school at fourteen and went to work in the clothing trade in the East End. When Marmot was a small child, his father’s fortunes began to improve and the family moved often, following a typical social migratory pattern for Jews at the time. From the slums of Whitechapel they moved to Victoria Park in Bethnal Green, then on to Stamford Hill, and then Edgware. At the time, many upwardly mobile Jewish families followed this arc around northeast London. “I suppose,” he told me, “the next step would have been Hampstead garden suburb, but then my father decided to move us all to Australia.”
Marmot went to medical school in Sydney in the 1960s, and it was then that he began exploring the relationship between society and disease. Early on he became impatient with his medical training. “When I was studying medicine,” he said, “I used to walk around the wards in hospital and see all these people with heart disease and chronic bronchitis and liver problems and so on and think, we’re putting Band-Aids on these people. There’s got to be a better way than to wait until people come here with all these problems and then patch them up and send them home or let them die.”
For every patient he treated or watched die, there were always ten more in the waiting room, and many others out in the world progressively becoming ill. Dealing with one patient at a time seemed to him terribly inadequate, like trying to patch up soldiers one by one in a war that is being lost. As he worked on those wards, Marmot’s ambition gradually began to take shape. He wanted to find out why people got sick in the first place. Curing individuals wasn’t enough. He wanted to cure entire societies.
Marmot found that a civil servant’s income was not the only thing that seemed to predict how healthy he was. The size of his house and whether or not he had a car also seemed to predict his likelihood of death or serious illness. “Why should having a three-bedroom house be worse for your health than having a four-bedroom house?” Marmot wondered at the time.
It is well known that people who smoke more and have high cholesterol and high blood pressure are more likely to have heart attacks. Indeed, at least some of Marmot’s top civil servants seemed healthier. More of them were taller and slimmer, fewer of them smoked, and more of them exercised than those in lower grades. What was odd was that class differences in death rates remained even among civil servants without blood pressure or cholesterol problems, and even among nonsmokers and joggers. Less than half of the excess risk of a fatal heart attack in lower-grade civil servants was explained by higher cholesterol, blood pressure, smoking, or other conventional risk factors for heart disease. Simply being senior assistant statistician, rather than chief statistician, increased one’s risk of having a fatal heart attack nearly twofold, even if one led an apparently salubrious life.
Studies of other groups of men in Framingham, Massachusetts, Finland, and the West of Scotland have found similar social patterns of disease. Smoking, diet, and other conventional health risks certainly matter, but social standing seems to matter too, and for some people it matters even more than all the other risks put together. Lower social status also seems to make ordinary risks worse. If a clerk and a manager both smoked twenty cigarettes a day, the clerk was more likely to die of lung cancer.
A growing number of researchers, including George Davey Smith of Bristol University, who worked with Marmot on the Whitehall study, and Sally Macintyre, believe that both health and social position are products of one’s life history. For them, heart disease may begin at birth or even before.
For example, many of today’s middle-class heart-attack victims were children during the 1930s and 1940s. There was considerable inequality then, even in Britain’s new welfare state. Richer children would have been better educated, and they would have eventually obtained better jobs. At the same time, they would have been better nourished, and their own parents would have been stronger and healthier. Stronger, healthier mothers have larger, healthier babies, and there is mounting evidence that heart attacks, strokes, and other chronic diseases are more likely to afflict adults who were small or underweight at birth.
Deprivation in the womb, childhood, and young adulthood may mark us for life. Davey Smith studied a sample of British men and found that those whose fathers had worked as laborers or drivers or at other unskilled jobs were more prone to heart disease and stroke in later life than men whose fathers had been skilled workers, such as professionals and managers. Transient periods of poverty seem to have lasting harmful effects on health, independent of smoking, diet, exercise, and so on. Because social mobility in Britain is limited, people from rich families still much more readily rise to the top of the civil service than people from poorer families. Many lower-ranking civil servants would have therefore experienced more and longer periods of deprivation in early life than their bosses. The residents of Sighthill and other very poor regions would have experienced even greater periods of deprivation, and their health as adults would therefore be that much worse.
Marmot accepts that deprivation in early life is likely to be very important for adult health. However, he also believes that the ways of being poor have changed. In the past poverty meant leaky roofs, exposed sewage, poor nutrition, and risky workplaces, and the diseases of poverty included tuberculosis, cholera, and scarlet fever. Today poverty means not being able to entertain friends, buy children new clothes, eat out, or have holidays. For Marmot, being poor today means feeling powerless and excluded from society.
Marmot suspects that the very poor, and his lower-grade civil servants as well, may all be suffering from different degrees of the same thing, a feeling of relative deprivation. Relative deprivation does not kill people the way open sewers and overcrowded slums do, but it does cause a certain amount of social stress, which may be harmful in other ways.
For most of us, stress is a broad term, often used to describe any kind of emotional problem. But physiologists know a great deal about what stress is. Animals under stress produce particular hormones and react in stereotyped ways. Doctors have long recognized a relationship between heart attacks and stress, and some have even ascribed the modern rise in heart disease to the “stress of modern existence,” traffic jams, deadlines, business trips, and so on, for which our evolution has left us unprepared.
Marmot used a standard psychological questionnaire to determine the types of stress experienced by different civil servants. Psychologists including Robert Karasek distinguish between stress caused by high demands on one’s capacities, such as tight deadlines and overwork, and stress caused by a low sense of “control” over one’s life. The kind of pressure an executive feels when he has too many appointments in his diary, or must make decisions affecting an entire organization, is very different from the kind of stress a clerk feels when he thinks that he is stuck in a routine, under someone else’s often arbitrary authority, and that his life has reached a dead end. Marmot found that feelings of low control over one’s life were associated with lower civil service rank, greater risk of heart attack, and higher blood levels of a substance called fibrinogen, which is associated both with stress and with heart attacks.