Michael Marmot: "The Health Gap"

The Health Gap: The Challenge of an Unequal World

By Michael Marmot

From Chapter 1 - The Organisation of Misery

I have used two terms, health inequalities and health inequities. From now on, I am going to use the term health inequities to refer to those systemic inequalities in health between social groups that are judged to be avoidable by reasonable means. Such an approach does not cut off debate. There is ample disagreement as to what are "reasonable means." But it focuses the argument. Why is this fundamental? Because if people are suffering from ill-health in ways that could be remedied but are not, that is quite simply unjust.

From Chapter 9 - Fair Societies

Proportionate universalism

It was the evidence provided by our Nordic colleagues that led us, at the UCL Institute of Health Equity, to come up with the ugly neologism "proportionate universalism." Let me explain.

When the British government was planning its Sure Start policy for early child development, I went to a meeting at Her Majesty's Treasury to discuss the proposed programmme. It turned out that the initial plans for Sure Start were to target it at the most deprived communities. I showed the group the social gradient in literacy of young people according to parents' education and pointed out that at the top, parents with the highest levels of education, our young people's literacy levels were on a par with Sweden and Japan. But the gradient was steeper in Britain than in Japan and Sweden; the result was that the lower you go in the social hierarchy the worse our young people score compared with Sweden and Japan. The implication was that Sure Start should be for everyone, not only for the worst off.

The senior Treasury official, the wonderful Norman Glass (deceased sadly), said: "Don't come to me with that Scandinavian nonsense about universal interventions. We're Anglo-Saxons. We target and focus on the worst off."

Anglo-Saxon? Norman was Irish-Jewish, but the point was well made. The default position of British social policy is to target interventions on the worst off. It seems to make sense. The problem with such "common sense" is that it ignores the gradient. All the social and related health problems that we see follow a social gradient. That disadvantage of focusing on the worst off is that you miss those, say, in the middle who have worse health than those at the top, albeit better than those beneath them on the ladder.

It is not just from the Nordic countries that we learned the importance of universalist policies. In Chile they talk of Chile Solidario. The aim is to bring the most socially excluded into the mainstream of society, to emphasize their rights and entitlements, not to see the state as a charitable institution handing out help to a grateful poor. Proportionate universalism is an attempt to marry the obvious need to work hardest on behalf of those in greatest need while preserving the universalist nature of social interventions. Services for the poor are poor services. We should want everyone to gain the benefits of universal policies while putting in effort proportionate to need. A key principle is social cohesion.


Key to living in society is empathy and connectedness - genuine feeling for our fellow members of society. The separate, compartmented lives of people at the top, middle and bottom damage this vital ingredient of society. The previous chapters spell out, in detail, how this lack can damage health through the life course and in communities.

From Chapter 11 - The Organisation of Hope

What the figures on income and wealth show is that there are oceans of money sloshing about. It is not easy to maintain the fiction that we do not have enough money to do good things. The problem is that, within countries, the concentration of wealth is becoming more extreme. That was the message of Piketty's "Capital in the Twenty-First Century." At the same time as wealth concentration is increasing, all across Europe and the US we are being lectured to on the dire importance of austerity. Public services have to be cut back because… because… we cannot afford them?

John Maynard Keynes, immediately after the Second World War, wrote: "The day is not far off when the economic problem will take the back seat where it belongs, and the arena of the heart and the head will be occupied or reoccupied, by our real problems - the problems of life and human relations, of creation and behavior and religion." In country after country, too much of our public conversation is about how we can grow national income, too little about how we can improve society.


One senior Conservative politician in Britain put it to me that my agenda is closer to social democratic than to Conservative thinking. I have tried studiously in public, and in this book, to make my case on the evidence, not on prior political beliefs. My response to this politician was that avoidable health inequality, health inequity, was the deepest injustice in our society. Was he saying that only social democratic politicians cared? I hoped not. Further, showing that politicians distort the evidence to suit their political ends was not a party-political act; it should be aimed at all our political leaders whatever their makeup. No political party has a monopoly on purveying misleading information.


If you are in a country with poorly developed social systems, do something. It will make a difference. If your country is on the way, do more. And if you are in the Nordic countries, do it better.

Do something. Do more. Do it better.

(Sir Michael Marmot is professor of epidemiology and public health at University College London, and current president of the World Medical Association.)



By Don McCanne, M.D.

As Michael Marmot explains so well in "The Health Gap," our health inequities stem from our failure to implement "proportionate universalism," which he describes in the excerpts above - a must read. In fact, after reading the excerpts, you may agree that his entire book is a must read.

A single payer system standing alone would not be enough to ensure health equity, as Marmot explains in "The Health Gap," but it would mesh perfectly with proportionate universalism. We just have to do more and do it better.