To Have and Have Not
Reviewed by Eric Klinenberg
Sunday, August 1, 2004; Page BW03
THE STATUS SYNDROME
How Social Standing Affects Our Health and Longevity
By Michael Marmot. Times. 319 pp. $26
Board the Metro train underground in Southeast Washington, D.C., and head up toward leafy Montgomery County, Md. With each mile you travel, life expectancy increases about a year and a half. The average suburbanite near the Shady Grove station will live 20 years longer than the typical city dweller around Capitol Heights. She will also outlast her counterparts in Dupont Circle and Chinatown. And, along the way, she'll enjoy better health, less stress and more autonomy. The same pattern holds in your office. The CEO will likely live longer and (by most measures) better than the vice president, the secretary will be healthier and happier than the receptionist, and so on. Education helps, so the staff attorney will outlive the sales manager, even if their salaries are identical. You're not exempt if you work in an unconventional field, either. According to a recent study, Academy Award-winning actors outlive unsuccessful Oscar nominees by roughly four years. Thank you, Academy, indeed.
Conventional accounts of American inequality portray it as a two-sided phenomenon. We have "two nations, one rich, one poor," or an "other America" hidden from view. But a subway ride through the capital and a bird's-eye view of the workplace suggest another condition. There is a social gradient, a status hierarchy, and everyone has a position in it. For most of us, that spot determines longevity and quality of life. If you don't keep up with the Joneses, they'll be around for your funeral. If you live in a place as socially unequal as an American city, they might be there for your children's funeral, too.
Nations are also unequal, and they have been growing more so for a generation. Today Japanese men have the world's longest life expectancy for their sex: 77 years (compared to 75 for American men, 79 for American women). An average Russian man lives to the age of 57, 20 years longer than men in Sierra Leone, who are lucky to make it past 37.
Michael Marmot, professor of epidemiology and public health at University College, London, calls this phenomenon the status syndrome. His bold, important and masterful new book not only explains the social sources of this global pandemic, it sets an agenda for a radically different approach to health policy. Drawing from his work as a participant in the British government's Independent Inquiry into Inequalities in Health (published as the Acheson Report), Marmot argues that investing in child care and better education for the disadvantaged, cleaning hazardous urban environments, and providing social support for the elderly are the best antidotes to the status syndrome. In the United States, where medical spending is double that of comparably healthy nations, Marmot's message is not just timely, it's urgent.
What causes the status syndrome? Money matters, particularly for the poor. For the 2.5 billion people in the world who live on less than $2 a day, absolute poverty -- a lack of food, shelter and sanitation -- is the primary problem. Yet income is not the whole story. Life expectancy in Israel, New Zealand, Malta and Greece is higher than in the United States, even though the GDP per person is less than $20,000 in each of these nations and more than $34,000 here. Costa Ricans outlive Americans by a full year despite a GDP per person that's less than $10,000, and Cubans, at about $5,000 per person, enjoy roughly the same lifespan we do. Extreme status disparities and social segregation at the national level undermine public health, whereas relative equality, social cohesion and strong public education systems promote collective well-being. Perhaps it's not surprising that the three countries with the longest life expectancy are Japan, Sweden and Canada.
Above a certain threshold it's deprivation relative to others in one's society that matters, even for those (like the Oscar nominees) near the top of the ladder. The reason, Marmot argues, is that social participation -- rewarding relationships, access to a community, and the respect of others -- and individual autonomy are crucial determinants of health and happiness. High status usually affords more opportunities for social involvement and control of one's conditions. Low status means that external forces -- a mean-spirited boss, a company that dumps toxic waste near your neighborhood -- are more likely to determine one's fate, social support is less reliable, and insecurity is a feature of daily life. Although the meaning of full participation varies from places to place, Marmot claims that the beneficial effects of being connected are constant.
Lack of agency produces dangerous forms of stress. People who labor in dull, dead-end yet demanding jobs suffer from an imbalance between their efforts and rewards. As recent studies of coronary disease in Britain and seven Eastern European countries show, work that deprives men and women of control destroys the heart as well as the soul. Moreover, a daily onslaught of difficulties makes people less likely to focus on their long-term health. Marmot believes that the vulnerable understand their grim condition, and that they engage in dangerous but pleasurable behaviors such as smoking or overindulging in fast food because they prefer enjoying the moment to holding out for a future they might not reach.
Marmot concedes that bad jobs, wealth disparities and status hierarchies are inevitable features of modern societies. But some societies are more equal than others. Governments can, and in the most flourishing countries do, decrease the slope of the social gradient and improve public health. In England, for example, the government has been quietly redistributing income since 1997, using fiscal policies to compensate for social divisions produced by the labor market. In the United States, however, recent tax changes have steepened the gradient. According to Marmot's surprising conclusion, the most effective and affordable health policies do not involve the medical system but programs that reduce income and educational inequalities, protect workers and families, provide access to housing and safe environments, and promote care for children and the elderly.
There's good evidence that skimping on these fundamental and wide-ranging social protections while spending lavishly on medical care is foolish public policy. Cross-nationally, the longevity gap tends to decrease during eras of social equalization and increase during periods of polarization. Americans have learned this the hard way. Outspending all competitor nations on health care has not helped to raise U.S. life expectancy above the level of Spain, Cyprus or Singapore, where the social gradients are more even. We've all heard officials say that the United States has the best medical system in the world. Whether or not that's true, longevity is greater in France, the United Kingdom and Canada.
Today, medical experts and ordinary voters may not connect their concerns over health to domestic policies that cut taxes for the affluent, assistance for the poor and security for the elderly. But The Status Syndrome shows that paring down these programs is more dangerous than most of us recognize. •
Eric Klinenberg is assistant professor of sociology at New York University and the author of "Heat Wave: A Social Autopsy of Disaster in Chicago."
© 2004 The Washington Post Company