Social Determinants of Health and the Commission on Social Determinants of Health

Michael Marmot, University College London, UK

In poor countries, tragically, people die unnecessarily. In rich countries, too, the higher death rate of those in less fortunate social positions is unnecessary. Can there be a link between these two phenomena: inequalities in health among countries and inequalities within? Surely, it might be argued, the depredations of grinding poverty – lack of food, shelter, clean water, and basic medical care or public health – that ravage the lives of the poor in developing countries are different in kind from the way that social disadvantage leads to poor health in modern Britain, for example. There is, however, a link. The unnecessary disease and suffering of the disadvantaged, whether in poor countries or rich, is a result of the way we organise our affairs in society. Failing to meet the fundamental human need of autonomy, empowerment, or human freedom is a potent cause of ill-health.

In making this case, I shall bring together two rather disparate streams of work. The first is a report of my own research endeavour. I have sought explanations for the social gradient in health, as observed in the Whitehall studies, pointing to the fundamental importance of the circumstances in which people live and work. I emphasise control and the opportunities for full social engagement. The second draws on the work of development economists Amartya Sen and Nicholas Stern. Sen suggests we should see development as freedom to lead the life people have reason to value. Stern’s concept of empowerment is close to Sen’s freedom. Without empowerment, argues Stern, economic growth will not bring developments in health and education as well as relief from poverty.