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Cadernos de Saúde Pública

On-line version ISSN 1678-4464

Cad. Saúde Pública vol.32 no.11 Rio de Janeiro Nov. 2016  Epub Dec 08, 2016 



Marcos Paulo de Lucca-Silveira¹  * 

¹Faculdade de Filosofia, Letras e Ciências Humanas, Universidade de São Paulo, São Paulo, Brasil.

THE HEALTH GAP: THE CHALLENGE OF AN UNEQUAL WORLD. Marmot, M. London/New York: Bloomsbury, 2015. 400p. ISBN: 978-1-63286-078-1.

In his book, The Health Gap: The Challenge of an Unequal World, Michael Marmot develops his already famous and important argument on the impact that societies' socio-economic characteristics have on the health of their populations. Presenting a study aimed at a wide range of readers, beyond the barriers of the academic and scientific community, Marmot seeks to answer this broad question: "what we can do to improve people's lives?" (p. 21). Using a wealth of data from his own studies as well as recent literature from various fields of research, the book argues that the conditions in which people live are key influences on their health.

However, it is necessary to go beyond this general observation. As the author suggests, the book can be understood as a reflection on the paradox of contemporary population health. If, on the one hand, we live at a time where there is a significant improvement in overall health, on the other hand, good health is unevenly distributed. Global health inequality has reached a very high level. Moreover, in many countries health inequity is growing, with the health of better off population groups progressing faster than that of worse off groups. Major contemporary scientific and technical advances have been made, but access to these advances is extremely unequal.

In short, one can say that the distribution of resources that matter - economic, social, cultural, material and symbolic resources, amongst others - is extremely uneven in most contemporary societies. The result of this unequal distribution, as Marmot shows throughout the book, is that health is unequally distributed amongst members of the population. There is a social gradient in health: "in between top and bottom, health improved steadly with rank" (p. 11). Thus, it is necessary to overcome the mistaken understanding that health inequalities are merely a marginal problem of the population health agenda, only generating significant results regarding the health of the extremely poor. The effects of the inequalities are not limited to their impact on the health of worse off groups; they affect the health of all members of society.

It would therefore be pertinent to ask: which health inequalities are unjust? Marmot exhaustively answers this question. In his eyes, "health inequalities that can be avoided are unjust" (p. 29), and, consequently, "social injustice is killing on a grand scale" (p. 20) in contemporary societies. According to the author, a key category for understanding the social gradient in health is the notion of empowerment. The worse off a person is in the social hierarchy, the less control they will have over their own lives and, consequently, the worse their health. On the other hand, the higher a person's economic and social status, the greater control over their lives and the better their health. Thus, a central argument in the study is evident: tackling disempowerment is crucial to improving health.

The author lists three means of empowerment: the material dimension, directly associated with well-being; the psychosocial dimension, having control over one's own life, and finally the political dimension, associated with having a voice and being heard (Chapter 7). Essentially, the notion of empowerment means the freedom to live a valued life, the freedom of doing and being what you want. According to the author, this fundamental freedom, of which many are now deprived, is crucial for good health.

In several chapters of the book, Marmot shows readers how the characteristics, conditions and resource distributions of contemporary societies impact population health. The study focuses on the conditions of early child development (Chapter 4), education (Chapter 5), employment and working conditions (Chapter 6), conditions for older people (Chapter 7), and of resilient communities (Chapter 8). Changes and improvements in contemporary conditions and distributions are necessary in order to improve health and reduce health inequities.

People who have the freedom to live life as they wish tend to make decisions that positively influence their health and well-being (Chapter 2). We should, for example, pay special attention to the education and empowerment of women, reducing the vulnerability associated with the issue of gender, moving towards health equity.

Undoubtedly, the existence of health care and high quality health assistance for all would be of great importance. However, what Marmot seeks to emphasize is that health inequalities are associated with conditions that make people ill, and which do not cease to exist in societies that provide free, high quality, public health assistance. Furthermore, the author even questions the focus often given to a country's economic growth, its gross domestic product (GDP) or its total expenditure on health. As he shows with the help of data, money matters more if you are in a poor country and have little of it than if your country is relatively economically well off (Chapter 9).

Moreover, Marmot proposes a radical and important change to measure the success and performance of a society. He proposes that instead of focusing our attention on economic agendas and measuring a country's performance through its economic growth rates or GDP, the level of health and the magnitude of the social gradient in the health of a population can be used to tell us how well a country is doing. A good society is one in which the health of the population is good, health equity is high, and both improve over time.

Thus, Marmot suggests that, when concerned with population health, we should pay attention to the distribution of power, money and resources, since this distribution gives rise to the inequalities in daily life that cause health inequity. As the author seeks to highlight, inequalities in health that are avoidable by reasonable means, but that are not avoided, are unjust, inequitable.

Finally, the message Marmot transmits to the reader can be summed up in the idea that "health is political" (p. 20). Moreover, we must "put health equity at the heart of all policy-making" (p. 309). A very important message, which per se encourages us to read the book.

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