The Health Gap book review: All’s not well

By: | Published: December 13, 2015 12:08 AM

The Health Gap delves deep into the world of health inequality to highlight how social gradient plays an important role in determining life expectancy

The Health Gap
Michael Marmot
Pp 387
Rs 499

WHEN WE speak of inequalities, the reference is usually to income or wealth, with the Gini coefficient used to depict it. However, health inequality is rarely analysed—probably because we take it for granted. Michael Marmot, in his amazing book, The Health Gap, delves deep into the world of health inequality to highlight how social gradient plays a very important role in determining not just access to health facilities, but also life expectancy. Interestingly, he shows how different parts of the same city can have different life expectancy rates because of dissimilar income levels of people.

Marmot’s research shows that culture makes a big difference to health quality. To prove this, he compares the general health conditions of the Japanese living in their own country and those who live outside. He finds that as they move out, the Japanese become distant from their families and are more likely to suffer health issues like hypertension and heart ailments compared with those still living in Japan. Staying in a big family eases living conditions, he says. Similarly, race makes a difference and Marmot explains why the US, despite being one of the largest spenders on healthcare, has lower life expectancy and more maternal deaths than, say, Italy. Also, the probability of an American boy aged 15 years living up to 60 years of age is lower than that of other developed countries—factors like large-scale immigration of people into the US and the low-quality living conditions of coloured people explain this difference.

The basic hypothesis is that once one is born in an underprivileged household, one will be discriminated against in terms of health, besides other cultural mores. Marmot argues that these initial conditions have a bearing on the future course of a person’s life and longevity as well.

The rich, the author argues, also face health issues despite having access to the best facilities, but this is due to their own doing, like eating the wrong food or getting addicted to alcohol, tobacco or drugs. Marmot’s analysis shows that in higher-income countries, obesity is related to lower incomes, but when it comes to low-income countries, it is the higher-income groups that fall prey to it. This is something we can see in India as well. A revelation in the book,
however, is that, in the UK, women with more education and of a high status drink more and hence endanger their health.

One of the solutions advanced by Marmot is education—even though that is also skewed—as an effective way to improve health. Here, the author provides data to show that educated people not only get better jobs and incomes, but also enjoy better health, as they become more conscious of their surroundings, eating habits, lifestyle, etc. Further, among males, education keeps them from trouble and hence improves their life. Marmot points out, quite rightly, that whenever there is a riot, it is always people from the lower-income groups who are involved. We, in India, can identify with this observation quite easily.

A factor that the author keeps harping on is his concern with outcome rather than expenditure. Again, we will find this relevant because we, too, in India spend money on education and health, but never pay attention to quality, which results in poor outcomes. Marmot links health and education while talking about the need for a more effective social system from the government. He is critical of conditional cash transfers for children in Brazil and Mexico, which have been showcased as progressive, as they get the children educated. However, Marmot questions the quality of this education and argues that we should also invest in institutions, so that children can become more able. This is worth thinking about because while in India children do go to school to get, say, a mid-day meal, the dropout rate is very high.

The book is full of such questions, which make the reader think. The author also espouses the role and quality of society, which have a huge bearing on the ‘health gap’. He gives examples of the earthquakes in Chile and Haiti, which happened almost at the same time and resulted in deaths of around a couple of hundreds in the former and over two lakh in the latter. This difference was due to the response of society, including the government, he says. This hypothesis also explains why infant mortality is the lowest in Kerala, as society there takes this issue very seriously.

In the same breath, Marmot argues that governments should not cut back on health-related expenditure, which, unfortunately, has become the norm in Europe after the financial crisis, where government austerity has been called for.

The book is refreshing and quite novel because it highlights issues we usually chose to ignore. By tracing all inequality to health and education, Marmot’s work appears to be an extension of Thomas Piketty’s—the flavour of the season. We talk of a market system, which is fair and open to all and where only the best succeed, but everybody doesn’t begin life with the same opportunities. As you peruse the pages of the book, you are likely to say, “Who doesn’t know this?”, but what we need is ask ourselves, “Why have I not thought of its significance?” and, as a corollary, “What should we be doing to reduce this social gradient?” to have a more equitable society. If you do this, as this reviewer did, the author would have accomplished a great deal.

Madan Sabnavis is chief economist, CARE Ratings

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