The Whitehall Studies

Donald Reid and Geoffrey Rose initiated the first Whitehall study in the 1960s to look into disease causes and risk factors (e.g., smoking and high blood pressure). This long-term study included over 18,000 men in the British Civil Service. The researchers originally considered social class to be a control variable and not a potential reason for differences in health outcomes (Ferrie, 2004; Marmot & Brunner, 2005).

When Michael Marmot joined the study team in the 1970s, he was interested in the social causes of ill health and so, the Whitehall researchers began to look closely at employment class as a health variable. A common belief at the time was that people in high-power jobs, such as business executives, would be under a lot of stress, which would lead to heart disease and ulcers. The expectation was that people in higher-level jobs would be more likely to have stress-related health problems than those in lower level jobs.

The Whitehall study results did not support this way of thinking. The researchers analyzed the middle-aged men in the study according to the grade or type of job they held. The data showed a steep social gradient such that the lower the employee was on the employment hierarchy the greater the risk for heart disease and every major cause of death (Marmot, n.d.). Furthermore, when the researchers conducted a follow-up ten years later, there was also a steep gradient based on level of employment for death from all causes. In other words, the lower the employees were on the employment hierarchy, the greater their risk of death (Marmot & Brunner, 2005).

The Whitehall study refuted another commonly held belief that the gradient exists because people who experience poverty are unhealthy while those who are not experiencing poverty enjoy reasonably good health (Ferrie, 2004). The Whitehall study subjects were not poor by most standards. They were in fact living above the poverty threshold. Thus, as Marmot (n.d., p. 2) says, “it was not just about poverty”. Marmot explains, “The usual explanation for inequalities in health is lifestyle. There are clear socioeconomic differences in smoking and other unhealthy types of behavior. . . yet controlling for these factors had little effect on the socioeconomic differences in coronary heart disease” (Marmot, 2001, p. 135). Thus, it is something other than the socioeconomic differences in lifestyle that accounts for the differences in heart disease rates.

Marmot and Brunner (2005) explain that the Whitehall II study was set up to investigate further the social gradient in death and disease. They also included women in this second study. The study began in the mid-1980s and included over 10,000 London civil servants aged 35 – 55. They held a variety of positions from lower level clerical to middle management to executive and senior positions. The researchers followed the subjects over time and collected data regularly on a variety of variables, such as:

  • Demographic and socioeconomic information (e.g., education, income)
  • Psychosocial work experiences (social support, demand-control)
  • Health behaviours (smoking, alcohol, diet, activity)
  • Cardiovascular disease
  • General health (subjective reporting)
  • Mental health (subjective reporting)
  • Health outcomes (objective measures such as sick leave, heart problems, stroke, depression)

Over 15 years of data have been analyzed for the Whitehall II study and there are inverse social gradients for a wide range of health problems, for example, heart disease, some cancers, lung disease, gastrointestinal disease, depression, suicide, sick leave, back pain and general feelings of ill-health (Ferrie, 2004; Marmot & Brummer, 2005). In other words, at each level of employment, people are more likely to be sick than people at a level higher.

In attempting to explain the reason for the social gradient for health, Marmot (n.d.) cites two important factors identified in the study: autonomy (having control over one’s life) and social participation (being involved in a social network and benefiting from social interaction). The lower people’s level of employment, the less autonomy they have and the less able they are to participate fully in society (Marmot, n.d.). Both low autonomy/control and social support were shown to contribute to the gradient in physical and mental health, independent of a person’s individual characteristics (Ferrie, 2004).

While the Whitehall studies were conducted in Britain, we see similar results around the world in developed countries (Ferrie, 2004) and in the majority world (Marmot, personal communication). The Whitehall studies contribute to our understanding of how social factors impact morbidity (disease rates) and mortality (death rates). Wilkinson and Marmot (2003) point out that focusing on the social determinants of health has great potential for improving the health of individuals and populations. Governments and health policy makers must pay attention to the social and economic factors that affect individual and population health. As Ferrie (2004, p. 4) points out, “inequalities in health cannot be divorced from inequalities in society. The inescapable conclusion is that to address inequalities in health it is necessary both to understand how social organization affects health and to find ways to improve the conditions in which people work and live.”

References

Ferrie, J. E., (Ed.). (2004). Work stress and health: The Whitehall II study.Council of Civil Service Unions/Cabinet Office. http://www.workstress.net/sites/default/files/whitehall_11_study.pdf

Marmot, M. (2001). Inequities in health. New England Journal of Medicine, 345(2), 134-136. https://www.nejm.org/doi/full/10.1056/NEJM200107123450210

Marmot, M. (n.d.). Interview with Sir Michael Marmot. 
https://unnaturalcauses.org/assets/uploads/file/MichaelMarmot.pdf

Marmot, M., & Brunner, E. (2005). Cohort Profile: The Whitehall II study. International Journal of Epidemiology, 34(2), 251-256. https://academic.oup.com/ije/article/34/2/251/746997

Wilkinson, R., & Marmot, M. (Eds.). (2003). Social determinants of health: The solid facts (2nd ed.). World Health Organization.