Marmot – health gradients

We see the gradient in health pretty well everywhere. I was talking with a group of researchers working in Sub-Saharan Africa, and one of them said to me “Oh, the gradient isn’t an effete concern of people in rich countries, where we’re working it’s the poorest of the poor , that’s the issue”. I said “If you found a group with an under five mortality, of 150 per thousand live births would you think that was worthy of your attention – 150 per thousand live births given that in the better off parts of Europe it’s three per thousand live births?” He said “yes”. Okay, that’s the middle quintile in Uganda.” In fact, the top quintile, the best off quintile in Uganda, oh sorry, that middle quintile in Uganda is worse than the bottom quintile in India.  

If you focus only on the bottom, you miss most of the problem. The fact is, everyone in Uganda is at high risk. And we see the gradient in under-five-mortality in Uganda, and India, and Kyrgyzstan, and Peru, and everywhere we look. Now I’m quoting under-five-mortality because these data are readily available – they come from demographic and health surveys. We have fewer data on adult mortality, but from those countries where we do have data, those middle and low income countries on adult mortality, that too shows the gradient.  

So what started as a finding in British civil servants is a really very general phenomenon. And that’s why it’s very much influenced the way that I’ve approached the policy issue which is that we have to take action across the whole of society.