Harry over at Crooked Timber draws my attention for the first time to a much talked about book by Michael Marmot, The Status Syndrome. By way in introduction, he lets former CT guest blogger Bill Gardner introduce us to the books arguments. Here’s Harry’s shorter Gardner:
Marmotï¿½s fundamental empirical finding is that there is a social gradient in health, that is, when you group people according to their places in social hierarchies, you find better health and greater longevity in each successively higher class. His classic work studied the British civil service. He placed civil servants into four grades: administrators who set policy, executives who carry it out, clerical staff, and support personnel. There was a four-fold greater mortality rate from ages 40-64 for support personnel versus administrators. This was a large effect, and much larger than the difference in mortality rates related to conventional measures of social class.
Marmot argues that the principal explanation for the status syndrome is not relative income, not higher rates of health-risk behaviors among the lower classes, and not status-related differences in genes. Income, heath-related behavior, and genes are all important determinants of health, but their effects are largely independent of the effect of your place in the social hierarchy and only partially explain the social gradient. What matters is autonomy:
for people above a certain material threshold of well-being, another sort of well-being is central. Autonomy ï¿½ how much control you have over your life ï¿½ and the opportunities you have for full social engagement and participation are crucial for health, well-being, and longevity. It is inequality in these that plays a big part in the social gradient in health. Degrees in control and participation underlie the status syndrome.
It is true that the finding of a more accute differential in mortality rates is interesting and in need of explanation. Nevertheless, I’m not quite sure what Marmot’s thesis about autonomy is supposed to be. (I’ve not read the book, so this post is about ideas, not the specifics of that work.)
First, I find curious the claim that “Income, heath-related behavior, and genes are all important determinants of health, but their effects are largely independent of the effect of your place in the social hierarchy and only partially explain the social gradient.” In order to understand what this means, we need to know what Gardner (and, presumably, Marmot) means by one’s “place in the social hierarchy.” Yet unless Marmot is working with technically stipulative definitions, surely one’s place in the social hierarchy is (at least partially) constituted by one’s income and opportunities for, and access to, health care and education. So how could it be true that the effects of social hierarchy are “largely independent” of the effects of certain indicies of one’s place is that very hierarchy?
Moreover, I would have thought that any account of autonomy worth its salt would have seen a clear connection between “how much control you have over your life” and your income, health, and education. Why think there is any competition between an explanation that makes one’s health dependent upon one’s opportunities fully to engage and paticipate in valued social institutions and practices, and an explanation that makes health dependent upon income and “health-risk behavior”? That’s just a silly, false dichotomy.
There is, however, a way of interpreting Gardner’s account of Marmot’s view that would be interesting. If somehow the data showed that what mattered most was the amount of autonomy one has on the job, then we would have an interesting proposal. Such a view would say that it is not social hierarchies at large that matter, but rather more local, professional hierarchies. Perhaps, as is likely, much more stress is placed upon support staff than is placed upon executives, and perhaps this is the sort of stress that cannot be mitigated by more money or improved social interaction with fellow citizens outside of one’s workplace. I think that something like this is probably true, and that it points to larger problems that arise in “developed”, efficient, and (therefore) highly stratified societies. But such a view would not make “your place in the social hierarchy” the salient causal factor, and thus cannot be Marmot’s view (as Gardner describes it).