Professor Michael Marmot writes the foreword for the Gradients issue of the Keppel Health Review exploring his life’s work and how the social gradient is more relevant today than ever.

My involvement in the social gradient in health began as a research challenge. Inequalities in health were not confined to poor health for the poor and reasonable health for everyone else, but health was socially graded: the lower the position in the social hierarchy the worse the health. I made this observation first, in 1978, in British Civil Servants—the lower the employment grade, the worse the health. But we have now seen social gradients in health in most countries of the world where data have been available, whether social position is defined by income, wealth, education, occupation, or degree of deprivation of area of residence. What started with the Whitehall Study of British civil servants is now of global concern.

Accumulating the evidence to explain the reasons for the gradient have led on to a second challenge: to use evidence to formulate recommendations for policy and practice to reduce health inequalities, to level up the gradient. To that end, I chaired the World Health Organisation (WHO) Commission on Social Determinants of Health. In our final report in 2008, we declared: “Social injustice is killing on a grand scale.” Following the global commission, we have had commissions in three of the WHO Regions: Europe, the Americas, and the Eastern Mediterranean; and a series of Marmot Reviews in England. To give a flavour of the evidence, in our English Reviews we have highlighted six domains that explain the social gradient and where action is needed: early child development, education, employment and working conditions, adequate income for a healthy life, healthy and sustainable places and communities, and addressing the social determinants of behaviours. Our most recent report, in June 2021, was “Build Back Fairer in Greater Manchester”.

The gradient addresses one of two common misconceptions about health inequalities, namely that it is really about poverty. Poverty does damage health but so, too, does position in the social hierarchy and the resulting inequalities in the six domains just listed. 

The second misconception is that inequalities in health are mainly to do with inequalities in access to health care. Universal access to high quality health services is important, but it is the social determinants of health that are responsible for developing inequalities in health, in the first place. In fact, so close is the link between social conditions and health that we can say that the level of health of a society tells us a great deal about how well, and how fairly, that society is meeting the needs of its members. 

The fact that the evidence shows us what needs to be done to reduce health inequalities—levelling up to make the gradient shallower—and it is not done, lends urgency to the calls for action. We need technical solutions, yes, but we need a greater commitment to social justice.

Often, I am asked if I am not frustrated that there seems to be so little action on the evidence. My response is evidence-based. There is huge interest in the topic of social determinants of health and health equity. In Britain, what may have been a disappointing response nationally, is matched by enthusiastic take up in cities and regions across the United Kingdom. Globally, it is the demand from countries that led to WHO Regions convening Commissions, and for countries in those regions working on health equity. It is reasonable to say that what began as a niche research concern has become a social movement.