The Marmot Review Essay

Although authors Canning & Bowser wrote the article “Investing in Health to Improve the Wellbeing of the Disadvantaged” to oppose Marmot’s article “The Marmot Review,” their above quote also debate points raised by other public health researchers such as Brunner and Krieger. The quote states that the health disparities from different populations results from lack of access to quality and affordable healthcare. This is partially true, but as the analyses of Marmot & Brunner and Krieger suggest, social exclusion due to race and economic status, the population’s work and childhood environment, in addition to other social factors, lead to problems in the medical care system (Marmot 3). In other words, health gradient is not only an indication of health systems failing but is also a result

of our society’s shortcomings with social issues. With insight from the Marmot & Brunner and Krieger readings, I will argue that Canning & Bowser’s stance on healthcare— as seen through the highlighted quote— underestimates the importance of social factors in healthcare and observes healthcare in a limited scope.
In the book Social Determinants of Health, Brunner & Marmot highlight that the health gradient between different populations is much more than having access to effective healthcare. They argue that “the right approach is to understand how the social environment impacts on biology to cause disease” (Brunner & Marmot 19). Moreover, the social environment is only one of the social determinants of health. Other social determinants of health include: childhood environment, work environment, patterns of social relationships, unemployment, social exclusion, food, addictive behaviors, and transport (Marmot 3).
An example of the impact of the social determinant on health is highlighted in the “Community Health Centers” article by Bonnie Lefkowitz. Lefkowitz gives a history lesson of how an African American region in South Carolina transformed itself from an improvised and disease burdened place to a prosperous and healthy community. However, this transformation took more than the completion of a community health center. With widespread health education, the cultural habit of going to “root doctors” decreased and sanitary practices increased. The physical environment was altered to include proper drainage and septic tanks. The social environment also had to change—economic growth occurred and supportive federal policies had to be in place. Collectively, these social determinants improved the health of the South Carolina Low Country community.
Other examples of the influence of social factors on health are seen in Krieger’s illustration with ex-felons and Brunner & Marmot’s discussion on stress biology.

In Krieger’s article, the reader gets a glimpse on how the war of drugs, targeting the African American population, is increasing the health disparity between different racial populations. Although illegal drug use rates are similar across all US racial groups, the US War on Drugs has disproportionately increased the incarceration of African Americans. After been released from prison, the individual (in this case, an African American) is discriminated against, and in turn, has limited access to factors of health such as employment, education, housing, and public benefits (Krieger 22). These limitations further set back the already marginalized individual and can lead to the negative health impact of “stress biology,” a term emphasized by Marmot & Brunner. Not only can the additional stress from the ex-felon’s social issues activate the neuroendocrine pathways and secrete higher levels of hormones that may eventually lead to chronic diseases, the additional stress may lead to harmful health habits such as smoking (Marmot

21).
For the above ex-felon example, Canning & Bowser’s stance— as highlighted in the initial quote— may only focus on the ex-felon getting medical treatment for the stress biology symptoms or trying to get the ex-felon to quit smoking. This stance only targets the symptoms rather than reducing the symptoms’ causes. Marmot’s approach calls for directly addressing the causes of the symptoms or asking why the individual began smoking in the first place. Canning & Bowser’s appeal for direct health interventions may not have much of an effect on decreasing the health disparities, because as the South Carolina example illustrates, social determinants are tied to the health of a community. Increasing the access to health centers is only a piece to puzzle— to have a noticeable impact in the health gradient across different communities, the whole picture, composed of the different social determinant puzzle pieces, need to be considered. This raises the question of the implications only tackling health issues in biological terms may have.

Additional question:
• In my essay, I quoted Marmot who mentioned that the right approach is to examine the effects of the social negatively impacting the biological. Is there truly a “right approach” in tackling health disparities? Is the health gradient a multifaceted issue with multiple solutions?