Life at the Top




IT'S that time when the world holds its breath: the annual ritual when we wait to see which glittering and famous person will become even more glittering and more famous. But the Academy Awards are more than just a spectator sport. They are a matter of life and death. On average, the winners live four years longer than nominees who don't win.

The Oscar winners are a quirky example of a phenomenon that is remarkably widespread: the higher your status in the social hierarchy the better your health and the longer you live. It appears to be a global syndrome. Americans with more income or education have better health than Americans with less; a Swedish Ph.D. graduate has longer life expectancy than a Swede with a master's degree; a British civil servant at the top of the employment hierarchy has greater longevity than one not quite at the top; health has been improving for Russians with university education, getting worse for those without. The reason the Oscar winners are so interesting is that they give insight into what is going on.

We are used to thinking that poverty is bad for health. Indeed it is. Life expectancy in some sub-Saharan African countries is less than 40 years compared with 80 years or more for people in the best-off countries. By these standards even poor Americans are not poor, yet they have shorter lives, as much as 20 years shorter, than richer Americans. The unsuccessful Oscar nominees, or the Swedish master's graduates, or the second-from-the-top civil servants, are certainly not poor. Yet each of these groups has worse health than those above them in the hierarchy. There is a social gradient in health that runs from the top to the bottom of society and affects all of us.

A way to understand this link between status and health is to think of three fundamental human needs: health, autonomy and opportunity for full social participation. All the usual suspects affect health - material conditions, smoking, diet, physical activity and the like - but autonomy and participation are two other crucial influences on health; and the lower the social status, the less autonomy and the less social participation. By participation I include the positive feedback one receives from social recognition and being a valuable member of society.

To understand the power of this force, consider the disparity that exists among Oscar winners themselves.

In their work, Donald Redelmeier and Sheldon Singh, the two scientists who studied the Oscar winners, also showed that the life-enhancing effect did not extend to screenwriters who won the prize. To understand why, try to name a screenwriter who has won an Oscar, much less what he or she wore to the Academy Awards ceremony. It's likely that you can't because screenwriters get little recognition, award winners or not. As writers from F. Scott Fitzgerald to Joan Didion and John Gregory Dunne have told us, screenwriters are at the bottom of the Hollywood totem pole. A successful novelist told me he writes books for satisfaction and recognition and screenplays for money. The satisfaction and recognition count more.

Differences in autonomy and social participation underlie the other examples of the social gradient in health. High-grade civil servants have more control over their working lives than those below them in the hierarchy. Higher control is associated with lower risk of heart disease, back pain, mental illness and ailments that make people stay home from work. Autonomy and participation have a direct effect on the body's stress pathways, which, in turn, affect the biological pathways that increase risk of heart and other diseases.

As bad as poverty is for health, what is at issue here is inequality. The link between inequality and health has profound implications. No one is in favor of poverty. Inequality is different. Libertarians might justify it as simply the result of policies that were pursued for other reasons, like freedom from state interference. Some economists justify it as providing incentives for the wealth producers to raise all boats. Some businessmen claim that low wages mean low costs to business and hence greater competitiveness. For some any justification would be cant - they like inequality because they are on top.

Those who argue that inequality is simply an inevitable part of life should not be complacent. Inequality, it seems, harms health. In this regard, it's worth noting that the United States ranks 27th in the world in life expectancy - behind countries with half the national income per capita of the United States and with a fraction of the expenditure on medical care, according to the United Nations 2004 Human Development Index. A lot of factors are at play in life expectancy, but it is notable that all but three of the 26 countries preceding the United States have more equal income distributions. These income inequalities indicate broader social inequalities.

The most egregious effects of inequality in the United States are seen on the streets of the inner cities among people with little hope for the future. The more subtle but far- reaching effects are seen in workers with insecure jobs; in people who fear that major illness will be a financial catastrophe; in poor or even middle-class people whose lives offer them little opportunity for control or meaningful social participation. These inequalities are in part inequalities in income, to be sure. But it is not just inequality of incomes that is at issue. More fundamentally these inequalities indicate a society that works well for those at the top, and far less well for everybody else.

My level of sympathy for the almost-did-it millionaire actors is, shall I say, appropriate to their misfortune. That is why, as the glitterati step out of their limousines on Oscar night, my thoughts will be elsewhere.


Michael Marmot, a professor of epidemiology and public health at University College London, is the author of "The Status Syndrome: How Social Standing Affects Our Health and Longevity."