The link between social and occupational standing on the one hand and health on the other has long attracted interest. Michael Marmot has investigated this issue for over 30 years, a program of research for which he received a knighthood in the United Kingdom. In a diverse and broad collection of studies, Marmot and his colleagues have shown that health follows a social gradient, such that the higher one’s position in the social-status hierarchy, the better one’s health. Simply stated, status has health benefits for a broad range of problems, including heart disease, kidney disease, stroke, lung cancer, infectious diseases, suicide, and violence. This holds true everywhere researchers have looked, including samples of British bureaucrats, Oscar-award-winning actors and actresses, and Swedish PhDs. Marmot has argued that autonomy and the opportunity for full social participation are central to understanding the social gradient in health and that one’s well-being and longevity are intimately intertwined in these factors. Specifically, he shows that people of lower status succumb to illness more often and to death more quickly, not because of poorer habits, diets, medical care, or genes but because they have less control over their lives and their social engagement.
We commonly categorize society and the world into the rich, the poor, and those somewhere in the middle. For the unfortunate individuals who find themselves in the poorest segments of our social world, their social position can have dramatic implications for nutrition, disease, and longevity. In itself, however, this situation is not the social gradient of health, nor is it simply a product of the division between rich and poor. The social gradient of health delineates the hierarchy much more finitely. People with postgraduate education generally have better health and longevity than people with undergraduate education, who generally have better health and longevity than people with high school education. Likewise, doctors are likely to have fewer health problems than skilled workers, who are likely to have fewer health problems than unskilled workers. The same can be said when people are grouped by income, by their parents’ social class, or even by height; higher rankings equate to superior health. Thus, regardless of where people fall in the status hierarchy, they will typically have better health than those people lower in the hierarchy and worse health than those people higher in the hierarchy. This trend is what Marmot has called the “status syndrome,” and this entry explains that it has important implications and lessons in understanding the relationship between careers and health. For this reason, we first need a better understanding of the status syndrome.
Could the status syndrome be the result of individual behavior? Is the status syndrome the result of people’s free choice to smoke cigarettes, drink alcohol, eat unhealthful foods, and refuse to exercise? Marmot has shown that the lower people find themselves in the gradient, the more undesirable are their health behaviors. Could this be a function of self-destructive behavior? Marmot has discounted this argument. First, research shows that individual risk factors account for only about a third of the health gradient. For example, at any risk factor level, the risk of heart disease is greater for smokers with lower social rankings and lesser for smokers with higher social rankings. Second, Marmot has questioned whether unhealthy habits may actually be autonomous choices made by socially deprived individuals who desire some form of control over their lives.
Could the status syndrome be genetically predetermined? Do people end up in life (and by extension, in certain careers) where they do because of who they are, making their social conditions indirectly related to the social gradient of health? While obviously not discounting the role of genetics, Marmot thinks not. Heredity clearly accounts for individual differences in intelligence; however, the degree to which genetics accounts for overall group differences is minimal. Accordingly, genetic differences do not sufficiently explain the gradient; environmental factors must help determine a person’s socioeconomic position in the hierarchy of health. Because socioeconomic status is so closely related to occupational class, recognizing this macroconnection is essential to understanding the link between people’s careers and health.
Could reverse causality be a plausible explanation, such that good health results in status and success, leading to high social rankings? Do the healthy prevail over the unhealthy? Health-related social mobility actually blurs the social gradient in health, making it appear less steep. Although healthier people are more likely to be upwardly mobile and unhealthy people are likely to be downwardly mobile, a distinct social gradient still exists after accounting for this tendency. Moreover, as healthy people move to a higher social status level, they are still less healthy than the people already occupying that position, and thus, they bring down the average measure of health for that status level. Similarly, as less healthy people move to lower ends of the status hierarchy, they are still healthier than the others already in that group, and therefore, they raise the average level of health for that group. Accordingly, health-related social mobility causes the status syndrome to be understated.
Thus, because bad habits, genetics, and health-related social mobility cannot explain the social gradient of health, Marmot has considered three socioeconomic conditions of societal inequality, namely, money, power, and status, and their relationships with health. Obviously, more money can benefit health for obvious reasons, especially for poorer people, and poverty reflects the inability to lead the lives people wish to lead and to fully participate in society. But there is more to it than money. An equally important distinction is between stress and challenge.
Stress operates through five characteristics, namely, lack of control, weak social support, unpredictable outcomes, absent outlets, and threats to status. This is not to be confused with the challenge of intense decisions, busy schedules, or high demands. Stress concerns the lack of control over the present and the future and the path in between. In the workplace, this describes the situation of lower-level employees, not the stereotypical, highly stressed upper-level managers. High-level executives may well experience great demands, but they have more control in meeting those demands. Thus, having money, status, and power or, alternatively, occupying a position high in the social hierarchy gives people the ability to direct their lives freely and limit uncontrollable stress. This kind of control, or more generally, these social conditions, may buffer individuals against the adverse effects of stress. How do social conditions influence the status syndrome? For Marmot, people lower in the hierarchy are in psychological states of uncontrollable stress more often then those people higher in the hierarchy, and this has negative health effects. Marmot believes that both acute and chronic stress contribute to a multitude of physical diseases.
A second psychological culprit is the feeling of social isolation. Like health, supportive social relations and networks follow a social gradient. Social support is positively related to good health and well-being; however, moving down the status hierarchy, less access to supportive social relations leaves lower-status individuals more vulnerable to a broad range of illness and causes of death. Consequently, both a lack of control and full social engagement underlie the social gradient and thus have important implications for career development and health. The following section discusses the roles that work and careers play in generating social hierarchies and health inequalities.
Careers, Control, and Social Engagement
Occupation is a central determinant of social status or class, and in the workplace, job characteristics are stratified by status, whereby higher-status workers experience more favorable job characteristics, such as job variety, autonomy, and more physically hygienic conditions at work. Similarly, job characteristics are also associated with worker health and well-being. For example, a model developed by Robert Karasek argues that low levels of job control combined with high levels of job demands lead to a number of stress-related physical illnesses, such as coronary heart disease. Likewise, employee health and well-being can improve with increased control and participation on the job. Conversely, working characteristics, including work overload, job insecurity, and low control, negatively influence workers’ physical health. More broadly, research studies have shown a significant association between mental and physical ill health and six workplace pressures, namely, factors in the job (e.g., hours of work, decision-making authority, job variety); organizational role (e.g., lack of power, role ambiguity, role conflict); relationships at work (e.g. support, isolation); career development (e.g., unclear expectations, over- or underpromotion); organizational climate (e.g., organization structure or design, lack of communication); and home/work pressures.
More recent research has shown that both physical and psychosocial job characteristics play a significant role not only in predicting health outcomes but also in explaining the relationship between socioeconomic status and health. After controlling for a number of lifestyle differences (e.g., smoking, body mass, exercise) and the social origins of low- and high-status individuals, job characteristics, such as physical cleanliness on the job, working hours, autonomy, postsecondary training requirements, workload, cognitive demands, and job challenge still help explain the social gradient in health. These findings illustrate the centrality of occupations and workplace experiences in explaining how health inequalities are created. Accordingly, researchers have argued that workplace and job design can be an important vehicle for understanding and reducing societal-wide health disparities.
The social gradient may also be manifest occupationally, helping us understand the link between careers and health. People’s choice of occupations and their associated characteristics are not the only “work” factors that determine their social status. Career paths also have a number of implications for a person’s position in the social gradient of health. Patterns of work experiences, such as upward and downward mobility, mobility in and out of the labor force, and transitioning into retirement, are also integral to understanding the relationship between socioeconomic status and health. In general, researchers have considered career progression in explaining the relationship between social class and health, noting that occupational demotions have a negative impact on employee psychological well-being due to the loss of perceived status and opportunity.
Occupational mobility also exerts consequences for status-related health risks. Although occupational classes themselves show a social gradient in mortality, within each class, mortality risks also differ by career paths and development. Specifically, individuals who experience upward occupational mobility to more favorable, higher-status jobs manifest lower mortality risks than individuals remaining immobile in their occupational classes of origin. Generally, greater levels of autonomy, variety, and physical cleanliness will characterize these higher-status occupations. The reverse is true for the downwardly mobile: Workers moving to lower-status positions experience higher mortality risks than their counterparts remaining stationary in their original occupational classes. In this case, downward occupational mobility is associated with an increase in working characteristics that are negatively related to heath, such as reduced control and work overload.
Individuals who are promoted to a higher occupational status, however, typically do not achieve the same low-mortality risk levels as individuals already occupying the higher social class, and vice versa. Overall, when people’s careers progress or regress to a new occupational status, their mortality risk adjusts to a level that is between the average risk level of the occupants in the class left behind and the average risk level of the occupants in the class joined. A similar trend exists for careers and health as measured by incidents of cancer, where lack of career progression is significantly related to a greater risk of cancer (including cancer in the upper respiratory and digestive track and the lungs) after accounting for various other risk factors. Accordingly, research findings show that although socioeconomic status is clearly important in predicting health, career development and upward career mobility are equally important explanatory factors.
Career movement in and out of the labor force is also predictive of health inequalities, and such moves can be a function of unemployment (and reemployment) or of retirement. Unemployed individuals have lower mental and physical well-being, including life satisfaction, self-esteem, and marital and family satisfaction, compared with employed individuals. The unemployed also have higher depression and mortality. In fact, feeling insecure about one’s job or employment has negative health implications even before employment status changes. Researchers have argued that this health effect occurs because unemployed individuals lose the positive benefits of employment influencing health, such as the opportunity for control and skill use, externally generated goals, variety, environmental clarity, physical security, financial income, socialization, valued social position and status, a feeling of purpose, and time structure.
Marmot has placed specific emphasis on the loss of status, the uncontrollability, and the unpredictability of job loss when considering its health consequences, arguing that stressful situations are defined by these factors. In addition, unemployed individuals’ well-being is mediated by social support, such that unemployed people who feel socially supported experience greater well-being than those who do not. Both the quantity and the quality of the support are critical. While unemployed individuals typically have similarly sized social networks compared with employed individuals, their social support comes predominantly from family members who provide emotionally based support, as opposed to friends and colleagues. This type of support can leave the unemployed feeling more vulnerable and socially isolated and therefore lead to further stress. Thus, unemployment, by definition the loss and lack of one’s occupational role, is ultimately characterized by a loss of control over one’s life and the ability to fully participate in society, two factors underlying the social gradient in health. On the other hand, a positive relationship exists between reemployment and well-being, mental health, and physical health. Longitudinal data show that individuals experience declining well-being as they move from employment to unemployment but experience increasing well-being as they move from unemployment to reemployment. Reemployment provides positive benefits of work that are integral to the status syndrome, including increased status, control, social support, and predictability.
The relationship between socioeconomic status and health is not static throughout a person’s life. Instead, research has shown that the social gradient in the incidence of cancers is most volatile in the beginning of an individual’s career and changes less after midcareer. However, the social gradient in health is present not only during a person’s working life. Socioeconomic status at middle age has been found to predict morbidity into old age, and, in general, socioeconomic health differentials persist well into a person’s retirement years. For example, mortality differences between people of high and low employment status have been shown to increase after retirement age. Although evidence conflicts as to whether health improves or deteriorates after retirement, a number of key patterns have appeared. First, people’s transitions into retirement are important predictors of their postretirement health. People who have control over the decision to enter retirement, and its timing, experience better health than do people who are forced into retirement. Second, environmental characteristics that motivate the social gradient in health also mediate the relationship between retirement and well-being. For example, retired individuals who perceive that they have the opportunity for personal control, variety in demands and opportunity, environmental clarity, physical security, social or interpersonal contact, and valued social position have better well-being or life satisfaction than do retired individuals who do not experience these benefits. Accordingly, people’s careers have implications for their status-related health not only during early or midcareer, when status changes most frequently, but well into their transitional and retirement years as well.
In conclusion, therefore, Marmot has delineated a unique perspective of the social causes of health, explicitly underscoring the role of work in generating health inequalities. This entry highlights various insights and their relevance to career development and health in a number of ways. First, as a macrophenomenon, the social gradient in health is an overarching explanation for societal and occupational health. Second, although job characteristics are thought to contribute to socioeconomic health inequalities, career paths themselves show a gradient in health. In particular, people who have upwardly mobile careers have better health and mortality than do people in the same social class with immobile careers. Finally, autonomy and social participation not only mediate the relationship between socioeconomic status and health but also help explain the relationship between health and other career factors, such as progression, unemployment, and retirement.
- Barling, J. 1990. Employment, Stress, and Family Functioning. Chichester, UK: Wiley.
- Breeze, E., Fletcher, A. E., Leon, D. A., Marmot, M. G., Clarke, R. J. and Shipley, M. J. 2001. “Do Socioeconomic Disadvantages Persist into Old Age? Self-reported Morbidity in a 29-year Follow-up of the Whitehall Study.” American Journal of Public Health 91:177-283.
- Cambois, E. 2004. “Careers and Mortality in France: Evidence on How Far Occupational Mobility Predicts Differentiated Risks.” Social Science and Medicine 58:2545-2558.
- Hellgren, J. and Sverke, M. Forthcoming. “Does Job Insecurity Lead to Impaired Well-being or Vice Versa? Estimation of Cross-lagged Effects Using Latent Variable Modelling.” Journal of Organizational Behavior.
- Karasek, R. A. 1979. Job Demands, Decision Latitude, and Mental Strain: Implications for Job Design. Ithaca, NY: Cornell University Press.
- Marmot, M. G. 2004. The Status Syndrome: How Social Standing Affects Our Health and Longevity. New York: Times Books.
- Marshall, B., Chevalier, A., Garillon, C., Goldberg, M. and Coing, F. 1999. “Socioeconomic Status, Social Mobility and Cancer Occurrence During Working Life: A Case-control Study Among French Electricity and Gas Workers.” Cancer Causes and Control 10:495-502.
- McKee-Ryan, F. M., Song, Z., Wanberg, C. R. and Kinicki, A. J. Forthcoming. “Psychological and Physical Well-being during Unemployment: A Meta-analytic Study.” Journal of Applied Psychology.
- Sparks, K. and Cooper, C. L. 1999. “Occupational Differences in the Work-strain Relationship: Towards the Use of Situation-specific Models.” Journal of Occupational and Organizational Psychology 72:219-229.
- Warr, P., Butcher, V., Robertson, I. and Callinan, M. 2004. “Older People’s Well-being as a Function of Employment, Retirement, Environmental Characteristics, and Role Preference.” British Journal of Psychology 95:297-324.
- Warren, J. R., Hoonakker, P., Carayon, P. and Brand, J. 2004. “Job Characteristics as Mediators in SES-health Relationships.” Social Science and Medicine 59:1367-1378.
- West, M., Nicholson, N. and Rees, A. 1990. “The Outcomes of Downward Managerial Mobility.” Journal of Organizational Behaviour 11:119-134.