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Status Syndrome. Michael Marmot. London: Bloomsbury Publishing, 2004,

pp. 288, 12.99 (PB) ISBN: 0747570493

Article  in  International Journal of Epidemiology · March 2005

DOI: 10.1093/ije/dyi032

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Published by Oxford University Press on behalf of the International Epidemiological Association International Journal of Epidemiology 2005;34:497–503

Book Reviews

doi:10.1093/ije/dyi032
Status Syndrome. Michael Marmot. London: Bloomsbury
Publishing, 2004, pp. 288, £12.99 (PB) ISBN: 0747570493.

In a few of the many anecdotes sprinkled throughout this book,

Marmot points to the insults which academics employ in their
intellectual wars. Misquoting one of these provides a good
summary of the latest monograph—all of it is interesting; much
of it is likely to be true. Irrespective of whether all Marmot’s
claims are correct the book makes a valuable contribution to the
debate about the basis of health inequalities.
The book is an elaboration of the case Marmot has advocated

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over some years that socioeconomic status (SES) inequalities in
health are partly a consequence of a lesser degree of control
manifested by those at different levels of the SES hierarchy. In a
research context social control is conceptualized as a mediating
variable, operating in much the same way, but independently of
other mediators such as tobacco use, diet, and physical activity.
The book comprises 10 chapters characterized by frequent
references to interesting studies, personal biography and
experience, and the theories and ideas of significant con-
tributors to national debates about social inequalities. Marmot’s
is a social view of health and the book will become a well-used
text for those who have an interest in the social and structural
basis of health inequalities.
The introduction begins the argument by suggesting that
health inequalities are pervasive, probably increasing, and likely
to be a consequence of a particular group’s degree of control
over, and participation in, society. Marmot makes much of the
gradient in health. Each step in the SES hierarchy is
characterized by its members as being less healthy than the SES
group above it, and of better health than the group below. This
directs attention away from poverty as a cause of diminished
health to factors associated with the continuum of
socioeconomic inequalities. Chapter 1 is an extension of this
latter argument, discussing the nature of the gradient and
considering what it is about the gradient that is important. It is
interesting that ‘Academy Award-winning actors and actresses
live an astonishing four years longer’ than equivalent
distinguished actors and actresses, but does this help us
understand why clerical workers live longer than, say, cleaners?
Marmot would seem to argue that it does, and points to a
common denominator—social control.
Chapter 2 summarizes some findings from the Whitehall
studies. Here he documents both the magnitude of
socioeconomic inequalities and discusses the biological and
social correlates of these inequalities. It is pleasing to see an
analysis of the nature/nurture debate which acknowledges the
deep and pervasive impact they have on each other. Chapter 3
comprises a discussion of income inequalities as a possible basis
for health inequalities. Income is described as not so much a
way of acquiring more material possessions, but rather as a way
of ‘keeping score’ of one’s social position and one’s social value.
No doubt higher income does lead to greater control.
Chapter 4 presents as a Weberian inspired discussion of
occupational standing. Status hierarchies are ubiquitous, have a
biological basis, and mental and physical health consequences.
Chapter 5 continues the Weberian theme with a discussion of
power inequalities and the impact these have on health. There
is, in this Chapter, a thoughtful consideration of the concept of
stress and ways that stress might be more usefully measured.
Control of one’s environment relative to the demands under
which one operates is seen as central to understanding the
health consequences of stress. Chapter 6 constitutes a discussion
of the health consequences of social networks (gossip to
humans, we are informed, is arguably equivalent to grooming by
monkeys—it facilitates the formation of social groups). There is
also a restatement of the ‘general susceptibility’ argument here
in the context of the health benefits of close social ties and social
networks. Perhaps the case is overstated and the evidence
quoted somewhat selective. Chapter 7 is Marmot’s analysis of
the association between ‘social capital’ and health. The physical
environment can, it is argued, contribute to a sense of trust and
cohesiveness with somewhat predictable health consequences.
The case for the importance of social capital seems, on the
evidence presented, overstated. Chapter 8 takes the recent
decline in health in the Soviet block as its focus. The point, of
course, is that rapid change in social life (and control?) may have
massive health consequences. Chapter 9 considers the case for
the fetal and childhood origins of adult health, locating some
adult health inequalities in the fetal and childhood period.
The final chapter has two themes, one questioning the moral
basis of health inequalities, the other a consideration of policy
options. The appendix is a reproduction of the recommen-
dations of the Acheson inquiry.

497
 498 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY
Marmot’s book is a valuable source of material on health
inequalities. It is an engaging piece of work which is not only
informative about the field but also about Marmot himself. More
difficult to determine is whether his major theme (the importance
of control) is sustained by the evidence he presents. There are a
number of causal pathways consistent with the evidence he
presents. A sense of control might lead to SES inequalities.
Inequalities in SES might lead to inequalities in a sense of control.
SES inequalities and health inequalities might both be a
consequence of control. There might be an association such that
increasing SES leads to a sense of control and vice versa. Some of
these options are canvassed by Marmot but the available evidence
is insufficient to do other than speculate about a factor that is
clearly associated with SES and possibly health outcomes.
However, in this book Marmot has extended the debate and put
the case for a potentially important research agenda.
JAKE M NAJMAN
doi:10.1093/ije/dyi050
Toxic Oil Syndrome: Ten years of progress. Benedeto
Terracini (ed.). World Health Organization. Regional Office for
Europe, 2004, pp. 191, ISBN: 92-890-1063-0.
The Toxic Oil Syndrome (TOS) was one of the diseases that
caused a severe impact on the population but which in course
of time faded into oblivion and is just remembered as a one-
time, historical event. Forgetfulness is not restricted to
researchers or health professionals but also affects the society
who suffers such outbreaks. There are several reasons that
might justify this behaviour such as: its appearance as a point
source epidemic; its geographic distribution limited to only
some provinces of a country, Spain; its food-borne origin linked
to a rapeseed oil, denatured with 2% of aniline for industrial
purposes and then sold as edible oil; and through having been
the cause of a great socio-political controversy for years.
However, a Joint Scientific Committee of experts of the WHO
Regional Office for Europe and the Instituto de Salud Carlos III
of the Ministry of Heath, Spain, presents us with a new book
entitled Toxic Oil Syndrome: Ten Years of Progress, which all
through its eight chapters and four annexes updates scientific
achievements reached during the period, almost 24 years,
elapsed since the epidemic. These chapters gather all available
information on this disease describing its more relevant
epidemiological aspects, including an annexe written by Sir
Richard Doll on causality of rapeseed oil denatured with 2%
aniline and the TOS. The evolution of the disease, progress
made in chemical analyses performed on oils, metabolic and
immunological susceptibility factors, and the efforts made to
produce an animal model are other issues treated in this book.
Hopefully, it will contribute to clarify the mechanisms and final
events of a new and tragic illness that caused the suffering of
thousands of citizens and their families and was proven to have
a dramatic effect on the Spanish society of the 80s and 90s.
TOS occurred within the framework of the complicated socio-
political situation of Spanish society in the 80s, when the young
Spanish democracy was just born six years before the epidemic
broke out, and the State was being decentralized into several
regions of Spain that became autonomous communities. At that
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time, due to reorganization in the country, the health care system
and the research structure were clearly inadequate. For this
reason, many scientists thought that these circumstances were,
though not sufficient, a necessary cause of the epidemic, thus
TOS was considered as an event that would not happen again.
This way of thinking had two negative effects on the
investigation, during the first years of the epidemic: loss of data
due to the simultaneous occurrence of judicial and political
investigations, and a desire to forget what had happened. These
aspects especially affected the future of the cohort of the
victims, making many professionals think that once the intox-
ication had ended the survivors would not be further affected
by any disorder associated with the consumption of that toxic oil.
Once again, the social pressure exerted by the associations of
affected subjects demanded that some social and scientific
measures had to be taken. These measures, among others, led
to the establishment of a collaborative agreement with WHO
that has resulted in the publication of three different books. The
first two books1,2 reviewed the results of the research carried
out during the first decade. This third book, reflects the specific
outcomes achieved by research carried out in the last decade
that albeit specific for TOS in some aspects, can be a model for
use in other conditions.
Unfortunately, we have had the opportunity to observe in
these past few years that some aspects of the way in which
individuals facing chemical intoxications respond is not unique,
as was seen after the outbreak of the eosinophilia myalgia
syndrome (EMS) which took place 10 years after the
appearance of TOS, in USA and some European countries, and
was associated with ingestion of a drug used as a health food
supplement. EMS showed similar features to those observed in
TOS. We have also learned that food chain adulterations—
exposure to dioxins in Belgium associated with the ingestion of
animals that had been bred on adulterated feed, CJD new
variant—are not exclusive to countries in the process of
democratization but form part of the kind of undesirable human
actions against which a clear-cut response must be given.
This book provides readers interested in different scientific fields
precise aspects on the difficulties linked to the study of a complex