91st Congregation (2022)

Whitehall—principal residence of the English Monarchs for just over one and a half centuries and, in its time, the largest palace in Europe with its 1,500 rooms. The first known performance of Shakespeare’s The Tempest was here, in 1611. Sadly, the palace was largely destroyed by fire in 1698, yet its Banqueting House, built by Inigo Jones with a ceiling painted by Rubens survives. This is its only substantial remnant, with a history of its own. In 1649 King Charles I stepped through its firstfloor windows onto a raised scaffold to have his head “severed from his body” as his sentence demanded, watched by a crowd of Londoners including the 15 year old Samuel Pepys. Whitehall was a name in the land; and although its role has changed it is still a name in the land.

The Monarchy moved elsewhere, but Whitehall remained at the heart of government as the citadel of Britain’s civil service. Here, in this ghost of a palace, Sir Humphrey, as a fictional Permanent Secretary, managed his Minister; but he did not do that unsupported. Below him were a myriad other career civil servants, above him a mere handful, all going about their allotted tasks, from doorkeeper and messenger to the most senior Advisors. In the 1960-70s most civil servants were male and white and they managed the administration of the country much as they had for more than a century. They lived highly structured lives on predictable trajectories with secure employment, and solid pensions awaiting when they finally retired. This highly homogeneous, some might say positively dull, group of people working within a single organisation became the subjects of one of the most influential population studies ever to be conducted. It was called the Whitehall Study, and it is famous around the world.

The study followed, initially for ten years, the lives (and sometimes deaths) of 17,530 men in the British Civil Service, aged 40-64 when the study began. The results were dramatic.

What might we have expected? In 1958 an American military psychologist, Joe Brady, working at the Walter Reed Army Institute of Research in Bethesda, Maryland, conducted a study on rhesus monkeys now notorious as the ‘Executive Monkey’ experiment. He reported that in pairs of monkeys in which one worked to avoid shocks which both simultaneously received if the ‘Executive’ monkey made a mistake, the monkey that suffered from stressinduced ulceration, and in some cases death, was the monkey in charge, not its powerless companion. (You can extrapolate to the hard lives of generals having to make decisions about when and how their comparatively luckier enlisted men should be ordered to engage the enemy.) This publication has been rightly criticised on several grounds, but it had an impact when published and it fitted —while perhaps also helping to create—a stereotype: decision-making is what’s really stressful.

The Whitehall Study observed nothing of the kind. The civil servants who were least healthy—on many measures—were the most junior grades: the cogs in the system, not the policy-makers. As the study continued that picture remained consistent, even on that starkest of measures: death rates. Those in the highest grades lived longest; those in the lowest grades had the shortest lives; intermediate grades showed intermediate mortality. This was a clear and robust effect—and it was startling. The principal investigator for the study was Dr (now Professor) Michael (now Sir Michael) Marmot. He was born in England and raised in Australia, educated at The University of Sydney and the University of California, Berkeley and then returned to London. He has spent over forty years there working on socioeconomic determinants of health—and of health inequity.

Homogeneous study groups are a mixed blessing in experiments. There is less random noise in the results; and if you do see something interesting then many extraneous factors are ruled out. On the other hand what’s true of a particular, homogeneous group may not be true of the wider world population, in the same way that highly reproducible results obtained with in-bred laboratory rat strains may not hold true in less controlled conditions. The Marmot group therefore followed up by looking for similar effects in quite dissimilar populations. They also sought to understand the underlying cause(s) of their finding—now often referred to quite simply as ‘The Whitehall effect’. And they started work on a third topic, too: what can you do about it? Could you give everyone that long life enjoyed by top grade civil servants?

A plethora of studies has confirmed the generality of the effect across very different countries. Health and life expectancy go with social status not just across Western Europe; increased education—in some ways a proxy measure—is associated with reduced mortality in Bangladesh, in Chile and in Russia. Deprivation means worse health, including right here in Hong Kong. The size of this difference within countries can be huge. Travel 2.7 miles in London from Somers Town, where my son lived as a student, to Hampstead where the former Governor of the Bank of England, Mark Carney, lived and male life expectancy goes up 11 years (fortunately my son has now moved). Take the metro from downtown Washington DC to Montgomery County, Maryland (where I used to live) and male life expectancy jumps a shocking 20 years (unfortunately, I too have moved…).

The Whitehall Study and its successor, Whitehall II which extended the work to women, identified cardiovascular disease, smoking, obesity and metabolic syndrome (precursors for diabetes), and mental illness amongst other features of low social position. Social primates, including us, are attuned to social status; low status goes with high stress levels across a variety of species and this, in turn, affects crucial features from cardiovascular markers to adult neurogenesis in the brain. Moreover, stressful events are exacerbated or ameliorated by the control we have—or think we have— over them. At its simplest, painful heat doesn’t hurt as much if we are told we have a switch available to turn it off, whether or not we ever actually choose to press it.

Minds matter and minds affect matter. Experiences don’t just change our thoughts and behaviour: they affect our hormones, our neurochemistry—even our adult brain structures. So there are good, a priori reasons to expect social and political interventions to help to tackle inequities in both mental and physical health. But for science to effect change, it must drive policy. This has been a key part of Professor Marmot’s life’s work, within the United Kingdom and beyond—indeed, globally.

The Royal Society for Public Health ranked the United Kingdom’s Government-commissioned Marmot Review, published in 2010, as number three in its top twenty public health achievements of the 21st century. (Competition was fierce: the ban on smoking in enclosed public places took first place). A commissioned follow up, the Marmot Review 10 years on, reassessed the position in 2020. It remains a topic in focus, and particularly so post-Covid as the pandemic has, if anything, exacerbated health inequity. Across the wider world, Professor Marmot chaired the World Health Organisation’s 2005-08 Commission on Social Determinants of Health, and in 2016 the Pan American Health Organization appointed him chair of its 2016 Commission on Equity and Health Inequalities in the Americas. Through appointments like these; through his Institute of Health Equity in London which now has a partner here at CUHK; and through a regular flow of books and articles for the more general public, Professor Marmot has been instrumental in effecting change for the better by enabling political initiatives that will give people control of their own lives, regardless of their social status.

Honours are rightly heaped upon him: it is our privilege today to join the long list of those who have recognised his extraordinary and continuing contributions. Justice is—or should be—blind; but his work has opened our eyes to how social justice in health may be achieved— and here vision, not blindness, is what we need. Mr Chairman, it is my privilege to present to you Professor Sir Michael Marmot for the award of Doctor of Science, honoris causa.

This citation is written by Professor Nick Rawlins