Sir Michael Marmot Interview: Conversations with History; Institute of International Studies, UC Berkeley

Redefining Public Health: Epidemiology and Social Stratification: Conversation with Sir Michael Marmot, Professor of Epidemiology and Public Health, University College, London; 3/18/02 by Harry Kreisler
Photo by Jane Scherr

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Background

Dr. Marmot, welcome back to Berkeley.

Thank you very much.

Where were you born and raised?

I was born in North London, but at age four-and-a-half I went to Sydney, Australia, and so I was raised in Sydney.

Do you remember the place that you were born, or were you too young?

Well, I now live about five miles from where I was born. So I have dim memories which I charged up again by going back to visit it.

Looking back, how do you think your parents shaped your character?

The family image, the family tradition, was that my parents were poor immigrants into East London, and that they thought that education was vitally important. But they both left school at fourteen, and so I grew up with the idea that, but for the opportunity, my parents would have been educated. That they were giving me this opportunity, and by golly, I better take advantage of it. So that was one thing, the importance of education, and, I suppose, the importance of opportunity to allow you to receive that education.

I think the second thing was that, again, the family image -- and I can't give you pounds, shillings, and pence (or dollars and cents), but the family image was that however much or little my father earned, some part of it was always for charity. The image in the family was that that was really very important. You didn't earn money just for yourself, it was important that some part of that went to charity. Both my parents were very much involved in communal activities, so that I grew up with a notion that education was important, that individual earnings should be shared, and that communal activities were vitally important.

What was conversation like at the dinner table, all of the above or something else?

No, I don't think it was very intellectual, in a way. It was very argumentative, particularly as my two brothers and I got older, and particularly when I went to university, and then, of course, questioned everything my parents believed in. We had quite vigorous argumentation at the dinner table about everything. I thought that it was like the Mark Twain view of your father, that's what I thought about my parents.

Do you remember any books that you read as a young person that made an impression?

There were books in our household, but I wouldn't say that I had the image of it being a very intellectual, cultural household. My parents always had books on the go, there were books in the household, but I couldn't say that my parents gave us this and inculcated a particular way of thinking. I suppose one part that I can't ignore was that after school three afternoons a week, and Sunday morning, I went to Hebrew school, so that whatever else was going on, I was doing all that extra. So my playing of cricket and rugby in the street was before or after, well, usually after, Hebrew school, because I had school and I had Hebrew school.

Any teachers, either at Hebrew school or public school that had an influence on you at a young age?

Not teachers so much, in a way. They were okay, nobody particularly outstanding. But one or two friends that were really rather important. One friend, particularly, whose father was a professor of organic chemistry. Somehow, almost by default, through his father and him, I was introduced to the idea that one ought to think a little bit more intellectually.

Where and when did you do your undergraduate work?

In the Australian system at that time, you went straight from school to medical school, and there wasn't a general undergraduate degree. So I went to medical school at the University of Sydney. I had one, for me, very important year there. It was a rather conventional medical undergraduate training, there was nothing particularly remarkable about it, but you had the opportunity to do a so-called intercalated BSc, a Bachelor of Science Medical, which was a year spent in a lab, which was wonderful. It was the most enjoyable part of my university. Firstly, I could do some research and I could follow my nose a bit, I had a bit of time to read literature, think about things. But, certainly, I met people outside medicine. So, for example, during that year, I attended lectures in English literature, and I met friends who were involved in political science and sociology. Up to that until that point, I had been a very conventional medical student, and suddenly my eyes were open. So I could do research, I could follow my nose, and there was a whole world out there.

What medical degree, then, do you have? Did you practice medicine?

I did a couple of years, I did my house jobs. In fact, during my first house job, I knew I had to get something extra, so despite working a hundred hours a week, I went off and finished first year English. I used to go with my bleeper to English lectures while on-call, waiting to be called ...

So, almost a separate degree in English literature?

I just did the first year, I did one year, but it was great fun. It was enormously interesting to do that, to get this extra dimension. In my second year, again, I didn't want to do just straight house jobs, and so I did a clinical research year. And that, again, was really rather important. I was working in thoracic medicine, asthma. I was looking after patients, but I was starting to pursue my own interests in research. In a way, that's what's convinced me to go into epidemiology, public health.

One very important person was a chest physician in Sydney at Royal Prince Alfred Hospital. I really wasn't terribly intellectual, in a way. I was not well read, but I used to walk around the hospital wards and I'd say, "We saw this chap three months ago, and he came in in acute cardiac failure, we treated him," or, "...chronic respiratory failure; we treated him. Sent him home. Here he is back again." And I used to think that medicine and particularly surgery is just failed prevention. That if we could treat these people properly and, particularly, if we could do something about prevention, we could empty the hospital wards. It was probably false, but that's what I used to think.

And this chest physician, a man named Peter Harvey, was interested in the idea that I had, some of the thoughts, other than just straight clinical medicine. He had a friend named Ian Prior in New Zealand, and they used to do studies of blood pressure in Polynesian islanders, looking at different prevalence of blood pressure in different Polynesian island groups. Ian Prior had a meeting in New Zealand that Peter Harvey went to, and he came back from this meeting, he said, "I've got just the thing for you, it's called epidemiology." I said, "What's that?" And he said, "Well, these guys, doctors and anthropologists and statisticians and biologists, all work together to try and understand why disease varies in different places." He said, "I met these two terrific people there." One was named Len Syme, who is a professor of epidemiology in Berkeley, and the other was named John Cassel, who is professor of epidemiology at Chapel Hill, University of North Carolina. And he said, "Would you like me to write to them?" So I said, "Yes, please."

So he wrote, and they both wrote back, and said, "We'd like to see your CV." I found not long ago the letter I had written at the time, and it was slightly embarrassing, really. It was embarrassing for two ways -- one, the sort of naiveté of a young man, but secondly, that my ideas haven't changed much, that I actually said in these letters that I thought that health was a manifestation of the way we organize society, and that by asking about health in society, we're asking about society itself. Where I got that idea from, I haven't a clue, but that's what I've been doing for the last thirty years.

I had never heard of Chapel Hill, and I had heard of Berkeley, so I came to Berkeley.

In looking back now, do you have any better sense of the roots of that broader picture, that need for locating what you were doing in a larger social context, or was it just curiosity?

I think it was curiosity. I think it came from one or two fellow students. I suppose I had read a little bit more than I'll admit. But I can't honestly say it came from my medical teachers in Sydney, I don't think it really did. And, in fact, when I was planning to come to Berkeley, and I remember one particular day when the deadline for applying for a residence position, a training position in internal medicine, the deadline was 5 o'clock Friday afternoon ...

This would be in Australia?

In Australia, yes. So the usual thing was if you could train in internal medicine, of course, you would. Who wouldn't? So if you could get a job at the premier teaching hospital, that's obviously what any sane sensible person would want to do. And 5 o'clock Friday afternoon came, and I hadn't put in an application. I didn't yet know whether I would be able to go to Berkeley, but I felt this wonderful sense of liberation. One of the older physicians said, "It's a big mistake, you know. You'll get off the ladder and you may never get back on." And it felt wonderful.

So I think it was more a reaction to conventional medicine than it was that I could point to a particular teacher who impressed me.

On the one hand, in conventional medicine, you were able to help people, be sympathetic; but I guess there's also a lot of rote work in that. Was it that you were dissatisfied, or was it that you saw something better?

I loved clinical medicine, I liked dealing with patients -- real people, real problems. So I loved clinical medicine. I liked the problem-solving aspect of it, and I liked the science of it, and I liked the human warmth and contact of it. So I really loved it. Whether I would say that after doing it for thirty years, I can't say, but I really loved it. So it wasn't any dissatisfaction with the actual practice of clinical medicine, which was very satisfying. It was much more this feeling that this wasn't the right way to go about it. We really needed to think how to stop those unfortunate people coming back again and again and again every three months. It felt to me like we were putting Band-Aids on.

I also remember at the time talking to a friend about the experience of working in casualty and the emergency room. The teaching hospital I was at was the inner-city part of Sydney, and there were a lot of Italian and Greek immigrants. Some of the staff, as you might expect, were slightly rude about patients coming in who couldn't speak English properly, and it always seemed to me at the time that what these patients were expressing was a problem in living. When people would come in with nonspecific problems and we never quite got to the root of a medical diagnosis, it always seemed to me they were expressing problems in living, and that one needed to look at their problems in living, and how they manifested themselves in physical problems. So to the extent that I understood what Len Syme and John Cassel were doing, that seemed to me exactly what they were doing. And that's why I jumped readily, and said, "Yep, that's what I want to do."

How did Berkeley affect and shape the directions of your thinking?

It had an enormous impact, really. As I've already said, I came out of a rather conventional, straight up-and-down, high-quality but conventional medical education. I used to say at the time when I came to Berkeley that it seemed to me that it was one big Department of Social Concern. My wife was a graduate student in architecture and city planning, and she was being given the same books to read that I was being given. We were all reading Thomas Kuhn's, Structure of Scientific Revolutions, and we were thinking about systems analysis. So it didn't seem to matter which department you were in, you were reading the same books and thinking the same thoughts.

And in political science too.

And presumably political science, that was one big Department of Social Concern.

The second thing was that Len Syme said to me, "Just because you've read some medical books doesn't mean you have any particular insight on the determinants of health in societies." That was pretty shocking. I thought, "Who would know about determinants of health other than doctors?" I was a doctor, by golly, and if I didn't know, who would? The idea that sociologists, economists, psychologists, biologists who weren't doctors, might all have something to say about this was shocking, and illuminating -- just mind-opening. The plusses and minuses of the American educational systems -- the minuses are you do a lot that's a bit superficial; the plusses are you do a lot that's a bit superficial. Going round the campus and sampling in anthropology and sociology and economics, the philosophy of science -- I had a wonderful time in philosophy of science. And the fact that there were so many good people around really was mind-expanding, and changed the way I thought about research and about my subject.

The other thing, of course, was that this was the early seventies, and the sixties were not really yet over, certainly not at Berkeley.

So, in a way, what was fertile and creative about Berkeley at that time was an interdisciplinary, comparative, global perspective that got you out of the box of the thinking that you were doing. But you were heading in that direction before you came to Berkeley, you seem to be suggesting.

I suppose I was, which is why I was poised to take advantage of it here. If I hadn't been thinking about that, I could have come to Berkeley and studied epidemiology and statistics and health planning, and then I could have gone away again. But at Berkeley, I was poised ... I mean, it's gene/environment interactions! I'm not suggesting my interest was genetic, but you know what I mean: I had a predisposition, but there was an environment that allowed my predisposition to flourish.

So how did the sixties affect you, being in Berkeley in the sixties?

I only came to Berkeley at the beginning of the seventies, but still, Australia was in the world in the sixties.

So first tell us what happened in the sixties in Australia, and then how that was reinforced when you came here, if at all.

Australia was influenced by this worldwide epidemic of thinking. There was a sense that all the old canons were open to question, and one didn't necessarily accept things just because they had been accepted before. Now, within a medical education, that didn't change anything very much, but in the wider society and on student campus, that was all around. It was a wonderful sense, not terribly analytic, I have to say, but there was a wonderful sense that anything is possible. There was a sense that a focus on material goods was inappropriate. There was a sense that you didn't have to follow a conventional route. I suppose, in a way, my going off to Berkeley and stepping off the conventional ladder was a manifestation of that, because anything was possible. More money was being put into the universities, things were opening up, and that affected Sydney, as it did Berkeley and London and Berlin and Paris. Maybe it wasn't quite as exciting as Paris in 1968, but we knew about it and we understood it and we felt it.

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