A conversation with Sir Michael Marmot

UC Berkeley School of Public Health: How did you land at Berkeley?

I was a young doctor in Sydney, Australia, working in thoracic medicine. Observing our patients with asthma and chronic obstructive pulmonary disease, it was clear to me that their social conditions were impacting on their health. They would come into hospital, we would patch them up, send them home and, a little while later, back they would come again. Surely, prevention was a better option, and that would mean attending to their social conditions.

Acknowledging my concerns, a consultant physician, Peter Harvey, said, “I have just the thing for you: Epidemiology.”

He said that he had been at a meeting in New Zealand, hosted by Ian Prior, and had met two terrific people, Len Syme from Berkeley and John Cassel from Chapel Hill. Peter Harvey said that it would suit me because doctors, social scientists, and statisticians were working together to discover why patterns of disease vary depending on people’s living conditions. Peter wrote to both Cassel and Syme. Each replied: “Send the young man to me.“ I had heard of Berkeley and had never heard of Chapel Hill. Len Syme and Berkeley it was.

What were the highlights of your time here at Berkeley?

I had been through a high standard but rather conventional medical training in Sydney. UC Berkeley in the early 1970s seemed like one big Department of Social Concern. We were all reading the same books. I took classes outside the School of Public Health, in anthropology, sociology, demography, and economics. Len and I worked with Ros Lindheim, a professor of architecture. Good heavens!

Of course, the experience of immersing myself in a research project for the 2 to 3 years of my PhD allowed me both to focus, to drill down on a single topic (see below), while reading and exploring widely.

And my wife and I loved Berkeley and the easy access to the Sierras, summer and winter. Still, there’s only so long one can put up with good weather all year round. The slate grey skies and cold of London beckoned.

When we spoke a few years ago, for a profile of our late beloved Len Syme, you mentioned that when you came to Berkeley to work with him, epidemiology was a fringe science and social determinants of health was "the fringe of the fringe." Why were you not worried about stepping into such a fringe-y field?

In a way being in a fringe-y field was the point. I had offers to be involved in more mainstream projects. But, I thought and still do think, surely research is about exploring the edges of knowledge, about bringing fresh perspectives to bear on problems.

I thought that an earlier generation of epidemiologists had broken fresh ground by studying non-communicable diseases. But by the 1970s, the study of individual risk factors had become rather standard. If I wanted to study how the nature of society affected health and disease, that, almost by definition, meant I had to operate on the fringe.

Being uncomfortable is not such a bad state for a researcher. The probability of failure increases but success—if it comes in the form of new findings—is all the more rewarding.

I didn’t know of other people who were studying acculturation and coronary heart disease. One can’t get much closer to the edge than that. When I started to do research on social class (as we then labelled it) and health in the UK, there was more of a tradition of such efforts but it was still a fringe pursuit within medicine. A fourth rate discipline for second-rate minds, one professor of medicine called it.

When did you realize that you and your colleagues had succeeded in convincing the public health and medical worlds of the importance of social determinants of health? Was it gradual or was there a specific time or incident when you knew it was no longer fringe?

To misquote Hemingway, it happened gradually then suddenly.

Back in the UK, I was studying socioeconomic inequalities in health and mortality. Margaret Thatcher was prime minister and, famously, said that there is no such thing as society. There could then hardly be social inequalities in health.

Mine remained a fringe pursuit. I was advised by senior people to look elsewhere. Then in 1997 the government changed. The government of Tony Blair wanted to know how to reduce inequalities in health. Yesterday’s pure research became today’s applied research.

I suppose being knighted by Her Majesty the Queen, in the year 2000, meant that I had come in from the cold. The citation that accompanied my knighthood read: “for services to epidemiology and understanding health inequalities.”

The next step was being invited by the World Health Organization (WHO) Director-General, Jong-wook Lee, to work with WHO to establish a new Commission on Social Determinants of Health (CSDH), and for me to chair it. We reported in 2008 with the declaration: Social injustice is killing people on a grand scale.

UK Prime Minister Gordon Brown then invited me to conduct a strategic review of health inequalities. The question was how we could translate the conclusions and recommendations of the global CSDH for one country, England. In the way of things in the UK, our report was published as the Marmot Review in 2010.

I may have been beyond the pale for the government of Margaret Thatcher. Not so for the Labour Government of Gordon Brown.

What are the most important social issues affecting public and global health today?

I was invited by Winnie Byanyima, executive director of UNAIDS, to co-chair a high level Council on Inequality, AIDS and Pandemics. My co-chairs were Joe Stiglitz, Nobel Prize–winning economist at Columbia University, and Monica Geingos, former first lady of Namibia.

Our report, released during the G20 meeting in South Africa in November 2025, showed that inequality made pandemics worse, and pandemics made inequality worse—an inequality pandemic cycle. Our four domains of recommendations provide an answer to your question. They were made in relation to pandemics, but they apply to global health more generally.

• Remove the financial barriers in the global architecture to allow all countries sufficient fiscal capacity to address the inequalities driving pandemics.
• Invest in the social determinants of pandemics. Use social protection mechanisms to reduce socioeconomic and health inequalities and build societal resilience in order to prepare for, and respond to, pandemics.
• Build local and regional production alongside a new governance of research and development capable of ensuring the sharing of technology as public goods needed to stop pandemics.
• Build greater trust, equality, and efficiency in pandemic response by investing in multi-sectoral response and community-led pandemic infrastructure in partnership with government.

To repeat, these four areas are crucial for global health in non-pandemic times. To these four I would add: Deal with the consequences of the climate crisis.

How can this new Lancet article series—co-authored by social scientists, health professionals and community members around the world—help public health students and alumni work toward a world in which everyone has all they need to be fully healthy?

The opening line of my book, The Health Gap, was: Why treat people and send them back to the conditions that made them sick. Everyone needs access to high quality medical care, no matter how marginal or subject to social exclusion. But we also need to address the conditions that make people sick. These two principles are well illustrated by this important series of case studies.

The first case we will discuss deals with migration and an asylum seeker at the Tijuana border and the second with a health system working hard to care for people in a refugee camp.

Your PhD research at UC Berkeley under the mentorship of Syme also focused on migration and health. What about the field or migration and health helped lead you into your ongoing work on the social determinants of health?

At the broadest level, if rates of disease change when people change location it is an argument for social and environmental determinants of health—nurture rather than nature. By studying what changes when people change society and location we start to understand how social processes affect health.

That, to me, was the lesson of my PhD research on men of Japanese ancestry living in Japan, Hawaii, and California. It led to an enduring interest in ethnic and social inequalities in health and in the social determinants of health. Social Determinants of Health was the title we (Marmot and Wilkinson) gave to our OUP book in 1999.

Many of us feel saddened and deeply concerned about growing inequality and severe violence in the world today. Could you share with us what you are most passionate and/or inspired to work on over the rest of this year?

I described being shut out by the Conservative Thatcher government. It happened again with the Conservative-led government of David Cameron that was elected in 2010, two months after I published the Marmot Review. Social determinants of health? Forget it. Their priority was rolling back the state and delivering regressive cuts in social spending. But…

The English city of Coventry said, well if the government won’t implement your recommendations, we will. Coventry declared itself the first Marmot City. I was a bit embarrassed at the whiff of egomania implied by labelling it Marmot.

More so, when Greater Manchester declared that they would become the first Marmot City Region. One thing led to another. We are working on a national strategy for Scotland and with three Scottish Marmot places. Wales, in 2025 declared its ambition to be the first Marmot nation. We now have 60 Marmot Places in England, Wales, and Scotland. Yes, deepening inequality is a huge problem. But the enthusiasm with which cities and other places are embracing Marmot Principles is inspiring. It fills me with hope.

For what it’s worth, the Royal Society of Public Health rated the 10 most important public health innovations of the 21st Century. No. 1 is pre-exposure prophylaxis for HIV. New vaccines is No. 2. The Marmot Review into health inequalities is No. 3. It’s been quite a journey.