"We've got to look outside the laboratory at atherosclerosis and examine how it is distributed in the population and what it is in the environment that leads to different rates of clinical disease," Marmot said.

He also said that having little control of the work environment characterizes individuals who are at the bottom of the social hierarchy. "We have shown that low-status people have more coronary disease, but it follows a social gradient," Marmot said. "The lower an individual is in the hierarchy, the higher the risk."

His research has found a similar relationship between low job control, low social status, and heart disease in Sweden and throughout western European countries.

Having little control also associated with higher mortality

In a different aspect of social epidemiology, Marmot has studied the degree of control over one's life compared to mortality rates, in the countries of the former Soviet Union and in central and eastern Europe. "Low control seems to be epidemic in these countries," he said. "The lower the reported control over their lives in these populations, the higher the mortality rate."

According to Marmot, the most dramatic trends in mortality have come from the former Soviet Union. In one 7-year period in the 1980s, he found a 7-year decline in life expectancy of men. "A 7-year decline in life expectancy is absolutely enormous," Marmot pointed out. "A large part of that decline was cardiovascular disease and another major contributor was accidental, environmentally-caused deaths."

"We could argue that accidental environment deaths are related to a disrupted, disorganized society," he said. "We would argue that violent deaths are due to a disrupted, disorganized society. We could argue that a disrupted, disorganized society is related both to increased risk of heart disease and to violent deaths."

An internationally known researcher

Marmot specializes in epidemiological research into social and economic differences in health and disease within and between populations in the UK and in western and eastern Europe. In addition to the longitudinal Whitehall Studies of about 10,000 civil servants, he has directed the annual Health Survey for England with more than 16,000 adults and the Health Survey for Scotland which surveys 8,000 adults every 3 years.

As director of the International Center for Health and Society at UCL, Marmot has led research into the psychosocial work environment in countries of western Europe. He has coordinated CHEWE, Coronary Heart Disease in East and West Europe, and the Heart at Work network which is examining the contributions of the psychosocial work environment to social inequalities in health. At present, a research program is being established to create a bridge between the epidemiology of social factors and health and biological investigations of disease epidemiology.

From the social to the physiological

Marmot suggested possible biological pathways by which psychosocial factors might operate. In the social gradient, the lower the status, the higher the risk for developing the metabolic syndrome and for insulin resistance, he said. Marmot said he found that the lower the status, the higher the levels of plasma fibrinogen and von Willebrand factor.

Animal studies have similarly shown a social gradient in atherosclerosis, according to Marmot. "This provides plausible mechanisms by which position in the hierarchy might be related to atherosclerosis."