Social determinants of cardiovascular health: lessons from Whitehall

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Cardiovascular disease and socioeconomic status are inextricably linked, although the nature of this health relationship has not always been apparent. In the mid-twentieth century, cardiovascular disease was linked to affluence — the ‘executive stress model’ posited that those at the top of the socioeconomic hierarchy bore the greatest burden, which made them most susceptible to cardiovascular disease, particularly hypertension and coronary artery disease. The Whitehall study published by Michael Marmot and colleagues in 1978 challenged this paradigm and revealed the profound cardiovascular health inequities faced by those living with the greatest deprivation. These inequities persist to this day and continue to shape global approaches to health care.

The Whitehall study (named after the administrative centre of the UK government) was a seminal epidemiological demonstration that coronary heart disease mortality has a clear inverse relationship with socioeconomic status: lower socioeconomic status entails a significantly higher risk of cardiovascular mortality, and health status improves in line with economic and social position. Between 1967 and 1969, a total of 17,530 middle-aged, male, British civil servants of various employment grades were recruited and underwent baseline assessment of cardiovascular risk factors. After 7.5 years of follow-up, grade of employment was a stronger predictor of death from coronary heart disease than any traditional cardiovascular risk factor. Men in the lowest employment grade had 3.6 times higher mortality than those in the highest employment grade. Although men in the lower employment grades had higher baseline rates of smoking and hypertension, this difference could not explain the disparity in health outcomes: approximately 60% of the association remained unexplained after adjustment for established cardiovascular risk factors (blood pressure, blood glucose level, plasma cholesterol level, smoking status, body mass index and level of physical activity). The biomedical model of the time simply could not account for the profound effect of health inequity. Therefore, Marmot and colleagues posited that previously unacknowledged social and environmental factors, linked to socioeconomic deprivation, must be driving health disparities.