The health gapthe health gap the challenge of a

1. THE HEALTH GAP
THE HEALTH GAP
The Challenge of an Unequal World
MICHAEL MARMOT
For Alexi, Andre, Daniel and Deborah
CONTENTS
Introduction
1. The Organisation of Misery
2. Whose Responsibility?
3. Fair Society, Healthy Lives
4. Equity from the Start
5. Education and Empowerment
6. Working to Live
7. Do Not Go Gentle
8. Building Resilient Communities

2. 9. Fair Societies
10. Living Fairly in the World
11. The Organisation of Hope
Notes
Acknowledgements
Index
A Note on the Author
By the Same Author
Introduction
Why treat people and send them back to the conditions that
made them
sick?
The woman looked the very picture of misery. Her gait almost
apologetic, she approached the doctor and sat down, huddling
into the chair.
The dreariness of the outpatients clinic, unloved and uncared
for, could not
have helped. It certainly did nothing for my mood.
‘When were you last time completely well?’ asked the
psychiatrist in a
thick middle-European accent. Psychiatrists are supposed to
have middle-
European accents. Even in Australia, this one did.
‘Oh doctor,’ said the patient, ‘my husband is drinking again and
beating
me, my son is back in prison, my teenage daughter is pregnant,
and I cry

3. most days, have no energy, difficulty sleeping. I feel l ife is not
worth
living.’
It was hardly surprising that she was depressed. My mood
dipped further.
As a medical student in the 1960s I was sitting in Psychiatry
Outpatients at
Royal Prince Alfred Hospital, a teaching hospital of the
University of
Sydney.
The psychiatrist told the woman to stop taking the blue pills and
try these
red pills. He wrote out an appointment for a month’s time and,
still a picture
of misery, she was gone. That’s it? No more? To incredulous
medical
students he explained that there was very little else he could do.
The idea that she was suffering from red-pill deficiency was not
compelling. It seemed startlingly obvious that her depression
was related to
her life circumstances. The psychiatrist might have been correct
that there
was little that he personally could do. Although, as I will show
you, I have
come to question that. To me, that should not imply that there
was nothing
that could be done. ‘We’ should be paying attention to the
causes of her
depression. The question of who ‘we’ should be, and what we
could do,
explains why I discarded my flirtation with psychiatry and
pursued a career
researching the social causes of ill-health and, latterly,

4. advocating action.
This book is the result of the journey that began in that dreary
outpatients
clinic all those years ago.
And it was not just a question of mental illness. The conditions
of
people’s lives could lead to physical illness as well. The inner -
city teaching
hospital where I trained in Sydney served a large immigrant
population, at
that time from Greece, Yugoslavia and southern Italy. Members
of this
population, with very little English to explain their symptoms,
would come
into the Accident and Emergency Department with a pain in the
belly. As
young doctors we were told to give them some antacids and
send them
home. I found this absurd. People would come in with problems
in their
lives and we would treat them with a bottle of white mixture.
We needed
the tools, I thought, to deal with the problems in their lives.
A respected senior colleague put it to me that there is continuity
in the
life of the mind. Perhaps it is not surprising that stressful
circumstances
should cause mental illness, he said, but it is inherently unlikely
that stress
in life could cause physical ill-health. He was wrong, of course.
I did not

5. have the evidence to contradict him at the time, but I do now.
The evidence
linking the life of the mind with avoidable ill-health will run
right through
this book. Death, for example, is rather physical, it is not just in
the mind.
We know that people with mental ill-health have life expectancy
between
ten and twenty years shorter than people with no mental
illness.1 Whatever
is going on in the mind is having a profound effect on people’s
risk of
physical illness and their risk of death, as well as on mental
illness. And
what goes on in the mind is profoundly influenced by the
conditions in
which people are born, grow, live, work and age, and by the
inequities in
power, money and resources that influence these conditions of
daily life. A
major part of this book is examining how that works and what
we can do
about it.
The more I thought about it at the time, the more I thought that
medicine
was failed prevention. By that I mean most of medicine, not just
pain in the
belly in marginal groups or depression in women suffering
domestic
violence. Surgery seems a rather crude approach to cancer.
Lung cancer is
almost entirely preventable – by eliminating smoking. I didn’t
know it at
the time, but about a third of cancers can be prevented by diet.
Heart

6. disease – surely we would want to prevent that, rather than
simply wait for
the heart attack and treat. Stroke ought to be preventable by diet
and
treating high blood pressure. We need surgery for trauma, of
course, but
could we not take steps to reduce the risk of trauma? That said,
having had
a bad bicycle accident, I am very grateful for high-quality
surgical care, free
at the point of use (thank you, National Health Service).
As for prevention, it seemed to me then, and I have evidence
now, that
taking control of your life and exercising, eating and drinking
sensibly,
having time off on happy holidays, was all very well if you
were
comfortably off financially and socially (and going to the
private clinics,
not the public hospital where I was then working). Were we
going to tell the
woman in Psychiatry Outpatients that she should stop smoking
and, as soon
as her husband stopped beating her, she should make sure that
he and she
had five fruit and vegetables a day (we did know about healthy
eating then,
even if we didn’t have the ‘five a day’ slogan)? Were we going
to tell the
immigrant with a marginal, lonely existence to stop eating fish
and chips
and take out membership in a gym? And for those who assert

7. that health is
a matter of personal responsibility, should we tell the depressed
woman to
pull her socks up and sort herself out?
The thought then occurred that a preponderance of the patients I
was
seeing were disadvantaged socially. Not in desperate poverty:
the husband
of the depressed woman was working; the migrants, like
probably most
migrants, were working hard to get a toehold in society. But
they were at
the lower end of the social scale. In fact, all the things that
happened to the
depressed woman – domestic violence, son in prison, teenage
daughter
pregnant – are more common in people at that end of the scale. I
was seeing
social disadvantage in action; not poverty so much as low social
status
leading to life problems that were leading to ill-health.
She had an illness. The fire was raging. Treating her with pills
might help
put out the fire. Should we not be in the business of fire
prevention as well?
Why treat people and send them back to the conditions that
made them
sick? And that, I told myself, entails dealing with the conditions
that make
people sick, not simply prescribing pills or, if interested in
prevention,
telling people to behave better. At that time, and since, I have
never met a
patient who lost weight because the doctor told her to.

8. As doctors we are trained to treat the sick. Of course; but if
behaviour,
and health, are linked to people’s social conditions, I asked
myself whose
job it should be to improve social conditions. Shouldn’t the
doctor, or at
least this doctor, be involved? I became a doctor because I
wanted to help
people be healthier. If simply treating them when they got sick
was, at best,
a temporary remedy, then the doctor should be involved in
improving the
conditions that made them sick.
I had a cause. I still do.
It was not a cause, though, that many of my seniors in medicine
were
prepared to endorse. They were too busy putting out fires to
expend effort
improving the conditions that promoted these fires.
While thinking these thoughts and working as a junior doctor in
the
respiratory medicine ward, I had a Russian patient with
tuberculosis. When
I ‘presented’ the patient to my seniors, I didn’t start with his
medical history
but, I now blush to recall, said that Mr X, a Russian, was like a
character
out of Dostoevsky. He had stubbed his toe on the highway of
life (cringe).

9. He had been a gambler down on his luck, an alcoholic, unlucky
in love, and
now, as if in a Russian novel, had developed TB.
A few days later the consultant chest physician drew me aside
and said: I
have just the career for you, it’s called epidemiology. (Anything
to get me
out of his hair.) He said that doctors, anthropologists and
statisticians all
work together to figure out why people have different rates of
illness
depending on where and how they live. I was dispatched with a
fellowship
to the University of California Berkeley to do a PhD in
epidemiology with
Leonard Syme.
The idea that one could actually study how social conditions
affected
health and disease was a revelation. Walking round the hospital
wards, I had
been saying to myself that if social conditions caused physical
and mental
illness, then perhaps the rate of illness of a society could tell us
something
about that society. I know, it sounds obvious, but I was trained
in medicine,
not in thinking. It meant that the term ‘healthy society’ could do
double
duty. A healthy society surely would be one that worked well to
meet the
needs of its citizens, and hence would be one where health was
better.
In Spanish they say Salud (health); in German prosit (may it be

10. good for
you); in Russian Vashe zdorov’ye (for your health); in Hebrew
L’Chayyim
(to life); in Maori Mauri ora (to life). In English when we are
not saying
Cheers, Bottoms up or Here’s lookin’ at you kid, commonly we
say: Good
health. People value health. Even when they get together for
something not
favourable to health, alcohol, people remember to wish each
other good
health. Health is important to all of us.
But other things take priority.
I asked some people in a poor part of London, forty or so years
after the
experiences in Sydney, what was on their mind. They talked
about the
importance of family and friendships; concern for their children
– safe
places to play, good schools, not getting into trouble with
unsuitable
friends; having enough money to feed the family and to heat the
home, and
perhaps for the occasional indulgence; having adequate housing;
living in a
neighbourhood with green space, good public transport, shops
and
amenities, and freedom from crime; having reliable and
interesting work,
without fear of losing their job; older people not being thrown
on the
scrapheap. Actually, had I asked people in a well-heeled part of

11. London, the
answers would have been little different.
Then I asked what they thought about health. I was told that in
poor
countries, ill-health is the result of unsanitary living conditions
and lack of
health care. In rich countries, now that we all have clean water
and safe
toilets, they told me that ill-health is the result of difficulty
getting to see the
doctor and our own indulgent behaviour, we dreadful feckless
drinkers,
smokers and overweight sloths (I am translating slightly), or
just plain bad
luck in the genetic lottery.
My point in writing this book is that my informants were not
wrong
about what is important for health, just too limited. The
depressed woman
in outpatients, the migrants with pain in the belly, the Russian
with TB –
they are the rule, not the exception. We now know that the
things that really
matter to us in our lives, minute to minute, day to day and year
to year, have
a profound impact on our health. The conditions in which
people lead their
lives, all the things my London informants told me were on
their minds, are
the main influences on their health.
The central issue is that good conditions of daily life, the things
that
really count, are unequally distributed, much more so than is

12. good for
anything, whether for our children’s future, for a just society,
for the
economy and, crucially, for health. The result of unequal
distribution of life
chances is that health is unequally distributed. If you are born
in the most
fortunate circumstances you can expect to have your healthy life
extended
by nineteen years or more, compared with being born into
disadvantage.
Being at the wrong end of inequality is disempowering, it
deprives people
of control over their lives. Their health is damaged as a result.
And the
effect is graded – the greater the disadvantage the worse the
health.
Finding this out has been not only wonderfully interesting,
thrilling even,
but it turns out that the evidence provides us with answers. How
to improve
the conditions of our lives and improve health is the substance
of the
chapters that follow. The knowledge that we can make a
difference is
inspiring. The argument that we should make a difference I find
utterly
convincing.
My Damascus moment may have been in Sydney, but the
journey of
compiling the evidence began in Berkeley. As Len Syme, still in
Berkeley,

13. puts it, they sent me off from Sydney because I was asking too
many
awkward questions and thought that Berkeley, soon after its
experiences of
the student rebellions of the 1960s, was a better place to ask
awkward
questions. A great place, actually!
Syme, in Berkeley, shocked me by saying: just because you
have a
medical degree it doesn’t mean that you can understand health.
If you want
to understand why health is distributed the way it is, you have
to understand
society. I have been trying ever since.
An American colleague enjoys scrambled eggs for breakfast. He
studies the
impact of stress on health but he doesn’t rule out the importance
of fatty
diet, so limits his egg indulgence to Sunday mornings. One day
he opened
his carton of eggs and found a printed insert, a bit like a box of
pills. Poor
desperate souls, we addictive readers, we’ll even read package
inserts in
egg cartons. On the insert he was intrigued to discover that
Marmot’s study
of Japanese migrants in California, reported in the 1970s,
proved that
cholesterol was not bad for the heart. Stress was important, not
diet.
Not quite.
I am, of course, delighted that academics in Massachusetts can
learn

14. about my research over breakfast simply by reading what’s in
the egg
carton. I would be even more pleased if the advertising
copywriter had got
it right. Admittedly, it is just a tad complicated; it entails the
ability to hold
two ideas in your head at the same time – but writers of egg-
carton inserts
should be able to manage that.
As Japanese migrate across the Pacific, their rate of heart
disease goes up
and their rate of stroke goes down.2 Would I like to work on
this for my
Berkeley PhD? Would I! It was a brilliant natural experiment. If
you were
trying to sort out genetic and environmental contributions to
disease, here
were people with, presumabl y, the same genetic endowment
living in
different environments. Japanese in Hawaii had higher rates of
heart disease
than those in Japan, Japanese in California higher rates than
those in
Hawaii, and white Americans higher rates still.
This was terrific. You couldn’t have designed a better
experiment to test
the impact on health of ‘environment’, broadly conceived. Most
likely, the
changing rates of disease are telling us something about culture
and way of

15. life, linked to the environment. Simple hypothesis:
Americanisation leads to
heart disease, or Japanese culture protects from heart disease.
But what does
that mean in practice?
Conventional wisdom at the time was, and still is, that fatty
diets are the
culprit. Indeed, I have chaired committees saying just that.3
Japanese-
Americans had diets that were somewhat Americanised, with
higher levels
of fat than a traditional Japanese diet, and as a result had higher
levels of
plasma cholesterol than did Japanese in Japan.4 Diet and high
levels of
cholesterol were likely to be playing a part in the higher rate of
heart
disease. What’s more, the higher the level of plasma
cholesterol, the higher
is the risk of heart disease. So much for the egg-package insert.
It missed
idea one. It grieves me to say it, but conventional wisdom is not
always
wrong.
Now for idea two. Japanese-Americans may be taller, fatter and
more
partial to hamburgers than Japanese in the old country, but their
approach to
family and friends resembles the more close-knit culture of
Japan more than
it does the more socially and geographically mobile culture of
the US.
That’s interesting, but is it important for health? A Japanese-
American

16. social scientist with the very Japanese-American name of Scott
Matsumoto
had speculated that the cohesive nature of Japanese culture was
a powerful
mechanism for reducing stress.5 Such a diminution could
protect from heart
disease. I particularly liked the idea of turning the study of
stress on its
head. Not looking at how being under pressure messes up the
heart and
blood vessels, but how people’s social relationships were
positive and
supportive. We humans gossip and schmooze; apes groom. If,
whether
human or non-human primate, we support each other it changes
hormonal
profiles and may lower risk of heart attacks.
If this were true, I thought, then perhaps the Japanese in Hawaii
had more
opportunity to maintain their culture than the Japanese in
California – hence
the lower rate of heart disease in Hawaii. It seemed a reasonable
speculation, but I had no test for it.
I had the data to test the hypothesis much more directly among
the
California Japanese. Men who were more involved with
Japanese culture
and had cohesive social relations should have lower rates of
heart disease
than those who were more acculturated – had adopted more of
the
American way of life. That is what I found. And this research

17. result,
perhaps, is where the egg cartons got their ‘news’. The apparent
protection
from heart disease among the California men who were more
‘Japanese’
culturally and socially could not be explained by dietary
patterns, nor by
smoking, nor by blood pressure levels, nor by obesity. The
culture effect
was not a proxy for the usual suspects of diet and smoking.6
Two ideas then: conventional wisdom is correct, smoking and
diet are
important causes of heart disease; and, while correct,
conventional wisdom
is also limited – other things are going on. In the case of
Japanese-
Americans, it was the protective effect of being culturally
Japanese.
Everything I will show you in this book conforms to that simple
proposition – conventional wisdom is correct, but limited, when
it comes to
causes of disease. In rich countries, for example, we understand
a good deal
about why one individual gets sick and another does not: their
habits of
smoking, diet, drinking alcohol, physical inactivity, in addition
to genetic
makeup – we could call that conventional wisdom. But being
emotionally
abused by your spouse, having family troubles, being unlucky in
love,
being marginal in society, can all increase risk of disease; just
as living in
supportive, cohesive social groups can be protective. If we want

18. to
understand why health and disease are distributed the way they
are, we have
to understand these social causes; all the more so if we want to
do
something about it.
The British Civil Service changed my life. Not very romantic, a
bit like
being inspired by a chartered accountant. The measured pace
and careful
rhythms of Her Majesty’s loyal servants had a profound effect
on
everything I did subsequently. Well, not quite the conservatism
of the actual
practices of the civil service, but the drama of the patterns of
health that we
found there. Inequality is central.
The civil service seems the very antithesis of dramatic. Please
bear with
me. You have been, let’s say, invited to a meeting with a top-
grade civil
servant. It is a trial by hierarchy. You arrive at the building and
someone is
watching the door – he is part of the office support grades, as is
the person
who checks your bag and lets you through the security gate. A
clerical
assistant checks your name and calls up to the office on the fifth
floor. A
higher-grade clerical person comes to escort you upstairs, where
a low-

19. grade executive officer greets you. Two technical people, a
doctor and a
statistician, who will be joining the meeting, are already
waiting. Then the
great man’s, or woman’s, high-flying junior administrator says
that Richard,
or Fiona, will be ready shortly. Finally you are ushered in to the
real deal
where studied informality is now the rule. In the last ten
minutes you have
completed a journey up the civil service ranking ladder – takes
some people
a lifetime: office support grades, through clerical assistants,
clerical
officers, executive grades, professionals, junior administrators
to, at the
pinnacle, senior administrators. So far so boring: little different
from a
private insurance company.
The striking thing about this procession up the bureaucratic
ladder is that
health maps on to it, remarkably closely. Those at the bottom,
the men at
the door, have the worst health, on average. And so it goes.
Each person we
meet has worse health, and shorter life expectancy, than the
next one a little
higher up the ladder, but better health than the one lower down.
Health is
correlated with seniority. In our first study, 1978–1984, of
mortality of civil
servants (the Whitehall Study), who were all men unfortunately,
men at the
bottom had a mortality rate four times higher than the men at
the top – they

20. were four times more likely to die in a specific period of time.
In between
top and bottom, health improved steadily with rank.7 This
linking of social
position with health – higher rank, better health – I call the
social gradient
in health. Investigating the causes of the gradient, teasing out
the policy
implications of such health inequalities, and advocating for
change, have
been at the centre of my activities since.
I arrived at Whitehall through a slightly circuitous route,
intellectual as
well as geographic.
You couldn’t be interested in public health, or even just
interested, and
not be aware that people in poor countries have high rates of
illness and die
younger compared with those in rich countries. Poverty
damages health.
What about poverty in rich countries? It was a niche interest in
the US of
the 1970s. After all, the USA thought of itself as a classless
society, so there
could not be differences between social classes in rates of
health and
disease, right? Wrong – a piece of conventional wisdom that
was
completely wrong. The actual truth was handed around almost
like
Samizdat literature in the former Soviet Union in the form of a

21. small
number of papers, one of which was written by Len Syme and
my colleague
Lisa Berkman, now at Harvard.8 People with social
disadvantage did suffer
worse health in the USA. It was, though, far from a mainstream
preoccupation. Race and ethnicity were dominant concerns.
Class and
health was not a serious subject for study. Inequality and health
was
completely off the agenda, bar a few trailblazers, writing about
the evils of
capitalism.9
If there was a country on the planet that was aware of social
class
distinctions and had a tradition of studying social class
differences in health,
it was the United Kingdom. And if there was a place in Britain
that excelled
at social stratification it was the British Civil Service,
familiarly known as
Whitehall.
From Berkeley, then, I came home. It had taken a while. Born in
North
London, I went to Australia with my family when I was four
years old and,
after a few years playing cricket in the street and declaiming in
the school
debating team, studied medicine in Sydney, then went off to
Berkeley.
Donald Reid, Professor of Epidemiology at the London School
of Hygiene
and Tropical Medicine, offered me a job with the
encouragement that if I

22. wanted a position of low pay, limited opportunities for research
in different
places (such as Hawaii, for example), low research funding, but
high
intellectual activity, London was the place for me. How could I
turn down
such an attractive offer? Donald Reid said he was worried about
me in
‘Lotus Land’, i.e. Berkeley. It was too much fun. He was a
Scottish
Presbyterian and thought a bit of hard living would be good for
me. London
provided it. The British economy in 1976 had just been bailed
out by the
IMF. A sense of doom prevailed, and the Labour government,
staggering its
way to a dismal end, was cutting public expenditure like there
was no
tomorrow. We wondered if that might well be the case. But,
after being in
London for about six months (I had arrived at end October
1976), I saw the
sun come out, people shed their woolly sweaters, the roads
dried out, the
flowers bloomed, I stopped writing daily letters to friends back
in
California, and started to enjoy what Donald Reid promised. It
was
privilege, not hard living.
At first experience, London’s Whitehall was as much of a
culture shock
as San Francisco’s Japantown. Whitehall is home to the British
Civil
Service, and it looks it. To the east, in ‘the City’, financial
giants now flaunt

23. their hubris in soaring glass constructions, reaching for the
skies, like their
occupants. Whitehall’s buildings, heavy and stolid, proclaim
stability. Even
in the newer buildings, the corridors of power feel as though
unchanged
from the days of Empire. It is certainly a place to study class
distinctions,
but not poverty. There are no poor in Whitehall.
The Whitehall Study, a screening study of 17,000 men, had been
set up
by Professors Donald Reid and, another great teacher of mine,
Geoffrey
Rose. Why civil servants? A little more culture shock. Donald
Reid had
lunch at the Athenaeum Club with one of his friends who was
the chief
doctor for the Civil Service, and the study was born. Athenaeum
Club?
Think Gentlemen’s Club, with a classical façade and an
Athenian-style
frieze at the front, in a lovely setting not far from the Royal
Parks in
London, a stuffy dining room and overpadded armchairs.
Twice is a coincidence, three times a trend. In the 1970s I had
done only
two big studies, Japanese migrants and now Whitehall civil
servants, and
both had flown in the face of conventional wisdom. At the time,
everyone
‘knew’ that people in top jobs had a high risk of heart attacks

24. because of the
stress they were under. Sir William Osler, great medical teacher
from Johns
Hopkins University and the University of Oxford, had, around
1920,
described heart disease as being more common in men in high-
status
occupations. Osler fuelled the speculation that it was the stress
of these jobs
that was killing people.
We found the opposite. High-grade men had lower risk of dying
from
heart attacks, and most other causes of death, than everyone
below them,
and as I described earlier, it was a social gradient, progressively
higher
mortality going hand in hand with progressively lower grade of
employment.
Further, conventional explanations did not work. True, smoking
was
more common as one descended the social ladder, but plasma
cholesterol
was marginally higher in the high grades, and the social
gradient in obesity
and high blood pressure was modest. Together, these
conventional risk
factors accounted for about a third of the social gradient in
mortality.10
Something else had to be going on. In that sense, it was similar
to my
studies of Japanese-Americans. The conventional risk factors
mattered, but
something else accounted for the different risks of disease
between social

25. groups. In the Japanese case we thought it was the stress-
reducing effects of
traditional Japanese culture.
You may think: stress in the civil service? Surely not! My
colleagues
Tores Theorell in Stockholm and Robert Karasek, the man who
was eating
eggs in Massachusetts, had elaborated a theory of work stress. It
was not
high demand that was stressful, but a combination of high
demand and low
control.11 To describe it as a Eureka moment goes too far, but
it did provide
a potential explanation of the Whitehall findings. Whoever
spread the
rumour that it is more stressful at the top? People up there have
more
psychological demands, but they also have more control.
Control over your life loomed large as a hypothesis for why, in
rich
countries, people in higher social positions should have better
health.
I have written about the Whitehall Studies at length in a
previous book,
Status Syndrome, and will not rehearse all the evidence here.12
More recent
evidence will make its way into chapters of this book. Suffice it
to say that
the social gradient that we found in the Whitehall studies has
been found in
British national data, and now all over the world. There is much

26. effort
going into understanding it. In this respect, if no other, British
civil servants
do still lead the world!
More than that, some social scientists from Oxford beat a path
to my
door. They said that they had a view of how work, not just in
the civil
service but more generally, should be classified into
hierarchies. They
thought that the span of control was central: higher status, more
control.13
The second Whitehall Study showed that span of control was …
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INSTRUCTOR.
DUE DATE: THURSDAY, FEBRUARY 25, 2021 BY/NO
LATER THAN 9:15 P.M.
YOU ARE TO PROVIDE AN “ANSWER SHEET ONLY” AND
ATTACHED IT TO AN EMAIL TO ME AT THE SCHOOL’S
EMAIL SYSTEM AS A WORD DOCUMENT OR PDF FILE
ATTACHMENT.
WARNING!!!! DO NOT USE THE “FILE SHARING APP”
BECAUSE FOR REASONS THAT ARE BEYOND ME THE

27. SYSTEMDOES NOT ALLOW ME TO OPEN “FILE SHARING
APPS.” ALSO, DO NOT PLACE YOUR ANSWERS IN THE
BODY OF THE EMAIL.
DO NOT, I REPEAT-DO NOT PROVIDE YOUR ANSWERS
ON TEST ITSELF AND SEND ME ALL OF IT AS AN
ATTACHMENT. YOU ARE TO PROVIDE AN “ANSWER
SHEET ONLY”.
FURTHER, YOUR “ANSWER SHEET ONLY” SHOULD HAVE
YOUR FIRST AND LAST NAME INDICATED AND SHOULD
BE PROPERLY NUMBERED SO I KNOW WHICH QUESTION
OF THE TEST YOU ARE ANSWERING. YOU PLACE
EITHER A CAPITAL“T”FOR “TRUE” IF YOUR ANSWER IS
“TRUE,” OR A CAPITAL “F” IF YOUR ANSWER IS
“FALSE.”
NOTE: NO OTHER HEIROGLYPHICS, SYMBOLS,
CHARACTERS, MARKINGS, DRAWINGS WILL BE
ACCEPTED. IT IS EITHER A CAPITAL “T” FOR “TRUE” OR
A CAPITAL “F” FOR “FALSE.” ANY OTHER MARKINGS
WILL BE GRADED AS THE QUESTION NOT BEING
ANSWERED.
BEST FORM IS TO GO DOWN THE LEFT SIDE OF YOUR
ANSWER PAGE/SHEET STARTING WITH #1 AND THEN AT
ABOUT #26, PROCEED TO THE TOP OF THE MIDDLE OF
THE PAGE ACROSS FROM #1 AND START WITH #26 AND
GO DOWN THE PAGE/SHEET IN THAT MIDDLE COLUMN,
ETC.
ALSO, IT IS A TRUE/FALSE EXAM. NO EXPLANATIONS
OF YOUR ANSWER ARE PERMITTED AND CANNOT BE
TAKEN INTO ACCOUNT.
NOTE – PENALTY. IF A STUDENT’S “ANSWER SHEET
ONLY” IS NOT SENT IN IN ACCORDANCE WITH THESE
INSTRUCTIONS BY THE DUE DATE INDICATED ABOVE
AND THE INSTRUCTOR HAS NOT GRANTED AN
EXTENSION TO THE STUDENT OR OTHERWISE EXCUSED
THE STUDENT FROM SENDING THE TEST IN ON THE DUE
DATE, THEN 3 PTS PER DAY WILL BE DEDUCTED FOR

28. EACH DAY PAST THE DUE DATE UNTIL THE EXAM IS
RECEIVED BY INSTRUCTOR FROM THE STUDENT.
THERE ARE 64 QUESTIONS TO BE ANSWERED EITHER
TRUE OR FALSE. EACH QUESTION/ANSWER IS WORTH
1.6 POINTS. THIS MAKES A POTENTIAL POSSIBLE
SCORE OF 102.4. THUS, 2.4 CURVE POINTS HAVE
ALREADY BEEN BUILT INTO THE EXAM.
1.LAW CONSISTS OF RULES THAT
GOVERNS/CONTROLS/REGULATES THE
BEHAVIOR/CONDUCT OF THE INDIVIDUAL, THE GROUP,
ENTITY/BUSINESS, OR GOVERNMENT IN SOCIETY.
T F
2. ONE OF THE MOST IMPORTANT ASPECTS OF THE
LAW IS THAT IT IS ENFORCEABLE BY A LEGAL SYSTEM
OF COURTS IN SOCIETY
T F
3. DEVELOPING “CRITICAL THINKING AND LEGAL
REASONING SKILLS” IS IMPORTANT IN BUSINESS SO
THAT A BUSINESS PERSON CAN EVALUATE HOW LAWS
ARE APPLICABLE (RELEVANT) TO A GIVEN FACT
SITUATION, DETERMINE HOW THE LAWS APPLY TO
THAT FACT SITUATION, AND WHAT IS THE
OUTCOME/RESULT/EFFECT/CONCLUSION OF THAT
APPLICATION TO GUIDE A BUSINESS DECISION OR
INFORM THE DECISION TO BE MADE.
T F

29. 4. THE SIX (6) SOURCES OF LAW IN THE U.S. AND EACH
OF THE STATES ARE CALLED “PRIMARY AUTHORITY OR
PRIMARY SOURCES” BECAUSE THEY ARE THE ACTUAL
LAW.
T F
5. A CONSTITUTION IS A WRITTEN DOCUMENT WHERE
AN AGREEMENT IS MADE TO CREATE A GOVERNMENT
WITH CERTAIN PRINCIPLES EXPRESSED REGARDING
HOW THAT GOVERNMENT BEING CREATED IS TO BE
ORGANIZED, ITS POWERS, ITS LIMITATIONS, ITS
DUTIES, ETC., ALONG WITH A STATEMENT OF CERTAIN
GENERAL LEGAL PRINCIPLES.
T F
6. THE U.S. CONSTITUTION IS CONSIDERED THE
“SUPREME LAW OF THE LAND” MEANING THAT ANY
AND ALL LAWS ENACTED/CREATED NO MATTER AT
WHAT LEVEL OF GOVERNMENT IS NEVER HIGHER THAN
IT AND ALL LAWS MUST BE IN ACCORD WITH THE U.S.
CONSTITUTION AND NOT IN VIOLATION OF IT.
T F
7. A LAW IS CONSIDERED UNCONSITUTIONAL IF IT
EXPANDS RIGHTS GIVEN TO CITIZENS BY THE U.S.

30. CONSTITUTION.
T F
8. ON THE FEDERAL LEVEL, AN EXECUTIVE ORDER IS A
DIRECTIVE/COMMAND BY THE PRESIDENT USUALLY
DESIGNED TO IMPROVE THE PRACTICES AND
OPERATION OF THE FEDERAL GOVERNMENT, BUT IT IS
NOT A LAW
T F
9. ON THE FEDERAL LEVEL, AN EXECUTIVE ORDER CAN
BE CHALLENGED IN ONLY ONE WAY AND THAT IS BY A
LEGAL CHALLENGE BROUGHT IN THE COURT SYSTEM.
T F
10. IN THE U.S., A TREATY IS AN AGREEMENT BETWEEN
ANY STATE WITH A FOREIGN GOVERNMENT THAT
BINDS THE WHOLE NATION TO IT.
T F
11. A PROPOSED LAW DOES NOT BECOME A LAW UNTIL
THE CHIEF EXECUTIVE (PRESIDENT ON THE FEDERAL
LEVEL/GOVERNOR ON THE STATE LEVEL) SIGNS IT. IT
THEN BECOMES A STATUTE.
T F

31. 12. “STARE DECISIS” IS THE
PRACTICE/CUSTOM/TRADITION OF DECIDING PRESENT
OR NEW CASES IN THE AMERICAN (FEDERAL AND
STATE) LEGAL SYSTEM BEING BROUGHT TO THE COURT
SYSTEM OR IN THE COURT SYSTEM TODAY ALREAY BY
REFERRING TO PRIOR COURT OPINIONS/DECISIONS
WHICH ARE CONSIDERED PRECEDENT TO THE LEGAL
PROBLEM (ISSUE/QUESTION) IN THAT CURRENT CASE.
T F
13. PRECEDENT ONLY REQUIRES THAT THERE BE ONE
OF THE FOLLOWING PRESENT IN THAT PRIOR CASE
FOUND – THAT THERE BE SIMILAR OR SUBSTANTIALLY
SIMILAR FACTS TO THE CURRENT CASE.
T F
14. “STARE DECISIS” MAKES A DISTINCTION IN
PRECEDENT BETWEEN EITHER MANDATORY BINDING
PRECEDENT/AUTHORITY OR PERSUASIVE
PRECEDENT/AUTHORITY.
T F
15. THE EFFECT OF MANDATORY BINDING
PRECEDENT/AUTHORITY IS THAT A LOWER LEVEL
COURT TODAY THAN THE COURT ISSUING THE
MANDATORY BINDING PRECEDENT IS TO BE MORE

32. STRONGLY COMPELLED TO BE GUIDED BY IT IN TERMS
OF THE RESULT REACHED.
T F
16. UNDER “STARE DECISIS”, THE BIG EXCEPTION TO
BEING MORE STRONGLY COMPELLED FOR A COURT TO
BE GUIDED BY MANDATORY BINDING
PRECEDENT/AUTHORITY IS “UNLESS THERE IS A GOOD
LEGAL REASON FOR THE COURT NOT TO BE MORE
STRONGLY COMPELLED TO BE GUIDED BY IT.”
T F
17. AS A RESULT OF THE AMERICAN REVOLUTIONARY
WAR VICTORY AGAINST ENGLAND, A TRUE
DEMOCRACY WAS CREATED IN THE MODEL OF THE
ANCIENT GREEK DEMOCRACY WHICH EMPHASIZES
RULE BY THE PEOPLE AND NOT REPRESENTATIVES
ELECTED BY THE PEOPLE.
T F
18. COURTS EVOLVED IN OUR NATION AND EACH OF
THE STATES AS A RESULT OF OUR FOUNDING
PHILOSOPHY AND TYPE OF REPRESENTATIVE
GOVERNMENT WE CREATED SO THAT SINCE AND DOWN
TO TODAY COURTS IN ALL JURISDICTIONS (FEDERAL
OR ANY STATE) SPEND 99% OF THEIR TIME
INTERPRETING AND APPLYING EXISTING GOVERNMENT

33. ENACTED LAW AS IT APPLIES TO THE CASES BEFORE IT.
T F
19. A NATION THAT HAS THE CIVIL CODE LEGAL
SYSTEM IS A LEGAL SYSTEM BASED ON LAW PASSED
BY THE GOVERNING BODIES BUT ALSO INCORPORATES
THE ENGLISH COMMON LAW LEGAL SYSTEM BASED ON
STARE DECISIS AND PRECEDENT.
T F
20. AN ADMINISTRATIVE LAW CONSISTS OF THE RULES
AND REGULATIONS CREATED BY THE GOVERNMENT
AGENCIES AT ALL LEVELS OF GOVERNMENT CHARGED
WITH RESPONSIBILITY CREATING
RULES/REGULATIONS FOR THE AREA OF LAW THAT
HAS BEEN ASSIGNED TO IT AS WELL AS TO ENFORCE
ITS OWN RULES AND REGULATIONS.
T F
21. EVEN THOUGH “MORAL LAW” IS CONCERNED WITH
THE OBLIGATIONS/DUTIES MORALLY THAT PEOPLE
OWE TO EACH OTHER, THESE LAWS CAN STILL BE
ENFORCED IN THE COURT SYSTEM OF THE FEDERAL
GOVERNMENT AND IN THAT OF EACH STATE.

34. T F
22. IT IS CONSIDERED A MORAL DUTY TO COME TO THE
RESCUE OF ANOTHER HUMAN BEING, BUT THERE IS NO
LEGAL DUTY TO DO SO ESPECIALLY IF YOU LIVE IN A
STATE THAT HAS NO LAWS IMPOSING SUCH A LEGAL
DUTY.
T F
23. APPELLATE JURIDICTION (AUTHORITY) MEANS THE
POWER/AUTHORITY OF A COURT TO REVIEW THE
DECISION OF A LOWER COURT AND MAKE A
DETERMINATION OF WHETHER ERRORS OF
SUBSTANTIVE OR PROCEDURAL LAW WERE
COMMITTED.
T F
24. THE CIRCUIT COURTS OF APPEAL ARE THE TRIAL
COURTS OF THE FEDERAL COURT SYSTEM
T F
25. FEDERAL EXCLUSIVE JURISDICTION MEANS THAT
THE FEDERAL COURTS HAVE THE POWER/AUTHORITY
OVER A PARTICULAR AREA OR SUBJECT MATTER, I.E.
FEDERAL QUESTIONS.
T F

35. 26. THE SUPREME COURT OF THE U.S. WAS MADE A
COURT OF “DISCRETION” BY CONGRESS MEANING THAT
IT DECIDES WHICH CASES IT WILL TAKE PER COURT
TERM (OCTOBER-MARCH) AND THE GUIDELINE IS WHAT
CASES THEY FIND TO BE LEGALLY SIGNIFICANT AT
THAT TIME.
T F
27. A CONCURRING OPINION IS AN OPINION WRITTEN
BY A JUDGE WHO SAT/HEARD A CASE AND VOTED WITH
THE MAJORITY ON WHO SHOULD PREVAIL (WIN), BUT
NOT FOR THE REASONS WHY THE MAJORITY RULED
THAT WAY.
T F
28. A DISSENTING OPINION IS AN OPINION WRITTEN BY
A JUDGE WHO SAT/HEARD A CASE, WHO DID NOT VOTE
WITH THE MAJORITY AS TO WHO SHOULD PREVAIL
AND FEELS STRONGLY ABOUT WHY THE OTHER PARTY
SHOULD HAVE PREVAILED AND SETS FORTH HIS/HER
OPINION AS TO WHY HE/SHE FEELS THAT WAY.
T F
29. The unfair results and limited remedies provided by the law
courts led to the creation of the Chancery (Equity)Courts.

36. T F
30. The Federal Statutes passed by the U.S. Congress are
considered the supreme law of the land in the United States.
T F
31. Ordinances are codified laws that are issued by local
government bodies.
T F
32. The doctrine of stare decisis helps in creating stability,
predictability and flexibility in the American legal system by
allowing the use of precedent in deciding future cases.
T F
33. Precedent in the American Legal System (Federal and each
of the States is defined as a prior written published judicial
opinion that: (1) has similar or substantially similar facts as the
current case in the legal system or to be taken into the legal
system; and (2) has the same question/issue/dispute of law in it
or same principles of law applying as the current case in the
legal system or to be taken into the legal system
T F
34. A treaty does not require Senate approval before being
passed.

37. T F
35. Statutes what the laws are called when enacted by Congress
and state legislatures and signed by the respective chief
executive of the executive branch: the President on the federal
level, the Governor on the state level.
T F
36. Executive orders are an example of codified/statutory law.
T F
37. Executive orders are issued only by the executive branch of
the federal or state governments.
T F
38. More often than not, the law does not provide a bright-line
answer, so legal scholars, lawyers and courts must often
consider the "gray areas" in determining legal disputes.
T F
39. Conducting trials related to felonies and civil disputes is a
function of the State Supreme Courts.
T F
40. In general-jurisdiction trial courts, the testimony and
evidence at trial are recorded and stored for future reference

38. T F
41. Intermediate (mid-level) appellate courts review new
evidence or testimony that was not seen or heard in the lower
courts.
T F
42. The justices of the U.S. Supreme Court are appointed by
being nominated by the President and confirmed by the U.S.
Senate.
T F
43. In the United States, each state has only a single Federal
District Court.
T F
44. The jurisdiction (authority and power) of the U.S. Supreme
Court, which is an appellate court, hears appeals from federal
circuit courts of appeals and, under certain circumstances, from
federal district courts, special federal courts, and the highest
state courts. No new evidence or testimony is heard. As with
other appellate courts, the lower court record is reviewed to
determine whether there has been an error that warrants a
reversal or modification of the decision. Legal briefs are filed,
and the parties are granted a brief oral hearing. The Supreme
Court's decision is final.

39. T F
45. In the U.S. Supreme Court, if all the justices voting agree as
to the outcome and reasoning used to decide a case, it is a
majority decision.
T F
46. The U.S. Congress gave the Supreme Court discretion to
decide what cases it will hear.
T F
47. “Diversity of citizenship” cases refer to cases arising under
the U.S. Constitution, treaties, and federal statutes and
regulations.
T F
48. For “federal question” cases to be brought in a federal
court, the dollar amount of the controversy must exceed
$75,000.
T F
49. Ethics is the philosophy of moral principles or values and
addresses what is good or bad behavior or right or wrong
behavior that governs the conduct of an individual or a group.
T F
50. All laws are framed to meet the highest ethical standards.
T F

40. 51. An ethically wrong situation or condition can still be legal.
T F
52. In some situations, the law may permit an act that is
ethically wrong and ethics may require an act that the law
prohibits.
T F
53. Ethical fundamentalism is an ethical theory where a person
adheres to rules or commands that are from an outside source,
like a book or a central figure.
T F
54. Charlotte works as a teacher in Africa. Every Sunday, she
visits nearby villages and convinces families to send their
children to school. She arranges accommodation for these
children and helps them with their education. In a recent
interview, Charlotte mentioned that she looks up to Mother
Teresa not only for inspiration but also to resolve ethical
dilemmas. The ethical theory that would support Charlotte's
approach to ethics is ethical relativism.
T F
55. Rawls's social justice theory is a moral theory which asserts
that fairness is the essence of justice.
T F

41. 56. A perceived disadvantage of Rawls's social justice theory is
that it does not consider the fact that people would not want to
maximize benefits for the least advantaged persons
T F
57. Ethical relativism is a moral theory which holds that
individuals must decide what is ethical based on their own
feelings about what is right and wrong.
T F
58. Utilitarianism is a theory that chooses the greatest good to
society but does not mean the greatest good for the greatest
number of people.
T F
59. If an action would increase the good of twenty-five people
by one unit each and an alternative action would increase the
good of one person by twenty-five units, then, according to
utilitarianism, the latter action should be taken.
T F
60. According to Rawls's social justice theory, a person who is
in a state of "veil of ignorance" is best fit to select the fairest
possible ethical principles.
T F

42. 61. A social responsibility theory of business which says that a
corporation's duty is to make a profit while avoiding causing
harm to others is referred to as the moral minimum
T F
62. Social responsibility of business requires corporations and
businesses to act with awareness of the consequences and
impact that their decisions will have on others. Thus,
corporations and businesses are considered to owe some degree
of responsibility for their actions to society.
T F
63. The Sarbanes-Oxley Act, enacted by Congress in 2002,
requires public companies to adopt codes of ethics and
establishes criminal penalties for companies that partake in
violations.
T F
64. "Corporate citizenship" as a social responsibility theory in
business states that businesses are responsible to even helping
solve social problems that they did not cause.
T F
1
1
Chapter 5: Education and Empowerment.

43. Chapter 5 addresses various aspects of health and how
inequality plays out. In chapter five, the focus is on Education
and Empowerment across multiple subjects. The author seeks to
deconstruct and demystify education's perception regarding its
roles, gender perspectives, and relation to health and well-
being. The chapter is structured on how education creates
empowerment through the concept of gender, empowerment,
health, and addressing the several forms of inequality. The
author understands the structural myths that have overtaken
gender-based education inequalities and how misconceptions
override education regarding better pay and wealth
accumulation. The chapter is structured in terms of health,
gender, education, fertility reduction, especially in developing
countries, and child survival (Marmot, 2019). Education and
empowerment are closely interrelated. According to the author,
an educated child enhances its survival, improved health and
awareness, and self-protection initiatives. Marmot also proposes
the measures of addressing structural inequality, with the
Finland model being proposed.
The author has a clear outline, structure, and model of
addressing education-based misconceptions attached to gender
and its roles regarding the chapter's strengths. Marmot's
pertinent question is on the importance of education to parents,
children, and society concerning their health. Thus, the article
uses typical case studies in Finland to benchmark the
understanding of inequality methods and strategies. The author
also creates an objective approach to how education is related to
health, gender, and inequality across different aspects of
society. Marmot's chapter on education and empowerment has
an insightful, simple, and detailed assessment of various factors
associated with education and health. Education is viewed as a
tool that is more than just improved pay. The author appreciates
its role concerning awareness of risk factors, gender biases, and
inequalities.
However, the chapter has shortcomings regarding the

44. complexity of the correlation between education and health in
terms of gender. There is no clear clarity on which models the
author uses in comparing Finland's approach to addressing
inequality to any other specific country. Thus, the vagueness
creates confusion in connecting the variables. The weakness is
also in the more extended similarities of the issues discussed
through a language that is not smoothly comprehensive in most
aspects (Marmot, 2019). These components create a lack of
clarity, and the readers might lose track of what is expected of
them by the author (Wiggins, 2012)There is a thin line between
the chapter objectives and the prolonged narratives in the book's
chapter. These negative attributes constitute weaknesses,
characterized by vague reference to claims and concepts that the
author seeks to pass across. Two questions that I believe should
be considered for further studies are 1. How is education
creating health-related empowerment in developing countries
during global pandemics such as coronavirus? 2.How make
differences in educational curriculum and models impact health
inequalities among developed countries?
A reflective conclusion is that it forms the benchmark on the
argument between education's roles about empowering people
about their health status and well-being. The author has the
masteries of various case studies on the correlation between
these concepts, which underline their relevance in the modern
health setup. The gap in understanding education and its
implications on health and empowerment is addressed
throughout the chapter. Therefore, a recommendation on the
role of education on cultural empowerment should be
undertaken to achieve the desired outcomes.
References
Marmot Michael. (2019). The Health Gap: The Challenge of an

45. Unequal World. Bloomsbury Publishing.
Wiggins, N. (2012). Popular education for health promotion and
community empowerment: A review of the literature. Health
Promotion International, 27(3), 356–371.
https://doi.org/10.1093/heapro/dar046
Critical Review Grading Rubric
KINE 3353: Health and the Human Condition in the Global
Community
Fall 2020
Criteria
Ratings
Overview of the chapter
2 pts
Excellent

46. Reflects a full understanding of all key concepts and discusses
main arguments. Takes about 1/3 of the page. Ends with a
strong thesis that acknowledges both strengths and limitations.
1 pts
Satisfactory
Reflects a moderate understanding of all key concepts and
arguments. Takes about 1/3 of the page. Thesis does not
acknowledge both strengths and limitations.
0 pts
Needs Improvement
Overview is either too long or too short and does not accurately
summarize the text. Does not end with a thesis statement or
does not acknowledge either strengths or weaknesses.
Evaluation of Strengths & Weaknesses
2 pts
Excellent
Critically evaluates the text’s arguments and assumptions,
discussing its strengths and weaknesses using appropriate
evidence and examples. Synthesizes information and does not
merely list. About 1/3rd of a page.
1 pts
Satisfactory
Adequately evaluates the arguments made. Discusses strengths
and weaknesses but does not synthesize the information (instead
listing) and provides adequate examples. About 1/3rd of a page.
0 pts
Needs Improvement
Does not evaluate either the strengths or weaknesses of the text.
Too long or too short.
Conclusion: General Impressions or Recommendations
2 pts
Excellent
Discusses the text’s contribution to public health and any
recommendations for improvement. Proficiently supports
recommendations made and closing argume nts.
1 pts

47. Satisfactory
Concludes with only either public health contributions or
recommendations. Adequately supports recommendations for
improvement and closing arguments.
0 pts
Needs Improvement
Does not discuss the text’s contribution to public health nor
makes any recommendations for improvement.
Two Key Questions
2 pts
Excellent
At least two thoughtful questions are posed which provoke
further thought AND at least one relevant external source is
cited.
1 pts
Satisfactory
Only one thoughtful question is posed which provokes further
thought, no external sources are cited, or one external source is
cited with no questions posed.
0 pts
Needs Improvement
No questions are posed nor are any external sources cited.
Writing, Grammar & APA Format
2 pts
Excellent
Written in APA style using Zotero, in 11-point Times New
Roman font, one-inch margins, double-spaced, and paginated
with no errors. No spelling or grammar mistakes. 1 page or
more.
1 pts
Satisfactory
Written in APA style using Zotero, in 11-point Times New
Roman font, one-inch margins, double-spaced, and paginated
with a few errors. A few spelling or grammar mistakes. 1 page

48. or more.
0 pts
Needs Improvement
Not written in APA style, in 11-point Times New Roman font,
one-inch margins, double-spaced, and paginated or with many
errors. Does not use Zotero. Many spelling or grammar
mistakes. Less than 1 page. An assignment with 30% or more in
Unicheck will automatically receive a grade of zero.
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