Marmot & Brunner Models

Brunner and Marmot (see Chapter 2 in Social determinants of health, ed M. Marmot & R.G. Wilkinson, OUP, 1999) have proposed some very clear and simple models of the links between social structures and health outcomes, mostly applied to cardiovascular diseases:

  Fig. 2.2  Social determinants of health. The model links social structure to health and disease via material, psychosocial and behavioural pathways. Genetic, early life, and cultural factors are further important influences on population health.

Brunner & Marmot focus largely on the biological pathways:


Some of the discussion concerns whether to attempt to draw a model for all-cause mortality, or whether it is better to focus on particular diseases.   The latter becomes especially relevant when considering the biological end of the causal chain. 

Here is an example of Brunner & Marmot's thinking on CVD causation:


Marmot (bless him!) has also distinguished himself by re-awakening interest in Geoffrey Rose's ideas on population versus high risk interventions.  Marmot summarized Rose: "The individual level of analysis may be appropriate for understanding how individuals may be affected but may miss the operation of social causes. Amartya Sen has argued that famines do not occur in countries with well functioning democracies. How would a study of why one starving child in a refugee camp died more slowly than another help with this insight?" 
"The determinants of individual differences in risk may be different from the determinants of differences between social groups. This accounts for reluctance to apply the term inequality, as economists do, to individual differences in health.  Rose developed the ideas in this classic paper into his brilliantly clear book, Strategy of preventive medicine.  His conclusion was: ‘The primary determinants of disease are mainly economic and social, and therefore its remedies must also be economic and social' ’’.