Good Management Saves Lives

The relationship between formal or positional power (seniority & status) and psychological safety is strong. In general, we know that people holding more senior and higher status roles often feel safer speaking up in groups, and those in “low status” roles tend to self-censor more. But can a person’s seniority and status at work affect other things, such as their health, or risk of heart attacks?

Yes, it does, but not in the way we might instinctively think.

Typically, we might believe that individuals in higher status roles are more likely to suffer from stress-related illnesses, due to the higher pressure and responsibilities of their senior positions. Conditions such as high blood pressure and cardiovascular disease were often assumed to be more common amongst top executives, who faced the burden of making big decisions and carrying heavy responsibilities. What matters most is not pressure or responsibility per se, but control and autonomy about our work lives.

The Whitehall Studies

However, the findings from the famous (at least in public health realms) “Whitehall Studies” reveal a different truth. These studies focused on the social determinants of health (SDH) among British civil servants, particularly looking at the prevalence and mortality from cardiovascular disease.

The first of these studies, Whitehall I, started in 1967 by Professor Sir Michael Marmot and colleagues, spanned ten years. Contradicting common beliefs, it found that men in the lowest employment grades were significantly more likely to suffer premature death compared to those in higher status roles. Whitehall II, the follow-up study that started in 1985 and still ongoing, was expanded to include women and further explored this “social gradient” in health within the workplace.

This “social gradient” refers to a pattern where individuals with lower socioeconomic status (including income, education, and occupational status) have poorer health outcomes than those in more advantaged positions, with greater disparities leading to more pronounced health inequities. In Whitehall I, it was observed that mortality rates were three times higher for men in the lowest employment grades compared to those in the highest, with health improving consistently alongside employment rank, a phenomenon Michael Marmot termed “Status Syndrome”. See the image below for the social gradient effect in respect to neighbourhood deprivation.

Life expectancy and disability-free life expectancy (DFLE) at birth: England 1999–2003. Source: The Marmot Review (ONS).

The Whitehall studies were designed to control for the influence of variables other than job role status, and focused on a closely related set of occupations, where individuals in each grade were socially similar and lived in similar environments.

Further analysis of data from these studies showed that higher job stress, characterised by factors such as lack of skill utilisation, workplace tension, and unclear tasks, was linked to high blood pressure and cardiovascular disease. A subsequent examination of cortisol levels in the Whitehall II cohort revealed no significant difference in cortisol (a stress hormone, which is linked to heart disease) levels upon waking between different seniority levels. However, those in lower positions exhibited notably higher cortisol levels 30 minutes after waking, particularly on workdays. This was interpreted as a sign of chronic stress, especially due to the anticipation of stress later in the day. In other words, the stress response was not to what had already happened, but to what people expected to happen to them at work.

Age adjusted mortality rate ratios in a 25 year follow up of civil servants from the first Whitehall study. Rossum et al, 2000. (Note: “Administrative” is the highest status role in this context.)

The figure above illustrates a key finding made after the Whitehall Studies: lower status workers not only experienced poorer health during the study but also continued to face higher mortality rates from various causes of death as they aged. And this social gradient in health, where individuals with lower status at work have worse health outcomes, is not exclusive to the British Civil Service. Similar patterns have been observed in diverse settings, including among industrial workers in Finland, in national surveys in Sweden and the US, at Hawthorne Works, and within large organisations in Belgium.

This indicates that the relationship between work status and health is a widespread phenomenon. Factors such as the way work is organised, work environment and cultural climate, as well as social influences, early life and health behaviours all contribute to the social gradient in health.

From Sheffield Equality Group. People with intermediate or low job control (autonomy) had over twice the incidence of coronary heart disease. Data from Whitehall II study.

This is strikingly consistent with what we see in psychological safety research. Lower status is associated with higher interpersonal risk, less voice, and more self-censorship. The Whitehall findings suggest that these same dynamics don’t just shape learning and performance — they shape bodies, stress physiology, and life expectancy.

Job Autonomy and Health

What really stands out is that the authority to make decisions at work seems to be a crucial factor affecting stress levels. We might think of this as counterintuitive – surely those in higher status roles suffer greater stress through having to make “big” decisions, right? However, it turns out that those lower in the command hierarchy, with less control over their work and life, face greater stress. This lack of control is a major risk factor for cardiovascular disease. Having autonomy in how we work, including when and how tasks are performed, is associated with lower levels of cortisol, heart rate, and blood pressure compared to being micromanaged. Micromanagement isn’t merely irritating or inefficient; it functions as a chronic stressor. By stripping people of discretion while holding them accountable for outcomes, it reliably increases physiological load. Over time, that load translates into elevated cardiovascular risk.

Micromanagement is not only bad for team performance; it can kill people.

The upside of this is surely that the converse must also be true; good management saves lives.

Implications for managers

Increase discretion where accountability already exists
Reduce uncertainty created by arbitrary decisions and shifting priorities
Treat voice and autonomy as health-relevant work design variables, not “soft” extras

The social gradient in health demonstrates the key reason why we need to address societal imbalances in power, money and resources, and this research shows us that we can start in the workplace. If you’re interested in the social gradient in health, social determinants and why people at relative social disadvantage suffer health disadvantage and shorter lives, check out Professor Sir Michael Marmot’s “The Health Gap: The Challenge of an Unequal World”. If you’d like to dive a bit deeper into the Whitehall studies specifically, I can recommend this excellent write up from the Sheffield Equality Group. I’ve also added some links to related papers and content below.

The Whitehall Studies remind us that health is not simply a matter of individual choice, resilience, or coping. As Marx put it:

Men make their own history, but they do not make it as they please; they do not make it under self-selected circumstances, but under circumstances existing already, given and transmitted from the past.

The Eighteenth Brumaire of Louis Bonaparte. Karl Marx, 1852

Note: The Whitehall II team have a data sharing policy, allowing researchers from other institutions to analyse raw data from the Whitehall II cohort. Read the policy and find out more here.