Men and women working in higher employment grades in the British civil service live longer and report better health than those in lower employment grades. An important component of these differences in health is the large occupational gradient in the risk of circulatory disease which has existed on both sides of the Atlantic for the past thirty years (Hinkle et al. 1968; Marmot et al. 1978). During this period rates of coronary heart disease mortality have fallen, but the decline in coronary heart disease (Marmot and McDowall 1986; McLoone and Boddy 1994) as well as in all-cause mortality (Phillimore et al. 1994) has been greater among the more affluent, and socioeconomic inequalities in coronary heart disease have grown larger. For this reason the importance of work-related differences in cardiovascular disease is today perhaps greater than at the height of the epidemic.