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The second problem is that even when people know about their risk, they
find it difficult to change their behavior. There are many examples that
describe the failure of wonderfully designed and executed interventions to
help people lower their risk. In fact, I participated in one of them: the
Multiple Risk Factor Intervention Trial. This $200 million study involved
men in the top 10 percent risk category for developing heart disease. We
screened 500,000 men in 22 cities and selected 12,000 highly informed and
motivated participants for a 6-year trial. We asked them to change their
diet, take high-blood-pressure medication, stop smoking, and report
frequently to the clinic. Together, we cooked low-fat meals and read
labels at supermarkets. We conducted a superb intervention program, but
the trial failed. After 6 years, there was no statistically significant
difference in heart disease rates between our group and the control group.
Few men in our group changed their behavior.
The third problem, however, is the most challenging of all. Even if
those at risk did change their behavior to lower their risk, new people
would continue to enter the at-risk population at an unaffected rate. This
influx occurs because we rarely identify and intervene on those forces in
the community that cause the problem in the first place. This last problem
is a major challenge for public health. If our goal is to prevent disease
and promote health, I don't think we can accomplish it by focusing
exclusively on individual diseases and risk factors. And we can learn a
valuable lesson from the success we have had in preventing many infectious
diseases. Although vaccines account for some of that success, most success
is because of an improvement in the environment, specifically the way we
classify diseases. Disease classifications are in terms of water-borne
diseases, food-borne diseases, air-borne diseases, and vector-borne
diseases, meaning that while the classifications are not of much value
clinically — for example, in the treatment of individual cases — they
are of great importance in telling us where diseases are coming from and
where we should direct our prevention efforts.
Do we have a similar classification system for the noninfectious
diseases of concern today? That's an interesting question. Suppose we
wanted to develop a community-based framework for the prevention of
disease and the promotion of health. What would it look like? The first
job in developing such a framework would be to identify the most important
population determinants of disease. Where should we focus our attention?
We know the answer to this question, but until very recently we haven't
wanted to talk about it or do anything about it. The most important social
determinant of disease is social class. Social class has been an
overwhelmingly important risk factor for disease since the beginning of
recorded time, and it's related to virtually every cause of disease. We
have all made this observation, but we're not sure what to do about it. If
revolution is the only useful intervention to remedy the ills of social
class, it is not surprising that public health professionals have instead
pursued more straightforward research such as the relationship between
physical activity and diabetes.
If you were willing, however, to take on the issue of social class as
an intervention focus, how would you intervene? Money? Education?
Nutrition? Medical care? Housing? Jobs? Environment? Which of these is
most important? The answer, of course, is that these factors are all
important and they are inextricably bound, and the frustrating complexity
of social class as a risk factor leads most of us to change the subject
and study something else.
There has been a breakthrough, however, in this line of research. A few
years ago Dr. Michael Marmot studied coronary heart disease in 10,000
British civil servants and made an interesting discovery. He found, as you
would expect, that workers at the bottom of the civil-service hierarchy — guards and delivery people —
had heart disease rates 4 times higher
than workers at the very top of the hierarchy. But Marmot also observed a
gradient of disease from top-to-bottom of the civil-service hierarchy.
Workers at the top had the lowest rates of disease, but those one step
below them — professionals and executives, doctors and lawyers — had
heart disease rates twice as high as those at the very top.
We might be able to explain the high rates among those at the bottom in
terms of poverty, poor education, inadequate nutrition, or poor housing,
but that would not explain why doctors and lawyers had rates of disease
twice as high as those at the very top. Doctors and lawyers are not poor;
they do not have bad educations or poor medical care or poor housing, and
yet they have disease rates twice as high as those above them. A very
similar gradient has now been seen for virtually every disease in every
industrialized country in the world.
This is a major breakthrough in our thinking, and Marmot's findings
give us something to investigate. How can we explain the gradient? Many
researchers are working on this question, but my own hypothesis involves
what I call "control of destiny." By this phrase I mean the
ability of people to deal with the forces that affect their lives, even if
they decide not to deal with them. I think this is what empowerment means.
Even if control of destiny and empowerment are not worthwhile concepts —
and I think they are — we need other ideas like them. The point is that
to prevent disease, we must intervene on those community forces that cause
disease problems, and social class is the obvious and most important
factor. But because social class is also a complex issue, we should
identify concepts related to the social-class gradient that are amenable
to intervention. If "control of destiny" and
"empowerment" are important factors in the cause of disease at
the community level, they are also factors for which we can develop
interventions.
Additionally, if we can move away from a focus on diseases and risk
factors and begin to think about community and social forces, we can also
relate to the community in a more meaningful way and stand a better chance
of involving the community as an empowered partner. One example of such a
partnership is through a grant my group received recently from the Centers
for Disease Control to study fifth-grade children in a low-income
community near Berkeley. The grant focuses on cigarette smoking and other
drug use, violence, poor school performance, sexual behavior, and so on,
but we decided not to study any of those things. We decided instead to
focus on the fundamental issue underlying all of these problems; we
decided to focus on hope. If these children, mostly from minority groups
and very poor families, had no hope for the future, what difference would
it make if they smoked or used drugs or missed school or engaged in
violent behavior? So we decided to help these children see that they could
have a future. We're working with them over a 3-year period to teach
them ways of implementing their dreams: how to make things work for their
benefit; how to select a problem and succeed in solving it; how to develop
strategies for getting done what they want to get done; how to take
control of their destiny. We trained high school students from the
fifth-graders' own community, along with hand-picked Berkeley
graduate students, to work with the children as partners. The project is just
starting, and we have our fingers crossed.
Our study of 2,000 San Francisco bus drivers offers another example of
empowerment. The project started when one of my former students, as
director of health for San Francisco city employees, began supervising
physical exams for bus drivers. Among drivers over the age of 60, the
prevalence of hypertension was 90 percent, so we launched a study. But then we
noticed that drivers complained of back pain, then gastrointestinal and
respiratory difficulties. We also observed high rates of alcohol use after
work. We secured more funding and designed more interventions, but our
work did not solve the essential problem. We were so focused on specific
diseases that we failed to recognize the fundamental problem: the job.
We then investigated why the job caused so many problems. Computers
devised a rigid bus schedule that allocated time depending on the number
of buses available, but the computers were allocating time in a city with
a bus shortage. Drivers had to get from Mission and Army Street to Mission
and Geneva Street, for example, in 2 minutes. A fast ride in your
Ferrari on Sunday morning would take longer. In addition, because drivers
were penalized when they arrived late, they gave up rest stops and dashed
into fast-food restaurants instead. And since the drivers were almost
always late, the passengers were almost always angry. Drivers lacked
control over a host of variables such as traffic and terrible shift
arrangements, and drove during both morning and evening rush hours without
enough time to go home in between shifts. At the end of a long day, many
visited the local tavern. When they got home, they did not often
socialize, but went to bed, only to get up at 4:00 a.m. to begin another
grueling day.
Yes, they have health problems and should be helped, but obviously it's
the job that needs to be fixed, and we are trying to do that by focusing
on control of destiny and empowerment. But to develop a partnership with
the community, we will have to resolve 3 problems:
1. The challenge of inappropriate funding mechanisms.
It is important that we recognize the pervasiveness of funding
mechanisms that reinforce a clinical, individual approach to disease. Most
research grants are funded to deal with specific diseases. Most training
grants do the same, and most of the researchers in the field today are
working in programs that focus on a particular disease or a particular
risk factor. This emphasis on diseases produces a group of disease experts
and expertise-driven intervention programs. This approach is effective as
long as there are other programs that focus on fundamental issues
affecting people's daily lives. By also addressing these "people
issues," we have an opportunity to work with people in the community
to become empowered partners.
2. The challenge of working with people in different disciplines.
Inevitably, a focus on the community requires that we in public health
think across disciplinary lines, and in the past we have not done this
very well. I was the graduation speaker at my school of public health 2
years ago, and I noted that the students in the graduating class
represented a wide variety of disciplines: virology, endocrinology,
medicine, mathematics, engineering, political science, geography,
genetics, sociology, nutrition, anthropology, economics. While we all had
different interests, we were united in our desire to help make the world a
better place; I suggested that as they went forth to do that, they
would likely fail because we at the university had failed them. We had
trained them in specific disciplines, but they would soon discover that
the problems people face transcend those disciplines and involve schools,
parks, roadways, housing, employment, schools, crime, and politics. As
faculty we were trained in disciplinary silos, and we continue to receive
research and training grants that reinforce our silos; moreover, we will
continue to train people as we have been trained. If this cycle continues,
it is unlikely to lead to collaboration with empowered community partners.
3. The challenge of intervening at many levels.
So far, I have emphasized that we have not done a very good job in
helping people change their behavior, but, as we all know, people change
their behavior all the time, on their own and without our help. A good
example is cigarette smoking: the prevalence of smoking in California has
decreased from 43 percent to less than 20 percent in recent years. This
achievement is phenomenal, and it far outstrips the successes we in public
health have had in
our smoking-cessation programs. The decline in smoking was because
of a series of interventions at every level: we learned about smoking
addiction from research in experimental psychology and applied that
knowledge; we learned about techniques of behavior change and benefited
from that knowledge; and we informed people about the health risks of
smoking. But we also raised the price of cigarettes, limited access to
cigarette machines, enforced strict limitations on advertising in
magazines and on billboards, and outlawed smoking in many public places.
We developed a health intervention that involved a variety of partnerships
and went far beyond the narrow confines of the health field. And it
worked. Most of the successes we have achieved in behavior change have
come about because they have been the subject of a multi-pronged,
multilevel, multidisciplinary approach. These approaches involve not only
information but also regulations and laws, mass media campaigns, workplace
rules, and better environmental engineering and design.
And we have had other successes. Despite the challenges I mentioned in
coronary heart disease, since 1970 there has been a tremendous decline in
death rates from this disease, one of the most dramatic declines in
disease ever recorded. Coronary heart disease is still the number-one
cause of death, but such a dramatic decline in mortality is an impressive
achievement; it's because of not only the tremendous advances in the
medical treatment of people who already have the disease but also because
people have in fact changed their high-risk behavior. And the death rate
from many other diseases is also declining. Obviously, we are doing
something right, but, as is true of most topics, even success is
complicated. Death rates have gone down, but the gap in health between
those at the top and those at the bottom of the social-class gradient has
widened and continues to widen every year.
These are difficult issues, and I have struggled with them for many
years. Especially difficult is the problem of working with members of the
community as empowered partners. And by "community" I mean any
group of people we target for intervention, whether they are fifth graders
or MRFIT participants or residents of Richmond, California, or bus
drivers. Whatever the group, I have not done well in the past working with
them. After considering my efforts, I have begun to think about where we
should direct our efforts in public health. The medical-care system is under enormous strain in this country, and baby
boomers haven't even entered the older population yet. When they do, in
2020 or 2030, the number of older people in this country will double. If
we think our medical-care system is in trouble now, we ain't seen nothin'
yet. Our only hope is to develop better proactive strategies for
preventing disease and promoting health, rather than waiting to fix
problems after they occur. And to carry out those strategies successfully,
we will have to work with the community as an empowered partner, which
ultimately means changing our public-health model at a fundamental level.
We will have to change the way we classify disease, train a new generation
of experts, change the way we organize and finance public health education
and research, and deal with our arrogance. These are very difficult and
humbling challenges, but I know we can meet them. We really have no
choice.
S. Leonard Syme, Professor Emeritus of Epidemiology
University of California, Berkeley
Adapted from his presentation at the 17th National Conference on
Chronic Disease Prevention and Control
St. Louis, Mo, February 19-21, 2003
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