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Social Determinants of Health: The Community as an Empowered Partner

Social Determinants of Health: The Community as an Empowered Partner VOLUME 1: NO. 1 JANUARY 2004 ESSAY Social Determinants of Health: The Community as an Empowered Partner S. Leonard Syme ment the project for 5 years. Our team worked hard, fol- Suggested citation for this article: Syme SL. Social deter- lowed the design carefully, and at the end of 5 years we minants of health: the community as an empowered part- compared the results we achieved in smoking cessation ner. Preventing Chronic Disease [serial online] 2004 Jan with our 2 comparison communities, Oakland and San [date cited]. Available from: URL: http://www.cdc.gov/pcd/ issues/2004/jan/03_0001.htm Francisco. We found no difference in smoking quit rates. It was only later, after I finished brooding, that I understood hile we in public health know the importance of the challenges of that community-partnership model. Winvolving community partners in our programs, we Richmond is a very poor city. It has many unemployed peo- also know how difficult it is to do. The challenge of involv- ple, high crime and drug use, very few health services, and ing the community is especially difficult if one has been air pollution from nearby oil refineries. Of all the problems trained, as I have been trained, to be an arrogant, elitist faced by people in that community, I doubt that smoking prima donna. I am the "expert," after all, and I help people was very high on their priority list. But of course I had by sharing my expertise. never asked them about their priorities, and even if I had, I probably would have persisted with my plan anyway; I Let me begin by describing my own humbling attempts was, after all, the expert. at community involvement through a smoking-cessation project I directed several years ago in Richmond, I learned another painful lesson from that experience. California. I came to the project with a dismal record in Early in the Richmond project, a group of teenagers came assisting people individually to quit smoking, so in the to us and said they would like to make a rock video about Richmond project I resolved to take a different tack; I smoking. They offered to write the music and the words, designed the Richmond project as a community project. By but wanted our help to invite a famous rock star — I can't having a block captain in every neighborhood in remember her name now — to spend one day on the proj- Richmond, I planned to involve the business community, ect, and they wanted a music-video director from the schools, and community groups. My idea was to change Hollywood to come, too. We hadn't budgeted for such the climate in Richmond with regard to smoking by chal- expenses, but we did it anyway. The rock star came in her lenging its acceptance, its values, and its attractiveness. limousine and the Hollywood director showed them how to set up the scenes for filming. Afterward, the students Toward that end, I wrote a brilliant 5-year research showed the video they produced at a large movie theater grant and sent it to the National Cancer Institute (NCI). It in the community. They printed the tickets for this show, was a bold, expensive project at $2 million, and for that made the advertisements, and served as ushers, and the reason NCI sent a large site-visit team to discuss it. By the sold-out show received a long standing ovation from the end of the visit, NCI agreed that my project was brilliant, audience. The video was subsequently shown in many and in fact later used the design as the basis for the places around the world, and the community received roy- nationwide COMMIT study conducted in more than 20 alty money for it. communities around the nation. Unfortunately, the video was not part of my brilliant With NCI's enthusiastic support, we proceeded to imple- research plan, and we had no money to evaluate its bene- The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, Centers for Disease Control and Prevention, or the authors’ affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above. www.cdc.gov/pcd/issues/2004/jan/03_0001.htm • Centers for Disease Control and Prevention 1 VOLUME 1: NO. 1 JANUARY 2004 fits. So the one thing in the project that came from the clinic. Together, we cooked low-fat meals and read labels community — and incidentally the one thing that probably at supermarkets. We conducted a superb intervention pro- made the biggest impact — was not conceived, imple- gram, but the trial failed. After 6 years, there was no sta- mented, or evaluated by our research team. So much for tistically significant difference in heart disease rates my brilliance. between our group and the control group. Few men in our group changed their behavior. To add to my embarrassment, the nationwide COMMIT study, based on my Richmond design, reported its results: The third problem, however, is the most challenging of the study failed to show a difference in smoking cessation all. Even if those at risk did change their behavior to lower rates between the study and comparison communities. their risk, new people would continue to enter the at-risk population at an unaffected rate. This influx occurs Why was it so hard for us — for me — to see the impor- because we rarely identify and intervene on those forces in tance of embracing the community as an empowered part- the community that cause the problem in the first place. ner? Part of the answer is that public health experts focus This last problem is a major challenge for public health. If on diseases and risk factors. Although we have important our goal is to prevent disease and promote health, I don't messages to convey to people, we also recognize that peo- think we can accomplish it by focusing exclusively on indi- ple have lives to lead, and often there is a gap between our vidual diseases and risk factors. And we can learn a valu- focus on diseases and our intent to convey information able lesson from the success we have had in preventing with enough impact on people's lives to foster change. many infectious diseases. Although vaccines account for some of that success, most success is because of an In my view, there are 3 major problems we should con- improvement in the environment, specifically the way we front in thinking about community partnerships and com- classify diseases. Disease classifications are in terms of munity empowerment. The first problem is that we have water-borne diseases, food-borne diseases, air-borne dis- such a difficult time identifying disease risk factors. eases, and vector-borne diseases, meaning that while the Identifying these factors is important, because we hope classifications are not of much value clinically — for exam- that if people knew about their risk, they would rush home ple, in the treatment of individual cases — they are of and change their behavior in the interest of good health. great importance in telling us where diseases are coming Consider the problem we've had identifying risk factors for from and where we should direct our prevention efforts. coronary heart disease, which is the number-one cause of death in this country. We now know the big risk factors for Do we have a similar classification system for the non- the disease — cigarette smoking, hypertension, and high infectious diseases of concern today? That's an interesting serum cholesterol — and there are perhaps a dozen more question. Suppose we wanted to develop a community- risk factors such as physical inactivity, obesity, diabetes, based framework for the prevention of disease and the and so on. Taking all of the known risk factors together, we promotion of health. What would it look like? The first job can explain about 45 percent of the coronary disease that in developing such a framework would be to identify the occurs, but the rest is unexplained. most important population determinants of disease. Where should we focus our attention? We know the The second problem is that even when people know answer to this question, but until very recently we haven't about their risk, they find it difficult to change their behav- wanted to talk about it or do anything about it. The most ior. There are many examples that describe the failure of important social determinant of disease is social class. wonderfully designed and executed interventions to help Social class has been an overwhelmingly important risk people lower their risk. In fact, I participated in one of factor for disease since the beginning of recorded time, them: the Multiple Risk Factor Intervention Trial. This and it's related to virtually every cause of disease. We $200 million study involved men in the top 10 percent risk have all made this observation, but we're not sure what to category for developing heart disease. We screened do about it. If revolution is the only useful intervention to 500,000 men in 22 cities and selected 12,000 highly remedy the ills of social class, it is not surprising that pub- informed and motivated participants for a 6-year trial. We lic health professionals have instead pursued more asked them to change their diet, take high-blood-pressure straightforward research such as the relationship medication, stop smoking, and report frequently to the between physical activity and diabetes. The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, Centers for Disease Control and Prevention, or the authors’ affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above. 2 Centers for Disease Control and Prevention • www.cdc.gov/pcd/issues/2004/jan/03_0001.htm VOLUME 1: NO. 1 JANUARY 2004 If you were willing, however, to take on the issue of intervention. If "control of destiny" and "empowerment" social class as an intervention focus, how would you inter- are important factors in the cause of disease at the com- vene? Money? Education? Nutrition? Medical care? munity level, they are also factors for which we can devel- Housing? Jobs? Environment? Which of these is most op interventions. important? The answer, of course, is that these factors are all important and they are inextricably bound, and the Additionally, if we can move away from a focus on dis- frustrating complexity of social class as a risk factor leads eases and risk factors and begin to think about communi- most of us to change the subject and study something else. ty and social forces, we can also relate to the community in a more meaningful way and stand a better chance of There has been a breakthrough, however, in this line of involving the community as an empowered partner. One research. A few years ago Dr. Michael Marmot studied example of such a partnership is through a grant my group coronary heart disease in 10,000 British civil servants and received recently from the Centers for Disease Control to made an interesting discovery. He found, as you would study fifth-grade children in a low-income community near expect, that workers at the bottom of the civil-service hier- Berkeley. The grant focuses on cigarette smoking and archy — guards and delivery people — had heart disease other drug use, violence, poor school performance, sexual rates 4 times higher than workers at the very top of the behavior, and so on, but we decided not to study any of hierarchy. But Marmot also observed a gradient of disease those things. We decided instead to focus on the funda- from top-to-bottom of the civil-service hierarchy. Workers mental issue underlying all of these problems; we decided at the top had the lowest rates of disease, but those one to focus on hope. If these children, mostly from minority step below them — professionals and executives, doctors groups and very poor families, had no hope for the future, and lawyers — had heart disease rates twice as high as what difference would it make if they smoked or used those at the very top. drugs or missed school or engaged in violent behavior? So we decided to help these children see that they could have We might be able to explain the high rates among those a future. We're working with them over a 3-year period to at the bottom in terms of poverty, poor education, inade- teach them ways of implementing their dreams: how to quate nutrition, or poor housing, but that would not make things work for their benefit; how to select a problem explain why doctors and lawyers had rates of disease twice and succeed in solving it; how to develop strategies for get- as high as those at the very top. Doctors and lawyers are ting done what they want to get done; how to take control not poor; they do not have bad educations or poor medical of their destiny. We trained high school students from the care or poor housing, and yet they have disease rates twice fifth-graders' own community, along with hand-picked as high as those above them. A very similar gradient has Berkeley graduate students, to work with the children as now been seen for virtually every disease in every indus- partners. The project is just starting, and we have our fin- trialized country in the world. gers crossed. This is a major breakthrough in our thinking, and Our study of 2,000 San Francisco bus drivers offers Marmot's findings give us something to investigate. How another example of empowerment. The project started can we explain the gradient? Many researchers are work- when one of my former students, as director of health for ing on this question, but my own hypothesis involves what San Francisco city employees, began supervising physical I call "control of destiny." By this phrase I mean the abili- exams for bus drivers. Among drivers over the age of 60, ty of people to deal with the forces that affect their lives, the prevalence of hypertension was 90 percent, so we even if they decide not to deal with them. I think this is launched a study. But then we noticed that drivers com- what empowerment means. Even if control of destiny and plained of back pain, then gastrointestinal and respiratory empowerment are not worthwhile concepts — and I think difficulties. We also observed high rates of alcohol use after they are — we need other ideas like them. The point is that work. We secured more funding and designed more inter- to prevent disease, we must intervene on those communi- ventions, but our work did not solve the essential problem. ty forces that cause disease problems, and social class is We were so focused on specific diseases that we failed to the obvious and most important factor. But because social recognize the fundamental problem: the job. class is also a complex issue, we should identify concepts related to the social-class gradient that are amenable to We then investigated why the job caused so many prob- The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, Centers for Disease Control and Prevention, or the authors’ affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above. www.cdc.gov/pcd/issues/2004/jan/03_0001.htm • Centers for Disease Control and Prevention 3 VOLUME 1: NO. 1 JANUARY 2004 lems. Computers devised a rigid bus schedule that allocat- medicine, mathematics, engineering, political science, ed time depending on the number of buses available, but geography, genetics, sociology, nutrition, anthropology, the computers were allocating time in a city with a bus economics. While we all had different interests, we were shortage. Drivers had to get from Mission and Army Street united in our desire to help make the world a better place; to Mission and Geneva Street, for example, in 2 minutes. I suggested that as they went forth to do that, they would A fast ride in your Ferrari on Sunday morning would take likely fail because we at the university had failed them. longer. In addition, because drivers were penalized when We had trained them in specific disciplines, but they they arrived late, they gave up rest stops and dashed into would soon discover that the problems people face tran- fast-food restaurants instead. And since the drivers were scend those disciplines and involve schools, parks, road- almost always late, the passengers were almost always ways, housing, employment, schools, crime, and politics. angry. Drivers lacked control over a host of variables such As faculty we were trained in disciplinary silos, and we as traffic and terrible shift arrangements, and drove dur- continue to receive research and training grants that rein- ing both morning and evening rush hours without enough force our silos; moreover, we will continue to train people time to go home in between shifts. At the end of a long day, as we have been trained. If this cycle continues, it is many visited the local tavern. When they got home, they unlikely to lead to collaboration with empowered commu- did not often socialize, but went to bed, only to get up at nity partners. 4:00 a.m. to begin another grueling day. 3. The challenge of intervening at many levels. Yes, they have health problems and should be helped, but obviously it's the job that needs to be fixed, and we are So far, I have emphasized that we have not done a very trying to do that by focusing on control of destiny and good job in helping people change their behavior, but, as empowerment. But to develop a partnership with the com- we all know, people change their behavior all the time, on munity, we will have to resolve 3 problems: their own and without our help. A good example is ciga- rette smoking: the prevalence of smoking in California has 1. The challenge of inappropriate funding mechanisms. decreased from 43 percent to less than 20 percent in recent years. This achievement is phenomenal, and it far out- It is important that we recognize the pervasiveness of strips the successes we in public health have had in our funding mechanisms that reinforce a clinical, individual smoking-cessation programs. The decline in smoking was approach to disease. Most research grants are funded to because of a series of interventions at every level: we deal with specific diseases. Most training grants do the learned about smoking addiction from research in experi- same, and most of the researchers in the field today are mental psychology and applied that knowledge; we working in programs that focus on a particular disease or learned about techniques of behavior change and benefit- a particular risk factor. This emphasis on diseases pro- ed from that knowledge; and we informed people about the duces a group of disease experts and expertise-driven health risks of smoking. But we also raised the price of cig- intervention programs. This approach is effective as long arettes, limited access to cigarette machines, enforced as there are other programs that focus on fundamental strict limitations on advertising in magazines and on bill- issues affecting people's daily lives. By also addressing boards, and outlawed smoking in many public places. We these "people issues," we have an opportunity to work with developed a health intervention that involved a variety of people in the community to become empowered partners. partnerships and went far beyond the narrow confines of the health field. And it worked. Most of the successes we 2. The challenge of working with people in different disci- have achieved in behavior change have come about plines. because they have been the subject of a multi-pronged, multilevel, multidisciplinary approach. These approaches Inevitably, a focus on the community requires that we in involve not only information but also regulations and laws, public health think across disciplinary lines, and in the mass media campaigns, workplace rules, and better envi- past we have not done this very well. I was the graduation ronmental engineering and design. speaker at my school of public health 2 years ago, and I noted that the students in the graduating class represent- And we have had other successes. Despite the challenges ed a wide variety of disciplines: virology, endocrinology, I mentioned in coronary heart disease, since 1970 there The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, Centers for Disease Control and Prevention, or the authors’ affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above. 4 Centers for Disease Control and Prevention • www.cdc.gov/pcd/issues/2004/jan/03_0001.htm VOLUME 1: NO. 1 JANUARY 2004 has been a tremendous decline in death rates from this S. Leonard Syme, Professor Emeritus of disease, one of the most dramatic declines in disease ever Epidemiology recorded. Coronary heart disease is still the number-one University of California, Berkeley cause of death, but such a dramatic decline in mortality is an impressive achievement; it's because of not only the Adapted from his presentation at the 17th National tremendous advances in the medical treatment of people Conference on Chronic Disease Prevention and Control who already have the disease but also because people have St. Louis, Missouri, February 19-21, 2003 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 top- ics, 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 pre- venting 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 com- munity 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 hum- bling challenges, but I know we can meet them. We really have no choice. The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, Centers for Disease Control and Prevention, or the authors’ affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above. www.cdc.gov/pcd/issues/2004/jan/03_0001.htm • Centers for Disease Control and Prevention 5 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Preventing Chronic Disease Pubmed Central

Social Determinants of Health: The Community as an Empowered Partner

Preventing Chronic Disease , Volume 1 (1) – Dec 15, 2003

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VOLUME 1: NO. 1 JANUARY 2004 ESSAY Social Determinants of Health: The Community as an Empowered Partner S. Leonard Syme ment the project for 5 years. Our team worked hard, fol- Suggested citation for this article: Syme SL. Social deter- lowed the design carefully, and at the end of 5 years we minants of health: the community as an empowered part- compared the results we achieved in smoking cessation ner. Preventing Chronic Disease [serial online] 2004 Jan with our 2 comparison communities, Oakland and San [date cited]. Available from: URL: http://www.cdc.gov/pcd/ issues/2004/jan/03_0001.htm Francisco. We found no difference in smoking quit rates. It was only later, after I finished brooding, that I understood hile we in public health know the importance of the challenges of that community-partnership model. Winvolving community partners in our programs, we Richmond is a very poor city. It has many unemployed peo- also know how difficult it is to do. The challenge of involv- ple, high crime and drug use, very few health services, and ing the community is especially difficult if one has been air pollution from nearby oil refineries. Of all the problems trained, as I have been trained, to be an arrogant, elitist faced by people in that community, I doubt that smoking prima donna. I am the "expert," after all, and I help people was very high on their priority list. But of course I had by sharing my expertise. never asked them about their priorities, and even if I had, I probably would have persisted with my plan anyway; I Let me begin by describing my own humbling attempts was, after all, the expert. at community involvement through a smoking-cessation project I directed several years ago in Richmond, I learned another painful lesson from that experience. California. I came to the project with a dismal record in Early in the Richmond project, a group of teenagers came assisting people individually to quit smoking, so in the to us and said they would like to make a rock video about Richmond project I resolved to take a different tack; I smoking. They offered to write the music and the words, designed the Richmond project as a community project. By but wanted our help to invite a famous rock star — I can't having a block captain in every neighborhood in remember her name now — to spend one day on the proj- Richmond, I planned to involve the business community, ect, and they wanted a music-video director from the schools, and community groups. My idea was to change Hollywood to come, too. We hadn't budgeted for such the climate in Richmond with regard to smoking by chal- expenses, but we did it anyway. The rock star came in her lenging its acceptance, its values, and its attractiveness. limousine and the Hollywood director showed them how to set up the scenes for filming. Afterward, the students Toward that end, I wrote a brilliant 5-year research showed the video they produced at a large movie theater grant and sent it to the National Cancer Institute (NCI). It in the community. They printed the tickets for this show, was a bold, expensive project at $2 million, and for that made the advertisements, and served as ushers, and the reason NCI sent a large site-visit team to discuss it. By the sold-out show received a long standing ovation from the end of the visit, NCI agreed that my project was brilliant, audience. The video was subsequently shown in many and in fact later used the design as the basis for the places around the world, and the community received roy- nationwide COMMIT study conducted in more than 20 alty money for it. communities around the nation. Unfortunately, the video was not part of my brilliant With NCI's enthusiastic support, we proceeded to imple- research plan, and we had no money to evaluate its bene- The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, Centers for Disease Control and Prevention, or the authors’ affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above. www.cdc.gov/pcd/issues/2004/jan/03_0001.htm • Centers for Disease Control and Prevention 1 VOLUME 1: NO. 1 JANUARY 2004 fits. So the one thing in the project that came from the clinic. Together, we cooked low-fat meals and read labels community — and incidentally the one thing that probably at supermarkets. We conducted a superb intervention pro- made the biggest impact — was not conceived, imple- gram, but the trial failed. After 6 years, there was no sta- mented, or evaluated by our research team. So much for tistically significant difference in heart disease rates my brilliance. between our group and the control group. Few men in our group changed their behavior. To add to my embarrassment, the nationwide COMMIT study, based on my Richmond design, reported its results: The third problem, however, is the most challenging of the study failed to show a difference in smoking cessation all. Even if those at risk did change their behavior to lower rates between the study and comparison communities. their risk, new people would continue to enter the at-risk population at an unaffected rate. This influx occurs Why was it so hard for us — for me — to see the impor- because we rarely identify and intervene on those forces in tance of embracing the community as an empowered part- the community that cause the problem in the first place. ner? Part of the answer is that public health experts focus This last problem is a major challenge for public health. If on diseases and risk factors. Although we have important our goal is to prevent disease and promote health, I don't messages to convey to people, we also recognize that peo- think we can accomplish it by focusing exclusively on indi- ple have lives to lead, and often there is a gap between our vidual diseases and risk factors. And we can learn a valu- focus on diseases and our intent to convey information able lesson from the success we have had in preventing with enough impact on people's lives to foster change. many infectious diseases. Although vaccines account for some of that success, most success is because of an In my view, there are 3 major problems we should con- improvement in the environment, specifically the way we front in thinking about community partnerships and com- classify diseases. Disease classifications are in terms of munity empowerment. The first problem is that we have water-borne diseases, food-borne diseases, air-borne dis- such a difficult time identifying disease risk factors. eases, and vector-borne diseases, meaning that while the Identifying these factors is important, because we hope classifications are not of much value clinically — for exam- that if people knew about their risk, they would rush home ple, in the treatment of individual cases — they are of and change their behavior in the interest of good health. great importance in telling us where diseases are coming Consider the problem we've had identifying risk factors for from and where we should direct our prevention efforts. coronary heart disease, which is the number-one cause of death in this country. We now know the big risk factors for Do we have a similar classification system for the non- the disease — cigarette smoking, hypertension, and high infectious diseases of concern today? That's an interesting serum cholesterol — and there are perhaps a dozen more question. Suppose we wanted to develop a community- risk factors such as physical inactivity, obesity, diabetes, based framework for the prevention of disease and the and so on. Taking all of the known risk factors together, we promotion of health. What would it look like? The first job can explain about 45 percent of the coronary disease that in developing such a framework would be to identify the occurs, but the rest is unexplained. most important population determinants of disease. Where should we focus our attention? We know the The second problem is that even when people know answer to this question, but until very recently we haven't about their risk, they find it difficult to change their behav- wanted to talk about it or do anything about it. The most ior. There are many examples that describe the failure of important social determinant of disease is social class. wonderfully designed and executed interventions to help Social class has been an overwhelmingly important risk people lower their risk. In fact, I participated in one of factor for disease since the beginning of recorded time, them: the Multiple Risk Factor Intervention Trial. This and it's related to virtually every cause of disease. We $200 million study involved men in the top 10 percent risk have all made this observation, but we're not sure what to category for developing heart disease. We screened do about it. If revolution is the only useful intervention to 500,000 men in 22 cities and selected 12,000 highly remedy the ills of social class, it is not surprising that pub- informed and motivated participants for a 6-year trial. We lic health professionals have instead pursued more asked them to change their diet, take high-blood-pressure straightforward research such as the relationship medication, stop smoking, and report frequently to the between physical activity and diabetes. The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, Centers for Disease Control and Prevention, or the authors’ affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above. 2 Centers for Disease Control and Prevention • www.cdc.gov/pcd/issues/2004/jan/03_0001.htm VOLUME 1: NO. 1 JANUARY 2004 If you were willing, however, to take on the issue of intervention. If "control of destiny" and "empowerment" social class as an intervention focus, how would you inter- are important factors in the cause of disease at the com- vene? Money? Education? Nutrition? Medical care? munity level, they are also factors for which we can devel- Housing? Jobs? Environment? Which of these is most op interventions. important? The answer, of course, is that these factors are all important and they are inextricably bound, and the Additionally, if we can move away from a focus on dis- frustrating complexity of social class as a risk factor leads eases and risk factors and begin to think about communi- most of us to change the subject and study something else. ty and social forces, we can also relate to the community in a more meaningful way and stand a better chance of There has been a breakthrough, however, in this line of involving the community as an empowered partner. One research. A few years ago Dr. Michael Marmot studied example of such a partnership is through a grant my group coronary heart disease in 10,000 British civil servants and received recently from the Centers for Disease Control to made an interesting discovery. He found, as you would study fifth-grade children in a low-income community near expect, that workers at the bottom of the civil-service hier- Berkeley. The grant focuses on cigarette smoking and archy — guards and delivery people — had heart disease other drug use, violence, poor school performance, sexual rates 4 times higher than workers at the very top of the behavior, and so on, but we decided not to study any of hierarchy. But Marmot also observed a gradient of disease those things. We decided instead to focus on the funda- from top-to-bottom of the civil-service hierarchy. Workers mental issue underlying all of these problems; we decided at the top had the lowest rates of disease, but those one to focus on hope. If these children, mostly from minority step below them — professionals and executives, doctors groups and very poor families, had no hope for the future, and lawyers — had heart disease rates twice as high as what difference would it make if they smoked or used those at the very top. drugs or missed school or engaged in violent behavior? So we decided to help these children see that they could have We might be able to explain the high rates among those a future. We're working with them over a 3-year period to at the bottom in terms of poverty, poor education, inade- teach them ways of implementing their dreams: how to quate nutrition, or poor housing, but that would not make things work for their benefit; how to select a problem explain why doctors and lawyers had rates of disease twice and succeed in solving it; how to develop strategies for get- as high as those at the very top. Doctors and lawyers are ting done what they want to get done; how to take control not poor; they do not have bad educations or poor medical of their destiny. We trained high school students from the care or poor housing, and yet they have disease rates twice fifth-graders' own community, along with hand-picked as high as those above them. A very similar gradient has Berkeley graduate students, to work with the children as now been seen for virtually every disease in every indus- partners. The project is just starting, and we have our fin- trialized country in the world. gers crossed. This is a major breakthrough in our thinking, and Our study of 2,000 San Francisco bus drivers offers Marmot's findings give us something to investigate. How another example of empowerment. The project started can we explain the gradient? Many researchers are work- when one of my former students, as director of health for ing on this question, but my own hypothesis involves what San Francisco city employees, began supervising physical I call "control of destiny." By this phrase I mean the abili- exams for bus drivers. Among drivers over the age of 60, ty of people to deal with the forces that affect their lives, the prevalence of hypertension was 90 percent, so we even if they decide not to deal with them. I think this is launched a study. But then we noticed that drivers com- what empowerment means. Even if control of destiny and plained of back pain, then gastrointestinal and respiratory empowerment are not worthwhile concepts — and I think difficulties. We also observed high rates of alcohol use after they are — we need other ideas like them. The point is that work. We secured more funding and designed more inter- to prevent disease, we must intervene on those communi- ventions, but our work did not solve the essential problem. ty forces that cause disease problems, and social class is We were so focused on specific diseases that we failed to the obvious and most important factor. But because social recognize the fundamental problem: the job. class is also a complex issue, we should identify concepts related to the social-class gradient that are amenable to We then investigated why the job caused so many prob- The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, Centers for Disease Control and Prevention, or the authors’ affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above. www.cdc.gov/pcd/issues/2004/jan/03_0001.htm • Centers for Disease Control and Prevention 3 VOLUME 1: NO. 1 JANUARY 2004 lems. Computers devised a rigid bus schedule that allocat- medicine, mathematics, engineering, political science, ed time depending on the number of buses available, but geography, genetics, sociology, nutrition, anthropology, the computers were allocating time in a city with a bus economics. While we all had different interests, we were shortage. Drivers had to get from Mission and Army Street united in our desire to help make the world a better place; to Mission and Geneva Street, for example, in 2 minutes. I suggested that as they went forth to do that, they would A fast ride in your Ferrari on Sunday morning would take likely fail because we at the university had failed them. longer. In addition, because drivers were penalized when We had trained them in specific disciplines, but they they arrived late, they gave up rest stops and dashed into would soon discover that the problems people face tran- fast-food restaurants instead. And since the drivers were scend those disciplines and involve schools, parks, road- almost always late, the passengers were almost always ways, housing, employment, schools, crime, and politics. angry. Drivers lacked control over a host of variables such As faculty we were trained in disciplinary silos, and we as traffic and terrible shift arrangements, and drove dur- continue to receive research and training grants that rein- ing both morning and evening rush hours without enough force our silos; moreover, we will continue to train people time to go home in between shifts. At the end of a long day, as we have been trained. If this cycle continues, it is many visited the local tavern. When they got home, they unlikely to lead to collaboration with empowered commu- did not often socialize, but went to bed, only to get up at nity partners. 4:00 a.m. to begin another grueling day. 3. The challenge of intervening at many levels. Yes, they have health problems and should be helped, but obviously it's the job that needs to be fixed, and we are So far, I have emphasized that we have not done a very trying to do that by focusing on control of destiny and good job in helping people change their behavior, but, as empowerment. But to develop a partnership with the com- we all know, people change their behavior all the time, on munity, we will have to resolve 3 problems: their own and without our help. A good example is ciga- rette smoking: the prevalence of smoking in California has 1. The challenge of inappropriate funding mechanisms. decreased from 43 percent to less than 20 percent in recent years. This achievement is phenomenal, and it far out- It is important that we recognize the pervasiveness of strips the successes we in public health have had in our funding mechanisms that reinforce a clinical, individual smoking-cessation programs. The decline in smoking was approach to disease. Most research grants are funded to because of a series of interventions at every level: we deal with specific diseases. Most training grants do the learned about smoking addiction from research in experi- same, and most of the researchers in the field today are mental psychology and applied that knowledge; we working in programs that focus on a particular disease or learned about techniques of behavior change and benefit- a particular risk factor. This emphasis on diseases pro- ed from that knowledge; and we informed people about the duces a group of disease experts and expertise-driven health risks of smoking. But we also raised the price of cig- intervention programs. This approach is effective as long arettes, limited access to cigarette machines, enforced as there are other programs that focus on fundamental strict limitations on advertising in magazines and on bill- issues affecting people's daily lives. By also addressing boards, and outlawed smoking in many public places. We these "people issues," we have an opportunity to work with developed a health intervention that involved a variety of people in the community to become empowered partners. partnerships and went far beyond the narrow confines of the health field. And it worked. Most of the successes we 2. The challenge of working with people in different disci- have achieved in behavior change have come about plines. because they have been the subject of a multi-pronged, multilevel, multidisciplinary approach. These approaches Inevitably, a focus on the community requires that we in involve not only information but also regulations and laws, public health think across disciplinary lines, and in the mass media campaigns, workplace rules, and better envi- past we have not done this very well. I was the graduation ronmental engineering and design. speaker at my school of public health 2 years ago, and I noted that the students in the graduating class represent- And we have had other successes. Despite the challenges ed a wide variety of disciplines: virology, endocrinology, I mentioned in coronary heart disease, since 1970 there The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, Centers for Disease Control and Prevention, or the authors’ affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above. 4 Centers for Disease Control and Prevention • www.cdc.gov/pcd/issues/2004/jan/03_0001.htm VOLUME 1: NO. 1 JANUARY 2004 has been a tremendous decline in death rates from this S. Leonard Syme, Professor Emeritus of disease, one of the most dramatic declines in disease ever Epidemiology recorded. Coronary heart disease is still the number-one University of California, Berkeley cause of death, but such a dramatic decline in mortality is an impressive achievement; it's because of not only the Adapted from his presentation at the 17th National tremendous advances in the medical treatment of people Conference on Chronic Disease Prevention and Control who already have the disease but also because people have St. Louis, Missouri, February 19-21, 2003 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 top- ics, 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 pre- venting 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 com- munity 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 hum- bling challenges, but I know we can meet them. We really have no choice. The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, Centers for Disease Control and Prevention, or the authors’ affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above. www.cdc.gov/pcd/issues/2004/jan/03_0001.htm • Centers for Disease Control and Prevention 5

Journal

Preventing Chronic DiseasePubmed Central

Published: Dec 15, 2003

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