|Re: Cohousing is good for your health - potentially related verbatim interview||<– Date –> <– Thread –>|
|From: Hans Tilstra (tilstrasmartchat.net.au)|
|Date: Wed, 10 May 2000 16:27:37 -0600 (MDT)|
Dr. L. Syme, (9 November 1998) "Mastering the Control Factor" Interview by Norman Swan, published on www.abc.net.au/rn/talks/8.30/helthrpt/stories/s14314.htm Introduction: Why do we become ill or stay well? We rightly become obsessed with things like cholesterol, smoking and blood pressure, but what about the link between our physical health and our psychological and social way of being? The pioneer of this research many years ago, and still prominent today, is Professor Len Syme, Emeritus Professor of Epidemiology, University of California. Professor Len Syme: My first studies were in North Dakota, showing that when people changed jobs, moved geographically or moved from farm backgrounds in their childhood to city jobs, rates of heart disease were two to three times higher after adjusting for all known respectors. I call it cultural mobility, moving from one world that you knew about to another world that you were unfamiliar with. I never really understood why that would increase rates of disease, and it turned out it was wrong, it was really an early indication of something going on, but when I followed that idea up in our mass of study of Japanese migrants from Japan to Hawaii to California, which to me was the ultimate test of the mobility idea, it turned out that there was a fivefold increase in heart disease amongst the migrants, but half of the migrants in California had no increase in disease at all. So to me, that was a rejection of the mobility idea. Clearly there was more going on than that. Q: So if you took 100 people who migrated from Japan, half of them got an increase in heart disease and half of them didn't, is that what you're saying? A: That's exactly right. Our assumption was that the fivefold increase in heart disease would clearly be due to diet, and in fact there is a tremendous westernisation of diet amongst the migrants, but that westernisation did not account for the fivefold increase in disease. Those who had adopted western ways had the high rates of disease, whereas those who retained traditional Japanese ways had rates as low as in Japan, after accounting for things like diet and smoking and all the usual risk factors. Q: You're saying that that was explained by the extent to which one kept to the traditional lifestyle or not? A: When people were children, the question was did they live in a Japanese neighbourhood with Japanese friends? Did they go to a Japanese language school and in other ways maintain life in a Japanese community, or not? And as adults, did they live in a Japanese community, belong to Japanese organisations? And in fact the key question was when you need to go to a doctor, dentist or lawyer, do you go to a Japanese doctor, dentist or lawyer, or doesn't it matter? So those kinds of questions were the ones that differentiated those who had rates five times higher after adjusting for diet and so on. So the question was, what does 'western' mean, what does 'traditional' mean? And I spent two years of my life travelling to Japan, trying to get a sense of what the fundamental issue was. And the one common theme was that westerners were seen as lonely. I said, 'What do you mean, lonely?' And they said, 'Well, when you go to the United States you see people walking around by themselves.' 'That's not lonely.' And they would all look at me quizzically and after a while I thought, you know maybe they're on to something. So I solved that problem by coming back to Berkeley, and this doctoral thesis was done by Lisa Berkman, who's now a professor at Harvard, and she did actually the very first empirical study of the concept of social support. Her thesis was done in the large population of Alameda County, showing that people who had connections with other people had mortality rates in the subsequent nine years following the interview, had higher mortality rates than those who were well connected. Q: 'Connectiveness' was defined as what? A: Well it was very primitive. It was, Are you married, and do you belong to church? And do you have organisations? It was the very first study, and we really didn't know what we were talking about, so it was really being involved with other people not in a very subtle or sophisticated way, but this was after adjusting again (everything I'm telling you is after adjusting for age and health practices, and all the things that you'd think would matter). This social connection was independently related to mortality rates in a very dramatic way for men and women. Q: All-cause mortality, or just coronary heart disease? A: It was all-cause mortality. That's one of the interesting things that we need to talk about, but that it seems to me, is a very important issue in this work. But that began a world-wide explosion of research on social support, and it seems to me, many of the other research ideas that have come forth since on type A behaviour can really be seen as a way of people unsuccessfully trying to maintain connections but not being able to. The whole concept of stressful life events is really, because it turns out it's divorce and death of people, again breaking social connections. But I now have rejected the social support idea; I no longer feel that that's the central issue. Q: There's something up-stream, you believe? What gives you the feeling there's something up-stream? A: Because we now have research evidence in other work that we've done. For example, let's take the Marmot study of British Civil Servants. Q: This is the Whitehall study of which there've been two main studies of different hierarchies within the British Civil Service. A: That study was the beginning of my re-thinking of the importance of social connections and so on. In that study, Marmot and his group studied I think it was 10,000 British Civil Servants, and he found this dramatic difference in disease from those at the top of the Civil Service hierarchy compared to those at the bottom. Those at the top are senior executives and head of the British Civil Service agencies, the guys who wear black bowler hats and have the umbrellas, all of whom have gone to Oxford and Cambridge, and all of whom retire with a knighthood, compared to those at the bottom of the hierarchy, guards and messengers and so on. And he has a fourfold difference in disease rate, top to bottom. Now that in itself is not surprising, because the most important predictor of health and wellbeing since the beginning of time has been social class. It's always true that people at the bottom have higher rates of disease than people at the top, almost without exception. There are some exceptions: prostate cancer, breast cancer. The Civil Service finding in itself is not very surprising; what is surprising is the gradient. That is to say, those at step 2, one step from the top, professionals and executives in the British Civil Service, doctors and lawyers, have rates twice as high as those at the very top. Q: So that there's a very sharp increase. A: Oh yes, it's dramatic. Why people at the bottom have higher rates, we all think we understand it. We talk about low income, low education, poor medical care, poor housing, but that is not true of professionals and executives. My first assumption was that that was a unique observation among British Civil Servants in London. We did a review of the world's literature on this, and it turns out it's a universal observation; in all of the industrialised world for virtually every disease we know about there is a step-wise gradient. The most interesting part of the British Civil Service study is that the first thing Marmot and his group did was try to explain this gradient by reference to the important risk factors that we know about. He adjusted for diet and for smoking and for blood pressure and for physical activity and obesity and social support, and hundreds of other variables. And the fact that there's a gradient is true in spite of the fact that you adjust for all these factors. So those factors explain something like 25% - 35% of the gradient, but the rest is unexplained by those factors. So that's why I put social support aside as the explanation. Clearly it's involved, but I'm looking for the answer and that is not the answer. My hypothesis is that it's control of destiny. And what I mean by that is that the lower down you are in social class standing, the less opportunity and training you have to influence the events that impinge on your life. Q: This is the notion that it's not the high powered executive sitting on phones and jumping on jets to Paris and London who drops dead, it's actually the person below that person, who has been told what to do, has very little chance to decide how they do their work; they've been told what to do, they're given the time line, and they've got very little latitude, and they're just spinning out of control and often at home the same thing's occurring. A: Exactly. There are two streams of research that support that idea. One is work by an American, one a Swede, on what they call 'demand latitude'. And what they find is that people who have very high demands at work and very little latitude in discretion for dealing with those demands, have the very highest rates of disease, and that's exactly what we found in the British Civil Service. I went to each of the British Civil Service agencies, to the personnel directors, and examined all the jobs in terms of the demand in latitude, and that's clearly what's going on. The second thread of evidence however, is even more dramatic. As I said, Marmot has looked at several hundred factors to explain the gradient, without success. Maybe for 10, 15 years he's been trying as hard as he can, looking at things ranging from fibrinogen to whether you have a car, without success. But in July of 1997 there's a paper in 'Lancet' where he, for the first time, controls this gradient for the concept of control. Q: And? A: The gradient disappears. Q: So that becomes the key factor? A: In fact, 'Lancet' asked me to write a commentary; and my argument was this is the most important finding in the last several decades. So I now understand why social support is seen to be important. I now regard social support as one of the ways that we use to control our lives. That is to say, if I challenge you with a problem and you look to others for advice and support, that helps you negotiate life's challenges. Q: How does it translate to the home and the family? A: If I challenge you, Norman, with a very difficult life challenge about which you know nothing, I know that you're not worried about it, because I know what you're going to do: you're going to talk to some other people, you're going to make some phone calls, and within a day or two you're going to work out a scheme to deal with it. You may not know at the moment what's going to work, but you know that you'll be able to do it. That kind of confidence, and not only the confidence but the knowing how to go about solving the problem, is almost automatic. When I interview people in lower social class circumstances, and present them with that kind of problem, you can watch their shoulders slump with another life problem that they don't know how to deal with. It's not a question of intelligence, it's a question of knowing that you can work it out, and having the training and experience to work it out. Once you give people in lower social class circumstances a clue, they get it in a minute and they're off. Q: So mastery is infectious; it goes across things. Once you've mastered your life you master the circumstances which confront you on a day-to-day basis, is that what you're saying? A: Yes, exactly. In the 1960s in a little town called Ypsilante, Michigan, they did an amazing study by inviting three-and-four-year-old children, (they were all poor, all black) inviting them to come to an early education program. The idea would be for three-and-four-year-olds to come to a year or two of early education. This was the program that preceded Headstart, in fact it was the reason for Headstart starting. Q: Headstart being an extra educational activity for underprivileged children. A: Yes, and three-and-four-year-olds, now in the United States a national program that's been remarkably successful. It had begun because of this Ypsilante study. They were overwhelmed when they invited these children. So they randomly allocated kids to either have the program or not have the program. And these children were in the program for a year or two, and then they followed them at age 19, still poor, still black, and they got almost 100% follow-up with these kids. And they couldn't believe the results, and nor could I. Double the high school graduation, double the college admission, half the welfare, half the crime rate; for girls, half the teenage pregnancies. And this dramatic difference in their lives. In fact the book they wrote about that is called 'Changed Lives'. They then followed these kids up at age 28. Again, very high response, and their lives are still different, really dramatically changed. What did they do in that one or two years? And I've done a lot of work interviewing teachers in the program saying, 'What is the key issue here?' And it's very hard to tell, because all the teachers have different stories, but I can tell you one that I learned about from a teacher in Oxford in England. And she said, 'Well, the common theme is the children come to the school and they're asked, 'What do you want to do today?' Typically the new kids say they don't know, so they get assigned to work with children who do know. Eventually they do choose something, and then all the resources of the school are brought to bear to help them do what it is they said they'd like to do. This woman in Oxford said 'Yesterday a kid came in and said, "I want to do aeroplanes", and all the other kids said, "Me too". So they all got together and they made paper aeroplanes and they flew them and the planes crashed. Then they sat around and talked about what happened, and they re-designed the planes and they flew them again, and the planes crashed. Then they got together and discussed it again and they flew them and the planes crashed. She said, 'That's all we do all day, and that's basically all we do all year.' Now to me, what this is about is teaching children about failure and about success and about being creative and hanging in, learning how to succeed; learning how to succeed to me is a critical issue. What happens is they then go to Grade I with a different view of life and that persists throughout their careers. Now interestingly, when you take this program to children in middle and upper-middle class groups, the children are bored. So my sense is that somehow from the earliest days of life, certain kids get this kind of challenge and experience and other kids don't. And there's something you can do about it. See, one of the problems with social class is that we rarely study it in public health, rarely, even though everybody knows it's most important. The reason we in the United States don't study it is that first of all it's so overwhelmingly important that if you don't adjust for it statistically in your research, it overwhelms everything else under study and you'll never be able to study anything else. The second reason is you can't do anything about it anyway, they say. So why study a risk factor that you can't do anything about. If it turns out that an important dimension in the social class gradient is this control idea, there is something you can do about it, as evidenced by this Ypsilante project. So here we're not talking about work, control, we're talking about the concept of control in everyday life as a phenomenon that can be taught early in life as to how to manage one's life. Q: What's the leap then? Because you can imagine how it might lead to coronary heart disease, you know, stress, high blood pressure, brain-body connections. A bit harder to see how it can talk about cancer, but it may be easy to see how it could lead to alcoholism and suicide. Where's the link to all-cause mortality, death by any cause? A: Well I think that's a very interesting idea. Here are the two facts that pose a major problem to all of us doing health research: on the one hand,. there are risk factors like cholesterol and blood pressure and smoking and viruses and noise and all the other noxious influences we know about. Though one thing we know about those risk factors is that they are related to the occurrence of disease, but imperfectly. In fact if you took all the risk factors for heart disease that we know about, and they're 20 or 30, they explain about 40% of the heart disease that occurs. No matter how good these risk factors are, they rarely are predictive in any dramatic way. The second observation is that there are a number of psycho-social factors like social support and social class that are related to all classes of death. Now in the first case, it's puzzling and disappointing that these important risk factors are so imperfectly related to disease; in the second case, it's really puzzling how psycho-social factors could be related to everything. That just offends biologic thinking. So to me, the solution is that the psycho-social factors are related to the vulnerability and defences that people have to disease, not to what disease you get. So that these factors affect the body's defence systems and make you vulnerable to smoking and cholesterol and viruses and so on. That would explain both phenomena. But this is just a theory. But now we're coming to a whole new generation of research in the psycho-neuroimmunology field via McEwan and others, actually showing how loss of control actually affects cortisone levels and hormone functioning, and we're now beginning to open a whole new area of research, of how defence systems are compromised by these factors. Q: You're saying don't give up the idea that social class is unchangeable, there are changeable things in it. Give me some example, apart from say the Ypsilante and Headstart studies, of what you can do on the ground which will make a difference to large numbers of people rather than just individuals. A: Well what we've done is develop (this is at the University of California at Berkeley) - we've developed what we call a Wellness Guide. This is an 80-page document that begins with pregnancy and birth, and ends with old age. It is a Wellness Guide that doesn't talk about drinking orange juice or getting physical activity, but rather it says, 'Look, in each of these phases of life there are major challenges that we all experience. With these problems there are things you can do. Here are some ways to deal with these problems, and here's where you can get help in your community to do that.' For example, if you are going to have a baby, you can have the baby at a hospital or at home, you have a choice. Here are the issues, and here's how you can learn more about it. If you decide to have the baby in the hospital, you can have the baby with you in the hospital, or not with you in the hospital; you have a choice. Here's how you can learn more about it. We also tell people for example, when you're calling a State agency or a government agency when you're making the phone call to that group, the very first thing you have to do is get a chair. You have to sit down, it's going to be a long, difficult situation, bring your knitting, bring a book, write down your questions because you mustn't forget them, and it's going to be a long, hard go. So it's homely advice, I guess to put it bluntly, how to work the system. So the wellness guide tries to give people secrets for how they can negotiate their life: how to find a job, how to keep a job, how to change a job, what to do for kids with drugs. Now what we've done is distributed this book to 100,000 mothers in a program in California called WIC, that's Women, Infants and Children. What we've done is take advantage of the fact that they have to come a WIC clinic to introduce them to the book and to show them how it works. We got a grant from a foundation to do this work, and the foundation gave another grant to an independent group to evaluate our effort. They took random groups of mothers who got the guide or didn't get the guide, at four months and at eight months after receiving the guide, to ask the difference that it makes for people. The first thing that was really dramatic to me, after eight months, was the confidence that mothers who read the guide had in solving life problems. It was really dramatic. When we challenged them with life difficulties, they were confident they could work it out, and we said, 'Well what would you do?' and they'd give us a much more creative and interesting list of alternatives. Q: They had become more resilient. A: Some of the questions were right out of the guide: things about What would you do if a child needed medical care and you didn't have money? What would you do if you were spending more money in your family than you actually had? So these are in the guide. But we asked questions that were not in the guide, with the idea that if they were empowered by reading one or two pages in the guide that they would have a better way to handle things that were not in the guide. We'd say, 'Suppose you think the tax people cheated you on your income tax return, what would you do?' And the mothers were better with that too. This was random groups, and very impressive differences. Q: What about the barrier that comes before that for many people? I mean here you had people who in a sense are a captured group, they weren't just anybody out there in the community. And the recurrent finding in this area which is that people have got a lot of this information already. They kind of know what to do. You could quiz almost everybody in the community about cholesterol and smoking and everything else, but it's that jump to actually do something about it and taking control. And also, somebody handing you a book called The Wellness Guide, 'I haven't got time for this; I've got three kids, my husband's out of work etc. How am I going to have time to do this?' How do you get over those barriers, is there anybody working on that area? A: Well I think this is the major area in health promotion. It's absolutely clear that providing information to people is, I don't want to say it's useless, but it's close to useless. It turns out for example, we think we've done well with the reduction in smoking in the adult population, and we have. They don't quit smoking in our clinics, they quit smoking on their own. But behind our backs, the kids are now smoking at an alarmingly increasing rate. When we do surveys of those kids, it turns out they know all about the hazards of smoking, they have 100% understanding of all the issues and they smoke anyway. The idea that you can give people a pamphlet or a poster with the idea that it will change behaviour, just simply doesn't work. In fact I can give you the classic example of all time of where I got that lesson. Many years ago, we did the most expensive, elaborate, ambitious clinical trial that the world has ever seen, on heart disease. It was in the 1970s when we first really accumulated solid evidence about risk factors for heart disease. And the first factors about which we had information that was absolutely clear, was the importance of cigarette smoking and high blood pressure and serum cholesterol. And we decided to recruit a group of people in very high risk categories for those reasons, and to help them reduce that risk to show the difference it would make. Unfortunately the statisticians told us that we would have to have 12,000 men in order to do this study, half of whom would work with their doctors and half of whom would work with us in the clinic. In order to recruit those 12,000 men, we had to screen 500,000 men in 22 different cities in the United States. It cost $180-million. So we did this elaborate study -- Q: The Mr Fit study? A: Exactly. Ten years of my life. And what we did was we said to these men, they went through three elaborate screenings of ten hours,- we told these people, 'Look, you may be eligible for this trial, but do not volunteer unless you really are clear about the terms. The first consideration is, you're going to be asked to work with us in the clinic, or work with your own doctor, a random decision. And if that's not acceptable, don't volunteer. If you work with us in the clinic, you're going to have to come in with your family for many sessions, you're going to have to come in frequently at the beginning; we're going to ask you to stop smoking, take pills for blood pressure, change your diet, and you're going to have to come in to the clinic for six years.' Then we had a psychologist get rid of people that we thought would be faint of heart. So we ended up with these highly motivated, highly knowledgeable, informed people who knew they were in the top 10% of risk and who were currently free of heart disease. And then we did the best intervention that I've ever been involved with. I mean we brought all the families in and showed them in the clinics how to do low fat cooking; we took them to the supermarket to show them how to read the labels in the market; we went to their homes and cooked with them in their homes with things they already had in their home; we did that with all the issues, and it was really intense and elaborate. And after six years of intervention there was no difference in the two groups. The special care group didn't change enough, but the control group changed too much. It turned out that when we informed these people of their circumstance and dismissed them, we energised a whole generation of people to say, 'By God, if you're not going to help me, I'm going to do it myself.' And they did. It turns out the only way you really make important life decisions and changes in behaviour, all of us, is sitting down in a dark room and coming to terms with the reality of our circumstance. We don't do it with brochures. You have to make the hard decision. I went back over the Mr Fit experience, I was a smoking counsellor at that time, and I think what we did was interfere with the Mr Fit people in coming to that kind of term. What we did was have them get involved in all the smoking cessation tricks, the rubber bands and the diaries and other exercises. We had them so busy doing those things that I think they mistook those activities as what smoking cessation is all about. And it's not. Q: So they missed out on the revelation on the road to Damascus which you gave to your control group inadvertently. A: Yes. You have to come to this decision on your own, and to put it bluntly, I think you have to reach bottom. You do have to say 'You know, I'm not going to do this any more.' And I think we professionals interfere with that hard decision by 'helping' people. So we have lots of experience now of failures to get people to change their ways by doing what we think is right. Q: You're coming back to a sense that if you actually equip people with a sense of mastery and you give them the information they need that creates a sense of crisis in a sense, they'll use the mastery to make their own decisions, and they'll find the information if it's available. A: Exactly correct. And I have dozens and dozens of stories of massive interventions by the best people in the world, that have failed completely. Whereas the kind of interventions that are the kind you describe, are the ones that succeed. Q: If you are a State or Federal politician, a Minister, or you're a senior bureaucrat, you handle large sums of money, what does it mean? A: It means that if you're going to work with communities, you have to somehow get the communities to participate in the events that they're involved in. You can't do top down. The exception for that is making laws. You can require a speed limit or require that cars be designed safely, that's one way to make things happen, and that works. But if you want people to change their behaviour, you can't do it with proclamations from the top down by experts. Experts need to learn a new way of being an expert, to empower people to participate in the events that impinge on their life. The evidence from WIC is overwhelming and I think it's now becoming clear in our every day lives as well. Further Reading: www.abc.net.au/rn/talks/8.30/helthrpt/index/fullidx.htm The Health Report - Program Transcripts - Full Complete Index www.abc.net.au/rn/talks/8.30/helthrpt/index/recentix.htm www.abc.net.au/rn/talks/8.30/helthrpt/stories/s14314.htm Part Two http://www.abc.net.au/rn/talks/8.30/helthrpt/stories/s17092.htm Part Three http://www.abc.net.au/rn/talks/8.30/helthrpt/stories/s17187.htm Part Four http://www.abc.net.au/rn/talks/8.30/helthrpt/stories/s17549.htm
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