Re: Cohousing is good for your health - potentially related verbatim interview
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

  • (no other messages in thread)

Results generated by Tiger Technologies Web hosting using MHonArc.