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Investments in Research and Intervention at the Community Level S. Leonard Syme University of California, Berkeley We “need to think more creatively about the prevention of disease and promotion of health,” Dr. Syme said. In particular, we must make two major innovations: classify diseases not just in terms of their clinical presentation but by their psychosocial precursors and focus not only on the individual but the community. To do so, however, will “require a fundamentally different way of funding research and training programs” from what is currently the norm. Our identifications of disease risk factors have been based entirely on a clinical model of disease. Taking coronary heart disease as an example, he said, “we have done a good job of identifying several important risk factors for this disease. We all know the list: serum cholesterol, other blood lipids, blood pressure, cigarette smoking, diabetes, physical activity, and so on. [But] the problem is that over half the cases of coronary heart disease are not explained by any of these factors.” Though we will undoubtedly discover new risk factors, he said, “I suggest the problem is a more fundamental one. . . . This way of classifying disease is of obvious importance for diagnosing and treating sick people. . . . But is it relevant for preventing disease?” We might take a cue from infectious disease epidemiologists, Dr. Syme said, who “many years ago developed a very different and very successful classification system based on the modes of transmission—waterborne diseases, foodborne diseases, airborne diseases, vectorborne diseases—that dif-
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ferent clinical entities had in common. This scheme was not useful in the diagnosis and treatment of sick individuals. But it was useful in helping to understand where in the environment disease was coming from, and it was certainly helpful in directing prevention programs.” We do not have an equivalent prevention-oriented classification scheme for the noninfectious diseases we are concerned about today, Dr. Syme maintained, and this issue is of particular importance in the social and behavioral sciences. “Many of the social risk factors we have identified are related not just to one or two clinical diseases but to a long list.” We need to study the ways in which these risk factors interact in “compromising the body’s defense systems rather than in causing specific diseases. We have been trained to study one clinical disease at a time from one disciplinary perspective, and this may be the reason why our search for risk factors to explain disease occurrence may be less than 100 percent successful.” Unfortunately, he said, “the precise measurement of psychosocial factors is very difficult because the diseases we study are the end result of a very complex series of biological processes. Disease is a very distal consequence of the psychosocial factors under study.” But if we could “continue the progress that is now being made in studying such biological concepts as allostatic load or other similar intermediate disease processes, we might be able to improve this situation,” Dr. Syme said. “By studying the relationship of psychosocial factors to these more proximal outcomes, two important advances could be made. One advance is that we would have for the first time a disease-related yardstick to help define psychosocial variables more precisely. “The second advance would be in moving closer to a more appropriate disease classification system. This would help us understand how certain social factors—poverty, social isolation, and particular types of job stress, for example—make people vulnerable to a variety of diseases. And it would help us to think in a way that is more oriented toward disease prevention. It would also provide a useful and efficient way to evaluate the effectiveness of interventions. Instead of having to wait five or 10 years for enough disease to develop in the intervened-upon group, we would be able to observe physiologic changes much sooner.” Our tendency in the health sciences is to focus on individuals rather than the communities in which people live. “As has been demonstrated in many of the presentations at this symposium, we are making important progress in helping people change their behavior to lower their risk of dis-
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ease,” Dr. Syme said. “This is good. But it is important to recognize another dimension of this issue. Even as high-risk people change their behavior and lower their disease risk, new people enter the population to take their places—forever. This is because we rarely identify and take action on those forces in the population that cause the problem in the first place.” To work at the level of the job or the community, we need to develop job- and community-based intervention programs as well as individually oriented ones, he maintained. “It is not a question of one approach versus the other; we need to consider both.” Cigarette smoking offers a good example of working at both levels, Dr. Syme said. “We have had phenomenal success, as Margaret Chesney noted, in reducing the prevalence of cigarette smoking—from a mid-40 percent level to around 20 percent today. Part of that success was due to better research on the biology of addiction, and part was due to better clinical treatment methods, both individual and group. But a major part of the success was due to the increased taxes on cigarettes, restrictions on cigarette advertising in magazines and on television, no-smoking laws in public buildings, prohibitions about cigarette sales to minors, changes in the culture about the desirability of smoking, and so on.” Research and intervention programs should be based on an “ecological” model, Dr. Syme said. “This model assumes the differences in level of health and well-being are affected by a dynamic interaction among biologic, behavioral, and environmental forces—an interaction that unfolds over the life course of individuals, families, and communities. This model further assumes that age, gender, race and ethnicity, and socioeconomic differences shape the context in which individuals function and that they therefore directly and indirectly influence health risks and resources. “An intervention directed to the behavior of adolescents, for example, should take into account not only the adolescents themselves but the environments in which they live, including peer norms, social and neighborhood supports, and ties to community institutions. Similarly, workplace interventions should consider not only the individual attributes of workers but social supports, family and neighborhood influences, environmental and social practices, and so on.” Essential to such interventions and in fact the “common denominator” in our successful efforts, Dr. Syme said, “is that they are multidisciplinary and multilevel in approach.” He offered the analogy of designing an airplane, a project that necessarily involves people from hundreds of different disciplines who do not have the option of refusing to interact with one
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another or to work across disciplinary boundaries. “They have a job to do,” he said, and “they need to pool whatever skills and talents they have to accomplish their goal. They must work across disciplinary boundaries and at many levels. “We in the health field have a difficult time behaving in a similar way,” Dr. Syme observed. Influenced by the traditions of academia, professionals are organized by discipline, and they tend to stick to their own kind. “There is not as much interdisciplinary interaction as might be expected or hoped for,” he said, “and our students of course note this and eventually emulate it in their own lives.” The way we fund research and training programs perpetuates, even encourages, this tradition, Dr. Syme said. “We will not, in my view, begin to deal with this problem until we are able to offer financial incentives to the university to bridge disciplinary perspectives.” But there are already some steps in the right direction, he noted. The counterpart of National Institutes of Health (NIH) in Canada, called the National Institutes of Health Research, not only “contains institutes on heart disease and cancer and arthritis but has also established new institutes that cross disease lines, such as the Institute of Population Health, Institute on Gender, and Institute of Aboriginal Health. . . . And the funding for these institutes is, importantly, determined by the degree to which each institute collaborates with the other institutes.” In a similar spirit, “the Robert Wood Johnson Foundation is currently soliciting proposals from universities to train a generation of population health scholars,” Dr. Syme noted. “The emphasis in this program would be on the degree to which universities can develop truly interdisciplinary programs directed toward community health issues.” He acknowledged as well the MacArthur Foundation Network groups and referred to “other beginning initiatives, at both government and foundation levels, that think in terms of community and environmental prevention programs. But all of these efforts are at the very early stages, and funding is still quite limited.” Dr. Syme reminded his audience that “as the population of the United States continues to grow, and to age, the burden of providing appropriate medical care will grow exponentially.” Given that our medical care system is already strained, unless we “take more seriously the issue of prevention, and especially community-based prevention programs, . . . it is fair to say we ain’t seen nuthin’ yet.”
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