Dr. S. Leonard Syme has been pioneering research on the social determinants of health since the 1950s. He is regarded as the “father of social epidemiology” for both his ground-breaking work and his mentorship of numerous leaders in the field, including Sir Michael Marmot, Dr. Lisa Berkman, and Dr. Nancy Krieger. His body of work has focused on child health, job stress, social support, poverty, and social inequities on health. He joined the faculty at the UC Berkeley School of Public Health in 1968, where he is now an Emeritus Professor and Co-Director of the Health Research for Action Center. Dr. Syme was elected into the Institute of Medicine and has won numerous awards, including the Lilienfeld Award for Excellence in Teaching by the American Public Health Association and the JD Bruce Award for Distinguished Contributions in Preventive Medicine from the American College of Physicians. His pioneering work on the social determinants of health, and his commitment to translating this research into successful interventions, make him a clear choice to profile as a public health hero.
Career in Profile:
- 1953: Completed BA in Anthropology and Sociology from UCLA
- 1955: Completed MA in Sociology from UCLA
- 1957: Completed PhD in Medical Sociology from Yale
- 1957 – 1960: Sociologist, Heart Disease Control Program, US Public Health Service
- 1960 – 1962: Executive Secretary, Human Ecology Study Section, NIH
- 1962 – 1965: Sociologist and Assistant Chief, Field and Training Station, Heart Disease Control Program, US Public Health Service in San Francisco
- 1966 – 1968: Chief, Field and Training Station, Heart Disease Control Program, US Public Health Service in San Francisco
- 1968 – 1993: Professor of Epidemiology, UC Berkeley School of Public Health
- 1975 – 1980: Chairman, Department of Biomedical and Environmental Health Sciences, UC Berkeley School of Public Health
- 1993 – Present: Professor of Epidemiology and Community Health (Emeritus) and Professor in the Graduate School of Public Health, UC Berkeley
You are often called “the father of social epidemiology.” How did you get into this work?
In graduate school, I came across Emile Durkheim’s work on suicide. He observed that the causes of suicide are thought to reside within individuals, but certain groups have consistently high or low rates of suicide. If individuals come and go in a community, then why do group rates stay high or stay low? He proposed that there must be something in the community that increases the rate of suicide, even though it doesn’t predict which individuals will succumb. I said, Whoa. It’s like the symphony orchestra. You can study the violin or the trumpet or the drums to become an expert on the individual instruments, but that won’t help you understand symphonic music. That’s when I began to get into community stuff.
My early work focused on social class as a determinant of health. Michael Marmot’s work with the British Civil Servants was the breakthrough. The Civil Service is divided into different Steps (with higher pay grades associated with more prestigious steps), which means you’ve got a cross-section of socioeconomic strata right within the Civil Service. Marmot’s initial research focused on heart disease, and he showed that the Ministers at the very top of the Civil Service hierarchy at Step 1 have half the rate of heart disease as those who in Step 2 – Professionals and Executives – doctors and lawyers – just one level down. This gradient existed throughout the Civil Service. The lower the Step, the higher the rate of heart disease! But the higher rates are not just among people at the bottom. They exist from top to bottom.
When I was with Marmot in London, we decided to look at all diseases. It turns out this gradient exists for all diseases in the Civil Service. When I got back to Berkeley we reviewed the world literature, and we found that the gradient exists for all diseases, in every industrialized country. We controlled for blood pressure and cholesterol, smoking and physical activity, but there’s still a three-fold difference. If you don’t control for social class, it overwhelms everything. So we control for social class so that we can study other things, but that means that the elephant in the room – the most important determinant of health – sits bright and unexamined.
So then let’s just get rid of social class and everything will be fine! That’s not going to happen tomorrow. In fact, there’s evidence that it’s impossible to get rid of social class. In the 1930s the Israeli kibbutz tried to eliminate social class, but that failed. We have evidence that social class divisions begin in nursery school. But what is it about social class that really matters? Is it low income or low education? Is it poor medical care, poor housing, poor jobs? It’s a whole list of things associated with low social class, and they’re so hopelessly intertwined that you can’t tease them apart. Many of us – Marmot and others – hypothesize that the most important factor is whether or not you have control over your destiny. We now know there are biological changes in immune function when people have less control.
Health Research for Action is devoted to helping people have more control over their lives. We have guides for new mothers, we have guides to help older people avoid falls, we have a guide for disability. None of these guides deal directly with diseases or risk factors, but they do help people deal with the problems that they face in their daily life. Our theory is that when people have more ability to influence the events in their life, better health will follow. So that’s what the center is about. Our evaluations show that people keep the guides and refer to them, they share them with their friends, and they’ve changed the way they think about life. But you can’t show a change in health because we’re talking about a change in immune functioning, so we’re talking long-term. This is not the type of work we do in public health. It’s very hard to get outcomes information, and it’s very hard to get a grant that is not focused on one disease or another.
Translating research to practice is really, really hard. First of all, we “authorities” always pick the wrong topic to focus on, because we never pick the topics that people care about. We rarely think about health literacy. Almost all of our interventions have failed. We’ve done two things well. Smoking rates have declined, and seat belts have saved lives. Most of those successes are due to changes in laws and policies, tobacco price increases, and limitations on where you can smoke and how you can drive. Rarely has our brilliant statistical work on risk factors translated into successful interventions by itself.
What’s been a challenge in your career?
A major flaw in our field is our focus on diseases. We’re really talking about psychosocial risk factors and compromised immune functioning, and while these don’t cause one disease, they increase the risk of all diseases. Once you pick a disease, you’ve lost the power of the approach. But where would you send a grant to study discrimination diseases? Or hopelessness diseases? We don’t have a way to do that, because all the money is focused on clinical outcomes and risk factors.
Awhile ago, the CDC offered a grant to study kids in fifth grade. The CDC was interested in violence, smoking or drugs, inappropriate sexual behavior, school performance, things like that. We submitted a proposal to study “hope.” Our prior work with fifth graders in Richmond, CA – a very poor community – showed that many of them didn’t think they would live beyond the age of 20. If you don’t think you have a future, smoking and drugs and school performance don’t matter that much. So we wanted to see if we could help these fifth graders achieve a goal they’d set for themselves. We thought improvements in smoking and violence would follow from that. I’m really amazed, but the CDC made ours the #1 rated grant in their program. So that was very nice. We did that for 3 years, and we really did a good job.
We used Photo Voice, where we gave out cameras and asked the students to take pictures of the things they cared about, and that started the conversation. For example, one group was embarrassed by graffiti in their school. We worked with them on removing the graffiti, because you don’t just go out and buy paint brushes and cover the graffiti, you have to get permission from the principal and the school board, you have to get money for paint brushes, it’s a whole thing. That was just one group. We had a lot of groups, and they all had their own thing. At the end of 3 years, we talked to the students and it was clear their lives had changed. I’d like to follow them and find out what difference it made, but where do I get money? The CDC did “hope” once, but what foundation is interested in hope? It’s one of the most fundamental risk factors, but it isn’t diabetes or obesity, so it’s very hard to get money. I’m sitting out here in the wilderness concerned about things like hope, and my field is not with me.
What has been a career success for you?
The students that I’ve worked with. I do medium research. I do medium teaching. But I’m really fortunate to mentor a group of the world’s best people, like Michael Marmot, Lisa Berkman, Nancy Krieger, George Kaplan. They’re just a group of outstanding students who are now leaders in the field. Everybody attributes their success to me and that’s just not true. They’re all fabulous people, and I was just fortunate enough to be involved in their work.
The fact that Michael Marmot is knighted is a reflection of the fact that his work with the British Civil Servants has changed everything! He’s now the most famous public health person in the world, and he’s changing the agenda everywhere. Or the work of Lisa Berkman – these people are changing everything. And I just get to sit back and watch.
What’s a persistent public health problem that you see?
Inequalities in health. Inequalities are not just devastating to the people involved, they’re devastating to the entire country and society. It’s also a toxic issue for all of us. When some of us don’t thrive, none of us thrive. That keeps me up at night. When 1% of society has 50% or 60% of resources, this is not a good society. We really need to pay attention to income inequality. If you think you can get away with being the winner and not caring about other people … you’ve seen our statistics! The U.S. has a fancy, expensive medical care system but we still rank 37th or 38th in the world. We’re behind Slovenia! We need to study all levels of social class, because all of us still have higher rates of obesity and diabetes than other countries. We need to refocus to wellness. We’ve got to get our country back. It’s not a question of being nice to poor people. It’s good for all of us. Being on a losing team is not good for any of us.
What is your ideal solution to this problem?
I would study kids, from birth to age five. What happens in the early years doesn’t necessarily track into adulthood – you’re not necessarily doomed – but birth to five is tremendously influential. By studying kids, you would discover the important early life risk factors. You’d also have a fighting chance with your interventions, because parents care about kids! The problem with studying children is that they don’t have enough disease. But we now have a whole slew of biological markers that measure adult immune function – like interleukin – and I’d try to understand if those are appropriate markers in young people. Or I’d look for a series of new biological markers that show up in early childhood. They wouldn’t be diseases, but they would be things that lead to diseases. I’d investigate what really matters to children, so that we can intervene early in life.