Ichiro Kawachi, MD, PhD

IchiroTrained in both internal medicine and epidemiology, Ichiro Kawachi, has been a pioneer in the field of social epidemiology. Dr. Kawachi’s first foray into public health began as a doctoral student in New Zealand in the 1980’s, when he published a paper quantifying the estimated annual deaths due to second-hand smoke. This paper stoked the ire of the tobacco industry but ultimately led to the passage of historic legislation in New Zealand limiting cigarette smoking and tobacco use. Currently the chair of the Department of Social and Behavioral Sciences at the Harvard School of Public Health, Dr. Kawachi is a professor in social epidemiology and has taught for over 20 years. He has published over 500 articles on social determinants of population health. His books include the Health of Nations with Bruce Kennedy, Social Epidemiology with Lisa Berkman (Oxford University Press, 2000; Completely revised 2nd edition forthcoming in summer of 2014); and Globalization and Health and Social Capital and Health co-edited with S.V. Subramanian and Daniel Kim.

Career in Profile

  • 1985 – Received M.D. from Otago University, New Zealand
  • 1991 – Received Ph.D. from Otago University, New Zealand
  • 1993-NOW – Professor, Harvard School of Public Health, Department of Social and Behavioral Sciences

You have several titles: professor, department chair, social epidemiologist, and more recently, behavioral economist/scientist. Tell me a little about your work in each of these roles and which one is consuming the most of your time these days.

I spend about 75% of my time on research, 20% on teaching, and the remainder on administration. I’ve been very conscientious of trying to protect research time. I have a lab – the Society and Health Lab – that currently has a dozen postdoctoral fellows from all over the world. I try to prioritize research including a NIH-funded R01 project on the aftermath of the tsunami and earthquake in Japan. We’re in the field right now, trying to trace the people who were affected by the tsunami.

I’m still very passionate about teaching. I spend at least twenty percent of my time teaching. My classes are Health and Society, which I’ve been teaching here for over 20 years. I do that twice a year in the summer and the fall. I teach about 400 students altogether each year. Recently, I recorded Health and Society for edX. Thirty-two thousand students registered for it. It was really amazing to see this because as you follow the online chat in the classroom, you can see that the very time if you drop a pin from where one of these comments came from, within a day or so, you quickly draw a map of the world. I also teach Behavioral Economics, which started out small and has done the equivalent of going viral in the classroom because we are in the largest lecture theater now at the Harvard School of Public Health. The chair’s duties are administrative, shepherding academic and strategic concerns of the department. I try to keep it to a tenth of my time.

You were trained in medicine, became an epidemiologist, and have been a leader in the field of social epidemiology. You co-wrote the book on social epidemiology. How did you come to do this work?

I trained as a physician in New Zealand. I switched to epidemiology when I got fed up with doing downstream medicine day after day. It wasn’t what I expected. What I had underestimated was the sheer repetitiveness of day-to-day clinical medicine. I trained in internal medicine. I’d say that 80% of my patients had heart attacks, strokes, congestive heart failure, or chronic respiratory disease. If you take those four diagnoses, they comprise about 80% of internal medicine, at least it was when I was practicing. The bread and butter of medicine are these common things.

What do these things have in common? A lifetime of poor behavior, smoking, stress, bad diet, lack of exercise. So I started to realize that there must be a better way to go upstream and try and prevent these people from ever getting any illness. So, that was my initial stimulus to go from clinical medicine to doing something upstream, such as tobacco control.

I became very active in the New Zealand Public Health Association at that time. I was elected as the National Secretary. Just at that time, the Health Minister of New Zealand was Helen Clark, who later became the longest serving prime minister of New Zealand, and who is currently the head of the United Nations Development Program in New York. Under her leadership, she decided to pass legislation to ban all forms of tobacco advertising in New Zealand and to restrict smoking in workplaces. She was way ahead of the curve. She started thinking about this in 1989 and it finally passed in 1991. This was right at the time when I decided to make the switch to public health. So I became very excited by this.

I spent a lot of time lobbying for the passage of this legislation. That’s how I got interested in public health. Through my interest in tobacco control I then did a PhD in Epidemiology and then came to Harvard, now over 20 years ago. My initial reason for coming here was to study the benefits of stopping smoking in large cohort studies. While I was here, I met Sol Levine, who was one of the founding chairs of my current department. I got exposed to this idea of health inequality. I suddenly realized that the problem of tobacco control is actually one of health inequality. I suddenly realized that unless you tackle inequality, you aren’t going to really tackle tobacco control. People smoke because it is one of the cheapest pleasures, it is one of the few things that someone can have for himself/herself in a life that is full of stress and chaos and few options. That got me interested in social epidemiology.

Twenty years ago, when I was recruited into this department, I wanted to use the term social epidemiology to distinguish what I was doing from what I had been doing before, which was chronic disease epidemiology. At HSPH the students have to declare a major field of study for their thesis. One of the first things I did, when I took on one of my earliest doctoral students [was to suggest] that he declare social epidemiology as his field. Much to my annoyance, this was rejected by the school’s Committee on Admission and Degrees. In 24 hours it had come back and the chair of the Committee had said that there is no such field. That got me sufficiently riled and I decided to work on a textbook. Lisa Berkman also had the same idea and already we got a book contract from Oxford University Press. So we decided to write the textbook together and we declared the arrival of this field. These days, no one questions that there is a field of social epidemiology. Len Syme had been doing similar work for years but I guess he never used the term social epidemiology. The same with Sir Michael Marmot. They were doing it. But they hadn’t declared it an academic discipline. The past twenty years can be seen as an effort to build a training program in social epidemiology, which is what we say that we have at Harvard.

Describe your interests and focus in behavioral economics. What are the implications of this field on public health practitioners and policy? Does it represent a fundamental shift in how we are approaching research and interventions?

I became interested in behavioral economics when, five years ago, I became chair of the Department of Society, Human Development and Health. We are now called the Department of Social and Behavioral Sciences. Being a chair of a behavioral sciences department, I decided to review the curriculum. What are we teaching our students about behavior? Much to my amazement, it turned out that there was nothing in our curriculum about behavioral economics, which has been in the background of economics and psychology for the last thirty years, as it really started in 1980.

I was amazed by this gap because on the one hand you have those behavioral economists and psychologists who don’t speak to public health people, yet all of their examples concern health behavior. They’re practicing public health without a license! On the other hand, when I looked at our curriculum, we are the behavioral science department at the School and there wasn’t a single course listed on our whole department roster that taught behavioral health. So I decided that we better quickly fill this gap.

I think behavioral economics is very interesting because it does seem to me a remarkable confluence of ideas – in disparate fields from psychology to neuroscience to economics and public health – to more fully understand the basis of human behavior. I don’t think that by any means it’s a panacea, but it’s something new that we haven’t done. I think if we do it right, it has the potential at least to reduce inequalities as well. Because we know that all the things we speak about in behavioral economics – the heuristics, the biases, and the problems of delayed gratification – all of these things are even more acute in populations that face poverty and scarcity. To the extent that we can address these things, it has the promise of reducing inequalities and boosting the effectiveness of health behavior interventions.

What is a career success or highlight that you are particularly proud of?

My most efficacious paper to this date remains my 1987 article published in the New Zealand Medical Journal, which I wrote when I was a doctoral student. I always tell this to my students, because much as I try to work toward writing elegant papers in high-profile journals, the one that really had public impact is still the one that I wrote as a doctoral student in epidemiology. Back in 1987, the New Zealand Parliament was starting to debate whether or not they should pass legislation to restrict second-hand smoking. I had this idea to calculate how many deaths second-hand smoking in New Zealand causes. I used the technique of Population Attributable Risk, which I had learned in my epidemiology courses. I got some numbers and did a calculation. I discovered that nearly (an estimated) 300 Kiwis (New Zealand residents) were killed every year by inhaling second-hand smoke in the workplace and the home. Three hundred deaths each year might not seem like large numbers, but in New Zealand, that’s roughly two-thirds of the annual death toll from traffic accidents.

My point was that the New Zealand Traffic Ministry spent millions of dollars in anti-drunk driving campaigns, so why didn’t New Zealand government take passive smoking just as seriously. I published in the New Zealand Medical Journal and it had enormous impact. It was picked up by local anti-smoking organizations that held a demonstration in front of Parliament where 300 of them got dressed in crosses and laid down in front of Parliament. Politicians started to cite it in their speeches to Parliament. The next thing I know, I got a letter attacking the paper. Someone submitted a letter attacking the paper and it was written by none other than Nathan Mantel, who every public health student knows because of the Mantel-Haenszel odds ratio. This world famous statistician turned out to be a consultant for the tobacco industry.

When I saw that letter, I knew that I had made an impact. I had sufficiently disturbed the tobacco companies that they had paid this world famous statistician to attack my paper in the New Zealand Medical Journal (which I doubt he had ever read before my article appeared). To this day, I contend that that was the most important, directly policy-relevant paper I’ve written. It just shows that I peaked early. Students can still do really important work. I’ve never had that kind of success since then.

What is a challenge that you’ve faced or continue to face in your career?

A challenge in behavioral economics and social epidemiology is the massive disparity in power between “us” versus “them”. In this country, at least, economic power has become so concentrated in the last 30–40 years, it’s becoming harder and harder to make an impact through the mechanism of democracy. If you want to make some point of view, it is hard to get it represented through the ordinary channels of media.

It’s exactly like Joseph Stiglitz described in The Price of Equality. He articulated what I always wanted to say about income inequality’s corrosive effects on the body politic. His argument is that the concentration of wealth in the top one percent is distorting political decision-making in a functioning democracy. It is distorting media, the rules of the game by which the economy is run, and I think this is a huge challenge both inside and outside of public health.

To get something done within public health, you have to influence institutions, the laws, and regulation. Developing evidence is the initial step. We also say that lots of policies get made on the basis of no evidence. If there is a will to do it, they’ll do it. If you want something to be passed, at least on our side, you have to have evidence. What researchers at the School of Public Health are doing is providing the knowledge base. As has been said before, that is only one of the ingredients. You have to have the political and popular will to do something and you have to have an appropriate strategy to translate that evidence into policy. Unless those things come together, you won’t get change. The problem with growing polarization is that you can produce lots of evidence but the political will is stuck.

Is there a persistent public health problem that still concerns you today?

I have to say that it is health disparities, persisting inequality between rich and poor countries, and persisting inequality within rich countries. The field of social epidemiology is really an attempt to focus attention on that problem.

It is not enough that the average gets dragged up. You have to lift everybody. There is a lot of attention on global health but basically, you don’t need to go that far. Look in our backyard. You will see disparities in life expectancy that span the entire globe. A man born in a New Orleans’ parish has a life expectancy in his ‘50’s, compared to an Asian-American woman born in a rich Bergen County, NJ, who has a life expectancy of 90. A forty-year difference in life expectancy pretty much spans the average differences in the countries of the globe. I tell young, idealistic youth who want to make a contribution to global health that you don’t have to go all the way to Malawi. You can do something in rural Mississippi. Health centers like the one in Mound Bayou, MS, because basically it’s the model of physician responsibility. The primary care doctors basically said that it’s not enough to provide primary care, you’ve got to invest in educating the people, making them leaders, and make it self-sustaining (Editor’s note: Mound Bayou was the first community health center in the country).

This feature was interviewed, transcribed and partially edited by our guest editor, Ted Henson. The photo was provided by Maki Miyashita.

Len Syme, PhD

Len Syme, PhDDr. 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.