Portal de Periódicos da CAPES

A Conversation With Leonard Syme

2011; Lippincott Williams & Wilkins; Volume: 22; Issue: 6 Linguagem: Inglês

10.1097/ede.0b013e31822f9cc0

1531-5487

W. Thomas Boyce,

Food Security and Health in Diverse Populations

S. Leonard Syme was born on 4 July 1932 in Dauphin, Manitoba, Canada. He trained in medical sociology at Yale University and served in the US Public Health Service and at the National Institutes of Health in his early career. Since 1968, he has been a Professor of Epidemiology at the School of Pubic Health, University of California, Berkeley, CA. He was the first sociologist to hold a faculty position in epidemiology. As one of the progenitors of the field of social epidemiology, Syme foresaw how socioeconomic gradients in health might herald a broader role for social factors in the genesis and distribution of human morbidities. Although his contributions to social epidemiology are legion, he maintains that his principal gift to the field has been his cohort of students who have changed the face of the discipline. With this cadre of gifted and prolific younger scientists, Syme's work illuminated how social factors and acculturation are linked to cardiovascular mortality (with Michael Marmot), how supportive social ties alter susceptibility to chronic disease (with Lisa Berkman), and how community socioeconomic position predicts differential mortality (with George Kaplan). Revered by a generation of junior colleagues for his generous mentoring, Len Syme's kind and intelligent presence has truly been one that "launch'd a thousand ships." INTERVIEW WTB: Very few people start out their careers with the intent of becoming an epidemiologist. How did that happen for you? LS: Well, I'm certainly one of them. I got my PhD in the first medical sociology program ever offered. It was at Yale University, and there were 4 of us in the program. Two survived. There was really no field of social epidemiology. We were supposed to do the usual sociology, but because I was being drafted into the Korean War, my professor suggested I might want to join the Public Health Service to fulfill my national obligation. So I agreed. He said, "Well, actually, there's a job in the Heart Disease Control Program in the Public Health Service." I knew nothing about this, but I took the job. It turned out I was doing epidemiology without ever having had a class in epidemiology. I did research on heart disease for 10 years in the government, and ended up as a professor of epidemiology at Berkeley without ever having had a formal class in the subject or ever really having spent any time in a school of public health. WTB: You were an accidental epidemiologist. LS: Yes. That's right. WTB: At what point did you discover that, in fact, you were doing epidemiology? LS: It turns out sociology is very much like epidemiology, without the health focus, but studying the differences in occurrence of events between one group and another. So the real question was adding health, and that was something I was really interested in. Even during my doctoral thesis, I wanted to understand the differences that social factors made in health and well-being. My professor was engaged in one of the largest studies ever done on mental health, on social class, and mental illness in New Haven, CT. I didn't want to do my dissertation on that because it seemed to me that social factors and mental illness were too closely related, and that it would not be very surprising to find a connection. I wanted to study things that were seemingly unrelated and independent, so my doctoral dissertation was on infertility. My thought was that, if these social forces really matter, they ought to manifest themselves in conditions that appear unrelated, like infertility.Figure 1: S. Leonard Syme, circa 1968.WTB: I also know that how you got into sociology is an interesting story. LS: Yes, that's a somewhat embarrassing story. I came from a very poor family, I was going to UCLA as an undergraduate, and I had 5 jobs. I worked in the cafeteria for my food, the college bookshop for money, a furniture store at 5 in the evening, a department store at midnight, and looked after a paraplegic, for which I got free rent. So I was pretty busy. My senior year I was asked if I was interested in becoming a teaching assistant, and I said, "You mean you pay me to go to school?" I said, "I'll do it." And it turned out that the position was with a sociology professor. So I became a graduate student in sociology, and when I got my Master's degree, they told me it really wasn't a very useful degree and you needed a doctoral degree. So I applied to 7 doctoral programs, and I took the fellowship that offered the most money, which was the medical sociology fellowship at Yale. It was not a very thoughtful way of planning a career. WTB: But it's an interesting path. Say a little about your boyhood in Winnipeg, and what moved you in the direction of an academic and scholarly life. LS: My father had gone to grade 7, and my mother had finished high school but really had no intellectual interests. So I ended up in my local library. The library had been built by Andrew Carnegie, and I knew his somewhat unsavory reputation, but to me, he was a hero. That Andrew Carnegie library basically became my home. I found that by being in the library, I could learn things and achieve things that my father couldn't criticize. When I finally ended up at the University of Manitoba, it was really a pivotal experience. While it may sound like a small provincial college, it was actually totally remarkable. The faculty were virtually all Oxford and Cambridge dons who were in the provinces temporarily until they could find an academic post in England. We had an Oxford education that was highly rigorous. I read all of Shakespeare and Chaucer—it was just a remarkable education. By the time I finished my 2 years at Manitoba and moved to UCLA, I was really getting interested in academic pursuits. WTB: What person would you single out as having most strongly influenced your career? LS: It was Émile Durkheim. His work completely changed my view of things. Here was a man who studied suicide,1 saying that the causes of suicide have to be seen as the most individual and personal forces that could possibly impinge on a person's life. Then he pointed out that, despite the personal intimacy of the act, there were patterned regularities in suicide rates around the world, in that certain groups had higher rates over time than other groups, even as the individuals in those groups came and went. If the causes are to be found in individuals, how could the rates maintain higher or lower status over time? So he argued there must be something about the world in which people live that generates a certain rate, even though it fails to predict which individuals are affected. And I remember saying, "Whoa!" This was really eye-opening, and changed everything for me. WTB: Any other mentors or role models who you encountered in your early career? LS: When I took the job in the Public Health Service, they really were driving me crazy because I was this very young guy just starting out, and they had me being a consultant to the State Health Department officer in Illinois on rheumatic fever programs. What I really needed was a postdoctoral education. So I basically resigned and was summoned by the Assistant Surgeon General, who said, "What's this about resigning?" I said, "I need to do my research. I can't go running around being a consultant on things that I don't know about." So he said, "How about being the executive secretary of the very first study section at NIH?" I said, "What's that's got to do with it?" He said, "You can do your administrative work halftime, but in the other half, you'll be working with the best minds and ideas in the country. That will be the best postdoctoral education you could have." So I agreed. Except, we couldn't call it epidemiology. That word was reserved for infectious diseases, and we were going to be studying the whole range of noninfectious diseases. So we had to call it human ecology. We had 2 or 3 applications per round. Can you imagine? So we went on site visits everywhere, all the time. We'd get an application from some guy in North Carolina called John Cassel, and we'd go out to the hills and visit him. Abraham Lilienfeld was on the committee. So I was coming in contact with some of the best minds in the country, and I did that for 2½ years. It was an amazing education.Figure 2: S. Leonard Syme, circa 2010.WTB: You are known, among your students and the junior faculty who have had the benefits of being part of your life, as the gold standard of mentors. So say a little bit about mentoring and about how that became such a prominent and important part of your identity. LS: It's a total misunderstanding. I'm pretty good at picking remarkable people, and so I admit to that talent. But after that, people just find their way, and I've been there to aggravate and nudge. None of the people you're mentioning were following my lead and my inspiration. Many people who are wonderful mentors have students who go out and follow their path. None of my people has done that; they have all found their own way. So for me, it's really a question of finding outstanding people, stimulating them to do their best, and staying out of their way. WTB: I think maybe part of what is unique about the way that you have led and fostered so many careers has been your ability to help people discern what their own path and own interest are. How have you chosen the research questions that you have addressed over the course of your career? LS: When I first began, I was doing normal epidemiology; it was more or less conventional. From about 1958 to 1968, I was working at NIH doing research in heart disease, and I finally realized, "I can't do this anymore, I'm becoming an administrator." So I resigned again, and the Assistant Surgeon General called me again and said, "Now what?" I said, "I'm becoming an administrator again, I need to do my research." He said, "We'll find you a job in Washington," and I said, "No. Washington is not the place to do research; I need to do research where I can really do research!" So they set up a field station in San Francisco where I could pursue my interests away from Washington. I did that for quite awhile, until they made me chief of the field station. So I resigned once more, and this time I stuck with it. That's when I came to Berkeley. But up until then my research had been fairly pedestrian. It was okay, but I really was getting impatient with doing normal things, and I really wanted to figure out what the most important research was that I could do. Then I developed a relationship with Reuel Stallones, who was a professor of epidemiology at Berkeley. I came to see him, and I knew he was a brilliant guy. So I said to him, "What are the most important questions we ought to be dealing with?" And we spent 2 years working together, filling up all the blackboards and trying to identify the truly pivotal issues that we needed to investigate. That led to our study of Japanese migrants from Japan to Hawaii and California.2 It turned out to be a major enterprise, and it began by trying to discern critically important questions. Since that time, I just haven't been interested in ordinary research. I really am only interested in work that will make the world a different place. I've talked to my doctoral students, saying, "That's a very interesting project, but what I'm looking for is for you to come to a professional meeting, present your paper, and when you're finished, have the world not be the same anymore." So that means digging as deep as you can. WTB: Which of your papers do you think has been the most influential, and which one would you cull out that you think is the most underappreciated? LS: I think the one that's been the most influential was one titled "Rethinking disease: where do we go from here?"3 I was trying to say that epidemiology is not fulfilling its mission by focusing on clinical diseases, one at a time, looking at heart disease, then arthritis, then cancer.3 We really need to rethink the conceptual framework if we're going to do appropriate epidemiology. I used the example that infectious-disease epidemiologists use when they categorize morbidity into water-borne, food-borne, air-borne, and vector-borne diseases. It's a classification of diseases in terms of where they come from in the environment and where to direct interventions. That transcends what we do at NIH, where you look at arthritis, heart disease, and cancer. We've fallen into what I think is a clinical way of thinking about diseases that really makes it impossible to do good epidemiology. That "Rethinking disease" paper tried to suggest that there are certain psychosocial and cultural forces that compromise a person's ability to withstand insult, compromise immune functioning, make people more vulnerable to disease, but without predicting what disease you get. The disease you get, I was arguing in that paper, is attributable to the cholesterol you're exposed to, or the smoking, or the viruses. What we really need is a 2-stage model, and the epidemiology part really ought to focus more on susceptibility. We're making real progress on the link between social forces and biologic processes, and that, it seems to me, is the most interesting and important work we can now do. The paper that I think is not as appreciated reflects another part of my world, and that is the world of interventions. I'm codirecting a center at Berkeley called Health Research for Action, where we try to take the results of epidemiologic research and develop interventions that actually make a difference. I chaired a committee at the Institute of Medicine, and we wrote a big, thick volume called "Promoting Health,"4 which basically said we have failed in this intervention enterprise. The issue is that we come up with risk factors and develop messages to give people, but people have lives to lead. The messages and the people rarely coincide. So I wrote a paper on "Social determinants of health: the community as an empowered partner,"5 trying to say that we need to withdraw from being experts on diseases and risk factors and need instead to become experts in working with the people who are the intended recipients of our interventions. It's a new way of thinking about working with the community, instead of making speeches and posters. And that message I don't think has gotten through. We still tell people to eat 5 fruits and vegetables a day and exercise, and it's going in one ear and out the other. WTB: It strikes me, with respect to the "rethinking disease" paper, that this is a nice exemplar of the kind of question that you searched for on the blackboards with Reuel Stallones. LS: It is. Another thing that I've been brooding about is my diminished interest in studying old people. I think the origins of disease and disorder can be found early in life, and we really need to do better work early in life. Most of the risk factors we study in adults you can find in early life: blood pressure, obesity, respiratory function, and temperament—many things we care about are found early in life, and we know when we intervene with children, we can really make a difference. The problem is that children don't have enough disease, and the main thing an epidemiologist needs for his research is disease. So if you've got a fundamentally healthy population, it really is a downer. We need a new way to think about health and well-being in the early years that transcends those clinical categories of disease that we rely on. And that is something I think people are beginning to work on. When we can figure out how to tell if a child is doing well or not, we can do effective epidemiology. To me, that's the future. WTB: Of all of the contributions you've made over your career, which is the one for which you would most like to be remembered? LS: There's no question about that: it's the students that have come out of the program. They are moving the field forward in ways that are far beyond anything I could have imagined. There's a list of maybe 10 or 20 that are now leading the field, and they're doing work that I couldn't even imagine. My role has been really limited—it's the students who are really the fabulous product. WTB: What would be your assessment of the current state of the "health" of epidemiology; what are the biggest risks that the discipline faces? LS: I used to have a training grant at Berkeley. It went on for 25 years, and it was the mechanism that provided support for many of my students. After I had retired, I applied for 5 more years, and NHLBI wrote back and said, "You know, you've done a wonderful job, and it's a terrific training grant, but we can't support you anymore. Do you realize you've mentioned heart disease maybe only 2 or 3 times in the entire application? And looking back over the years, it's become less and less a focus. It's good work, but we can't support it if it's not heart disease." So the question was, where could I find support for looking at these forces, over the life course, that transcend any particular disease? The Child Health institute does children, and the National Institute on Aging does old people, and there is no place at NIH to support an interdisciplinary focus over the entire life course. If I sent a grant proposal to NIH to study "poverty diseases," they wouldn't know what to do with it. The same would be true for inappropriate sexual behavior or nutritional diseases. There's no place to study fundamental forces. That, to me, is one major limitation in our field. The other problem is that, from an intervention perspective, we need to go beyond giving people injections and asking them to exercise. We need to involve schools, we need to involve parks, and we need to involve transportation and community structures; we don't reach out to these agencies and groups that provide a richer perspective on the forces that make a difference. So we tend to be narrow in our field, because that's where we get our training money. The exception is the Robert Wood Johnson Foundation, which now has a program in Health and Society that actually is arguing that we can train a group of postdoctoral fellows to transcend disciplinary boundaries. It's hard to find universities that have faculty who can support that, and hard to find students and fellows who are willing to abandon their disciplinary background. It is just beginning and it's very small, but this looks like a way forward. ABOUT THE AUTHOR W. THOMAS BOYCE is a lapsed pediatrician with social epidemiologic leanings who had the great good fortune of encountering, early in his own professional life, both Leonard Syme and John Cassel. Boyce's work has shown that children's biologic responses to adversity or challenge are not uniform in character and that a subset of children inherits or acquires a neurobiological sensitivity to social contexts. His studies have found that biologically reactive subgroups of children, under conditions of social or psychologic adversity, are at heightened risk of both biomedical and psychiatric disorders.