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Historical Keynote
Addresses
Syme Presents Keynote
Talk at ACE Meeting in San Francisco
Failures Call For a
Rethinking of Community Intervention Trials
The American College of
Epidemiology won kudos from attendees at its recent annual meeting in
San Francisco for choosing community intervention trials as the theme.
The topic interests many in epidemiology, and probably no one more so
than Berkeley’s Leonard Syme who gave the keynote
address entitled “Community Participation, Empowerment and Health.” As
an epidemiologist, Syme described his long standing interest in
“intervening” to make a difference in the health and well-being of
people, and not just in collecting data.
In pursuing his interest, Syme
has been directly involved or become familiar with several community
trials using educational interventions to modify high risk behavior
such as MRFIT (Multiple Risk Factor Intervention Trial), COMMIT
(Community Intervention Trials for Smoking Cessation) and other major
coronary heart disease (CHD) community intervention trials. His talk
gave a candid evaluation of the “largely disappointing” results of
these community intervention trials and the audience seemed to
resonate with his “from the trenches view” of the very challenging and
frustrating difficulties of successfully designing and implementing
community trials.
40 Year Journey
Syme structured his talk as the
story of his career–-a 40 year epidemiological journey replete with
examples of disappointing studies. He recounted his experiences with
the MRFIT trial which, according to Syme, “is a classic because it
represents probably the most intensive effort ever developed at that
time to educate highly motivated people to change behavior. After six
years, the men in the intervention group did not achieve a lower death
rate from coronary heart disease than men in the control group.”
Following this experience, Syme
conducted a community smoking intervention program in Richmond,
California. After five years of work, according to his report, the
smoking cessation results in Richmond were no better than in two
companion cities. Equally disappointing results were achieved when
this study design was rolled out nationwide in the massive and
expensive COMMIT trial of 10,000 heavy smokers in 11 intervention
cities. At the end of this trial, according to Syme, there was no
difference in quit rates despite the study being expertly carried out
by some of the best smoking cessation people in the United States.
Syme finds equally disappointing
the preliminary results from major coronary heart disease trials
(Stanford Five-City Coronary Heart Disease Project, The Minnesota
Heart Program, and the Pawtucket Community Heart Disease Project)
which have for the most part failed to significantly modify risk
factors for CHD.
One encouraging set of findings
described by Syme are those from the North Karelia Finland trial where
a 60% decline in heart disease was achieved in a community over a 27
year period. A notable feature of the trial is that the interventions
were established by the citizens of North Karelia and not by the
experts. And from this experience and other successes, Syme has drawn
several lessons about community trials.
Lessons Learned
One lesson is that the success
is not due to focusing on the risk factors as much as it is on
empowering the community members to deal with their problems.
Furthermore, by empowering people, more than one risk factor can be
tackled, and Syme proposed social class as the single most important
risk factor worth addressing.
He reviewed the research
indicating the importance of social class and in particular the
evidence to suggest that disease risk occurs in a gradient from the
lowest to highest social classes. He explains the gradient phenomenon
by hypothesizing that lower class individuals may believe they have
less control over their own lives. This is an important concept
because, as Syme indicated, “although it may be difficult to intervene
on social class inequalities, there are more opportunities to
intervene on control.” He ended his presentation by describing a
recent project which intervenes on people’s sense of control. “The
Wellness Guide,” is a book designed to inform California residents,
particularly people in lower social class positions, about the
determinants of their health and to guide them to community resources.
Community members have been heavily involved in its preparation.
Success
According to Syme, “when the
evaluators had finished analyzing the data, we were summoned to San
Francisco to learn the results. Given my past record of failure, I
trudged across the bridge with heavy heart. I was astonished to find
that the project might actually have succeeded! So I knew the
researchers had made an error in their analyses. After months of
scrutiny, we could not find the error and I have now concluded that we
may actually have done something that worked!”
Syme continued, “While successes
like these are rare and it is tempting to be excited about these
results, it is important to realize that we have not yet been able to
show that these improvements in knowledge, confidence, problem-solving
skills, and behavioral changes do finally result in better health.
Nevertheless, the epidemiologic evidence suggests that when people
have greater control over their lives, when they are better able to
influence the events that impinge on them, their health is better.
More research, as they say, is needed on this issue, but I am betting
that this idea is on the right track.”
A key concept for Syme is that
experts must learn to “be creative and inventive enough to become
experts in the role of not being an expert.” He quoted John
McKnight who stated “the dilemma we face is lack of
familiarity with the real community...many health professionals begin
to discover that their powerful tools and techniques seem weaker, less
effective, and even inappropriate in the community.”
Syme summarized his observations
by stating, “...most educational interventions, either individual or
community based, have thus far not proven to be as effective as we
would like. Most people do not change high risk behaviors, and those
who do seem to, do so for reasons unrelated to our special efforts. It
is important to learn what we can from the successes that we have
seen. In my view, the common element in these successes is that people
have found ways to influence the events that impinge upon them and to
change behaviors that do not support a healthy lifestyle. To do this,
of course, they need information which they can shape to fit to their
life, and social circumstances. This is a major challenge to us in
epidemiology. We have not paid sufficient attention to this problem in
our training, research, or intervention programs. We need to do
better...By putting the challenge of “intervention” right up front as
a major issue, we have a wonderful and exciting opportunity to think
hard about it. Let us begin.”
Published October
1998
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