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03 August 2004

Exploring ideas
How social status affects our health

Nancy Adler is director of the 4-year-old Center for Health and Community at the University of California at San Francisco. The research center studies the relationship between ethnicity, behavior, economics and health. Adler, 58, a professor of medical psychology, discussed her work at UC San Francisco's Laurel Heights campus in a recent telephone interview with Insight. Following are excerpts:

Q: How does status in society affect health?

A: Status is made up of many things -- it's a matter of education, money, ethnicity and gender. What we're learning is that in each of those areas health is better the higher up you are.

Q: What kind of research are you doing?

A: The center has brought together faculty who are interested in different aspects of health disparities. Some are focused on race and ethnicity, particularly on issues of differential access and treatment in health care. Others are interested in more upstream causes and are looking at what it is in communities that makes a difference (in health).

Q: How do you go about studying this topic?

A: There is no typical approach. People bring their own perspective. You can look at almost any problem area within health care and see disparities.

I'll give you an example of a recent study we've launched in collaboration with Kaiser. People with diabetes -- all at Kaiser and all with equal access to care -- have very different rates of complication. One thing we're trying to understand is what is it about higher (levels of) education that leads you to have few complications. Are you able to take better care of yourself? Are you treated differently by the doctors you see? We're trying to understand the process so we can improve it.

We were also involved in a project in Oakland where we were trying to understand what is it about certain neighborhoods that leads to better health. We had focus groups and neighborhood residents tell us what was important to them in their neighborhoods.

Q: Doesn't much of being healthy come down to fairly simple things like eating oatmeal or other good foods for breakfast, walking every day -- things that may not cost that much money? What about those factors, which would seem to be available to almost everyone?

A: Let's take walking every day, because that's a great example. We know that the No. 2 threat to health right now is obesity. And health habits make a huge difference. Behavior accounts for about 40 percent of premature mortality.

Let's say you have two people who are equally motivated and you tell them both to get exercise. The person who is wealthier, who lives in a better neighborhood, probably has more time because he or she is not working two jobs. Also, if you're living in a poorer neighborhood and it's dark, you probably can't go out and walk because it may be dangerous. And there are fewer gyms in poor neighborhoods. So it's not just a matter of individual will.

Q: How many people work at the center?

A: We're actually a virtual center. We're like a filter that we put over the university to say: "In this wonderful place, how many people are working in these areas?" We have about 275 faculty members who are part of this virtual center, with about 100 of them located at Laurel Heights, where we've tried to create some critical mass.

Q: To what degree is stress a factor in overall health? Stress is high at the lower rung of the socioeconomic ladder, but also high at the very top, for example, among corporate CEOs. Are there different kinds of stress?

A: The issue for stress is not how many demands you have, but your sense that they are manageable. So a demand that comes in that you feel you have the resources to deal with -- that you have some control over it -- actually can be invigorating. It's the difference between a challenge and a threat.

What we find is that control goes up at each step up the social ladder and that usually works to diminish stress.

Q: In a practical sense, how is your research at the center used and what impact has it had in the community?

A: There are two levels at which the research will be useful. And it really is probably more in the future, because we're still trying to build the science base for future policies and intervention.

First, it has implications for policy. One example is the San Francisco Department of Public Health. They did an analysis a while back about the living wage. When you're considering something like the living wage, the considerations are mostly about economics -- what it will cost small businesses, etc.

But if you factor in potential health savings, that may change the balance a bit. So the kind of work that people are doing here can feed into that kind of policy analysis.

Another area we're working with is obesity. That's something's that typically hits lower SES (socioeconomic status) folks. We're starting an obesity group and will be working with the San Francisco schools. We're trying to get better nutrition in the schools, hoping to encourage policies that will get the vending machines out.

Q: In terms of diet, especially for school children, how do you counter all the mass marketing out there?

A: We don't have a level playing field. If you look at what's being advertised on TV, there aren't too many compelling advertisements for oatmeal, broccoli and other healthful items. Probably one approach is to invest more dollars in mass marketing for healthy behavior.

Q: What's the biggest health problem in America today?

A: Cardiovascular disease is the top killer. That's attributed to diet, sedentary behavior and smoking.

Q: How did you get involved in this research?

A: I've always been interested in the question: "Why do people not do what's good for them?" I've spent much of my career looking at risk behavior, particularly teen risk behavior.

About 10 years ago I was in a network looking at health behaviors, and we held a conference to predict who would stay well and who would fall ill. Leonard Syme from the (UC Berkeley) School of Public Health came in and said: "If you could only ask one question of a person, and you wanted to be able to predict what their state of health would be, it would be their social class."

He showed us data from a study. What was so dramatic about the data was that it wasn't just the top administrators who had a longer lifespan and better overall health than those at the bottom, but it was each step up the (social) hierarchy.

I had the notion like everybody else -- that when you're talking about socioeconomic status and health it's poverty vs. everybody else. So this particular finding was very mysterious.

Q: A couple of years ago Don Redelmeier, a professor at the University of Toronto, analyzed the life span of actors who had won an Academy Award. His study found that, on average, winning an Oscar added four years to an actor's life. What do you think that tells us about status and health?

A: There is some benefit to being at the top of the ladder. We know from animal research that dominant animals do better.

I think it was an incredibly creative way of testing this out. It's another bit of evidence that higher status, in and of itself, may make a difference for your health.

Nancy Adler: a snapshot

Age: 58

Background: Born in New York City, raised in Denver.

Education: Bachelor's degree from Wellesley College; master's degree and Ph.D. from Harvard University.

Family: husband, Arnold Milstein, who is U.S. health care thought leader for William M. Mercer and medical director of San Francisco's Pacific Business Group on Health, a coalition of health care purchasers. They have two daughters: Julia, 25 and Sarah, 20.

Best time for strategic thinking? "When I'm hiking. When I'm not in the midst of the day-to-day stuff."

Favorite vacation? "We went to Merida in Mexico last December. We stayed in a 17th century hacienda and explored the ruins."

What's on your bookshelf now? "Michael Marmot's 'Status Syndrome.' I just finished 'Middlesex.' It was very good. And 'The Perfect Sister.' "

Source: San Francisco Chronicle




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