Today, Roseto is an unremarkable small town in eastern Pennsylvania, but in the 1960s it had a reputation as being the healthiest place in America. People lived longer in Roseto. The little Italian- American settlement had a rate of heart disease half the national average. For men aged 55-64 the rate was near zero. Unlike, say, Seventh Day Adventists, the good health of Rosetans could not be attributed to lifestyle. Rosetans drank and smoked as freely as other Americans of that time. The men had dirty and dangerous jobs in the local slate mines. Was it their imported Mediterranean diet that was keeping Rosetans healthy? Hardly. The poor immigrants could not afford to import olive oil from their homeland. They fried their sausages and meatballs in lard. Was it something in the water? No, a study of the nearby town of Bangor served by the same water supply, doctors and hospitals showed that none of those factors could account for their good health.
What made the difference, studies suggested, was cohesive family and community relationships and mutual support. All the houses contained three generations of family. For most people life revolved round the community activities and the church. However, by the 60s Roseto was beginning to change. Increasing prosperity, new subdivisions with single-family homes and conspicuous consumption began to unravel the tight-knit community. In 1971 for the first time in Roseto a person less than 45 years old died of a heart attack. The Rosetan rate of heart disease soon rose to the national average and the longevity advantage disappeared.
The “Roseto Effect”, as it’s known, is now no more than a curious footnote in the annals of medicine. The success of modern antibiotics in controlling infectious diseases and the wonders of high-tech surgery in repairing and replacing body parts mean that health is almost always seen now from a biomechanical perspective, disease as a malfunctioning of the body machine caused by viruses, faulty genes or unhealthy lifestyle. But what if, as the Roseto Effect implies, there are powerful underlying social causes of disease that make our current preoccupation with diet and exercise if not futile, then the equivalent of wearing a seatbelt and driving blindfold?
Why do people get ill? As in any good mystery story, the clues are scattered far and wide, from the corridors of power in London, to the jungles of Kenya, to the grim housing blocks in post-communist Russia, to an allergy clinic in suburban Christchurch.
But first to Japan. Land of the 18-hour work day, broom-cupboard apartment living, pressure-cooker education system. Despite all the stresses of modern life in Japan, Japanese health is the envy of the world. Japan tops the table of country life expectancy. It has one of the lowest rates of death from coronary heart disease in the world. In the Pharmac Annual Review last year, Professor Rod Jackson of Auckland University wrote: “There’s no reason why New Zealanders shouldn’t have rates at least as low as the Japanese, which are only a quarter to one third of our current rates.” Jackson points out that New Zealand’s tobacco consumption has fallen dramatically over the past 30 years, and that our coronary heart disease death rates are down to a third of 1960s levels. He recommends that we should eat less animal fat, lower blood pressure through weight control, drink less, consume less salt and stop smoking.
However, the traditional Japanese diet has always been high in salt, and more than half of all Japanese men smoke compared to one in four New Zealanders. Studies also show that since World War II, the Japanese have increased their fat consumption from animals and dairy (there are 3600 McDonald’s branches in Japan), have packed on more weight and had rises in blood pressure and cholesterol. Over the same period, their low rate of deaths from heart attacks declined even further.
Could it be the protective effect of good genes? In the 1970s a Briton, Dr Michael Marmot (of whom more later), studied Japanese who emigrated to the US. He found that Japanese emigrants who assimilated quickly increased their risk of heart disease by a factor of four. But Marmot could find no correlation with classical risk factors such as diet. Japanese who retained their traditional culture had the same low rate of heart disease as observed in Japan, even though they had switched to a more Western diet. “Japanese culture is characterised by a high degree of social support. There is evidence that this may contribute to the low rate of heart disease in Japan and among Japanese-Americans who retain their traditional culture,” observed Marmot.
Then there is the conundrum of Indians who emigrate to the US. Despite the fact that many are non-smoking vegetarians, they have three to four times the rate of heart disease of ordinary Americans. This may also be related to a loss of social support. One study found the same high rate of heart disease even among Indian doctors in the US. “The CADI [Coronary Artery Disease among Asian Indians Research Foundation] study focused on physicians – cardiologists, internists, family practitioners – who were aware of the risks of heart disease and were on the whole doing the best they could to live a healthy lifestyle in terms of diet, exercise, weight management and so on,” noted the study’s author, cardiologist Dr Enas A Enas.
Perhaps the strongest evidence that psychosocial effects have a greater impact on health than lifestyle comes from a longitudinal study of British civil servants. In 1967, a study of 18,000 men in Whitehall, the engine room of British government administration, showed that men in the lowest grades were much more likely to die prematurely than those in the highest grades. The Whitehall study was extended in 1985 to cover both men and women aged 35 to 55 and all grades from messenger to mandarin in 20 government departments in Central London. Whitehall II has been tracking the health of civil servants for over 20 years. This study not only confirmed the initial findings of a social gradient for mortality, it also showed a social gradient for a range of different illness: heart disease, some cancers, chronic lung disease, gastrointestinal disease, depression, suicide, back pain and general feelings of ill-health.
Professor Sir Michael Marmot, as he is now, led the research and analysed the findings in his book Status Syndrome: How Your Social Standing Directly Affects Your Health and Life Expectancy. The findings do not relate only to class-ridden Britain. “We see similar findings in the US, in Canada, in Australia, New Zealand and most European countries that have looked for it,” says Marmot.
Although people at the top had generally healthier lifestyles than those at the bottom, that did not account for the huge difference in health and life expectancy. Factors such as smoking, blood pressure, cholesterol, being overweight and lack of exercise were taken into account in the study, but Marmot estimated that such lifestyle differences explained only between a quarter and a third of the health gradient. “It is not that genes, medical care or lifestyle are unimportant, but they miss out on the major influences on health of the way we live our lives. The circumstances in which people live and work are intimately related to the risk of illness and length of life,” he writes.
Support for Marmot’s hypothesis came from an unlikely quarter, the jungles of Kenya. Since the late 1970s American biologist Robert Sapolsky has spent his summers getting up close and personal with a troop of baboons in Masai Mara Reserve. Baboons, our primate cousins tipped to take over if our species is ever wiped out, live in a competitive social hierarchy similar to humans. They don’t eat junk food or become couch potatoes, but some – the lower-ranking males – develop atherosclerosis, the narrowing of the arteries often associated with unhealthy lifestyle and high cholesterol. The cause, Sapolsky surmised, was the stress of being at the bottom of the pecking order. He was able to confirm this by anaesthetising the baboons with darts to take blood samples. The lower the rank of baboon the higher the level of cortisol, the stress hormone, early in the morning. The higher the morning cortisol, the lower the HDL cholesterol. Lower levels of HDL “good” cholesterol are associated with an increased risk of heart disease.
“All things considered, we thought better of trying to adopt Sapolsky’s darting method for our civil servants,” says Marmot. However, tests showed that the lower the employment grade, the higher the HDL cholesterol. Over-secretion of cortisol also causes weight gain around the middle, which is linked to heart disease and diabetes. The study showed that the lower the grade, the higher the waist-hip ratio.
Status, in itself, cannot confer health benefits or cause deficits, of course. It had to be a marker for something else. Analysing the copious data from 20 years of research, two factors stood out for Marmot. It seemed that how much control you have over your life and how much opportunity you have to participate in society were powerful determinants of health, quality and length of life.
But couldn’t it simply mean that people with better genes do better in life? What sort of experiment would confirm the validity of the hypothesis? Marmot found the answer in the fall of communism in the late 1980s. In the first years of the upheaval, health in Russia and Eastern Europe went into a tailspin. Coronary heart disease among men rose by 30 percent; life expectancy dropped by seven years. Marmot says, “Whole nations don’t get changes like that because of changes in genetic predisposition.” It was lack of control and social meltdown on a grand scale and the health effects were reflected in the statistics.
Not everyone was affected to the same degree. Women suffered fewer ill effects because, Marmot says, they had supporting social networks. The men most affected by the increases in disease and premature death were single, widowed or divorced. There is good evidence why long-term relationships, social connectedness and a sense of perspective can act as buffers, ameliorating some of the psychosocial effects that cause ill health.
In Christchurch, Dr Brian Broom is concerned at a very personal level with the question of why people get ill. Broom trained as a doctor, then gave up a career in the Christchurch School of Medicine to retrain in psychiatry. He had become frustrated at the way clinical medicine compartmentalised mind and body. The author of the recent book Meaning-Full Disease, he sees psychosocial effects at work every day in his work as a doctor specialising in allergies and as a psychotherapist. Broom finds that many of his patients’ physical complaints are related to their “story” – the emotional upsets and traumas they’ve experienced. As a doctor and psycho-analyst he is able to take an integrated approach to his patients’ illnesses. “If you look at the biomedical factors and the emotional factors you get a much better [healing] response.”
As an example, Broom cites the condition of urticaria and angioedema (weals and swellings). “In the 19th century physicians used to call it ‘angioneurotic edema’, but in the 20th century the division between physical illness and mental illness became cemented and they removed ‘neurotic’. As a result angioedema has been very difficult to treat because allergists contend that urticaria is not a psychosomatic illness but a physical illness; but most [cases] don’t have a discernible allergy sitting behind them.”
Broom has a particular interest in symbolic illness, “that is, illness that appears to express in the body in a way that tells the same story as the person expressed in words”. He tells of a 60-year-old woman referred to him with a facial rash that had persisted for five years. In that time she’d undergone a battery of tests, including having her liver biopsied on suspicion of a carcinoid tumour. Broom could find no evidence of allergic factors. So he asked the “smorgasbord” question he often puts to patients: “What was the most interesting problematical, worrying, difficult, frustrating event that was happening in your life at that time?” After some thought she replied, “My husband’s depression.” Broom asked her how she coped and she said, “Oh, I keep a brave face on it.” When she repeated the expression a few minutes later, he drew her attention to a possible link between her facial rash and the phrase “brave face”. Later that week, Broom spent a hour with the patient exploring her bottled-up feelings about her husband’s depression. Within 10 days of her first visit, the rash was gone for good.
“While the mind-body approach is relevant to everyone,” says Broom, “it’s particularly relevant to chronic illness where biomedicine does not have quick answers or cheap answers, or the answers are a constant drain on the healthcare budget.”
Alternative healers sometimes have more success with chronic conditions than orthodox doctors. However, Broom says that some so-called natural therapies and diets “are about as mechanistic in their approach to people as giving a person a drug”. Medicine should be more “person-centred”, he believes. “If a person has a fractured leg, what they need is plaster. On the other hand, if a person has a traumatic background and a persistent rage expressed in a chronic debilitating ill-ness like arthritis, rash, recurrent migraine or back problem, what that person needs is not another technological response but a person to get alongside them and invite them into an acknowledgment and a resolution of that material.”
The term “psychosomatic illness” has come to have negative connotations – “there’s nothing wrong with you, it’s all in your head” – but Broom has found that patients respond well to the idea that their physical symptoms may be related to their emotional life. “It gives people permission to explore something that they seem to intuitively know. It’s the doctors who are most resistant [to mind-body healing], it’s not the patients.”
Broom cites the work of Israeli medical sociologist Aaron Antonovsky who, in the 1980s, developed the concept of salutogenesis, now widely used as a research tool in public health. Instead of seeing health and illness in opposition to each other, Antonovsky pictured health and illness as two poles on a continuum. Where you happen to be on that continuum depends on how well you are able to adapt to the stresses in your life and in the social environment. He argued that the key to adaptation was a strong sense of coherence, which he defined as a life that is comprehensible, manageable and meaningful. As an example, Broom points to New Zealand’s economic restructuring in the 1980s, with its record job losses. “A lot of those men who got sacked became unwell because the whole purpose and meaning of their lives was thrown in disarray by restructuring.”
To Broom, it seems obvious from his experience of treating patients that how we see our lives, consciously or unconsciously, can play a large role in the development of illness, either as a trigger or something that serves to prolong it. It’s now widely accepted, for example, that many conditions, such as arthritis or asthma, flare up under stress.
“All illnesses,” says Broom, “emerge in a multidimensional, multifactorial arena.” Worrying about our intake of antioxidants or the aerobic value of our walk to work may in the end not matter that much. “A good diet and plenty of exercise are important. I don’t have any doubt about that,” says Broom. “But it’s such a simplistic approach to health.”