An Hour That Changed My Life 

On January 26^th, S. Leonard Syme died. Len is considered the father of social epidemiology, the study of how social structures, institutions, and relationships influence health. Len’s work helped to define what we now call the social determinants of health. He was part of a small cadre of researchers who insisted that we cannot understand population-level patterns of disease by looking at the biology and behaviours of individuals. Few people can claim to have changed how society thinks; Len was one such person. 

I met Len for the first time on the 1^st of October 2015. I was on some bizarre, self-funded tour of California in search of what I now call community-oriented innovation. It was part of a project I called Wellthcare. Somehow I got to meet David Erickson, one of the editors of the superb book, Investing in What Works for America’s Communities. He invited me to his house for dinner and there I met his partner, Doug Jutte, the founder of the Build Healthy Places Network. That evening, as I marvelled at how knowledgeable they both were, they allowed me to share my half-baked ideas about health innovation. They said I needed to meet Len and made an introduction. 

Len’s office was in University Hall of the University of California, Berkeley. I’ve spent a lot of my career trying to find professors in university buildings. There’s rarely a receptionist, the signposting is atrocious, and everyone you encounter is working hard not to make eye contact knowing full well that you’re a visitor and lost. Somehow, I found Len’s office. 

The hour I spent with him changed my life. 

At the time, I was fascinated – perhaps even obsessed – with the observation that little of the innovation in health took into account the circumstances in which people live, especially those at the sharper end of society. Earlier that year, I’d held a meeting of community-oriented innovators that I’d called the Creating Health Collaborative. Collectively, the innovators had sensitised me to the idea that what really matters is whether people had control over their lives. This, it turned out, was an idea that Len had proposed in 1989, some 26 years earlier. 

I’ve never been able to get my hands on that 1989 book chapter. However, he wrote another one a year later and Len had the book in his office. What Len told me – and what the chapter said – was that the endless pursuit of risk factors to health never fully explained why some people are sicker than others. Something else was going on and there were numerous theories – constraints on the ability to cope, diminished authority over decisions, threats to status and self-esteem, fewer opportunities to learn new skills. For Len, what all of those theories were pointing to is whether people had control over their destinies.

Len wasn’t trying to throw a blanket over all of the theories. He understood that they differed slightly. Some saw control as a property of individuals (of being in control) whereas others said it was about situations (things are under control). Some said control came from life being predictable, whereas others said it was about life being coherent. Some said what mattered was the perception of control rather than actual control. The theories were numerous. What Len did was make the point that there was too much here to ignore. Research on control may, he said, be the best use of our effort to understand patterns of disease. 

My conversation with Len was more like an interrogation. I said something and he asked me multiple questions in response. He was leant forward in his chair, animated, with a quizzical look on his face that somehow blended genuine interest and healthy scepticism. I left the meeting filled with that rare combination of being full of doubt and burning with the desire to learn more. 

Fast forward ten years and multiple projects. I have not seen anything to suggest that control is not fundamental to health. Of course, in the 36 years since Len first wrote about control and health, we’ve understood what equity is, we’ve had global reports on the social determinants of health, and we’ve started to understand that the social is determined by the structural. As these ideas have emerged and consolidated, they’ve changed the context of our work but the fundamental importance of control has persisted. Indeed, there has been recent work to bring together all of the theories linking control and health. 

Last week, I found myself talking to a small group of health system leaders in Lancashire in the north of England. They’re under pressure to cut costs but improve health. It’s basically impossible, and everyone knows it. A more ‘efficient’ system is not the answer. It might be part of the answer but what’s the rest? For me, it’s innovation around control. As I told the leaders, there is no instruction manual for this. There is lots of evidence that points to its importance but turning that into a strategy will take brave leadership and creativity. One of the leaders has got in touch to say she wants to explore the possibilities. 

I firmly believe that Len’s work will continue to change how society thinks. And I think he knew it. As his daughter, Karen Englund said, he felt at peace with his life. So he should have. 

Thank you, Len. 

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Image caption: S. Leonard Syme (right) speaking at the Community Agency & Health symposium in 2017, with me (centre) and Carl Baty (left)