No. 2, April 2004
LETTER TO THE EDITOR
Response to S. Leonard Syme’s
Suggested citation for this article: Robinson
R. Response to S. Leonard Syme's essay [letter to the editor]. Prev Chronic
Dis [serial online] 2004 Apr [date cited]. Available from: URL: http://www.cdc.gov/pcd/issues/2004/
To the Editor:
The recent essay by Dr Leonard Syme contributes constructively to the
dialogue on disparities (1). It validates the idea that the traditional focus on
the individual and risk factors is limited and underscores the importance of
environment and community. The complexity of community, however, is
not apparent in the essay, and this oversight adds to
deficiencies in interventions. Public health needs a different paradigm for
assessment and intervention development.
One barrier mentioned by Dr Syme is arrogance, and to that I would add elitism;
both prevent experts from relating and adopting paradigms that use
community as the unit of analysis. Both challenge diversity and inclusivity,
which are necessary for community partnerships.
Also troublesome is a limited definition of competency. Dr Syme illustrates
the ineffectiveness of interventions in several studies. Others have outlined limitations
in addressing community: McKenzie (2) (on the impact of racism
and community), Vena and Weiner (3) (on the social determinants of health and
community), and Richards, Kennedy, and Krulewitch (4) (on evaluation models
that insufficiently encompass community complexity).
Dr Syme uses environment as a metaphor for community, but environmental
change is safe verbiage that disguises the limitations of theory and
practice. Environmental change factors are merely risk factors writ large.
They are reductionist, failing to build a
comprehensive understanding of community and reinforcing
traditional analyses, which assess outcomes in terms of etiology or
predictive factors. They do not assess relationship to community but impose it. Because risk factors relate to individual well-being,
we often incorrectly assume they relate to community outcomes.
Dr Syme also uses social status as a metaphor for community. The construct is
simple: draw a circle around an entity and name it community. Indeed, Dr
Syme defines as community any group that is targeted: citizens of Richmond,
Calif, fifth-graders, bus drivers. Each possesses an ethos and a
consciousness, but each also lacks the complexity of community. The most critical
mistake in targeting a social stratum is creating the illusion
that we are targeting a community. We design an intervention for welfare mothers,
for example, and write up our findings as a community intervention. But
targeting the poor is not the same thing as targeting the community. Change theory derives from the individual unit of analysis and from constructs
that do not reflect the complexity inherent in communities.
Another flaw in Dr Syme's essay is the exclusion of race/ethnicity.
This exclusion is compounded by insufficiency of community theory and practice and
emphasis on etiology and risk factors. Multivariate analysis suggests variables that are
important based on statistical significance. Education and income knock
race/ethnicity "out of the box." This exclusion is incorrect.
Etiology assumes a core role in developing interventions. This may make
sense when the unit of analysis is the individual, but it is unfounded when
the target is the community.
Communities defined by race/ethnicity magnify the error. Although
poverty is the predictive variable, poor people tend not to live in
integrated communities. The social reality of imposed segregation is
ignored. Indeed, observations of an area of homelessness in Los Angeles
showed that white, black, and Latinos each reside on separate street corners
We must develop interventions at 2 levels: by identifying causal factors
and deciding at what depth the intervention is to occur and by relating the causal factors
to the target population. What do causal factors mean to the population? What is the best
protocol for delivery? Superimposing the community over the multivariate
analysis is a paradigm shift from traditional biostatistical training, and
we need to explore it.
The challenge for the 21st century is to develop theory and practice that
resonate with community and its determinants: history, culture, context, and
geography. Community competence, a protocol for
intervention development, is one solution (6). It avoids the reductionism
inherent in cultural competency, and is enhanced by language, literacy,
positive imagery, salient imagery, multiple generations, and diversity.
Progress in public health science and practice throughout the 20th
century reflects our understanding of the individual. While progress in
environmental health has been obvious, progress within race/ethnic
communities is not so evident. Upgrading our sanitation and
related regulatory protocols benefited populations defined by geography and
work site. African Americans and Native Americans continue to demonstrate
disparities. Ethnic communities within Latino and Asian/Pacific Islander
aggregations demonstrate similar disparities. Why? Our science and practice
fails to assess community trends or develop tailored interventions. The 21st
century should be the "century of the community," and the emphasis
of efforts to improve theory and practice ought to reflect this paradigm.
Robert G. Robinson, DrPH
Senior Science Fellow
Associate Director for Program Development
Office on Smoking and Health
Centers for Disease Control and Prevention
- Syme L. Social determinants of health: the community as an
empowered partner. Prev Chronic Dis [serial online] 2004 Jan [cited 10
Feb 2004]. Available from: URL: http://www.cdc.gov/pcd/issues/2004/jan/03_0001.htm.
- McKenzie K. Racism and health: antiracism is an important
health issue. BMJ 2003 Jan 11;326:65-6.
- Vena JE, Weiner, JM.
research in environmental epidemiology: the challenges and needs. Int J Occup Med
- Richards L, Kennedy PH, Krulewitch CJ, Wingrove B, Katz K, Wesley B,
et al. (2002). Achieving success in poor urban minority community-based research:
strategies for implementing community-based research within an urban
minority population. Health Promotion Practice 2002;3 (3):410-20.
- LeDuff C. Skid row still down on its luck.
International Herald Tribune 2003 Jul 15:5.
- Robinson RG. Community development model for public health
applications: overview of a model to eliminate population disparities.
Journal of Health Education Practice. Forthcoming.
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