Freedom and responsibility, how much of each and how they are balanced, have
profound implications for our personal lives and for our work. The health of a population
and its achievement in the workplace are enhanced when individuals have some freedom and
some responsibility, but not too much of either, and when civil associations of individuals
rather than individuals acting alone are the essential social units. The consistent
association of social contacts with health and productivity provides strong support for the
premise that intimate relationships are the focus around which people's lives revolve.
Membership of a "social network" may be merely conforming to a reigning social norm, and
this could mean having to pay an important price in the loss of creativity associated with
individualism. But social conformity should not prevent individuals from going their own
way, and it should be possible to combine the luxury of individuality with an active life in
civic affairs. Less than complete freedom may fall short of existential utopia, but it may
be best for our health and wellbeing.
The human yearning for freedom, countered by the urge to escape from it and from
responsibility, has commanded the attention of both metaphysical and political philosophers
over the centuries. Some individuals seem to need the total, or near total, freedom exalted
by Ralph Waldo Emerson and practised by Henry David Thoreau. At the other extreme there are
many who voluntarily relinquish their freedom, as described in Erich Fromm's Escape
from Freedom and exemplified by the mass movement of groups, and even whole populations,
to fundamentalism. Though the philosophical and religious debates continue, new evidence
from studies of the length and quality of life indicate that humans, on average, fare better
when they have some freedom and some responsibility, but not too much of either- that is,
when they live and work in an environment of "bounded freedom" and "bounded
responsibility."
Autonomy at work
Freedom and responsibility go hand in hand, and
how they are balanced has profound implications for our personal lives and our work. In the
workplace a low level of worker responsibility and freedom is widely recognised to result in
poor quality of work. The high levels of industrial productivity in Japan have been
attributed to greater worker participation in shaping their own work, group loyalty, and
social equality.(1)(2) Japanese workers' freedom and responsibilities are
sharply constrained, however,(3) and it seems to be the sense of shared community
goals and social coherence that are the key to motivation and industrial productivity.
American economist Robert Putnam also suggested that strong community and "networks of
civic engagement" were responsible for the high level of industrial productivity in
Northern Italy.(4)
The conditions under which people work also greatly affect
their health (above and beyond the hazards of occupations such as exposure to toxic
substances and physical injury). British civil servants in top managerial positions enjoy
greater health and longevity than middle management, and those in middle management are
healthier than those at lower levels.(5) This association of health with position in
an occupational hierarchy has been explained in part by the degree of control individuals
have over their work, and in part by early life, current health behaviours, and psychosocial
circumstances.(6)
Social support
To exercise control a person must have the
freedom to act; the two go hand in hand, and more of each can therefore be equated with
better health. However, there seems to be an upper limit to their beneficial effects. The
health of the Japanese again provides an example. Japanese living in Japan are relatively
free from heart disease and as a result have a long life expectancy. Most Japanese who live
in America rapidly assume the higher rate of heart disease of other Americans, but those who
maintain the tight family structure traditional in Japan retain their immunity to heart
disease.(7) The prevalence of coronary heart disease in families who have adopted an
American lifestyle was three to five times greater than that in those retaining a
traditional Japanese culture, a difference that could not be accounted for by diet, smoking,
or any of the other major coronary risk factors.
Similar observations have been reported
for Italians who emigrated from the Italian town of Roseto to the United States, settling in
Pennsylvania and founding a town by the same name.(8) Residents of the new Roseto
retained the relative freedom from coronary artery disease that their relatives in Italy
enjoyed as long as they kept their traditional family oriented social structure. But as
people became assimilated into the surrounding American culture, where the individual rather
than the family and community was considered to be the dominant unit, the incidence of
coronary heart disease rose rapidly. Again, the deterioration of cardiac health could not be
explained by the usual risk factors. Diet had improved and smoking had fallen greatly.
Although the Rosetans had become more sedentary, it was not enough to explain the large
increase in coronary heart disease. The authors concluded that "attention directed to
broader aspects of behaviour of individuals and groups, specifically those that lead to or
reflect social disintegration, has suggested a strong influence of individual social values
and collective morale on the heart and coronary vessels."(8)
The better health of
individuals with strong ties to family, friends, and community has been widely documented.
Adults who live together live longer than those who live alone; members of the church or
other social groups live longer than those who have fewer social contacts. The plausible
role of biological pathways leading from social disconnection to disease has been explored
in a nine year study of residents in Alameda County, California.(9) Smoking, alcohol
consumption, a sedentary lifestyle, and other adverse risk factors were strongly associated
with the ill health of individuals with fewer social contacts, but so, nearly equally, were
marital status, contact with friends and relatives, and organisational membership, the so
called social network within which individuals
function.
Fig 1 - Some people need almost total freedom. Thoreau
retreated to his cabin on Walden Pond, Concord, Massachusetts, in pursuit of the simple
life
Value of positive
relationships
We can only speculate how social networks benefit health. It may be that
social support provides a milieu in which the threat and impact of everyday stresses can be
successfully coped with and the neuroendocrine response to stresses moderated.(10) The
capacity to develop positive relationships arises from good internal object relations (the
internal representations of early relationships that influence the pattern of later
relationships, as developed by Freud, and later by Klein, Fairbairn, and Winnicott).
Continuing involvement in positive relationships is likely to reinforce emotional security
and enhance self esteem. Successful relationships may increase people's influence over the
immediate environment and thus their perception of control. They will also provide
individuals with a sense of meaning to the social environment and an awareness of their
position within it.
Thus it seems likely that health is enhanced by positive personal
attributes: control over personal and professional life, optimism, a sense of self worth,
the ability to cope, and Antonovsky's sense of coherence. On the other hand, it is not clear
to what extent poor or poorer health results from anxiety and depression, alienation,
hostility, a sense of helplessness, pessimism, or even anger.
Whatever the explanation,
the consistent association of social contacts with health provides strong support for the
premise that intimate relationships, derived from the experience of infants with their
parents, are the focus around which a person's life revolves. Early within this relationship
the mother takes responsibility for containing the child's feelings. As the child becomes
more self reliant and develops the capacity to contain his or her own feelings, freedom and
responsibility become circumscribed, providing a model for relationships beyond the family.
Fig 2 - Japanese business management school: bonding seems to
be the key to increasing productivity
The association of social integration with health is therefore consistent with the
importance of clear behavioural guidelines in childhood and with the growing awareness of
the relevance of cultural rules and social conventions that underlie acceptable human
behaviour at all ages. Similarly, the association of social contacts with health mirrors
current philosophical and political opinion, in which civil associations of individuals,
rather than individuals acting alone, are the essential units of a productive and successful
democratic society.(4)(11)
Price of individualism
Membership of a
"social network" may simply be conforming to a reigning social norm, and this may mean
paying an important price in the loss of the creativity associated with individualism and
solitude. The American transcendentalist Ralph Waldo Emerson, writing in the middle of the
19th century, urged self reliance and eschewed conformity (coining the familiar aphorism,
"a foolish consistency is the hobgoblin of little minds"). Nietzsche, exalting the
individual, considered that it is only with the greatest effort that man can raise himself
above the mediocrity of the herd and undertake "the great tasks 'to which higher men' may
apply themselves." David Riesman in his influential book 'The Lonely Crowd' deplored
the pressures for conformity in middle class America and the failure of individuals to
assert independence and autonomy.(12)
But membership in a wide social network need
not make us predominantly a society of conformers. Mass conformity does not prevent
individuals from going their own way, and there will continue to be the occasional Henry
David Thoreau, Ludwig Wittgenstein, and Emily Dickinson whose genius is expressed in
solitude. And is it not possible to combine the luxury of individuality, if not solitude,
with a life of active participation in civic affairs? The psychiatrist Anthony Storr, while
noting that "many highly creative people were predominantly solitary," argues that "all
human beings need interests as well as relationships."(13)
If individuals vary in
their needs- some needing more, and some less, freedom- so also does society as a whole. The
social pendulum and political climate will continue to swing back and forth between
libertarian and fundamentalist philosophies in response to changing public moods. The
philosophical and political compromise is nicely stated by Isaiah Berlin: "We must preserve
a minimum area of personal freedom.... We cannot remain absolutely free, and must give up
some of our liberty to preserve the rest."(14) Less than complete freedom may fall
short of existential utopia, yet it may be best for our health and wellbeing.
We
thank Drs Jane W Bunker and Robert M Bunker for their good advice, unwavering support, and
patience in reviewing earlier drafts.
Department of Epidemiology and Public Health,
University College London Medical
School,
London WC1E 6BT
John P Bunker,
visiting professor
Stephen
Stansfeld,
senior lecturer
Tavistock Clinic,
Tavistock Centre,
London NW3
5BA
Jenny Potter,
senior registrar
Correspondence to: Professor J P
Bunker
Cancer Research Campaign Clinical Trials Centre,
Rayne Institute,
London SE5 9NU.
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support in the etiology of physical disease. Health Psychology 1988;7:269-97.
11 Oakeshott M. Hobbes on civil association . Berkeley, CA: University of
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Commentary: Understanding it all - health, meta-theories, and mortality trends
George Davey Smith, Matthias Egger
Investigations into the determinants of health within and between countries
contribute to a generally slow, but incremental process. Leaping forward to the big picture
of how it all fits together represents an attractive alternative to merely continuing with
this laborious spadework. Bunker and colleagues advance the idea of bounded freedom as being
the key to health and wellbeing, a viewpoint which shares some characteristics with others
who consider embeddeness within strong social networks as being the important determinant of
population health.(1) The positive benefits of strong social ties seem self evident,
but "the plausible role of biological pathways leading from social disconnection to
disease" that Bunker and colleagues evoke has not been satisfactorily elucidated. Indeed,
degree of social support may be influenced by health rather than the reverse. The supposedly
protective influence of social support has been shown among the majority populations of the
United States, United Kingdom, and Scandinavia, but in groups that have different
connotations for such networks social ties can appear detrimental, rather than beneficial,
to health.(2)
One theory of population health that has received considerable
attention is the income inequality perspective of Richard Wilkinson, recently elegantly
summarised in his book 'Unhealthy Societies'.(3) This view, which incorporates
explanations relating to social networks, considers that the psychological consequences of
living in an unequal society are the primary determinants of overall state of health.
Several alternative models of the important determinants of population health to these
essentially psychosocial accounts exist. The high profile of the human genome project has
certainly led to the revival of primarily genetic accounts of the distribution of sickness.
Conversely, the importance of lifestyle factors and their concomitants - for example,
smoking, alcohol consumption, cholesterol concentrations, and blood pressure - may have been
underestimated because only one measurement is used in epidemiological studies. Thus some
contend that if proper account is taken of their importance there might be little left to
explain,(4)(5) within developed countries at least. An almost diametrically
opposed view took its lead from the failure of such lifestyle factors to account for the
geographical and social distribution of many diseases.(6)(7) The hypothesis
that influences from early life, particularly intrauterine and infant growth, influence long
term health was advanced and has now been tested in an impressive array of ecological and
prospective studies.(8) The arrival of a new paradigm of the determinants of adult
health was announced.(9)
These, then, are some of the meta-theories of population
health: social cohesion and the psychological consequences of inequality; genes; lifestyle
factors; and long term effects of suboptimal early development. It would be worth
considering how they fare in accounting for the important population differences in health:
the large time trends in life expectancy and the unequal distribution of mortality risk
between and within countries. Let us briefly consider one issue that has generated a great
deal of interest- the relative (and in some cases absolute) deterioration in state of health
in eastern Europe.(10-12)
Fig 1 - Life expectancy and income inequality in post-transition eastern Europe
The data seem to provide strong support for the income
inequality hypothesis since life expectancy and income inequality (measured by the Gini
coefficient) are inversely correlated(13) (fig 1). Changes in income inequality and
changes in life expectancy between 1987 and 1993 also show a sizeable correlation ( r
= 0.62). These countries have undergone a transformation from Stalinist
pseudosocialism to the vagaries of the free market, and even the chief cheerleader for
unfettered free market capitalism, the World Bank, was forced to ask: "Is transition a
killer?"(13) The growth of capitalism in Britain after the industrial revolution was
associated with unfavourable mortality trends(14) and a growth in inequalities in
health,(15) and the same now seems to be happening as capitalism penetrates the final
frontier.
With the exception of genetic accounts, the various
explanatory categories have been proposed as major contributors to the unfavourable
mortality trends in eastern Europe. Thus in discussing the potential contribution of
psychosocial stress Bobak and Marmot suggest that 30% of the excess mortality can be
accounted for by a sense of pessimism.(11) The unfavourable mortality trends in Russia
have been attributed to alcohol misuse, with the improvements in mortality during
Gorbachev's antialcohol campaign being cited in support of this.(13) Smoking and
nutritional factors have also been considered important.(12) Much of Eastern Europe
suffered greatly during the second world war, and unfavourable mortality trends have been
attributed to the long term effects of people living through these times.(16) Indeed,
mortality rates of men and women who were born or were children in the most affected parts
of the former Soviet Union during the war show just such an effect,(17) although the
overall contribution to changing life expectancy seems to be comparatively small.
Taken
together, the mechanisms that have been advanced could account for greater mortality changes
than have actually happened. This is probably because we are in some cases double
counting- for example, the psychosocial effects of social disintegration will be expressed
in increased alcohol and tobacco consumption and decreased self care. Direct psychological
mechanisms, are, indeed, unlikely causes of mortality trends: the reduction in mortality in
Britain since the late 19th century has hardly been accompanied be improved social support
and social networks. Happiness, life satisfaction, and job satisfaction in Britain have
changed little over the past 30 years, while death rates have continued to
plummet.(18)(19) The causes of death responsible for rising mortality in
eastern Europe - coronary heart disease, lung cancer, and accidents(14) - are those
that increased during a period of generally declining mortality in western Europe and the
United States. As these diseases can increase while overall mortality is falling and
economic progress is being made their accompaniment by a general worsening of health or
increasing social disintegration is not inevitable. A mainly psychological attribution may
be as one sided as earlier attempts to consider these conditions, which affect poor people,
as diseases of affluence. At that time coronary heart disease was considered by many to be
caused by type A behaviour - the rushed, time pressured businessman was the paradigmatic
coronary case. This association, which soon stopped being apparent, was generated by
socially conditioned perceptions of associations, which were then reified into
pathophysiological mechanisms. As many plausible biological pathways between type A
behaviour and coronary heart disease were produced as is now the case for the currently
fashionable psychosocial factors.
The problems psychosocial explanations have with
accounting for trends and geographical differences in mortality are also seen with respect
to the other categories of explanation. Consider (among many others) these paradoxes: low
overall and cardiovascular disease mortality in Japan, a country with high smoking rates;
the decreasing overall death rates during increases in smoking and dietary fat intake that
occurred in many countries; and the low international correlations between past infant
mortality rates or current birth weight and mortality from coronary heart disease. For
different causes of death, and in different temporal and geographical situations, the
determinants of mortality patterns will be distinct. Extrapolating from the past to the
present and from one place to another is necessary for broad theorising on the underlying
determinants of mortality trends but, in the end, this can only be the start of the more
difficult empirical task of understanding the particular factors which act together to
produce the patterns seen in any one specific instance.(20)
Department of Social Medicine,
University of Bristol,
Bristol BS8 2PR
George Davey Smith,
professor of
clinical epidemiology
Department of Social and Preventive Medicine,
University
of Berne,
Berne,
Switzerland
Matthias Egger,
senior research fellow
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19
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Occupational Psychology 1996;69:57-81.
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