Am J Epidemiol 2002; 156:684-685.
Copyright © 2002 by the
Johns Hopkins Bloomberg School of Public Health
BOOK REVIEWS |
Stress and the Heart: Psychosocial Pathways to Coronary Heart Disease
Department of Epidemiology Johns Hopkins Bloomberg School of Public Health Baltimore, MD 21205
Edited by Stephen A. Stansfeld and Michael G. Marmot
ISBN 0-7279-1277-1, BMJ Books, London WC1H 9JR, United Kingdom (Telephone: 44-(0)20-7383-6600, Fax: 44-(0)20-7383-6662, E-mail: hrobertson@bmjbooks.com), 2002, 304 pp., $25.99 (paperback)
During the last five decades, the history of the study of stress and its effects on health has been the central narrative in the field of social epidemiology. This is not to imply that stress has been a stable object of study or a source of cozy consensus. Rather, stress has been an inherently problematic concept whose meaning has shifted and dodged with the changing fashions of the field. The modern age of stress research within epidemiology was launched by one paper by Cassel that appeared in this Journal more than 25 years ago (1). That paper called researchers to arms in the battle to understand stress and its effect on health. As if to anticipate the trouble that was to follow, that same paper was also booby-trapped by a stern warning about the dangers of what Cassel called the "simple-minded invocation of the word stress" (1, p. 108).
The release of the book Stress and the Heart: Psychosocial Pathways to Coronary Heart Disease is an important event for a field ready to declare its maturity to the rest of the scientific community. This volume usefully summarizes the findings and the thinking that have accumulated since Cassel’s paper was published (1). The book was compiled by the top figures in the field, and it is appealingly constructed to summarize a broad set of literatures for a broad scientific readership. Beyond its usefulness as a cogent synopsis of several decades of research, this volume raises questions about the place of stress in the field of social epidemiology. Has it become the inkblot onto which all of social epidemiology projects itself, or is stress the keystone concept that links the macro and micro, the social and the physiologic? Evidence for both views can be found in these pages.
As an organizing principle for a book, the concept of stress generates as much controversy as it does clarity. In his foreword to this book (p. ix), Syme refers to stress as a "forbidden word" and describes getting over the shock of seeing it used in the title after deciding that it was being usefully applied as a "sensitizing concept." The editors introduce the volume by telling us that "many of us working in the field do not find it necessary to use the word ‘stress’" (p. 2). We are later told that they gave "no specific instructions to the authors as to their use of the word ‘stress’." One immediately wonders how a concept that practitioners find so problematic can possibly be useful as the organizing principal for a book designed to summarize a large field for a wider scientific audience. The answer appears to be that the diaphanous features of the term serve the authors’ purposes to the extent that lack of specificity allows them to cover a tremendous range without getting bogged down in paradoxes and anomalies.
Among the important definitional questions that remain unanswered regarding stress is whether it is an objective property of external circumstances or the consequence of internal subjective processing of circumstances that become stressful because of the interpretations given them. For example, some of the chapters, including the excellent review of work "stress" and coronary heart disease by Marmot et al. (chapter 4), focus on external conditions—in this case "conditions at work" or, more specifically, the balance of job demands and rewards and the degree to which work is controllable. Other chapters, such as the one by Williams (chapter 6), focus on psychosocial risk factors such as anger and hostility. What is foreground information in one chapter is background in the other, however. Marmot et al. are interested in the way in which work is perceived, and Williams gives passing attention to the role of life circumstances. To the extent that these chapters hang together, one can imagine a group of scholars, blindfolded, describing eloquently their particular part of the elephant before them. Perhaps as Syme suggests in the foreword, the fact that no one is concerned that the "elephant" itself is never seen, defined, or discussed is not so bad. On the other hand, perhaps this book reveals that the study of the effect of the social environment and heart disease would be better off abandoning the elephant and talking instead about the things we have come to study directly.
These chapters can be read also as an attempt to bring together investigators who study macro-level social processes (most notably social inequality) with those who study more proximal or downstream factors such as smoking and blood pressure. The inability of these groups to talk to one another has been a chronic problem in the field. The editors deserve credit for trying to demonstrate how the marriage of upstream and downstream factors can increase the explanatory power considerably. This concept is illustrated nicely, for example, in the chapter by Jarvis on smoking and stress (chapter 9), in which social disadvantage is linked to stress and smoking patterns. However, this discussion makes me wonder about the place of the concept of stress. If looked at from a top-down, social determinism viewpoint, stress and its incumbent physiologic sequelae are ultimately epiphenomenal. The real action is to be found in the social origins of inequality, which drives the social patterning of stress. On balance, the authors of these chapters deal uneasily with this question.
In summary, this edited volume contains thoughtful chapters written by leading figures in the field of social epidemiology from both the United States and Europe. It will appeal to a broad range of readers interested in learning about what has been learned about the role of the social environment and coronary artery disease. These chapters demonstrate the real progress that has been made since Cassel’s paper was published (1). First, the intellectual barriers that have separated social/behavioral scientists and biologic scientists are breaking down as researchers focus more closely on how the social world gets under the skin. Second, some measure of convergence can be seen between researchers who study macro-social processes and more proximate or downstream risk factors such as smoking and blood pressure. These chapters reflect the emerging consensus regarding the need to construct elongated causal chains. Finally, these chapters reflect a growing emphasis on life-span developmental perspectives rather than the more synchronic approach that has generally characterized the field of stress research. I find it noteworthy that these were all directions foreshadowed by Cassel in these Journal pages more than 25 years ago.
REFERENCES
- Cassel J. The contribution of the social environment to host resistance: the Fourth Wade Hampton Frost Lecture. Am J Epidemiol 1976;104:107–23.
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