Response to S. Leonard Syme’s Essay

S. Leonard Syme's essay [letter to the editor]. Preventing Chronic Disease [serial online] 2004 Apr [date cited]. 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 etiolo-gy 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 …