I.     Rudolph Virchow  (massive typhus outbreak in 1847 & doomed European revolution of 1848):  “Medicine is a social science, and politics nothing but medicine on a large scale.”  “Physicians are the natural attorneys of the poor.”

II.        Pecking orders among beasts with tails

A.       Pecking order among hens:  “Resources, no matter how plentiful, are rarely divvied up evenly.”

B.        Baboons: ranks can be changing, hereditary, situationally dependent, or coalitional.

1.        Confrontation can be anything from a menacing scowl to a bloody fight.

2.        Subordinates: full of physical and psychological stressors, lack of control or predictability, few outlets for frustration.

       C.    Physiology of subordination

1.        Glucocorticoids:  high basal levels, smaller and slower response to a real stressor, slow recovery.

2.        High BP, sluggish response to real stressor, sluggish recovery.

3.        Suppressed levels of good cholesterol.

4.        Testosterone more easily suppressed by stress.

5.        Fewer circulating white blood cells and of insulin-like growth factor-I (helps heal wounds, also promotes neuron growth in hippocampus and cortex). 

6.        Comparable situation across many species.

       D.    Not just that bad physiology à subordination: Rank drives the stress profile.

III.   Species in which subordinance does not à overactive stress response

A.       Marmosets:  cooperative breeders  (relaxed waiting strategy)

B.        Wild dogs and dwarf mongooses: dominance requires frequent overt aggression à high glucocorticoids

C.       Social factors

1.      monkey culture with high rates of reconciliation

2.      drought causes dominant animals to spend so much time looking for food that they don’t harrass the subordinates. 

3.      unstable dominance hierarchy à high glucocort. in dominant animals

4.      Personal experience:  how often attacked

5.      Personality

IV. Do humans have ranks?

       A.    Executive stress syndrome: people at top give ulcers, rather than get them.

               1.    Middle management gets the ulcers: responsibility without control

B     People belong to a lot of different ranks.

C.       Spin inside our heads:  runner 5 vs. runner 5000 in marathon:  the latter may feel more triumphant just because s/he finished.  (race against against themselves)

V.    Socioeconomic status, stress, and disease  (role of poverty)

       A.    Physical stressors:  physical labor, hunger, uncomfortable living conditions, little medicine

B.        Psychological stressors:  lack of control or predictability, series of temporary jobs, uninteresting work, lack of outlets and social support.

C.       The SES gradient: biggest factor in all of behavioral medicine.

1.        A few exceptions: melanoma, breast cancer, some autoimmune diseases

2.        Example: nuns

3.        Less access to health care, health-promoting factors (more likely to smoke drink in excess, not exercise, eat unhealthy diet, be mugged), or education (haven’t heard that cig.s are bad, don’t understand how body works).

D.    The case for stress as the cause of the gradient

1.        Socialized med. in Britain à gradient has gotten worse!

2.        Poor people had more cardiovasc. disease, despite making more use of medical resources.

3.        Access-proof diseases (ex. juvenile diabetes & rheumatoid arthritis): gradient still there

4.        Michael Marmot: mortality rates within british civil service system:  all have adequate pay and access to medical care.  Control for smoking and other health risks: still have 4-fold increase in mortality comparing highest vs lowest rungs.

5.        Greatest gradient occur for diseases most sensitive to stress: heart disease, hypertension, psychiatric disorders

6.        Antonovsky: sense of coherence à salutogenic effect

a.         being linked to mainstream of society

b.         society’s messages = information, not noise. (education)

c.         coping responses (fixed rules and flexible strategies)

d.         resources to carry out plans

e.         meaningful feedback from society (not seeing homeless people)

7.        “The human relationship is a sledgehammer that obliterates every societal difference.”  (We’re worse than monkeys at this.)

8.        Agriculture à stratification of society.  (stockpiling of resources)