Empowerment in future worklife.

Is power related to health? A large number of epidemiologie studies has demonstrated that health may indeed be strongly related to power differentials those in the upper class have the best health profile, while those in the working class and those who are marginally employed have the worst health. Marmot and others (1 4) have reported a marked health gradient across the class structure in Great Britain, which, they report, is not due to traditional biomedicai risk factors, access to medical care, or artifactual reasons. Indeed, although mortality rates for chronic diseases, such as cardiovascular disease, appear to be falling throughout Western Europe and North America, we find that the discrepancy between those in the managerial and professional classes and those employed in working-class and service occupations actually seems to be increasing. As housing, nutrition, education, access to medical care, basic sanitation, and the like improves for society as a whole, the importance of the class-based social environments within a given society may prove to be a critically important set of interlocking risk factors ones that we have tended to ignore until fairly recently in public health (5). Evidence is increasing that the differences in health status across social class groups may be explained with reference to the relative inequality in access to social resources, such as power and control over critical aspects of daily life (6 8). It is in this context that understanding the role of the workplace becomes essential. Epidemiologie and psychobiological research on the work environment has shown that low levels of empowerment in daily worklife, measured in relation to few possibilities to control work content and process, is strongly related to neurohormonal arousal, drug and alcohol use, mental distress, excess chronic disease, and even risk of early death (9 15). Efforts to increase levels of power and control at the rank-and-file level of modern industrial organizations have resulted in improved health behavior, greater activation, participation in occupational health and safety activities, and reduced levels of self-reported stress. The strong and consistent findings across societies, using different designs and focusing on various outcomes, provides powerful evidence that powerlessness may indeed be causally related to chronic illness (16 19). The concept of control both individual and collective control is essential in order to understand the structural and historical determinants of empowerment at the workplace. It links historical, sociological, psychobiological, and epidemiologie research into a common research program. Increasing control and power for rankand-file workers has also been an important goal of the labor and occupational health movements that have focused on the adverse psychological, physical, and spiritual effects of the degrading and alienated work processes that emerged with the rise of industrialization and became consolidated under the rubric of "scientific management". The Swedish-Hopkins Collaborative Group (20-23) has examined empowerment at work along the following two dimensions of control: possibilities for control over the work process and possibilities for collective social or group action. In a recent study performed in Sweden, we were able to measure the combined exposure to both low levels of work control and low levels of work-related social support over the course of 25 years of occupational history (24). The workers that were exposed to both low levels of control and low levels of social support had a 170% excess risk of dying of cardiovascular disease during the 14-year follow-up period even after adjustment for age, smoking, exercise, social class, physical