Johns Hopkins Magazine
Johns Hopkins Magazine Current Issue Past Issues Search Get In Touch


Though Evagrius of Pontus included both in his eight offenses, sadness and sloth (in Latin, tristia and accidia) were eventually folded together. These days, you may find either listed as a sin, and both are more about spiritual torpor than true sorrow.

Beating Work-Time Blues
Ennui & Charles Carroll Jr.
Why So Many Don't Vote
When Dying Kids Live Well
A Sympathetic Ear
A Nation of Lazy Listeners
Hazards of a Broken Heart


Getting People Back to Work
For U.S. businesses to stay competitive with those in other industrialized nations, employers need to go after every ounce of productivity gain that they can. But it's hard to squeeze production out of a person who's laid up in bed, notes Edward Bernacki, director of the Johns Hopkins School of Medicine's
Occupational and Environmental Medicine Division. "Sloth is my area," he says. "How do you get people to work [who have been sick or injured] in a manner that won't compromise their health?"

Illustration by
Gilbert Ford
In the United States today, the major ailments that keep employees on the sick list, Bernacki says, fall into five categories: muscular skeletal disorders, arthritic conditions, depression, migraines, and cardiovascular disease. Decreasing the incidence and duration of these ailments, Bernacki says, can have a far greater impact on productivity than any motivational speech or office space makeover. In Bernacki's eyes, any effort to increase worker productivity should follow a three-word strategy: Keep people well.

"That is the goal of our division," Bernacki says. "As the workforce ages, we need to ask ourselves how we can intervene to reduce the risk of disability from disease. Thus, our research mission is to look at the application of medicine to reduce disability duration and actual medical care cost, etc., amongst working-age individuals."

To accomplish its goals, Occupational Medicine provides consulting services and occupational health programs to businesses. The division currently has contracts with such major employers as Pepsi Bottling Group and Hughes Electronics Corp., where it places Hopkins-trained nurse practitioners and physician assistants to help manage health care for employees. The major problem in U.S. health care today, Bernacki says, is that care is fragmented and people often don't have a primary physician to "quarterback" their care.

"Employees don't see a physician right away, or they might fail to keep a doctor's appointment and let something progress too far, which in turn can lead a person to be out of work for long periods," Bernacki says. "What we attempt to do is intervene early in the disease process and help knit together a person's care to get them back to work. This is exactly what we do for Pepsi and employees here at Johns Hopkins — we try to manage the individual's case so they don't become worse. Muscles, for example, get deconditioned very rapidly though inactivity. If you can slow down the downward trajectory by coordinating care, he or she can get back to work a lot earlier."

What someone might perceive as laziness, might in reality be an undiagnosed ailment that can be controlled. "Depression, for instance, can mask for laziness," Bernacki says. "That individual may not be lazy, but he or she has so many competing problems that they are unable to do their job properly. But once an individual is on the proper medication they are fine and able to work."

Johns Hopkins holds itself up as a role model in terms of occupational health, Bernacki says. Twelve years ago Hopkins had roughly 240 people out on any given day on worker's compensation, compared to the 40 to 45 absent on any given day now for a workforce twice as large. Hopkins has been successful in reducing lost hours by pooling its health-related resources, Bernacki says, whether that means offering flu shots, initiating programs in ergonomics-based injury prevention, or going latex-free as part of an effort to reduce contact dermatitis. The net result: more people able to come to work. —GR


On the Sin of Being a Layabout
Homewood House took five years and $40,000 (four times its planned expense) to complete. Today, It stands as one of the most elegant and widely copied Federal-period homes in the country. So it's hard to believe that the man who oversaw its design and construction, Charles Carroll Jr., was a bit of a layabout.

Photo courtesy of Homewood House Museum In 1808, after most of the ongoing improvements to Homewood were completed, Carroll complained of a debilitating ennui in a letter to his father-in-law, Benjamin Chew: "I should have done long since had I been regularly instituted a man of business, but unfortunately, from having little or nothing to do, I am like most men in my situation — unwilling to do anything or constantly putting off from hour to hour what might be as well done at first as last. This strange spirit of procrastination has gained ascendancy even over my best intentions" (quoted in Homewood House, by Catherine Rogers Arthur and Cindy Kelly).

Such sloth was not lost on Charles' father, Charles Carroll of Carrollton, one of the signers of the Declaration of Independence and the one who funded Homewood's construction. From a father-to-son letter, dated July 1, 1809: "This cool pleasant weather will contribute to remove yr indisposition, but you must lend your assistance by keeping your mind employed, by due exercise of body and mind, and by light regimen, and abstinence from wine and heating liquors, by going to bed at 9 o'clock and rising by 5 o'clock in the morning — I believe lounging in bed, after waking in the morning to be very injurious to health, particularly of persons inclinable to a corpulent habit."

Apparently his words fell on deaf ears: Charles, who began drinking when he got up in the morning, was known to consume up to two quarts of brandy a day, in addition to wine. (Maybe his father should have suggested he sleep later.) His increasingly erratic behavior made his wife miserable and eventually led to their separation. He died at the age of 50. —CP


Party Manners
In the 2004 U.S. presidential election, more than 122 million people cast ballots. That's a lot of citizens exercising their right to vote — but it only constituted 60 percent of those who were eligible to participate. The previous record voter turnout, 1968, involved only 61.9 percent of eligible voters, according to the Committee for the Study of the American Electorate.

Why do so many Americans choose the slothful path and opt not to vote?

"Contrary to democratic mythology, people don't vote entirely of their own volition. It's a party to which most people have to be invited, and if no one has invited them, many will probably stay home," says Johns Hopkins political science professor Benjamin Ginsberg, director of the Washington Center for the Study of American Government.

Ginsberg notes that the '04 election was one in which both conservatives and liberals made an uncommon effort to increase turnout — to issue more invitations, as it were. Among conservatives, it was a strategy designed to reelect George W. Bush. "The GOP worked hard to bolster turnout among religious conservatives," Ginsberg says, "and they were pretty successful in selected states. Ohio, for example. One of the things they did was launch ballot referenda on hot-button issues like gay marriage." On the liberal side, he says, efforts to increase voter participation were a side effect of the Bipartisan Campaign Reform Act of 2002. That legislation, which regulated the use of nonfederal funds by political parties, candidates, and officeholders, resulted in the formation of a host of nonprofit political organizations. These organizations — called 527 and 501(c)3 groups after sections of the tax code that pertain to them — poured money into voter registration drives designed to generate more votes for any Democratic candidate.

Education has much to do with whether someone will vote without being recruited, Ginsberg says. He notes that 90 percent of college graduates cast ballots and adds, "In a state of nature, people do not line up at a polling place. It takes years of what is politely called 'civic education' — I call it propaganda — before people come to believe that they have to vote no matter what. Individuals with high levels of education are like Pavlovian voters: Ring the bell at election time and we drool and line up at the polls. But those who have not been adequately exposed to this level of indoctrination in high school and college are not as likely to make the effort."

The U.S. government could take a few simple actions that would significantly increase election turnouts, he says. It could eliminate bothersome voter registration, as many European countries have done. Upon turning 18, any citizen would automatically be registered. Present identification at the polls and you could vote, simple as that. Another action would be to hold elections on weekends instead of weekdays. Says Ginsberg, "Elimination of registration plus weekend voting would probably bolster levels of turnout in the United States by 15 percentage points." —DK


Giving Voice to the Unspeakable
Coping with the death of a loved one is excruciating. When the loved one is a child, the sadness can seem unspeakable, concedes Cynda Rushton, Johns Hopkins associate professor of nursing. "Children aren't supposed to die."

That may be why, in the palliative care movement launched nationally in the mid-1990s, the focus was almost entirely on adults. "Children came very late" to the discussion — only within the last several years, Rushton says: "The death of a child was something people did not want to consider."

Rushton is part of an interdisciplinary team at the Hopkins Children's Center (including Barbara Hall and Nancy Hutton) that, since 2000, has been working to integrate pediatric palliative care into clinical practice. The goal: To help dying children with life-threatening conditions "live well," and to offer much-needed support to those closest to them — parents, siblings, and health care providers — when a child dies.

The team's work usually includes a patient care conference, initiated once it has become clear that a child is dying or when there are questions or conflicts about the goals of care. The meeting brings together everyone involved with a young patient's treatment: physicians, nurses, chaplains, respiratory therapists, nutritionists, pharmacists, occupational therapists, child life specialists, social workers. "To look around the room and see it standing room only . . . it's really [heartening]," says Elizabeth Reder, bereavement coordinator for the Harriet Lane Compassionate Care program.

Discussions run the gamut: Is the patient getting enough pain relief? Does he want to spend his last weeks at home — or would he feel more secure remaining in the hospital? How are mom and dad faring? Are the family's spiritual needs being met? How to resolve one specialty recommending one course of treatment — and another specialty a different course? "Everyone on the care team gets to hear everything, to feel empowered," Reder notes. "It's not after the child's death that people are saying, 'We should have done this or done that.'"

Rushton says that the focus on helping dying kids "live well" often comes down to a basic question: What would make today a really great day for this child? The kids' requests are usually simple. To spend time out in the sunshine, to feel less pain, to eat favorite foods, to play with pets, to make a video to leave behind for my family.

After a young patient dies, Reder offers bereavement debriefing sessions for Hopkins staffers who had cared for the child. Sometimes, if the child has spent months in the hospital, staff members are so affected by the loss that multiple sessions are necessary. Participants are often surprised to discover that others feel the pain as deeply as they do. "They realize. I'm not in this alone. They try to support each other, and ask: 'What works for you?'" she says. In 2003, Reder led 25 such bereavement sessions. In 2004, that number jumped to 39.

These sessions, coupled with other initiatives such as "palliative care rounds" and the Harriet Lane Compassionate Care Network (a 65-member network of staffers throughout the Children's Center who meet quarterly to discuss issues such as pain management and communication), have made a major impact on the medical community at Johns Hopkins, according to Rushton.

"In this environment that is so focused on technology and 'cure,' I think there's been a cultural shift," Rushton says. "There's a willingness now among doctors, nurses, and others to talk about their feelings and responses to caring for dying children and their families. It's been quite amazing to watch the transformation."

Reder follows up with families for two years, offering individual counseling sessions, as well as monthly bereavement groups for parents and siblings. "The courage these families show is amazing," she says. Many set out to keep their child's spirit alive by establishing a foundation or raising money to combat the illness that claimed their child. One family that recently spent months at Hopkins Hospital, far away from home, decided to make "comfort bags" (complete with tissues, stamps, granola bars, and a neck pillow) for other long distance parents.

Reder and Rushton both believe that a better integration of palliative care into a patient's "whole cycle of care" is immeasurably beneficial. "We want to provide care at the end of life with the same skill we provide it at other times," Rushton says. "This is not an 'extra.' It's foundational." —SD


A Sympathetic Ear
They come because of sadness and homesickness, stress and anxiety, fear and uncertainty. They come because they need to talk. And they need someone to listen.

For the last two decades, thousands of Johns Hopkins undergraduates have come to A Place to Talk, the peer counseling center located in the student dormitory, AMR1. There, five evenings a week, they find Hopkins students who have been trained to listen to their problems, without judging them or offering advice.

"We give people the ability to talk about issues that are close to their heart. They can get everything off their shoulders, guilt free," says Stephanie Shen, A&S '06, current director of APTT. "Sometimes you really can't do that with your friends because you're too afraid of being a burden or upsetting them."

The program, launched in 1984, was modeled after peer counseling programs at Harvard and Stanford universities. Students apply to be peer counselors; if accepted they undergo a semester-long training program to learn basic communication skills, including nonverbal communication.

Counselors are trained not to draw directly on their own experiences when talking with peers, but their histories still influence how they communicate, according to Clare King, a social worker at the Johns Hopkins Counseling Center who has overseen the program from its founding. "What we find is that they use their own experience in the service of helping others. If the peer counselor has been through a problem like depression, it empowers them to be more helpful and see in others the characteristics they have seen in themselves," says King.

Students with problems too serious to be handled through A Place to Talk are referred to the Counseling Center for professional help, King notes. —MB


Listen Up
So often music in public spaces is either used to drown out background noise or to lay down a motivational background. We therefore become lazy listeners. Many, many times I've gone into a restaurant and asked them to turn off or down the music because it's very distracting. I get quizzical looks from the staff because they don't hear it anymore. They've been playing the same loop over and over again and they've learned to tune it out.

"This is all part of a desensitization of people to the aural stimuli around them. From the point of view of serious musicians and listeners, this is a cultural disaster, because once people have heard the Pachelbel canon 400 times in the elevator, how do we expect them to listen to baroque music as serious art and derive some sort of higher meaning from it? They're already conditioned to ignore it.

"There is a whole challenge to music as a communal act. The latest technology is to walk around with a little iPod and two earphones plugged in and music playing as a kind of exclusive soundtrack of your life. What's the next step? That we have actual chips implanted in our cerebral cortex, where we just think about a tune and it will appear? That might be preferable. You'd at least have to think about the tune."

—Robert Sirota, outgoing director of the Peabody Conservatory, on how America has become a nation of slothful listeners.


Killer Sadness
It turns out you really can die of a broken heart.

Emotional shock caused by the death of a family member, a traumatic breakup, or another catastrophic event can trigger stress hormones that stun the heart and cause sudden, life-threatening heart spasms in otherwise healthy people, according to a Johns Hopkins study published last February in The New England Journal of Medicine. "A broken heart can kill you and this can be one way," lead researcher and Hopkins assistant professor Ilan S. Wittstein told The Washington Post.

Illustration by
Gilbert Ford
This is just one of the most recent examples of how sadness can take its toll on your heart's health, according to Roy C. Ziegelstein, executive vice chairman of the Department of Medicine at Johns Hopkins Bayview Medical Center and director of the Residency Program in Internal Medicine. "There are a variety of ways that sadness and heart health are connected," he says.

Heartfelt Connection: "It's possible that the two conditions, depression and heart disease, are linked in a way that people might be more prone to develop both," Ziegelstein says. The link could be biochemical. "One chemical in particular, serotonin, is implicated both in depression and in blood clot formation," he says. "Disturbances in the biochemistry of serotonin in the brain and in blood platelets, the cells that contribute to blood clot formation, have been described in people with depression."

The connection between heart disease and depression could also be genetic. A 1998 Johns Hopkins study led by Daniel E. Ford, an associate professor of medicine, found that men with clinical depression are more than twice as likely to develop coronary artery disease as their non-depressed counterparts. The study, published in the Archives of Internal Medicine, used data from the Johns Hopkins Precursors Study, a long-term investigation of 1,190 male medical students who were enrolled at Hopkins between 1948 and 1964.

Risky Business: People who are depressed or have problems with low mood or sadness often exhibit behaviors that may harm the heart, like smoking. "It's clear that people who are depressed have more 'unhealthy' behaviors as a rule," Ziegelstein says. "They tend to smoke more and engage less in 'heart healthy' behaviors like a healthy diet, regular exercise, and visiting the doctor." Such risky behavior could not only lead to heart disease, it could also negatively affect recovery from a heart attack or stroke. Some depressed heart attack survivors are so convinced they'll never be healthy again that their belief becomes a self-fulfilling prophecy, according to a 2001 Hopkins study of 160 men and women recovering from heart attacks. "Depressed patients think they're in poor physical health and that changing their behavior isn't going to make a difference," explains David E. Bush, senior author on the study and assistant professor of medicine.

Tipping the Balance: The way the body responds to sadness and emotional stress may affect bodily functions in people with heart problems and make them more likely to experience either a major heart disease, recurrent episodes of heart problems, or complications of heart disease.

"It turns out that stress in the body activates parts of the brain and adrenal gland to make hormones like adrenaline," Ziegelstein says. "These activate the sympathetic nervous system." In all of us, the heart is stimulated by both the sympathetic and parasympathetic nervous systems. "It's the balance between these two lines of communication to the heart that results in heart health," he says. "Disease can result when the sympathetic stimulation of the heart is in overdrive, as it appears to be under conditions of emotional stress or during episodes of sadness." This disturbed balance, with excessive sympathetic stimulation, can result in either the development of a weak heart, such as in the "broken heart" study cited above, or in greater susceptibility to potentially lethal heart rhythm disturbances. —MB

Return to The Seven Deadly Sins ... Lust | Gluttony | Envy | Pride | Sloth | Avarice | Anger
Return to September 2005 Table of Contents

  The Johns Hopkins Magazine | 901 S. Bond St. | Suite 540 | Baltimore, MD 21231
Phone 443-287-9900 | Fax 443-287-9898 | E-mail