Mitchell Memorial Lecture 2015

What causes wellness?

Nottingham 22nd April 2015

What people believe about Scotland’s health

The Scots are unhealthy It’s because they smoke a lot They eat the wrong kind of food They drink too much If only they adopted healthy habits,

they would be healthy Only ONE of these statements is true!

World Health Organization (1997 and 2003)

www.heartstats.org

Prevalence of smoking by country, in 15 year olds by sex, 2000/01, Europe

0

5

10

15

20

25

30

35

40

45

50

Ukraine

Lith

uania

Ger

man

y

Eston

ia

Slove

nia

Czech

Repu

blic

Latvi

a

Finlan

d

Hungar

y

Russia

n Fede

ratio

n

Austri

a

Franc

e

Polan

d

Switzer

land

Spain

Belgiu

m -

Flemish

spe

aking

Croat

ia

Nether

land

s

Belgiu

m -

Frenc

h sp

eakin

gIta

ly

United

Kin

gdom

- Eng

land

Irelan

d

Norway

Portu

gal

Denm

arkIs

rael

Malt

a

United

Kin

gdom

- Sco

tland

United

Kin

gdom

- W

ales

Mac

edonia,

FYR

Gre

ece

Sweden

% r

egu

lar

smo

kers

Boys

Girls

Smoking prevalence - Europe

Males

Coronary heart disease mortalityMen aged 15-74 years

100

200

300

400

500

600

1950 1960 1970 1980 1990

DenmarkFinlandNorwaySwedenScotland

Age

-sta

ndar

dise

d m

orta

lity

per

100

,000

The challenge of health inequalities

We oversimplify the problem through inadequate analysis

We apply inappropriate thinking to the search for solutions

As a result, we use ineffective procedures to try to change behaviour

Life expectancy trendsLife expectancy: Scotland & other Western European Countries, 1851-2005

Source: Human Mortality Database

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

1851

-185

3

1855

-185

7

1859

-186

1

1863

-186

5

1867

-186

9

1871

-187

3

1875

-187

7

1879

-188

1

1883

-188

5

1887

-188

9

1891

-189

3

1895

-189

7

1899

-190

1

1903

-190

5

1907

-190

9

1911

-191

3

1915

-191

7

1919

-192

1

1923

-192

5

1927

-192

9

1931

-193

3

1935

-193

7

1939

-194

1

1943

-194

5

1947

-194

9

1951

-195

3

1955

-195

7

1959

-196

1

1963

-196

5

1967

-196

9

1971

-197

3

1975

-197

7

1979

-198

1

1983

-198

5

1987

-198

9

1991

-199

3

1995

-199

7

1999

-200

1

2003

-200

5

Portugal

Scotland

The pathogenesis paradigm

“Health is a complete state of physical, mental and social wellbeing and not merely the absence of disease or infirmity”

WHO 1948

Medicine’s silver bullets

Diabetes and insulin 1922 Tuberculosis and streptomycin 1943 Polio and Salk vaccine 1955

All cause mortality,men 65-69

0

500

1000

1500

2000

2500

3000

3500

4000

4500

SIMD quintile

Mo

rtal

ity

per

100

,000

1665

3951

Slope index of inequality

0

500

1000

1500

2000

2500

3000

3500

4000

4500

SIMD quintile

Mo

rtal

ity

per

100

,000

2763

Mean =2694

X

XX

XX

All cause, M65-692763/2694 = 1.025

Male inequalities, all causes, all ages

0.0

0.5

1.0

1.5

2.0

0- 5- 10- 15- 20- 25- 30- 35- 40- 45- 50- 55- 60- 65- 70- 75- 80- 85+

Age

Slo

pe

ind

ex o

f in

equ

alit

y d

ivid

ed b

y m

ean

ra

te

Slope index of inequality breakdown by cause of death

0

500

1000

1500

2000

2500

3000

3500

4000

4500

S IMD quint ile

0

500

1000

1500

2000

2500

3000

3500

4000

4500

S IMD quintile

0

500

1000

1500

2000

2500

3000

3500

4000

4500

S IMD quint i le

SII=2763

SII=792

SII=1971

All cause IHD Other causes

Male inequalities, all ages, by cause

0.0

0.5

1.0

1.5

2.0

0- 5- 10- 15- 20- 25- 30- 35- 40- 45- 50- 55- 60- 65- 70- 75- 80- 85+

Age

Slo

pe

ind

ex o

f in

equ

alit

y d

ivid

ed b

y m

ean

ra

te

IHD

All other causes

Relative inequalities in mortality by causeMen, Scotland 2000-02

0.0

0.5

1.0

1.5

2.0

0- 5- 10- 15- 20- 25- 30- 35- 40- 45- 50- 55- 60- 65- 70- 75- 80- 85+

Age

Slo

pe

ind

ex

of

ine

qu

alit

y d

ivid

ed

by

me

an

ra

te

Chronic liverdisease

All neoplasms

Disorders due touse of drugs

All other causes

Suicide

Assault

Accidents

Disorders due touse of alcohol

Chronic lowerrespiratory diseases

Cerebrovascular disease

Ischaemic Heart Disease

Chronic liver disease, including cirrhosis

Source: Whyte B., Ajetunmobi T. Still “the sick man of Europe”? GCPH, 2012

So, what causes wellness?

Corey Keyes and Flourishing

• They are happy and satisfied; they tend to see their lives as having a purpose;

• They feel some degree of mastery and accept all parts of themselves;

• They have a sense of personal growth in the sense that they are always growing, evolving, and changing

• They have a sense of autonomy and an internal locus of control, they chose their fate in life instead of being victims of fate. 

“.....expresses the extent to which one has a feeling of confidence that the stimuli deriving from one's internal and external environments in the course of living are structured, predictable and explicable, that one has the internal resources to meet the demands posed by these stimuli and, finally, that these demands are seen as challenges, worthy of investment and engagement."

Antonovsky and sense of coherence....

00-046

-1.2

-1

-0.8

-0.6

-0.4

-0.2

0 10 20 30 40 50

Months of Orphanage Rearing

*linear trendline

Evening Cortisol Levels Increase withMonths of Orphanage Rearing *

The Founders’ Network

STRESS AND GRADE OF EMPLOYMENT: MEN

0

2

4

6

8

10

12

14

16

18

2008

-8.3

0

10-1

0.30

12-1

2.30

14-1

4.30

16-1

6.30

18-1

8.30

20-2

0.30

22-2

2.30

nmol

/l Higher GradeLower Grade

Salivary Cortisol

Time of DaySteptoe et al. 2003, Psychosomatic Medicine, 65, 461-470

Depcat % smokers Never-smokers Smokers

1 36.8 0.71 1.42

2 35.9 1.00 2.34

3 39.1 1.11 2.25

4 44.1 1.21 2.44

5 46.6 1.13 2.53

6 49.3 1.25 3.07

7 55.5 1.48 3.29

Environmental determinants of inflammatory status

CRP (median) mg/dl

affluent

deprived

0

1

2

3

4

5

0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5

Q1 : <0.66 mg/l

Q5: > 4.18 mg/l

Years in study

% diabetic

CRP and cumulative risk of type 2 diabetes

Freeman et al. Diabetes 2002,51;1596

Inflammation in plaques

Inflammatory cells

MMPs, IL-6, IL-15, IL-18, CRP

Lumen

Core

Cap

Thin Fibrous Cap

InflammatoryCells

SMC apoptosis

Degradedmatrix

Unstable

cytokines MMP

The molecular biology of a hug

Adverse childhood events study

Physical/sexual/emotional abuse Neglect (physical/emotional) Domestic substance abuse Domestic violence Parental mental illness Parental criminality

Adverse childhood events risk of alcoholism

Hillis et al 2011

Adverse childhood eventsrisk of perpetrating violenceBoys experiencing physical abuse

Duke et al 2010

heart dise

asecancer

depression

alcoholic

IV drugssuicid

e1

3

5

7

9

11

13

ACE and morbidity(adjusted odds ratio, 4+

ACE)

circu

latory

system

all ca

ncers

exter

nal cau

ses

suicid

e

alcohol

drugs

100

120

140

160

180

200

220

240

260

Glasgow excess mortality(cause-specific SMR,

compared to Liverpool & Manchester)

Creating wellness

Sense of coherence

Seeing the world as:StructuredPredictable

Feeling that it is:ManageableMeaningful

Wanting to engage

Resources which enhance resilience

Family Nurture

IntelligenceWork

Material resourceIdentity

Cultural stabilityStable set of answers

Optimism

Events

Stress

Tension

Resolution

Wellbeing

The cycle of alienation

WorklessnessPoverty

In education offending

healthChaotic early

years

Unequal outcomes Consequences

Alienation

Initial event

Mental health problems

Loss of self efficacy, esteem, control

The causes of wellness?

Optimistic outlook Sense of control and internal locus of

control Sense of purpose and meaning in life Confidence in ability to deal with problems Supportive network of people Nurturing family

What does this mean for policy?

Inequality in Scotland (and elsewhere?) is not primarily due to conventional risk factors

Early years experience is important in building resilience and wellbeing in later life

Conventional methods for preventing illness will not be effective in creating wellness

DESIGN DESIGN DESIGN DESIGN APPROVE

Conference Room

Real World

The Typical Approach…

IMPLEMENT

DESIGN

TEST & MODIFY

TEST & MODIFY

APPROVEIF

NECESSARY

Conference Room

Real WorldTEST & MODIFY

The Quality Improvement Approach

START TO IMPLEMENT

In the social era - connecting

Large scale change…..developing our thinking over time

Workstream 2

Societal Issues

85% of all children have all the

developmental skills and abilities

expected of a 27-30 month old by the

end of 2016

Child’s physical &

mental health and

emotional development

Carer’s physical &

mental health and skills

Aim Primary Drivers Secondary Drivers

46

Click icon to add picture

90% of children at Grassmarket nursery school will receive a bedtime story at least 3

times a week.

Children receiving a bedtime story

Median

Goal

0

10

20

30

40

50

60

70

80

90

100

M T W TH F M T W TH F M T W TH F M T W TH FDay of the week

Perc

en

tag

e

of

ch

ild

ren

Family garden party

A very hot weekend

Nina and her bed time bear

Big gains from many small changes

Jimmy Reid 1971

Trade Union leader

Elected by students as Rector of Glasgow University

Alienation in 1970s Scotland “Let me right at the outset define what I mean by

alienation. It is the cry of men who feel themselves the victims of blind economic forces beyond their control. It's the frustration of ordinary people excluded from the processes of decision making. The feeling of despair and hopelessness that pervades people who feel with justification that they have no real say in shaping or determining their own destinies....”

Fr Greg Boyle

“Here is what we seek: a compassion that can stand in awe at the burdens the poor have to carry rather than stand in judgment at how they carry them.” ― Gregory Boyle

Confucianism

“We indicate to rulers after Us that rather than punish the countries deviants, instead consider the poverty of the multitutdes and relieve their misery and then criminals will disappear. The reason why ordinary people act badly comes from widespread inability to survive day to day. There is no source of criminality in the country but waste of natural resources. There is a reason why ignorant underclasses are not honest: its because the rulers, who should be honest, are not

Emperor Saga 802-823 (after Mencius)

What do you mean, “it’s a bit muddy”?