Colin Cox Public Health Consultant Public Health Manchester The science and art of promoting health: public health and the role of culture Colin Cox Public Health Consultant Public Health Manchester

Defining Health “Health is a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity” World Health Organization So. The first thing we’ve got to do is define what we mean by health. This is the World Health Organization’s definition, and while it’s obviously a tall order, it’s a pretty succinct description of what those of us working in public health would see health as being. Its key strength is that it’s a positive definition – health is a positive state. It’s not the opposite of illness. As soon as you take this view of health, the idea that it can be the job of the health service to create it becomes clearly absurd. The health service can’t create social wellbeing; social wellbeing is created by things like having a job and social networks. Which brings us to the determinants of health.

Defining public health “The science and art of promoting and protecting health and well-being, preventing ill-health and prolonging life through the organised efforts of society” Faculty of Public Health

It all starts with the Greeks… Whoever wishes to investigate medicine properly, should proceed thus: in the first place to consider the seasons of the year, and what effects each of them produces. We must also consider the qualities of the waters and the mode in which the inhabitants live, and what are their pursuits, whether they are fond of drinking and eating to excess, and given to indolence, or are fond of exercise and labour, and not given to excess in eating and drinking. Hippocrates, 400 BC Public health isn’t new. It all starts, as everything does, with the Greeks. Hippocrates, long known as the father of modern medicine, was quite the public health thinker as well. Quote is from his treatise “On Airs, Waters, and Places”, published in about 400 BC. In summary what he says here is that the basis of health is the weather – which I have to say remains underinvestigated as a factor in health; sanitation and clean water; not eating too much; not drinking too much; and taking enough exercise. How things change over 2,500 years...

Four waves of public health Third wave Welfare state; institutional reform; NHS established; social housing; focus on living conditions. Politicians key players. Fourth wave Focus on risk factors, especially lifestyles and behaviours; emerging concerns about inequalities. First wave Sanitary reform; great public works; growth of municipal power; concern for civil order. Social reformers key players. Second wave Rise of scientific medicine; hospitals, health services etc; rationalist/reductionist approach dominates. However, modern public health as we know it today really began in earnest in Victorian times. In the last 200 years or so it’s possible to discern four broad waves of public health, each building on the last. 1830 1900 1950 1980 2000 5

Characteristics of public health Population focus rather than services to individuals Upstream action: emphasising prevention and the determinants of health and wellbeing Focus on social justice: the role of the state and the need to tackle inequalities in health outcome and access to health improving resources Partnerships with all those who impact on the health and wellbeing of the population.

Determinants of health This diagram sets out a recent attempt to map the determinants of health. Each concentric layer illustrates a sphere of influence that seems to get further and further away from individual concerns, but all of which have a direct or indirect impact on health. Barton & Grant (2006): A health map for the local human habitat. Journal of the Royal Society for the Promotion of Health 156: 252-3 (after Dahlgren & Whitehead, 1991)

Tackling health inequalities I talked in the last slide about social justice. Really this slide summarises one of the major issues of social justice in health – the fact that across the board, wealth and health are consistently and positively correlated. You can see in this slide that the life expectancy gap between those in social class 1 and those in social class 5 stands at about 7 years. And the crucial thing here is that these differences are not created by chance, nor by differences in genetic makeup or even simply poor lifestyle choices. They exist because of social and economic inequalities in society, and as such we don’t consider them to be mere variations – they are fundamentally unfair. Life expectancy at birth by social class, England and Wales, 2002-05

“On the state of public health” Cancer Circulatory disease This public health has led to some very significant advances: Rising life expectancy Many communicable diseases largely under control (in developed countries) Dramatic and ongoing reductions in mortality from CHD and cancer Increased recognition of role of social determinants of health and health inequality 9

However… Health inequalities still rising; failing to tackle some significant challenges that have been known about for quite some time, especially obesity and rising levels of poor mental health and wellbeing; and there are emerging challenges such as climate change, resource depletion and other environmental problems that could well lead to very significant public health problems in the future, about which we generally have very little to offer other than bemoaning the problem. 10

Phil Hanlon “What happens After Now?” However, there are some public health thinkers out there who are tackling these big questions head on. There’s a group in Scotland led by Prof Phil Hanlon from Glasgow Uni that’s been writing about this sort of stuff for a couple of years now, and they see a pretty significant role for culture in addressing these public health challenges.

The challenge for future PH Changing ourselves, our mindsets and our culture; Re-integrating dimensions of life that have been separated in recent times: the interior and the exterior; the objective and the subjective; the individual and the collective; the true, the good and the beautiful (science, ethics and aesthetics) Greater future focus In essence, Hanlon and his colleagues suggest that the major public health challenges of today are not amenable to the sort of strategies that have worked for some other public health challenges, like CHD for example. So we need to start a fifth wave of public health with a radically different approach, one in which we seek to re-integrate a number of dimensions of human experience that are currently treated somewhat separately. 12

Wilber’s integral model Subjective – Interior Objective - Exterior Individual level I (mind) The inner world of the individual: how I think and understand myself; my values; my ethical stance It (body and environment) The physical body and brain; the results of empirical, objective study of human experience and the physical world that produce scientific evidence and theories Collective level We (culture) Our intersubjective or cultural world of learned and shared beliefs, ideologies and values; collective, negotiated and symbolic systems of meanings; the basis for our ethics Its (society) Economies; social structures and hierarchies; organizations; government policies; the world of business and production; eco-systems Point – public health has traditionally focused on the two right hand quadrants. But all four matter as neglecting any one can negate benefits from working in another. 13

Public Health response - wellbeing Subjective - Interior Objective - Exterior Individual level I (mind) Contemplative, mindful practices such as meditation, prayer and yoga to promote self-awareness and ethical self-mastery It (body and environment) Treatments such as anti-depressant medication/ cognitive behavioural therapy; healthy lifestyle advice; relationship counselling Collective level We (culture) We understand our motivations in order to change deep-seated individualist and materialist values. We move towards global forms of consciousness, aware of the finite and vulnerable nature of our environment. We think and act out of concerns for a sustainable, equitable human future. Its (society) Policies and action on structural determinants of health; promotion of work–life balance; community development; social capital development; move towards a globally sustainable society through contraction and convergence 14

Implications? New economic models Contraction and convergence More holistic focus on individuals including greater psychological/cognitive input “Mobilising inner resources for self healing” Phil Hanlon talks very much about what’s needed not just as a fifth wave but as a new era, not just for public health but for society. The challenges of climate change and peak oil threaten the whole of modernity and could therefore knock back so many of the public health successes that have been a product of the modern age. They argue that we need new economic models that don’t depend on permanent growth and resource depletion, and that for global justice we need these to adopt models of resource use based on contraction and convergence – we can’t achieve equity by levelling the poor up to the lifestyles of rich western nations, because that’s not sustainable, so we need to reduce our resource use in order that the whole world can live within its total resource envelope. At an individual level the suggestion is that if we’re integrating these dimensions of life effectively we need a much more holistic approach, one that recognises the importance of subjective factors to a much greater extent than at present. One of the contributors to the group is David Reilly from the centre for integrative care at the Glasgow Homeopathic Hospital – a doctor who became increasingly frustrated with modern medicine, moved towards alternative approaches, and now is even moving to some extent away from these towards what he describes as mobilising people’s inner resources for self healing. 15

Stress and grade of employment: men Now with any luck, the last couple of slides should have sparked some connections about where the cultural sector might fit in to this fifth wave. But before we get to that let me take you through some biochemistry. Men at the top of an occupational hierarchy have higher diurnal cortisols that men lower down a hierarchy and this is assumed to be due to be due to control. At the top of a hierarchy if someone was given a task they didn’t like they can pass it down the line. At the bottom of the hierarchy, the person has no possibility of passing it on. He has less control over his work and this is stressful. Time of Day Steptoe et al. 2003, Psychosomatic Medicine, 65, 461-470

Environmental determinants of inflammatory status Deprivation level (low to high) CRP (median) mg/dl Never smoked Smokers 1 0.71 1.42 2 1.00 2.34 3 1.11 2.25 4 1.21 2.44 5 1.13 2.53 6 1.25 3.07 7 1.48 3.29 Its not only the stress response which seems to be elevated according to social class. The inflammatory system exists to repair damage and its activation is measured by CRP. As you go down the social scale, CRP increases. If you smoke, CRP doubles and if you are obese, CRP doubles again.

hs-CRP and risk of future MI in apparently healthy men P Trend <0.001 P<0.001 1 2 3 P<0.001 P=0.03 Relative Risk of MI The significance of this observation is that CRP predicts for MI. Highest quartile men have a 3fold elevated risk compared to lowest quartile men. The reason inflammation is important is that it is the inflammatory system that causes plaque disruption and therefore clotting and stroke or MI 1 2 3 4 <0.055 0.056–0.114 0.115–0.210 >0.211 Quartile of hs-CRP (Range, mg/dL) Ridker. N Engl J Med. 1997;336:973–979. 18

Freeman et al. Diabetes 2002,51;1596 CRP and cumulative risk of type 2 diabetes Q5: > 4.18 mg/l 5 4 % diabetic 3 2 CRP also predicts for diabetes. In 5000 Glasgow men, those in the highest quintile were considerably more likely to be diagnosed as diabetic than those in the lowest quintile 1 Q1 : <0.66 mg/l 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5 Years in study Freeman et al. Diabetes 2002,51;1596 19

Aaron Antonovsky 1923-1994 So what’s going on here? Let me introduce you to Aaron Antonovsky. Antonovsky was an American sociologist who spent the latter part of his career in Israel studying people who as children had been in concentration camps. (etc) 20

Sense of coherence.... “.....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 described the sense of coherence, something children developed if the parenting they experienced allowed them to understand that the world was predictable and explicable, that they had the resilience to cope with what the world threw at them and that the effort of coping was worthwhile expending. While this may sound a bit long winded, it’s obviously got a very significant overlap with what we would today call wellbeing. And the evidence for the importance of this – or something like it – is mounting up. 21

Action vs Pride So why am I telling you this? Fundamentally it’s about showing you that there’s nothing wooly about concepts of things like stress and low wellbeing having an impact on health – we’re starting to be able to track the biochemical pathways responsible here, this is hard science. It’s illustrating one of the crucial pathways between deprivation and poor health, one that is strengthened by but acts independently from behavioural factors such as smoking and poor diet. The pressures of living in deprived circumstances leads to a stress response and a long term low level inflammatory response, which in turn has a significant impact on physical health outcomes. As a final illustration of the importance of these psychosocial dimensions of health, let me just tell you about a study conducted just over 10 years ago, involving the Pima Indians of southern Arizona – a people with a very high rate of diabetes, to the extent that they’ve been used to demonstrate the genetic links to diabetes… etc

The true, the good and the beautiful Creating new symbols and narratives to facilitate culture change Creativity as part of wider wellbeing Inspiring new solutions I just want to finish by coming back to the Greeks, and to some of what Phil Hanlon has been saying. Plato talked about the true, the good and the beautiful – that is, science, ethics and aesthetics – and Phil Hanlon argues that the new public health has to find ways of integrating the three. And in keeping with the new wave theory, we need to build on the best of what’s gone before, but also seek to establish new ways of doing things across all three dimensions. The last of these is a factor of human experience that public health has paid very little attention to in the past – our current engagement with culture and the aesthetic world is very much focused on art as therapy, with some recognition that in regeneration it’s better for places to be beautiful than ugly. What we need to do now, both as public health practitioners and as cultural practitioners, is to explore how the cultural sector can contribute to an emerging aesthetic that supports both individual wellbeing and wider social and cultural change. I don’t know how we’re going to do it, so I’m very encouraged by the number of people who’re interested enough in it to come here today. Connections to regeneration Art and creativity as therapy 23