Sir Harry Burns

Professor of Global Public Health

University of Strathclyde

Adverse childhood events study

u Physical/sexual/emotional abuse

u Neglect (physical/emotional)

u Domestic substance abuse

u Domestic violence

u Parental mental illness

u 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

1

3

5

7

9

11

13

ACE and morbidity(adjusted odds ratio, 4+ ACE)

100

120

140

160

180

200

220

240

260

Glasgow excess mortality(cause-specific SMR, compared to Liverpool &

Manchester)

All cause mortality,men 65-69

0

500

1000

1500

2000

2500

3000

3500

4000

4500

SIMD quintile

Mo

rtality

per

100,0

00

1665

3951

Slope index of inequality

0

500

1000

1500

2000

2500

3000

3500

4000

4500

SIMD quintile

Mo

rtality

per

100,0

00

2763

Mean =

2694

X

X

XX

X

All cause, M65-69

2763/2694 = 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 in

dex o

f in

eq

uality

div

ided

by m

ean

rate

Slope index of inequality

breakdown by cause of death

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 in

dex o

f in

eq

uality

div

ided

by m

ean

rate

IHD

All other causes

Relative inequalities in mortality by cause

Men, 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

in

de

x o

f in

eq

ua

lity

div

ide

d b

y m

ea

n r

ate

Chronic liver

disease

All neoplasms

Disorders due to

use of drugs

All other causes

Suicide

Assault

Accidents

Disorders due to

use of alcohol

Chronic lower

respiratory diseases

Cerebrovascular

disease

Ischaemic Heart Disease

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

Workers in the 1950s

Better housing?

US mortality 1999-2015

US mortality 1999-2015

Based on NSPCC

5% Children

sexually abused 650,000

(Est. UK)

980,000 (11-17yrs) experienced

high levels of abuse/neglect

(est. UK)

Three in five people describe child abuse and neglect as “common” in the UK

Child Abuse - Distribution and Focus

63 Child Homicides UK 2012/13Under15’s Deaths assault or undetermined 44

Sexual offences against children 23,633 police UK 2012/13 36,202 NSPCC helpline abuse or neglect

contacts in 2012/13

7,964 Cruelty & neglect offences

Police UK 2012/13.

42,500 Children looked after due to abuse

and neglect 31 March 2013.10 -15yrs Violent crime 250,0002012/13 (Est UK).

Focus

Distribution

Adverse Childhood Experiences

Bellis et al, BMC Medicine, 2014Aged 18 to 69 (n = 3,885)

0

5

10

15

20

25

1 2 3 4 5

Pe

rce

nta

ge

Deprivation Quintile

Verbal Physical Sexual

Adverse Childhood Experiences

Bellis et al, BMC Medicine, 2014Aged 18 to 69 (n = 3,885)

0.000

0.100

0.200

0.300

0.400

0.500

0.600

0.700

0.800

0.900

1.000

0-9 10-19 20-29 30-39 40-49 50-59 60-69

Cu

mu

lati

ve

pro

po

rtio

n n

ot

dia

gn

ose

d

at

per

iod

en

d

Survival period

0 ACEs 4+ ACEs

Cumulative Proportion of Individuals

not diagnosed with a Major Disease with Age

Cancer

Type II Diabetes

Cardio Vascular Disease

Digestive/Liver Disease

Stroke

Respiratory Disease

Aged 18 to 69 (n = 3,885) Bellis et al, Journal of Public Health, 2014

35% have history of major disease

70% have history of major disease

Differences are independent of Deprivation

Chronic NCD

risk

Plasticity

Life course

No intervention

Mother

& infant

Earlier intervention

improves functional

capacity & responses

to new challenges

Inadequate response

to new challenges

Childhood

Adulthood

Early intervention

Late intervention

Late intervention

impactful for

vulnerable groups

Lifecourse strategy for

disease prevention

Gluckman, Hanson, Cooper et al New Engl J Med 2008; 359: 61-73 Harvey NC et al J BoneMiner Res 2014; 29: 1917-25

Economic cost of child maltreatment

u “The total lifetime economic burden resulting

from new cases of fatal and nonfatal child

maltreatment in the United States in 2008 is

approximately $124 billion in 2010 dollars.

This economic burden rivals the cost of other

high profile public health problems, such as

stroke and Type 2 diabetes (Fang et al.,

2012).”

The Minsk Declaration

The Minsk DeclarationActing Early

• Minimise childhood exposure to poverty and health inequalities

• Provide equal opportunities for social participation to all children

• Prevent maternal to child transmission of infection

• Maximise vaccination coverage

• Minimise exposure to intrauterine over and under-nutrition

• Avoid hazards including chemicals/drugs, poor air quality

• Minimise adverse childhood experiences, injuries and neglect

• Optimise cognitive development

• Recognise that education is a major social determinant of health

The Minsk DeclarationActing Appropriately during Life’s Transitions

• Promote quality preconceptional information/services/care, including women from disadvantaged backgrounds

• Promote, support and protect breastfeeding

• Support families to build parenting capacities

• Promote adequate and inclusive education throughout childhood and adolescence

• Focus on healthy adolescence including building resilience; promotion of life skills; access to safe environments and supportive community networks

• Promote universal health coverage for youth services, quality maternal care, management of STI and mental health disorders

• Promote sexual and reproductive health

• Promote healthy ageing across the lifecourse

The cycle of alienation

WorklessnessPoverty

In education offending

health

Chaotic early years

Unequal outcomes Consequences

Alienation

Initial event

Mental health problems

Loss of self efficacy, esteem, control