The science and art of promoting health: public health and the role of culture

Colin CoxPublic Health ConsultantPublic 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

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

Four waves of public health

First waveSanitary reform; great public works; growth of municipal

power; concern for civil order. Social reformers key players.

1830 1900 200019801950

Second waveRise of scientific medicine;

hospitals, health services etc; rationalist/reductionist approach

dominates.

Third wave Welfare state; institutional

reform; NHS established; social housing; focus on living

conditions. Politicians key players.

Fourth waveFocus on risk factors, especially

lifestyles and behaviours; emerging concerns about

inequalities.

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

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

66

68

70

72

74

76

78

80

82

84

86

I II IIIN IIIM IV V

Social class

Ag

e Male

Female

Life expectancy at birth by social class, England and Wales, 2002-05

“On the state of public health”

Falling mortality

0

20

40

60

80

100

120

140

160

180

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

DS

R/1

00,0

00

Cancer

Circulatory disease

However…

Phil Hanlon

“What happens After Now?”

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

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

Public Health response - wellbeingSubjective - 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

Implications?

New economic models Contraction and convergence More holistic focus on individuals

including greater psychological/cognitive input

“Mobilising inner resources for self healing”

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

Sal

ivar

y co

riso

l lev

el: n

mol

/l

Higher Grade

Lower Grade

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

PP<0.001<0.001PP<0.001<0.001

PP=0.03=0.03

Quartile of hs-CRP (Range, mg/dL)Quartile of hs-CRP (Range, mg/dL)

P P Trend <0.001Trend <0.001

<0.055<0.055 0.056–0.1140.056–0.114 0.115–0.2100.115–0.210 >0.211>0.211

Re

lati

ve

Ris

k o

f M

IR

ela

tiv

e R

isk

of

MI

Ridker. N Engl J Med. 1997;336:973–979.

0

1

2

3

1 2 3 4

hs-CRP and risk of future MI in hs-CRP and risk of future MI in apparently healthy men apparently healthy men

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

Aaron Antonovsky 1923-1994

“.....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."

Sense of coherence....

Action vs Pride

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

Connections to regeneration

Art and creativity as therapy