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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