1. Mitchell Memorial Lecture 2015

2. What causes wellness? Nottingham 22 nd April 2015

3. What people believe about Scotland’s health u The Scots are unhealthy u It’s because they smoke a lot u They eat the wrong kind of food u They drink too much u If only they adopted healthy habits, they would be healthy u Only ONE of these statements is true!

4. World Health Organization (1997 and 2003)www.heartstats.org

5. Smoking prevalence - Europe Males

6. Coronary heart disease mortality Men aged 15-74 years Age-standardised mortality per 100,000

7. The challenge of health inequalities u We oversimplify the problem through inadequate analysis u We apply inappropriate thinking to the search for solutions u As a result, we use ineffective procedures to try to change behaviour

8. Life expectancy trends Portugal Scotland

9. The pathogenesis paradigm u “Health is a complete state of physical, mental and social wellbeing and not merely the absence of disease or infirmity” WHO 1948

10. Medicine’s silver bullets u Diabetes and insulin 1922 u Tuberculosis and streptomycin 1943 u Polio and Salk vaccine 1955

11. All cause mortality,men 65-69 1665 3951

12. Slope index of inequality 2763 Mean = 2694 X X X X X All cause, M65-69 2763/2694 = 1.025

13. Male inequalities, all causes, all ages

14. Slope index of inequality breakdown by cause of death SII= 2763 SII= 792 SII= 1971 All causeIHDOther causes

15. Male inequalities, all ages, by cause IHD All other causes

16. Relative inequalities in mortality by cause Men, Scotland 2000-02

17. Chronic liver disease, including cirrhosis Source: Whyte B., Ajetunmobi T. Still “the sick man of Europe”? GCPH, 2012

18. So, what causes wellness?

20. 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.

21. “.....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....

23. STRESS AND GRADE OF EMPLOYMENT: MEN Salivary Cortisol Time of Day Steptoe et al. 2003, Psychosomatic Medicine, 65, 461-470

29. Environmental determinants of inflammatory status CRP (median) mg/dl affluent deprived

30. 0 1 2 3 4 5 00.511.522.533.544.55 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

31. Inflammation in plaques Inflammatory cells MMPs, IL-6, IL-15, IL-18, CRP Lumen Core Cap Thin Fibrous Cap InflammatoryCells SMCapoptosis Degradedmatrix Unstable cytokinesMMP

32. The molecular biology of a hug

33. 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

34. Adverse childhood events risk of alcoholism Hillis et al 2011

35. Adverse childhood events risk of perpetrating violence Boys experiencing physical abuse Duke et al 2010

37. Creating wellness Sense of coherence Seeing the world as: Structured Predictable Feeling that it is: Manageable Meaningful Wanting to engage Sense of coherence Seeing the world as: Structured Predictable Feeling that it is: Manageable Meaningful Wanting to engage Resources which enhance resilience Family Nurture Intelligence Work Material resource Identity Cultural stability Stable set of answers Optimism Resources which enhance resilience Family Nurture Intelligence Work Material resource Identity Cultural stability Stable set of answers Optimism Events Stress Tension Resolution Wellbeing Events Stress Tension Resolution Wellbeing

38. The cycle of alienation Worklessness Poverty In education offending health In education offending health Chaotic early years Unequal outcomes Consequences Alienation Initial event Mental health problems Loss of self efficacy, esteem, control

39. The causes of wellness? u Optimistic outlook u Sense of control and internal locus of control u Sense of purpose and meaning in life u Confidence in ability to deal with problems u Supportive network of people u Nurturing family

40. What does this mean for policy? u Inequality in Scotland (and elsewhere?) is not primarily due to conventional risk factors u Early years experience is important in building resilience and wellbeing in later life u Conventional methods for preventing illness will not be effective in creating wellness

41. DESIGN APPROVE Conference Room Real World The Typical Approach… IMPLEMENT

43. DESIGN TEST & MODIFY APPROVE IF NECESSARY Conference Room Real World TEST & MODIFY The Quality Improvement Approach START TO IMPLEMENT

44. connecting In the social era - connecting Large scale change….. developing our thinking over time

45. Workstream 2 Societal Issues expected of a 27-30 month old 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. 46

47. 90% of children at Grassmarket nursery school will receive a bedtime story at least 3 times a week. Family garden party A very hot weekend

48. Nina and her bed time bear

49. Big gains from many small changes

50. Jimmy Reid 1971 Trade Union leader Elected by students as Rector of Glasgow University

51. 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....”

53. 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 BoyleGregory Boyle

54. Confucianism u “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)

56. What do you mean, “it’s a bit muddy”?