Life expectancy trends Portugal Scotland Trends in male

Life expectancy trends Portugal Scotland

Trends in male life expectancy: Scotland Richest 20% Poorest 20%

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

Smoking prevalence - Males

Smoking prevalence - Females

Income deprivation - Liverpool

Income deprivation - Glasgow

Standardised mortality rates by cause, all ages: Glasgow relative to Liverpool & Manchester Source: Walsh D, Bendel N. , Jones R, Hanlon P. It’s not ‘just deprivation’: why do equally deprived UK cities experience different health outcomes? Public Health, 2010

All cause mortality males 15 -44

Cirrhosis mortality males 15 -44

Workers in the 1950 s

Alvin Toffler – Future Shock 1970 u “To survive, to avert what we have termed future shock, the individual must become infinitely more adaptable and capable than ever before. We must search out totally new ways to anchor ourselves, for all the old roots - religion, nation, community, family, or profession - are now shaking under the hurricane impact of the accelerative thrust.

Aaron Antonovsky 1923 -1994

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. "

For the creation of health. . . . the social and physical environment must be: u Comprehensible u Manageable u Meaningful u. . . or the individual would experience chronic stress

u “A child who lacks a sense of coherence interprets all the events around him as noise not as information. This he finds very stressful” Antonovsky

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

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

Inflammation in plaques cytokines Lumen MMP Inflammatory Degraded Cells SMC matrix apoptosis Cap Core Inflammatory cells MMPs, IL-6, IL-15, IL-18, CRP Unstable Thin Fibrous Cap

CRP and cumulative risk of type 2 diabetes % diabetic Q 5: > 4. 18 mg/l 5 4 3 2 1 Q 1 : <0. 66 mg/l 0 0 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

Adipocyte programming insulin resistance, inflammation and ALP skeletal muscle Insulin resistance triglyceride NEFAs liver Adipose stores Low HDL small LDL Atherogenic Lipoprotein Phenotype IL-6/IL-6 s. R TNF-a/ TNF-a s. R-I CRP SAA Pro-inflammatory state

Persistence hunting

Adding insult to injury…….

The molecular biology of a cuddle

Attachment theory § § Ainsworth § Deep emotional connection that infant develops with primary caregiver § Reflects an “internal working model”expressing the infant’s expectations of parental behaviour in meaningful situations § Basis for development of later relationships Increasingly recognised as determinant of later emotional, cognitive and social outcomes

Adverse childhood events study Physical/sexual/emotional abuse u Neglect (physical/emotional) u Domestic substance abuse u Domestic violence u Parental mental illness u Parental criminality u

Adverse childhood events risk of alcoholism Hillis et al 2011

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

Risk of heart disease and early adversity

The Dunedin cohort § § § 1000 children recruited in late 1972/3 At age 3, “at risk” children identified on the basis of chaotic circumstances, emotional behaviour, negativity and poor attentiveness As adults, those “at risk” were more likely to : § § § be unemployed have criminal convictions (especially for violence) been pregnant as a teenager have a substance abuse problem exhibit signs of insulin resistance and metabolic syndrome

Creating wellbeing Generalised resistance resources Family Intelligence Work Material Identity Cultural stability Optimism Stable set of answers Sense of coherence Events Seeing the world as: Structured Predictable Stress Feeling that it is: Manageable Meaningful Resolution Wanting to engage Wellbeing

Do social conditions determine the incidence of disease? u For centuries they have and they still do in the developing world – Plague, leprosy, polio, diphtheria, typhoid, tuberculosis – BUT in the developed countries u It is mainly our physiological response to social conditions which largely determines our risk of chronic ill health

Health Deficits approach u Focuses on problems, needs and deficiencies in a community such as deprivation, illness and health damaging behaviours. It designs services to fill the gaps and fix the problems. As a result, communities can feel disempowered. People become passive recipients of services rather than active agents in their own lives

Social connectedness 148 studies comprising 308, 849 participants, high levels of social integration conferred a 50% increased likelihood of survival. u Complex patterns of social integration conferred a 90% increase in survival. u Simple indicators such as living alone versus living with others conferred a survival benefit of only 19%. u

Health Assets u A health asset is any factor or resource which enhances the ability of individuals, communities and populations to maintain their health and sustain wellbeing. The assets can operate…as protective and promoting factors to buffer against life’s stresses Morgan 2009

Alienation and Frankenstein u "I came across people, other beings which I could see were almost like myself. Or so I thought at first when I approached them, though, I found that they did not consider me as one of their own kind. As soon as they saw me, their faces became twisted with fear. They shouted at me and threw things and ran away from me, just as my own maker had done. So this is what I learned about myself - that I was a disgusting creature. Even though I had given them no cause, all men hated me. "

The pathology of poverty 24 th European Congress of Pathology Prague 11 th September 2012

Jimmy Reid 1971

Rectorial Address § § “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. . ”

Improving complex systems Build secure knowledge of the problem u Build the will to change u Execute the change u Drive the change with data u

Central line infection rate (per thousand line days) 2. 8 70% reduction 0. 84

% ICU mortality 24% improvement 18. 2% 13. 9%

HSMR up to September 2012 Standardised Mortality Ratio 1. 1 1. 0 12. 4% re duction 0. 9 0. 8 Oct-Dec Apr-Jun Oct-Dec Apr-Jun 2006 2007 2008 2009 2010 2011 2012