Dr Ayman Shenouda
Shaping Australia: one GP at a time
For those who attended GP17 in October, I’m sure you will agree that it was delivered to its usual high standard and there was plenty of diversity in terms of viewpoints. Some perspectives were what could only be described as poles apart. Dr Jay Parkinson and Sir Harry Burns for example.
Dr Parkinson with his discussion around consulting in the cloud through to Sir Harry’s on tackling poverty. There have been some blogs and articles around the technology discussion including recent Opinion in the Medical Observer.
It was Sir Harry’s discussion that moved me the most as he provided some important insights into poverty and particularly around social chaos and its flow-on effects in eroding wellness. In some ways, this discussion gave me renewed hope. That as a community we can together tackle disadvantage particularly in ensuring our children get the best start in life.
Not enough wellness
Sir Harry Burns from Strathclyde University and former Chief Medical Officer for Scotland provided the research keynote address. This was a spirited defence of poverty which really got to the heart of the issue.
The issue, of course, being disparities in terms of health outcomes and ways to counter these. It’s about how societies can create wellness and also how they can destroy it. In explaining this, he brings the consequences of poverty and inequity into sharp focus.
His own country’s poor health, he says, is a reflection only of the health of the poor. Studies he’d undertaken led him to believe that the problem was in fact not enough wellness (and not too much illness). Social conditions as fundamental causes of health could be seen through countless studies he shared.
We’ve all seen this of course in our own communities. I know in Wagga like most regional towns there are some deeply entrenched social disparities. But in addressing these, our national policy I think is structured in a way to deal with consequences, not poverty prevention and reduction. And without significant change, these patterns will only continue.
The science behind wellness
Sir Harry’s work has sought to unravel the science behind wellness. And I think some of the key learnings from his research can really transform our policies here in Australia today.
It was the work of a colleague, Professor Alastair Leyland, which examined his own community of Glasgow against the slope index of inequality, which began his own inquiry around what causes health inequalities.
Some very specific insights were shown in terms of what happened in society to slow down growth and life expectancy in the poor. The peak in mortality shown in these studies was in the young – teenage and young working age people – and from very specific causes – drugs, alcohol, suicide, and violence.
Inequality mortality was not a feature of the elderly. These were not people dying from heart disease or cancer but there was something else going on in the population. These outcomes were pyschosoically determined - society determined causes of premature death - and they needed to work out what the key drivers were.
It was social chaos that intervened which came with the housing disruption more than five decades ago. Traditional communities were broken as a consequence alongside loss of employment, opportunity, and hope. This was what eroded wellness and it is clear the same social disruption occurred here and we are also dealing with these same issues.
Causes of wellness
Looking more to those causes of wellness. Salutogenesis and the work of an American Sociology Dr Anton Antonovsky around a Sense of Coherence which relies on a life which is structured, predictable, explainable. Having resilience or the internal resources and will to deal with challenges.
In quoting Antonovsky he said: “Unless you can see the world as comprehensible, manageable and meaningful you will experience a state of chronic stress.” This provided what he was looking for. It showed the link between social circumstances and ill health.
Poverty and elevated stress
The research presented really showed the relationship between poverty and elevated stress and how that leads to chronic disease and ill health. Those with a difficult start are less equipped to adapt to change which often manifests in poor behaviours.
Studies by Bruce McEwen of Rockefeller University has made those links as well as Sir Harry’s own associated work undertaken in Glasgow. Early-life stress and the long-lasting behavioural, mental and physical consequences. For those wanting to learn the full science behind this here is his presentation and this discussion is about 20 minutes in.
And there’s something in a cuddle.
The molecular biology of a cuddle was shown. Comforting and its effect on suppressing the stress response. The biochemical toll of early neglect. Stress in infancy and the fact that neglected babies don’t get enough 5-HT.
The work of Michael Meaney’s and the difference in brain development for those children who experience adversity in early life was shown. Other studies were shown which have looked at different types of adverse childhood events – neglect, abuse, domestic violence, alcoholic parent – which is then linked to outcome. It showed children exposed to adverse events in early life had a higher risk of alcoholism, depression or drug abuse.
Breaking the cycle
Social turbulence was the description used. More specifically, he described a cycle that alienates people and impairs their ability to control their wellbeing. And that it starts with chaotic early years.
The policy learnings for us include around Scotland’s approach to improving wellness. That is to focus on breaking that cycle by doing things in early life.
There are some key learnings in the policy approach itself. It was those at the front-line who developed the policy solutions in Scotland in response to these issues. They asked front-line staff for solutions, then took their ideas and tested them and shared them across the country.
The secret, he says, is in marginal gains. Go out there try lots of things see what works and then do it all consistency. I think there’s a lesson in that for our own policy development.
It is through those small gains which from a range of interventions that add up to produce significant overall improvements. In early years, it was simple things like attachment is improved if kids are read bedtime stories. The solution lies in enabling that to occur.
The shift in policy approach is really about enabling policy change. That is change as opposed to full reform. It is in enabling those incremental shifts to existing structures, or the adoption of new and innovative approaches that can facilitate that change.
The risk in full reform is that it stifles innovation which can limit participation and if it’s not realised quickly then all is lost including those approaches that proved to work. Politicians turn to the next new thing which may not be as effective.
In Scotland, they’ve had 1500 small tests of change carried out in child health with 60 or 70 of them now implemented. Similar community strengthening type approaches which can facilitate incremental gains are what we need here to shift disparities.
The key message from the discussion is that it is those experiences in early life which can set off a life course of adversity. Those clear links in social circumstances and the beginnings of chronic ill health.
We need much more focus here in Australia on what causes wellness. It’s not that we haven’t had a focus here on concepts which include community resilience. Those social capital discussions were full of it in the early 2000s.
There seems less focus now and perhaps its due to governments not realising fully how investments now pay health dividends later on. There also may not be that political will to invest in wellness knowing the results will not be seen in the space of an electoral term.
Dr Ayman Shenouda