Goldfish and What They Teach Us!

Last week, I had the privilege of listening to Prof Sandro Galea, from Boston State University talking on the subject: “What do guns, obesity and opiates have in common?!” It was an amazing walk through the world of epidemiology – and the answer? Well – all three things are hugely important problems, they are all complex and therefore simple solutions cannot fix them! 

 

Virchow, one of the earliest and most influential thinkers in the realm of Public Health famously said, “Medicine is a social science and politics is nothing else but medicine on a large scale.” Sandro Galea takes this idea and modifies this slightly, suggesting that, in fact, politics IS health on a large scale. In other words, if we don’t get health and wellbeing (of ALL people and the planet) written into every policy, then we will never tackle the huge issues of health inequality and environmental disaster. 

 

Sandro gave an amusing analogy about his pet goldfish. He told us that every morning, he goes downstairs and sees his lovely goldfish swimming in their goldfish bowl. He cares for them, makes sure they are well fed, doing their exercises, having time for mindfulness to build resilience and ensures their contraceptive needs are catered for. Sadly, one morning, he goes downstairs and finds all his goldfish are dead. He’d forgotten to make sure the water was clean. The fish were, in effect, swimming in a cesspit (needless to ask whether or not fish are meant for a glass bowl!).

 

He has developed several principles when it comes to thinking about epidemiology. Principle number 5 states: “Small changes in ubiquitous causes may result in more substantial change in the health of populations than larger changes in rare causes.” His goldfish illustration shows that the goldfish are surrounded by water and everything they do is influenced by the QUALITY of the water they live in; therefore water is a ubiquitous factor in influencing the fish and needs to taken into consideration EVERY TIME we want to improve the lives of the fish. His point is this: if we don’t care for the environment and the external factors that give us life and wellbeing, then our other little interventions are futile. The problem is that we spend so much of our time making interventions that we can measure and feel successful about, like giving people statins, getting kids to run a mile a day, encouraging breast feeding, getting people through the ED in a timely manner or even giving them smart technology to nudge them towards better health outcomes, but we pay little attention to tackling the much bigger issues of poverty, poor housing, or air pollution.

 

The biomedical model for tackling the huge issues of population health has failed and will continue to fail. Our politics and economic model is broken! We have simply not written health and wellbeing into every aspect of our lives and have developed patterns of education and work that are actually doing more harm than good and driving health inequalities and the health of our planet in the wrong direction. Therefore, where there is evidence that policy is actually making health inequalities worse, or damaging the environment, we must challenge them with the evidence base, and plain common sense!

 

I do believe that communities can together make a massive difference, and increasingly I recognise just how vital policy is in helping us shape a just and fair society and in stewarding an environment, which is sustainable for the future. Policy and law can be love-fuelled and compassionate, and they need to become so, because politics IS health and we need to re-imagine it as such.

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Our Nation’s Biggest Public Health Problem

The subject of this blog is sensitive and difficult. It may stir up some difficult issues or memories for you, as you read. If this happens, then please take time to seek the help you need. I believe this blog and ones to follow might be some of the most important I have written to date.

 

UnknownI am currently reading a phenomenal book, sent to me in the post, by a dear friend of mine, who is a trained counsellor and knowing the work I do, felt that I should read it also. The book is called “The Body Keeps the Score” by the eminent Psychiatrist, Bessel Van Der Kolk. In my humble opinion, it should be compulsory reading for every person training in any of the clinical specialities, including public health and for those working in education. The book focusses on the detailed research and work done by Van Der Kolk and others at Harvard over the last 30 years in the whole area of Complex Post Traumatic Stress Disorder (CPTSD), or “Disorders of Extreme Stress, Not Otherwise Specified” (DESNOS). It is not a part of our vocabulary, unfortunately, because even now, after a huge evidence base and many studies, there still remains no such psychiatric diagnosis. However, it is a hidden epidemic affecting huge numbers of our population and is the root of many of our major public health issues. So what causes this problem and just how wide spread is it? The evidence shows so strongly that the cause of CPTSD or DESNOS is Adverse Childhood Experiences, which we more starkly call Child Abuse.

 

Child abuse falls into four main categories: Physical abuse, Sexual Abuse, Verbal Abuse and Emotional abuse – usually in the form of neglect. 10% of children suffer regular verbal abuse. 25% suffer regular physical abuse. 28% of women and 16% of men have suffered sexual abuse. 16% regularly watch domestic violence. 87% of all those who suffer one type of abuse, are also abused in other ways. Each of these forms of abuseUnknown lead to major health problems later in life and studies are showing that it is not just mental health issues (many of which lead to inappropriate diagnoses like Borderline Personality Disorder or Bipolar Disorder and ineffective treatments) but also major physical health problems. Those who have been abused are twice as likely than others to develop cancer and four times as likely to have emphysema. The more difficult a person’s experiences, the higher the chance of developing heart, liver or lung disease at an early earlier age with much higher chances of taking more health risks with smoking, becoming overweight or having multiple sexual partners. There is good evidence to suggest a link with autoimmune diseases, such a lupus, and other complex conditions like chronic pain, chronic fatigue and fibromyalgia. The body cannot be separated from the mind and literally keeps the score of the internalised turmoil. So, even if the abuse happens before memories are formed, or our minds manage to forget or block out what has happened, the body simply cannot forget and sometime and in someway, the damage will show itself. Studies show that the overall cost of this appalling reality far exceed those of cancer or heart disease. In fact, eradicating child abuse would cut depression rates by over 50%, alcoholism by 66% and suicide, IV drug use and domestic violence by 75%. Antidepressants and antipsychotics are now some of our largest prescribing costs. We know this, but are doing very little about it. Perhaps it feels too big. Perhaps we don’t want to face the demons involved. Instead, we are numbing the problem, trying desperately to get people to be just functional enough to keep on serving the needs of our economic system, but we are not facing up to or dealing with this horrific problem, nor its true cost.

 

What can be done in the face of such evil? How can we develop aimages culture of compassion and restorative justice in which we can find a new way through for humanity? It isn’t getting any better. It is just as widespread and far reaching in its consequences as it was a generation ago. Is it possible for us to face up to the startling reality we face? Van der Kolk offers much hope, but it is not within the gift of the health service and social services to tackle this alone. If we are to take this issue seriously, we must embrace what Bessel refers to (at the end of chapter 2) as four fundamental truths:

 

  1. Our capacity to destroy one another is matched by our capacity to heal one another. Restoring relationships and community is central to restoring wellbeing.
  2. Language gives us the power to change ourselves and others by communicating our experiences, helping us to define what we know and to find a common sense of meaning.
  3. We have the ability to regulate our own physiology, including some of the so-called involuntary functions of the body and brain, through simple activities such as breathing, moving and touching – (learning to be present in our own bodies is a vital way of separating out the memories of the past which can overwhelm us at times).
  4. We can change social conditions to create environments in which children and adults can feel safe and where they can thrive.

images-1People can be healed of trauma. We need this at both an individual and corporate level. We have become so focussed on saving money, on quick fixes to ensure the NHS and Social Care System can survive, but we are ignoring the root cause of many of our ill health issues. If we are willing to face up to the truth of child abuse in our society and its long lasting and far reaching impact on overall health and wellbeing, then we might just be able to find a way through to healing and restoration of what has become an extremely broken society. In the blogs that follow, I will look at some of the ways we might find a way through this crisis of epidemic proportions. One thing we must face straight away is that we are spending our resources in the wrong places and are focussing our attention in the wrong areas. We must protect our children and help people learn how to be good parents. We must strengthen our school teachers and sense of community. We must invest in the first five years of life far more than we are doing so currently, especially those key first 12 months of bonding and attachment. Together, if we want to, with love, care, bravery and determination, we can change the future. There is hope. There is healing. Our systems are not yet designed to cope with this, but we must speak the unspeakable, break the silence and face up to the truth. The truth will set us free and enable us to develop the kind of wellbeing that every human being should be able to live within.

 

 

 

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We Need to Be Ambidextrous in Solving our Health and Social Care Conundrum

Tweet All this week on the BBC, there has been a focus on the NHS and the crisis we are in – don’t panic Mr Mainwaring…..There is a heady mix of opinions being thrown around – Question Time became quite a furore of ideas and thoughts last night – not enough beds, not enough staff, not [Continue Reading …]

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