The science and art of promoting
health: public health and the role
of culture
Colin Cox
Public Health Consultant
Public 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
Third wave
Welfare state; institutional
reform; NHS established; social
housing; focus on living
conditions. Politicians key players.
First wave
Sanitary reform; great public
works; growth of municipal
power; concern for civil order.
Social reformers key players.
Fourth wave
Focus on risk factors, especially
lifestyles and behaviours;
emerging concerns about
inequalities.
Second wave
Rise of scientific medicine;
hospitals, health services etc;
rationalist/reductionist approach
dominates.
1830
1900
1950
1980
2000
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
86
84
82
80
Age
78
Male
76
Female
74
72
70
68
66
I
II
IIIN
IIIM
IV
V
Social class
Life expectancy at birth by social class, England and Wales, 2002-05
“On the state of public health”
Falling mortality
180
160
Cancer
120
100
80
Circulatory
disease
60
40
20
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
0
1993
DSR/100,000
140
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 - wellbeing
Subjective - Interior
Objective - Exterior
Individual I (mind)
level
Contemplative, mindful practices
such as meditation, prayer and
yoga to promote self-awareness
and ethical self-mastery
It (body and
environment)
Treatments such as antidepressant medication/
cognitive behavioural
therapy; healthy lifestyle
advice; relationship
counselling
Collective
level
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
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.
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
18
16
14
12
Higher Grade
Lower Grade
10
8
6
4
2
22-22.30
20-20.30
18-18.30
16-16.30
14-14.30
12-12.30
10-10.30
0
08-8.30
Salivary corisol level: nmol/l
20
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
Smokers
1
Never
smoked
0.71
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
1.42
hs-CRP and risk of future MI in
apparently healthy men
Relative Risk of MI
P Trend <0.001
P<0.001
3
P<0.001
2
P=0.03
1
0
1
<0.055
2
0.056–0.114
3
0.115–0.210
4
>0.211
Quartile of hs-CRP (Range, mg/dL)
Ridker. N Engl J Med. 1997;336:973–979.
CRP and cumulative risk of type 2
diabetes
Q5: > 4.18 mg/l
5
4
%
diabetic
3
2
1
Q1 : <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
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."
Action vs Pride
The true, the good and the beautiful
Creativity as part of wider wellbeing
Inspiring new solutions
Creating new symbols and
narratives to facilitate culture
change
Art and creativity as therapy
Connections to regeneration