We face alternative health futures

By Dr. Trevor Hancock

Last week, I referred to Norman Henchey’s categorization of four sorts of future: Probable, possible, plausible and preferable. This week, I explore the latter three, especially in the context of the future of health and the health-care system.

But first, an important distinction. Many of those who describe themselves as health futurists are really health-care-system futurists. They are focused on the future of the health-care system, rather than on health itself.

But if you want to think about the future of health, you have to think about much more than just the health-care system; you have to think about the future of society as a whole and the state of our environment, as they are what largely determine the health of the population.

In fact, our society also determines what kind of health-care system we have, because that system will reflect the values and social norms of the society of which it is a part — not the other way around. So with that in mind, what can we say about the possible, plausible and preferable futures of health and health care?

The possible future encompasses all the things we can imagine happening, which can take it into the realm of science fiction. This is not to disparage science fiction; at its best, it can illuminate our present world and its values, and imagine and test ideas most of us have never considered.

But the possible can also get pretty wild, both scientifically and socially, which can make it implausible. The transporter beam of Star Trek is a case in point, as perhaps are its instant diagnostic scanners, or the extreme genetic manipulations in the novels of William Gibson or Iain M. Banks. I would put the visions of limitless free energy and hopes for instant cures for cancer and other diseases in the implausible zone.

The plausible future is a narrower band within the wide range of possible futures. It can be best explored by the use of scenarios — narratives of alternative futures based on what we know and can reasonably anticipate. In scenarios work, we not only explore the “business as usual” scenario, but a plausible future in which many things go wrong, which can be described as decline or collapse.

This is definitely not a preferable future, and people don’t like to explore it, but if asked, they find it plausible, even quite likely. By exploring such a future we can both recognize what we need to do to avoid it and/or to cope with and manage it.

Other plausible scenarios include some form of eco-social, economic and to some extent spiritual transformation, a sort of “green” future that sees us move away from the more high-tech “business as usual” or the conditions that lead to decline or collapse. Not surprisingly, such a future, while not necessarily seen as all that plausible or feasible, is often seen as quite healthy and thus desirable, especially when allied with the appropriate use of high-tech.

But embedded within and underlying each scenario are sets of values that guide the scenario, such as the value placed on health and how health is understood in that society — which in turn shapes that future’s health-care system. For example, is health just about physical well-being and length of life, or mental well-being and quality of life, or balance and harmony within society and nature?

In the first option, we might expect a more high-tech, biomedical system, but in the other two, a system more focused on achieving mental well-being or ecological well-being, while in a decline or collapse scenario we can imagine there would be a quite minimal, survival-oriented health-care system, and mainly for the rich and powerful.

But beyond imagining a range of plausible futures we face, the key question is what sort of healthy future we want for our kids and grandkids. As I said in last week’s column, thinking about the future should help us decide what we do and how we live today. Rather than just adapting to whatever happens, how do we help to shape and create the future we prefer? That will be the topic of next week’s column.

Dr. Trevor Hancock is a retired professor and senior scholar at the University of Victoria’s School of Public Health and Social Policy.

© Trevor Hancock, 2019

Originally published in Times Colonist, 31 March 2019

Future thinking can pay off

By Dr. Trevor Hancock

I am often accused, not unjustly, of being a “doom and gloom” merchant when it comes to the state of the planet and of our society. While there are good reasons to hold that view, it is not the only way of looking at the future.

Part of my professional work has been as a futurist, specifically a health futurist. That is to say, I have worked with people to help them think more effectively and creatively about the future of health and health care.

Futurists often get a bad rap, accused of being too visionary, even dreamy, by some, while others think futurists have done a poor job of predicting the future. Both those views, however, miss the point of good futures thinking.

Many years ago, I worked with James Robertson, a British futurist and author of an influential 1978 book, The Sane Alternative. In 1984, I brought him to Toronto to speak at a conference I was organizing, and one of the things he said captured for me the essence of good futures work.

“Thinking about the future,” he said, “is only useful and interesting if it affects what we do and how we live today.”

So good futures work is practical, because it helps us make better choices and decisions today that will shape our future. Of course, there is no guarantee that we will do so; witness the litany of failed opportunities over the past 50 years to avoid the environmental crisis that was predicted then and that we now face.

Which points to the other sort of problem: Futurists might help us understand and anticipate future events, but there is no guarantee their ideas will be understood, taken to heart and acted upon. Moreover, prediction is a bit of a mug’s game. As another colleague, and one of the world’s leading futurists, Jim Dator, used to say, the probable future is the least likely future.

By that he meant that predicting the future as a form of “business as usual,” especially based on past trends and performances, is inherently wrong, because it assumes that things will continue much as they are, when in fact the only thing that is constant is change. The future, as futurists like to remark, is plastic, it can and will be shaped, often in ways we don’t anticipate — witness the way the internet has changed our world.

Moreover, as we have come to understand complex adaptive systems better — systems such as the human body, the economy or the Earth’s natural systems — we have come to understand two important things about them that make prediction hard, if not impossible.

First, within such systems, small changes can perturb the system in ways that result in massive change, the so-called butterfly effect. (The analogy is that the beat of a butterfly’s wings in China today can spawn a tornado days later in America.) The opposite is also true. Large changes in input can have little or no effect, as the system adapts to them and smoothes out or absorbs their impacts.

The second realization is that there can be sudden, non-linear state-shifts in such systems. These systems are dynamic, but stable, though when enough strain builds up, or just the right small nudge occurs and they cross a threshold — which we might not know about in advance — they can shift suddenly to a different state. Some climate models, for example, suggest the Earth’s climate can be stable in its present configuration or two much different states: “Snowball Earth” or “ice-free Earth.” At present, we are pushing the Earth toward the latter.

All of this suggests that there is no such thing as the future, but rather we face many different futures. The Canadian futurist Norman Henchey put it well many years ago when he described four categories of future: Probable, possible, plausible and preferable.

The probable, as we have already seen, while interesting, might be neither likely nor preferable; the other three are more interesting, and I will describe them next week, particularly in the context of the future of health and health care, before turning to thinking positively about creating a preferred future in a third column.

Dr. Trevor Hancock is a retired professor and senior scholar at the University of Victoria’s School of Public Health and Social Policy.

© Trevor Hancock, 2019

Originally published in Times Colonist, 31 March 2019

Time to shift the bell curve toward health

By: Dr. Trevor Hancock

Life is lived on a bell curve. Many attributes of a population — height, for example — are distributed on a bell-shaped curve, with the average at the centre and then decreasing numbers of people as we get further from the centre.

At each end of the curve are the small number of people who are either extremely tall or extremely short. This pattern is found throughout nature, and is one of the most important concepts in biology, medicine and public health.

Understanding the bell curve is important for the work of public health. For example, we know that being overweight or obese increases the risk of developing diabetes.

An example from a Canadian population-health primer notes that those who are very obese have a 32 per cent chance of developing diabetes over the next 10 years, while those who are obese have a 21 per cent risk. But people who are overweight but not obese have only a 10 per cent risk, and those with a normal healthy weight or who are underweight have only a three to seven per cent risk.

So you might think it would make sense to focus our prevention efforts on those who are obese — and you would be wrong. Because in doing so you would miss 61 per cent of those who develop diabetes. Forty per cent of cases would occur in the overweight population and an additional 21 per cent of cases would occur in the low-risk normal weight population.

This is known as Rose’s Paradox, identified by the noted British epidemiologist Sir Geoffrey Rose. He pointed out that while the people at one end of the bell curve have a higher risk of getting a disease, more cases are found in the population with moderate or low risk. This is because there are far more people in these categories. For this reason, it is better to try to shift the curve for the entire population a bit.

Moreover, this doesn’t just apply to individuals, but to entire neighbourhoods. My friend and colleague, the late Clyde Hertzman, established and led the Human Early Learning Partnership at UBC. He led pioneering work in B.C. on early child development, and as a result, B.C. became the first jurisdiction in the world with maps of early development for every neighbourhood and school district in the province. These maps helped to show the relationships between patterns of vulnerability in young children and their socio-economic conditions.

As would be expected, lower incomes and more impoverished living conditions and neighbourhood resources were linked to worse outcomes. But importantly, HELP also showed that “although the highest risk of vulnerability is found in the poorest neighbourhoods of town, the largest number of children at risk is spread across middle-class neighbourhoods.”

This has important implications for public-health policy and programs. It is tempting to focus only on the small number of high-risk people, groups and communities — so called “targeted” interventions — because it seems as if that would be cheaper. But it’s not a very effective strategy because it misses most of the cases. For example, B.C.’s Nurse-Family Partnership provides regular visits by a public-health nurse throughout a woman’s first pregnancy, and those visits continue until the child reaches two years of age.

But it is only available to a select group of women; those under 19, or those age 20 to 24 who are lone parents, or have low income and education or are experiencing social, financial or housing challenges, including being homeless. Nobody would argue that this is not a high-risk group, but Rose’s Paradox and Clyde Hertzman’s work suggest the program may be missing most of the cases that need support.

If we want to have the greatest impact, we need to affect the entire population. What is needed, as Clyde and his colleagues at HELP point out in the B.C. Atlas of Child Development, is a combination of civil-society interventions that “create family-friendly environments across class and ethnic divides”; universal interventions, with barriers to vulnerable people removed; and targeted interventions.

In the U.K., this is known as “proportionate universalism”; everyone gets the intervention, but those with the greatest need get more. It’s the best way to shift the curve toward health.

Dr. Trevor Hancock is a retired professor and senior scholar at the University of Victoria’s School of Public Health and Social Policy.

© Trevor Hancock, 2019

Originally published in Times Colonist, 10 March 2019

 

Planning to feed a one-planet region

By Dr. Trevor Hancock 

The concept of a one-planet region is simple: We need to reduce our collective impact on the Earth so we — and others around the world — can live within the ecological and physical constraints of this one small planet we all share.

But at the same time, we want to maintain a high quality of life for all, both locally and globally.

When Jennie Moore and Cora Hallsworth determined the ecological footprint of Victoria and Saanich last year, they found, unsurprisingly, that we are consuming well above one planet’s worth of ecosystem goods and services. But what might have been surprising for many is that they found more than 40 per cent of our footprint is related to food; this compares with the 26 per cent of humanity’s overall global footprint that is related to food, according to a 2017 report from the Global Footprint Network.

The extent of the impact of our global food and agriculture system on the Earth is not widely appreciated. But a 2017 study by Michael Clark and David Tilman inEnvironmental Research Letters notes that agricultural activities are the source of between one-quarter and one-third of all greenhouse gases, occupy 40 per cent of Earth’s land surface and account for more than two-thirds of freshwater withdrawals, as well as being a significant contributor to deforestation, habitat fragmentation, biodiversity loss and pollution.

Moreover, the UN’s Food and Agriculture Organization reported in 2014 that 75 per cent of the world’s agricultural land is used for raising animals, and world average meat consumption per person doubled between 1961 and 2011. But meat production is a large contributor to global warming and other environmental problems, with beef being particularly problematic. A 2014 study in the Proceedings of the National Academy of Sciences found beef production has a much larger impact — between five and 28 times as much, depending on the issue — than the average of dairy, poultry, pork and egg production.

In their study of the Victoria and Saanich footprints, Moore and Hallsworth found more than half our food footprint was due to fish, meat and eggs, and another 18 per cent was due to dairy production. So reducing our local footprint means changing our diet. Happily, a 2014 U.K. study found a low-meat diet results in only 65 per cent of the emissions resulting from a high-meat diet.

Two important reports that speak to the issue of food, health and the environment have come out this month. The first is from the EAT-Lancet Commission on healthy diets from sustainable food systems. Since 2015, The Lancet — one of the world’s leading medical journals — has drawn attention to the concept of planetary health, because “far-reaching changes to the Earth’s natural systems represent a growing threat to human health.” The Lancet has produced reports on the health impacts of climate change, pollution — and now, diet.

Authored by 37 leading scientists from 16 countries, the report states “food is the single strongest lever to optimize human health and environmental sustainability on Earth.” Their prescription is clear: To safeguard both planetary and human health, “global consumption of fruits, vegetables, nuts and legumes will have to double, and consumption of foods such as red meat and sugar will have to be reduced by more than 50 per cent.”

The good news is that “a diet rich in plant-based foods and with fewer animal-source foods confers both improved health and environmental benefits.” They estimate their diet could prevent about 11 million deaths a year, globally.

Now Health Canada has issued its revised Canada Food Guide, and while not focused on the environmental benefits, it concludes, on health grounds, that we should eat plenty of vegetables and fruits (about half our diet), choose whole-grain foods and eat protein foods — not just lean meat, chicken, fish and eggs, but nuts and seeds, lentils, tofu, yogurt and beans.

I have noted before that a good food policy would be to follow Michael Pollan’s strictures: “Eat food, not too much, mostly plants.” If we are to shift to a one-planet region, we need a one-planet diet, and that means a low-animal-based and high-plant-based diet. The good news is we will be healthier for it, too.

Dr. Trevor Hancock is a retired professor and senior scholar at the University of Victoria’s School of Public Health and Social Policy.

© Trevor Hancock, 2019

Originally published in Times Colonist, 27 January 2019

Solstice a timely reminder of our place in the universe

By Dr. Trevor Hancock 

I have never lost the sense of awe I experienced one night as a teenager as I lay down in a dark spot and really looked at the Milky Way. It was overwhelming and humbling to realize what a small part of the galaxy our own seemingly vast solar system is, and what a tiny part of all that I am.

But it also gave me a strong sense of my connectedness to the universe, a sense that has never left me. I can get much the same sense of awe and connection by looking at the immensity of the ocean or a mountain, or the beauty of a butterfly or a flower.

But many people, perhaps most of us these days, have lost that connection — or at least experience it too infrequently. A vivid illustration of our loss of connection comes from Los Angeles, where in 1994, an earthquake knocked out power. According to a subsequent report in the journal Environmental Health Perspectives: “Many anxious residents called local emergency centres to report seeing a strange ‘giant, silvery cloud’ in the dark sky. What they were really seeing — for the first time — was the Milky Way, long obliterated by the urban-sky glow.”

Sadly, this loss of any awareness of the night sky is hardly surprising. The first world atlas of the artificial night sky brightness tells us: “Two-thirds of the U.S. population and more than one-half of the European population have already lost the ability to see the Milky Way with the naked eye.” But if we can’t see the stars, how do we know our connection to and place in the universe?

At a somewhat smaller scale, how many people realize that we are almost at the midwinter solstice? For that matter, how many pay attention to the midsummer solstice, the spring and fall equinoxes and the phases of the moon? But for most of our history, these have been of immense significance to humans, helping to connect us with the great cycles of nature.

We often forget — or perhaps choose to ignore — that many of our various faith-based celebrations have been superimposed on these much older traditions. Christmas itself is about the birth of a child, the “light of the world,” just as the winter solstice marks the return of the sun and the birth of the new year, while Hanukkah is also a festival of the light. Indeed, the later Romans celebrated Sol Invictus, the birth of the invincible sun, on Dec. 25, thought to be grafted on to an older cult of the sun.

Many of the aspects of our modern celebration of Christmas — bringing green boughs and trees into the house, lighting fires and candles, hanging mistletoe — have their roots in pagan traditions such as yule, and it seems fires and lights were an important part of the celebration of the winter solstice in many cultures.

Other celebrations are related to the lunar calendar. Easter and Passover are tied to the full moon around the time of the spring equinox, while Sukkot (a Jewish harvest festival) and the Christian tradition of harvest festivals are also around the time of the fall equinox. They are reminders that we were once deeply connected to the seasons and the Earth.

But too many people, indeed much of society, have lost touch with nature, which is part of the reason we are in such environmental trouble. Yet while we might imagine that our technology and our cleverness have made us separate from — and even superior to — nature, that is far from the truth. We are as dependent upon nature as we ever were. It is still where all our food, water, air, fuels and materials come from.

If we could but experience that sense of wonder, awe and connection that our ancestors felt — and perhaps some of the fear, too, for nature’s power remains immense — we might treat the Earth with more respect. So take a few moments this week to contemplate the turning of the year. Go out and look at the night sky, admire the ocean and the flowers, because we need more than ever to re-establish our connection with nature. Happy Solstice.

Dr. Trevor Hancock is a retired professor and senior scholar at the University of Victoria’s School of Public Health and Social Policy.

© Trevor Hancock, 2018

Originally published in Times Colonist, 16 December 2018

A Youth Perspective on Proportional Representation

My Experience with First Past the Post

By Marco Zenone

 I have voted in one provincial election (2017) since becoming of legal age. I was ecstatic to vote and be engaged in the democratic process – this was a major milestone. I had completed significant research on the platforms of the major parties and was confident in my voting decision.

On voting day the party I supported received 332,387 votes – or a total of 16.84% of the popular vote. They won 3 seats out of a possible 87. This was the most successful election of this party in the history of their existence.

Although I was happy to see this success – it was disconcerting that although 16.84% of British Columbians voted for this party – they only had about 3% of the legislative voting power. It was more concerning for me that the closest representative I felt I could contact was 147KM away from where I live.

Regardless of your political orientation – this should concern you and is a major flaw of the current first past the post electoral system.

Our previous three governments (2005-2013) had majority governments that did not receive 50% of the popular vote (2005-45.8%, 2009-45.8%, 2013-44.1%). The first past the post system allowed them to pass legislation unopposed – disregarding any opposition from other parties regardless of the validity of their concerns. Parties that were elected to represent those who voted against the majoritarian government based on their needs, values and beliefs.

This is not a system that represents the diversity of voices in British Columbia. We need to ensure all BC residents are adequately represented to inform public policy – regardless if your political beliefs align with the Liberal, NDP, or Green parties. We need proportional representation.

The Benefits of Proportional Representation

Reforming our electoral structure to a system of proportional representation will strengthen our democracy and reflect the needs of BC residents.

Proportional representation will encourage our governments to work collaboratively on public policy – having rich debate that will highlight the context of all BC residents instead of only a certain segment. PR may result in more minority governments and this is not negative – policy that is adequately debated will be better informed and of optimal quality.

Proportional representation will represent everyone fairly –if a party receives 40% of the vote, they will receive 40% of the seats and power – not 100%. All votes cast in an election will be meaningful – regardless of geographic location or which party a person supports.

Proportional representation encourages better and more transparent elections – our current system leads to parties focusing on electoral areas that are considered to be “undecided” – they will present platforms that are appealing to these specific areas to gain seats. Proportional representation will make major political parties focus on pressing issues affecting the entire province.

Proportional representation promotes equality and well-being – when people are confident their democratic engagement can have a real impact they are more likely to participate and advocate for the issues that affect them. Our most underserved and marginalized populations will benefit under proportional representation as their issues and votes are just as important as anybody else.

Closing Thoughts  

I encourage all persons regardless of your political leanings or prior beliefs to read how each system objectively operates.

We know that certain groups – in support or against proportional representation – are advocating aggressively through various forms of ads on social media. This can be effective in influencing our perceptions and we need to be aware of the motivation behind these ads. Question the advertisements you see.

Is their language positive and focusing on increasing democratic engagement – or is it fear mongering? Are they concerned with how this referendum affects everyone in BC – or only certain populations?

I’ve examined each system and questioned the advertisements I’ve seen – I strongly in proportional representation. We can change the way we do government for the betterment of all British Columbians. This referendum is an exceptional opportunity that we do not get often.

Our government has the chance to meaningfully represent all our residents – not only 40% of them.

Loneliness a growing public-health concern

By Dr. Trevor Hancock

It is ironic in this internet age, when everything and everyone seems to be connected, that we seem to be increasingly disconnected and lonely; moreover, many more of us are living alone.

The 2016 census found that the proportion of one-person households has been increasing steadily from 1951 (when it was 7.4 per cent) until 2016, when it became the most common type of household, at 28.2 per cent.

Living alone is not the same thing as being lonely; at various times we probably all want to be alone, and some people like to be alone a lot. But while being alone can be a choice, that is very different from loneliness, which the Oxford Dictionaries define as “sadness because one has no friends or company.”

That kind of being alone is involuntary, and the key word in the definition is sadness, which is only a step or two away from depression. After all, humans are social animals, so while being lonely on occasion is part of being human, chronic social isolation and loneliness are problematic.

In a 2017 report on connection and engagement, the Vancouver Foundation found that “14 per cent of residents say they feel lonely often or almost always” — which is one in seven people. But among people with a household income less than $20,000, more than one in three people are often or almost always lonely, while it is almost one in three of 18-24 year-olds and about one in four of those who are unemployed or are age 25 to 34.

Clearly, loneliness is an issue that affects the young and the poor, not just seniors, although it is often thought of that way.

Indeed, the mental and physical health consequences of loneliness are an emerging public-health concern; the U.K. appointed a ministerial lead on loneliness this year. This was greeted with derision in some quarters, perhaps in part because of a failure to understand both the difference between loneliness and being alone, and the severe health consequences of loneliness.

In his landmark book Loneliness: Human Nature and the Need for Social Connections, the late Dr. John Cacioppo, director of the University of Chicago’s Center for Cognitive and Social Neuroscience, described loneliness as “social pain” and “a deeply disruptive hurt” analogous to physical pain. He reported loneliness affects our immune system and our stress hormones, and can lead to suicidal thoughts and other mental and physical health problems.

Even more dramatically, he noted “social isolation has an impact on health comparable to the effect of high blood pressure, lack of exercise, obesity or smoking.” In fact, a 2015 review based on 70 studies from around the world found that, on average, those who reported they were lonely at the beginning of the study were 26 per cent more likely to die — greater than the increased risk of death due to obesity overall, and comparable to the mortality risk for moderate and severe obesity.

If loneliness is largely a lack of social connection, then presumably the answer is to create social connections among those who are lonely or are at risk of being lonely. But it is not that easy, especially among those who are chronically lonely. Cacioppo makes the point that loneliness itself can “create a persistent, self-reinforcing loop of negative thoughts, sensations and behaviours” that make it difficult to reach out or get out and make connections.

In a 2015 article in Perspectives on Psychological Science, Cacioppo’s team largely dismissed such seemingly common-sense approaches as providing social support, encouraging social engagement or teaching social skills, commenting that: “Interpersonal contact or communication per se is not sufficient to address chronic loneliness in the general population.” Instead they suggested a combination of cognitive behavioural therapy and some hoped-for medication.

I find that completely unsatisfactory, not only because it would be individualized and very expensive, but because with such a large-scale problem we need a population-wide public-health approach, just as we do for smoking or obesity. Clearly, we need to give a lot more thought to how we combat loneliness at a community level and strengthen social connections.

© Trevor Hancock, 2018

Originally published in Times Colonist, 19 August 2018

Two BC tools for healthier built environments

By Dr. Trevor Hancock

We are lucky in B.C. to have two useful initiatives to help us create healthier built environment

The first, which I described briefly last week, is the Healthy Built Environment Linkages Toolkit. The second is a B.C. Ministry of Health-funded initiative, PlanH, which “facilitates local government learning, partnership development and planning for healthier communities.” I will describe them both here.

(Full disclosure: PlanH was developed and is implemented on behalf of the ministry by the non-profit B.C. Healthy Communities Society, of which I am vice-chair of the board.)

For each of the five key elements of the built environment that the toolkit considers — neighbourhood design, transportation networks, natural environments, food systems and housing — it provides a chart showing the impact on the built environment and the strongest research correlations found in evidence reviews. I briefly covered the first two elements last week, so here I want to examine the others.

For the natural environment, the focus is on preserving and connecting environmentally sensitive areas, expanding natural elements across the landscape and maximizing the opportunity for everyone to access these natural environments. By doing so, we can increase the tree canopy, reduce urban air pollution and create cooler urban areas. (For a great discussion of the health benefits of trees and urban forests see the book Planet Heart by Dr. Francois Reeves, an interventionist cardiologist in Montreal.)

Among the health benefits identified in the toolkit for which there is strong evidence are reduced deaths from heart and urban heat events; improved mental health and social well-being; increased physical activity; and improved respiratory health. Other benefits include reduced health-care costs, energy savings, reduced pollution-control costs, and increased recreation and tourism.

Turning to food systems, the toolkit focuses on increasing equitable access to affordable and healthy food options, protecting agricultural land, increasing the capacity of local food systems, and supporting community-based food programs such as community gardens and community kitchens.

The health-related impacts of these approaches include improved diet quality and social well-being. Evidence suggests community kitchens, such as the Shelbourne Community Kitchen in Saanich, are particularly useful.

This small NGO provides small-group cooking, a pantry and gardening programs that help participants from low-income families acquire food skills and learn to access nutritious food affordably, while at the same time building community.

Finally, the toolkit looks at four approaches to creating healthy housing, particularly through prioritizing affordable quality housing options, especially for marginalized groups. The evidence supports the need for diverse housing forms and tenure types, located so as to avoid environmental hazards. There are many health benefits, including improved overall health and social well-being and reduced domestic abuse, crime and violence. (I will return to the topic of healthy housing in a future column.)

While the toolkit provides evidence and is intended primarily for planners, PlanH is more concerned with how to bring the health implications of decisions to the attention of municipal governments and citizens to support “leading-edge practices for collaborative local action.” It focuses on three key interconnected themes: Healthy people, a healthy society and healthy environments.

In considering healthy people, PlanH emphasizes that our health behaviours and choices are shaped by local social and environmental conditions. We need to create “vibrant places and spaces [that] cultivate belonging, inclusion, connectedness and engagement” in the context of “well-planned built environments and sustainable natural environments.”

To do so, PlanH helps local governments and their citizens learn about these issues and provides action guides and other practical resources and tools. It helps them connect and build relationships with community partners in other sectors (including regional health authorities) and with other local governments. And it helps them innovate with a funding program to support action, and by sharing success stories from around B.C. and beyond.

Together, these two initiatives give municipal governments, urban planners and citizens powerful support to help them make decisions that will improve health and well-being, which is surely one of their most important roles. So if you want healthier built environments in which to lead your life, raise a family and grow old, you might want to talk to your local government, community association and neighbours about the toolkit and PlanH.

© Trevor Hancock, 2018

Originally published in Times Colonist, 29 July 2018

Deepest Well-Trauma and Social Inequities

By Jennifer Wile

There are many facets to stories of childhood trauma, and many layers. When I was 4 years old, I developed, in rapid succession, strep throat, scarlet fever, and then rheumatic fever. My older brother started his 10 year journey of obesity. We had both been victims of violence and other abuse from my earliest memory. Then as a teenager and in my early twenties, I had multiple surgeries requiring general anesthesia for various rare but treatable physical ailments – strangely all in the same location, but caused by different factors. As an adult, I worked on the emotional effects of PTSD best helped through cognitive behavioral therapy. I discovered exercise helped my mood significantly. Even so, I did not consider the the stress of my childhood might have affected my body until I read Dr. Nadine Burke Harris’ book, The Deepest Well: Healing the Long-Term Effects of Childhood Adversity.

Trauma is no stranger to anyone: if we haven’t experienced ourselves, we know a loved one who has experienced or witnessed violence, abuse or neglect. When I read this book, I could not help but think of the children who are now separated from their parents at the borders as well as of children fleeing Syria. There are sadly many places where trauma is a fact of life, and the inner city can be one of them. It is a matter of public as well as individual health.

WHO recognizes that social conditions are important factors in health, and the all contribute to our total health. Nadine Burke Harris gives a gripping account of her exploration of the link between adverse childhood experience or (ACE) and toxic stress. She is a social innovator in public health and serves a vibrant and economically disadvantaged community, in San Francisco’s Bayview Hunters Point (BHP). She describes the challenges she faced personally and professionally when she opened the Center for Youth Wellness (CYW) as well as her attempts to have ACE and toxic stress, recognized as serious issue in children’s health, which included getting pediatricians to use screening protocols for ACE in pediatric assessments.

Burke Harris, a pediatrician with a Master’s in Public Health, writes with passion about connecting the stress of her patients with their emotional and physical well-being. When offering free pediatric care to children via her clinic, CYW, in BHP, an area that is on the extreme end of San Francisco’s social and economic inequality, Burke Harris saw clear relationships between the trauma that the community’s children experienced and their emotional and physical health. Toxic stress can, and often does, manifest itself in disease and poor health. Her examination discusses how poverty in the inner city can result in greater incidence of poor health with difficult living conditions, more exposure to violence, and untreated mental illness. While San Francisco’s median income was above $100,000 in 2016, City-Data shows that 31% of residents of Bayview Hunters Point live below the poverty line as of the last U.S. Census.

Poverty contributes to trauma, but Burke Harris reminds her audiences that trauma crosses all socio-economic boundaries. She tells us not only the stories of the children that she treated, and still treats, at the BHP Center, but also about her personal journey of trauma. Trauma does not stop in the wealthier neighborhoods. Helping overcome childhood trauma depends on your caregiver. There are engaged and nurturing caregivers in every community, just as there are neglectful caregivers in any community; however, if you live in inner city poverty, your chance of seeing violence randomly outside the home is likely. In one of Burke Harris’ case studies, a teenage boy, recovering well from childhood abuse, sees his best friend is killed on the street in front of him. Understandably, this incident is a setback for his health. The children Burke-Harris treated suffer from multiple adverse reactions, and have debilitating physical and psychological challenges ranging from asthma, obesity, failure to thrive, to stunted growth.

Although Burke-Harris’ accounts of traumatic experience can be shattering, such as the boy who stopped growing at age four when he trauma is exclusive to inner city poverty. Burke Harris reminds her audience repeatedly that toxic stress is an issue in any income bracket. Bringing this to a wider audience, Burke Harris shows us that society suffers when it ignores childhood trauma.

Thankfully, something can be done to help children (and adults) suffering from toxic stress. In fact, according to Burke Harris, part of the antidote to toxic stress is truly integrated health treatment including a combination of healthy relationships, counselling, meditation, exercise, and nutrition. The caregiver and their response to trauma play a huge role, but, sadly for those in underserved areas, so do the resources available to the child.

Though the subject matter is tough, the book and its author are inspiring, positive and passionate. This title comes as a hardcopy, eBook and is also available as an audiobook narrated by the author, which I highly recommend.

Watch Dr. Nadine Burke Harris here: https://www.youtube.com/watch?v=95ovIJ3dsNk or find her book at your local library in audio, eBook or hardcopy: Burke Harris, Nadine. (2018) The deepest well: Dealing with the long-term effects of childhood adversity. Houghton Mifflin Harcourt

 

Does Mental Health matter most?

By Dr. Trevor Hancock

There is an interesting common thread underlying many of my recent columns. It is the question in my title: Does mental health matter most? By which I mean, in high-income countries in the 21st century, does mental health matter more than physical health? Which in turn means, in terms of public health, does mental health promotion and the prevention of mental disorders matter more than preventing heart disease, cancer and other physical disorders?

There are many threads to my emerging argument. To begin with, the 70 year-old definition of health from the World Health Organisation is that health is a state of complete physical, mental and social wellbeing. Since social wellbeing is primarily about how we feel about and respond to our links to and relationships with others in our families and communities, it means a significant part of the definition is really about our mental wellbeing.

Add to this the relationship between the mind and the body – our state of mind affects our neuro-hormonal and immune systems, and the latter is involved in allergy, auto-immune disease, and the detection and elimination of both infection and abnormal cancer cells – and our state of mind assumes an even greater importance.

Another important issue is the changing pattern of disease and death. Globally, the World Health Organisation noted last year, “Depression is the leading cause of ill health and disability worldwide” – depression, we should note, is only one form of mental ill health. WHO also notes that there are “strong links between depression and other non-communicable disorders and diseases” and that “depression increases the risk of substance use disorders and diseases such as diabetes and heart disease”, while pointing out that “the opposite is also true . . . people with these other conditions have a higher risk of depression”.

We can also see the importance of mental health in the decline in life expectancy in the USA in each of the past 2 years, the first time this has happened in more than 60 years. But that decline is driven not by physical disorders such as heart disease and cancer but from the so-called ‘diseases of despair’; alcohol and drug use and suicide, which are largely mental and social disorders. And as I pondered in my last column, we may need to consider whether the growing concern about the state of our environment is adding to that despair.

Another factor to consider is the impact of poverty and inequality. Absolute poverty is unhealthy because people lack the basic necessities for life and health – clean water, food, shelter and so on – and we have some of that in Canada. But for the most part our problems are now those of relative poverty. Kate Pickett and Richard Wilkinson, in their book “The Spirit Level”, showed that in high-income countries, a range of health and social outcomes are not related to national income per person, but to the degree of inequality.

It seems that being lower in the ‘pecking order’ of society is harmful to health because we experience inequality as a lower sense of self-esteem and self-worth, relative powerlessness and even helplessness. All of which are mental and social experiences that, again, can translate into physical conditions.

The implication is that if we want to have a healthy population we need to pay much more attention to mental and social wellbeing than we have been doing. We need to provide more funding to research focused on understanding the root causes of mental and social health problems, and to policies and programming for preventing mental and social health problems, as we do to understanding and preventing heart disease and cancer – because we have under-invested on the mental health side.

Beyond that, we need to give at least as much attention to promoting mental and social wellbeing as we do to promoting physical wellbeing and fitness, recognizing that they are mutually beneficial. What would it take to create mentally healthy families, schools, workplaces, colleges and universities? How do we help people maintain mental wellbeing in the face of adversity, or as they age? How do we re-focus our society – including public health – to ensure mental health matters at least as much as physical health – maybe more.

© Trevor Hancock, 2018

Originally published in Times Colonist, 20 March 2018