The Commonwealth

Okay, the title of this session is “The Commonwealth.” Like Katherine and Cam Donalds earlier on, I thought I would play around with the title because the Commonwealth has connotations of money, riches, and economic growth. To be perfectly honest, I’m fed up hearing about it.

 

 

 

Wellness vs. Wealth

So, that’s what I thought we’d talk about: the Commonwealth, well, as in wellness. Adam Smith talked about this—not in his book The Wealth of Nations, but in the book he wrote a few years earlier. What was it called again? The Theory of Moral Sentiments, in which he talked about the fact that there is something in us that requires us to see the happiness of others, even though we derive no profit from it except the pleasure of seeing it.

He said that at one end of the scale, he saw people behaving for their own good in terms of their involvement with the market, and at the other end of the scale, he saw people behaving for the good of others. There’s clearly a spectrum between either end. He said even the greatest ruffian, the most abject violator of the laws of society, is subject to this notion of sympathy, he called it. He didn’t actually mention bankers, but I guess they’re probably in there somewhere.

 

 

 

The Question of Wellness

So, what I thought I would do is pose the question: What causes wellness? What is it that creates wellness in society? What is it that makes us well? You’re probably sitting there thinking, “Stupid question! Isn’t this guy a doctor? Doesn’t he know that what causes wellness is avoiding the causes of illness? Doesn’t he know that what makes us well is not being sick?”

Well, that’s fair enough for you to believe that because we have, for the last 100 to 150 years, been brainwashed into thinking that what matters is not being ill. But the reality is there is a spectrum here, just as there was in Adam Smith’s thinking about well-being and wealth. There’s a spectrum between pathogenesis at one end and salutogenesis at the other.

 

 

 

Pathogenesis vs. Salutogenesis

Doctors are trained exclusively in pathogenic thought—the causes of disease. We’re trained to diagnose it, we’re trying to take histories to detect it, we’re trying to treat it, and we’re trying to find ways of preventing it. But it’s a disease focus. Salutogenesis, on the other hand, is a term that comes from salus. Salus was the Roman goddess of well-being, also interestingly the Roman goddess of safety—an interesting combination of thought there.

 

 

 

Observations from Experience

The idea that there is a spectrum first occurred to me about 30 years ago when I went to work in the Royal Infirmary as a surgeon. I was there for about two weeks, and I noticed something strange: Patients took longer to heal their wounds in the East End. In all the hospitals I’d worked in previously, if you did an abdominal incision, by about 8 to 10 days it was healed up, and they could go home. In the Royal, it was about 10 to 11 days—subtle, but it wasn’t just me; others had noticed it. We put it down to the fact that, well, they smoke more, they eat the wrong kinds of food, and so on, that that would slow down healing.

But over the next few years, it became very plain to me that that wasn’t the cause. Since then, in the last 25 years, our analysis has shown that—now, don’t get me wrong, smoking is very, very bad for you, okay? If anyone here smokes, stop it at once! But we cannot ascribe the gap between rich and poor to the commonly held beliefs of smoking and fatty diets. These have an effect, but they don’t explain nearly enough of it.

 

 

 

Seeking Additional Explanations

So, I began to look for other theories that would begin to explain what it is that was missing in the lives of people in the poorest parliamentary constituencies in Britain that had the lowest life expectancy. What was it that they didn’t have that others had? And that’s when I stumbled on the notion of salutogenesis.

I’ll just mention one or two theories. Emily Werner, for example, is a psychologist who studied the health of children living in a particular island in the Hawaiian archipelago where there was a high level of alcoholism, child abuse, and just general chaos in life. She found that 70% of the children grew up to have serious difficulties and followed their parents into these particular patterns of living, but 30% of them survived and did well.

What she said was they acquired resilience, and what allowed them to acquire resilience was they had developed positive attributes. They were outgoing, positive, optimistic, bright. They had significant relationships with a sensible adult, who might have been a parent or a grandparent, but there was a mentor there to help them, and they received support within the community from their peers.

 

 

 

The Search for Meaning

Another theory came from Viktor Frankl. Viktor Frankl was an Austrian psychotherapist who spent the war years in Auschwitz, and he wrote a book—he went on to live until he was 95. He wrote a book entitled Man’s Search for Meaning, and in the introduction to it, he says, “If you have a why to live, you can bear with almost any how.”

Meaning and purpose allow you to hang on to life and make the best of it, no matter how miserable the circumstances are. If you think about the way meaning and purpose in lives began to disappear in West Central Scotland when the shipyards closed, when the steel foundries disappeared, when men suddenly had no jobs that gave their lives meaning and purpose.

 

 

 

Flourishing as a Cause of Well-Being

Another notion is the notion of flourishing. Corey Keyes, an American psychologist, talks about flourishing as a cause of well-being. People who flourish are happy, satisfied; they see themselves as having a purpose. They are optimistic, they have a degree of mastery, they have a sense of control over their lives, and they have a degree of self-esteem. They accept themselves for what they are. All of these themes run through all of the different theories of well-being.

 

 

 

The Link Between Psychology and Biology

But it was when I came across an American sociologist called Aaron Antonovsky that things began to make sense because I was looking for a link between psychology and biology. When I was a surgeon at the Royal Infirmary, I would sign death certificates all the time, but I never signed a death certificate that said he died because he was unemployed. You die of a molecular event.

So what was the link between social circumstances and the increased risk of molecular events like thrombosis and malignancy, and so on? Antonovsky began to fill in that space. He said unless we learn that the world is comprehensible, manageable, meaningful—unless we learn that we can make sense of the world and we can control, to a certain extent, the events round about us and want to engage with that—we would experience a state of chronic stress.

 

 

 

Insights from Concentration Camp Survivors

Antonovsky derived that thought from interviewing many hundreds of concentration camp survivors. He found that 70% of them were unhealthy, but again, 30%—the same as Werner’s discovery—30% of those adults who, as children, had been in concentration camps survived. He said unless you acquire this sense that the world is comprehensible, manageable, and meaningful, children who don’t acquire that sense see all the events round about them as noise, not as information, and they become stressed by it.

 

 

 

The Biological Consequences of Social Chaos

I don’t have time to go into the detail, but we’ve followed through in great detail the biological consequences of social chaos. I’ll just show you one example: the way in which stressful events in early life change the way brain structures develop. We know that even from the earliest months, children living in children’s homes—a Canadian study—found that the longer a child is being looked after away from a single significant parent, the greater their stress hormone levels are.

They grow up to have changes in structures in the brain. That squiggly bit in the middle of that brain picture is an area called the hippocampus. That’s the bit of the brain that, among other things, allows you to learn and remember appropriately, but it also helps you suppress the stress response.

 

 

 

The Impact of Early Life Stress

We know from measurement of the volume of the hippocampus in affluent versus deprived people—not just in the West of Scotland but in other parts of the world—that chaotic early life leads to a reduced ability to manage stress, upregulation of stress responses, reduced ability to learn, and reduced ability to make sense of the world around you and behave appropriately. The biology is very clear: chaotic, difficult circumstances lead to increased risk of physical ill health. So let’s not spend a fortune trying to find drugs to fix that; let’s change the chaotic and difficult circumstances so that they don’t happen.

 

 

 

The Cycle of Alienation

In 1971, I was a medical student when we elected the great Jimmy Reid as rector of Glasgow University. His rectorial address was reprinted in full in The New York Times, which called it the single most important speech since the Gettysburg Address. Those of us who were there thought that comparison rather flattered Abraham Lincoln, to be perfectly honest. His speech was about alienation, which he defined as the cry of men, the victims of blind economic forces beyond control, the feeling of despair and hopelessness that pervades people who feel, with justification, they have no say in shaping or determining their own destinies.

 

 

 

The Consequences of Alienation

This is what I think is happening in West Central Scotland: a cycle of alienation that may begin with chaotic early years, leads to mental ill health in childhood, leads to behavior problems at school. Oh, and by the way, when a child who is becoming alienated has behavior problems at school, what do we do with them? We exclude them from school, alienating them even further.

I heard recently about a kid who was permanently truanting. What did they do? They excluded him from school. Madness! They fail in education, and they end up often in prison. When I visit the young men in prison, I say to them, “What are you going to do when you get out?” “I’ll never get a job.” “So what are you going to do?” “I’ll just sit at home and watch TV and drink.” Their lives are ended at age 18.

The consequences of that are worthlessness and poverty, which feeds even more into this sense of alienation. We think if only we fix poverty, it will all be all right. Poverty is part of a cycle, and poverty can often be as much a consequence of this cycle as a cause of it. Action that’s required has to happen across the whole of that life course. We have to deal with early years; we have to deal with teenagers; we have to help young people who are being alienated even further; we have to help older people who become isolated.

 

 

 

Initiatives in Scotland

And we’re doing it. We’re doing things in Scotland that the rest of the world is looking on enviously. Tomorrow, down in the SECC, we will have the fifth meeting of the Early Years Collaborative. The Early Years Collaborative brings together 800 practitioners, plus some senior people.

One of the guys in the foreground in that slide is the permanent secretary in the Scottish government, who comes to all of these things because he thinks it’s that important. Ministers come; they come and they stay—they don’t just do the 20-minute speech and go away. What’s happening is practitioners have decided that they will change childhood. They will stand up and work out what’s happening; they will test things.

For example, if you improve attachment between parent and child, you improve cognitive function by bedtime stories. I was probably the only chief medical officer in the world who knew from one day to the next how many children in Scotland got bedtime stories because we counted it. This is a nursery that says, “Okay, we’ll ask all the kids if they got a bedtime story, and if it falls below 90%, we’ll do something to make it better.”

Just like the British cycling team made huge performance improvements by attention to lots of little details, there’s bedtime stories, there’s breastfeeding, there’s smoking cessation, and there’s a whole range of things going on across the whole of Scotland to make Scotland the best place in the world for children to grow up with wellness. With method, we can transform Scotland.

 

 

Inspirational Initiatives in New York

Last April, I went to visit a lady called Rosanne Haggerty in New York. In 2010, Rosanne decided to set out to find 100,000 homes for homeless people. I checked this morning; the counter on her website shows that she has found homes for 99,114 people. Four years later, she found it by connecting with people. Volunteers would go out waking up folks sleeping under bridges and ask them their names. Once they had asked them their names, connections occurred, and they found them homes. These people had been homeless for an average of seven years, and she’s doing it.

 

 

 

The Power of Connection

I’ll just finish by quoting this guy. The guy in the middle with the daft grin on his face is a priest who 30 years ago was sent to a parish in South Los Angeles. The police told him he would be lucky to survive a week because of the gang warfare that was taking place. Thirty years on, he is surrounded by adoring fans because he connected with them. He just went out and asked them their names, and he found that the thing was they felt as if they had no meaning and purpose.

So he got a rich friend of his to buy a disused bakery, and Homeboy Bakery was born. He employed them. He quickly found he had to start a second enterprise called Homeboy Tattoo Removal because they all had gang tattoos and they were all fighting with each other. A plastic surgeon friend of his gave him a laser and showed two or three of the gang members how to take tattoos off.

 

 

 

A Call for Compassion

Greg came to Glasgow a few months ago at the request of the Violence Reduction Unit, and I took him to visit a school at lunchtime. He told me that the 14 and 15-year-olds he spoke to there asked him far harder questions than most academics asked them. But I just want to leave you with one final comment that he made to these kids, and it’s the comment that should drive us to strive harder to fix the broken bits of Scotland.

What he said to them was, “What we need in this world is a compassion that stands in awe at the burdens the poor have to carry rather than stands in judgment at the way they carry them.” If we live by that, we’ll make Scotland a much better place.