It was the third time in a year that John had been admitted with acute pancreatitis. The cause was obvious. ‘John,’ I said to him, ‘if you keep on drinking, you’ll die!’ ‘Ach, I know,’ he replied. ‘But I don’t care. Life is crap and the booze is the only pleasure I get!’
As a surgeon in Glasgow Royal Infirmary in the 1980s, this kind of conversation took place with patients on a regular basis. Eventually, I decided that my patients did not need more surgery – they needed more wellbeing. I resigned my consultant post and became a trainee in public health medicine.
It was during that training that I first heard the term ‘salutogenesis’. During six years as a medical student and 15 years as a surgeon, I had only ever heard of ‘pathogenesis’. Doctors learn that the main cause of poor health is illness, a pathological process.
Salus was the Roman goddess of safety, wellbeing and prosperity. The idea that poor health could be due to the absence of a positive, salutogenic influence in someone’s life seemed, given my experience with poor Glaswegians, novel but entirely obvious.
So, what causes wellbeing? Sociologists and psychologists have described the characteristics of individuals who have a strong capacity for wellbeing. They tend to feel in control of their lives – they make their own decisions about their life and don’t leave it to some external agency. They are confident they can deal with whatever life throws at them and as a result, they are optimists.
The biological science which underpins salutogenesis is as robust as that which underpins pathogenic mechanisms of disease, and it explains more accurately the origins of health inequalities in our society. Sir Michael Marmot described the relationship between socioeconomic status and stress levels. Others, notably the late Bruce McEwen, have described the effect stressful environments have on brain development in early life.
These changes leave the individual less likely to be able to control their emotions and with poorer memory. Such an individual is more likely to get into trouble and do badly at school. Adverse experiences in childhood, such as neglect, exposure to domestic violence and parental mental health problems lead also to low serotonin levels.
These effects are the biological basis of poor wellbeing. They are on a path to an unhealthier and less fulfilling life.
So how should we use this science to improve the wellbeing of our population? How are we to support those at the lower end of the social scale who have no jobs, little income and who do not feel in control of their lives?
Often the approach is to tell them that their drug taking, alcohol consumption, overeating and lack of exercise is very naughty and will surely cause them harm! They must stop it at once! Do we really think they don’t know that already? Are they going to benefit if we lecture them about the bad choices they make?
Time to open our minds
Conventional health promotion has not been particularly successful in tackling inequality because it tends to relate behaviours and illness as part of a pathogenic paradigm. Recently Andy Cooke, the chief constable of Merseyside police, said that if he was given money to cut crime, he would put 80% of it into tackling poverty and only 20% into law enforcement. He concluded that ‘the best crime prevention is increased opportunity and reduced poverty’.
In 1971, I was a medical student when we elected a local trade unionist, Jimmy Reid, as Lord Rector of Glasgow University. His rectorial address was about alienation. He defined it as: ‘the cry of men who find themselves the victims of blind economic forces beyond their 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.’
A policeman and a shipyard worker both understood the problem of inequality. It is time we in the health professions opened our minds to new ways of solving the problem.
This is why, as president of the BMA, I have made addressing health inequalities across the UK the focus of my presidency. To support clinicians to reduce health inequalities in their local area, we are launching a call for input into a new best practice toolkit.
I want to be clear this will not be a replacement for BMA campaigning to ensure UK governments are meeting their responsibilities. Rather, this will be a resource for interested or frustrated clinicians who want to do something more.
To inform the toolkit, we are asking members to send us examples of initiatives they have seen or participated in and which work to reduce health inequalities. We want this toolkit to be relevant and helpful, no matter where or how you practise, so the more clinicians we hear from the better!
Health inequity is a scourge on our society. Let us do our bit to see that everyone can live a long and healthy life, no matter who or where they are.