Unhealthy Glasgow: a case for ecological public health?

Ecological public health has been proposed as an approach appropriate for addressing the multiple transitions that currently affect human health and sustainability. The paper draws on the author's experience in public health in Glasgow to analyse the health challenges faced by this postindustrial Scottish city. Like other such cities, it not only faces multiple health challenges but also demonstrates a currently unexplained excess mortality that has been dubbed the 'Glasgow Effect'. To explore this troubled mixture, the paper outlines four historical waves of public health challenge and response in Glasgow over the last century, and proposes that a fifth is emerging. The challenge now is how to negotiate environmental sustainability with social, political and economic sustainability to enhance health for all. The paper suggests that gains made by past approaches still need to be protected and can be included within ecological public health, but they lack the wider vision, coherence and capacity required if cities are to address the scale and range of contemporary conditions. A number of lessons are offered for the ecological public health perspective.

Systems Medicine 2.0: potential benefits of combining electronic health care records with systems science models.

BACKGROUND: The global burden of disease is increasingly dominated by non-communicable diseases.These diseases are less amenable to curative and preventative interventions than communicable disease. This presents a challenge to medical practice and medical research, both of which are experiencing diminishing returns from increasing investment. OBJECTIVE: Our aim was to (1) review how medical knowledge is generated, and its limitations, (2) assess the potential for emerging technologies and ideas to improve medical research, and (3) suggest solutions and recommendations to increase medical research efficiency on non-communicable diseases. METHODS: We undertook an unsystematic review of peer-reviewed literature and technology websites. RESULTS: Our review generated the following conclusions and recommendations. (1) Medical knowledge continues to be generated in a reductionist paradigm. This oversimplifies our models of disease, rendering them ineffective to sufficiently understand the complex nature of non-communicable diseases. (2) Some of these failings may be overcome by adopting a "Systems Medicine" paradigm, where the human body is modeled as a complex adaptive system. That is, a system with multiple components and levels interacting in complex ways, wherein disease emerges from slow changes to the system set-up. Pursuing systems medicine research will require larger datasets. (3) Increased data sharing between researchers, patients, and clinicians could provide this unmet need for data. The recent emergence of electronic health care records (EHR) could potentially facilitate this in real-time and at a global level. (4) Efforts should continue to aggregate anonymous EHR data into large interoperable data silos and release this to researchers. However, international collaboration, data linkage, and obtaining additional information from patients will remain challenging. (5) Efforts should also continue towards "Medicine 2.0". Patients should be given access to their personal EHR data. Subsequently, online communities can give researchers the opportunity to ask patients for direct access to the patient's EHR data and request additional study-specific information. However, selection bias towards patients who use Web 2.0 technology may be difficult to overcome. CONCLUSIONS: Systems medicine, when combined with large-scale data sharing, has the potential to raise our understanding of non-communicable diseases, foster personalized medicine, and make substantial progress towards halting, curing, and preventing non-communicable diseases. Large-scale data amalgamation remains a core challenge and needs to be supported. A synthesis of "Medicine 2.0" and "Systems Science" concepts into "Systems Medicine 2.0" could take decades to materialize but holds much promise.

Spatial inequalities in life expectancy within postindustrial regions of Europe: a cross-sectional observational study.

OBJECTIVES: To compare spatial inequalities in life expectancy (LE) in West Central Scotland (WCS) with nine other postindustrial European regions. DESIGN: A cross-sectional observational study. SETTING: WCS and nine other postindustrial regions across Europe. PARTICIPANTS: Data for WCS and nine other comparably deindustrialised European regions were analysed. Male and female LEs at birth were obtained or calculated for the mid-2000s for 160 districts within selected regions. Districts were stratified into two groups: small (populations of between 141 000 and 185 000 people) and large (populations between 224 000 and 352 000). The range and IQR in LE were used to describe within-region disparities. RESULTS: In small districts, the male LE range was widest in WCS and Merseyside, while the IQR was widest in WCS and Northern Ireland. For women, the LE range was widest in WCS, though the IQR was widest in Northern Ireland and Merseyside. In large districts, the range and IQR in LE was widest in WCS and Wallonia for both sexes. CONCLUSIONS: Subregional spatial inequalities in LE in WCS are wide compared with other postindustrial mainland European regions, especially for men. Future research could explore the contribution of economic, social and political factors in reducing these inequalities.

A perspective on the future public health: an integrative and ecological framework.

Modernity has brought health and social benefits to many societies, not least through the insights of science and technology. Yet, modernity has also been associated with a number of cultural characteristics, such as materialism, individualism, consumerism and an addiction to continuing economic growth, that seem potentially harmful to health and well-being and inimical to social equity. There is an emerging body of evidence that suggests that, in the affluent world, some of our most intractable contemporary health problems are, in fact, the product of modernity. This suggests that the tools of modernity (its science and its technology) are ill suited to finding solutions. This poses a problem for public health, as this discipline is itself a product of modernity and thus appears ill equipped to deal with the conditions and challenges of a rapidly changing and unstable world, one where the very sustainability of human society is now in question. This paper argues that a new paradigm for the future public health is needed. It presents an integrative, ecological framework as a starting point from which public health might grasp the opportunities for change inherent in the 'modern' threats we face. It suggests a number of features that will need to underpin such a paradigm shift in thinking and practice. However, as this paper is written from the perspective of an affluent, developed society (albeit from a perspective that is explicitly critical of the goals, trends and values that seem to characterise such societies), other voices from other places need to be heard. We hope that others will want to engage with our arguments and suggestions, whether to challenge and refute these, or to further their development.

A perspective on the future public health practitioner.

In the centuries following the Enlightenment, scientific and technological developments gave 'modern people' an unprecedented ability to understand, predict and control the natural world. This has brought health and social benefits unimaginable to our ancestors and sets us apart from all previous generations. Yet there is a wide-ranging body of evidence that suggests that modernity is now in decline, largely because its methods and mindset are increasingly recognized as unsustainable. Problems are manifest in the emergence of new public health epidemics such as obesity and addictive behaviours, the loss of well-being and increase in anxiety and depression in affluent society, and the persistence of ever-widening health and social inequalities at national and global levels. Still larger problems now confront us, such as climate change, peak oil and the loss of biodiversity, all of which are linked to the 'modern' way of life. We are potentially faced with the collapse of certain aspects of modern society: we are certainly faced with the prospect of inevitable change. While the broad public health community has an important role to play in developing workable solutions to such daunting problems, we argue that some profound changes will be needed in order for us to cope successfully. No blueprints for dealing with change exist, which means that we will need to learn our way into the future. In this paper we take a perspective on the role and nature of the future practitioner in public health and health promotion. We argue that future practitioners will need to develop new ways of thinking, being and doing; new perspectives and new forms of understanding the world. We believe our discipline - and people generally - to be capable of such development, as insights from multiple sources tell us that human nature is malleable, not fixed. We use this analysis to trace, as examples, the imagined lives of five women living in different eras over the course of history in a Western society, and the emergence of different mindsets or worldviews, as the social, economic and cultural context changes. Post-modern analysts might insist that we have no basis for making value judgements between such different worldviews. In this paper, however, we argue that future practitioners should be empathetic to different views and willing to move beyond them, as necessary. We will need to learn and develop in ways that are compatible with our intrinsic needs as human beings and the needs of our ecosystem. We conclude by suggesting just some of the supportive processes of change needed in mapping out a more sustainable future for the public health community.

Learning our way into the future public health: a proposition.

This article attempts to bridge the gap between the values and skills that currently inform public health and those that we need to confront the future. We draw on a set of radical arguments. Firstly, the ability of modern people to understand, predict and control the natural world has brought many benefits but evidence is accumulating that the methods and mindsets of modernity are subject to diminishing returns and adverse effects. This is manifest in the rise of new epidemics: obesity, addiction-related harm, loss of well-being, rising rates of depression and anxiety and widening inequalities. Secondly, there is little evidence that people are embracing new forms of thinking or practice, despite other threats which have the potential for massive effects on many lives, such as climate change and peak oil. Thirdly, if the problems we face may indicate that 'modernity' is in decline because unsustainable, then profound change is necessary if we are to avoid collapse. This analysis suggests that public health needs a new approach. We set out propositions and models that could help us learn our way into the future.

Protocol for a mixed methods study investigating the impact of investment in housing, regeneration and neighbourhood renewal on the health and wellbeing of residents: the GoWell programme.

BACKGROUND: There is little robust evidence to test the policy assumption that housing-led area regeneration strategies will contribute to health improvement and reduce social inequalities in health. The GoWell Programme has been designed to measure effects on health and wellbeing of multi-faceted regeneration interventions on residents of disadvantaged neighbourhoods in the city of Glasgow, Scotland. METHODS/DESIGN: This mixed methods study focused (initially) on 14 disadvantaged neighbourhoods experiencing regeneration. These were grouped by intervention into 5 categories for comparison. GoWell includes a pre-intervention householder survey (n = 6008) and three follow-up repeat-cross sectional surveys held at two or three year intervals (the main focus of this protocol) conducted alongside a nested longitudinal study of residents from 6 of those areas. Self-reported responses from face-to-face questionnaires are analysed along with various routinely produced ecological data and documentary sources to build a picture of the changes taking place, their cost and impacts on residents and communities. Qualitative methods include interviews and focus groups of residents, housing managers and other stakeholders exploring issues such as the neighbourhood context, potential pathways from regeneration to health, community engagement and empowerment. DISCUSSION: Urban regeneration programmes are 'natural experiments.' They are complex interventions that may impact upon social determinants of population health and wellbeing. Measuring the effects of such interventions is notoriously challenging. GoWell compares the health and wellbeing effects of different approaches to regeneration, generates theory on pathways from regeneration to health and explores the attitudes and responses of residents and other stakeholders to neighbourhood change.

The health and socioeconomic impacts of major multi-sport events: systematic review (1978-2008).

OBJECTIVE: To assess the effects of major multi-sport events on health and socioeconomic determinants of health in the population of the city hosting the event. DESIGN: Systematic review. DATA SOURCES: We searched the following sources without language restrictions for papers published between 1978 and 2008: Applied Social Science Index and Abstracts (ASSIA), British Humanities Index (BHI), Cochrane database of systematic reviews, Econlit database, Embase, Education Resources Information Center (ERIC) database, Health Management Information Consortium (HMIC) database, International Bibliography of the Social Sciences (IBSS), Medline, PreMedline, PsycINFO, Sociological Abstracts, Sportdiscus, Web of Knowledge, Worldwide Political Science Abstracts, and the grey literature. Review methods Studies of any design that assessed the health and socioeconomic impacts of major multi-sport events on the host population were included. We excluded studies that used exclusively estimated data rather than actual data, that investigated host population support for an event or media portrayals of host cities, or that described new physical infrastructure. Studies were selected and critically appraised by two independent reviewers. RESULTS: Fifty four studies were included. Study quality was poor, with 69% of studies using a repeat cross-sectional design and 85% of quantitative studies assessed as being below 2+ on the Health Development Agency appraisal scale, often because of a lack of comparison group. Five studies, each with a high risk of bias, reported health related outcomes, which were suicide, paediatric health service demand, presentations for asthma in children (two studies), and problems related to illicit drug use. Overall, the data did not indicate clear negative or positive health impacts of major multi-sport events on host populations. The most frequently reported outcomes were economic outcomes (18 studies). The outcomes used were similar enough to allow us to perform a narrative synthesis, but the overall impact of major multi-sport events on economic growth and employment was unclear. Two thirds of the economic studies reported increased economic growth or employment immediately after the event, but all these studies used some estimated data in their models, failed to account for opportunity costs, or examined only short term effects. Outcomes for transport were also similar enough to allow synthesis of six of the eight studies, which showed that event related interventions--including restricted car use and public transport promotion--were associated with significant short term reductions in traffic volume, congestion, or pollution in four out of five cities. CONCLUSIONS: The available evidence is not sufficient to confirm or refute expectations about the health or socioeconomic benefits for the host population of previous major multi-sport events. Future events such as the 2012 Olympic Games and Paralympic Games, or the 2014 Commonwealth Games, cannot be expected to automatically provide benefits. Until decision makers include robust, long term evaluations as part of their design and implementation of events, it is unclear how the costs of major multi-sport events can be justified in terms of benefits to the host population.

The aftershock of deindustrialization--trends in mortality in Scotland and other parts of post-industrial Europe.

BACKGROUND: Post-industrial decline is frequently cited as one of the major underlying reasons behind the poor health profile of Scotland and, especially, West Central Scotland (WCS). This begs the question: to what extent is poor health a common outcome in other post-industrial regions and how does Scotland's experience compare to these other comparable regions? METHODS: Regions were identified by means of an expert-based consultation, backed up by analysis of regional industrial employment loss over the past 30 years. Mortality rates and related statistics were calculated from data obtained from national and regional statistical agencies. RESULTS: Twenty candidate regions (in: Belgium; France; Germany; Netherlands; UK; Poland; Czech Republic) were identified, of which ten were selected for in-depth analyses. WCS mortality rates are generally higher and-crucially-appear to be improving at a slower rate than in the other post-industrial regions. This relatively poor rate of improvement is largely driven by mortality among the younger working age (especially male) and middle-aged female populations. CONCLUSION: WCS mortality trends compare badly with other, similar, post-industrial regions of Europe, including regions in Eastern Europe which tend to be characterized by higher levels of poverty. This finding challenges any simplistic explanation of WCS's poor health being caused by post-industrial decline alone, and begs the question as to what other factors may be at work.

Is 'modern culture' bad for our health and well-being?

Evidence is accumulating that well-being in high-income societies may be static or in decline. One influential theory argues that this is because 'modern' societies are influenced by values of materialism, individualism and consumerism. Does this intellectual critique resonate with ordinary people? This article reports on interviews with purposefully selected groups in Scotland, where the relevance of the cultural critique was explored. Participants in the study believed that cultural values such as individualized consumerism do exert a damaging influence on well-being. They suggested that such values are given particular power in the context of widespread social change and increasing inequalities. Nevertheless, they also believed that individuals and communities possess the capacity to resist such trends. This article concludes that efforts to achieve material improvement for disadvantaged people may not suffice in redressing deep-seated inequalities, if the contribution of some subtle but pernicious effects of contemporary culture remains neglected. However, the research does suggest that positive responses are also possible.

'Wellbeing': a collateral casualty of modernity?

In the now vast empirical and theoretical literature on wellbeing knowledge of the subject is provided mainly by psychology and economics, where understanding of the concept are framed in very different ways. We briefly rehearse these, before turning to some important critical points which can be made about this burgeoning research industry, including the tight connections between the meanings of the concept with the moral value systems of particular 'modern' societies. We then argue that both the 'science' of wellbeing and its critique are, despite their diversity, re-connected by and subsumed within the emerging environmental critique of modern consumer society. This places concerns for individual and social wellbeing within the broader context of global human problems and planetary wellbeing. A growing number of thinkers now suggest that Western society and culture are dominated by materialistic and individualistic values, made manifest at the political and social levels through the unending pursuit of economic growth, and at the individual level by the seemingly endless quest for consumer goods, regardless of global implications such as broader environmental harms. The escalating growth of such values is associated with a growing sense of individual alienation, social fragmentation and civic disengagement and with the decline of more spiritual, moral and ethical aspects of life. Taken together, these multiple discourses suggest that wellbeing can be understood as a collateral casualty of the economic, social and cultural changes associated with late modernity. However, increasing concerns for the environment have the potential to counter some of these trends, and in so doing could also contribute to our wellbeing as individuals and as social beings in a finite world.

Mental health as a reason for claiming incapacity benefit--a comparison of national and local trends.

BACKGROUND: Getting incapacity benefit (IB) claimants into work has become a focus for policy makers. Strategies to help this group depend on an understanding of the reasons for claiming benefit at a local level where variations from a national strategy may be needed. METHODS: Data supplied by the Department for Work and Pensions (DWP) was analysed to establish reasons for claiming benefit in Scotland and Glasgow between 2000 and 2007. RESULTS: There has been a continuing rise in mental health diagnosis and a corresponding fall in musculoskeletal diagnosis during this period. More people were claiming because of mental health problems in Glasgow than in Scotland. Also those with a poor employment history (credits-only claimants) are more likely to claim IB because of a mental health problem. This study has shown a breakdown into 25 categories those claiming IB because of a mental health problem. CONCLUSION: DWP data can be used to provide important insights into the trends in reasons for claiming IB, in particular those claiming because of mental health problems. This study also highlighted the growing importance of problems caused by alcohol and drug-abuse claimants, a subset of the mental health category. DWP data should be used at a local as well as a national level to guide and evaluate interventions to help this vulnerable group.

Thesis: Do we face a third revolution in human history? If so, how will public health respond?

BACKGROUND: A range of evidence suggests that the dominant culture associated with the economic systems of 'modern' societies has become a major source of pressure on global resources and may precipitate a third revolution in human history, with major implications for health and well-being. OBJECTIVE: This paper aims to consider whether there are historical analogies with contemporary circumstances which might help us make connections between past and present predicaments in the human condition; to highlight the underpinnings of such predicaments in the politico-economic and cultural systems found in 'modern' societies; to outline questions prompted by this analysis, and stimulate greater debate around the issues raised. METHODS: We draw on evidence and arguments condensed from complex research and theorizing from multiple disciplines. RESULTS: Contemporary evidence suggests that global depletion of a key energy resource (oil), increasing environmental degradation and imminent climate change can be linked to human socio-economic and cultural systems which are now out of balance with their environment. Those systems are associated with Western-type societies, where political philosophies of neo-liberalism, together with cultural values of individualism, materialism and consumerism, support an increasingly globalized capitalist economic system. Evidence points to a decline of psychological and social well-being in such societies. CONCLUSION: We need to work out how to prevent/ameliorate the harms likely to flow from climate change and rising oil costs. Public health professionals face the challenge of preventing adverse health consequences likely to result from continued adherence to the have-it-all mindset prevailing in contemporary Western societies. Equally, we need to seek out the potential health dividends that could be realized in terms of reduced obesity, improved well-being and greater social equity, while not under-estimating the likelihood of profound resistance, from many sectors of society, to unwanted but inevitable change.

Status, taste and distinction in consumer culture: acknowledging the symbolic dimensions of inequality.

The relationship between social position and health has been the focus of extensive public health debate. In the UK and elsewhere, most researchers have focused on physical aspects of health, using indicators such as mortality and morbidity to draw a picture of profound and widening social inequalities. This paper draws attention to the (neglected) influence of contemporary culture on wellbeing, arguing that the social meanings created within consumer culture possess symbolic force that can add to wider inequalities. The possession of greater material and cultural resources by people of higher social status enables them to label their preferred forms of consumption and lifestyle as desirable and legitimate, thus conveying messages about superior taste and social distinction. Symbolic rather than material forms of inequality are implicated here, with consequences for the psychological wellbeing of disadvantaged people. This paper argues that analyses of inequality need broadening to include such considerations. However, there are implications for efforts to address health inequalities because this analysis suggests that if some forms of social inequality are removed, elements within society would be motivated to invent new forms to replace them. Therefore, this article suggests processes whereby people can develop the self-awareness needed to resist the glossy illusions of the good life represented by modern consumer capitalism.

Establishing the potential for using routine data on Incapacity Benefit to assess the local impact of policy initiatives.

BACKGROUND: Incapacity Benefit (IB) is the key contributory benefit for people who are incapable of work because of illness or disability. METHODS: The aims were to establish the utility of routinely collected data for local evaluation and to provide a descriptive epidemiology of the IB population in Glasgow and Scotland for the period 2000-05 using data supplied by the Department for Work and Pensions. RESULTS: Glasgow's IB population is large in absolute and relative terms but is now falling, mainly due to a decrease in on flow. Claimants, tend to be older, have a poor work history and suffer from mental health problems. The rate of decline has been greater in Glasgow than Scotland, although the rate of on flow is still higher. CONCLUSIONS: Department for Work and Pensions (DWP) data can be used locally to provide important insights into the dynamics of the IB population. However, to be truly useful, more work needs to be undertaken to combine the DWP data with other information.

Well-being and consumer culture: a different kind of public health problem?

The concept of well-being is now of interest to many disciplines; as a consequence, it presents an increasingly complex and contested territory. We suggest that much current thinking about well-being can be summarized in terms of four main discourses: scientific, popular, critical and environmental. Exponents of the scientific discourse argue that subjective well-being is now static or declining in developed countries: a paradox for economists, as incomes have grown considerably. Psychological observations on the loss of subjective well-being have also entered popular awareness, in simplified form, and conceptions of well-being as happiness are now influencing contemporary political debate and policy-making. These views have not escaped criticism. Philosophers understand well-being as part of a flourishing human life, not just happiness. Some social theorists critique the export of specific cultural concepts of well-being as human universals. Others view well-being as a potentially divisive construct that may contribute to maintaining social inequalities. Environmentalists argue that socio-cultural patterns of over-consumption, within the neo-liberal economies of developed societies, present an impending ecological threat to individual, social and global well-being. As the four discourses carry different implications for action, we conclude by considering their varied utility and applicability for health promotion. (AU)

Well-being and consumer culture: a different kind of public health problem?

The concept of well-being is now of interest to many disciplines; as a consequence, it presents an increasingly complex and contested territory. We suggest that much current thinking about well-being can be summarized in terms of four main discourses: scientific, popular, critical and environmental. Exponents of the scientific discourse argue that subjective well-being is now static or declining in developed countries: a paradox for economists, as incomes have grown considerably. Psychological observations on the loss of subjective well-being have also entered popular awareness, in simplified form, and conceptions of well-being as happiness are now influencing contemporary political debate and policy-making. These views have not escaped criticism. Philosophers understand well-being as part of a flourishing human life, not just happiness. Some social theorists critique the export of specific cultural concepts of well-being as human universals. Others view well-being as a potentially divisive construct that may contribute to maintaining social inequalities. Environmentalists argue that socio-cultural patterns of over-consumption, within the neo-liberal economies of developed societies, present an impending ecological threat to individual, social and global well-being. As the four discourses carry different implications for action, we conclude by considering their varied utility and applicability for health promotion.

A computational method to detect epistatic effects contributing to a quantitative trait.

We develop a new computational method to detect epistatic effects that contribute to a complex quantitative trait. Rather than looking for epistatic effects that show statistical significance when considered in isolation, we search for a close approximation to the quantitative trait by a sum of epistatic effects. Our search algorithm consists of a sequence of random walks around the space of sums of epistatic effects. An important feature of our approach is that there is learning between random walks, i.e. the control mechanism that chooses steps in our random walks adapts to the experiences of earlier random walks. We test the effectiveness of our algorithms by applying them to synthetic datasets where the phenotype is a sum of epistatic effects plus normally distributed noise. Our test statistic is the rate of success that our methods achieve in identifying the underlying epistatic effects. We report on the effectiveness of our methods as we vary parameters that are intrinsic to the computation (length of random walks and degree of learning) as well as parameters that are extrinsic to the computation (number of markers, number of individuals, noise level, architecture of the epistatic effects).