Harry Burns: 'Properly functioning families are the key to making Scotland healthier'
WHEN he was a surgeon at Glasgow's Royal Infirmary, Dr Harry Burns, Scotland's chief medical officer, began to notice something about his patients. When he operated on a patient from the city's deprived East End, he found that, commonly, the wound he had opened would take at least a day more to heal than for someone from a wealthier part of the city. The explanation, at first, seemed obvious. "At the time, we thought it was because they smoked and didn't have a good diet," he says. That was certainly contributing to the problem, but it didn't entirely answer the question.
More recently, researchers at Glasgow University studying mortality rates in the UK coined what they called "the Scottish effect". Even when deprivation was taken into account, Professor Phil Hanlon and others found that more people were dying early in Scotland – as many as 17 per cent more in some parts of the country. The difference could not be explained away simply by saying that people were worse off. Something else was going on.
Burns last week published his annual report into Scotland's health, often described as the nation's yearly MoT. The paper offered plenty of observations about the trends on the country's well-being – showing, for example, a narrowing in the gap between women's life expectancy and that of men. But it also contained a possible answer to Scotland's poor health puzzle which could soon revolutionise the way the country deals with its sick.
Two days after publishing his report, Burns is sitting in front of his laptop at the Scottish Government's offices in Glasgow, the city where he has worked all his life. He is discussing the concentration camps of Nazi Germany, and the research of a little-known sociologist called Dr Aaron Antonovsky. "He spent a large part of his career in Israel where he studied adults who had been in concentration camps. Most of them had poor mental and physical health but a lot of them were extremely healthy and not just healthy but successful," he says.
Antonovsky noted that those survivors who had coped with their experience in the camps had, during their childhood and early years, developed what he called "a sense of coherence". As a result, says Burns "you could comprehend what was happening to you – your ability to analyse what people were doing round about you at a very mundane level and you could make sense of that. You had the resources to manage that and, thirdly, you wanted to make the effort".
Those who hadn't learned this "coherence" during childhood, Antonovsky noted, failed to cope after their release. "You would be swept along and it wouldn't make any sense, and you would then experience the physical effect of chronic stress," says Burns.
Antonovsky concluded that the differences between the two groups were set in stone during childhood by the key external influences of family and environment. Consistent parenting, he argued, was the key to ensuring that a child would grow up making sense of the world around them. And without it, Antonovsky suggested, they would display high rates of stress.
Burns used his report to similarly declare that a lack of that "sense of coherence" is behind too much of Scotland's ill health. Deprivation is undoubtedly a major factor behind this deficit. But Burns also hit out at the parenting skills of many mothers and fathers in the country, saying their inconsistency was setting in train huge problems for their children in later life.
He offers the example of a new born baby, and the "attachment behaviour" it displays in its first few weeks. "Attachment behaviour is the process by which kids learn, where they learn about control over their environment," he says. In a functioning family, a baby will learn from the responses it gets from its parents. "The only way it knows how to create an impression is to cry, so mum picks it up, cuddles it and feeds it. It is learning to make sense of the world and is finding that the world is explicable and manageable."
In a dysfunctional family, however, the lessons are different. "The chaotic environment sends the child completely chaotic signals. Sometimes it'll get fed when it cries, sometimes mum will be drunk. Sometimes mum will lose the rag and hit it. It gets the signal that it can't control the world because it doesn't know when it's going to get a good response or a bad one, so it can't explain it, can't manage it. And that makes it stressed."
Burns says that, over the last year, he has spent more time with teachers than with doctors in his attempt to understand the issue. "I've spoken to thousands of teachers," he says. "They recognise this. They see their kids coming in into early years and they see the dysfunctionality and their inability to respond appropriately to their peers. If a kid next to you is annoying you, some kids will just turn away, but others will lash out because that is what they've seen as the way to conduct relationships."
The reason why Burns is picking up this essentially sociological insight is because there is now clear medical evidence that if such children grow up unable to make sense of their environment or find it meaningful, they will grow up with poor health. He cites a study from Finland which found men who were defined as having a sense of hopelessness, negativity, or pessimism, were found to be four times more likely to die prematurely of heart disease than their optimistic peers. The research even found that the more "hopeless" men deposited fat in their arteries far faster than men in the most optimistic group. Having high levels of stress, says Burns, is like "turning a thermostat up on a central heating boiler – you know the boiler will wear out faster". And that stress is evident in the brains of children before primary school.
Controversially, Burns suggests it is Scotland's history of economic and social disruption – and the consequent stress upon its populace – which may be the reason behind "the Scottish effect"; a poisonous cocktail of economic and childhood turmoil that has been felt worse in parts of Scotland, such as Glasgow, than other parts of the UK. "You had a hopelessness pervading the community," he says. "This didn't happen in, for example, the West Midlands because you had a vibrant car industry, electronics and so on. West-Central Scotland never replaced the steel works and we have now had 50-60 years' worth of that – three generations of people who have not expected to be employed. It would be understandable if there was a psychological negativity."
So what can be done? For such a complex set of problems, Burns does not offer a simple solution. But he is clear where it starts. The psychological scars, he says, begin right from birth. Therefore, it is within the family and in childhood that the answer lies. "We need to evolve a process by which we try to give children a sense of coherence," he declares. He cites the example of parenting programmes in Australia which provide support for young mothers unprepared for the pressures of a baby. But these may not be enough.
"I feel that we are going to have to intervene even before girls are pregnant." Too many are still drinking, taking drugs, or remaining in an abusive relationships, he says. "We are going to have to make sure that pregnancy is a different experience for them". And then, once the baby is born, the help will have to continue, he says. "We are going to have to help them through the first few years." But Burns is not a policy-maker. "My role in all of this is to unveil the science," he says.
In the new year, Scottish ministers will reconvene a group looking at health inequalities. Burns praises the fact that the group includes seven ministers, across different departments, saying that such a formula understands that this is an issue which crosses portfolios.
Indeed, is it really for a chief medical officer to raise all this? "I've got to where I am on this because it is a medical issue. When I was a consultant, the level of ill health that we saw couldn't just be explained by smoking and diet. There was psychological despair that was apparent in a lot of the patients and I saw a number of instances where the psychological drivers were clearly having physiological effects."
He concludes: "We are looking at the biological consequences of sociological chaos." He may not be a policymaker, but the policy implications of Burns' work are huge. He says: "What we've got is a clear chain of events that link social circumstances to molecular causes of death."
He says his motto now might be: "Whatever it takes." For the politicians hoping to improve Scotland's health record, the challenge is set.