A better future for healthcare – series

This November (2020) the College of Medicine is 10 years old. We intend to use this as an opportunity for renewal. For some time it has become clear that we need a new medical perspective. Not only to withstand the ever-increasing incidence of long-term disease but also to overcome problems created by our current methods such as increasing antibiotic resistance and addiction to opioids. Covid has further shaken medical complacency.

Consequently, we have brought together some of the best talents and leaders within the College of Medicine to write 15 short chapters on how medicine needs to change in all its various areas from addressing inequalities and developing local communities to improving the lifestyle of our young and the elderly. The five extracts that follow are a preview of a manifesto to be launched later this year. It will not be just another think-piece; it outlines quite specifically how the college and others will extend the reach and effectiveness of medicine over the next 10 years. The time for talking is over and we need to be bold and challenging, which is exactly what we intend to do. You can be the judge of that and this issue of JHH will give you a flavour of our revolution to come.

Michael Dixon

Chair if Council, College of Medicine

The 5 extracts including this one:

  1. Reimagining a healthful environment
  2. Reimagining medical research
  3. Nurturing self-care
  4. Reimagining practitioner wellbeing
  5. Creating a fairer society and answering the challenges of Marmot

Reimagining a healthful environment

William Bird, GP; CEO, Intelligent Health

Published in JHH17.3 – Beyond Covid

The vast, beautiful and complex environment in which we live provides our very existence of life, health and meaning. However its size and strength belies its fragility in which even the smallest change could cause it to collapse, and with it switch off our life support. For hundreds and thousands of years we were completely in tune with our surroundings and every part of our body evolved to survive, prosper and enjoy the natural abundance providing us with food, water and shelter. So it’s not surprising that within a few minutes in nature we feel more at peace and less threatened, resulting in an immediate reduction in pulse rate and blood pressure as our neuro-endocrine system lowers its guard. But as we distance ourselves from nature we have lost the deep-seated connections of understanding and knowledge that have made humans care for the natural world. This has led to ‘an extinction of experience’ (Soga and Gaston, 2016) in which this knowledge and wisdom built up over generations is in danger of being permanently lost.

Key Points

  • Disconnection from the natural environment causes chronic stress
  • Health professionals have a responsibility to say that the planet’s sickness is making us ill
  • A healthy environment is a foundation for health and resilience
  • Access to green space on every housing estate in every town and city in the UK
  • Plant 10 million trees a year in the most deprived urban areas
  • Open up council land for people to grow vegetables or plant flowers
  • Reduce car park space to increase use of public transport
  • A government air quality monitor leasing scheme for public to measure their air quality
  • Government to continue supporting retrofitting insulation to every dwelling

So what?

Although we continue to see great technological advances in medicine, and even though we live longer than ever before, most of us in urban settings, the natural world still matters. It matters because alongside having a strong social network and a sense of purpose, a healthy environment is a foundation of our health and resilience. When we are disconnected from the natural environment in which we evolved, our deep primitive brain sends out alarm signals making us stressed and anxious. This mismatch syndrome’ (Li et al, 2018), first coined by Prof Li from the university of Singapore, triggers the release of stress hormones – cortisol and catecholamines. The resulting chronic stress changes our health behaviours: we slump into inactivity, eat an impoverished diet, sleep badly and are increasingly prone to addictive behaviours.

The immune system responds to this chronic stress by attacking our own body leading to chronic inflammation (Tian et al, 2014) in which there is a rise of circulating cytokines. There’s a small but significant rise in CRP or Il-6 and other circulating cytokines. This chronic inflammation starts in childhood and is the foundation of many longterm conditions particularly dementia, cardiovascular disease, diabetes, and some forms of depression and anxiety. Chronic stress and chronic inflammation create other biological changes: for instance reactive oxidative species undermine mitochondrial health (Aschbacher et al, 2013), leading to premature cell death and telomere shortening resulting in faster ageing (Simon et al, 2006). So we may live longer, but we carry a greater burden of frailty and long-term conditions, we are less happy and more anxious. And, as poverty makes such chronic stress more prevalent, heath inequalities widen.

Not only have we disconnected ourselves from our natural environment but we have dumped vast quantities of toxic products of over-consumption into this fragile world of beauty. Our continual dumping of this waste is changing the climate and the ecosystems that support the habitats of 8.7 million species. Though we are just one among them the fate of them all is now in our hands. We have polluted our land, contaminated our lakes, rivers and oceans; even the air we breathe has been blighted by our waste. And so we retreat indoors where those in the poorest parts of society in poorly ventilated, damp cold housing bear the brunt of winter’s peak in respiratory disease, depression and hospital admission and death.

Climate change is the greatest signal of the environmental imbalance humans have created. The huge loss of habitat and mass extinction of species is no longer the exclusive concern of botanists, zoologists and environmentalists. All health professionals now have a core responsibility to recognise that the planet is sick, that this man-made illness is infecting our patients, and that not even the greatest advances in medicine will bring about a cure. Medicine as we have known it is appearing increasingly redundant and irrelevant. So health professionals have a call to action.

Actions for government

  • Policies and funding to ‘level up’ the places where people live so that the ‘leafy suburb’ is no longer the preserve of the wealthy but is the norm for every housing estate in every town and city in the UK. This can be achieved by:
    • 10 million trees a year (as part of the target of 50 million trees a year) to be planted by communities over the next five years in the most deprived urban areas. These will provide shade and shelter, absorb pollution and carbon, reduce the urban heat island effect, purify the air, increase biodiversity and reduce the chronic stress for those living nearby
    • open up as much council land including verges, small corners of wasteland, land around public housing, car parks and allotments so that every resident has access to some small area of land to grow vegetables or plant flowers
    • all car park spaces in designated metropolitan areas in which there is good public transport should attract a fixed levy to support the council to maintain parks and greenspace. Reducing car park spaces is the most effective way to increase use of public transport.
  • The government should set up an air quality monitor leasing scheme allowing community groups, schools, colleges and workplaces to lease air quality monitors to measure the quality of air where they live. The data will be shared with the council on a public dashboard with full explanation of its significance. This will empower the public to become actively involved with understanding and dealing with poor air quality in the area where they live or work.
  • The government should continue to support retrofitting adequate insulation to ensure every dwelling can maintain, at a diminishing carbon cost, correct
    room temperature and humidity in winter This will reduce the UK’s carbon footprint and the excess winter mortality in which the UK has one of the highest rates in Europe.

References

  • Aschbacher K, O’Donovan A, Wolkowitz OM, Dhabhar FS, Su Y, Epel E (2013) Good stress, bad stress and oxidative stress: insights from anticipatory cortisol reactivity. Psychoneuroendocrinology, 38(9) 1698–1708.
  • Li NP, van Vugt M, Colarelli SM (2018) The evolutionary mismatch hypothesis: Implications for psychological science. Current Directions in Psychological Science, 27(1) 38–41.
  • Simon NM, Smoller JW, McNamara KL, Maser RS, Zalta AK, Pollack MH,
  • Nierenberg AA, Fava M, Wong KK (2006) Telomere shortening and mood disorders: preliminary support for a chronic stress model of accelerated aging. Biological psychiatry, 60(5) 432–435.
  • Soga M and Gaston KJ (2016) Extinction of experience: the loss of human–nature interactions. Frontiers in Ecology and the Environment, 14(2) 94–101.
  • Tian R, Hou G, Li D, Yuan TF (2014) [Online]. A possible change process of inflammatory cytokines in the prolonged chronic stress and its ultimate implications for health. The Scientific World Journal, June 3.