By Dr. Trevor Hancock

It is ironic in this internet age, when everything and everyone seems to be connected, that we seem to be increasingly disconnected and lonely; moreover, many more of us are living alone.

The 2016 census found that the proportion of one-person households has been increasing steadily from 1951 (when it was 7.4 per cent) until 2016, when it became the most common type of household, at 28.2 per cent.

Living alone is not the same thing as being lonely; at various times we probably all want to be alone, and some people like to be alone a lot. But while being alone can be a choice, that is very different from loneliness, which the Oxford Dictionaries define as “sadness because one has no friends or company.”

That kind of being alone is involuntary, and the key word in the definition is sadness, which is only a step or two away from depression. After all, humans are social animals, so while being lonely on occasion is part of being human, chronic social isolation and loneliness are problematic.

In a 2017 report on connection and engagement, the Vancouver Foundation found that “14 per cent of residents say they feel lonely often or almost always” — which is one in seven people. But among people with a household income less than $20,000, more than one in three people are often or almost always lonely, while it is almost one in three of 18-24 year-olds and about one in four of those who are unemployed or are age 25 to 34.

Clearly, loneliness is an issue that affects the young and the poor, not just seniors, although it is often thought of that way.

Indeed, the mental and physical health consequences of loneliness are an emerging public-health concern; the U.K. appointed a ministerial lead on loneliness this year. This was greeted with derision in some quarters, perhaps in part because of a failure to understand both the difference between loneliness and being alone, and the severe health consequences of loneliness.

In his landmark book Loneliness: Human Nature and the Need for Social Connections, the late Dr. John Cacioppo, director of the University of Chicago’s Center for Cognitive and Social Neuroscience, described loneliness as “social pain” and “a deeply disruptive hurt” analogous to physical pain. He reported loneliness affects our immune system and our stress hormones, and can lead to suicidal thoughts and other mental and physical health problems.

Even more dramatically, he noted “social isolation has an impact on health comparable to the effect of high blood pressure, lack of exercise, obesity or smoking.” In fact, a 2015 review based on 70 studies from around the world found that, on average, those who reported they were lonely at the beginning of the study were 26 per cent more likely to die — greater than the increased risk of death due to obesity overall, and comparable to the mortality risk for moderate and severe obesity.

If loneliness is largely a lack of social connection, then presumably the answer is to create social connections among those who are lonely or are at risk of being lonely. But it is not that easy, especially among those who are chronically lonely. Cacioppo makes the point that loneliness itself can “create a persistent, self-reinforcing loop of negative thoughts, sensations and behaviours” that make it difficult to reach out or get out and make connections.

In a 2015 article in Perspectives on Psychological Science, Cacioppo’s team largely dismissed such seemingly common-sense approaches as providing social support, encouraging social engagement or teaching social skills, commenting that: “Interpersonal contact or communication per se is not sufficient to address chronic loneliness in the general population.” Instead they suggested a combination of cognitive behavioural therapy and some hoped-for medication.

I find that completely unsatisfactory, not only because it would be individualized and very expensive, but because with such a large-scale problem we need a population-wide public-health approach, just as we do for smoking or obesity. Clearly, we need to give a lot more thought to how we combat loneliness at a community level and strengthen social connections.

© Trevor Hancock, 2018

Originally published in Times Colonist, 19 August 2018

By Dr. Trevor Hancock

We are lucky in B.C. to have two useful initiatives to help us create healthier built environment

The first, which I described briefly last week, is the Healthy Built Environment Linkages Toolkit. The second is a B.C. Ministry of Health-funded initiative, PlanH, which “facilitates local government learning, partnership development and planning for healthier communities.” I will describe them both here.

(Full disclosure: PlanH was developed and is implemented on behalf of the ministry by the non-profit B.C. Healthy Communities Society, of which I am vice-chair of the board.)

For each of the five key elements of the built environment that the toolkit considers — neighbourhood design, transportation networks, natural environments, food systems and housing — it provides a chart showing the impact on the built environment and the strongest research correlations found in evidence reviews. I briefly covered the first two elements last week, so here I want to examine the others.

For the natural environment, the focus is on preserving and connecting environmentally sensitive areas, expanding natural elements across the landscape and maximizing the opportunity for everyone to access these natural environments. By doing so, we can increase the tree canopy, reduce urban air pollution and create cooler urban areas. (For a great discussion of the health benefits of trees and urban forests see the book Planet Heart by Dr. Francois Reeves, an interventionist cardiologist in Montreal.)

Among the health benefits identified in the toolkit for which there is strong evidence are reduced deaths from heart and urban heat events; improved mental health and social well-being; increased physical activity; and improved respiratory health. Other benefits include reduced health-care costs, energy savings, reduced pollution-control costs, and increased recreation and tourism.

Turning to food systems, the toolkit focuses on increasing equitable access to affordable and healthy food options, protecting agricultural land, increasing the capacity of local food systems, and supporting community-based food programs such as community gardens and community kitchens.

The health-related impacts of these approaches include improved diet quality and social well-being. Evidence suggests community kitchens, such as the Shelbourne Community Kitchen in Saanich, are particularly useful.

This small NGO provides small-group cooking, a pantry and gardening programs that help participants from low-income families acquire food skills and learn to access nutritious food affordably, while at the same time building community.

Finally, the toolkit looks at four approaches to creating healthy housing, particularly through prioritizing affordable quality housing options, especially for marginalized groups. The evidence supports the need for diverse housing forms and tenure types, located so as to avoid environmental hazards. There are many health benefits, including improved overall health and social well-being and reduced domestic abuse, crime and violence. (I will return to the topic of healthy housing in a future column.)

While the toolkit provides evidence and is intended primarily for planners, PlanH is more concerned with how to bring the health implications of decisions to the attention of municipal governments and citizens to support “leading-edge practices for collaborative local action.” It focuses on three key interconnected themes: Healthy people, a healthy society and healthy environments.

In considering healthy people, PlanH emphasizes that our health behaviours and choices are shaped by local social and environmental conditions. We need to create “vibrant places and spaces [that] cultivate belonging, inclusion, connectedness and engagement” in the context of “well-planned built environments and sustainable natural environments.”

To do so, PlanH helps local governments and their citizens learn about these issues and provides action guides and other practical resources and tools. It helps them connect and build relationships with community partners in other sectors (including regional health authorities) and with other local governments. And it helps them innovate with a funding program to support action, and by sharing success stories from around B.C. and beyond.

Together, these two initiatives give municipal governments, urban planners and citizens powerful support to help them make decisions that will improve health and well-being, which is surely one of their most important roles. So if you want healthier built environments in which to lead your life, raise a family and grow old, you might want to talk to your local government, community association and neighbours about the toolkit and PlanH.

© Trevor Hancock, 2018

Originally published in Times Colonist, 29 July 2018

By Jennifer Wile

There are many facets to stories of childhood trauma, and many layers. When I was 4 years old, I developed, in rapid succession, strep throat, scarlet fever, and then rheumatic fever. My older brother started his 10 year journey of obesity. We had both been victims of violence and other abuse from my earliest memory. Then as a teenager and in my early twenties, I had multiple surgeries requiring general anesthesia for various rare but treatable physical ailments – strangely all in the same location, but caused by different factors. As an adult, I worked on the emotional effects of PTSD best helped through cognitive behavioral therapy. I discovered exercise helped my mood significantly. Even so, I did not consider the the stress of my childhood might have affected my body until I read Dr. Nadine Burke Harris’ book, The Deepest Well: Healing the Long-Term Effects of Childhood Adversity.

Trauma is no stranger to anyone: if we haven’t experienced ourselves, we know a loved one who has experienced or witnessed violence, abuse or neglect. When I read this book, I could not help but think of the children who are now separated from their parents at the borders as well as of children fleeing Syria. There are sadly many places where trauma is a fact of life, and the inner city can be one of them. It is a matter of public as well as individual health.

WHO recognizes that social conditions are important factors in health, and the all contribute to our total health. Nadine Burke Harris gives a gripping account of her exploration of the link between adverse childhood experience or (ACE) and toxic stress. She is a social innovator in public health and serves a vibrant and economically disadvantaged community, in San Francisco’s Bayview Hunters Point (BHP). She describes the challenges she faced personally and professionally when she opened the Center for Youth Wellness (CYW) as well as her attempts to have ACE and toxic stress, recognized as serious issue in children’s health, which included getting pediatricians to use screening protocols for ACE in pediatric assessments.

Burke Harris, a pediatrician with a Master’s in Public Health, writes with passion about connecting the stress of her patients with their emotional and physical well-being. When offering free pediatric care to children via her clinic, CYW, in BHP, an area that is on the extreme end of San Francisco’s social and economic inequality, Burke Harris saw clear relationships between the trauma that the community’s children experienced and their emotional and physical health. Toxic stress can, and often does, manifest itself in disease and poor health. Her examination discusses how poverty in the inner city can result in greater incidence of poor health with difficult living conditions, more exposure to violence, and untreated mental illness. While San Francisco’s median income was above $100,000 in 2016, City-Data shows that 31% of residents of Bayview Hunters Point live below the poverty line as of the last U.S. Census.

Poverty contributes to trauma, but Burke Harris reminds her audiences that trauma crosses all socio-economic boundaries. She tells us not only the stories of the children that she treated, and still treats, at the BHP Center, but also about her personal journey of trauma. Trauma does not stop in the wealthier neighborhoods. Helping overcome childhood trauma depends on your caregiver. There are engaged and nurturing caregivers in every community, just as there are neglectful caregivers in any community; however, if you live in inner city poverty, your chance of seeing violence randomly outside the home is likely. In one of Burke Harris’ case studies, a teenage boy, recovering well from childhood abuse, sees his best friend is killed on the street in front of him. Understandably, this incident is a setback for his health. The children Burke-Harris treated suffer from multiple adverse reactions, and have debilitating physical and psychological challenges ranging from asthma, obesity, failure to thrive, to stunted growth.

Although Burke-Harris’ accounts of traumatic experience can be shattering, such as the boy who stopped growing at age four when he trauma is exclusive to inner city poverty. Burke Harris reminds her audience repeatedly that toxic stress is an issue in any income bracket. Bringing this to a wider audience, Burke Harris shows us that society suffers when it ignores childhood trauma.

Thankfully, something can be done to help children (and adults) suffering from toxic stress. In fact, according to Burke Harris, part of the antidote to toxic stress is truly integrated health treatment including a combination of healthy relationships, counselling, meditation, exercise, and nutrition. The caregiver and their response to trauma play a huge role, but, sadly for those in underserved areas, so do the resources available to the child.

Though the subject matter is tough, the book and its author are inspiring, positive and passionate. This title comes as a hardcopy, eBook and is also available as an audiobook narrated by the author, which I highly recommend.

Watch Dr. Nadine Burke Harris here: https://www.youtube.com/watch?v=95ovIJ3dsNk or find her book at your local library in audio, eBook or hardcopy: Burke Harris, Nadine. (2018) The deepest well: Dealing with the long-term effects of childhood adversity. Houghton Mifflin Harcourt

By Dr. Trevor Hancock

There is an interesting common thread underlying many of my recent columns. It is the question in my title: Does mental health matter most? By which I mean, in high-income countries in the 21^st century, does mental health matter more than physical health? Which in turn means, in terms of public health, does mental health promotion and the prevention of mental disorders matter more than preventing heart disease, cancer and other physical disorders?

There are many threads to my emerging argument. To begin with, the 70 year-old definition of health from the World Health Organisation is that health is a state of complete physical, mental and social wellbeing. Since social wellbeing is primarily about how we feel about and respond to our links to and relationships with others in our families and communities, it means a significant part of the definition is really about our mental wellbeing.

Add to this the relationship between the mind and the body – our state of mind affects our neuro-hormonal and immune systems, and the latter is involved in allergy, auto-immune disease, and the detection and elimination of both infection and abnormal cancer cells – and our state of mind assumes an even greater importance.

Another important issue is the changing pattern of disease and death. Globally, the World Health Organisation noted last year, “Depression is the leading cause of ill health and disability worldwide” – depression, we should note, is only one form of mental ill health. WHO also notes that there are “strong links between depression and other non-communicable disorders and diseases” and that “depression increases the risk of substance use disorders and diseases such as diabetes and heart disease”, while pointing out that “the opposite is also true . . . people with these other conditions have a higher risk of depression”.

We can also see the importance of mental health in the decline in life expectancy in the USA in each of the past 2 years, the first time this has happened in more than 60 years. But that decline is driven not by physical disorders such as heart disease and cancer but from the so-called ‘diseases of despair’; alcohol and drug use and suicide, which are largely mental and social disorders. And as I pondered in my last column, we may need to consider whether the growing concern about the state of our environment is adding to that despair.

Another factor to consider is the impact of poverty and inequality. Absolute poverty is unhealthy because people lack the basic necessities for life and health – clean water, food, shelter and so on – and we have some of that in Canada. But for the most part our problems are now those of relative poverty. Kate Pickett and Richard Wilkinson, in their book “The Spirit Level”, showed that in high-income countries, a range of health and social outcomes are not related to national income per person, but to the degree of inequality.

It seems that being lower in the ‘pecking order’ of society is harmful to health because we experience inequality as a lower sense of self-esteem and self-worth, relative powerlessness and even helplessness. All of which are mental and social experiences that, again, can translate into physical conditions.

The implication is that if we want to have a healthy population we need to pay much more attention to mental and social wellbeing than we have been doing. We need to provide more funding to research focused on understanding the root causes of mental and social health problems, and to policies and programming for preventing mental and social health problems, as we do to understanding and preventing heart disease and cancer – because we have under-invested on the mental health side.

Beyond that, we need to give at least as much attention to promoting mental and social wellbeing as we do to promoting physical wellbeing and fitness, recognizing that they are mutually beneficial. What would it take to create mentally healthy families, schools, workplaces, colleges and universities? How do we help people maintain mental wellbeing in the face of adversity, or as they age? How do we re-focus our society – including public health – to ensure mental health matters at least as much as physical health – maybe more.

© Trevor Hancock, 2018

Originally published in Times Colonist, 20 March 2018

By Dr. Trevor Hancock

A colleague once remarked that people are so busy dealing with the important that they don’t have time to deal with the critical. That applies to the healthcare system as a whole. It is so busy dealing with people who are ill or injured that it doesn’t give much priority to looking upstream and trying to stop people becoming sick in the first place.

That especially applies to the field of mental health and addictions, which has been described as the orphan of the health care system, neglected and underfunded. But in fact mental health problems are among the most common and most expensive health problems today. The Centre for Addictions and Mental Health (CAMH) in Toronto reports that “the disease burden of mental illness and addiction in Ontario is 1.5 times higher than all cancers put together”.

CAMH reports that “in any given year, 1 in 5 Canadians experiences a mental health or addiction problem” (including dementia) and that “mental illness is a leading cause of disability” and can markedly shorten life. Not surprisingly, people with mental illness have high rates of unemployment and work absence; at least half-a-million employed Canadians are off work due to a mental health problem every week. The overall societal cost of mental illness cost in Canada in 2011 was estimated in one study to be about $42 billion, with half that being health care costs.

This is why the creation of a new Ministry of Mental Health and Addictions in BC is an interesting development. Time will tell whether it proves to be an important strategy to focus attention on a long-neglected issue or whether, as some have suggested, it divides resources and attention and becomes a problem. One thing is for sure; it highlights the growing importance of mental health problems in society.

But simply managing the problems of people with mental disorders or addictions is not enough; we need to reduce the toll of mental health in our communities. This means the new Ministry needs to focus on why people develop mental health problems in the first place, how we can prevent that happening, and how we can improve the overall mental health of the population.

Happily, BC has developed quite a strong focus on the prevention of mental health problems and on mental health promotion in the past decade. Its 10-year mental health strategy, adopted in 2010 and updated in 2017, states “Research tells us that doing a better job of promoting mental wellness, preventing mental illness and harmful substance use, and intervening at the beginning of illness, especially for our children and youth is a wise investment”.

As with much else in public health, what this means in practice is that we need to look well beyond the health care system, to society as a whole. A recent report from the UK’s Faculty of Public Health suggests what needs to be done.

First, we need to focus on childhood factors, and in particular, family relationships. Infants and young children need to feel secure in their attachment to their family, which enables them to develop trust in others. Failure to do so “leads to lifelong problems in learning, behaviour, resilience, coping, and both physical and mental health”. Adverse childhood experiences such as abuse, neglect, parental substance use or mental illness compound the problems, and call for early intervention.

In addition to good parenting, the school environment is also important: “The school ethos, mental wellbeing of teachers, relationships with peers and prevalence of bullying all matter”. And as young people transition from school to college or work – “a time of upheaval and uncertainty” – strong relationships with caring friends and adults are important, while loneliness is a problem. This continues into adultood, where stable relationships and mentally healthy workplaces are important, while unemployment increases the risk of anxiety or depression by 4 to 10 times.

Good mental health benefits us all, but clearly is a much bigger issue than the new Ministry can address on its own. It will need to engage the whole of government and the wider society – schools, workplaces and communities – in creating a mentally healthy society. In my next column, I will discuss in more depth how this can be done.

© Trevor Hancock, 2017

Originally Published in Times Colonist