Friday, 31 July 2015

Thinking about Cecil


The lioness was walking towards us. It stopped when it caught sight of four people walking towards it on small path in the Zambian bush– Geoffrey, the guard with a rifle, Andrew, the guide, myself, and Jonas, a trainee guide. For a few moments, I watched this fully-grown adult lion, perfectly framed through a forked branch in a small tree. She was yards away. The she turned, like animals do, and walked away, leaving us realizing we had been holding our breath, with that facial expression of wonder. We all turned and smiled at each other and we too, turned and walked off the other way.

Last month, I was staying at a bush camp in the South Luangwa national park in Zambia, a holiday after completing some work in Lusaka. Encounters with wild animals in the African bush is a white privilege. Safaris cost a lot of money. You can stay in the sort of luxury that local people will never experience. Their encounters with wild animals – unless they work in the tourism industry – are fraught with danger or non-existent. People either have to eke out a living in close proximity to national parks, leaving them exposed to crocodiles, elephants, buffalo - all animals that kill - let alone lions and hyenas. Others, such as those living in Lusaka, may never encounter the wildlife that draws so many foreigners to their country.  Our driver James, whom I have known for over 12 years, asked me recently, “What kind of elephants do you have in England?” It had never occurred to me that he wouldn’t know that elephants are peculiar to Africa and Asia, and thus possibly wouldn’t know how special the wildlife of Africa is. Only once in thirty years have I come across black Africans on safari – a couple in the South Luangwa national park in Zambia.

I have always been interested in wildlife and am a good amateur ornithologist. At school, all I could imagine becoming was a wildlife ranger in Kenya. I’m glad I didn’t take that route, but I seek out encounters with the wild whenever I travel.  On this trip and anothers, I have felt acutely uncomfortable being a rich white tourist. Of course, that is what I am, but on this latest trip, I decided that I didn’t want to do this kind of safari again. I do have other perspectives on Africa due to my work experiences; but for many other tourists, this is Africa – a land of elephants, lions, plains, forests; superb thatched lodges where Africans ask if you want a gin and tonic or a Mosi. And of course, this is a part of Africa, but it’s a part that has been manufactured to produce a white phantasy experience. Europeans played a large part is establishing national parks, in the past called game parks. British people like Norman Carr was instrumental in encouraging Zambians to set aside land for conservation, helping to set up Kafue National Park in 1956. Years before, he had shot his 50th elephant at the age of 20, but retired in 1960 from the Game Department and lived the rest of his life in the Luangwa Valley. It’s not uncommon for people – men, actually – to turn from shooting animals to helping to preserve them, and eco-tourism is now a major industry.

Which brings us of course to Cecil the Lion.

If you watch the video footage, you see an extraordinarily beautiful animal. Here is a beast that can only inspire awe. To have seen him in the wild must have been a once in a lifetime experience that you would keep in your mind’s eye till you too die. To want to kill such an animal is beyond all comprehension. The outpouring of outrage this week shows that the man who killed Cecil, the American Walter Palmer is indeed a throwback, a reminder of the times when trophy hunting was ‘normal’. The photos of him posing with a shot leopard, rhino, other lions, are surely some kind of strange homage to an Ernest Hemingway era. His relationship with animals deeply troubles the contemporary consciousness, causing other men to choke with emotion and to question Palmer’s motives, his psychological health and his manhood. See footage of Jimmy Kimmel ‘choking’ talking about Cecil:


Palmer reportedly paid $50,000 for the privilege of killing Cecil. Why anyone wants to kill animals in this way, as I said above, is unfathomable to me, as is the approach to guns in North America. President Obama has said recently that his failure to reform the gun laws in the USA is one of the biggest disappointments of his tenure. I have written elsewhere in this blog about the inability of Europeans to understand the North American attitude to these weapons that cause the casual death of so many. It’s the hunting lobby that has been very vocal about not curbing guns.

Anyway, back to Cecil.

Immersion in the natural world, having access to green spaces, to trees and to the wildlife that live in those spaces is one of the most fundamental aspects of mental wellbeing. More and more is being discovered about the importance of nature and green space to our health as humans. I’m not going to rehearse those arguments here or present evidence, but our own personal experience confirms it. It goes without saying that such access is based on social class, but that’s another point I’m going to leave for now. For many people too, having strong bonds to animals is a key part of wellbeing.

For example, alongside the coverage of Cecil in The Guardian, there’s another story in the Society section, about a scheme called Henpower. See:


It’s heralded as a scheme that decreases loneliness, decreases the need for anti-psychotic medication, reduces depression and generally increases wellbeing. It’s a project that started in the North East of England, introducing hens – chickens – to residents of 20 care homes covering 700 residents. It’s just been extended to London and there are plans to develop in Leeds too. It was started by a charity called Equal Arts, to use hen-keeping to tackle social isolation, and contribute to mental health. In my part of rural Yorkshire, hen-keeping is a normal activity, but this project enables people to simply hold hens, and it’s proven to be calming and therapeutic. The article is heart warming, as is the accompanying picture of a row of elderly people each holding a hen and looking happy. Whilst hens don’t float my boat, I could imagine cuddling an orphaned orangutan for hours on end. The point is that contact with beings other than humans does add to our wellbeing. An article in the BMJ from 2005 reviews the evidence about the benefits of pet ownership and is inconclusive, but again, the lived experience of pet owners is perhaps a better guide.



Having pets is something of a privilege of the Global North. This rather rambling blog about the complexity of our relationships with animals and how it affects health needs also to consider the complexity of relations between Europe and Africa, and its focus on Africa’s wildlife. It’s easy to see why Africans often think that Europeans care more about animals than people.  The Oxford University study group that was studying Cecil as part of its project on lion movements, has received thousands of pounds to its charitable trust from people all over the world, presumably furious and saddened as a result of Cecil’s death. (As an aside, the Devon Donkey Sanctuary in the UK got £30.7 million in donations (2013/14 figures) yet the three biggest charities concerned with domestic violence got £15.1 million put together. These kinds of figures do cause bemusement among those who would put people before donkeys).

But back to that problematic relationship between the former colonial powers and contemporary Africa - another issue that warrants thought is the economic benefits of wildlife tourism to a poor country like Zambia, or Zimbabwe, which is where Cecil lived. The ban on hunting has been lifted in the area surrounding national parks, called the Game Management Area or GMA, in order to raise more international currency for cash-strapped African countries. Many have argued that the amount of tourist cash that could have been generated by people coming to see Cecil far outweighs the one-off $50,000 that Palmer paid. It’s estimated that Cecil brought in the same amount every five days that this hunter paid to kill him. In terms of raising foreign reserves, therefore, Cecil was far more valuable alive. In Zambia recently, everyone I met was appalled by the lifting of the hunting ban, including Zambians working in the tourist and safari industry. For Zambia, tourism is a major contributor to its GDP. 

Although economies in certain African countries are growing at rates faster than those in the so called ‘developed’ world, many African countries are still poor due to the legacy of colonialism, the unfair conditions of trade, historical debt and so on. There is something symbolic about what has happened to Cecil.  That one man feels he has the right to kill an iconic animal, an animal that belongs to no one and to us all, is a moral outrage. That African countries have to rely on cash from privileged white people coming either to look at wildlife, or to kill them, surely too is a moral outrage.

Sunday, 31 May 2015

Strokes, behaviour change and austerity


May is National Stroke Awareness Month in the UK. The Stroke Association and NHS official data show that the number of middle aged people suffering a stroke increased dramatically last year. In England, men aged 40 to 54 saw a rise of 46% over the last fifteen years, from the year 2000 to now. That’s 4,260 men in 2000 to 6,221 last year. Women of the same age saw a 30% rise, and for all those aged 20-64, there was a 25% increase. So the message seems to be that people of working age are experiencing strokes, and that strokes are happening at younger ages. The reasons put forward for these rises – at least in the popular media and by the government – are obesity and sedentary lifestyles. The Stroke Association is quite right to point out the dangers of strokes, and to publish information so that people can educate themselves about risks and lifestyle. However, there is perhaps more to the statistics and more to the discussion of causes that needs to be interrogated.

Firstly, the overall incidence of stroke has actually fallen over the 20 years from 1990 to 2010, (from 141.97 per 100,000 to 115.50 per 100,000) and the number of UK deaths fell, from 87,974 in 1990 to 40,282 in 2013. A number of factors contributed here – the decline in smoking, the development of clot-busting drugs and also the changes in emergency treatment, which meant that more stroke sufferers received speedy attention. However, there does seem to be a rise in the last few years among those below the age usually considered as ‘elderly’, that is, amongst the middle-aged, still-working groups in their forties and fifties. Why?

A Department of Health spokesperson commenting on the statistics this month said, “Strokes can have a devastating impact on people and their families. Adopting a healthier lifestyle, like plenty of exercise and eating the right food, is really important to reduce the risk of stroke.” The Stroke Association’s website has four categories giving advice to people wanting to change their lifestyles to reduce stroke – the usual four suspects of Diet and Nutrition, Physical Activity, Smoking, Alcohol.

The high profile stroke of the English broadcaster and journalist, Andrew Marr, has highlighted the fact that, as his wife the journalist Jackie Ashley wrote recently, “Even super fit gym bunnies have strokes”.  Not surprisingly, she has embarked on something of a crusade to point out to the public the predictors of stroke, and how simple it can be to keep a check on the obvious precursor, high blood pressure. For well and fit people, such as Andrew Marr, there might be no reason to check blood pressure. In his case, the stroke seemed to be brought on by attempting a new approach to very high intensity exercise. Jackie Ashley comments at the end of her article “But with just a little more public awareness, the figures for strokes among working-age people could be going down by 50%, rather than up.”

With respect to both these journalists, their experience is not typical, and it arguably would take a lot more than “just a little more public awareness” to reduce strokes.

To say that stroke and other circulatory diseases can be halted purely by ‘behaviour change’ or lifestyles, is utterly victim blaming. ‘Lifestyles’ play a role of course, if by lifestyle we mean the freely chosen ways we decide to live our lives. Everyone makes choices within the broader or narrower range available to them. But there are wider factors over which people have little control. For example, there has been research available for years that shows that noise pollution raises blood pressure and is linked to heart disease. Those living near airports have raised blood pressure in response to aircraft noises, even when they are asleep. The HYENA study of six large European airports in 2008 found this (Jarup et al 2008), and follow up studies reported in the BMJ in 2013 found the same. The British Study (Hansell et al 2013) found that people living near Heathrow had significantly higher rates of stroke, and in the USA, Gan et al (2013) showed higher admission rates for heart problems for anyone living near a major airport.  Studies from the occupational health field show similar elevated risk for those working in noisy environments; a study in Occupational and Environmental Medicine, for example in 2010 show rates of heart problems, hypertension and angina two to three times higher than those who work in quieter settings.

Noise is merely one of the reasons why blood pressure might be elevated. Salt consumption is certainly another well-known contributor to high blood pressure. We know that simple steps like making the holes smaller on saltshakers can reduce salt consumption, and many people do know about these messages. But – we also know that the food industry has a major role to play – and isn’t keeping its side of the bargain. In 2012, the food industry and supermarkets agreed voluntary pledges to act to reduce the amount of calories consumed in the UK, mainly to combat obesity, but also to make eating healthier. A study commission by the government, carried out by the London School of Hygiene and Tropical Medicine, which reported recently, (Knai 2015), shows that the ‘responsibility deal’, where food producers voluntarily make their food healthier, such as by reducing salt, has not worked. The authors conclude, “The current nature and formulation of the responsibility deal food pledges is such that pledge implementation is unlikely to have much effect on nutrition-related health in England”. The are glaring absences from the voluntary deal, such as there being no focus on sugar intake, (an obvious contributor to obesity, and thus to elevated blood pressure) and the actions of the food industry have been to focus on education and information, all of which, as the study points out, “may have limited effect. It is well established that interventions which improve information and awareness of health issues or risks do not necessarily translate into positive behavior change.” Indeed. The damning summary of the failure of the ‘responsibility deal’ led to Barbara Gallani, director of regulation, science and health at the Food and Drink Federation saying that the responsibility deal “is the most ambitious and inclusive framework for voluntary action on public health the UK has ever seen.”


 The audacity of these claims is breathtaking, as is the failure of those in power to take any account of what is perhaps the real driver behind the increased rates of stroke - the evidence of the impacts of the government’s austerity programme, or of the unequal consequences of economic recession on poorer people and on different parts of the country. Arguably, it’s social conditions that are the main causal ingredient of raised blood pressure and other signs of stress – yet these are never mentioned in relation to stroke prevention.

When the Journal of Public Health published its March 2015 edition, full of articles about the ongoing effects of poverty and inequality on health, the Guardian reported it by interviewing a man from Newcastle on Tyne whose weekly income fell from £72 a week to £47 as a result of the bedroom tax. (This tax, for those unfamiliar with it, was introduced for those living in social housing who had an ‘unused’ bedroom, as an incentive for people to move to smaller houses). All he ate was sausage rolls and he reportedly said, “I can’t sleep at night. I regularly see my doctor, I suffer from depression.” He is a 56 year old unemployed warehouse worker, and is just one of those reporting increased stress, anxiety, hunger, poor diet and depression as a result of the bedroom tax. Others reported needing ‘blood pressure tablets’.

Copeland et al’s (2015) study shows very clearly how economic recessions affect the poorer north east of the UK more than other parts of the country, whilst De Agostini et al’s study, published in November 2014, patently makes the point that we were ‘not all in it together’, and that certain parts of the country – the poorer ones – were disproportionately affected by the Coalition government’s tax-benefit policy changes. Schreker and Milne’s editorial to the Journal of Public Health March 2015 edition provides an overview of some of this literature, as well as suggesting a manifesto for improving public health inequalities.

This week, the Guardian has another headline – “Thousands plunged into poverty by benefit cap.” The Guardian claims to have seen an internal memo which shows that due to the limit introduced in April 2013, on what benefits families will be able to claim in a year, another 40,000 children will be placed on or below the official poverty line, unless their parents can find extra work. This is on top of the 50,000 children already in this position. The memo says, “Around 40,000 more…children might, in the absence of any behavior change, find themselves in poverty as a result of a reduction in the cap to £23,000. If these families respond to the cap by making behavior change, for example, moving into work, they are likely to see themselves and their children move out of relative poverty.” (Reported in The Guardian 30.05.15 p1). So, here’s another explicit statement that poverty is caused by improper behaviours, and that all that’s needed is behavior change.

The Department of Work and Pensions’ own figures showed that in the 22 months of the new cap, only 11% of households that were just below the cap moved into work. Their own qualitative study into the effects of the cap showed that most capped tenants struggled to afford basic necessities, went without food, and used loan sharks. A quarter was under threat of eviction as they had run up rent arrears. How is it possible to maintain normal blood pressure under these threatening socioeconomic conditions?

If people living in these stressful conditions were to visit their GP, what would that GP do? The GP might take the patient’s blood pressure and what then?

Some other opinions expressed recently have also cast doubt even on Jackie Ashley’s suggestion above, that people need to get checked more regularly. Capewell et al suggest that the NHS Health Checks are a waste of resources. They write that:

“We briefly review here the evidence that the NHS Health Checks (NHSHC) programme represents an ineffective strategy and is currently wasting scarce resources.
The NHSHC programme invites everyone in England aged 40–74 without cardiovascular disease (CVD) for a check every 5 years. The NHSHC website advertises that health checks can
               prevent heart disease, diabetes, kidney disease stroke and dementia,
               provide support and advice to help individuals manage and reduce their risk of future disease.1
However, the NHSHC programme fails to achieve both of these primary objectives. Furthermore, it relies on weak concepts, denies strong scientific counter-evidence and ignores persistent implementation issues.”

This medical solution to keeping people healthy doesn’t appear to be preventing the main causes of mortality and morbidity. Strokes of course do happen to people of all social classes but the emphasis on ‘behaviour change’ and the failure to take into account the social gradient in the incidence of stroke, the failure to look at socioeconomic factors that are implicated in their cause, plus the failure to curb the food industry, means that the rates making the headlines in this Stroke Awareness month, of younger people having strokes, are only likely to get worse.



Capewell, S. McCartney, M., Holland, W., (2015)  Invited Debate: NHS Health checks – a naked Emperor? Journal of Public Health, 37 (2): 187-192.
doi: 10.1093/pubmed/fdv063


Copeland, A., Kasim, A., Bambra, C. (2015) Grim up North or Northern grit? Recessions and the English spatial health divide (1991–2010) Journal of Public Health 37 (1): 34-39. doi: 10.1093/pubmed/fdu019 First published online: March 18, 2014

De Agostini, P., Hills, J., and Sutherland, H. (2014) Were we really all in it together? The distributional effects of the UK Coalition government's tax-benefit policy changes. Working Paper 10 November 2014. Available from: http://sticerd.lse.ac.uk/dps/case/spcc/wp10.pdf


Gan WQ, Davies HW, Demers PA, et al. Exposure to occupational noise and cardiovascular disease in the United States: the National Health and Nutrition Examination Survey 1999-2004. Occup Environ Med 2010; DOI:10.1136/oem.2010.055269
Hansell AH, Blangiardo M, Fortunato L, et al. Aircraft noise and cardiovascular disease near Heathrow airport in London: Small area study. BMJ 2013; 347: DOI:10.1136/bmj.f5432.

Jarup L, Babisch W, Houthuijs D, et al. Hypertension and exposure to noise near airports: the HYENA study. Environ Health Perspect. 2008 Mar;116(3):329-33. doi: 10.1289/ehp.10775.

Knai, C., Pettigrew, M., Durand, M et al (2015) Has a public–private partnership resulted in action on healthier diets in England? An analysis of the Public Health Responsibility Deal food pledge.  Food Policy,  54, July, Pages 1–10

Schreker, T., and Milne, E. (2015) Health and politics for 2015 and beyond.  Journal of Public Health, 37 (1): 1-2.
doi: 10.1093/pubmed/fdu112 First published online: January 7, 2015


Tuesday, 24 February 2015

Mental health and wellbeing


I spent much of January in Zambia, one pleasant task being to establish a new research capacity building project on mental health, funded by the British Academy. The aim was to recruit 40 colleagues to work on four strands – HIV, maternal health, prison health and workplace health – all in relation to mental health. We got off to a flying start!

Mental health has always been championed by African colleagues, for example at WHO symposia, arguing for its higher priority. They haven’t always been successful. All over the world, mental health services are described as the ‘Cinderella services’ – under-resourced, stigmatized, neglected, whilst the conditions that create good mental health and good social health are less researched, understood and planned for than physical health. The drift into a wellbeing paradigm could be expected to focus more firmly on mental salutogenesis and certainly health promotion is concerned with how we create the kind of society which brings about mental health justice as well as merely health justice.

It can take a high profile incident to bring emotional vulnerability to the fore, but too often the news fades and nothing changes. One example is Robin Williams’ suicide last year – a hugely successful actor yet prone to some of the demons that seem to beset some very creative people.  (He’s been described as ‘the genius who fizzed with divine madness’). His death did spark a national debate about mental health and suicide; suicide is the biggest killer of men between 20 and 49 in the UK, overtaking road accidents, cancer and coronary heart disease.  It’s the second biggest killer of people aged 15-29 globally, and rates also increase among those over 50. According to the WHO, (Preventing Suicide: A Global Imperative 2014), every 40 seconds someone somewhere in the world kills themselves. This is bound to be an underestimate.


Of all suicides in the UK in 2012, 76% were men.  A condition that affects one gender more than another suggests that ‘something is going on’ regarding masculinity or femininity, and it’s easy, though perhaps simplistic, to relate suicide to men’s seemingly lesser ability to ask for help, to be transparent and to talk about their feelings. One man who did open up was the MP John Woodcock, who in 2013 talked about his depression. He also noted that mental health trusts are making cuts of 20% higher than other hospitals, and that mental health organizations have warned that the cuts are threatening people’s lives. The charity Calm – Campaign Against Living Miserably – has called for men to challenge archaic male stereotypes and instead to define themselves on their own terms.

There’s a clear link between mental health and social health, if depression can be said to be related to loneliness. The charity Relate issued a research report last year which said that 19%  of people (total sample size n=5778 people)  questioned said they had never or rarely felt loved in the previous two weeks. One in ten people said that didn’t have a close friend, which, if extrapolated to the whole UK population, would be 4.7 million people.  Friendship is surely one of the great joys of life, essential to our wellbeing. Creating and keeping friendships is a skill, and surely one that needs to be nurtured as part of a salutogenic environment.

It’s difficult to know how far to pathologise mental illnesses such as depression, but certainly, Robin Williams’ suicide led the Royal College of Psychiatrists to argue that only about a third of cases of depression are treated in the UK. The parity between mental and physical health services seems to be widening; Prof. Simon Wessley, the President of the RCP said it would be unheard of if say, 70% of cancer patients were not only receiving no treatment, but if their condition was not even recognized. The last time statistics were collected centrally on child mental health, in 2004, they showed that 1.3 million children had a recognizable mental health problem. Signs are that this has worsened over the interval of time. In 2014 Public Health England reported a 41% increase in children self-harming and a 33% rise in their suicidal thoughts.


Survey after survey shows this kind of emotional vulnerability  – and studies also highlight the inadequacy of services to help those in need. These services are often provided by the NGO sector which tried to fill in the gaps.

As a health promoter, whilst understanding the need for downstream services to pick up the emotional pieces, I’m more interested in how societies create the conditions for good mental and emotional health. Of course, there’s been a great deal of policy work both to identify and measure the factors that lead to wellbeing, following the example of Bhutan, which has been measuring it since the early 1970s. Bhutan has challenged the idea that increasing wealth does not equate to increasing happiness. Certainly aspects such as social connections are high up on the OECD’s Better Life initiative, and this confirms the points made above about the importance of friendship, loneliness and suicide prevention – see:



However, this doesn’t mean that material factors are not significant  - jobs, earnings, income and wealth are essential elements of mental wellbeing. In 2012, one in five households in the UK reported difficulty or great difficulty in making ends meet. Economic downturns often create greater mental health problems and ironically, this is also when mental health services are cut due to austerity measures. The UK government’s new mental health strategy published in April 2014, No Health without Mental Health, will rely upon better ways of calculating the psychological harm done by, for example, being made unemployed or not being able to live on your household budget. Money isn’t everything and we need to resist financial determinism, but on the other hand, it’s hard to be happy when you’re worried all the time about making ends meet and about basic survival. In the same week as Robin Williams’ high profile suicide, a coroner recorded the suicide of Stephanie Bottrill, aged 53, who had suffered from depression but killed herself reportedly over extra worries about finding money to pay the ‘bedroom tax’.  She left a suicide note blaming the government. In another study, by the Children’s Society, a third of children said that their families had been affected by the economic crisis, and these children were more likely to have low wellbeing.

I’ve only dipped into the issues here, but we can see that there is a lot of work happening in the Global North on mental health and how to create it. There is less happening in the Global South.

Colleagues in Zambia have already made the connections between mental health and poverty. See:

Mayeya, J., Chazulwa, R, Mayeya, P., Mbewe, E., Magolo, L., Kasisi, F. & Bowa, A.C. (2004) Zambia mental health country profile. International Review of Psychiatry, 16(1-2):63-72

There is a need to too, to understand social constructions of mental health and mental distress, and to continue some of the work started for example by Magna Aidoo and Trudy Harpham:

Aidoo, M. and Harpham, T. (2001) The explanatory models of mental health amongst low-income women and health care practitioners in Lusaka, Zambia. Health Policy and Planning 07/2001; 16(2):206-13. DOI: 10.1093/heapol/16.2.206

Peter Chipimo is another researcher and practitioner in this area, and he joined the first part of our recent workshop in Lusaka. See:

 Chipimo, P.J  and Fylkesnes, K  (2009)Mental distress in the general population in Zambia: Impact of HIV and social factors BMC Public Health.; 9: 298. Published online 2009 Aug 18. doi:  10.1186/1471-2458-9-298


Our new Zambian project will enable research on mental health in the country and also provide opportunities for colleagues to hone their research skills and to do research in teams. Importantly, it will bring an African perspective to the global debate and policy agenda about how to tackle mental distress, and how to create the conditions under which people’s mental and emotional health can be nurtured.