JOAN passed away recently. Her body was overtaken by cancer. She was 85. That was a particularly good age for someone who lived in the wrong place and struggled to make ends meet. On average, women in her home town of Bolton are expected to live to 81 — a couple of years less than the national average. But Joan lived in one of the most deprived council estates; so her life expectancy was lower: about 11 years less than someone half a mile down the road.
More than 30 years ago, I married her daughter; so I knew Joan well. If we had moved her that half-mile, and provided her with an additional income, I wonder if she would still be with us. Of course, this is speculation. But this is how we think about the social context for health: if we can change the conditions in which people live, then we can improve their health and longevity.
The public-health specialist Professor Sir Michael Marmot promotes this idea of the “social determinants of health”. He has chaired a commission on this for the World Health Organization since 2005, and established a principle that has been widely adopted in public policy.
These “determinants” include housing, employment, education, and environmental factors. His thinking implies that people’s well-being is subject to their social context, and that this will be an overwhelming influence on their state of health.
In parallel, economists and behavioural scientists have been discussing the links between wealth and well-being. Politicians tend to consider that their primary mandate is to increase Gross Domestic Product (GDP). They assume that growth in the economy lifts people out of the miseries and struggles of poverty to make them happier and healthier. The link between increasing wealth and improving health, however, is more complex than this. Higher wages are no guarantee of greater well-being.
Richard Easterlin, who is currently Professor of Economics at the University of Southern California, observed, in research published in 1974, that, while wealthier people were generally happier than poorer people, the increase in GDP of a country did not necessarily make the general population demonstrably happier. In 2010, the American academics Angus Deaton and Daniel Kahneman concluded that there was a plateau effect on happiness once a person earned $75,000 per annum. Reviewing a range of studies that measured happiness and life satisfaction, they could not identify any appreciable increase in happiness beyond that level.
Linking the idea of social determinants with measures of well-being, the epidemiologists Kate Pickett and Richard Wilkinson have identified income inequalities as the key determinant for diminished health. Their book The Spirit Level, published in 2009, argues that social determinants are not alone in affecting people’s well-being, but that it is widening income differences between people in competitive societies which cause a range of ills, both medical and social.
Pickett and Wilkinson point out that the experience of anxiety, shame, and poor self-esteem triggers the stress hormone cortisol, which may inflict physical damage to the body and brain. “The biology of chronic stress is a plausible pathway which helps us to understand why unequal societies are almost always unhealthy societies,” they say.
They pare down their theory to a simple mechanism: if you reduce income inequalities, you reduce the deleterious hormonal effects of shame. But their thesis prompts the question: is the human condition so simple?
The Nobel Prize-winning economist Amartya Sen raises a paradox about health inequalities from his observations of life in India. In the state of Kerala, health services are more advanced than the rest of India: women are more likely to survive childbirth; their children are more likely to survive into adulthood. Their ailments will be addressed by the multitude of clinics and hospitals. They will die later than their fellow citizens in Uttar Pradesh or Bihar.
Surveys assessing attitudes to their state of health, however, show that the people of Kerala are more likely to be negative. They have a greater level of education, and are exposed to greater opportunity. They aspire to a high level of wealth and happiness. They are aware of those things that limit their capacity to live the good life; so their sense of well-being is diminished.
The poor in other parts of India do not enjoy so much education, and do not expect to achieve more than surviving their hard, rural self-sufficiency. In accepting these things, they live with the reality as they and their neighbours experience it. They do not perceive poor health as those from Kerala do.
Unlike Wilkinson and Pickett, Sen argues that awareness of inequality may carry some positive benefits to health — such as motivating people to challenge the poor environment in which they live — even if their perception of well-being might diminish.
He also argues that a growing middle class improves family living conditions and promotes aspiration for greater improvement, and that, in contrast, a historical norm of uniform poverty may promote passive acceptance. Sen argues that freedom and aspiration are good for people’s health and well-being, particularly when affecting the opportunities for women.
LAST year, Joan enjoyed a boost through her membership of a new food-club in Bolton: the Storehouse Pantry, based at St Andrew’s, on the Johnson Fold estate. The club was developed between the Christian charity Urban Outreach, the social-housing provider Bolton at Home, and St Peter’s, Halliwell (St Andrew’s is one of four churches in the parish).
Given that there is a large and tempting McDonald’s next to the estate, the club is seeking to improve access to fresh food for all residents by offering food sourced from discarded items from the supermarkets, charitable donations, and bulk buying. For a weekly subscription of £2.50, residents can fill their baskets with their pick of up to 15 items — groceries, fruit and vegetables, toiletries, and cleaning products — whose retail value averages £15.
Joan liked a traditional diet of meat and three veg, but it is impossible to know how well it served her; there are many complex factors affecting health and longevity. But she was not driven by the social determinants that suck many others into a poor diet.
”Our mission is about meeting people’s needs where they are as part of the gospel; and this is an obvious way in which we can meet the need, where people are short of food,” the Vicar of St Peter’s, Halliwell, the Revd Paul Hardingham, says of the vision behind the food club at Johnson Fold.
Inherent in the initiative is the idea that in an area of high deprivation it enhances people’s sense of self worth. “It’s more than just a foodbank: it’s an opportunity to give people dignity and worth, in that they have that ability to choose what they want,” Mr Hardingham says.
”In the work of Storehouse Pantry, we are really looking to see how we can enhance that experience; so we’re looking to start a CAP [Christians Against Poverty] life-skills course. . . It’s about enhancing their life and bringing value; so it’s a value-added food-bank idea.”
The CAP course is designed to help people survive and thrive despite being on a low income. It offers practical help with skills such as such as cooking on a budget, eating healthily, and managing money. Besides offering the potential to improve the health culture of those on the Johnson Fold estate, “the vision is to replicate what is happening here in different areas of Bolton,” Mr Hardingham says. A second food club is currently in development in the New Bury area of Bolton.
Alongside an unhealthy diet, smoking is the biggest cause of preventable early death in Bolton, as it is in England as a whole. Although few of us are comfortable with the idea of “determinism”, which smacks of fate, social determinants inevitably interact with culture and personal choices. Joan chose not to smoke. But, while the number of smokers is dropping consistently — in response to many long-term public-health initiatives — it is in the poorest communities that smoking rates remain the highest.
The root causes of health behaviour are more complex than an account of social determinants and inequalities: it is subject to the human story, and relationships. Public Health England’s Director for Drugs, Alcohol, and Tobacco, Rosanna O’Connor, was recently reported in The Guardian as saying: “Marketing campaigns and price increases are especially useful in triggering quit-attempts. But we are also influenced by the people around us. The more ex-smokers there are among your friends and family, the more likely you are to quit for good, and the less likely your children are to start.”
Public policy has a part to play in improving these forms of behaviour, but individuals, families, friends, and community structures — including the Church — can have a crucial part to play.
The power of relationships to affect change is key to a new health and well-being course, Intentional Health, originally piloted at the Wadebridge Christian Centre in Cornwall, and now being offered to churches nationwide by a former health and well-being trainer, Niky Dix. The course follows the typical pattern of a ten-week course, but focuses body, mind, and spirit in creating healthy habits.
The aim of the course is to prompt people to take more control of their health by utilising the spiritual and community strengths of the Christian faith. “It’s not that people need telling what to do, it’s that people need support in how to do it,” Mrs Dix says. “We all have been given a body, one body: it’s the only thing we’ve each got that’s unique. And we get to choose how we look after it. Whether we go to church, believe in God, or any of that, we can still make wise or not-so-wise choices about what we do with our body.
”If you’re a Christian, you have more of a responsibility to steward the body that God gives you; so it’s
a good opportunity to start with us as a discipleship element. But it’s something that can help people, whether they believe in God or not; so it’s kind of loving your neighbour as yourself.”
Since its national launch in 2015, Mrs Dix has worked with five churches to run Intentional Health, and volunteers from four more churches are set to start. As a minimum, interested churches need to have two or three volunteers available to train as course facilitators. “People with poor health die sooner, and live in poorer conditions than people who are well off. Health poverty is a whole new dimension, and you can’t just lift yourself out of it: somebody has to come and help you learn something new, or do something different so you can change your health and well-being.”
THEOLOGY concerning the state of the body sits uneasily alongside contemporary attitudes to health and longevity. Its pessimistic view of flesh, and natural attention to the mind, leaves little to be said about the physicality of personhood. The 1995 Doctrine Commission’s report The Mystery of Salvation recognises the essential psychosomatic unity of the person. But, with the incomplete revelation of God’s final transformation of all things, we simply do not know what continuing meaning emerges from our flesh. And our longstanding assumption about the separation of the physical from the spiritual leaves many in the Church doubtful whether to apply ourselves to the health of that psychosomatic unity.
As an example of the difficulty in practice, the Church of England’s Mission and Public Affairs Council’s 2010 paper Dementia and a Christian Perspective sought to articulate hope amid death: “All that assailed us in our human experience is left behind. Here there is no place for mental illness, for dementia, for learning disabilities, and a whole range of other conditions.”
If we can describe a mind in this way, what might we say about the eternal significance of our brains and bodies? Are all the compromised elements of ourselves perfected to some ideal in heaven? Those whom we tend to describe as “disabled” wonder what their essential selves might look like for eternity; to what extent will there be continuity and discontinuity?
Despite the absence of clarity on eternity, there are many examples of Christian health-mission emerging across the country. These take seriously the contemporary pursuit of health through a theological understanding of the pursuit of justice for the poor, loving one’s neighbour, and a holistic understanding of God’s love for us as human beings, even as we continue to support the sick.
Interested churches can help to nurture mental well-being through running Livability’s four-week course “Happiness”, which seeks to promote prevention rather than cure. Its founder, Dr Andy Parnham, is both a church leader and a GP, and offers the course to churches to encourage people to take on board insights from those theories of Positive Psychology that are in keeping with Christian teaching.
JOAN had a fair degree of vitality, both physically, spiritually, and mentally. She had had a stall at Bolton market in past years, and she enjoyed getting out to markets in Bury and Oldham. The bus was her lifeline, but between buses she walked, and her heart pumped with vigour as a result. Her fate was not determined simply by the physical and social environment in which she lived, nor by the low income she endured. She was affected by patterns within her family, and among her friends, and by the support of her church. And she made choices of her own.
Public policy offers tools to improve people’s lives. But there is much that churches can do, alone and in partnership, to nurture physical and mental vitality in an unequal society. Christian people may find themselves on uncertain theological ground about the eternal fate of the body, but the demands of those in the communities we serve here and now call out for our growing involvement.
The Revd Paul Holley is the former co-ordinator of the Anglican Health Network, and Priest-in-Charge of Bodmin with Lanhydrock and Lanivet, and Assistant Curate of Cardynham in the benefice of St Neot and Warleggan with Cardynham.