This is the wicked problem. While medical research has made such a spectacular impact on communicable disease, we are struggling when it comes to non-communicable disease. We face rising rates of diabetes, heart disease, obesity and mental ill-health, with ever-closer connections between them. We have been very good at describing the causes of these diseases, but less successful at coming up with solutions. Almost 90% of our health research funding is invested in biomedical research hoping to find new molecular or genetic cures, but paradoxically almost 90% of the determinants of health are social and environmental.
We scientists (like engineers) do tend to like our simple solutions. Removing pump handles to prevent cholera epidemics, or stopping smoking to reduce lung cancer. However we live in increasingly complex systems where there a few neat, linear pathways between simple exposures and isolated outcomes. Systems can complicated but still predictable and controllable. Complex systems are unpredictable and create feedback loops that can accelerate or dampen change. They have emergent properties and unintended consequences. Sending a rocket to the moon is a complicated, raising a child is complex.
In Bradford and Tower Hamlets our children in deprived neighbourhoods are more likely to grow up in houses that have few books and more overcrowding. Their houses are more likely to be damp and of poor quality, with lack of adequate cooking facilities. Their roads are likely to be busy with traffic with air full of pollution. Their neighbourhoods are less safe and have higher rates of crime. The parks are of poor quality. The high streets are food swamps of fast food outlets, and yet food deserts with lack of healthy food options. The schools they attend will be struggling to fulfill educational attainment when so many children have English as a second language and parents often less engaged.
There are no magic medicines for these upstream risk factors. The health and life chances of these children is going to be shaped by teachers, transport engineers, urban designers, lawyers, policy makers, house builders. Our impact as doctors and nurses is frustratingly limited.
Our UK Prevention Research Partnership Consortium has just set off on its 5 year journey. ActEarly will focus on early life where so many roots of ill-health lie. We will establish City Collaboratories in Bradford and Tower Hamlets that bring together novel inter-disciplinary researchers to work with communities and policy makers to turn red zones of ill-health into blue zones of good health. This will be a tough journey – forging new paths and climbing steep mountains. On the sunny uplands far away in the distance lies our destination, and this is what we hope it will look like.
People-powered research. Our communities are at the heart of our programme. If we are going to achieve sustainable change in our systems then we need to start in harnessing the views and creativity of our citizens. This includes developing a city-wide network of citizen scientists to help us prioritise, collect and understand the data.
Rich data tapestries. We have some of the best whole system data sets in the UK through Born in Bradford and Whole System Data in Tower Hamlets. Google and Facebook are using our data to flog us stuff we don’t really need. We need to build broad and deep linked data sets that allow us to understand needs and develop predictive models to target upstream support.
A critical mass of prevention interventions. Prevention interventions often focus on single risk factors (cooking classes or the daily mile) and we scatter them around the country so they are almost homeopathic. Our hypothesis is that we need a critical mass of interventions across the whole system to reach a tipping point for change. We will aggregate these interventions in our City Collaboratories and test their impact across system-wide outcomes.
Policy and practice-embedded research. Our NHS research networks are the envy of the world, yet our local authorities are research-free zones. If we are going to develop whole system evidence that is useful for decision makers we need to spread our research expertise into local authorities – rather than a Director of Research for a hospital, we will establish a City Director of Research.
Our ActEarly Consortium has three themes – Healthy Places, Healthy Learning and Healthy Livelihoods. It has two Centres – Bradford and London. It will unite communities and citizens with academic experts from education, urban design, transport, arts and culture and social justice. It is a complex system in itself, and over the next five years we will share our lessons – our times of despondency and our moments of joyful success. Watch this space!
John Wright October 2019