The full lecture is available at http://www.actuaries.org.uk/news/pages/autumn-lecture-sir-harry-burns

A summary of Sir Harry's lecture produced by the BAJ Editorial team appears below.

The Chairman, Mr R. S. Bowie, F.F.A., Immediate Past-President, the Institute and Faculty of Actuaries, welcomed a large audience to the first Autumn Lecture of the Institute and Faculty of Actuaries.

He welcomed a number of guests from outside the profession: Professor Anne Glover, the Chief Scientific Adviser for Scotland; Graeme Brown, the Director of Shelter in Scotland, a number of distinguished professors and emeritus professors, and representatives from business and from other professions.

He also welcomed, from within the Profession, a number of Honorary Fellows, especially those from outside the UK: Georg Harbitz; Jean-Louis Massé, the Secretary-General of the International Actuarial Association, a number of past presidents; Jane Curtis, our current President, and Derek Cribb, the Acting Chief Executive of the Profession.

He introduced Sir Harry Burns, the Chief Medical Officer for Scotland.

He explained that it is part of the public interest goal of the Institute and Faculty of Actuaries to make constructive contributions to public debate on matters of importance, and, as a consequence, it is absolutely committed to research. He also mentioned the three sponsored projects on longevity which are due to be reported in 2012, and the need to build links with academia, with business, with other professions and with government.

He explained that the Profession is trying to increase awareness of the factors that affect longevity. In September 2011 it sponsored a symposium on longevity with themes such as socio-demographics and genetics, and the second longevity bulletin, which will look at the optimal ways of comparing longevity from country to country and from region to region, will come out in December 2011.

On introducing Sir Harry Burns, he explained that Sir Harry had graduated from the University of Glasgow in 1974 and that his early career was as a surgeon. But looking after patients in the east end of Glasgow, he became increasingly interested in the link between social conditions and health, and ultimately longevity.

In 1990 he gained a Masters in Public Health. In 1994 he became Director of Public Health in Glasgow. In 2005 he became Chief Medical Officer for Scotland in which he has been a champion of the important link between social conditions, health and longevity.

In his lecture, Sir Harry covered a number of areas, starting from his early days as a consultant surgeon.

It very quickly became apparent to him that the conventional explanations for ill-health were inadequate. The health, or the lack of it, that he saw in the east end of Glasgow was like nothing he had seen previously: patients took longer to heal their wounds than they did in other ordinary hospitals in the West of Scotland.

His interest was the metabolic response to surgery. He found that it was deeper and longer in these patients and that there was no adequate explanation for the difference. It was necessary to go beyond the conventional risk factor-based explanations for ill-health and come up with some different solutions.

As an example, he pointed to the difference in longevity between the most affluent and most deprived areas of Glasgow being of the order of 10 to 15 years. He explained the need to establish the link between the impact of social conditions and the molecular cause of death, in order to have hope of being able to interfere with that link.

He also emphasised that many individuals can come from adverse social conditions where most people will have an adverse life expectancy or an adverse health expectancy, and not experience those effects.

The lecture covered life expectancy in Western European countries drawing out that Scotland, which started off 150 years ago in about the middle of the range, stayed steadfastly in the middle all the way up until about the 1950s, and then other Western European countries began to overtake Scotland in terms of life expectancy and have consistently done so since the 1950s. Scotland, since the 1950s, has failed to improve at the same rate as our Western European neighbours.

By comparison, in the early 1950s, Portuguese life expectancy was about 14 years or 15 years less than that of Scotland. It has improved rapidly and overtaken us.

It was pointed out that there has been a steadily widening gap of life expectancy between rich and poor since the 1950s, to the extent that if the poorest men had increased their life expectancy at the same rate as the most affluent men, Scottish life expectancy would be three or three and a half years better than it is, putting it back towards the Western European average.

It therefore followed that Scotland's poor health is essentially a function of the health of the poor and we need to understand what is it about the state of being poor that has led to that condition.

A number of possible reasons since the 1950s were explored: unemployment, as heavy industry declined; the introduction of the welfare state, and the question of whether the social protection it brought has been adequate for the task of improving the health of the poor; and a number of more conventional risk factors.

In a World Health Organisation study of its European region among 15-year-old teenagers, Scottish teenagers at the start of the last decade were the fifth lowest smokers in Europe. This was before the introduction of the smoking ban. Scottish females were closer to the European average. It therefore appears that Scotland does not have the lowest life expectancy because it has the highest smoking rate.

Sir Harry also reaffirmed his view that smoking is intensely harmful, and that he would continue to strive to help eradicate smoking in Scotland.

Another example was diet, and in particular the extent of consumption of saturated fat. A comparison was made with Finland, where significant social policy changes were made to effect changes in diet to combat very high premature mortality rates for heart disease. The rates of improvement achieved were similar to those in Scotland, where there was no such program. There is evidence to support the theory that the fall in mortality from heart disease is largely a function of the introduction of new forms of treatment. Central to that fall has been the introduction of statins which are there, it is believed, to reduce cholesterol, but that is maybe not how they have reduced the heart disease mortality rate.

A further example was given on income inequality, with reference to a study in Glasgow, Liverpool and Manchester. The distribution of income was the same in each of the cities, and the standardised mortality rates were the same in Liverpool and Manchester. Glasgow showed an excess. But 60% of the excess premature mortality in Glasgow compared to Liverpool and Manchester is due to the following four causes of death: drugs, alcohol, suicide and violence. These are psycho-social causes of deaths. But there is little in the literature which considers psycho-social risks. For example it appears that those risks account for a third of myocardial infarction risk: a bigger risk factor than hypertension and obesity.

There is possible further support for the impact of psycho-social factors on mortality rates when considering the improvement in mortality rates in Saxony in East Germany following the decline of communism.

Sir Harry referred to two papers by Susan Everson. The first showed a link between hopelessness and premature death from heart disease and cancer in men in Finland.

The second showed that more pessimistic men deposited fat in their arteries at a greater rate than more optimistic men. There was a hypothesis in the discussion in the paper that pessimism about the future is linked to stress, and that in turn provides a link to the key stress hormone, cortisol, which mobilises fat in the bloodstream.

He also referred to the work of Aaron Antonovsky, an American sociologist who spent the latter half of his career at the University of the Negev in Israel. He studied the health of adults who, as children, had been in concentration camps. He argued that that must be such a crippling experience that they must all be unhealthy.

When he traced them all and studied them he found that 70% of them were desperately unhealthy – physically, mentally, socially unhealthy. He wondered, in contrast to the classic medical model, why the 30% were healthy. The critical thing, he said, is that the adults who survived concentration camps in a healthy state did so because as children, before they experienced what they experienced, they had acquired what he called a sense of coherence. A sense of coherence is basically the ability to make sense of and manage events around you. He said it consisted of these three things: that the stimuli that we perceived from our internal and external environments are structured, predictable and explainable; secondly, that we felt that we had the resources to respond to those stimuli appropriately; and, finally, that we saw those stimuli as challenges worthy of investment and engagement.

Antonovsky said that unless we find the social and physical environment to be those three things, comprehensible, manageable and meaningful, we would experience a state of chronic stress.

Sir Harry referred to other areas where you find high levels of cortisol, with an example from Canadian orphanages which show that higher levels are found when a child is separated from a single significant adult in its life. A further example from Whitehall showed that the lower down the hierarchy is a civil servant, the higher their level of stress hormones. The implication is that this is linked to the level of control the civil servant has; the lower down the hierarchy you are, the less control you have. It is Antonovsky's second principle: you must find the external environment manageable. If you do not, you are stressed.

Sir Harry also referred to research by Martin Bobak in the countries of the former Soviet Union at the end of the 1990s. He asked the population how much control they felt they had over their lives and related it to standardised death rate in the country each year.

The Russians reported the lowest level of control. They had the highest mortality. Poles and Czechs had high levels of control, and there was a linear relationship between the two. Interestingly, the Hungarians had actually the highest level of control but relatively high mortality which may be linked to their relationship with alcohol, although this is not clear.

Sir Harry then went on to explain that cortisol is a remnant of our hunter-gatherer past, noting that humans can run further than just about any other animal on the planet. Part of the reason for this is cortisol which mobilises fat as a fuel for our muscles.

Another remnant of our hunter gatherer past is the inflammatory response. Inflammatory response is measured using c-reactive protein (CRP). CRP has been measured in 5000 West of Scotland men. It doubles as you go down the social scale. It doubles if you smoke because the chronic irritation in your lungs leads to a chronic healing response. And it doubles again if you are obese.

The significance of that is that it is the inflammatory response, not cholesterol, that causes heart attacks and strokes. Cholesterol is deposited under the lining of the artery, the endothelium, which is a layer of cells that behave like Teflon to stop things sticking to the wall of the artery. It narrows the artery. It reduces the blood supply through the artery but you do not get an acute occlusion of the artery until you get a clot in the lining of the artery. You get the clot when endothelium cells are ruptured. The inflammatory response causes the rupture.

The clever thing about statins is that although they were discovered as a means of reducing cholesterol deposition, they are among the most potent anti-inflammatory agents that we have. They block the inflammatory response and that is probably why they have been so successful.

The relative risk of heart attack depends on which quartile of a population of men in which you happen to be. There is a three-fold relative risk if you are in the highest CRP quartile compared to the lowest.

The other thing that CRP predicts is your risk of type II diabetes. Of 5000 West of Scotland men in five quintiles, of men in the lowest quintile over a five-year period, one in 200 of them were diagnosed as having type II diabetes. In the highest quintile, one in 20 were diagnosed as having type II diabetes.

Sir Harry then moved onto the question of what is it about social conditions that leads to this chronic elevation of the inflammatory response? He referred to an experiment from a New York university which demonstrated that young monkeys are most stressed if their mothers are inconsistent from day to day in the time they are absent to seek food rather than the amount of time they are absent. In addition, those monkeys which were most stressed became fat when they were adults.

Rockefeller University discovered a hormone called leptin. Whenever you eat fat, the fat fills up the abdominal adipocytes which release leptin which go to the fullness centres in the brain and switch off hunger, unless you have high levels of cortisol. Cortisol blocks the entry of leptin into the brain.

The baby monkeys had a chronic upsurge of cortisol at a very important time in their development.

Further research from Rockefeller University also gives evidence that brains develop differently in threatened baby animals compared to normally raised young in three key areas. The outcome is that those parts of the brain which suppress inappropriate behaviour grow less well than those which govern the responses to threats to survival, to which there may be a violent response.

He also referred to the impact on the part of the brain which senses the circulating level of cortisol given the presence of domestic violence. The genes that call for the required proteins become blocked, and this can then lead to an intergenerational effect where children are unable to suppress their stress response.

Sir Harry then linked the various strands above into consideration of what happens in dysfunctional families, where drug-related issues and domestic violence can occur, with the impact on their children being higher stress levels. He pointed out that a baby's brain grows at a rapid rate in the early years, up to the age of about five.

Drawing on the Adverse Childhood Events Study, looking at adversities in children's lives, he pointed out that the incidence of alcoholism in later life was eight times higher for children who had experienced four or more adversities compared to those who had experienced none.

He also noted that boys who have experienced physical abuse are eight times more likely to beat up their dates as teenagers compared to boys who have experienced none. Domestic violence perpetuates across generations, and domestic violence leads to physical ill-health.

Significant numbers of childhood adversities also more than doubles your risk of teenage pregnancy.

Significant numbers of adverse experiences link to a three-fold increased risk of heart disease in later life. It is much more important than smoking and obesity. Yet it is not taken into account in policy, nor, perhaps, in terms of calculating risk.

Sir Harry noted that not a month goes by but there is some new report consistent with similar analyses being reported from major cohort studies in the literature. Early years adversity leads to social risk which, in turn, is associated with risk of physical ill-health and premature mortality.

Sir Harry mentioned that some aspects have been measured in some detail in the West of Scotland population. An example given was on the impact on choice reaction time. Choice reaction time is when you flash up a picture on a computer screen and you have to react by pressing the appropriate key very quickly.

What this shows is that, on average, a deprived individual will take about 140 milliseconds longer to get the right answer than an affluent individual.

There are significant implications of this, and it is not because you do not have rapid reflexes, it is because you take slightly longer to integrate the new information into your brain.

He noted that the impact is not irrevocable, and gave some examples in the literature on the growth in the part of the brain which integrates long and short-term memory: the hippocampus. London taxi drivers and those who practice meditation were the examples given.

Sir Harry then moved onto the public policy response. In particular he observed that, in general, we are good at measuring binary things such as dead/not dead or smoker/non smoker. But we are poorer at measuring more complex situations like the longevity of the social framework in which people live.

Increasingly we are moving towards a position of considering health assets. This is in stark contrast to consideration of the deficits which individuals have in their lives. The question is what assets do the people have? What can we activate in people that will enhance their sense of control, their ability to understand the world round about them? Those assets might operate as protective factors against adversity.

The voluntary sector has an approach which seems more suited to working with people, by building trusting relationships with people over a period of time.

Such an approach helps people rediscover alternatives for themselves. It helps support people to put those alternatives into practice and it builds networks that support them. Once it transforms an individual's life, that individual often wants to come back and volunteer for the organisation.

We need to find ways of applying that model more consistently across our society.

Sir Harry recounted a quotation he had recently been sent which captured the essence of the approach: “The greatest good you could do for another is not just to share your riches but to reveal to him his own.”

The lecture then progressed to consider the current view of health as having a binary outcome, when in the course of a single day a person's sense of well-being can move back and forth.

There was also consideration of a different approach to dealing with people: rather than trying to control some factors, it may be better to equip people with better information so that they can better navigate through life by giving them the skills to value themselves and to take the appropriate action to look after themselves as they go through life. So, perhaps, we need to stop talking about health improvement and start talking about life improvement. By doing so, we may help individuals feel in control over their lives, and by doing so they may be more likely to feel healthy and well.

Sir Harry finished with some quotations. The first was from Adam Smith, who wrote the Theory of Moral Sentiments. He understood that what drives us as human beings is the importance of seeing other human beings be happy. “There are some principles in his nature which interest him in the fortunes of others and render their happiness necessary to him, though he derives nothing from it except the pleasure of seeing it.”

His second quotation was from Jimmy Reid, a communist shop steward who, when the Heath Government wanted to close Upper Clyde Shipbuilders, decided to take industrial action not by leading the workers out on strike, but, instead, leading them into work, and to keep the doors locked and to keep building ships. The quotation is from his rectorial speech on becoming rector of Glasgow University in 1971, a speech which was printed in full in The New York Times, which described it as the single most important piece of public rhetoric since the Gettysburg Address.

His rectorial address was about alienation. “The cry of men who feel themselves the victims of blind economic forces beyond their control.” “It is the frustration of ordinary people excluded from the processes of decision-making. The feeling of despair and hopelessness that pervades people who feel with justification that they have no real say in shaping or determining their own destinies.”

Sir Harry surmised that what has happened in the marginalised communities of Scotland is a perpetuation of this alienation. It has very highly definable biological consequences, not just in those who are alive just now but in those who are about to come. It has lasted for three or four generations and we need to find ways of intervening. The way to intervene is not to continue to do things to those communities but to do things with them and to involve them by activating them in transforming their communities.

He concluded by identifying that the challenge is twofold: finding a way to intervene; and finding ways of measuring success in a much more reliable way.