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Chapter 1: What is the main topic discussed in this episode?
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Hello and welcome to this special edition of Doctor's Notes. I'm Dr. Chris. And I'm Dr. Zand. And last month we recorded an episode of What's Up Docs live at the Hay Literary Festival in Wales. It's fantastic, the Hay Festival.
Maybe the highlight for me was that on the first day I went to the very good artisanal bakery in town to get some baked goods and it was closed because I didn't look at the website and I'm a wally. And then we talked about it in the show. You knew it. And then I left the next day. I never found out. Did you get to the bakery? I went to the bakery and I bought everything. What were they called?
The thing that I was after was a Breton butter cake. Okay. You made it to the bakery. I made it to the bakery. I bought loads of stuff. I met people at the bakery who'd enjoyed the show. The whole thing was absolutely fantastic.
And I guess the point we made in the show was that, you know, we were talking about weight and health and diet, all the things that affect your health and whether you're in charge of your health. And I went to the bakery confident in the knowledge that I was making a good choice for for me and for the bakery.
Well, as loyal listeners will know, Zandi, What's Up Docs fits nicely, in fact precisely, into the allotted 30-minute slot on Radio 4. It has to do that, we should say. There's no coincidence that it happens to run to 30 minutes. So our production team had to work some editorial magic because the conversation lasted an hour in hay.
There's something about a full hour conversation that is really lovely. It was very interesting and enjoyable. So we thought for this Doctor's Notes, we would bring you pretty much the unedited version of the entire recording. Zandi, in the main episode, we focus on the factors that shape our health as we get older. Things like diet and exercise.
So we were asking to what extent you can control these things. That's right. I think we were exploring this tension between whether the responsibility lies with you to look after yourself or whether you should be looked after. There should be structures in the world that enable you to look after yourself if you want to.
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Chapter 2: How does individual responsibility impact health outcomes?
Let's open the hay. The notes. The bales of hay. Unpack the bales. Hi, everyone. Can you hear me? Welcome to What's Up Docs. I'm Dr Chris. I'm Dr Zand. We are so excited to be here at the Hay Festival recording Radio 4's Health and Wellbeing podcast. Thank you all so much for coming. First of all, are you looking after yourselves? There's a little hesitancy there. That's good.
I'd say at least half the room. Are you looking after each other? Well, a bit more confidence there, which is nice to hear. Which is nice to hear. And that's really what we're asking today. Which is more important for your longevity and for your well-being, looking after yourself or being looked after? That is the dilemma that we're wrestling with today.
And people have been interested in this dilemma for a long time, Zandi, particularly in the concept of longevity, haven't they? That's right, Chris. So if we were recording this episode at the first ever Hay-on-Wye Literary Festival... 1983. 3,000 years ago... Top of the charts would be The Epic of Gilgamesh. That would have been the only book in the charts.
Well, that's true, and quite good, that, actually. If you were going to try and buy it, it was written in cuneiform on big stone tablets. Probably the only one you could really take home in a tote bag. That's the oldest known major work of literature. King Gilgamesh of Uruk. He's obsessed with cheating death. And is he still around? Spoiler alert. He does not succeed in his quest.
But as the Hay Festival reminds us, if you write a good enough book, you live forever. So longevity is a really ancient idea. It's an ancient quest. But there's a more modern idea of health. span, the amount of that long life that we spend living for a long time. That's more contemporary, is it, Zand? Yeah, I'm sorry, Chris, this actually really annoys me.
So those of you that follow a range of the sort of longevity literature, the podcast, the stuff on the social media, will be familiar with this idea that there's a whole new concept in medicine, the idea of healthspan, this ingenious thing that doctors... In the past, only wanted us to live for a long time, but now we figured out that a long, healthy life is much more important.
And this is not a new idea. If you had been living in ancient Greece, this would have been a very familiar story. Eos, the goddess of the dawn, loved the Trojan prince Tithonus so much she asked Zeus to make him immortal. Zeus grants the wish, but she forgets to ask for eternal youth. Gah, what a mistake.
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Chapter 3: What historical context is provided regarding longevity?
But 2000 years ago, you could have been having the same conversation that is going on in many of the longevity mortality podcasts nowadays. OK, Zandi, but what has been a common concept across this discussion, across cultures for a very long time, is the idea that there is something out there external to ourselves that can confer on us a longer, better life.
I think we're all familiar with this, Chris. I guess the Holy Grail would be a great example. It's part buried in Christian stories, part of its Arthurian legend. Indiana Jones. Indiana Jones. Dan Brown, if that's how you've accessed it, not a bad source. Of course, the Grail is a metaphor for the idea that we could all be looking...
for something that really is out there that can rejuvenate us and make us live longer. So there's these old ideas, but we see these vampire headlines now. There's this much more contemporary idea, Silicon Valley billionaires injecting themselves with the blood of the young to rejuvenate.
So this is a familiar idea, but in fact, if we go back, Chris, to 1492, Pope Innocent VIII, aged 60, his doctors hired three young boys, drained out their blood for the pontiff's benefit. So the story goes. It's a difficult story to confirm, but the measures failed. The pope died, as did all the boys. It's an unusual operation that has a 400% mortality rate.
That rather poor outcome did not deter Louis XIII of France, or at least didn't deter his doctors. 1642, his doctors have tried enemas, bleeding, leeches, all the various things they can do. And eventually they go, why don't we do the first ever blood transfusion and hook him up to a lamb and pump the lamb's blood directly into Louis' veins? And how did this go? He's here tonight. It
Louis, welcome. He actually died a few days after the procedure. And the lamb? Delicious. But what about hormone supplements? Because this feels like the most modern idea that we are all aggressively confronted with. This idea is not new. It goes back at least to 1889.
Brown Saccard, the great French physician, starts grinding up guinea pig and dog testicles and injecting extracts of them under his skin. And he reports that he gets stronger, his bowels improve, his brain fog clears, all the things you see on the posters on the tube today. And he urges other physicians to try it, and they do try it, and they kill a lot of people.
But nevertheless, the science of this has improved, and after the show, I will be selling my guinea pig, proprietary guinea pig testicle extract. Zahn, this is the BBC. Sorry, I should say other guinea pig testicle extracts are available, but mine are organic, and they're made from real long-haired Peruvian guinea pigs. Zahn, Zahn.
The point is, not all of this is kooky, Silicon Valley extreme stuff. There is serious, sensible science around sleep, exercise, diet, stress, smoking, alcohol intake. These are the issues that are also really widely reported on. That's right.
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Chapter 4: What modern concepts of healthspan are discussed?
Are there people here who are sort of aiming to live a bit longer or would like to live a little bit longer? That's getting, okay, that's great. So that's getting a few nods. So people are sort of roughly bought into it, but perhaps a little bit sceptical about the specifics. Is anyone here aiming to get to a thousand? Anyone? OK, so no hails of derisive laughter. What about 500?
Anyone aiming for 500? Do I have 250? Do I have 150? Anyone trying to get to 100 and get the telegram from the king? OK, so that's great. So we do have an interest in living beyond what we might call our life expectancy. But there was an interesting headline in The Guardian very recently, which said that at least 80% of the responsibility for ill health in old age is down to the individual.
So people who are trying to live longer may well be doing the right thing, according to this headline. And that idea to me seems potentially really exciting and really empowering that we could take charge of our health. And perhaps that's what we should be doing in this tent today is setting you up to kind of grapple with your longevity. A little bit of advice.
It would be a great thing to do on the radio. Who can argue with that? I can argue with that. Ah. So I'm going to quote directly from the report that that headline referenced. It talked about these pillars of living well. It talked about what we eat, the air we breathe, the water we drink, above all stress and smoking. Zand, we don't choose the air we breathe, the water we drink.
How can these things be our responsibility? That's a reasonable point, isn't it? We don't choose the air we breathe or the water we drink. But the headline said 80% of our ill health in old age. It didn't say 100%. So, sure, maybe it's hard to change the air you breathe or the water that you drink, but you could do all kinds of things to improve your health, couldn't you?
That other 80% really should be our responsibility, and we can make choices that are good or bad for us. So, for instance, this morning... I had a choice on what to have for breakfast and I got up early and I headed to the bakery. And Chris, what I was particularly interested in, Hay-on-Wye has got some superb bakeries, was a particular kind of Breton butter cake.
Sand, the Breton butter cakes in Hay-on-Wye are not the reason that a majority of us are living with death and disease due to poor diet in the UK. Artisanal bakeries are not driving a public health crisis. Now, it's worth saying that the butter lamination is the key issue, Chris.
No one cares.
The sugar and the butter caramelise. Technically, it's called a Queen Amand. Zand, they are not deliberately engineering food that you can't stop eating. They're making food with love and purpose forever. for probably relatively small profit margins.
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Chapter 5: How do environmental factors influence personal health?
This sense that I do have some free will and I can choose to go to the bakery, but I feel a pressure that I should and can take responsibility for my health. And I'm told this all the time. There are many companies who want to sell me apps and subscriptions and supplements and wearable tech. But Zand, in spite of this deluge of information, all the available tech, our life expectancy is shrinking.
And our health span is also shrinking. So in the last decade, our years of healthy life have shrunk by two full years to 60 years. So five years below the age of retirement in this country when you get a state pension. So all of this isn't working. We live for a quarter of our life in the UK with chronic disease. So this is where Chris and I are beginning this episode.
is this dilemma about going, should we be sending you home with a shopping list of things to do that you can do to make yourselves feel better and live longer? Zand, or do we send you home with things that you should try and demand of your politicians and the corporations that shape your health environment? This is a complex topic. It is a complex topic. And I will say...
I think it may, for many of us, get quite emotional. I think when I think about my health struggles, a lot of it is about self-loathing and about guilt and about recriminations. So I think we will have to wrestle with this over the next hour. This, Zand, is the argument, the dilemma that I think runs through every single episode of What's Up Docs.
And we are thrilled to be joined by an incredible expert who's going to help us wrestle with it. Exactly, Chris, we have. Professor Devi Sridhar. She is Chair of Global Public Health at the University of Edinburgh. She's written a pile of books, including her latest, How Not to Die Too Soon. She is a world expert on public and global health. I am very excited. Please welcome Devi to the stage.
Devi, it's wonderful to have you here. Hello.
Hi.
Hi.
Your work in public health has reached a huge number of people. People here will have read your books, read your pieces in the international press. But you have a personal connection to public health as well, don't you?
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Chapter 6: What role do commercial interests play in public health?
And so I guess it's easy to say it, but when you go deeper, it's much more linked to the circumstances that you're in, the policies that your government follows, and kind of your luck of living in a certain community or in a certain neighborhood or in a certain place in the world.
We want to drill into a few of these things in more detail. Can you start by just giving us a sense of the big things that affect our health?
Yeah, so a lot of them you'll probably be able to identify yourself. Like you need to exercise, move enough. That's a big factor in longevity. You need to eat a certain kind of varied diet, a nutritionally dense diet. Don't smoke, you know, be happy, mentally healthy and supported. Have a community and that ties into your mental health.
Don't be unlucky to live in a neighborhood with high gun violence. I have to mention that as an American. I mean, if you look at the number one cause of child deaths or adolescent deaths in the States, it's actually guns and firearms. But if you're somewhere like Vietnam, it's actually road traffic accidents. So actually... How do your roads look? How do you get to different places?
Is that safe? And then water, air, and healthcare. I have to mention, like, what kind of healthcare system do you have? Is it going to pick up if you have early signs of cancer? Is it going to pick up if you got prediabetes? Is the ambulance going to get there fast enough if you're in a car accident? Because we know that every second makes a difference.
So yeah, so I look in my book at nine different factors that I say contribute from what we know in the public health evidence of what makes us live longer collectively as a population, as a community.
Clearly, some of those things are outside of our control. The air you breathe, don't breathe the air if you live in New Delhi. It's quite a tough bit of advice. So some of those things are outside of our control. But that headline had this idea that 80% of the health outcomes we can do something about. So can we start with a couple in detail? If we start with exercise, exercise is free.
And it's easy to do. You can go to a park. You can go for a walk. If you don't walk, you can curl some tins of beans. I mean, there are endless things that you can do that are free, accessible. Why is exercise not a pure matter of personal responsibility?
Well, let's take a step back at, again, population level trends. So what you see is actually levels of physical inactivity are going up and they've actually increased. And actually, if you go to the developing world, the higher your GDP per capita goes, the less physically active your population is. Why? Because usually people would need to...
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Chapter 7: How can community support improve mental health?
And so I guess that despite kind of this push to, like, go exercise and all the YouTube campaigns and all the fitness campaigns, like, we all know we should exercise, right? Like, we all know that kids should do it. So why aren't we doing it? It's that. And I think it's because it's become... and I would argue harder to in a lot of places. So you say parks.
If you live in an area where there's green space is taken away, where are you going to go exercise? If it's not safe, especially as a woman, to go out running early morning or late at night if you're working in the park, are you going to go do it? You know, I think you have to think about actually how does someone's daily life look, and can they actually get fitness within it?
And also, some people don't like exercise. So what we need to do is think about, well, how do places that get people moving, like the Netherlands, or Paris do it? Well, they make people walk to work and back. They create public transport systems. So you're not exercising. You're just going about your day. And in going about your day, you move.
It's not merely that governments make people exercise. They create joyful spaces that people want to physically commute through to work, don't they?
Exactly. So I give the examples of like Amsterdam. So many of you might know it as the cycling city and you think, oh, the Dutch, they love to cycle. But actually, it's quite a recent history. In the 1970s, they didn't have those cycle lanes. It was actually a concerted campaign by parents and the cyclist unions to say, we actually want streets that are
pedestrian lanes that our kids can get around safely with we're worried about child deaths and they transform the city and you're seeing that happening in Paris you know live in Edinburgh you're seeing trying like attempts in Edinburgh towards that and so I feel like here we can't just assume things will happen we actually have to make the efforts to try to change the environments we're in to make it safer to get around your day whatever it might be.
In the book, you talk about Paris and the changes. If anyone's been to Paris over the last decade or so, you've seen it transformed. You talk about the resistance that was faced. Can you just explain a bit about that?
Yeah, and I should say there's always resistance to change. Like you do see that it takes people, when the smoking bans were brought in, there was resistance. When seatbelts were brought in, there was resistance. And so there's always actually some friction where people are like, oh, what is this going to mean for me, this change? I don't like it. So yeah, so Mayor Hidalgo came in.
She says, I want to make a cycling city. And she had certain principles, which some of you might recognize. One is that the biggest danger to a cyclist is a motor vehicle. And guess what? People don't want to be on roads cycling next to motor vehicles. You have to create separate lanes. And then people will use them. So she did that.
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Chapter 8: What actionable advice is given for healthier living?
To have restrictions. And the air has improved so much more. And it's easy to take that for granted until you say, if those hadn't been brought in, what would London's air look like? What would your kids' air look like? Would they develop more asthma, more wheezing? All these kind of things that you're seeing and you are seeing in other places in the world.
So I think there it's easy to be like, oh, we just take it for granted, but they were the result of deliberate choices of how they wanted the city to look for the people within it.
You have a particular interest in exercise. You do try and help people get fit. Can you talk about that? Because it's quite unusual for a professor of public health.
Yeah. So this happened to me during the pandemic. I used to go to like an outdoor boot camp. Remember, we could do outdoor stuff, but not indoor. And when I was there one day, the instructor didn't show up. So I was like, I'll take it.
I can do this and they're like no you can't you have no certification and I was like I come every day and they're like no doesn't count so I decided to become a personal trainer so I did that over like a year-long course I'm now a level three trainer did boot camps in the park and all that and people find it funny but I actually would say it's the same as being like a doctor and being in public health I see it as like I do public health but when I'm reading studies which is like the more you exercise the longer you live you know you need to do cardio and flexibility and strength training I'm like
this is too abstract at some level for me we can do the studies I actually want to see people I want to talk to people I want to be in gyms I want to be in communities I want to understand anatomy and the body and how it all works together so yeah I've done that but again I feel like you know and I do talk about the importance of like personal trainers but you're kind of reaching those who are already wanting to get fit and I think the hardest thing in public health is reaching those who don't necessarily want to step into a gym and I think it's so interesting that we talk in public health about an upstream downstream phenomenon
Where, you know, as a physician, I see people who there's this metaphor of people sort of floating down in the river and you haul them out and and resuscitate them. And you never have time to go upstream and work out who's pushed them in the river. Why? Why are they in there in the first place? Why am I?
So you're you're experiencing this as a as a PT, the sort of the sharp end of of the difficulty of people getting fit. And also you're experiencing who isn't in your fitness class, I'm guessing. Yeah, no, I love it.
Completely. And I would say, you know, we think of health as the NHS and, you know, medics have a huge role to play in that. But I would say health is made in supermarkets. It's made in parks. It's made in gyms. It's made in swimming pools.
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