MIC CAVAZZINI: Tena koutou, Tena koutou, Tena koutou katoa. Welcome to Pomegranate Health. I’m Mic Cavazzini for the Royal Australasian College of Physicians.
The next couple of episodes deal with two of the cruxes in a child’s development. Today you’ll hear about the first few years of life, and how predictive this period is for lifelong health and social outcomes. And in the next episode we talk about transition to adolescence for cohorts with complex care needs.Todays’ stories should be of interest to all listeners, not just paediatricians.
The speakers were recorded at the 2019 RACP Congress in Auckland and have kindly allowed their talks to be adapted for this podcast. We’re going to start with an introduction to the Dunedin longitudinal study, one of the most detailed and most cited studies of human development ever undertaken. Over the forty seven years its been running, the study has resulted in a new peer-reviewed publication every two weeks on average.
The researchers recorded over 1000 births in Dunedin in 1972 and have followed these people ever since, even though only a third have remained in New Zealand. All sorts of measures have been taken throughout the participants’ lives; physical and mental wellbeing, emotional profile, relationships, economic success and criminal convictions.
The study is centred at the Dunedin Multidisciplinary Health and Development Research Unit directed by Professor Richie Poulton. He is also Chief Science Advisor to the Ministry of Social Development of New Zealand-Aoteroa. In his seminar, Dr Poulton showed the incredible predictive power of one behavioural trait in particular. He also referred to the Pareto principle, the idea that 80 per cent of wealth or land is owned by just 20 per cent of the population. Sadly, this rule also holds true at the other end of the spectrum.
RICHIE POULTON: So, the Dunedin Study, a cohort of 1000 people, just over 1000 people. One important point to draw your attention to is that we’ve maintained the cohort pretty much intact through time. That’s important because the major threat to the validity of these types of projects is what is known as non-random loss to follow-up—the people that drift away aren’t random. Multiple difficulties aggregate within the individuals that most cohort studies in the world have failed to follow-up and retain over time. So, that gives us some confidence in our causal inferences. That’s all I would say about that, I’m not trying to show-off.
I’m going to present some data which identify the importance of the early years in particular, and I’ll show that it predicts important life outcomes not just in one particular area but in multiple important life domains and that that prediction withstands control for all the usual suspects; distribution across social strata, cognitive measures, IQ and the like. It applies equally to men and women and it just doesn’t result from the extremes driving the association.
The first thing we’re going to look at is self-control. What is self-control? It’s intuitively what you would think self-control is. Depending on your disciplinary background you might call it “impulse control” or “executive function” or “emotion regulation” and it’s about basically thinking before you act, about being able to delay gratification in pursuit of goals. Nothing esoteric about this.
The first version of this self-control work is the famous marshmallow study that came out of California where children were placed in front of a marshmallow and the nasty experimenter left the room pretending to do something else and said, “If in 10 minutes when I get back you haven’t eaten that you’ll get a second one.” And there’s some lovely original footage on the web which I recommend you look at because these kids were delightful in trying to resist the urge to grab the marshmallow and scoff it. And they go under the table, they bite their hands, they cry, and they cry after grabbing the marshmallow and eating it. And I can tell you, I would have grabbed it as soon as the guy was out the door.
Anyway, it’s probably a useful thing to study in this day and age where we’ve got really tempting distractions all around us all the time. We used the composite measure; if you composite via multiple measures from multiple sources you reduce the overall error. All the findings I present now are from the composite, but I can assure you that if you just use the age three measure, three decades later you can predict significantly the outcomes we’re talking about, and the pattern is exactly the same. And I use the term “pattern” advisedly; there’s a certain type of pattern that occurs between your level of self-control as a child and whether you’re going to do well in terms of here, physical health, as a grown-up.
So, we didn’t just use a self-report measure of physical health or one particular domain of physical health; we combined multiple indicators of poor physical health. Of course, they are measured directly because we bring everyone back from wherever they are in the world and we measure them with the proper physiological testing. We combined metabolic abnormalities, gum disease, STIs and inflammatory markers as well, some FEV measures.
So, we’ve got quintiles along the bottom of self-control. And what you see there is a lawful, graded association. The lower your level of self-control during childhood, by the time you are 32 your likelihood of ending up in poor health—highest level to lowest level of self-control—what you might expect if you were hypothesising based on the extant literature—those with the highest level of self-control had the best health.
What wasn’t predicted though was this graded association. There’s the control, so it applies whatever point in the socioeconomic distribution you look, it also applies to the extremes, it’s for boys and girls and it’s not just driven by clinical levels of low self-control, ADHD.
What about substance dependence as our next outcome? So, we get that via the gold-standard structured diagnostic interview. We got a bunch of diagnoses for tobacco, so the licit and the illicit grouped it as one. And you see again a lawful relationship; the highest rate for substance problems the lowest quintile of low self-control and a graded association down to the high level where it was lowest. But we also went outside the study member because of error or potential bias and asked people that knew them well whether our study member had a problem using substances. Same pattern.
What about wealth? These are things that governments are interested in. We measured income and prestige in occupation, the usual sort of stuff. Same pattern. So, lowest level of self-control, lowest socioeconomic status rising lawfully across the quintiles depending on what level of self-control you exhibited when you were a child.
Crime. These are official stats not just self-reported, so it’s from the Australian and New Zealand jurisdiction. There we have not so much of a graded association—we’ve got a big dip from the lowest self-control quintile but essentially, it’s still there.
Parenting. This is about being a single parent. Low self-control? Surprise, surprise, you’re going to be a solo parent. And we have also done a paper that shows that you start having children much younger than the rest of the cohort, and that’s under review right now. The right type of parenting—you’d all know this being paediatricians—warm, sensitive, stimulating, measured directly with the child and the study member-parent at their own home when their first-born child was age three, and we see a lawful relationship yet again. It seems to matter everywhere and it follows the same graded association.
Economic measures. There’s welfare benefit use done in months—you can monetise that. So, what do you see at the top? The kids with the lowest level of self-control spend the best part of four years, 50 months, on benefits, and they compare with those at the higher end of childhood self-control who spent 14, 15, 16 months. That’s an appreciable difference. You’re taken out of the workforce at that time when you’re developing workforce skills, right—you’re laying down the basis of a career or a good job history, or not, as the case may be.
So, looking at the level of self-control by age three, and its precursors, could, if you did the right thing from conception through to age three, materially impact upon these trajectories and reduce all these things, which governments like. But I always think of this in terms of personal and family suffering and whānau suffering and low-quality of life. You’re going to have a meaningful impact upon that if you start early. And it’s not a tenuous set of linkages to get there. A general population sample, not selected, right, generalizable back to the whole of the population, that’s one of the strengths of this study. Ninety-one per cent of the births at the Queen Mary Hospital were enrolled. The nine per cent who said, “No, I don’t want a bar of this study” didn’t look any different in terms of sociodemographic factors and perinatal data.
Now, I don’t want to leave this stage before having talked about the follow-up study we did to test the 80/20 principle, the Pareto principle. I think one of the more innovative things we’ve done in recent times is to link our data to the National Administrative Data sets so, we were able to take our 1000 study member cohort and quantify their use of services, and you can see the numbers begin to stack up. And we’ve chosen things that are again of interest to governments in terms of indicators of poor health. So there’s a lot of fat there, excess kilograms of fat, and there’s all the smokers and everything else.
And we thought, “Let’s have a look.” In each one of those areas are about 20 per cent of the population accounting for 80 per cent of those figures? “Yes,” was the answer in short. And here’s just one example. This is social benefits. So, you can see that literally it was 20 per cent of the sample who accounted for a little over 80 per cent of the months on benefits.
Probably the last column which your eye is going to more likely than not be drawn to is “ACC claims.” That’s accidents, so it’s a mix of accidents where you’ve got high-risk behaviour but genuine accidents as well. Pretty much the 80/20 dropping down a bit here; that’s obesity. They didn’t always come in quite like that, but what we noticed was that these segments be it kilograms, tobacco use, use of hospital beds, use of pharmaceutical preparations, number of months on benefits, time in jail—they were not independent. There is a group that we could identify within the cohort, and it was 22 percent in proportion, and they accounted for 80 percent, with some variation, of those outcomes.
Now, we could predict that group using multiple measures obtained between birth and age 11 from multiple sources, but no government has that information available to them, so this is where it gets very interesting and exciting. We went back to a simple age three, 45-minute interview. Paediatricians played a role here. We group it under the term “brain health” all right? So, it’s five scores; a short neurology exam, basically some measurements of both fine and gross motor ability; the ability to understand and to express language; and that measure of self-control. Now, that coupled together, composited together, explained with great strength compared to most data ever published before over three-plus decades, the relationship between being in that group that used all those services and that simple 45-minute interview.
Anyone that understands ROC curves knows that a score of 0.8 is bloody impressive over even a short period of time. That means 80 per cent of the time you can actually predict whether a person’s going to be in your risk group and not in your risk group; sensitivity and specificity. Where this “early determinants” work has always run into trouble is the relationships have not been that strong and that’s made people hesitate on churning, throwing a whole bunch of money into the early life-course including politicians.
If I had a magic wand—in fact, if I was a very effective science advisor, I would persuade the government that this is one of the things they should be doing at age three. I could only dream of being that effective. Today the point is to show you that within the first 1000 days you can begin to meaningfully predict how people’s lives are going to turn out in multiple important life domains. It’s just two examples from our study—there are many, many other studies that converge on this basic point. Thank you. I’ll hand over to one of my colleagues.
MIC CAVAZZINI: The powerful associations you’ve just heard about will be explained by countless factors, only some of which we currently understand. But there is compelling evidence for the impact of deprivation in early childhood on brain development.
This was outlined Dr Johan Morreau, a retired paediatrician from Rotorua who remains an active board member of the Lakes District Health Board. Dr Morreau began by describing how the proportion of New Zealand children living in poverty went from 10 per cent in late 80s up to 30 per cent by 2001, from which it has declined by only a few points. In such an environment, the barriers to a child flourishing begin even before birth. Indeed, “the first 1000 days” we talk about is taken to start at conception.
JOHAN MORREAU: Let’s go back to this slide and reflect on the importance of a pure pregnancy. This is the notion of this being a planned, wanted child, where the parents get to dream and attach to their baby during the pregnancy. Where there’s good nutrition, no alcohol, drugs or cigarettes, and where antenatal care is needed it occurs. You can’t talk about this subject without reflecting on neuroscience, the whole science around the development of the infant’s brain, or about attachment at a process that’s facilitated by oxytocin, that social neuropeptide that makes you feel good about somebody, you know that notion of love is what grows an infant’s brain. So, the genes are the blueprint but it’s that experience that’s the carpenter, and together they build the brain from the base up.
This slide shows the proliferation of neurons and neural pathways that’s occurring in those first three years—billions and billions and billions of these happening. And if you don’t use those neurons or if they’re damaged by the toxic stressors that apply to so many of the people’s lives that we deal with, then these get pruned back, and with a brain it’s really hard to get that back later. A mature brain doesn’t grow neurons like it does early, so the window of opportunity is when the child is young.
So, development occurs when a child and somebody else interact, ideally somebody who’s besotted with that kid and gives them the time that they need. And so, through observing, through interacting, through playing, a child then develops abilities, and in time, their identity. And you can’t have this conversation without reflecting on what happens when things go wrong. And I think of a pregnancy that’s been compromised by smoking—smoking reducing placental blood supply, therefore, placental size, so the child doesn’t grow so well, is more likely to become growth-retarded, more likely to be born early. The foetus decides when it wants out earlier because things aren’t so good inside. The placenta doesn’t stand the labour and so there’s more likely to be birth asphyxia, foetal distress, delivery by Caesarean Section, admission to a special care baby unit, separation from a mother, a child who’s less likely to breastfeed, problems with attachment, and the baby has smaller airways because of the smoking and gets sicker with their bronchiolitis and therefore more likely to end on CPAP, more likely to end up ventilated. So, these are the origins of vulnerability.
David Barker was an epidemiologist in the ‘70s and ‘80s in the U.K. and he identified the relationship of a growth-retarded child to later metabolic syndrome, so the issues of insulin resistance, of fatty metabolism problems, high blood pressures and issues managing one’s weight. Another subject which also at least partially explains why it is so difficult for people to turn their lives around is the epigenome. Experiences before and soon after birth can result in the genes being modified and determine whether they are expressed at all. So, it’s those injuries during pregnancy that we talked about, it’s the toxic stress that we’ve talked about that influence the architectural software of the developing brain. And the classic that I always think of is the gene for conduct disorder which is expressed after exposure to emotional abuse and violence. But if you don’t have exposure to it, it can remain unexpressed.
Adverse childhood experiences, the ACEs, also explain a lot of the issues that we struggle with. So, Kaiser Permanente in the U.S. sent out questionnaires to 17,000 of their middle-class people and asked whether they’d been subject to physical abuse, sexual abuse, emotional abuse, neglect, domestic violence, whether there was an incarcerated family member, mental illness, separation or divorce; a whole range of adverse childhood experiences, and the literature now adds poverty and racism to those. And what they found was really interesting. If you had four or more ACEs as a woman, 50 per cent were likely to suffer from chronic depression, and men around 30 per cent, and that’s huge. Suicide attempts, 20 per cent if you’ve got four or more ACEs. Again that’s huge and almost certainly relates to the high youth suicide rates that we have in this country. Six or more ACEs lowers life expectancy by 20 years. Seven or more ACEs leads to a threefold lung cancer risk and a fourfold risk of heart disease. So, they’re a predictor of all the issues that we struggle with.
You can’t talk about this without talking about stress. So, there’s the positive stress which is the sort of transient experience that gives a child the confidence to know that they can manage. In this tolerable stress, which is where something major happens—the loss of a parent, the loss of a sibling—but the child is wrapped under the umbrella of a family, a whānau that’s supportive and helps to make it all work, and that becomes tolerable.
But then there’s toxic stress where there are none of the supports, where the child is on their own, neglected, left in an orphanage or in a house, nobody responding, to the point where the child’s then giving up. And in that situation the stress levels are really, really high, they remain activated, the sympathomimetic system is turned on, cortisol is turned on. That toxic stress actually damages neural connections. This is all information that comes from the Centre for the Developing Child in Harvard. And especially those areas that are damaged are those that are devoted to those high-order skills, that executive functioning, the functions like empathy, the ability to make judgments, the ability to control emotions and the ability to learn, and that leads to all sorts of issues around behaviour, physical health, mental health.
And that’s where you know areas like early childhood centres and schools can also make a difference. And we know that actually this is also one of the most important things you can do for a child that’s been neglected, that’s already been subject to a whole lot of stressors, that already has a damaged brain—that actually this is also part of the healing. So, we do seriously need to invest in early childhood—“spend a dollar and save 17” are some of the figures that are quoted in relation to this. The first thing I would do is to invest in our workforce, and this has to be a workforce that actually knows how to engage with the population that needs us the most, learns to oil the wheels for that family, whatever it is that’s happening, and follows that child through at least until school-age. And in New Zealand that’s likely to be around whānau ora, “family start”-related activity, and it needs to be community-driven.
We can also go for the “Child, Youth and Friendly City” thinking but also getting young people who are going to become that next set of parents, and we haven’t talked about colonisation, racism, financial systems and the increasing gap between rich and poor in this country and our loss of an egalitarian society, clearly contributors to all of those ACEs that we talked about earlier. So, ma te huruhuru, ka rere te manu—"you give a bird feathers and the bird will fly.” Thanks.
MIC CAVAZZINI: The lectures you’re hearing today were framed by the launch of an RACP position statement on early childhood titled “The Importance of the Early Years.” The document makes 47 recommendations to the Australian and New Zealand health ministries, including early childhood programs for the most disadvantaged, six months parental leave for either parent and banning the advertising of poor diet choices to children.
We must also remember that for the First Peoples of Aotearoa and Australia, socioeconomic disadvantage is often compounded by the intergenerational trauma of colonisation. This includes the stress of explicit racism but also the implicit prejudice when applying for jobs, say. And it recognises the dilution of cultural identity that can be so important for building resilience. You can go back to episodes 12 and 31 for more discussion of this. The RACP acknowledges The First 1000 Days Movement, which merges modern clinical standards with Indigenous wisdom around family and community.
Some of these elements have been explored by Professor Susan Morton, a public health physician and Director of the University of Auckland cross-faculty Centre for Longitudinal Research. She designed the Growing Up in New Zealand Study, which has been following 6800 children since before their birth. At regular intervals, participants and their families are surveyed about wellbeing, family life, identity, education and psychological development. Dr Morton said that a life-course approach can inform not just an understanding of population health, but also everyday community practice.
SUSAN MORTON: And I think it’s easy sometimes to think that a life course is a lifespan. And sometimes when we think about the privilege of having someone in front of us in a clinic situation, we often see them in that time of vulnerability. We see them in that moment, and yet they come to us with a past and they leave us to head into a future, whatever that future might be. Health is really shaped as much by social environments and by inequities as it is by biology. And a lot of what we’ve done in the study is to try and understand why that gap exists, and I guess not just why it exists but what we can do about it, what can we do to close that gap? So, sometimes the policies were not reaching the target audience, sometimes they were not having the impact that they were expected to have.
So, this study was born really by 16 government agencies saying, “We need to know about our current generation of children in a life course way.” And of course, health and wellbeing was central to that but it wasn’t the only thing that we were interested in. We were interested in how children’s interaction with all of the environments around them over time brought them to particular outcomes at particular points in time.
So, just to give you a quick overview about the cohort, we do have over 6000 children in the cohort. They were recruited from before their birth because the importance of that early development for setting trajectories for children, was well-known. We also wanted to recruit the dads because dads matter too, or the partners of the mum if there was a partner around and see them right from pregnancy onwards.
Most importantly I think in this cohort study, and what we’ve found out of it so far is that we have Māori and Pasifika children represented in sufficient numbers to be able to understand what shapes their development and actually what creates wellbeing, not just what creates poor outcomes.
So, our population of interest has always been current births, and the cohort represents the current diversity of ethnicity and socioeconomic status of the families having children in New Zealand today, which is really important when we’re trying to inform policy, and we need to hold on and create relationships and partnerships with these children and their families to ensure that we keep hearing their voices over time, and the children are currently turning nine.
So, we have focused on poverty in the first 1000 days but we can define poverty not by a single proxy but by a clustering of things that go on for families, and we see in this cluster quality of housing, tenure, stability of housing; as well as things like income that is available to families; ability to take leave; hardship that exists at the family level; as well as human capital—how do families get on? Are they supported in their communities? What are their relationships with each other like as parents and the rest of their family and what are the relationships like with their children? So, we think about poverty in this sort of multi-dimensional way.
And using the information that we have from these 6800 families we’ve been able to look at children who are exposed to four or more of these factors, or one to three, or none, at three time points in those first 1000 days and we’ve been able to compare what has happened to them in their preschool years.
And here’s an example of what we’ve found. When we look at those children who have experienced what we might call persistent poverty with clustering of those factors, there’s almost one in two of them who are likely to be experiencing behavioural difficulties by the time they’re four and a half, before they go to school, compared to only four per cent in the group who are not exposed to any. And we can also see that there’s a gradient that exists here, so dose matters and duration matters.
So, these children are experiencing higher rates of behavioural issues and it doesn’t matter what outcome we look at, it’s comorbidity that happens for these children. So, here’s just an example of obesity, but equally we could have put literacy or we could have put numeracy or we could have put peer relationships and we could have put admissions to hospital, we see the same picture, different magnitude but the same graded impact.
So, we could have stopped there and said, “Well, yes, poverty is bad. Yes, there is more likelihood that those who experience persistent vulnerability or poverty are going to already be showing inequitable outcomes by the time they are four and a half.” But actually not every child who is exposed to that clustering of poverty will have a poor outcome. In fact, we can see on this slide that two out of three of the children, or more, nearly three out four, in fact, actually don’t have a problem with obesity by four and a half despite having experienced these adverse conditions.
So, what we then did is say, “Well, what is it that is different about these children?” And we went beyond the risk factors. Yes, they are living in poverty, yes, their housing is poor, yes, we must do something about those things. But what else is going on? What is creating resilience in the face of this adversity?” So, we worked with the communities where that adversity is greatest and we found some of the things that actually your grandmother might have been able to tell you about, or certainly mine did. Things like spending time, quality time with your children, having protected time to be with your child. Having support in your community, having loving relationships around you. Things that seem really straightforward but are not so easy for people who are living chaotic lives, lives that are challenged.
So, working with other groups, again in partnership, developed this community initiative where spaces in libraries are no longer quiet spaces in South Auckland for young children, they are places where young mums, young parents, young families can gather with their children and actually spend that quality time and interact with others. Others can come to them, so that these most vulnerable people are not needing to go out and to find all the solutions for themselves, people can come to them. And we’re just evaluating whether that works.
But I think the key thing in that is that partnership approach, listening to those voices of the vulnerable, listening to, in this case, a group of families. We need to actually work as doctors collectively, but we need to work outside of the health field as well because so much of what happens to be health outcomes and inequities in health outcomes is so much driven by what’s going on in the social and the economic context.
So, I just want to conclude with always acknowledging that it is really always my privilege to bring the voices of these nearly 7000 families and children to the table and I really want their voices to be able to make a difference. And I hope that sharing a little of their journey and their collective stories can help to inform some of the ways that you think about your practice as well. And I always remember that we stand on the soldiers of giants, in this case the wonderful Dame Whina Cooper, who died some 25 years ago now, but whose words are still profound, that you know, “We need to take care of our children because they are us in the future.” Thanks for listening.
MIC CAVAZZINI: Many thanks to Richie Poulton, Johan Morreau, and Susan Morton for allowing me to re-purpose their lectures for this podcast. You’ll find links to their presentations at our website racp.edu.au/podcast, and all the other literature mentioned today. Before I go, I just want to acknowledge how their work and that of other devoted College members has gone into influencing government policy.
Last year the RACP released another position statement about childhood inequity which called for the appointment of a national chief paediatrician and proposed clear targets that government agencies would be held accountable to. It makes a strong moral case for the right of all children to flourish but also points to the ultimate cost of inaction; up to $14 billion per year in Australia and $6 billion per year in New Zealand when you add up the downstream costs of remedial health expenditure and lost productivity.
In August, this statement was presented to Australia’s health minister by Melbourne paediatrician, Professor Sharon Goldfeld and the government has agreed to fund a $5 million Action Plan for the Health of Children.
Just two weeks after that government was election, an even more brazen vision was unveiled on the other side of the Tasman. The so-called “Wellbeing Budget” starts from the premise that GDP alone is an inadequate measure of growth and of true value in society. And that despite a ‘rock star economy’, New Zealand has the worst homelessness rate of the OECD countries. The Finance Minister of New Zealand-Aotearoa is Grant Robertson, and I’ll leave you with a prosaic trailer of this budget which he presented a few months ago at the International Conference on Well-being and Public Policy in Wellington. I’m Mic Cavazzini. Nga mihi nui kia koutou.
GRANT ROBERTSON: In a room such as this I am loathe to start a debate about the definition of well-being. I am attracted, however, to ideas of Amaratya Sen of giving people the capabilities to live lives of purpose and meaning for them. Equally it is clear that well-being is a long-term proposition—in particular an intergenerational one.
This was made more than clear here in New Zealand at the election last year. The topics that I was questioned about the most in the campaign, be it in the boardroom or the smoko room, were child poverty, the quality of our rivers and lakes, the state of our public services and institutions… The complex, messy problems that create poverty and inequality require us to look beyond basic economic issues, as essential as they are to solving them, to the wellbeing of our wider communities, the impacts of cultural alienation and our understanding of what makes for security and hope.
Those three issues—the future of work, climate change and inequality—are to me the defining economic and social issues that this government must face up to, and they all require a well-being approach to deal with them. Indeed, strengthening human, social and natural capital is essential to building a foundation of sustainable growth in the face of these issues…
The work of the OECD has been extraordinarily helpful, but we must acknowledge the importance of te ao Māori, the Māori worldview… One example draws on a tikanga Māori concepts such as manaakitanga, care and respect, kaitiakitanga, guardianship or stewardship and whanaungatanga, connectedness and relationships, drawn together into the concept of waiora or well-being…
I am often asked for a practical example of how a well-being approach would affect budget prioritisation or policy-making. One of the most difficult issues our government faced on coming into office was to do with the decrepit Waikeria Prison. We were presented with a number of options, and I was advised that the best option was to replace the prison with a 2,500 bed mega-prison because the per-bed cost was the cheapest option. Well, what a well-being approach tells us is that a better option is a smaller prison, with a specialist mental health unit attached, and more resources for transitional housing for released prisoners and more funding for addiction services. The per-bed cost will be higher but the long-term benefits, fiscally and socially, will be far more significant. And That is the approach that we took—and I believe that that is what a well-being lens will do for us across our policy framework…
Because if we can change the way we think about success, if we find our North Star in the well-being of all our people, now and in future generations, and if we value all that people are capable of, then we will be a better place. We will be a country that is prosperous, but cares about who shares in that prosperity, how we look after our land and our water, how we make our people healthier, more secure, more skilled and more reflective, and where we connect our communities… And as a bonus we will have done as my mother taught me to look out for others as we would want them to do us. That would be a legacy of wellbeing, and of that I would be immensely proud.