Monday 3 November 2014

The Big Challenge

The first in a series of guest posts from Sam

What are the big issues for Scotland, independent or not?

"Of all the challenges facing Scotland, the gaping health inequalities and high mortality rates are clearly our biggest."  That quote comes from Gerry McCartney's academic paper published in 2012, "What would be sufficient to reduce health inequalities in Scotland?"

So, what are the effects on Scottish society that health inequalities cause and what are the reasons for those inequalities? Most people in Scotland know that there are areas in Scotland, particularly in West Central Scotland, where life expectancy is much lower compared with areas nearby. A map of the Glasgow underground, for instance, can reveal how much life expectancy differs in short hops across Glasgow.
For too many years Scotland has been known as the "sick man of Europe". For example, mortality in the 15-44 age group among women in 2009 was 46% higher in Scotland than in England and Wales, while for men in that group it was 54% higher. In this age grouping, mortality reduced from the mid 1950s to the mid 1980s, the decline stalled from 1982 for men and from 1987 for women. Scotland's relative ranking for this group is now the highest among the 16 Western European countries studied. What happened in the 1980s to stall mortality reductions in Scotland?

Mortality for women in Scotland from lung cancer has either been the highest or second  in Western Europe for 50 years.

Bear in mind that 50 years ago life expectancy in Portugal was 10 years less than that in Scotland. Now, Portugal has overtaken Scotland. Why? What began to happen 50 years ago that started this change in comparative rates of life expectancy?  In Scottish society at this time life expectancy between the richest and poorest in Scotland began to diverge. If the poorest men in Scotland had seen their life expectancy keep the same gap to that of the wealthiest as it was 50 years ago, Scottish life expectancy would be three years higher  than it is today. It is likely to be the health of the poor that makes the difference.

Mortality rates for Scottish men of working age (15-74 years) have been falling at a similar pace to other Western European countries but have remained consistently higher than the West European average. For women, reductions of the mortality rate in Scotland have not fallen at the same pace as in Western European countries. The mortality rate of Scottish women of working age (15-74) has remained 30% higher than the mean in Western Europe. Scotland has had the highest mortality in Western Europe among working age men and women since the late 1970s.

The causes of  changes in Scottish life expectancy starting after 1950 are not clear and further research is needed.The most likely explanation is that Scotland suffered a combination of more precarious employment, overcrowding, poverty and ill-conceived reconstruction than other countries during this period.

 The changes to life expectancy in the 1980s - the halting of the declines in mortality rates - are to do with the "neoliberal" economic policies of the 1980s. Thatcherism. 

This is a human tragedy, but it also causes a reduction in economic output and social problems. Of all the challenges facing Scotland, the gaping health inequalities and high mortality rates are clearly our biggest."  (McCartney, 2012 "What would be sufficient to reduce health inequalities in Scotland?)

It is a tragedy that mostly affects the poor. The fundamental drivers of health inequalities are the inequalities in Scotland of wealth, power and income. That needs to change.

McCartney again: "It is only a reduction in the current inequalities in income, wealth and power, which are contributed to by policies across the UK, Scottish and local government, that would be sufficient to generate a reduction in health inequalities."


"If health inequalities in Scotland are to be reduced, this will require leadership at all levels to reduce the stark inequalities in the socio-economic circumstances prevalent today."


  1. "The changes to life expectancy in the 1980s - the halting of the declines in mortality rates - are to do with the "neoliberal" economic policies of the 1980s. Thatcherism."

    I'd partially agree with this assessment. However with some caveats.

    Did her 'shock therapy' deregulation, tax reducing, de-industrialising policies have extremely negative knock on effects on health etc in those communities most affected? Sure. But that was 40 years ago. And can't justifiably remain a central explanation now in 2014 why health outcomes are so poor in these areas.

    In an era where UK child poverty figures were massively reduced during the 13 years of New Labour, and public spending on the NHS sky-rocketed; there seems something else going on.

    In part there is a very bad public concept of acceptable levels of drinking, smoking, eating deep fried foods etc. And this hasn't been seriously challenged by any government in terms of a soft-power public education campaign. After all, home economics lessons in schools remain a laughable joke. No progress there!

    And let's be serious, the underlying malaise, of a Scotland with a bad concept of what constitutes a healthy lifestyle has run a lot longer than Mrs T. Maybe the public spending, and overly high tax levels of the 1970s have gone and don't hide the fundamental problem here: social attitudes remain unreformed since the 1950s in terms of lifestyle choices for far too many of my fellow Scots.

    And that, not Mrs T, is the real causality behind the negative health outcomes. And socio-economic ones too.

    1. Dean,

      Let me say that I am not either medically qualified or an academic. I have read something of a topic of interest and Tris has kindly allowed me to post. There are more to follow if there is sufficient interest.

      To your question about the effects of neo-liberal policies. First, the effects will take time to show up. Second, the effects are likely to be lasting unless there are interventions. Unemployment and hopelessness play a part in early deaths. You are right about smoking, substance abuse, drinking and violence playing a part. Why that should be is an interesting part of the research. But research points to the main drivers of health inequalities being inequalities in wealth, income and power and the Conservative governments of the 80s and 90s widened those inequalities.


    2. This comment has been removed by the author.

    3. My thoughts on this subject are that given the level of poverty, much induced by Mrs Thatcher and her destruction of employment, those men who lost their jobs and with them their sense of value have clung to the things which made them feel better. Unfortunately none of these things like drink, smoking or drugs do your health any good and it has been passed onto the children who also have very little prospect of a job similar to their parents. I notice the difference here in Fife where similar factors are at play than from where I come from originally Edinburgh, it is easier not to see the fact that people do indulge in all these things as well but not to the same level.There is a bigger middle class who drink in the comfort of their own homes, ring for their unhealthy food, but tend to go out running and if they use drugs it tends to be the socially acceptable sort and again not outside. Peoole still smoke all over Scotland but I notice more of it in
      Glasgow, and through contact with people in Glasgow, alcohol is definitely
      used more and in harder amounts. I do think though that the present level of poverty will reduce the lifespan further unless something is done, and sadly we gave away the right to be able to do so in September. I do not have high hopes for our Scottish Health Service unlike those who voted NO.

  2. "It is only a reduction in the current inequalities in income, wealth and power, which are contributed to by policies across the UK, Scottish and local government, that would be sufficient to generate a reduction in health inequalities.""

    I think focusing on income equality is a distraction, I take exception to the suggestion that income per capita necessarily links to health outcomes.
    Take basic economic growth theories like the Solow Model, it doesn't even account for the role of health in economics. When it's expanded into an augmented version, and it does, it more often than not shows when applied in practice that health outcome may have numerical CORRELATION but not causality with GDP per capita.

    Equality of outcomes isn't it. Health outcomes do impact on economic growth, yes. BUT the link between poor health and GDP per capital levels isn't so clear cut.

    After all, the suggestion that being wealthier means you can afford to eat well, exercise regularly etc is built on the rubbish assumption that living healthily is expensive (it isn't).

    1. Dean

      The World Health Organisation says this about the social determinants of health: " the high burden of illness responsible for appalling premature loss of life arises in large part because of the conditions in which people are born, grow, live. work and age. In their turn, poor and unequal living conditions are the consequence of poor social policies and programmes, unfair economic arrangements, and bad politics."

      Also, there is research that looks at the "fine grain" or the fine level of social differentiation in health risks. for example, life expectancy is greater in those who own their own homes and two cars than in home owners who own one car.

      There is also research (Marmot et al 1991; Davey Smith et al 1990) comparing life expectancy between nations which confirms that the average amount of income available to each member of a population is less strongly related to life expectancy in whole countries than is the distribution of that income.


    2. I agree with you Sam and I think poor housing does as much damage as anything. The stress of poorly insulated both in terms of heating and noise is a killer on it's own. Having lived in a couple of council houses, with my parents and after marriage, the first flat we had was damp, the second was a great improvement. We have had badly built and insulated private bought houses and our last flat in Edinburgh was noisy, so I can tell you that can drive you to despair. Now have detached house and boy the relief is tangible, so I understand how even bad private housing drives people to despair but social housing where you can not make a change is intolerable.

  3. Drink, drugs, sugar and tobacco. And they vote Labour.

    I recall a phone in on radio Scotlandshire - I no longer listen of course - where a doctor was wheeled on to kick off the discussion about health inequalities. He nailed it right away. Smoking. The show was a damp squib after that truism.

    1. Anon,

      More to it than smoking, unfortunately.


    2. Helena,

      My brother and I both suffer from chronic lung problems arising from poor housing when we were young children.


  4. Anon,

    I should try to add a little to my not very informative reply to your post. I want to copy and paste a short section of the report in 2011 by then Chief Medical Officer, Sir Harry Burns, "Health in Scotland 2011: Transforming Scotland's Health". 700 volunteers from affluent and deprived areas had blood taken and tested, and measurements made of how affected arteries were by atherosclerosis.

    "Socioeconomic status (SES) and vascular disease
    The first study used ultrasound to measure the thickness of arteries and also
    allowed the investigator to assess the number of cholesterol deposits in the carotid
    artery. It showed a strong relationship between a measure of area level
    socioeconomic deprivation and atherosclerosis. However, classic cardiovascular risk
    factors did not fully explain the difference in plaque presence between participants
    from the most deprived areas and those from the least deprived areas, confirming
    the view that current public health messages directed at classic risk factors (diet,
    blood pressure, smoking) would be unlikely to adequately address the continuing
    inequality in cardiovascular disease. Also, the difference in atherosclerosis rate could
    not be explained by low vitamin D levels. Individuals with low levels did not have a
    higher incidence of markers of arterial atherosclerosis.
    This observation underlines the fact that health status is a reflection not only of
    features of the individual but also of wider social and economic influences, health
    and social services, early life experiences, and environmental factors."


  5. Dean,
    "But that was 40 years ago. And can't justifiably remain a central explanation now in 2014 why health outcomes are so poor in these areas."
    Maybe, but only if you're entirely discounting the possibility of any transgenerational epigenetic effects, (see for example or the Heijmans et al (2008) study on the transgeneration effects of famine and under nourishment.

  6. jake,

    Thanks for that.
    I was digging about and found reference to epigenetic effects in Sir Harry Burns's 2011 Annual Report, "Health in Scotland 2011: Transforming Scotland's Health".

    Epigenetics is the study of how the environment influences our genetic code in our DNA and how those changes are expressed. Laboratory studies in experimental animals have shown that diet during pregnancy, nurturing behaviour by mothers and exposure to stress can alter the way an infant's genes are modified.

    Sir Harry pointed to research done in the Swedish county of Norbotten. Meticulously kept agricultural records enabled researchers to estimate how much food had been available to the children in the early 1900s. The researchers showed that boys who experienced overabundance of food winters, often going from normal eating to gluttony in a single year, had sons and grandsons who lived shorter lives.

    Sir Harry suggested that the emerging evidence on epigenetic change "suggests it is an important pathway by which the socioeconomic environment becomes embedded at a biological level. It is also transmissible between generations. It is not unreasonable to suggest that the persistence of health inequalities across the social spectrum, particularly in West Central Scotland, may be associated with such seems biologically plausible that an accumulation of similar nutritional, [similar to the Swedish village above] and other adverse experiences 50 years ago in West central Scotland might contribute to the 12 year disparity in life expectancy currently observed."


  7. I really do not know enough about the medical aspects of this but it seems to me that inadequate housing, inadequate facilities, inadequate parenting, inadequate opportunities are all contributory factors. It must be soul-destroying leaving school with little or no qualifications and you are competing with others with infinitely more qualifications for even the most menial of jobs. Aspirations quickly disappear and hopelessness sets in. Even if employment is achieved it may well be on the iniquitous zero hours contract where you do not know from one day to the next if you are employed or not. If the Tories get their way and manage to avoid the EU Working Directive rules then the situation will, inevitably get worse and a grim future lies ahead.

    1. I agree.
      If you live in a cold, (due to cost), and damp, uninspiring location with little or no hope of ever leaving or having it improved this must affect your health.
      I think that people's basic needs are not being fulfilled. Warmth without worrying about the cost. Enough money to eat and clothe your family, and a wee bit extra for dreams. The last bit is essential, a wee treat, lifts the spirit.

  8. When I was at university an explanation of, the high incidence, heart disease in Scotland; was attributed to Scotlands soft water.
    I know not of why, there is a correlation between the softness of water and heart disease, though evidence seems to be available.
    Where to find the evidence, I do not know; I graduated in 2000 (Construction management and civil engineering) as a mature student.
    Scotland also has some of the worst housing stock, in Europe, with dampness a perennial problem.
    It may have been a generation ago but, there are whole villages and towns where, Thatchers destruction; has left those communities barren.
    Barren of hope, jobs, a future and self worth; surely it can be argued that, these factors have a detrimental effect on health and lifespan.

  9. John and Annie and jimnarlene

    All that you mention is relevant to whether the individual has or has not good health. Health inequalities persist over time in Scotland. They persist despite the rise and fall of specific causes of mortality. For that reason McCartney claims that the "fundamental causes" of health inequalities are the most important, and the only sufficient, explanation of how health inequalities arise and persist. Those fundamental causes are the socio-economic inequalities in income, wealth and power.So,alcohol related deaths might be reduced as a result of an alcohol pricing policy but other "competing causes" such as obesity-related disease will maintain the inequalities in overall mortality unless the inequalities in underlying socio-economic conditions are also reduced.

    The ways in which the determinants of health - for example, income, employment, housing, transport and social networks -are distributed within a population explain the health inequalities in a population. This can include the access that different population groups have to positive assets and influences.For example, a low income as a result of basic employment or dependence on welfare benefits would reduce opportunities for buying a house in a safe and pleasant environment, or for ensuring access to the best education for children.

    It is the World Health Organisation Commission on Social Determinants of Health that makes the recommendation that the inequitable distribution of power, money and resources should be tackled. McCartney claims that inequalities in power,money and resources are at historically high levels in the UK over the last 30 years. It is unlikely that health inequalities will decline in Scotland until these inequalities in power, money and resources are also reduced.


  10. I'd like to thank everyone form their comments. Munguin Towers has been flooded and Sam doing the necessary with this helped Munguin and Tris out enormously as Munguin directed Tris's bail out... with buckets and towels.

    The water has stopped pouring through ceiling now and the carpets are starting to dry out, thanks to excessive central heating and a carpet cleaning suction machine.

    Tomorrow various and sundry personages are coming to inspect the damage, although I'm told Nicola Sturgeon can't make it. (Munguin will be disappointed. He'd splashed out [pardon the unfortunate pun] on French fancies too!!) In the meantime we have no hot water, so Tris will have to have a cold bath tonight.