York University, Toronto Global Health degree (BA and BSc) Chronic Disease and Care IHST2100

1. York University, TorontoGlobal Health degree (BA and BSc)Chronic Disease and Care IHST2100 28th February, 2017 Health and Health Inequalities in Scotland: Explaining Glasgow’s ‘excess mortality’ Chik Collins, Professor of Applied Social Sciences, University of the West of Scotland

2. Public Health Challenges in Scotland • Scottish mortality is around European median until 1950 then diverges – “the ‘sick man’ of Europe”. • No improvement in premature mortality for 30 years – associated with increased alcohol & drug related deaths and suicide • Health inequalities have grown and are wider than the rest of western and central Europe • Higher mortality in Scotland as compared to England & Wales is progressively LESS explained by deprivation (1981-2011) – “Scottish Effect”/Scotland’s “Excess Mortality” These represent thousands of unnecessary and unjust premature deaths and colossal human misery.

3. 1. Life expectancy improving more slowly than comparable nations Source: McCartney G, Walsh D, Whyte B, Collins C. Has Scotland always been the ‘sick man’ of Europe? European Journal of Public Health 2012; 22(6): 756–760. Data extracted from the Human Mortality Database for: Australia, Austria, Belgium, Canada, Chile, Denmark, England & Wales, Finland, France, Germany, Ireland, Iceland, Israel, Italy, Japan, Luxembourg, Netherlands, New Zealand, Northern Ireland, Norway, Portugal, Scotland, Spain, Sweden, Switzerland, Taiwan & West Germany.

4. 2. Little/no improvement in mortality for young adults Source: Still the ‘sick man of Europe’? Scottish mortality in a European context 1950-2012. An analysis of comparative mortality trends. Glasgow, Glasgow Centre for Population Health, 2012.

5. a. Trends in alcohol-related mortality in Scotland Source: National Records Scotland, MESAS team

6. b. Trends in Suicide mortality (15-44y) in Scotland Source: Mok PLH, Kapur N, Windfuhr K, et al. Trends in national suicide rates for Scotland and for England & Wales, 1960-2008. British Journal of Psychiatry 2012; 245: 245-51.

7. 4. Scotland’s ‘Excess’ mortality (i.e. after accounting for age, sex and deprivation)

8. Scotland’s and Glasgow’s ‘Excess Mortality’ • Excess is clear however we look at it (deprivation, SES), and even after controlling for behavioural and biological risk factors (McCartney et al, 2014). • ‘Excess mortality’ in Glasgow v’s Liverpool and Manchester – @15% all ages; @ 30% for < 65s; = 4,500 deaths 2003-2007 (controlled for deprivation and deindustrialisation). • Key points of divergence: • 1950s (chronic diseases) • 1980s (‘external causes’ – alcohol, drugs, suicide and violence). • Worst in West Central Scotland and Glasgow, and worst amongst poorest groups – but present across Scotland and across income groups (and age groups, except under 16s).

9. Premature mortality by social class Age-standardised all-cause mortality rates by Social Class, England and Scotland, males aged 20-64, 1991-93 (Source: Scottish Executive, 1993 (from data originally presented by Uren et al, 2001))

10. Glasgow, Liverpool and Manchester 50% of excess deaths attributable to cancer, heart disease & stroke 50% of excess deaths attributable to alcohol & drugs

11. Glasgow compared to other UK cities

12. How do we explain this ‘excess mortality’? • These phenomena have often referred been to as: • ‘The Scottish Effect’ • ‘The Glasgow Effect’ • Meaning: ‘We don’t have an explanation!’ • But we have to have an explanation in order to address the problem. • Since 2016 WE DO – building on work over the previous decade! • How did we get there? How was this knowledge achieved?

13. Towards an Explanation The Aftershock of Deindustrialisation? (2008):* Not in any very straightforward way – other deindustrialised areas poorer and doing better, in eastern Europe too. Collins and McCartney (2011) ‘The Impact of Neoliberal "Political Attack" on Health: The Case of the "Scottish Effect".’ ‘The article begins to develop and test … a "political attack hypothesis." It shows … that after 1979 the United Kingdom as a whole was exposed to neoliberalism in a way other European nations were not and, crucially, that the west of Scotland was more vulnerableto its damaging effects than other U.K. regions (in terms of industrial employment, housing and sociopolitical culture).’ * Walsh, Taulbut and Hanlon, 2008; Walsh, Taulbut and Hanlon, 2010; Taulbut et al., 2011; Taulbut et al., 2013; Taulbut et al., 2014.

14. Other hypotheses (15) and syntheses (2011/12) McCartney, Collins, Walsh and Batty (2012) ‘Why the Scots Die Younger: Synthesizing the Evidence’. Post-1950 divergence: Something at work amidst SDOH …. “…it is … plausible, that unemployment, more precarious industrial employment, inequality, overcrowded housing conditions and the large-scale reconstruction which resulted in the peripheral council housing estates around Glasgow, Edinburgh and other large Scottish conurbations could be important in providing a causal explanation.” Post-1980 divergence: Realignment/reconfiguration of SDOH arising from ‘political attack’ … “…the political attack hypothesis seems … best placed to bring together the most likely structural, cultural and behaviouraldeterminants of health into a coherent narrative which can explain the post-1980 mortality phenomenon”

15. More Recent Work(in collaboration with Gerry McCartney and Martin Taulbut, NHS Health Scotland; David Walsh, Glasgow Centre for Population Health; Ian Levitt, University of Central Lancashire) Interdisciplinary collaboration has been focused on following main aspects: Re-examining historic ‘deprivation’ – esp. housing conditions/overcrowding; The impact of UK ‘regional policy’ on Scotland and particularly on Glasgow – ‘vulnerabilisation’? (today’s focus); Local authority responses to ‘Thatcherism’ in the 1980s – Glasgow, Liverpool and Manchester.

16. Trends in overcrowding

17. Overcrowding 1951

18. Overcrowding 1971 Source: 1971 census

19. Glasgow, 1945-1980: A process of ‘vulnerabilisation’? Work in collaboration with Professor (Emeritus) Ian Levitt, University of Central Lancashire (and author of Treasury Control and Public Expenditure in Scotland, 1885-1979, British Academy/Oxford UP, 2014).

20. The ‘Economic Modernisation’ of ‘Central Scotland’ • Glasgow designated as ‘declining’ – its population and its industries. • ‘New Towns’ and other areas away from Glasgow designated as the priority for investment. • Skilled labour for the new industries to be selectively removed from Glasgow. • Policy developed by Conservatives up to 1964 and continued by Labour after 1964. • Implemented via ‘the Scottish Office’ – in a forceful and co-ordinated manner. • Glasgow left to rehouse its remaining population with limited resources – leading to poor conditions in new areas of housing.

21. Growing government awareness of ‘harm’: A • 1966: “it is true that today we are getting rid of some of our best tenants and are leaving ourselves with this gap, and we are losing the capacity for leadership in the very communities which are creating the social problems” (Hugh Brown, MP,1966); • 1971 “Glasgow is in a socially, and purely from the city point of view, an economically dangerous position. The position is becoming worse because, although the rate of population reduction … is acceptable, the manner of it is destined within a decade or so to produce a seriously unbalanced population with a very high proportion of the old, the very poor and the almost unemployable … the above factors amount to a very powerful case for drastic action to reverse present trends within the city. [But] there is an immediate question as to how much room exists for manoeuvre.” (1971 Review of the impact of selective removal of population, “The Glasgow Crisis”, emphasis added). • 1975: Severe deprivation and related problems recognised as “unwanted side effects” of policies, but policy makers concerned for “the good repute of those with past responsibility” (1975).

22. Growing government awareness of ‘harm’ B • Late 1970s: New Secretary of State for Scotland attempts to reverse the policy, but is advised that this would “endanger … the economic prospects of the whole region” (submission to ministers, Sept 1977, agreed Jan 1978). This meant giving up on “saving Glasgow”. “the remote likelihood of adopting and implementing the policies required to save Glasgow points to the contrary course i.e. not to save it. This was something we always regarded as unthinkable while there was hope of doing something positive. Ministers’ minds may be sharpened by reminding them that the alternative becomes less unthinkable every day they fail to grasp the nettle”(Under Secretary for Housing, December 1977, on “The Future of Glasgow”). Focus becomes limited environmental improvement and some targeted health provision in areas of greatest deprivation. Spatial priorities remain largely the same until 2003/2004.

23. Glasgow, 1945-1980: A process of ‘vulnerabilisation’ to impending shock? • Glasgow loses massive share of population on highly selective basis (“creaming off”); sees its economic infrastructure designated as declining, and otherwise undermined; seen as having ‘lesser eligibility’ for social investment – all of this appreciated, but not addressed by government. • Timing: G-L-M diverge early 1970s and again after 1981; • key causes of death important – ‘external causes’ from early 1990s in particular; • Suggestive of ‘dislocation’ producing outcomes beyond those predicted by obvious vulnerabilities (deprivation and deindustrialisation);

24. Local government responses 1980s • Summary of difference between Glasgow and Liverpool: • “In Liverpoolthe actions of the council in the mid-1980s were, for all the controversy associated with them, genuinely popular and apparently invigorating; even for those who disagreed with them, there was a meaningful discussion about the needs of the city, the damage being done by central government and how best to address all of that. • “In Glasgow, however, there was little scope for that, and in fact there seems to have been an ongoing process of managing and manipulating communities in ways which compounded their problemsand led, perhaps, to even more damaging outcomes – breaking down fragile bonds of community and turning frustration into something rather more dangerous.” (Collins. 2015) • So, clear links to ‘social capital’…

25. 4) Local government responses 1980s • Different local government responses to right-wing UK (Conservative Party) Government policies • Seen in approaches to regeneration, and in aspects of local democracy • Manchester: • resisted co-operation with UK government until 1987 (3rd Conservative victory) • Liverpool • New Labour council (following years of (e.g.) Liberal control) • Rise of Militant, confrontation with UK government • Participation and politicisation of the public • Priority given to (e.g.) poverty, new council housing • All contrasts greatly with Glasgow • focus on inner-city gentrification • limited priority given to poverty/living conditions in peripheral estates • (NB: lots of evidence for all this)

26. Local government responses 1980s • Liverpool: • “Labour’s radical rhetoric struck a chord with despondent voters. Support for the council reflected a groundswell of popular opinion against the government.”(Carmichael, 1995) • “There is no doubt at all that the politics of the financial crisis electrified the people and alerted them to its problems in a way that was simply never there before. Everyone knew about it and everyone had an opinion.” (Lane 1987) • Glasgow: • “…the peripheral areas of Glasgow are to some extent politically disarmed. Nor is there necessarily a serious danger of social disorder, as geographically isolated, alienated youth would have nothing to attack but their neighbours” (Keating 1988)

27. The current perspective on ‘excess mortality’ in Glasgow and Scotland • Scotland and Glasgow emerge from WWII less well-placed to benefit from potential for health improvement – relative harshness of conditions inherited from earlier part of 20th C. • ‘Economic modernisation’of 1960s and 1970s damages Glasgow, leaving it vulnerable, but does not benefit other parts of Scotland in ways hoped for – so both Glasgow and Scotland more generally lose out. • Both Scotland and Glasgow are then more adversely affected by ‘Thatcherism’ post-1979. • The policy responses at both Glasgow and Scottish level fail to address the economic and social issues in the subsequent decades – and arguably can be seen to make them worse. • All of this is reflected in the accumulating health outcomes in Scotland and Glasgow up until the present. • So: What should be DONE about it?

29. Inadequate measurement of the experience of poverty & deprivation • Available measures of poverty don’t capture essence of living in deprived circumstances in Glasgow/Scotland • Lots of supporting evidence e.g. • Causes of death linked to the excess (‘diseases of despair’) • Other stuff I don’t have time to get into…

30. Conclusion • Scale of excess mortality is enormous – and tragic • Most likely underlying causes identified • Highly complex and multifactorial • Glasgow made more vulnerable to economic/political exposures by a whole series of adverse historical factors and decisions • Emphasises importance of political (especially economic) decisions for population health • Report includes 26 specific policy recommendations to address the issue • The ‘Glasgow Effect’ is an unhelpful term which has now lost its meaning – please don’t use it

31. Further details (if that hasn’t been enough???) • Report available from: http://www.gcph.co.uk • Blog re. “Glasgow Effect” terminology also available from GCPH website