The Scotland effect

Accounting for Scotland’s excess mortality: towards a synthesis

Gerry McCartney

Chik Collins

G. David Batty

David Walsh

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1751 1801 1851 1901 1951 2001

Year

Life

exp

ecta

ncy

(yea

rs)

Male life expectancy in available high income nations

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 & USA.

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1751 1801 1851 1901 1951 2001

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1971 1976 1981 1986 1991 1996 2001 2006

Year

Life

exp

ecta

ncy

at b

irth

(yea

rs)

Higher overall mortality than comparable nations

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, Spain, Sweden, Switzerland, Taiwan & West Germany.

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80

85

1971 1976 1981 1986 1991 1996 2001 2006

Year

Life

exp

ecta

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at b

irth

(yea

rs)

Higher overall mortality than comparable nations

Scotland

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.

60

65

70

75

80

85

1971 1976 1981 1986 1991 1996 2001 2006

Year

Life

exp

ecta

ncy

at b

irth

(yea

rs)

Higher overall mortality than comparable nations

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 & USA.

USAScotland

Emergence of the ‘Scottish Effect’

112114

105

108 108

115

100

103

106

109

112

115

118

1981 1991 2001Year

Dir

ectl

y st

anda

rdis

ed m

orta

lity

(Eng

land

& W

ales

= 1

00)

Scotland SMR (age & sex)Scotland SMR (age, sex & Carstairs)

62% explained by deprivation

47% explained by deprivation43% explained by

deprivation

Source: Hanlon P, Lawder RS, Buchanan D, et al. Why is mortality higher in Scotland than in England and Wales? Decreasing influence of socioeconomic deprivation between 1981 and 2001 supports the existence of a 'Scottish Effect'. Journal of Public Health. 2005; 27:199-204.

Scot

lan

d

Source: Mackenbach 2008 and Popham 2010

Scot

land

Source: Mackenbach 2008 and Popham 2010

Summary: the Scottish mortality phenomena

1. Scottish mortality is around European median until 1950 then diverges

2. Scottish mortality pattern changes and diverges again around 1980

3. Deprivation explains less of the higher mortality in Scotland and Glasgow from 1981 onwards (the Scottish/Glasgow Effect)

4. Scottish health inequalities are wider than the rest of western Europe

Aims

• Identify the various hypotheses for mortality phenomena• Evaluate each hypothesis using Bradford-Hill criteria • Begin to synthesise the valid aspects of the hypotheses

Methods• Systematic search for hypotheses in health literature

combined with outputs of dissemination seminars• Application of Bradford-Hill criteria

– Strength of association*– Consistency– Specificity**– Temporality*– Biological gradient– Plausibility*– Coherence– Experiment– Analogy

• Synthesis drawing on Hegelian approach * Criteria given most weight by the Academy of Medical Sciences:

Identifying the environmental causes of disease: how should we decide what to believe and when to take action? . London: Academy of Medical Sciences; 2007.

** Criteria given more weight by other authors (e.g. Weiss NS. Can the "specificity" of an association be rehabilitated as a basis for supporting a causal hypothesis? Epidemiology 2001;13:6-8).

Identified hypotheses – artefactual and ‘downstream’

1. Poverty and material deprivation*2. Genetic vulnerability3. Health behaviours

* Only artefactual in relation to the Scottish/Glasgow Effect

Identified hypotheses – ‘midstream’

5. Migration6. Different culture of substance misuse7. Different individual values (time, aspiration)8. Family, gender or parenting differences9. Health service supply or demand10. Greater inequalities11. Greater concentration of deprivation12. Deindustrialisation13. Sectarianism14. Different culture (boundlessness, alienation)15. Lower social capital

Identified hypotheses – ‘upstream’

15. Culture of limited social mobility (Craig)16. Political attack

17. Climate (sunlight, cold weather)

Number of Bradford-Hill criteria met by each hypothesis for the divergence of Scottish mortality in the mid-20th Century

0 1 2 3 4 5 6 7 8 9

Health service supply and demand

Culture of limited social mobility

Different culture (boundlessness, alienation)

Different culture of substance misuse

Climatic differences

Genetic differences

Deprivation and poverty

Family and gender differences

Migration

Sectarianism

Political attack

Lower social capital

Different individual values (time, aspiration)

Deprivation concentration

Deindustrialisation

Greater inequalities

Health behaviours

Hyp

othe

sis

in r

elat

ion

to t

he d

iver

genc

e of

Sco

ttis

h

mor

tality

pat

tern

fro

m e

lsew

here

in

Euro

pe

Number of Bradford-Hill criteria

Meets criteria

Does not meet criteria

0 1 2 3 4 5 6 7 8 9

Health service supply and demand

Culture of limited social mobility

Climatic differences

Different culture (boundlessness, alienation)

Different culture of substance misuse

Genetic differences

Family and gender differences

Migration

Sectarianism

Different individual values (time, aspiration)

Deprivation concentration

Deindustrialisation

Lower social capital

Artefact

Greater inequalities

Health behaviours

Political attack

Hyp

othe

sis

in r

elat

ion

to t

he e

mer

genc

e of

a

Scot

tish

Eff

ect

or G

lasg

ow E

ffec

t

Number of Bradford-Hill criteria

Meets criteria

Does not meet criteria

Number of Bradford-Hill criteria met by each hypothesis for the later divergence and Scottish/Glasgow Effect

Political attack• Was the UK exposed to a form of neoliberalism not seen

elsewhere; and was Scotland more vulnerable to it, targeted or have a particular reaction?

• Deindustrialisation managed and mitigated in other countries• Parallels with transitions in Eastern Europe and USA • Accommodation in Scotland not seen in England • Linked to alienation, disempowerment and democratic deficit • Timing and plausibility rate highly

Sources:

Collins C, McCartney G. Is a ‘political attack’ an explanation for the ‘Scottish Effect’ in health outcomes? . International Journal of Health Services (in press).

Stuckler D, King L, McKee M. Mass privatisation and the post-communist mortality crisis: a cross-national analysis. Lancet 2009;373:399-407.

Boyle M, McWilliams C, Rice G. The spatialities of actually existing neoliberalism in Glasgow, 1977 to present. Geografiska Annaler; series B, Human Geography 2008;90:313-25.

Phillips J. The industrial politics of devolution: Scotland in the 1960s and 1970s. Manchester: Manchester University Press; 2008.

• “The passage of 30 years does not alter the fact that a great many people were hurt, and hurt very badly, because of Margaret Thatcher. … she willed an economic catastrophe. A large part of a generation never recovered. Some sickened; some died too soon. It's true” (Ian Bell, Herald)

• “A war without bullets” (Cathy McCormack)

Substance misuse

Rise in inequality and poverty

Instability of industrial employment

Increased stress

Gender disharmony

Possible mechanisms and key factors Outcomes

Poverty and inequality

Migration patterns

Industrial dependence

Sectarian divide

Cardiovascular disease

Respiratory disease

Stroke

Cancer

Insecurity of employment

Overcrowded city centre housing

Development of new peripheral housing

estates

Scottish culture

Synthesis for the divergence of Scottish mortality from mid-20th Century

Substance misuse

Rise in inequality and poverty

Instability of industrial employment

Increased stress

Gender disharmony

Possible mechanisms and key factors Outcomes

Poverty and inequality

Migration patterns

Industrial dependence

Sectarian divide

Cardiovascular disease

Respiratory disease

Stroke

Cancer

Insecurity of employment

Overcrowded city centre housing

Development of new peripheral housing

estates

Scottish culture

Synthesis for the divergence of Scottish mortality from mid-20th Century

Reduced community cohesion

Breakdown in confidence of working class communities

Decreased well-being

Substance misuse

Suicide

Vulnerability

Rise in inequality and

poverty

Increased violence

Disempowerment and hopelessness

1976 financial crisis and subsequent

'political attack' by Thatcher government on numerous elements

of the organised working class

Increased stress

Individuation and competition

Reduced self-esteem & self-efficacy

Trigger Mechanisms Outcomes

Scottish culture

Greater poverty and inequality

Industrial dependence

Sectarian divide

Scottish climate

Genetic factors

Road-traffic accidents

Alcohol-related

Drugs-related

Cardiovascular disease

Respiratory disease

Stroke

Cancer

Family breakdown

Deindustrialisation

Synthesis for the emergence of the ‘Scottish Effect’ and ‘Glasgow Effect’

Reduced community cohesion

Breakdown in confidence of working class communities

Decreased well-being

Substance misuse

Suicide

Vulnerability

Rise in inequality and

poverty

Increased violence

Disempowerment and hopelessness

1976 financial crisis and subsequent

'political attack' by Thatcher government on numerous elements

of the organised working class

Increased stress

Individuation and competition

Reduced self-esteem & self-efficacy

Trigger Mechanisms Outcomes

Scottish culture

Greater poverty and inequality

Industrial dependence

Sectarian divide

Scottish climate

Genetic factors

Road-traffic accidents

Alcohol-related

Drugs-related

Cardiovascular disease

Respiratory disease

Stroke

Cancer

Family breakdown

Deindustrialisation

Synthesis for the emergence of the ‘Scottish Effect’ and ‘Glasgow Effect’

Reduced community cohesion

Breakdown in confidence of working class communities

Decreased well-being

Substance misuse

Suicide

Vulnerability

Rise in inequality and

poverty

Increased violence

Disempowerment and hopelessness

1976 financial crisis and subsequent

'political attack' by Thatcher government on numerous elements

of the organised working class

Increased stress

Individuation and competition

Reduced self-esteem & self-efficacy

Trigger Mechanisms Outcomes

Scottish culture

Greater poverty and inequality

Industrial dependence

Sectarian divide

Scottish climate

Genetic factors

Road-traffic accidents

Alcohol-related

Drugs-related

Cardiovascular disease

Respiratory disease

Stroke

Cancer

Family breakdown

Deindustrialisation

Synthesis for the emergence of the ‘Scottish Effect’ and ‘Glasgow Effect’

Political attack by the Thatcher

government post 1979

Reduced community cohesion

Breakdown in confidence of working class communities

Decreased well-being

Substance misuse

Suicide

Vulnerability

Rise in inequality and

poverty

Increased violence

Disempowerment and hopelessness

1976 financial crisis and subsequent

'political attack' by Thatcher government on numerous elements

of the organised working class

Increased stress

Individuation and competition

Reduced self-esteem & self-efficacy

Trigger Mechanisms Outcomes

Scottish culture

Greater poverty and inequality

Industrial dependence

Sectarian divide

Scottish climate

Genetic factors

Road-traffic accidents

Alcohol-related

Drugs-related

Cardiovascular disease

Respiratory disease

Stroke

Cancer

Family breakdown

Deindustrialisation

Synthesis for the emergence of the ‘Scottish Effect’ and ‘Glasgow Effect’

Political attack by the Thatcher

government post 1979

Conclusions

• No single ‘cause’ is likely to explain the mortality phenomena

• There is a greater degree of uncertainty about the divergence of mortality from the mid-20th Century

• ‘Downstream’ causes are necessary but insufficient to explain the Scottish Effect and Glasgow Effect

• Politics of the 1980s and the cultures arising from this are likely to be important in explaining the recent divergence

Acknowledgements

• Co-authors: Chik Collins, G. David Batty & David Walsh• Glasgow Centre for Population Health for supporting the

work

Contact: Gerry McCartney ([email protected])