the scotland effect
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Accounting for Scotland’s excess mortality: towards a synthesis
Gerry McCartney
Chik Collins
G. David Batty
David Walsh
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90
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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10
20
30
40
50
60
70
80
90
1751 1801 1851 1901 1951 2001
Year
Life
exp
ecta
ncy
(yea
rs)
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, 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
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 (gmccartney@nhs.net)
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