‘Grasping’ Health in Scotland: The role of politics and policy in creating the ‘Scottish Effect’? - Chik Collins
‘Grasping’ Health in Scotland: The role of politics and policy in creating the ‘Scottish Effect’?Chik Collins, School of Social Sciences, University of the West of Scotland (presentation based on work conducted in collaboration with Gerry McCartney, Public Health Observatory, NHS Health Scotland) Self Directed Support in North Lanarkshire: The Bigger Picture Ravenscraig Regional Sports Facility, Motherwell 8 November 2011
Lagging Outcomes I: The Scottish EffectExcess mortality in Scotland, compared to England and Wales, after accounting for deprivation: Increases after 1981 Source: Hanlon et al, 2005 118 Directly standardised mortality ratio 115.1 115 (England & Wales = 100) 113.8 112.4 112 109 107.9 108.1 106 104.7 103 100 1981 1991 2001 Year Scotland SMR (age & sex) Scotland SMR (age, sex & deprivation)
Lagging Outcomes II: Broader comparisons Source: Extracted from The Human Mortality Database (www.mortality.org)
Lagging outcomes IIICauses• Post 1950: Cardiovascular, stroke, respiratory and cancer.• Post 1980: + Alcohol- and drug-related deaths, suicide, violent deaths and RTAs.Where this leaves us• Scottish life expectancy between that of Eastern and Western Europe.
What’s up doc?• Deindustrialisation hypothesis? • Walsh, Taulbut and Hanlon, 2008: The Aftershock of Deindustrialisation? Glasgow Centre for Population Health • Answer: Clearly very important, but not ‘the answer’. • Deepens the problem.• A ‘political attack hypothesis’? • Not ‘our’ hypothesis. • Impact of Thatcherite neo-liberalism after 1979: ‘political attack’. • + Encompasses deprivation, deindustrialisation ... • + Temporal aspect – ‘Scottish Effect’ emerges in 1980s ... • Evidence from elsewhere: Russia, EE, Baltics ... • AIM: To influence the agenda of the health researchers ... Collins and McCartney, “The impact of neo-liberal ‘political attack’ on health: the case of the ‘Scottish Effect’”, International Journal of Health Services, 2011
Political Attack and Health in Scotland: A prominent ‘hypothesis’• Ian Bell: “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. Its true”• Iain MacWhirter : “The social cost of this socioeconomic disruption lingers to this day in the appalling mortality figures from heart disease, suicide and depression in West Central Scotland”.
The UK ‘political attack’• 1950s/60s: Neo-liberal economic and political thought - Hayek, Friedman• Early implementation in Latin America: “planned misery” (Rudolfo Walsh).• Mid-1970s: Keith Joseph and the IEA – advocating Friedmanite “shock treatment” on lines of Chile.• Post 1979: Engineered recession, forced deindustrialisation, mass unemployment, attacks on trade unions and on social provision/welfare state – esp. council housing.• ‘The lady is not for turning’ ….. The Ridley Report (1977): “there is no point in undertaking it if we are not prepared to go through with it”.• Scotland doubly targeted – “to seek revenge for the various humiliations of the early 1970s” (Phillips, 2008, p. 138).• Christopher Harvie: “sado-monetarism” - inevitability of acute social and psychological distress.
LINKING POLITICAL ATTACK TO HEALTH OUTCOMES“The deep fried Mars Bars and Buckfast wine are a symptom, not thecause. The communities that gave meaning to the lives of hundreds ofthousands of working-class Scots disintegrated” (Iain MacWhirter, 2009).
Determinants of Health• Downstream: Buckfast and deep-fried Mars Bars ...(health behaviours)• Upstream: deprivation, deindustrialisation, inequalities .... (“causes of the causes” – Marmot).• Evidence base for upstream determinants linked to political attack: unemployment, welfare provision, inequality, material deprivation and privatisation.• What are ‘pathways’ which connect?
Pathways :‘political attack’ to poor health outcomes Use of rising Unemployment and fear of Breakdown in confidence of Substance unemployment to unemployment working class communities misuse disempower workers and control wages Harshening welfare regime/stigmatisation of Decrease in claimants Privatisation and Declining social mobility; well-beingPolitical decision marketisation of the stigmatisation and shame; Rise in inequality and poverty to attack the economy lowering self- Poor health economic and esteem/efficacy negative Adverse impact on labour outcomes as socio-political outcome expectancies; market pathways for working compared with bases of a decline in coping Attacks on trade union class youth other working class movement deindustrialised culture Lack of Individuation and competition areas threatening the control agenda of the Disempowerment of Economic and geographical Thatcher elected local polarisation of communities Higher government authorities and Breakdown in cohesion and levels of centralisation self-regulation of working Reduced ability of working class stress class communities communities to respond to problems and act in common Attack on council Increase in interest housing - sales and violence funding cuts leading to rent increases, Disempowerment of council stock deterioration tenants and residualisation
The UK and Neo-liberalism“The UK followed a different policy coursefrom the European comparison nationsidentified by the GCPH for itsdeindustrialization study – one which involveda significantly more resolute pursuit of a neo-liberal policy agenda.” (Collins and McCartney,2011)
Scotland’s heightened vulnerability to ‘political attack’Notion of heightened vulnerability widelyarticulated – Phillips, Foster, Harvie, Devine ...Key markers of vulnerability:– Economic: Industrial employment– Social: Council housing– Cultural: Power and controlCumulative effect ….
Economic: Industrial Employment Source: Walsh, Taulbut and Hanlon (2008) Proportion of industrial employment at peak (1971)70% Proportion of industrial employment lost 1971-2005 59.9% 58.1%60% 50.9%50% 47.5% 44.9% 45.4%40% 37.3% 35.9%30%20%10%0% Northern Ireland Swansea & South Merseyside West of Scotland Wales Coalfields UK deindustrialised region
Social: Council Housing1979: Councilhousing twice 0.2proportion in houses per capita (1979)England (54%) Number of council 0.16Glasgow – twothirds. 0.12Motherwell (96% ofhouseholds – ’70s) 0.08Residualisation –concentrating 0.04poverty; esp.Glasgow (Hirsch/JRF,2004) 0Figure: Data from Wales North-West West North-East ScotlandRegional Trends (not Midlandsideal, but enough). UK deindustrialised region
Cultural: Disempowerment and loss of control• Disempowerment and loss of control - a well- established cause of ill-health and barrier to management of chronic illness and changing behaviours.• Deindustrialising regions – Labour voting• Scottish ‘region’ – compounded by national dimension – the ‘doomsday scenario’ and the ‘democratic deficit’.
Conservative Voting by Region West of Scotland Other regions Mean UK vote 45constituencies within each region at 40 Mean % Conservative vote in 35 general election 30 25 20 15 10 5 0 1974 October 1979 1983 1987 1992 1997 General Election
Conclusion• UK experience of deindustrialisation different from elsewhere in Europe.• Within UK, Scotland, and esp. WoS, seems more exposed to damaging impacts.• “The ‘political attack’ hypothesis offers an important avenue for researchers seeking an explanation for the Scottish Effect ... Clearly Scotland in the 1980s is not quite Russia in the 1990s, but it seems slightly anomalous, if not entirely inexplicable that more of the kind of thinking which has been brought to bear on the latter has not more clearly shaped the kind of thinking brought to bear on the Scottish experience” (Collins and McCartney, 2011).
Impact?• Constructive and supportive dialogue with key GCPH staff in developing the case – Phil Hanlon and David Walsh.• Positive indications that being taken seriously.• Input to next stage of ‘three cities’ research programme – Glasgow, Liverpool, Manchester.• Accounting for Scotland’s Excess Mortality: Towards a Synthesis (McCartney, Collins, Walsh and Batty, forthcoming GCPH publication).• “Has Scotland always been the ‘sick man’ of Europe? An observational study from 1855-2006”, McCartney, Walsh, Whyte and Collins, European Journal of Public Health.
Closing Remarks I• Scottish health and mortality is not inevitable/fated (Austria, Finland, Portugal, NI).• Not making some simplistic link between politics and health regardless of context and circumstances: pathways, mediations and transitions.• Contemporary relevance ... The return of TINA …
Closing Remarks II• Grasping health…. “the self”, community/culture, and “socio-economic structure” (politics): ‘inside’ and ‘outside’• Analogy with ‘rediscovery of poverty’ and ‘culture of poverty’ in the 1960’s/70’s: What was learned then?• Community development and Helping the Community to Organise (Strathclyde Regional Council)
Closing Remarks III• Vocal/resistant/campaigning v’s quiescent/docile/co-opted.• Where are these community organisations now?• Too few and far between: BUT: The Clydebank Independent Resource Centre (see The Right to Exist, Oxfam, 2008)