Accounting forScotland’s excessmortality: towardsa synthesisGerry McCartneyChik CollinsG. David BattyDavid Walsh
Male life expectancy in available high income nations                                    90                               ...
Higher overall mortality than comparable nations                                                 85              Life expe...
Higher overall mortality than comparable nations                                                 85              Life expe...
Higher overall mortality than comparable nations                                                 85              Life expe...
Emergence of the ‘Scottish Effect’                                                            Scotland SMR (age & sex)    ...
nd                                                t la                                            o                       ...
nd                                                t la                                            o                       ...
Summary: the Scottish mortality phenomena1.   Scottish mortality is around European median until 1950     then diverges2. ...
Aims•   Identify the various hypotheses for mortality phenomena•   Evaluate each hypothesis using Bradford-Hill criteria• ...
Methods •         Systematic search for hypotheses in health literature           combined with outputs of dissemination s...
Identified hypotheses – artefactual and‘downstream’1.      Poverty and material deprivation*2.      Genetic vulnerability3...
Identified hypotheses – ‘midstream’1.    Migration2.    Different culture of substance misuse3.    Different individual va...
Identified hypotheses – ‘upstream’•   Culture of limited social mobility (Craig)•   Political attack•   Climate (sunlight,...
Number of Bradford-Hill criteria met by each hypothesis for the divergence     of Scottish mortality in the mid-20th Centu...
Number of Bradford-Hill criteria met by each hypothesis for the later                    divergence and Scottish/Glasgow E...
Political attack•          Was the UK exposed to a form of neoliberalism not seen           elsewhere; and was Scotland mo...
• “The passage of 30 years does not alter the fact that a  great many people were hurt, and hurt very badly,  because of M...
Synthesis for the divergence of Scottish mortality from mid-20th    Century                            Possible mechanisms...
Synthesis for the divergence of Scottish mortality from mid-20th    Century                            Possible mechanisms...
Synthesis for the emergence of the ‘Scottish Effect’ and ‘Glasgow    Effect’Vulnerability            Trigger              ...
Synthesis for the emergence of the ‘Scottish Effect’ and ‘Glasgow    Effect’Vulnerability            Trigger              ...
Synthesis for the emergence of the ‘Scottish Effect’ and ‘Glasgow    Effect’Vulnerability            Trigger              ...
Synthesis for the emergence of the ‘Scottish Effect’ and ‘Glasgow    Effect’Vulnerability            Trigger              ...
Conclusions•   No single ‘cause’ is likely to explain the mortality    phenomena•   There is a greater degree of uncertain...
Acknowledgements•   Co-authors: Chik Collins, G. David Batty & David Walsh•   Glasgow Centre for Population Health for sup...
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The Scotland effect

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The Scotland effect

  1. 1. Accounting forScotland’s excessmortality: towardsa synthesisGerry McCartneyChik CollinsG. David BattyDavid Walsh
  2. 2. Male life expectancy in available high income nations 90 80 70 Life expectancy (years) 60 50 40 30 20 10 0 1751 1801 1851 1901 1951 2001 YearData 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.
  3. 3. Higher overall mortality than comparable nations 85 Life expectancy at birth (years) 80 75 70 65 60 1971 1976 1981 1986 1991 1996 2001 2006 YearData 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.
  4. 4. Higher overall mortality than comparable nations 85 Life expectancy at birth (years) 80 Scotland 75 70 65 60 1971 1976 1981 1986 1991 1996 2001 2006 YearData 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.
  5. 5. Higher overall mortality than comparable nations 85 Life expectancy at birth (years) USA 80 Scotland 75 70 65 60 1971 1976 1981 1986 1991 1996 2001 2006 YearData 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.
  6. 6. Emergence of the ‘Scottish Effect’ Scotland SMR (age & sex) Scotland SMR (age, sex & Carstairs) 47% explained by 43% explained by deprivation 118 62% explained by deprivation deprivation 115 Directly standardised mortality 115 114 (England & Wales = 100) 112 112 109 108 108 106 105 103 100 1981 1991 2001 YearSource: Hanlon P, Lawder RS, Buchanan D, et al. Why is mortality higher in Scotland than in England and Wales? Decreasinginfluence of socioeconomic deprivation between 1981 and 2001 supports the existence of a Scottish Effect. Journal of PublicHealth. 2005; 27:199-204.
  7. 7. nd t la o ScSource: Mackenbach 2008 and Popham 2010
  8. 8. nd t la o ScSource: Mackenbach 2008 and Popham 2010
  9. 9. Summary: the Scottish mortality phenomena1. Scottish mortality is around European median until 1950 then diverges2. Scottish mortality pattern changes and diverges again around 19803. 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
  10. 10. Aims• Identify the various hypotheses for mortality phenomena• Evaluate each hypothesis using Bradford-Hill criteria• Begin to synthesise the valid aspects of the hypotheses
  11. 11. 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 forsupporting a causal hypothesis? Epidemiology 2001;13:6-8).
  12. 12. Identified hypotheses – artefactual and‘downstream’1. Poverty and material deprivation*2. Genetic vulnerability3. Health behaviours* Only artefactual in relation to the Scottish/Glasgow Effect
  13. 13. Identified hypotheses – ‘midstream’1. Migration2. Different culture of substance misuse3. Different individual values (time, aspiration)4. Family, gender or parenting differences5. Health service supply or demand6. Greater inequalities7. Greater concentration of deprivation8. Deindustrialisation9. Sectarianism10. Different culture (boundlessness, alienation)11. Lower social capital
  14. 14. Identified hypotheses – ‘upstream’• Culture of limited social mobility (Craig)• Political attack• Climate (sunlight, cold weather)
  15. 15. Number of Bradford-Hill criteria met by each hypothesis for the divergence of Scottish mortality in the mid-20th Century Health behavioursHypothesis in relation to the divergence of Scottish Greater inequalities mortality pattern from elsewhere in Europe Deindustrialisation Deprivation concentration Different individual values (time, aspiration) Lower social capital Political attack Sectarianism M igration Family and gender differences Deprivation and poverty Genetic differences Climatic differences Different culture of substance misuse Meets criteria Different culture (boundlessness, alienation) Does not meet criteria Culture of limited social mobility Health service supply and demand 0 1 2 3 4 5 6 7 8 9 Number of Bradford-Hill criteria
  16. 16. Number of Bradford-Hill criteria met by each hypothesis for the later divergence and Scottish/Glasgow Effect Political attack Health behavioursHypothesis in relation to the emergence of a Greater inequalities Artefact Scottish Effect or Glasgow Effect Lower social capital Deindustrialisation Deprivation concentration Different individual values (time, aspiration) Sectarianism Migration Family and gender differences Meets criteria Genetic differences Does not meet criteria Different culture of substance misuse Different culture (boundlessness, alienation) Climatic differences Culture of limited social mobility Health service supply and demand 0 1 2 3 4 5 6 7 8 9 Number of Bradford-Hill criteria
  17. 17. 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 highlySources:Collins C, McCartney G. Is a ‘political attack’ an explanation for the ‘Scottish Effect’ in health outcomes? . International Journal ofHealth Services (in press).Stuckler D, King L, McKee M. Mass privatisation and the post-communist mortality crisis: a cross-national analysis. Lancet2009;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.
  18. 18. • “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” (Ian Bell, Herald)• “A war without bullets” (Cathy McCormack)
  19. 19. Synthesis for the divergence of Scottish mortality from mid-20th Century Possible mechanisms and key factors Outcomes Development of new Poverty and Industrial peripheral housing inequality dependence estates CardiovascularInstability of industrial Gender disease Scottish culture employment disharmony Respiratory Substance disease misuse Migration patterns Insecurity of Stroke Increased stress employment Cancer Overcrowded city centre housing Sectarian divide Rise in inequality and poverty
  20. 20. Synthesis for the divergence of Scottish mortality from mid-20th Century Possible mechanisms and key factors Outcomes Development of new Poverty and Industrial peripheral housing inequality dependence estates CardiovascularInstability of industrial Gender disease Scottish culture employment disharmony Respiratory Substance disease misuse Migration patterns Insecurity of Stroke Increased stress employment Cancer Overcrowded city centre housing Sectarian divide Rise in inequality and poverty
  21. 21. Synthesis for the emergence of the ‘Scottish Effect’ and ‘Glasgow Effect’Vulnerability Trigger Mechanisms Outcomes Drugs-related Individuation and Breakdown in confidence of competition working class communities Alcohol-relatedGreater poverty Reduced self-esteem & 1976 financial crisis Suicide and inequality self-efficacy and subsequent Decreased Substance Road-trafficScottish culture political attack by well-being misuse accidents Thatcher government Industrial on numerous elements Increased Family dependence of the organised Cardiovascular stress breakdown working class diseaseSectarian divide Disempowerment Increased Respiratory and hopelessness violence diseaseGenetic factors Rise in Stroke Reduced community inequality andScottish climate cohesion poverty Cancer Deindustrialisation
  22. 22. Synthesis for the emergence of the ‘Scottish Effect’ and ‘Glasgow Effect’Vulnerability Trigger Mechanisms Outcomes Drugs-related Individuation and Breakdown in confidence of competition working class communities Alcohol-relatedGreater poverty Reduced self-esteem & 1976 financial crisis Suicide and inequality self-efficacy and subsequent Decreased Substance Road-trafficScottish culture political attack by well-being misuse accidents Thatcher government Industrial on numerous elements Increased Family dependence of the organised Cardiovascular stress breakdown working class diseaseSectarian divide Disempowerment Increased Respiratory and hopelessness violence diseaseGenetic factors Rise in Stroke Reduced community inequality andScottish climate cohesion poverty Cancer Deindustrialisation
  23. 23. Synthesis for the emergence of the ‘Scottish Effect’ and ‘Glasgow Effect’Vulnerability Trigger Mechanisms Outcomes Drugs-related Individuation and Breakdown in confidence of competition working class communities Alcohol-relatedGreater poverty Reduced self-esteem & 1976 financial crisis Suicide and inequality self-efficacy and subsequent Decreased Substance Road-trafficScottish culture political attack by Political attack by the well-being misuse accidents Thatcher government Thatcher government Industrial on numerous elements post 1979 Increased Family dependence of the organised Cardiovascular stress breakdown working class diseaseSectarian divide Disempowerment Increased Respiratory and hopelessness violence diseaseGenetic factors Rise in Stroke Reduced community inequality andScottish climate cohesion poverty Cancer Deindustrialisation
  24. 24. Synthesis for the emergence of the ‘Scottish Effect’ and ‘Glasgow Effect’Vulnerability Trigger Mechanisms Outcomes Drugs-related Individuation and Breakdown in confidence of competition working class communities Alcohol-relatedGreater poverty Reduced self-esteem & 1976 financial crisis Suicide and inequality self-efficacy and subsequent Decreased Substance Road-trafficScottish culture political attack by Political attack by the well-being misuse accidents Thatcher government Thatcher government Industrial on numerous elements post 1979 Increased Family dependence of the organised Cardiovascular stress breakdown working class diseaseSectarian divide Disempowerment Increased Respiratory and hopelessness violence diseaseGenetic factors Rise in Stroke Reduced community inequality andScottish climate cohesion poverty Cancer Deindustrialisation
  25. 25. 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
  26. 26. Acknowledgements• Co-authors: Chik Collins, G. David Batty & David Walsh• Glasgow Centre for Population Health for supporting the workContact: Gerry McCartney (gmccartney@nhs.net)

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