Oxfam Discussion Papers

Health inequalities in Scotland: looking beyond the blame game
A Whose Economy Seminar Paper

Gerry McCartney and Chik Collins
June 2011

www.oxfam.org.uk

About the authors
Gerry McCartney is a consultant in public health medicine and Head of the Public Health Observatory, NHS Health Scotland. He was a previously a General Practitioner and public health doctor for NHS Greater Glasgow and Clyde. He trained in medicine at the University of Glasgow (MBChB 2001, MPH 2006, MD 2010) and has an honours degree in economics and development (University of London, 2007). His MD thesis was on the host population impacts of the Glasgow 2014 Commonwealth Games. His main research interests and publications focus on the causes of health inequalities and the health impacts of socio-economic, political and environmental change. He writes here in a personal capacity and his views are not necessarily representative of NHS Health Scotland. Email: gmccartney@nhs.net Chik Collins is Senior Lecturer in the School of Social Sciences at the University of the West of Scotland. He holds a BA (Honours) in Social Science from Paisley College of Technology (1987), a postgraduate diploma in housing from the University of Stirling (1991), and a doctorate from the University of Paisley (1997) – published as Language, Ideology and Social Consciousness (Ashgate, 1999). He has written on urban policy, community development, the role of language in social change, and more recently, in collaboration with Gerry McCartney and others, on health. He has also worked with Oxfam and the Clydebank Independent Resource Centre in producing The Right to Exist: The Story of the Clydebank Independent Resource Centre (2008) and To Banker from Bankies: Incapacity Benefit – Myth and Realities (2009). Email: Chik.Collins@uws.ac.uk

Whose Economy Seminar Papers are a follow up to the series of seminars held in Scotland between November 2010 and March 2011. They are written to contribute to public debate and to invite feedback on development and policy issues. These papers are ‗work in progress‘ documents, and do not necessarily constitute final publications or reflect Oxfam policy positions. The views and recommendations expressed are those of the author and not necessarily those of Oxfam. For more information, or to comment on this paper, email ktrebeck@oxfam.org.uk

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Health inequalities in Scotland: looking beyond the blame game A Whose Economy Seminar Paper, June 2011

Contents
Executive summary ................................................................................. 4 Introduction: looking beyond ‘the blame game’.................................... 5 Health inequalities: separating myths from reality ............................... 6 Health inequalities aren’t inevitable ..................................................... 10 Inequalities: why we do care and why we should care ....................... 11 Conclusion.............................................................................................. 12 References .............................................................................................. 13

Health inequalities in Scotland: looking beyond the blame game A Whose Economy Seminar Paper, June 2011

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Executive summary
People in Scotland suffer from large and unjust inequalities in health. These inequalities are best explained by considering the stark and growing inequalities in income, wealth and power between groups. The likelihood that a child will suffer premature mortality or debilitating health conditions is very substantially determined by where the child is born, the resources it will have at its disposal and the social class of its parents. If where one is born can be thought of as a ‘lottery’, then life (and death) is indeed ‘a gamble’. Health-determining inequalities are, like health inequalities themselves, neither fixed nor natural, but arise from particular political choices and the values they reflect. In the decades after WWII, the UK became a significantly less inequitable country. Since the late 1970s, a series of neo-liberal economic and social policies have served once again to widen the inequalities which do so much to shape health outcomes. During this latter period, Scotland has suffered from growing health inequalities, a faltering in its improvement in overall life expectancy compared to other countries, and increasingly worse overall health outcomes than might be expected – even considering the high levels of poverty and deprivation which prevail here. Moreover, the available evidence suggests that the association between neoliberal policies and the observed trends in overall health outcomes and health inequalities is of a causal nature. Health inequalities have become, particularly in recent years, a source of great social and political concern. The injustices they crystallise challenge our basic humanity. It is inherently distressing to understand how a newborn child, losing out in the lottery of birth, faces such a challenge to achieve a decent, healthy life span. But such inequalities have much broader negative consequences for the whole of society – this is also a source of great concern. All of this concern should – and can – be translated into activities likely to redress the still-heightening inequalities in the socio-economic determinants of health.

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Health inequalities in Scotland: looking beyond the blame game A Whose Economy Seminar Paper, June 2011

Introduction: looking beyond ‘the blame game’
One of us – Gerry McCartney – used to be a General Practitioner. Gerry left General Practice frustrated: frustrated at the inability to make a sufficient difference for too many of his patients; frustrated because the prevailing medical model of health care urged him to prescribe more cholesterol medicines, more aspirin and more inhalers for people who were not sick because of a lack of medicine, but who were sick because they were suffering the consequences of poverty, inequality and toxic politics. Gerry’s patients knew that the medicines were not very likely to solve their problems, but they appreciated the effort and attention his practice and his colleagues provided. Appreciation, however, doesn’t always cut both ways. Some find it difficult to be sympathetic to people who smoke, drink too much alcohol, use heroin or eat too much. It’s their own fault, isn’t it? Yet, drinking and eating too much, and using alcohol and drugs, are the well-recognised reactions of significant proportions of people when faced with a system that disempowers, stigmatises and undervalues them.1 Nonetheless, every day in the press there are stories which portray poor people as feckless, careless, irresponsible or as scroungers (see Welford and Mooney, both this collection). This hostility (sadly there is no other word for it) has been encouraged by successive governments seeking to evade responsibility for health inequalities.2 Blaming the sick for being sick was actively promoted by the Thatcher government in response to the Black report3 and by the post-1997 Labour government in relation to both health4,5 and welfare policy.6 This discussion paper attempts to outline why inequalities in health exist (and in many instances are worsening) in Scotland today, why we should care about them, and how we could – indeed can – begin to address them.

Health inequalities in Scotland: looking beyond the blame game A Whose Economy Seminar Paper, June 2011

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Health inequalities: separating myths from reality
Health inequalities are the unjust and avoidable differences in health between groups or populations.i Most causes of premature mortality in Scotland (cancer, cardiovascular disease, stroke, violence, suicide, alcohol-related deaths and drugs-related deaths) are avoidable and disproportionately affect people born in the poorest areas, people of the lowest social class and people who have the lowest income and wealth.7 Despite an overall reduction in mortality over the years in Scotland, mortality rates have improved more slowly than in other Western European countries since around 1950. Furthermore, since around 1980, Scotland has seen much less improvement than in other parts of western Europe. The USA is somewhat similar to Scotland in this latter respect.8 Within Scotland, there are vast inequalities between the richest and poorest communities, both in terms of health and in many of the factors which influence health.9 The stark health inequalities can be illustrated by observing the drop in life expectancy of 2.0 years for males and 1.2 years for females for each station as you travel east on the railway across Glasgow, between Jordanhill and Bridgeton (Figure 1).
Figure 1 – The life expectancy gap across Glasgow (adapted from McCartney, 10 2010).

i

Many authors describe health inequalities as the systematic differences in health observed between different groups in a society, and health inequities as the unjust and avoidable differences in health observed between groups. In practice, the terms are often used interchangeably with an implicit understanding that the differences are unjust. The more commonly-used term, health inequalities, is used throughout this article.

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Health inequalities in Scotland: looking beyond the blame game A Whose Economy Seminar Paper, June 2011

Males - 75.8y Females - 83.1y
Hillhead Jordanhill Hyndland Partick Exhibition Centre Charing Cross QUEEN STREET Argyll St. CENTRAL St Enoch Bridgeton St George’s Cross Buchanan Street

Anderston Govan Ibrox Cessnock

Males - 61.9y Females - 74.6y

Life expectancy data refers to 2001-05 and was extracted from the Glasgow Centre for Population Health community health and wellbeing profiles. Adapted from the Strathclyde Partnership for Transport travel map by Gerry McCartney.

While people at the bottom of the social hierarchy often smoke more, drink more alcohol, take more drugs and have worse diets than their more affluent counterparts, it is hardly reasonable to suggest that this in itself provides a sufficient understanding as to why these people die younger. The sheer scale and the clear social patterning of the problem defies such an individualistic or purely behaviouralistic perspective. We need to grasp why unhealthy behaviours are more prevalent in these groups. As Michael Marmot, editor of the World Health Organisation report on health inequalities, puts it: only by grasping the ‘causes of the causes’ can we understand how health inequalities arise.11 Working class people suffer from worse health because they have less income, less wealth and less access to the institutions and pathways in life that provide life chances and confer status. These factors combined mean that they typically have less control over how their lives turn out: they have less power.12 It is clear that, from 1979, working class people were exposed to a concerted and sustained ‘political attack’ across the UK.13 It was an explicit political aim during the years of Conservative government, and a continuing aim during the years of Labour government, to weaken, disempower and delegitimise the ‘equalising institutions’ (such as trade unions, council housing, local government, the welfare state) which had in previous decades been created through the efforts of working class people. The results have included rising income inequalities, erosion of trade union rights, ‘residualisation’ of council housing, the growth in wealth and power of unelected elites, and the increasing stigmatisation of benefit recipients. This political attack has once again intensified since the formation of the Conservative-Liberal coalition in 2010. Clearly schooled in the arts of Friedmanite ‘shock treatment’, the coalition has insisted that that ‘there is no alternative’ to privatisation and cuts in public services because of the financial crisis resulting from the banking collapse.14

Health inequalities in Scotland: looking beyond the blame game A Whose Economy Seminar Paper, June 2011

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But, of course, there are alternatives. And, as the aforementioned WHO report has put it, the ‘toxic’ politics which prevent these alternatives being discussed and acted upon have been a key driver of the rise in health inequalities in many parts of the world. Such politics and policies are also seen by many as responsible for the faltering improvement in Scotland’s life expectancy since around 1980 (see Figure 2, overleaf) and the emergence of the so-called ‘Scottish Effect’ and ‘Glasgow Effect’.15 As already indicated, this kind of experience is by no means limited to Scotland. Patterns of increasing health inequalities on the one hand, and an associated disempowerment of ordinary people due to the implementation of a neoliberal economic model on the other, are to be seen in many countries.16 The implications of all of this are as disconcerting as they are clear. There is nothing fated or inevitable about the health inequalities in Scotland, or about the nation’s distressing excess mortality.17 People live less healthy lives and die unnecessarily young in our country because they are poor, live in ‘the wrong area’ and are more generally disempowered in their lives by the operation of the prevailing economic and political system. If politics is, as Harold Laswell famously put it, ‘who gets what, when and how’, then the prevailing politics have created this situation.18
Figure 2 – Trends in whole population life expectancy in Scotland (in red) ii compared with a selection of other nations (adapted from McCartney, Walsh, 8 Whyte and Collins).

ii

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, and West Germany.

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Health inequalities in Scotland: looking beyond the blame game A Whose Economy Seminar Paper, June 2011

Life expectancy at birth (years)

85 80 75 70 65 60 1971 1976 1981 1986 1991 1996 2001 2006

Year

Health inequalities in Scotland: looking beyond the blame game A Whose Economy Seminar Paper, June 2011

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Health inequalities aren’t inevitable
The differences in health outcomes between areas in the UK have not always been as stark as they are today. Figure 3 (overleaf) shows that during the 1920s and 1930s premature mortality in the worst tenth of areas was almost twice (1.9 times) that of the best tenth of areas. These differences rapidly reduced following WWII and remained lower until the 1980s. This period in history was characterised by a rise in the relative power of working class communities. It is not that the working classes dominated – far from it – but it was a time when the welfare state was introduced, state pensions became available, the NHS free at the point of need was introduced, and basic working and trade union rights were established. These ‘equalising’ developments – which were, we should remember, initiated after a long and very costly war, when the nation’s finances were under very great strain – were in part funded by taxing the incomes of the richest in society: the top rate of income tax was 84 per cent by 1979 and corporation tax was set at 56 per cent. But from 1979 onwards the tide turned and power flowed from working class communities to the richest in society. It was also from this point, as Figure 3 shows, that health inequalities rapidly worsened.21 iii Not only have health inequalities in the UK been much narrower in the past than they are today, there is great variation in the extent of health inequalities across Europe.19 Again, this demonstrates that there is not some ‘natural’ or ‘inevitable’ rate of health inequalities. It is also clear that those countries which adopted the same kind of neoliberal economic model as implemented in the UK after 1979 have seen a rapid rise in inequalities.16,20 Health inequalities in Scotland are very likely to persist to the extent that inequalities in the factors that determine health (income, wealth, power, status, employment, housing etc.) remain. Inequalities in these health determinants are not a consequence of some natural order, but are the result of a process by which power (and all its consequences) has become concentrated in the hands of a relative few. Redistribution of power from central government and corporate interests, which is, after all, not where power is supposed to be located in a ‘democracy’, would provide some basis for effective means of redress – the rediscovery of the value and purpose of ‘equalising institutions’ in the life of our nation and its communities.

iii

The differences between areas illustrated here are not strictly inequalities, because the areas have not been ordered by poverty, class or some other marker of social status. This is because there are no consistent geographical areas with attached social status markers available for this prolonged time series. It is likely that variations between areas in this instance represent inequalities, but this cannot be formally demonstrated.

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Health inequalities in Scotland: looking beyond the blame game A Whose Economy Seminar Paper, June 2011

Figure 3 - Ratio of standardised mortality ratios (0-64years), UK local authorities, iv 21 1921-2007 (adapted from Thomas, Dorling and Smith)

Ratio of best to worst deciles for area-based mortality

2.2 2 1.8 1.6 1.4 1.2 1
19 21 -1 93 0 19 31 -1 93 9 19 50 -1 95 3 19 59 -1 96 3 19 69 -1 97 3 19 81 -1 98 9 19 90 -1 99 8 19 99 -2 00 7

Year

Inequalities: why we do care and why we should care
The culture of blaming the poor and the sick for their hardships in a curious way reflects something of the humanity of those who do the blaming. The hardships of the poor and sick are distressing to us all as human beings. We actually do care, but many people don’t want to feel that someone other than the poor and the sick themselves might have had a hand in causing their hardships, or that many others might have somehow benefited from things which have caused those hardships. But the blaming which then ensues, while reflecting something of our humanity, ultimately represents a loss of humanity. However much some media outlets or commentators might suggest that the poor and the sick must somehow have ‘deserved what was coming to them’,22 others have had a very big hand in causing their suffering, and many others have benefited from the things which have caused it.

iv

The figure is adapted from Thomas, 2010. The data series is not continuous, with no data for 1940s and gaps in mid-‘50s, mid-‘60s, and from early ‘70s to early ‘80s; nor are time periods always of equal duration. For 1980s, the harmonic mean of decile SMRs for two periods of which it was composed (1981-5 and 1986-9) were used. Confidence intervals were unavailable for data for 1950s-1980s.

Health inequalities in Scotland: looking beyond the blame game A Whose Economy Seminar Paper, June 2011

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To build a suitably human response on the basis of this initial human reaction – a response not of hostility and blame, but of care for and solidarity with our fellow human beings – requires that people grasp the fact that there are alternatives to the inequalities which are causally implicated in producing unnecessary hardship and suffering. It is absolutely not necessary that a baby boy born in North West Paisley has a life expectancy of only 61.7 years, while a baby boy born only two miles away in Houston has a life expectancy of 87.5 years – a 26-year gap.23 We repeat: this is not necessary, and the decisions which could begin to change the situation can be made tomorrow, next week, or next month if there is the political will to advocate them, to make them and to defend them. But for those who do not suffer the worst effects of health inequalities there is, perhaps, a more self-interested reason to care. Amongst relatively rich, developed countries like Scotland, the greater the equality in society, the better the outcomes are for everyone living there, across a whole range of health and social indicators.24 Both richer and the poorer people within more equal societies have better health, and experience less crime and greater happiness than those living in less equal societies.

Conclusion
Tackling inequalities in general, and health inequalities in particular, should therefore be a priority for every government. It is the human response, the just response and also in everyone’s interests. Health is not a commodity that is to be gained at someone else’s expense. Health is a public good: people can enjoy good health without detracting from anyone else’s health; indeed the evidence is that everyone will enjoy better health when politics is made to reflect this fact in the social and economic policies it produces. Health inequalities arise because of political decisions and processes that reflect certain values and priorities – values and priorities which are open to deliberation and to alteration. Those concerned with public health, health inequalities and – as indicated above – even those only concerned with their own selfish interests, should actively campaign for a narrowing in the power, income and wealth gaps which cause health inequalities.

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Health inequalities in Scotland: looking beyond the blame game A Whose Economy Seminar Paper, June 2011

References
1 2 3 4 Alexander, B. (2008) The globalization of addiction: a study in poverty of the spirit, Oxford: Oxford University Press. Carlisle, S. (2001) ―Inequalities in health: contested explanations, shifting discourses and ambiguous policies‖, Critical Public Health, 11(3): 267-281. Townsend, P., Davidson, N. and Whitehead, M. (1988) Inequalities in Health: the Black Report and the Health Divide, Harmondsworth: Penguin. Shaw, M., Dorling, D., Gordon, D. and Davey Smith, G. (2005) ―Health inequalities and New Labour: how the promises compare with real progress‖, British Medical Journal 330: 1016 [doi: 10.1136/bmj.330.7498.1016]. Shaw, M., Dorling, D., Mitchell, R. and Smith, G.D. (2005) ―Labour‘s Black Report Moment?‖ British Medical Journal 331: 575 [doi: 10.1136/bmj.331.7516.575]. Collins, C. with Dickson, J., and Collins, M. (2009) To Banker, from Bankies. Incapacity Benefit: Myth and Realities, Glagow: Oxfam and Clydebank Independent Resource Centre. Leyland, A., Dundas, R., McLoone, P. and Boddy F.A. (2007) Inequalities in mortality in Scotland 19812001, Glasgow: MRC Social and Public Health Sciences Unit. McCartney, G., Walsh, D., Whyte, B. and Collins, C. (Forthcoming) ―Has Scotland always been the sick man of Europe?‖ (Manuscript submitted for publication). Hanlon, P., Walsh, D. and Whyte, B. (2006) Let Glasgow Flourish, Glasgow: Glasgow Centre for Population Health. McCartney, G. (2010) ―Illustrating Glasgow‘s health inequalities‖, Journal of Epidemiology and Community Health [doi 10.1136/jech.2010.120451]. Commission on the Social Determinants of Health (2008). Closing the gap in a generation: health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health, Geneva: World Health Organization. Hofrichter, R. and Bhatia, R. (eds) (2010). Tackling health inequities through public health practice: theory to action, Oxford: Oxford University Press. Collins, C. and McCartney, G. (2011). ―The impact of neo-liberal ‗political attack‘ on health: The case of the ‗Scottish Effect‘, International Journal of Health Services 2011; 41(3): 501–523 [doi: 10.2190/HS.41.3.f]. Collins, C. and McCartney, G. (2010). ―TINA is back‖. In: Scottish Review. The annual anthology, Kilmarnock: Institute of Contemporary Scotland. McCartney, G., Collins, C., Walsh, D. and Batty, D. (2011) Explaining Scotland’s mortality: towards a synthesis. Glasgow: Glasgow Centre for Population Health [Downloaded from http://www.gcph.co.uk/publications/238_accounting_for_scotlands_excess_mortality_towards_a_synthesis on 26th May 2011]. Beckfield, J. and Krieger, N. (2009) ―Epi+demos+cracy: Linking Political Systems and Priorities to the Magnitude of Health Inequities—Evidence, Gaps, and a Research Agenda‖, Epidemiologic Reviews, 31: 152-177 [doi: 10.1093/epirev/mxp002]. Dorling, D. (2010) Injustice: why social inequality persists, Bristol: Policy Press. Lasswell H. D. (1990). Politics: who gets what, when and how. Gloucester MA: Peter Smith Publisher. Mackenbach, J.P., Stirbu, I., Roskam, A.J.R., Schapp, M.M., Menvielle, G., Leinsalu, M., and Kunst, A.E. (2008) ―Socioeconomic Inequalities in Health in 22 European Countries‖, New England Journal of Medicine 358: 2468-81. Leinsalu, M., Stirbu, I., Vagero, D., Kaledien, R., Kova, K., Wojtyniak, B., Wroblewska, W., Mackenbach, J. P. and Kunst, A.E. (2009) ―Educational inequalities in mortality in four Eastern European countries: divergence in trends during the post-communist transition from 1990 to 2000‖, International Journal of Epidemiology 38: 512–525 [doi:10.1093/ije/dyn248]. Thomas, B., Dorling, D. and Smith G.D. (2010) ―Inequalities in premature mortality in Britain: observational study from 1921 to 2007‖, British Medical Journal 341: c3639 [doi:10.1136/bmj.c3639]. Raphael, D. (2011) ―Mainstream media and the social determinants of health: is it time to call it a day?‖ Health Promotion International 2011; [doi:10.1093/heapro/dar008]. Gasiorowski, A. and Stockton, D. (2010) Health and Wellbeing profiles 2010: Renfrewshire CHP, Edinburgh: Information Services Division (ScotPHO). Wilkinson, R. and Pickett, K. (2009) The Spirit Level. Why more equal societies almost always do better, London: Allen Lane.

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© Oxfam GB June 2011 The text may be used free of charge for the purposes of advocacy, campaigning, education, and research, provided that the source is acknowledged in full. The copyright holder requests that all such use be registered with them for impact assessment purposes. For copying in any other circumstances, or for re-use in other publications, or for translation or adaptation, permission must be secured and a fee may be charged. Email publish@oxfam.org.uk The information in this publication is correct at the time of going to press. Oxfam is a registered charity in England and Wales (no 202918) and Scotland (SC039042). Oxfam GB is a member of Oxfam International. www.oxfam.org.uk

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Health inequalities in Scotland: looking beyond the blame game A Whose Economy Seminar Paper, June 2011

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