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Health in Scotland 2004
CHAPTER 1: THE SCOTTISH EFFECT
Tackling poverty and social exclusion is the first of
the four "health imperatives for the twenty-first century"
listed by the World Health Organization (WHO) in its 1997
World Health Report (1).
The relationship of health to wealth, or more
specifically of poverty to poor health, has been known
since biblical times. Health is a social justice issue.
Tackling health inequalities therefore rightly underpins
the approach to improving the health of the people of
Scotland. Progress over the last year is the first issue
covered in the next chapter, which deals with health
improvement.
Previous annual reports on the health of the people in
Scotland (2) have emphasised the need for good research and
clear thinking in the approach to solving these problems.
The relationship between health and wealth is complex. One
as yet unexplained paradox in Scotland is that, even when
matched with their English counterparts of comparable
socio-economic status, Scots are relatively less healthy
over a range of indicators from age standardised mortality
to specific disease outcomes
(Figure 1.1).
These findings suggest that there are factors at work,
other than simply wealth, which are making Scots more
unhealthy than their English counterparts. This unexplained
difference has been dubbed 'The Scottish Effect'.
Figure 1.1: Directly standardised mortality
rates per 1,000 population, 1990/92, by country and
deprivation quintile.
Source:
PHIS Chasing the Scottish Effect 2001
The factors behind this amplification of the effect of
wealth on health have been postulated to include social and
cultural norms (3) and factors affecting social capital of
Scotland. This chapter describes some of what is known and
what remains to be explored in this area. It also points to
new understanding of the molecular biology of the processes
underlying the link between poverty and ill health and to
the importance of initiatives such as the Scottish
Executive's investment of £1 million in the Glasgow Centre
for Population Health in taking this work forward.
Understanding the 'Scottish Effect'
Scotland's health is improving overall but it is doing
less well than many of its neighbours and the differences
in health experienced by more and less affluent Scots have
been widening. Why is this?
Life expectancy
On average, people in Scotland are living longer than
ever before
(Figure 1.2). With the exceptions of the
First and Second World Wars, average life expectancy for
Scottish males has increased steadily from around 50 years
in 1910 to 73.4 years in 2001 (4). Female life expectancy
has increased even more and now stands at 78.7 years.
Infant mortality rates have declined in Scotland to an
extraordinary degree, with only about six children in every
1,000 failing to reach their first birthday, compared with
130 a century ago and 20 children only 30 years ago.
Figure 1.2: Long-term improvement in life
expectancy.
The main reason for the increases in life expectancy in
Scotland over the last 30 years or so is that diseases of
the heart and circulatory system and certain types of
cancer are being prevented or delayed. Death rates have
been falling steadily for both men and women for stroke for
50 years and for Coronary Heart Disease for about 30 years
(5). Death rates from lung cancer among men (but not yet
women) have been falling for over 20 years. Much of this
can be explained by the decline in smoking rates over the
past 30 to 40 years (6) but other factors, including better
maternal nutrition during pregnancy (7), better medical
care and improved socio-economic conditions, have also
contributed.
These advances give no grounds for complacency.
Improvements have been slower than in many other comparable
countries. In the first half of the twentieth century,
Scotland ranked around seventh to ninth best among 16
Western European countries but by the mid-1990s its
position had fallen to fifteenth, only slightly ahead of
Portugal
(Figure 1.3) (8). In particular, Scotland
continues to have the highest death rates from heart
disease and lung cancer and the second highest death rates
for stroke in Western Europe.
Figure 1.3: 20th century trends in male life
expectancy in Scotland and 15 other Western European
countries.
Effects of deprivation
Scotland's overall health profile has continued to lag
behind England's. In 1991 the standardised mortality rates
were 12% higher than in England. Until recently, this
seemed to be related almost entirely to the relatively
lower levels of affluence in Scotland. Carstairs and Morris
(9) found that differences in levels of deprivation could
explain all but 3% of the higher mortality rates in
Scotland in 1981. However, Hanlon and his colleagues have
shown that, by 1991, deprivation appears to explain only
40% of the excess deaths in Scotland (10).
Gillis and his colleagues have found that, at comparable
daily smoking rates and levels of affluence, men in the
West of Scotland are more likely to die from lung cancer
than other populations in the UK or the US (11)
(Figure 1.4).
Health inequalities within Scotland
Health inequalities within Scotland appear to be
widening. In the 10 years to 2001, average male life
expectancy in Scotland increased by 3% but the rate of
increase was more rapid in the most affluent parts of the
country, with the least affluent areas falling behind. The
gap in male life expectancy between highest and lowest of
the 74 parliamentary constituencies in Scotland increased
from 7.8 years in 1991 to 13.7 years in 2001 (12). The
recent decline in death rates from common conditions such
as cardiovascular disease has also been more rapid among
the more affluent (13). Thus, despite the overall
improvements, the less favoured sections of the Scottish
population are falling behind.
Figure 1.4: Comparison of lung cancer mortality
in Renfrew and Paisley with three major cohorts in US
and UK.
Factors which have been advanced to explain the
differences between Scotland and England and within
Scotland include emigration, lifestyle and life
circumstances. For over 250 years, large numbers of Scots
have left the country for England or abroad in search of a
better life. It is estimated that between the 1920s and the
1950s over 1.5 million Scots emigrated and it is only
relatively recently that the outward flow has slowed (14).
It is possible that those who left were, on average, more
healthy and energetic than those who stayed and that this
could be expected to show through in higher mortality rates
among those who remained in Scotland. Unfortunately, no
reliable data are available to illuminate this issue, as
the health of migrants is substantially affected by their
circumstances and lifestyle wherever they settle.
At least part of the cause of the widening differences
within Scotland is that a higher proportion of more
affluent people have chosen or have been able to adopt
healthier lifestyles than the less affluent. Most
importantly, smoking rates have declined much more rapidly
in the more affluent sections of the population. In the
early 1970s, 43% of women in Scotland smoked and there were
relatively narrow social class differences. By 1998, this
had fallen to 28% but only about 10% of professional women
were smokers, compared with over 50% of unemployed or
unskilled women (15).
Differences in diet may also be important. For instance,
a much higher proportion of both adults and children in
social classes I and 2 eat healthy foods regularly compared
with those in classes 4 and 5 (16). Relatively few major
differences are evident, however, between the diets of the
Scots and the English.
The Scottish Mental Survey of 1932
Affluence may itself be a consequence of other factors
which also influence health. In 1932, almost all Scottish
children born in 1921 underwent a well-validated mental
ability test, the Scottish Mental Survey. Recent studies
have linked the results of these tests with the subsequent
social class and health of almost 1,000 people living in
west and central Scotland (17,18). These showed very strong
correlations between lower childhood Intelligence Quotient
(IQ) and both subsequent social class and a higher risk of
dying over a 25 year period and, in particular, of
cardiovascular disease up to the age of 65, even when
social class was taken into account.
The authors suggest that higher childhood IQ might be
related to better general health, the subsequent
development of healthier behaviours and the potential to
obtain safer and better-paid jobs. Consequently, these
people could afford better housing and to live in healthier
environments. A growing list of factors related to
socio-economic disadvantage and low social class are now
known to affect the development of a child's mental ability
and physical and mental health. These include maternal
smoking, drinking, illicit drug use and poor nutrition
during pregnancy, insufficient breast-feeding and lack of
intellectual stimulation during the early years (19, 20,
21, 22, 23). Differences in trends of these behaviours
among the social classes may at least partly explain the
widening gap between the most and least affluent.
Environment and life circumstances
Recent research suggests other important ways in which
the environment and life circumstances can affect
biological processes which in turn can make individuals
more susceptible to ill health. By following the progress
of male civil servants over a 10 year period, Marmot and
his colleagues found that mortality was approximately three
times greater among the lowest grades than the highest
(24). When deaths from heart disease were considered, the
recognised risk factors of smoking, high blood pressure and
elevated cholesterol levels could only account for a small
part of the differences between the groups. Other studies
have confirmed that higher levels of risk of death in a
working population are only partially explained by
health-related behaviours (25). There is mounting evidence
that at least part of the unexplained increase in risk
across the social classes is related to how the body
responds to social stress.
A number of studies of non-human primates have suggested
that social stresses can accelerate the progression of
Coronary Heart Disease in animals fed high-fat diets. In
humans, Everson (26) and colleagues have shown that men who
have high levels of negativity about the future deposit fat
more rapidly in their arteries. The resulting hormonal
responses to such a sense of hopelessness might mobilise
the fat that was deposited in arteries. Jousilahti (27) and
his colleagues in Finland have found a strong correlation
between increased levels of chronic inflammatory proteins
in the blood and low income and educational status. Similar
observations have been made by other groups who have
suggested that chronic activation of the body's defence
mechanisms may be the link between low socio-economic
status and increased risk of ill health (28).
How a stressful external environment might cause changes
in body chemistry is not yet entirely clear. However, there
is evidence that chronic social stress produces changes in
function in areas of the brain associated with the control
of the body's defence responses (29). Low IQ and
educational attainment, socio-economic disadvantage, a low
sense of control over one's life and other stresses may
thus produce neural responses which, over a prolonged
period, activate defence mechanisms which in turn damage
arteries and lead to an increased risk of diabetes.
Psychological stress might also increase the risk of
cancer by a direct effect on the DNA within cells. Epel
(30) and her colleagues have shown that women stressed by
having to care for a chronically ill child have changes in
their chromosomes which are associated with premature
ageing and may increase the risk of malignancy. They found
that the women with the highest perceived levels of stress
were biologically about 10 years older than their
chronological age. There is also evidence that people who
have little control over their lives may be more
neurologically vulnerable to become addicted to drugs such
as nicotine, alcohol and heroin, with consequently damaging
effects on their health and, potentially, their offspring,
transmitting disadvantage from one generation to the next
(31).
Whether Scots are more subject to these types of stress
than their counterparts in England or other parts of
Western Europe remains an unanswered question. However,
these ideas suggest new ways of investigating the causes of
health inequalities. As well as attempting to improve the
economic conditions of the most deprived sectors of the
community in Scotland, it is clear that the necessary
social, cultural and psychological resources must be made
available to meet the challenges of modern life.
Concentrating on making structural improvements through
regeneration projects which do not increase the resilience
and sense of control of people living in those areas may
lead to disappointing results. Effective action to reduce
health inequalities must include efforts to prevent young
children from being damaged physically and mentally during
pregnancy and the early years and to maximise the
opportunities for all to achieve their full educational and
employment potential in a safe and supportive
environment.
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