Harry Burns, the chief medical officer of Scotland and one of medicine’s philosophers, has spent a lot of time trying to understand why Scotland has such poor health and what might be done. He shared his thinking at a meeting in Edinburgh Royal Infirmary last week.
Scotland has not always had poor health. For most of the past 150 years Scots had a life expectancy around the average for Europe. It’s only in the past 40 years that Scots have fallen behind, and the poor health is concentrated in Glasgow. The rest of Scotland has a life expectancy similar to the rest of Europe.
Many people, including many prominent Glaswegians, assume that the cause is the hard drinking, heavy smoking, deep fried Mars Bar eating lifestyle of Glaswegians. But it’s not so simple. Scots don’t smoke more than other Europeans, and nor does it seem to be diet: deaths from heart disease fell as fast as in Scotland as in North Karelia without the Scots changing their diet as the Finns had done.
Nor does it seem to be income inequality—because Manchester and Liverpool have similar income inequality to Glasgow, but lower death rates. An analysis of the causes of the excess deaths in Glasgow compared with Manchester and Liverpool shows that 60% are caused by drugs, alcohol, suicide, and violence. Scotland’s excess deaths have psychosocial causes.
What changed 40 years ago? Burns projected a picture from perhaps 60 years ago of workers streaming out of the shipyards. In the 19th century and for much of the 20th Glasgow built many of the world’s ships. Helensburgh in the Firth of Clyde, where my wife comes from, boasts that in the heyday of shipbuilding on the Clyde it had more millionaires per square mile than Manhattan. More importantly the shipyards provided tens of thousands of skilled, well paid jobs with purpose. Glaswegians were proud that they built the world’s ships.
But then the shipyards closed. The most skilled moved to other cities that built ships. (My father in law spent five years in Japan.) Others developed new skills. But many were left unemployed in housing estates in the East End of Glasgow. Meaning had been taken from their lives. Their culture had been destroyed. People turned to drugs, drink, and violence.
An Australian visiting Glasgow observed that the Glaswegians were suffering the same fate as Australian Aboriginals.
Burns has tried to go further in understanding exactly how these changes in Glasgow have led to such poor health, and he has found most help from people writing in the 60s and 70s, particularly Aaron Antonovsky, a sociologist. Antonovsky studied people who as children had been in concentration camps. As adults 70% had terrible health, but why didn’t the other 30%? He decided that these 30% had achieved a sense of coherence. For them life was predictable and explainable. People, said Antonovsky, need to find life comprehensible, manageable, and meaningful, particularly in the early days of their lives. Antonovsky has put many ideas together to explain how a capacity for health can be built, and Burns, a molecular biologist in an earlier part if his career, said that we now understand a lot about how those early experiences are incorporated into the body’s biology.
Imagine a crying baby experiencing early in life the discomfort of hunger, said Burns. The mother picks up the baby, hugs, and feeds him. This happens a thousand times. Life for that baby makes sense. In contrast, a baby cries in the East End of Glasgow. The mother has taken heroin and is unconscious. Her partner doesn’t know what to do. The baby continues to cry, life is not coherent.
But can we increase the sense of coherence in those who have little? Public services are not good at this, argued Burns. Health services deal with problems. You must enter with a problem and then are exposed to a confusing, disempowering array of interventions. Things are done to you. We must, concluded Burns, find better ways to unlock the assets of people and communities and cocreate health.
Competing interest: RS also spoke at the meeting, had his expenses paid, and enjoyed a delicious dinner at the home of Professor Scott Murray, who was one of the organisers of the meeting.
Richard Smith was the editor of the BMJ until 2004 and is director of the United Health Group’s chronic disease initiative.