current challenges to public health in scotland dr gerry mccartney head of public health observatory...
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Current challenges to public health in Scotland
Dr Gerry McCartney
Head of Public Health Observatory Division
NHS Health Scotland
Is Scotland the ‘sick man’ of Europe?
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Historical international trends in life expectancy
Data extracted from the Human Mortality Database for all available nations: Australia, Austria, Belgium, Belarus, Bulgaria, Canada, Chile, Czech Republic, Denmark, East Germany, England & Wales, Estonia, Finland, France, Germany, Hungary, Ireland, Iceland, Israel, Italy, Japan, Latvia, Lithuania, Luxembourg, Netherlands, New Zealand, Northern Ireland, Norway, Poland, Portugal, Russia, Scotland, Slovakia, Slovenia, Spain, Sweden, Switzerland, Taiwan, West Germany, Ukraine & USA.
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Historical international trends in life expectancy
Data extracted from the Human Mortality Database for all available nations: Australia, Austria, Belgium, Belarus, Bulgaria, Canada, Chile, Czech Republic, Denmark, East Germany, England & Wales, Estonia, Finland, France, Germany, Hungary, Ireland, Iceland, Israel, Italy, Japan, Latvia, Lithuania, Luxembourg, Netherlands, New Zealand, Northern Ireland, Norway, Poland, Portugal, Russia, Scotland, Slovakia, Slovenia, Spain, Sweden, Switzerland, Taiwan, West Germany, Ukraine & USA.
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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, Spain, Sweden, Switzerland, Taiwan & West Germany.
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Scotland
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 & West Germany.
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1971 1976 1981 1986 1991 1996 2001 2006
Year
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exp
ecta
ncy
at b
irth
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rs)
Higher overall mortality than comparable nations
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, West Germany & USA.
USAScotland
USASloveniaScotlandCzech R.PolandSlovakiaHungaryEstoniaBulgariaLithuaniaLatviaBelarusUkraineRussia
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1971 1976 1981 1986 1991 1996 2001 2006
Year
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exp
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at b
irth
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Higher overall mortality than comparable nations
Data extracted from the Human Mortality Database for: Australia, Austria, Belgium, Belarus, Bulgaria, Canada, Chile, Czech Republic, Denmark, East Germany, England & Wales, Estonia, Finland, France, Germany, Hungary, Ireland, Iceland, Israel, Italy, Japan, Latvia, Lithuania, Luxembourg, Netherlands, New Zealand, Northern Ireland, Norway, Poland, Portugal, Russia, Scotland, Slovakia, Slovenia, Spain, Sweden, Switzerland, Taiwan, West Germany, Ukraine & USA.
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PortugalN. IrelandScotland
Higher overall mortality than comparable nations
Data extracted from the Human Mortality Database for: Australia, Austria, Belgium, Belarus, Bulgaria, Canada, Chile, Czech Republic, Denmark, East Germany, England & Wales, Estonia, Finland, France, Germany, Hungary, Ireland, Iceland, Israel, Italy, Japan, Latvia, Lithuania, Luxembourg, Netherlands, New Zealand, Northern Ireland, Norway, Poland, Portugal, Russia, Scotland, Slovakia, Slovenia, Spain, Sweden, Switzerland, Taiwan, West Germany, Ukraine & USA.
Alastair H Leyland, Ruth Dundas,Philip McLoone & F Andrew Boddy. Inequalities in mortality in Scotland 1981-2001. Glasgow, MRC SPHSU, 2007.
Glasgow City
Inverclyde
West Dunbartonshire
Dundee City
RenfrewshireEilean Siar
North Ayrshire North Lanarkshire
All cause death rates, men 0-64y, 2001
What is getting better about health and the things that influence health?
• Life expectancy & mortality– Infectious diseases– Heart disease– Cancers– Stroke disease
• Medical treatment and innovation• Absolute poverty
Source: Scottish CMO report 2009
Source: Scottish CMO report 2009
What is getting worse about health and the things that influence health?
• Inequalities in health and the determinants of health (national and international)• Obesity• Alcohol related harm• Mental health• Threats of climate change, resource scarcity • ‘Scottish Effect’
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General acute inpatient discharges with an alcohol-related diagnosis in any position, by gender, Scotland, 1982/3 - 2009/10
Hanlon P, Walsh D, Whyte B. Let Glasgow Flourish. Glasgow, Glasgow Centre for Population Health, 2006.
BMI distribution of GG&C adults (1995)
Source: adapted from the Scottish Health Survey
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<18 19 21 23 25 27 29 31 33 35 37 >39BMI
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Source: adapted from the Scottish Health Survey
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BMI distribution of GG&C adults (1995-8)
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Source: adapted from the Scottish Health Survey
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BMI distribution of GG&C adults (1995-2003)
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Source: adapted from the Scottish Health Survey
BMI distribution of GG&C adults (1995-2008)
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Source: Chasing progress. Beyond measuring economic growth. London, New Economics Foundation, 2004.
MDP = Measure of Domestic Progress
SWB = Subjective Well-Being
• Creation of a ‘hedonic treadmill’ • Choice anxiety• Loss of deeper meaning and purpose to life • Loss of hope with satiation • Uncertainty and insecurity • Homogenisation of culture • Deterioration in interpersonal relations • Stresses caused by the ‘pace of life’ • Personal identity defined by own consumption
Why is well-being not improving?
Health inequalities
All-cause deaths by deprivation decile: directly age/sex standardised rates per 100,000 population, Scotland, 2007
Source: ScotPHO 2009
Male age specific mortality rates by occupational social class. Scotland 1990- 92
Alastair H Leyland, Ruth Dundas,Philip McLoone & F Andrew Boddy. Inequalities in mortality in Scotland 1981-2001. Glasgow, MRC SPHSU, 2007.
Alastair H Leyland, Ruth Dundas,Philip McLoone & F Andrew Boddy. Inequalities in mortality in Scotland 1981-2001. Glasgow, MRC SPHSU, 2007.
Age specific contribution to inequalities of specific causes of death across SIMD income quintiles. Men, Scotland 2000-02.
Alastair H Leyland, Ruth Dundas,Philip McLoone & F Andrew Boddy. Inequalities in mortality in Scotland 1981-2001. Glasgow, MRC SPHSU, 2007.
Age specific contribution to inequalities of specific causes of death across SIMD income quintiles. Women, Scotland 2000-02.
Alastair H Leyland, Ruth Dundas,Philip McLoone & F Andrew Boddy. Inequalities in mortality in Scotland 1981-2001. Glasgow, MRC SPHSU, 2007.
Percentage change in age- and cause-specific mortality rates among menbetween 1991 and 2001.
Alastair H Leyland, Ruth Dundas,Philip McLoone & F Andrew Boddy. Inequalities in mortality in Scotland 1981-2001. Glasgow, MRC SPHSU, 2007.
Percentage change in age- and cause-specific mortality rates among men between 1991 and 2001.
Alastair H Leyland, Ruth Dundas,Philip McLoone & F Andrew Boddy. Inequalities in mortality in Scotland 1981-2001. Glasgow, MRC SPHSU, 2007.
Percentage change in age- and cause-specific mortality rates among women between 1991 and 2001.
Alastair H Leyland, Ruth Dundas,Philip McLoone & F Andrew Boddy. Inequalities in mortality in Scotland 1981-2001. Glasgow, MRC SPHSU, 2007.
Percentage change in age- and cause-specific mortality rates amongwomen between 1991 and 2001.
Alastair H Leyland, Ruth Dundas,Philip McLoone & F Andrew Boddy. Inequalities in mortality in Scotland 1981-2001. Glasgow, MRC SPHSU, 2007.
Jordanhill
Charing Cross
HyndlandPartick
Anderston
Exhibition Centre
CENTRAL
Argyll St.
Bridgeton
QUEEN STREET
Govan
Hillhead St George’s Cross
Buchanan Street
Life expectancy data refers to 2001-5 and was extracted from the GCPH community health and well-being profiles. Adapted from the SPT travel map by Gerry McCartney.
Males - 75.8yFemales - 83.1y
St Enoch
Males - 61.9yFemales - 74.6y
Ibrox
Cessnock
Each stop on the Argyll line travelling East represents a drop of 1.7 years in male life expectancy
• Black’s 4 hypotheses:– Artefact– Selection– Behavioural or cultural– StructuralRising inequalities in income
• Increasing power differences between groups – income, location, wealth, status etc.
Why are health inequalities getting worse?
Emergence of the ‘Scottish Effect’
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1981 1991 2001Year
Dir
ectl
y st
anda
rdis
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lity
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= 1
00)
Scotland SMR (age & sex)Scotland SMR (age, sex & Carstairs)
62% explained by deprivation
47% explained by deprivation43% explained by
deprivation
Source: Hanlon P, Lawder RS, Buchanan D, et al. Why is mortality higher in Scotland than in England and Wales? Decreasing influence of socioeconomic deprivation between 1981 and 2001 supports the existence of a 'Scottish Effect'. Journal of Public Health. 2005; 27:199-204.
Substance misuse
Rise in inequality and poverty
Instability of industrial employment
Increased stress
Gender disharmony
Possible mechanisms and key factors Outcomes
Poverty and inequality
Migration patterns
Industrial dependence
Sectarian divide
Cardiovascular disease
Respiratory disease
Stroke
Cancer
Insecurity of employment
Overcrowded city centre housing
Development of new peripheral housing
estates
Scottish culture
Synthesis for the divergence of Scottish mortality from mid-20th Century
Substance misuse
Rise in inequality and poverty
Instability of industrial employment
Increased stress
Gender disharmony
Possible mechanisms and key factors Outcomes
Poverty and inequality
Migration patterns
Industrial dependence
Sectarian divide
Cardiovascular disease
Respiratory disease
Stroke
Cancer
Insecurity of employment
Overcrowded city centre housing
Development of new peripheral housing
estates
Scottish culture
Synthesis for the divergence of Scottish mortality from mid-20th Century
Reduced community cohesion
Breakdown in confidence of working class communities
Decreased well-being
Substance misuse
Suicide
Vulnerability
Rise in inequality and
poverty
Increased violence
Disempowerment and hopelessness
1976 financial crisis and subsequent
'political attack' by Thatcher government on numerous elements
of the organised working class
Increased stress
Individuation and competition
Reduced self-esteem & self-efficacy
Trigger Mechanisms Outcomes
Scottish culture
Greater poverty and inequality
Industrial dependence
Sectarian divide
Scottish climate
Genetic factors
Road-traffic accidents
Alcohol-related
Drugs-related
Cardiovascular disease
Respiratory disease
Stroke
Cancer
Family breakdown
Deindustrialisation
Synthesis for the emergence of the ‘Scottish Effect’ and ‘Glasgow Effect’
Reduced community cohesion
Breakdown in confidence of working class communities
Decreased well-being
Substance misuse
Suicide
Vulnerability
Rise in inequality and
poverty
Increased violence
Disempowerment and hopelessness
1976 financial crisis and subsequent
'political attack' by Thatcher government on numerous elements
of the organised working class
Increased stress
Individuation and competition
Reduced self-esteem & self-efficacy
Trigger Mechanisms Outcomes
Scottish culture
Greater poverty and inequality
Industrial dependence
Sectarian divide
Scottish climate
Genetic factors
Road-traffic accidents
Alcohol-related
Drugs-related
Cardiovascular disease
Respiratory disease
Stroke
Cancer
Family breakdown
Deindustrialisation
Synthesis for the emergence of the ‘Scottish Effect’ and ‘Glasgow Effect’
Reduced community cohesion
Breakdown in confidence of working class communities
Decreased well-being
Substance misuse
Suicide
Vulnerability
Rise in inequality and
poverty
Increased violence
Disempowerment and hopelessness
1976 financial crisis and subsequent
'political attack' by Thatcher government on numerous elements
of the organised working class
Increased stress
Individuation and competition
Reduced self-esteem & self-efficacy
Trigger Mechanisms Outcomes
Scottish culture
Greater poverty and inequality
Industrial dependence
Sectarian divide
Scottish climate
Genetic factors
Road-traffic accidents
Alcohol-related
Drugs-related
Cardiovascular disease
Respiratory disease
Stroke
Cancer
Family breakdown
Deindustrialisation
Synthesis for the emergence of the ‘Scottish Effect’ and ‘Glasgow Effect’
Political attack by the Thatcher
government post 1979
Reduced community cohesion
Breakdown in confidence of working class communities
Decreased well-being
Substance misuse
Suicide
Vulnerability
Rise in inequality and
poverty
Increased violence
Disempowerment and hopelessness
1976 financial crisis and subsequent
'political attack' by Thatcher government on numerous elements
of the organised working class
Increased stress
Individuation and competition
Reduced self-esteem & self-efficacy
Trigger Mechanisms Outcomes
Scottish culture
Greater poverty and inequality
Industrial dependence
Sectarian divide
Scottish climate
Genetic factors
Road-traffic accidents
Alcohol-related
Drugs-related
Cardiovascular disease
Respiratory disease
Stroke
Cancer
Family breakdown
Deindustrialisation
Synthesis for the emergence of the ‘Scottish Effect’ and ‘Glasgow Effect’
Political attack by the Thatcher
government post 1979
Source: McCartney G, Collins C, Walsh D, Batty GD. Explaining Scotland’s higher mortality: towards a synthesis. Glasgow, Glasgow Centre for Population Health, 2011 (forthcoming).
What explains the Scottish Effect?
• 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
Future challenges for Scotland’s health
Alastair H Leyland, Ruth Dundas,Philip McLoone & F Andrew Boddy. Inequalities in mortality in Scotland 1981-2001. Glasgow, MRC SPHSU, 2007.
Demographic change
Climate change
Source: Bodagaj, IPCC, 2008
Climate change impacts often missed
• Failure of food supply and accompanying mass migration
• Economic disruption• Health impacts more likely to be mediated through
economic and social determinants of health than direct climate impacts
Resource scarcity: oil
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Year
Liq
uid
oil
pro
du
ctio
n G
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US
$ eq
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S
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qu
isit
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co
st o
f im
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rted
cr
ud
e o
il]
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2007 Peak oil?
1979 Iranian revolution
Source: James L. Williams, WTRG Economics, Houston, Texas.
Economic impact of peak oil
• Liquidation of sectors of the economy, increased costs for others
• Increased costs for trade in manufactured goods• Global trade in financial services for manufactured
goods interrupted• Food prices
Overall sustainability
Planetary ecological footprint trends
The ecological footprint is all the cropland, grazing land, forest and fishing grounds required to produce the food, fibre and timber consumed and to absorb the wastes emitted in generating the energy used and need to provide space for infrastructure. Living planet report 2006. Gland, WWF, 2006 [downloaded from http://www.panda.org/news_facts/publications/living_planet_report/index.cfm on 18th April 2008].
Financial problems
Source: Hellowell M , Pollock AM. The impact of PFI on Scotland’s NHS: a briefing. Edinburgh, Centre for International Public Health Policy, 2006.
Summary
• Many aspects of health in Scotland are getting better• Some aspects are not improving, or are getting
worse• Some important challenges have to be overcome if
health improvement is to be continued into the future