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Social Justice? Health inequalities after the referendum Gerry McCartney Consultant in Public Health & Head of Public Health Observatory NHS Health Scotland.

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Presentation on theme: "Social Justice? Health inequalities after the referendum Gerry McCartney Consultant in Public Health & Head of Public Health Observatory NHS Health Scotland."— Presentation transcript:

1 Social Justice? Health inequalities after the referendum Gerry McCartney Consultant in Public Health & Head of Public Health Observatory NHS Health Scotland Gerry McCartney Honorary Professor University of the West of Scotland (Thank you)

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4 For UWS to have a transformational influence on the economic, social and cultural development of the West of Scotland and beyond, by producing relevant, high quality, inclusive higher education and innovative and useful research. NHS Health Scotland is a national Health Board working with public, private and third sectors to reduce health inequalities and improve health.

5 Of all inequalities, injustice in health is the most shocking and inhumane Martin Luther King

6 Inequality in female life expectancy by local authority, (source: NRS)

7 Public health challenges in Scotland

8 1. Life expectancy improving more slowly than comparable nations Source: McCartney G, Walsh D, Whyte B, Collins C. Has Scotland always been the ‘sick man’ of Europe? European Journal of Public Health 2012; 22(6): 756–760. 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.

9 2. Little/no improvement in mortality for young adults Source: Still the ‘sick man of Europe’? Scottish mortality in a European context An analysis of comparative mortality trends. Glasgow, Glasgow Centre for Population Health, 2012.

10 Source: National Records Scotland, MESAS team Trends in alcohol-related mortality in Scotland

11 Trends in Suicide mortality (15-44y) in Scotland Source: Mok PLH, Kapur N, Windfuhr K, et al. Trends in national suicide rates for Scotland and for England & Wales, British Journal of Psychiatry 2012; 245:

12 3. Greater health inequalities than western Europe

13 Trends in absolute mortality inequality in Scotland ( using Carstairs index (all ages); 1996 onwards using SIMD (<75yand 15-44y); men and women combined)

14 Trends in relative mortality inequality in Scotland ( using Carstairs index (all ages); 1996 onwards using SIMD (<75yand 15-44y); men and women combined)

15 3. Greater health inequalities than western Europe Education based Relative Index of Inequality (RII) for all-cause mortality, males years, early to mid 2000s Source: Eikemo T.A. & Mackenbach J.P. (Eds). EURO GBD SE: the potential for reduction of health inequalities in Europe. Final Report. University Medical Center Rotterdam, 2012

16 Education based Relative Index of Inequality (RII) for all-cause mortality, females years, early to mid 2000s Source: Eikemo T.A. & Mackenbach J.P. (Eds). EURO GBD SE: the potential for reduction of health inequalities in Europe. Final Report. University Medical Center Rotterdam, 2012

17 Source: Taulbut M, Walsh D, McCartney G, et al. Spatial inequalities in life expectancy within postindustrial regions of Europe: a cross-sectional observational study. BMJ Open 2014; 4: e Box plots of spatial variation in female life expectancy (showing maximum, minimum, upper and lower quartile data within each region)

18 Source: Taulbut M, Walsh D, McCartney G, et al. Spatial inequalities in life expectancy within postindustrial regions of Europe: a cross-sectional observational study. BMJ Open 2014; 4: e Box plots of spatial variation in male life expectancy (showing maximum, minimum, upper and lower quartile data within each region)

19 ‘Excess’ mortality (i.e. after accounting for deprivation)

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21 Summary: the mortality phenomena 1.Scottish mortality is around European median until 1950 then diverges 2.Scottish excess mortality as compared to England & Wales is less and less able to be explained by deprivation ( ) – “Scottish Effect” 3.Health inequalities have grown and are wider than the rest of west and central Europe 4.No improvement in premature mortality for 30 years associated with increased alcohol & drug related deaths and suicide These represent thousands of unnecessary and unjust premature deaths and human misery. We have a moral duty to respond.

22 What causes health inequalities? Dominant theory about what causes health inequalities influences: –How important we believe it is –How preventable we think it is –Who is held responsible –What action, if any, is taken Possible explanations 1.Artefact (i.e. we aren’t measuring it well enough) 2.Selection theories (i.e. poor health causes social slide) 3.Behaviours and culture (i.e. poor people behave badly) 4.Structural & political economy (i.e. politics and policy are the cause)

23 Artefact Undermined by inequalities demonstrated using different statistical measures of social status …and in different places and different times Very difficult to sustain a theory that such outcomes are unrelated to social status

24 Selection The zombie hypothesis Selection – reverse causation argument (i.e. poor health causes social slide) Longitudinal studies which measure pre-morbid health and social status show little social slide Smith G. D., C. Hart, D. G. Watt, D. Hole, V. Hawthorne Individual social class, area-based deprivation, cardiovascular disease risk factors, and mortality: the Renfrew and Paisley study. J Epidemiol Community Health 52: Power C., S. Matthews Origins of health inequalities in a national population sample. Lancet 350(9091):

25 Behavioural and cultural Important, but partial, theory Advocates suggest that the prevalence of behaviours (e.g. smoking, alcohol & diet) cultures or skills (e.g. parenting) are the root causes of health inequalities

26 Unhealthy behaviours are more prevalent in lower socio-economic groups However: –Equal exposure does NOT result in equal outcomes –Ignores how and why individuals adopt unhealthy behaviours 1 2 –Health behaviours are explained by socio-economic exposures throughout life –Link between behaviours and social status can diminish without changing inequality 3 1 Nettle D. Social class through the evolutionary lens. The Psychologist 2009; 22(11): Lynch JW, Kaplan GA, Salonen JT. Why do poor people behave poorly? Variation in adult health behaviours and psychosocial characteristics by stages of the socioeconomic lifecourse. Social Science and Medicine 1997; 44(6): Stringhini S, Dugravot A, Shipley M, Goldberg M, Zins M, Kivima M, Marmot M, Sabia S, Singh-Manoux A. Health Behaviours, Socioeconomic Status, and Mortality: Further Analyses of the British Whitehall II and the French GAZEL Prospective Cohorts. PLoS Med 2011; 8(2): e doi: /journal.pmed Link BG, Phelan J. McKeown and the idea that social conditions are fundamental causes of disease. American Journal of Public Health 2002; 92(5): Mackenbach JP. What would happen to health inequalities if smoking were eliminated? BMJ 2011; 342: d3460.

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29 Unhealthy behaviours are more prevalent in lower socio-economic groups However: –Equal exposure does NOT result in equal outcomes –Ignores how and why individuals adopt unhealthy behaviours 1 2 –Health behaviours are explained by socio-economic exposures throughout life –Link between behaviours and social status can diminish without changing inequality 3 –Changes over time in the cause of death Nettle D. Social class through the evolutionary lens. The Psychologist 2009; 22(11): Lynch JW, Kaplan GA, Salonen JT. Why do poor people behave poorly? Variation in adult health behaviours and psychosocial characteristics by stages of the socioeconomic lifecourse. Social Science and Medicine 1997; 44(6): Stringhini S, Dugravot A, Shipley M, Goldberg M, Zins M, Kivima M, Marmot M, Sabia S, Singh-Manoux A. Health Behaviours, Socioeconomic Status, and Mortality: Further Analyses of the British Whitehall II and the French GAZEL Prospective Cohorts. PLoS Med 2011; 8(2): e doi: /journal.pmed Link BG, Phelan J. McKeown and the idea that social conditions are fundamental causes of disease. American Journal of Public Health 2002; 92(5): Mackenbach JP. What would happen to health inequalities if smoking were eliminated? BMJ 2011; 342: d3460.

30 Schematic representation of the changing causes of health inequalities over time

31 Structural and political economy Its about income, wealth and power Other theories are subordinate/incorporated or irrelevant Supporting evidence: –Health inequality trends follow societal inequalities –Health improves when people are given more resources by chance 1 –The richest are always the healthiest, regardless of their behaviours 2 –Even when genetics are important (such as cystic fibrosis), inequalities are wide and vary depending on the context 3 1 Costello EJ, Compton SN, Keeler G, Angoid A. Relationships between poverty and psychopathology. JAMA 2003; 290: Commission on Social Determinants of Health 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. 3 Barr HL, Britton J, Smyth AR, Fogarty AW. Association between socioeconomic status, sex, and age at death from cystic fibrosis in England and Wales (1959 to 2008): cross sectional study. BMJ 2011; 343: d4662.

32 Inequality in mortality between richest and poorest 5ths of the US population (sources: Krieger 2008 and Luxembourg Income Study)

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34 Inequality in mortality between best and worst 10 % of local authorities in Great Britain (sources: Thomas 2010 and Luxembourg Income Study)

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36 Conclusions Health is worse and improving more slowly in Scotland compared to the rest of Europe Health inequalities are large and increasing Policies and politics are the causes of health inequalities: behaviour and culture are only partial explanations More equitable distribution of income, power and wealth is important Regulation, taxation and structural changes to the socio- economic environment are also likely to help Health inequalities are not inevitable and can be reduced The current politicisation of Scotland represents a huge opportunity for change

37 Thanks to: David Walsh, Lauren Schofield, Chik Collins, Mhairi MacKenzie, Clare Beeston, Wendy MacDonald, Tom Russ, David Batty, Katherine Trebeck, Phil Hanlon, and many many others… Thank you for listening/heckling* *delete as appropriate Contact me at

38 Least likely actions to reduce health inequalities Information based campaigns (mass media information campaigns) Written materials (pamphlets, food labelling) Campaigns reliant on people taking the initiative to opt in Campaigns/messages designed for the whole population Whole school health education approaches (e.g. school based anti-smoking and alcohol programmes) Approaches which involve significant price or other barriers Housing or regeneration programmes that raise housing costs

39 Most likely actions to reduce health inequalities (1) Policies which make income, power and wealth more equitable (e.g. tax and benefit systems, democratisation) Structural changes in the environment: (e.g. area wide traffic calming schemes, separation of pedestrians and vehicles, child resistant containers, installation of smoke alarms, installing affordable heating in damp cold houses) Legislative and regulatory controls (e.g. drink driving legislation, lower speed limits, seat belt legislation, smoking bans in workplaces, child restraint loan schemes and legislation, house building standards, vitamin and folate supplementation of foods) Fiscal policies (e.g. increase price of tobacco and alcohol products)

40 Most likely actions to reduce health inequalities (2) Reducing price barriers (e.g. free prescriptions, school meals, fruit and milk, smoking cessation therapies, eye tests) Improving accessibility of services (e.g. location and accessibility of primary health care and other core services, improving transport links, affordable healthy food) Prioritising disadvantaged groups (e.g. multiply deprived families and communities, the unemployed, fuel poor, rough sleepers and the homeless) Offering intensive support (e.g. systematic, tailored and intensive approaches involving face to face or group work, home visiting, good quality pre-school day care) Starting young (e.g. pre and post natal support and interventions, home visiting in infancy, pre-school day care)


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