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Oxfam Discussion Papers

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

Gerry McCartney and Chik Collins

June 2011

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

2 Health inequalities in Scotland: looking beyond the blame game

A Whose Economy Seminar Paper, June 2011
Executive summary ................................................................................. 4

Introduction: looking beyond the blame game.................................... 5

Health inequalities: separating myths from reality ............................... 6

Health inequalities arent inevitable ..................................................... 10

Inequalities: why we do care and why we should care ....................... 11

Conclusion.............................................................................................. 12

References .............................................................................................. 13

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A Whose Economy Seminar Paper, June 2011
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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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.

Gerrys 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, doesnt 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. Its their own fault, isnt 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.

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A Whose Economy Seminar Paper, June 2011
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,

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.

6 Health inequalities in Scotland: looking beyond the blame game

A Whose Economy Seminar Paper, June 2011
Males - 75.8y
Females - 83.1y
Hillhead St Georges
Jordanhill Street

Partick Charing
Exhibition Cross QUEEN
Anderston Argyll St.
St Enoch Bridgeton
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

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

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A Whose Economy Seminar Paper, June 2011
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 Scotlands 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
nations 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)

compared with a selection of other nations (adapted from McCartney, Walsh,
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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A Whose Economy Seminar Paper, June 2011
Life expectancy at birth (years)




1971 1976 1981 1986 1991 1996 2001 2006


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A Whose Economy Seminar Paper, June 2011
Health inequalities arent 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 nations 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

10 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



































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 dont 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 11

A Whose Economy Seminar Paper, June 2011
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.

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 everyones interests. Health is not a commodity that is to be
gained at someone elses expense. Health is a public good: people can enjoy good
health without detracting from anyone elses 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.

12 Health inequalities in Scotland: looking beyond the blame game

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Oxfam GB June 2011
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