No mean city

Glasgow's official motto is 'Let Glasgow Flourish.'

City leaders in Victorian times truncated the phrase from “Lord, let Glasgow Flourish by the preaching of the word”, possibly because the more secular version befitted the thrusting industrial metropolis which had labelled itself ‘second city of the empire’ in terms of economic might.

It’s hard to describe the city’s health now as ‘flourishing’, however. Modern Scotland still has the lowest life expectancy in Western Europe, which has seen it labelled ‘the Sick Man of Europe’. While Europe has seen mortality rates dropping with improvements in living standards and healthcare, there has been no reduction at all in mortality among working-age Scots since the mid to late 1980s.

And at the sharp end of the statistics is its largest city. Glasgow itself houses more than 10 per cent of the country’s population, with more than a million people in the Greater Glasgow area.

The city saw a shrinking population go hand in hand with a decline in industry from the 1930s. This led to high levels of income inequality, with concurrent levels of health inequity.

A report last month showed that health inequalities in Scotland are still widening today, and Public Health Minister Michael Matheson said reducing the health gap between rich and poor was “one of our greatest challenges”.

At a recent conference, Professor Carol Tannahill, director of the Glasgow Centre for Population Health (GCPH), said: “Over 40 years ago, we successfully put man on the moon, yet we’ve not managed to make any impact on this sort of picture in our communities.” Many others have talked about looking ‘upstream’ for answers, recognising the link between income and health inequalities.

Reasons for Glasgow’s poor health outcomes seem clear then. In a Scottish context, it has the most socioeconomic drivers for poor health.

However, work by the GCPH has unearthed an anomaly: the country’s higher levels of morbidity and mortality are over and above that explained by deprivation. In short, it isn’t just about poverty. There is another, mysterious factor at work.

The riddle has caught the imaginations of politicians and journalists in recent years. People have blamed inaccurate poverty figures, migration, culture, diet and the deep fried Mars bar. And even the weather.

This has made life difficult for Dr David Walsh, Public Health Programme Manager at the GCPH: “Because what we’re looking at is not clear, it’s allowed people to put forward their pet theories, which cover all sorts of different things and health behaviours. But they’ve been able to suggest these things without any kind of evidence to back them up. So that’s what has now taken up quite a bit of our time, investigating these things and collecting data to see whether there was any reliable evidence to back these things up. And generally speaking, there wasn’t,” he says.

The Glasgow Centre for Population Health was set up in 2004 to collate and combine public health information with policy and initiative ideas. It has done an impressive amount of research into population health and inequalities, and has monitored a range of health promotion programmes, management programmes and targeted regeneration programmes.

It is best known, however, for investigating Glasgow’s enduring poor health.

Research revealed that Liverpool and Manchester had similar levels of deprivation and post-industrial decline to Glasgow, so in 2007, the GCPH started work on comparing the cities, and has been publishing its findings since 2010.

Report after report has shown that the three cities are extremely close in terms of inequality, economic spread and shared history. They even all described themselves the same way.

“As Glasgow was referred to as ‘the second city of the empire’, interestingly, Liverpool also referred to itself as ‘the second city of the empire’. And Manchester referred to itself as ‘the second city of Britain’, which basically meant the second city of the empire. So they were all vying for the same title,” says Walsh, whose work also shows an identical decline in industry across all three cities:

“Basically what you get is at the start of the 20th century, international competition starts to kind of screw things up. Then the advent of the Second World War kind of masks it a bit; there’s a rebirth of industry temporarily in terms of producing armaments and ships, and all this kind of stuff, but once that’s past, it just continues downwards. In terms of the periods covered, it’s exactly the same pattern you see for all three cities,” says Walsh.

The gradient of population decline is similar. Figures for income deprivation, for the numbers of ‘breadline poor’, for child poverty and core poverty are interchangeable in all three cities.

The GCPH also broke the cities down into small neighbourhoods of around 15,000 people to look at how that measure of poverty is distributed across the city. Again, the data showed that the cities were very close. Levels of smoking, obesity and poor diet are comparable.

“Even if you adjust statistically for any remaining differences in deprivation, you have a situation where premature deaths in Glasgow are 30 per cent higher compared with even these cities with such similar histories,” says Walsh, “and for deaths at all ages, it’s about 15 per cent higher.”

Moreover, when looking at the causes of death, some patterns emerge. The figures for premature deaths in Glasgow show that death from lung cancer is 27 per cent higher than the English cities, external causes including violence 30 per cent higher, suicides 70 per cent higher, alcohol-related deaths 2.3 times higher and drug-related deaths 2.5 times higher.

“The relative differences are driven by what you might call the ‘diseases of despair’,” explains Walsh.

Explanations for the differences are still elusive, but the three-city study provides the model to continue to explore different potential reasons. No evidence has been found to support ideas that the ‘excess mortality’ is down to health behaviours, genetics, values, diet or sectarianism, as has been suggested by some.

Some things are harder to investigate, such as a ‘sense of coherence’, which is a measure that has never been recorded in either country. To investigate this and other cultural factors such as values and optimism, GCPH conducted a survey of people in the three cities recently. Glaswegians reported that they were more optimistic than Manchunians, and that they had higher self-esteem than both cities. They also reported their childhood had been as happy as Liverpudlians and Mancunians.

Collating self-reported outcomes can be difficult, says Walsh: “There are various studies where they show that, for example, Scottish people tend to overestimate their health, they tend to suggest it’s better than it is. And in contrast, for example, people in Wales tended to suggest their health was actually worse than it really was. So there’s sort of cultural differences in terms of how people report these things, and because of that when we’re looking at this idea of excess poor health, we focus on mortality not self-reported measures.”

What explanations are left to explore? Walsh is working on a new report with Gerry McCartney at Health Scotland which will be published next year.

Drug and alcohol misuse plays a big role. These are symptoms not the cause, argues Walsh:

“Alcohol-related deaths are twice as high in Glasgow as they are in Liverpool and Manchester, and people drinking at that level, it’s not just about slightly higher levels of consumption. That’s people drinking at the level that it kills you. That obviously begs the question why is that? That’s not the reason of what’s going on, that’s an outcome. There’s lots of research that show that drinking at that level and other kind of drugs use tend to be described as coping mechanisms, so people turn to them in adverse circumstances.

“If you think back to the 1970s when there was still quite a bit of industry, and there was this image of Scotland as being a kind of hard working, hard drinking nation, actually, alcohol-related deaths, or deaths from liver cirrhosis, were actually very low compared to the rest of Europe,” says Walsh. New research will look in more detail at the rise in both through the 1980s onwards.

Political leadership may also come into the equation. The reaction of local government to national policies, whether more people in Glasgow were displaced by the slum clearances in the 1950s than in the other cities, or whether there was a greater psychological effect of economic policies in the 1980s, for example.

In the meantime, action to tackle Glasgow’s poor health is ongoing. A Glasgow City Council spokesman said that it was taking a long-term view: “There is an unavoidable link between poverty and health and that is why the council has focused so much of its energies on jobs and the economy and improving the city’s housing stock,” he said.

GCPH’s GoWell project is monitoring the city’s regeneration. Professor Tannahill said: “We’re looking at parts of the city that have consistently had poorer outcomes over time, and we’re looking at the processes and impacts of a range of different regeneration interventions in those areas. We’re able to compare regeneration areas where a whole range of different interventions are happening at once in a more coordinated way, with areas that are having interventions and individual issues like housing improvement, and we’re seeing some early signs of power shifts.”