Behind the "Glasgow effect"
Michael Reid reports on how the Scottish city is tackling the stark inequities in its people's health.
Glasgow was once revered as a leading centre of heavy engineering, most notably shipbuilding on the River Clyde. But in 2008, Scotland's most populous city 1.2 million in the greater urban area gained a less flattering image.
As chair of a World Health Organization commission on the social factors that determine health, Michael Marmot and his colleagues took Glasgow as an example of stark health inequities, noting that a boy in the deprived area of Calton had an average life expectancy of 54 years compared with a boy from affluent Lenzie, 12 km away in East Dunbartonshire, who could expect to live to 82.
Two years later in September 2010, Glasgow's health was again in the spotlight in a study entitled "It's not 'just deprivation': why do equally deprived cities in the United Kingdom experience different health outcomes?" published in the journal Public Health. It found that Glaswegians from socially deprived communities like Calton had lower life expectancy and poorer health than people from similarly deprived parts of other cities in the United Kingdom, especially Manchester, Liverpool and Birmingham. Terming this discrepancy the "Glasgow effect", its authors called for further study to find the root causes.
Scotland's chief medical officer Harry Burns agrees that health inequities in Glasgow cannot only be attributed to severe social and economic deprivation. They are "a psycho-social problem that will not be fixed by targeting conventional risk behaviours" alone. The answers lie in repairing a fragmented society where many people feel they do not have control of their lives. "We must not concentrate on deficits but on assets, skills and capacities. We must build social capital so individuals can offer each other friendship and mutual support."
Burns is influenced by sociologist Aaron Antonovsky, who coined the term "salutogenesis" to describe an approach that focuses on the factors that promote health and well-being, rather than those that cause disease.
"The 'don't do that, do this' approach doesn't work," he says. "Smoking cessation programmes can only go so far. To crack difficult lives, we need to discover what is really wrong in those lives and seek to transform them. You can tell people to eat less saturated fat but if someone is merely tolerating life on a day-to-day basis, they are not going to be motivated."
The picture is not all gloomy though. Burns notes that, overall, health and life expectancy in Glasgow have improved over the past 30 years. A 2006 report, Let Glasgow Flourish, suggests that some health problems in Greater Glasgow are recent. One example is the fourfold increase in alcohol-related deaths that occurred between 1991 and 2002.
Like Hanlon, an author of the 2006 report, Burns believes that some communities where as many as four generations have been unemployed have never recovered from the dismantling of the city's industrial base in the 1970s.
"Many parts of Glasgow have suffered loss of jobs which have never been replaced and the social capital has been degraded," Burns says, adding that he aims to reduce the resulting health inequities. "The key to the next phase in improving health overall is to bring the rate of improvement in lower socioeconomic areas to match that in the most affluent parts of society."
The Scottish Government says it is taking action across all sectors to tackle social disadvantage with the launch of three main initiatives. One of them, called Achieving Our Potential, aims to tackle poverty and income inequality and has been followed up by a Child Poverty Strategy published in March 2011. Another initiative, known as Equally Well, aims to address health inequities; and the third, known as the Early Years Framework, aims to ensure that all children are given the best possible start in life.
In addition, public services reforms have been implemented to enable local agencies and front-line workers to focus on delivering public services, and the public, private and voluntary sectors to work together to improve the quality of life and opportunities for people across Scotland. The reforms are based on five strategic objectives: to make Scotland a wealthier and fairer, smarter, healthier, safer and stronger, and a greener place.
Burns is encouraged by the appreciation among decision-makers that health "cuts across all areas of government policy and planning". Hanlon concurs: "We don't have to pressure politicians and local councillors to make tackling inequality a priority. We already have that buy-in."
Burns highlights the work of the Gal-Gael Trust, a charity based in the city that teaches woodworking and is a focal point for other crafts and community activity.
Alistair McIntosh, a founding director of GalGael, believes "a loss of soul" is at the root of Glasgow's health problems. "When the bottom has fallen out of people's lives, they try to fill it with various forms of addiction. A project like this calls back the soul into a community. It brings back to even the most broken people their sense of self-worth."
GalGael offers trainees up to 90 a year since 1997 a 12-week joinery course leading to a recognized qualification and a set of tools. But as McIntosh says, the course teaches them more than how to build a bread box: it helps people reconnect with their cultural roots, express creativity they never knew they had and develop networks and life skills to counter addictions and other health problems.
Joe Jones, a recovering alcoholic, says GalGael keeps him sober. "When I come in here, I leave the outside world behind. It's completely different to rehab and going to [Alcoholics Anonymous] meetings. There's always someone to talk to, but they don't preach at you, they just listen." Louisa Currie had become housebound after a series of bereavements. Since coming to GalGael, she has reduced her medication for depression, built an archway for her garden and prepares meals on field trips. Omair Ulhaq, another trainee-turned-volunteer, is attracted by the "warm atmosphere", while Jenny McCarry says GalGael helped restore her confidence depleted by a long period of convalescence.
GalGael's trainees belong to the section of Glasgow's population that has fared poorly in the post-industrial era, according to Phil Hanlon, professor of public health at Glasgow University and one of the authors of the 2010 study. Some have found employment in the city's financial and services sectors and prospered, leaving behind a small group with severe social and health problems. This explains the stark health disparities.
Rosie Robertson is a project officer with the Equally Well initiative, which is part of a programme that aims to integrate health and well-being considerations into urban planning. The Equally Well team has also been assisting residents from some of Glasgow's rundown eastern suburbs, including Calton, to participate in the regeneration process ahead of the 2014 Commonwealth Games and other infrastructure projects. Robertson agrees that there is broad support for tackling Glasgow's health challenges, although mutual suspicion between community members, planners and general practitioners (wary of referring patients to programmes for fear it might further increase heavy workloads) could mean that many initiatives and resources are not full exploited.
Links between social disparity and ill health have been on the political agenda in Scotland since long before Marmot and the Commission on the Social Determinants of Health drew attention to Calton's plight in 2008. In 1972, trade union leader Jimmy Reid, in his rectorial address to Glasgow University students that was hailed by the New York Times as "the greatest speech since President Lincoln's Gettysburg address", spoke about the effect of alienation on human well-being, words that later informed the work of Burns, a student in the audience that day.
So, if the social dimension of illhealth has been acknowledged for decades, why do these inequalities persist? Carol Tannahill, director of the Glasgow Centre for Population Health, says the long-term nature of the changes needed "does not fit in with political agendas much shorter than that".
"We have to change the background context, the way alcohol, for example, is promoted. We need to change the attitude in Scotland that you can't have a good time unless you have a drink in you."
Tannahill says there has been a lack of clarity about who is responsible for "social health" but is encouraged by the intention of the Scottish Nationalist Party, the governing party in Scotland's regional parliament, to set minimum alcohol prices in supermarkets.
Other programmes also offer hope of lasting health benefits. Hanlon highlights the 10-year Go Well programme, which is assessing the health impact of the Glasgow Housing Association's substantial investment in new homes and neighbourhood renewal.
He remains optimistic about Glasgow's health, citing the city's historical resilience. In the 1830s, when Glasgow expanded with migrants from the Highlands and Ireland, average life expectancy was about 36 years. It was a period of upheaval with high levels of violence and alcohol dependency, "but the people of the time found a way through it," he says. "We are capable of doing it again."