Glasgow, the largest city in Scotland – the cultural hub of the country. Emerging from the 20th century, and characterised by heavy industry, the city now also hosts an exciting music, arts and nightlife scene, drawing from its rich and deep-rooted traditions. But the city has a darker side – a mystery that has plagued epidemiologists for a number of years: the lowest life expectancy in Western Europe, known as Glasgow effect.
By Ronan McCabe
When compared to other post-industrial cities (e.g. Liverpool and Manchester), there remains an unaccounted part for ‘excess’ in poor health outcomes in Glasgow. Socio-economic deprivation, the foremost driver of poor health in any population, does not offer an adequate explanation. Even adjusting for behavioural (e.g. smoking, diet, exercise) and biological (e.g. blood pressure) risk factors does not elucidate the reason for this difference. It cuts across disease, age, gender, and social standing. For example, after controlling for confounding factors, premature mortality (<65 years) in 2010 was observed to be 30% higher in Glasgow than in both Liverpool and Manchester; a similar comparative study with the Northern Irish city of Belfast corroborated these findings. This excess in mortality is infamously, and colloquially, known as the ‘Glasgow Effect’.
What lies at the heart of the Glasgow effect, how is it being addressed, and what lessons can be learned?
According to epidemiologists, the concept of socio-economic ‘vulnerability’ is the key to understanding the Glasgow Effect. This concept could be understood as the balance between the exposure to detrimental factors (e.g. socio-economic deprivation) and the ability of the population to cope with this exposure. If in the face of this exposure the ability to cope is lost, then the population will be more vulnerable to poor health outcomes compared to a population whose ability to cope remains. It is thought that the Glasgow population’s ability to cope has been fragmented and eroded. With the loss of social coping mechanisms an excessive socio-economic vulnerability has been created, which compared to other cities, such as Manchester, has led to higher mortality.
But why is Glasgow particularly vulnerable?
The answer is thought to lie in social, economic, and physical changes, that occurred in the years following the end of World War II. These changes are thought to have compounded the effects of historically high levels of socioeconomic deprivation that had already existed there before. These changes included, for example, the creation of New Towns. Built in the surrounding countryside, the original intention was to ease the over-crowdedness of the city and resolve the health and economic problems of the time. However, during a delay in planning from 1946 to 1950, the original intention was subverted by a new notion of ‘modernisation’ which sought to increase economic growth through focusing the New Towns on lighter and higher skilled industries. This had the effect of being ‘socially selective’; swathes of the population moved from the city but only those who aligned with the New Towns’ economic criteria. Thus, sections of the population, particularly skilled and young people who are considered less vulnerable to detrimental exposures moved to the new towns, leaving behind a city that was seen to be waning economically at the time. This move left behind those considered more vulnerable, like workers and families of workers in the heavy industry with lower-incomes.
The policy of the UK Government during the 1980s, almost thirty years after the start of New Towns, is thought by epidemiologists to have worsened the situation. These policies included the heavy-handed de-industrialisation of Glasgow’s heavy industry, the erosion of trade unions, and a reduction in the available/affordable housing through a decrease in the financing of state-funded homes. The result was high unemployment and increased inequalities. Glasgow was not the only place in the UK that faced such policies, but it is thought to have suffered more due to inadequate local response falling short of providing the buffering effect seen in other cities.\
The concept of socio-economic ‘vulnerability’ is the key to understanding the Glasgow Effect.
Linked to the political circumstances of the 1980s, researchers in the field also contend with the relationship between vulnerability and the concept of the ‘democratic deficit’. Scotland has 59 seats out of 650 in the UK parliament; the entirety of the Scottish electorate could vote a certain way and still see a majority government elected that is in no way representative of that vote. The Conservative party, which formed the UK government from 1979-97, and who was responsible for the detrimental policies of that era, became deeply unpopular amongst the Scottish electorate. However, due to the ‘democratic deficit’ little could be changed as the Scottish vote was drowned out in elections. The result was a defeated and disenfranchised population, with a lost sense of agency over the events of daily life; the psychological toll of this has been noted by epidemiologists, particularly the role of agency and in mental health.
The 1980s left a bitter taste in the mouths of the Scottish electorate. Following the British Conservative party’s loss in 1997, it retained only one out of the 59 Scottish seats. Although 56 of 59 Scottish seats are currently held by the independence-supporting Scottish National Party, the British Conservative party once again forms a majority government. As UK politics become increasingly divergent (Brexit) to the political leanings of the Scottish electorate, the ‘democratic deficit’ is being felt, fuelling a desire for independence that is unabated since narrowly losing an independence referendum in 2014.
From the work of public health bodies such as the Glasgow Centre for Population Health, the understanding of vulnerability and its relation to health and wellbeing is gaining ground. This has led to the formation of various charities and organisations that have made the enhancement of social coping mechanisms their focus.
One of these is the GalGael Trust which has provided a means of social cohesion, solidarity, and purpose. It has notably achieved this through the community led building of Birlinn; these boats, of Norse influence, provided the backbone to the Gaelic culture of Scotland’s west coast until around 300 years ago. The GalGael Trust states that through this they have created a ‘cultural anchor’ for members of Glasgow’s population; both a reference to the shipbuilding industries that suffered heavily under the UK Government of the 1980s, and the sense of community that to this day is integral to the Gaelic culture which now mainly resides on the Western Isles of Scotland.
…that health and wellbeing (of a population) are not just dependent on the quality of the health care system, or specific health interventions… society’s function as an interlinked system, as an interconnected whole, plays an important part.
The Scottish population exhibits this excess in poor health outcomes, albeit to a lesser extent than Glasgow. What this shows – with the Glasgow Effect being a major component – is the extreme end of what social medicine and public health have been discussing for years: that health and wellbeing are not just dependent on the quality of the health care system, or specific health interventions. Rather, society’s function as an interlinked system, as an interconnected whole, plays an important part. In Scotland this has led to public health initiatives such as the AfterNow project, which encompasses a number of facets of modern society, exploring how they impact health while advocating change on a systems level.
Perhaps most importantly, the Glasgow Effect may exemplify a defining notion in public health this century. Looking beyond Scotland’s shores, with the global rise in health issues such as addiction, mental illness, obesity, and a general loss of wellbeing, the concept of vulnerability may apply on a wider scale. Several unanswered but high-priority questions arise with this observation: is exposure to detrimental factors increasing in daily life? Has the ability to deal with these exposures been decreased? Often the focus is placed on what has been gained in modern society, but do we sufficiently consider what has been left behind in its wake?
Published in Medicor 2017 #1